Non-pharmacological therapies for stress reduction in healthcare workers: An integrative review

Abstract

Background

Healthcare workers are constantly affected by stress due to their work specificities. The damages of this disorder are not limited to the worker, but extend to the entire society. In this sense, intervention actions are necessary for stress control.

Objective

To identify the non-pharmacological therapies used for stress management in healthcare workers and their effects on self-reported and physiological stress.

Methods

Integrative review with article search in the databases Scientific Electronic Library Online (SciELO), Latin American and Caribbean Health Sciences Literature (LILACS), and PubMed. The descriptors “cortisol”; “stress”, “worker” and their combination with the connector “AND” were used.

Results

A total of 14 articles were selected. The tested non-pharmacological therapies were meditation, yoga, interaction with dogs, self-care and relaxation techniques, physical activity associated with mindfulness, art therapy, auriculotherapy, forest therapy, and sensory body moisturizing. The results were satisfactory in reducing subjective and/or objective stress.

Conclusions

Therapies that promote relaxation, mindfulness, and self-care seem to be effective for stress management in healthcare workers.

Keywords

occupational stress occupational health health personnel cortisol complementary therapies epidemiology

Introduction

Stress constitutes a behavioral and physiological response to danger and/or threat situations. It occurs as a natural mechanism of alert, defense, and homeostasis. Depending on the period of exposure to stress, the effort to overcome it can be an obstacle to the orgainsm, harming both body and mind.¹

In the work context, the reductionist concept of stress based on causes and consequences can be expanded by the perspective of the capitalist logic of production as a generator of stressful work environments.²

Contemporary lifestyle has exacerbated and disseminated stress in the population, making it a global public health problem.³

In this context, there are healthcare workers whose occupational routine sometimes involves unhealthy environmental conditions; shortage of supplies; exhausting work hours; low remuneration; precarious work relationships; exposure to suffering and death; and even situations of moral harassment, threats, and violence in the workplace.^4–6

The persistence of these stressors can lead to anxiety, depression, muscle pain, metabolic syndrome, gastric ulcers, fatigue, poor concentration, insomnia, increased blood pressure, decreased libido, smoking, alcoholism, burnout syndrome, premature death, among others.⁷

Burnout syndrome, in fact, is already classified as an occupational disease

and characterized by emotional exhaustion, depersonalization, and low professional self-esteem.^7,8

At biological levels, stress manifests itself through the release of the hormone cortisol through the stimulation of the Hypothalamic-Pituitary-Adrenal (HPA) axis. Thus, cortisol measurement is considered a potential biomarker of stress.^1,9

Stress can also be assessed in its psychosocial aspects through validated self-reported scales.^10,11 In this way, its quantification, whether objective or subjective, can contribute to the development of coping strategies for stress in the workplace, such as non-pharmalogical therapeutic interventions.

Those therapies consist in non-drug tools and technologies that can be carried out, as such physiotherapy, physical activity, change of nutritional habits, psychological counselling and integrative and complementary health practices. These therapies contribute to the patient's overall health and well-being.^12,13

There is a scarcity of studies in the literature on interventions for stress management in healthcare workers, who may have neglected self-care due to work overload. Most research focuses on patients. This highlights gaps in the state of the art regarding the topic and emphasizes the importance of knowledge about non-pharmacological therapies applied in the context of occupational stress.⁶

In this sense, this study aims to identify non-pharmacological therapeutic interventions for health professionals to control stress and analyze their effects on physiological stress (cortisol levels) and psychosocial stress (self-reported).

Methods

This is an integrative, analytical review of the literature on non-pharmacological therapeutic interventions tested on healthcare workers in order to evaluate their effects on cortisol levels and psychosocial stress.

This study brings the following guiding question to the research's development: “What non-pharmacological therapies are used by healthcare workers to control stress and their effects on physiological stress (cortisol) and self-reported stress (subjective)?”

The research was conducted in September 2023 in the databases Scientific Electronic Library Online (SciELO), Latin American and Caribbean Health Sciences Literature (LILACS), and PubMed. The descriptors “cortisol” were used; “stress”, “worker” and their junction with the Boolean connective “AND”. The descriptors were selected from the list of Health Science Descriptors (DeCS) and their counterparts in the Medical Subject Headings (MeSH).

The eligibility criteria were complete articles published in the last 10 years for analysis of the most recent evidence on the subject. Articles in Portuguese, English, and Spanish were included in order to expand the scope of results. Since it is a review of therapeutic interventions, only experimental studies were analyzed. Only studies that applied cortisol measurement and subjective stress measurement and studies whose participants were health workers have been included.

The criteria for exclusion were articles that were not related to healthcare workers, theses, dissertations, final course papers, and duplicate articles. The criteria used in the search were outlined in Figure 1.

Figure 1.

Search scheme for articles in databases. Source: data from authors.

The selected articles were read in full and characterized according to year of publication, authors, country, journal, study design, type of therapy/experiment conducted, cortisol sample, psychosocial scale, professional category, and main results.

To execute the study, the process involved the elaboration of the guiding question, a literature search through databases, identification of articles, data collection, critical analysis of the selected texts, discussion, and presentation of the review study. This study, as a literature review, is exempt from Institutional Review Board approval. The study followed the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) orientations.

Results

A total of 14 studies were included in this research. Regarding the year of publication, three studies were published in 2019,^14–16 2020,^17–19 2021^20–22 and in 2022.^23–25 But only one study was published in the year 2017⁶ and in 2023²⁶ illustrated by Figure 2 and Chart 1.

Figure 2.

Quantity of articles published on experimental studies for stress reduction in healthcare workers (per year). Source: data from authors.

The research countries are distributed across the continents, with the exception of Africa, as illustrated in Figure 3 and presented in Chart 1.

Figure 3.

Distribution of countries with studies on therapies practiced by healthcare workers for stress management (in red). Source: Produced by the authors using the mapchart.com tool.

The most commonly used non-pharmacological therapies for stress control in studies were mindfulness/meditation techniques (6 studies),^{14,17–18,20,24–25} followed by yoga (3 studies)^22,25–26 and interaction with dogs (2 studies),^15,19 represented by Figure 4 and Chart 1.

Figure 4.

Quantitative data and identification of therapies/interventions for stress reduction in healthcare workers. Source: Data from the authors.

To measure physiological stress (cortisol), most studies (10)^{6,14–19,23–25} used salivary cortisol, 3 studies measured serum cortisol^21–22,26 and 1 analyzed hair cortisol²⁰ (Table 1 and Chart 1). Significant results in reducing cortisol levels were found in seven studies, two experiments using meditation/mindfulness,^18,20 two using interaction with dogs,^15,19 one using sensory body moisturizing,⁶ one using auriculotherapy²¹ (in the paired comparison of the intervention group, but not between groups) and a study through a psychomotor relaxation program,¹⁶ as shown in Chart 1.

Table 1.

Resume of the studies findings.

Characteristics	Quantity of studies
Cortisol's origin	10 studies with salivary cortisol 3 studies with serum cortisol 1 study with hair cortisol
Professional Category	4 studies with nursing professionals 4 studies with medical professional 1 study with nursing and medical professionals 5 studies covered more than 2 professional categories
Studies’ location	11 in hospital and emergency environments. 2 in medical institution 1 in municipal health center

Source: Authors’ data.

Chart 1.

Characterization of the selected articles.

Year, authors, country	Journal	Study design	Intervention instrument	Cortisol test	Type of scale (psychological index)	Characterization of workers	Synthesis of the results
2017. Leão ER, Dal Fabbro DR, Oliveira RB, Santos IR, Victor ED, Aquarone RL et al.⁶ Brazil.	PLOS ONE	Open-label randomized controlled clinical trial.	Four groups. 1) control (without intervention); 2) Monosensory—daily body moisturizing (DBM). with odorless cream; 3) Bissensory—DBM with scented cream; 4) Multisensory—DBM with scented cream associated with audiovisual material.	Salivary cortisol.	ISS—Inventory of Stress Symptoms (Lipp inventory of stress symptoms for adults), Rosenberg Self-Esteem Scale, Life Satisfaction Scale. Positive and Negative Affect Scale (PANAS),	93 female healthcare professionals	Compared to the other groups, the Bisensory group had lower stress across all three assessments (p = 0.017; 0.012; 0.036), 8% higher life satisfaction at follow-up than baseline (95% CI: 2% to 15%, p = 0.016), a 10% increase in positive affect (95% CI: 2% to 19%, p = 0.011), and a 12% reduction in negative affect (95% CI: 3% to 21% less, p = 0.014) after 30 days of intervention. The Multisensory group showed improved self-esteem (p = 0.012) and reduced cortisol (p = 0.036) after 30 days of intervention.
2019. Dunne PJ, Lynch J, Prihodova L, O'Leary C, Ghoreyshi A, Basdeo AS, et al.¹⁴ Ireland	Journal of Integrative Medicine	Randomized controlled trial	Training program based on mindfulness (meditation) for 7 weeks.	Salivary cortisol.	Maslash Burnout Inventory Depression, Anxiety, and Stress Scale	58 members of a multidisciplinary emergency team—hospital, 29 allocated to the intervention group and 29 to the control group	The mindfulness-based training program resulted in a significant reduction (P < 0.05; T1 [one week before the intervention] vs T3 [two months after the intervention]) in burnout, specifically emotional exhaustion, with an effect size of 59%. Similar reductions were observed for stress and anxiety (p < 0.05). Significant inverse correlations were observed between salivary cortisol concentrations and relative gene expression of TNF-a for participants in the intervention at T1.
2019. Machová K, Součková M, Procházková R, Vaníčková Z, Mezian K.¹⁵ Czech Republic	Int. J. Environ. Res. Public Health	Experimental study with cross-over randomization.	Therapy through interaction with dogs.	Salivary cortisol.	A self-reported stress scale was not used.	20 nursing professionals from a hospital	There was a significant difference in the complete group of nurses when participating in a normal day of work with interaction with dogs, as demonstrated by the reduction in cortisol levels (p = 0.02). Dog therapy can be a good strategy for reducing stress in healthcare professionals.
2019. Veiga G, Rodrigues AD, Lamy E, Guiose M, Pereira C, Marmeleira J.¹⁶ Portugal.	Complementary Therapies in Clinical Practice	Quasi-experimental before/after study, with convenience allocation into control and intervention groups.	Intervention study through a psychomotor relaxation program (body awareness, regulation of muscle tone, and breathing exercises) with two weekly sessions for 8 weeks.	Salivary cortisol.	Maslach Burnout Inventory (MBI), Mood State Profile	30 nurses from a hospital: 15 in the control group and 15 in the intervention group.	Compared to the control group, the relaxation group showed a decrease in emotional exhaustion, depression, and salivary cortisol levels. In the 15th session, salivary cortisol concentrations decreased significantly from pre-session to post-session (p = 0.016). These results provide preliminary evidence that relaxation interventions are effective strategies for reducing the habitual stress experienced by nurses.
2020. Allen R, Robinson A, Allen S, Nathan E, Coghlan E, Leung Y.¹⁷ Australia	Australasian Psychiatry	Non-randomized and non-controlled experimental study	Daily meditation for 21 days	Salivary cortisol.	Depression, Anxiety, and Stress Scale (DASS-21).	12 hospital-level doctors.	There were no differences over time in the measurement of pre and postoperative cortisol levels (p = 0.917). Scores on the anxiety and stress subscale of the participants significantly decreased (p = 0.012).
2020. Errazuriz A, Schmidt K, Undurraga EA, Medeiros S, Baudrand R, Cussen D, et al.¹⁸ Chile	Journal of Psychiatric Research	Three-arm controlled clinical trial	Mindfulness-Based Stress Reduction (MBSR), Psychoeducational stress management intervention (SMC), and control group	Salivary cortisol.	12-item General Health Questionnaire (GHQ-12), Outcome Questionnaire (OQ-45), Perceived Stress Scale, Job Satisfaction Scale, Chilean version of the Five Facet Mindfulness Questionnaire (FFMQ)	105 healthcare professionals from a hospital at the beginning of the research.	Mindfulness therapy showed a post-intervention effect in reducing psychological morbidity and psychotherapeutic progress compared to the other groups. In the secondary outcome, only the mindfulness group was associated with a 23% decrease in cortisol awakening response (p < 0.05).
2020. Kline JA, VanRyzin K, Davis JC, Parra JA, Todd ML, Shaw LL, et al.¹⁹ United States.	Academic Emergency Medicine	Randomized controlled trial	Intervention through therapy dogs versus art therapy (coloring) versus no intervention group.	Salivary cortisol at the beginning, middle, and end of the work shift.	Modified Perceived Stress Scale (mPSS-10), Visual Analog Scale (VAS),	122 healthcare workers (doctors and nurses) from an emergency department: 39 in the control group, 40 in the coloring group, and 43 in the dog group.	At T3, VAS decreased slightly with dogs (13.6 mm, p = 0.018 vs. coloring, Tukey's post hoc). The reduction in mean cortisol levels was significant in T3 when comparing the coloring group vs control group (p < 0.0001) and dog group vs control group (p = 0.003). Interaction with a therapy dog had a significant impact on reducing self-reported anxiety compared to the coloring group (p = 0.018, Tukey's post hoc).
2021. Fendel JC, Aeschbach VM, Schmidt S, Göritz AS.²⁰ Germany.	Journal International Medicine	Randomized controlled clinical trial	Eight-session guided mindfulness program with maintenance of three monthly sessions for four months	Hair cortisol	19-item Copenhagen Burnout Inventory questionnaire, 12-item General Health questionnaire, 10-Item Perceived Stress Scale, 8-item Irritation Scale	150 physicians at hospital level initially allocated: 77 in the intervention group and 73 in the control group.	The intervention group showed significant reductions in burnout at T2 (after the maintenance period, p = 0.046), perceived stress (p = 0.046), and perceived tension at work (p = 0.026) at T1 (after the program). There were significant decreases in hair cortisol within groups, but not between groups.
2021. Se-Na Lee, Bomi Kim, Hyojung Park.²¹ Korea	Complementary Therapies in Clinical Practice	A randomized clinical trial	Auriculotherapy once a week for a total of five weeks	Serum cortisol	Perceived Stress Scale (PSS) State-Trait Anxiety Inventory (STAI) Beck Depression Inventory-II (BDI-II),	60 outpatient nurses allocated in auriculotherapy groups (n = 30) and control (n = 30).	The stress scores decreased significantly within the experimental group (p < 0.001), as well as the cortisol levels (p = 0.02). However, no statistically significant differences were found between the two groups in relation to perceived stress (p = 0.087) and cortisol levels (p = 0.151). The depression scores showed significant differences between the two groups (p = 0.002).
2021. Mandal S, Misra P, Sharma G, Sagar R, Kant S, Dwivedi SN, et al.²² India	Journal of Evidence-Based Integrative Medicine	Randomized Clinical Trial	Yoga during 12 weeks, twice a week.	Serum cortisol	Perceived Stress Scale (PSS). Professional Quality of Life Scale (ProQOL)	113 hospital-level nursing workers allocated at the beginning of the research into yoga group (n = 58) and waitlist group (n = 55)	The average cortisol change did not differ between the groups. The perceived stress score differed significantly between the intervention group and the control group after the 12-week follow-up (p < 0.05).
2022. Kim Y, Choi Y, Kim H.²³ Korea	Int. J. Environ. Res. Public Health	Quasi-experimental study, of the before-and-after type.	Relaxation program to relieve stress, involving a forest walk and woodworking (forest healing therapies) lasting two days and one night	Salivary cortisol.	Epworth Sleepiness Scale (ESS) Stanford Sleepiness Scale (SSS) Korean version of the Pittsburgh Sleep Questionnaire Index (PSQI) Hospital Anxiety and Depression Scale (HADS). Perceived Stress Scale (PSS)	13 physicians from medical institutions.	There was an improvement in the perceived stress scale (from 30.92 to 28.23 points, p = 0.025) and a decrease in dehydroepiandrosterone sulfate (from 5.09 to 3.67, p = 0.039). However, the cortisol levels of the participants increased after forest therapy,
2022. Lipponen M, Hallikainen V, Kilpeläinen P.²⁴ Finland	Journal of Multidisciplinary Healthcare	Quasi-experimental before-and-after study.	Intervention study with outdoor physical activities and mindfulness in six collective meetings over a period of six months.	Salivary cortisol.	15-Item Bergen Burnout Indicator (BBI-15) and Modified Örebro Musculoskeletal Pain Questionnaire	11 health workers from a municipal health unit (nurses and administrative staff)	The concentrations of cortisol were lower on intervention days compared to non-intervention days, with an indicative difference (p = 0.05). Pain and exhaustion from work decreased during the period, but without statistical significance.
2022. Miyoshi T, Ida H, Nishimura Y, Ako S, Otsuka F.²⁵ Japan	Int. J. Environ. Res. Public Health	Non-controlled and non-randomized intervention study.	Yoga and mindfulness program 1 h weekly for 3 months.	Salivary cortisol.	Patient Health Questionnaire-9 (PHQ-9), Maslach Burnout Inventory-Human Service Survey (MBI-HSS), Sense of Coherence-13 (SOC-13), Connor-Davidson Resilience Scale (CD-RISC), Self-Compassion Scale, and Jefferson Scale of Empathy (JSE).	13 hospital-level medical professionals.	The self-measured pulse rates decreased significantly (before versus after the first program). However, there were no significant changes in salivary cortisol levels or in the burnout inventory.
2023. Misra P, Mandal S, Sharma G, Kant S, Rai S, Yadav K, et al.²⁶ India	Cureus	Single-arm quasi-experimental before-and-after study.	Twelve weeks of supervised yoga sessions were provided, with each session lasting 1 h, three times a week.	Serum cortisol	Depression, Anxiety, and Stress Scale (DASS-21), World Health Organization Well-Being Scale (WHO-5)	80 healthcare professionals from a hospital (doctors, nurses, support staff, security staff, laboratory technicians and pharmacists)	There was a statistically significant decrease in DASS-21 scores in all three domains: depression (1.1 ± 2.7 to 0.1 ± 0.3, p = 0.0017), anxiety (0.8 ± 1.7 to 0.2 ± 0.70, p = 0.0007), and stress (1.3 ± 2.5 to 0.2 ± 0.63, p = 0.0002). There was an increase in the WHO-5 score after the intervention (p < 0.001). No significant variations were found regarding cortisol levels (9.7 ± 3.9 mcg/dl before and 10.3 ± 0.4 mcg/dl post intervention, p = 0.176).

Source: Data from the authors.

Regarding the used scales, 11 studies resulted in a significant reduction in levels of psychosocial stress or other minor mental disorders, namely: four studies with meditation/mindfulness,^{14,17–18,20} one study with sensory body moisturizing,⁶ one study with dogs and art therapy (coloring),¹⁹ two with yoga,^22,26 one with forest therapy,²³ one with psychomotor relaxation¹⁶ and another one with auriculotherapy²¹ (paired analysis). The other studies, despite resulting in a reduction of some of their stress-related scales, did not have significant variations (Chart 1).

A total of 4 studies were conducted exclusively on nursing workers^{15–16,21–22} and 4 exclusively on physicians^17,20,23,25 and another one involving both.¹⁹ The others contemplated more than one professional category.^{6,14,18,24,26} It was observed that the hospital or emergency environment dominated the research location (11 studies).^{6,14–20,22,25–26} Two studies mentioned medical institution.^21,23 Only one was performed in municipal health center²⁴ (Table 1 e Chart 1).

Discussion

The non-pharmacological therapies used for reducing objective and subjective stress in healthcare workers were: meditation, yoga, interaction with dogs, self-care and relaxation techniques, physical activity combined with mindfulness, art therapy, auriculotherapy, forest therapy, and sensory body moisturizing. Most of them are part of the list of Integrative and Complementary Health Practices (ICHPs), such as meditation, yoga, auriculotherapy, and mindfulness programs.

The ICHPs were institutionalized in Brazil by the National Policy of Integrative and Complementary Health Practices (PNPICS) in 2006. Currently, 29 integrative practices are legitimized for use in the Unified Health System (SUS). These therapies contribute to the comprehensiveness of care, promote the decolonization of the hegemonic care model, value emotions and feelings, and reinforce autonomy in therapeutic decisions.²⁷

Furthermore, their positive effects have been proven in reducing osteomuscular pain, reducing the frequency of mental disorders, insomnia, blood pressure, improving quality of life, among others.²⁸

In the studies analyzed, significant effects of ICHPs on the reduction of subjective stress and/or other psychological morbidities in healthcare workers were found in four studies with meditation/mindfulness and in two that tested yoga. Studies on interaction with dogs, sensory body moisturizing, and relaxation programs also achieved significant results in self-reported symptoms. These therapies, although not included in the PNPICS, are considered complementary to health, as they contribute to self-care and quality of life.²⁸

Physiological stress measured by cortisol levels also showed a significant reduction through the application of ICHPs, such as meditation, auriculotherapy (paired comparison in the intervention group), and studies that used relaxation and mindfulness programs. The interaction with dogs and sensory body moisturizing also showed satisfactory results in reducing objective stress. It is evident that the non-pharmacological therapies tested have a positive effect not only on self-reported sensations but also at physiological levels.

It is noteworthy that no study used drug therapy in combination with non-pharmacological therapies. This shows that it is possible to use technologies without pharmacological actions, but with the potential for behavioral and self-care changes, representing excellent cost-effectiveness. The advantages of ICHPs are corroborated regarding their beneficial effects associated with low cost, no side effects, and good acceptance, especially considering popular knowledge and culture.²⁸

Salivary cortisol was the most commonly used measurement technique in studies, and it can also be measured through serum levels, capillary blood, and urine. However, saliva collection proves to be less invasive, better accepted by research participants, easy to execute, and more cost-effective for screening physiological stress in healthcare workers.²²

Studies indicate the hormone cortisol as a physiological biomarker for stress, showing significantly higher salivary concentrations in burnt-out physicians compared to a healthy control group,²⁹ higher hair cortisol levels in healthcare workers subjected to heavier workloads,³⁰ and a direct correlation between hair cortisol levels with perceived stress and the emotional exhaustion component of burnout in healthcare professionals.³¹

The analyzed studies presented relatively short application times for non-pharmacological therapies and participant samples ranging from 11 to 150. These data can be translated as limitations, leading to unsatisfactory outcomes in some studies. Many studies with quasi-experimental designs were also observed. Therefore, the importance of conducting studies with a higher level of scientific evidence is highlighted, such as randomized controlled trials, which typically yield more robust results.

Furthermore, there was a methodological diversity among the studies analyzed, as well as the use of many subjective scales, which could contribute to increased data collection time and increased stress in participants.

Most studies don’t bring the biological plausibility that describes the mechanisms of action of the non-pharmacological therapies that were used. Or the studies mention in a superficial manner compared to other results with other studies in the literature.

In this sense, the mandalas therapy and dog therapy promote mental distraction of work preoccupations, reducing human's perception of stress.¹⁹ The interventions based in nature act through the Theory of attention's restauration and the Theory of stress’ restauration.²⁴ Moreover, mindfulness can stimulate the left frontal lobe which is associated to the decreasing of anxiety.²⁵ Yoga, in turn, decreases the temporal oxidative stress which activates the parasympathetic nervous system, balances the Hypothalamic-Pituitary-Adrenal axis, and decreases stress and anxiety.²⁶ The hormonal homeostasis of the hypothalamic-pituitary chain seems to be a plausible justification of stress management.

A systematic review with meta-analysis indicated that auriculotherapy was significantly superior to the control group in terms of subjective stress index, blood pressure, heart rate variability, and pulse rate in adults.³²

In terms of meditation, a study revealed that participants in the experimental group, who received meditation recordings, experienced significantly lower levels of stress and anxiety on posttest surveys than the control group. That is, mindfulness meditation can reduce stress and anxiety levels.³³

A systematic review showed stress decreasing in 71% of studies measuring physiological outcomes and 65% of studies measuring psychological outcomes. Therefore, a single session of yoga components was effective in reducing acute stress reactivity in adults and could be recommended for stress management.³⁴

Despite the benefic evidence of therapies non-pharmacological to stress management, the ICHPs have limits to implementation of primary health care, as lack of time by the overload of work, lack of financial, material and organizational support by management, inadequate infrastructure and lack of qualification.³⁵

Nursed and physicians were the most studied categories. Healthcare workers, however, include all those involved in healthcare, including cleaning staff, security guards, porters, and administrative support. Therefore, future research could encompass other categories of workers or multiprofessional teams in the healthcare field, so that stress reduction practices extend to all healthcare workers and allow for the visibility of other healthcare providers.³⁶

Another point analyzed is the restriction of studies to the hospital level. Primary health care corresponds to the population's gateway to health services. Despite the use of low technologies, it is highly complex due to bond formation, longitudinality, surveillance and epidemiological actions, home visits, reception, among others. These situations lead to an accumulation of duties and responsibilities that urgently require attention and research focused on the mental health of primary health care workers.³⁷

Non-pharmacological therapies act on the consequences or prevention of disorders. Therefore, we raise issues regarding the causal stressor factors that persist after the end of these therapies. In this scope, employment relationships, economic dissatisfaction, and experiences of violence in the workplace are included. One study concluded that precarious work was positively associated with perceived stress in workers. The “vulnerability” and “salary” dimensions of precariousness were also associated with subjective stress, and among men, the “salary” dimension was associated with adrenal markers such as cortisol.³⁸

Another study reinforces this idea by concluding that higher levels of precariousness are associated with higher perceived stress, while greater social support is related to lower levels of perceived stress. However, no associations with stress biomarkers were found.³⁹

We highlight the issue of violence in the workplace, with the most common forms being moral harassment, verbal, and physical violence. This reflects mental disorders such as stress, emotional exhaustion, depression, and physical symptoms.^4,40

Therefore, we emphasize the need for the implementation of public health policies aimed at the health and protection of workers, as well as financial appreciation, adequate rest, and continuous programs of therapeutic interventions that provide well-being and quality of life to healthcare professionals.

The main limitations of our research were the search in few databases (only three) and the application of the filter for studies of the last ten years, which may have reduced the number of selected articles. Furthermore, other descriptors related to stress, such as burnout, were not used.

Therefore, we believe that this review can guide researchers, managers, and healthcare workers regarding the tested non-pharmacological therapies for reducing self-reported stress and cortisol levels. In this direction, strategies can be developed in work environments to minimize stress and improve the quality of life of these workers. Consequently, this leads to a decrease in absenteeism, social security expenditures, iatrogenesis, and an increase in patient satisfaction with the services provided.

Conclusions

Meditation, yoga, and relaxation programs focusing on mindfulness appear to be satisfactory for reducing self-reported stress and cortisol levels in healthcare workers, highlighting the importance of Integrative and Complementary Health Practices for well-being and quality of life.

Non-pharmacological therapies are low-cost, accessible technologies that appear to be effective in controlling stress and other mental disorders in healthcare workers. Therefore, we suggest that these therapies and other well-being-promoting tools be tested in future studies to contribute to the state of the art and to the health of workers.

Footnotes

ORCID iD

Kairo Silvestre Meneses Damasceno

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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