Effectiveness of Individual-Based Strategies to Reduce Nurse Burnout: An Umbrella Review

Aims . Tis umbrella review aims to comprehensively synthesize and analyze the fndings of available systematic reviews on the efectiveness of individual-based strategies for reducing nurse burnout occurring in hospital-based settings. Methods . Following JBI guidelines, an umbrella review was conducted to integrate the efectiveness of various strategies to reduce burnout. Systematic reviews were searched in the Embase, MEDLINE (Ovid), Cochrane Library, CINAHL (EBSCO), Scopus, and WOS databases. Inclusion criteria included studies published in any language from database inception to April 2023. Eligibility assessment involved two independent reviewers who evaluated titles, abstracts, and full texts. Te systematic reviews were critically evaluated using JBI SUMARI. Te results were narratively synthesized and grouped by strategy. Results . Eleven systematic reviews were included, covering the years 2012 to 2021. Te appraisal tools varied, though all included reviews were of high quality. Te strategies were categorized into three domains: mental health (51%), physical activities (26%), and professional competence (13%). Te interventions most identifed were mindfulness-based stress reduction for mental health, yoga for physical activities, and professional competence education. Tese individual-based strategies were shown to efectively eliminate emotional exhaustion (72.7%), depersonalization (44%), and occupational stress (78%) among nurses in hospital-based settings. Conclusion . Mental health, physical activities, and professional competence are strategies to reduce nurse burnout. Implementing these approaches in healthcare settings can improve emotional exhaustion, depersonalization, and occupational stress of nurses.

Aims.Tis umbrella review aims to comprehensively synthesize and analyze the fndings of available systematic reviews on the efectiveness of individual-based strategies for reducing nurse burnout occurring in hospital-based settings.Methods.Following JBI guidelines, an umbrella review was conducted to integrate the efectiveness of various strategies to reduce burnout.Systematic reviews were searched in the Embase, MEDLINE (Ovid), Cochrane Library, CINAHL (EBSCO), Scopus, and WOS databases.Inclusion criteria included studies published in any language from database inception to April 2023.Eligibility assessment involved two independent reviewers who evaluated titles, abstracts, and full texts.Te systematic reviews were critically evaluated using JBI SUMARI.Te results were narratively synthesized and grouped by strategy.Results.Eleven systematic reviews were included, covering the years 2012 to 2021.Te appraisal tools varied, though all included reviews were of high quality.Te strategies were categorized into three domains: mental health (51%), physical activities (26%), and professional competence (13%).Te interventions most identifed were mindfulness-based stress reduction for mental health, yoga for physical activities, and professional competence education.Tese individual-based strategies were shown to efectively eliminate emotional exhaustion (72.7%), depersonalization (44%), and occupational stress (78%) among nurses in hospitalbased settings.Conclusion.Mental health, physical activities, and professional competence are strategies to reduce nurse burnout.Implementing these approaches in healthcare settings can improve emotional exhaustion, depersonalization, and occupational stress of nurses.

Introduction
Globally, nurse burnout is a critical issue impacting on the healthcare workforce which is reported as 11.23% of burnout symptoms [1] and continuously spreading out within the healthcare sector [2].
Indeed, nurse burnout is amplifed during the COVID-19 pandemic, given their increased vulnerability to the virus and the multifaceted challenges encountered in providing care [3,4].Nurses constitute a large proportion about 60% in hospitals, and an increasing number of nurses are required to assist critical and general patient care during the COVID-19 pandemic [5].
Burnout in nurses has numerous detrimental efects on individuals, organizations, and patient care.It signifcantly afects the health and well-being of nurses by emotional exhaustion, depersonalization, and low personal accomplishment.Tese symptoms can have adverse consequences for nurses, including the development of physical and mental health problems such as depression and anxiety [6,7].Nurse burnout is linked to poor outcomes such as quality of care and patient satisfaction [6].Burnout can be detrimental to patient care quality, leading to an increase in medical errors that compromise patient safety [8].Addressing nurse burnout becomes imperative to uphold quality patient care and sustaining the healthcare system.Improving nursing burnout requires interventions at various levels, including national and organizational policy such as creating a positive work environment and healthy workforce strategies, as well as individual-based approaches.While national and organizational strategies to reduce burnout are generally directed towards the majority, individual-based strategies are needed to be designed for nurses to choose according to their preference.
Numerous interventions have been suggested to assist nurses in practicing self-care with the aim of mitigating or preventing burnout and various individual health-related outcomes [9][10][11][12][13].For example, physical activities such as yoga, Qigong, and Tai Chi have been proposed to improve sleep quality and alleviate post-shift stress [10].Emotionfocused tactics and psychosocial programs have been implemented to enhance mental health and prevent burnout [12].A variety of mindfulness-based interventions (MBSR) have been advocated to enhance nurse well-being.Tese interventions have shown positive impacts on sleep quality, anxiety, depression, and overall resilience [13][14][15].Interventions such as team-based training, communication skills enhancement, cognitive coping mechanisms, and problem-solving techniques have demonstrated efcacy in reducing nurse burnout and maintaining efectiveness [9,11].Multicomponent interventions have also positively afected physical and mental health and job satisfaction [12].
Recent research on nursing burnout has increasingly focused on multifaceted interventions with promising potential.Tese interventions often combined physical or psychological methods, yet researchers are interested in wide range of outcome indicators [16,17].Numerous original studies employing diferent approaches to reduce burnout have yielded varying results due to diferences in study design and implementation [17,18].Systemic review and meta-analysis on the topic of burnout have emerged prominently since the 1990s and have been essential to integrate the best evidence while evaluating research biases [19].However, difering criteria for research inclusion and exclusion, search terms, timeframes, language, and type of article have contributed to varied outcomes and interpretations on the efcacy of nurse burnout strategies.Te increasing number of such reviews can be overwhelming for those seeking clinical application.Furthermore, while numerous interventions are frequently used, their comprehensive evaluation in many meta-analyses remains lacking [20].
An umbrella review, alternatively known as an overview of reviews, represents a unique literature review format that aggregates fndings from multiple systematic reviews or meta-analyses on a specifc subject [21].Unlike traditional systematic reviews that examine primary studies, an umbrella review analyzes evidence from existing reviews to provide a more comprehensive overview of the research area.Tis method is particularly apt for a comprehensive synthesis of varied strategies and outcomes across a multitude of reviews, providing a more integrated understanding of efective interventions in a thoroughly researched domain [20,21].By compiling data from various reviews, an umbrella review yields clearer, more substantial, and elevated insights into the efcacy of individual-based strategies for mitigating burnout among nurses.Tis type of review facilitates a thorough assessment of current evidence, pinpointing both consistencies and discrepancies in the fndings [22].Terefore, the objective of this umbrella review is to comprehensively synthesize and analyze selected systematic reviews which have evaluated the efectiveness of individual strategies implemented to reduce burnout among nurses.

Methods
Tis umbrella review aims to synthesize the impact of individual-based strategies on reducing nurse burnout within hospital-based settings.Te methodology adhered to the guidelines developed by the Joanna Briggs Institute [23] and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting standards.Te umbrella review was registered in the PROSPERO system (Number: CRD42022330618).(2) no provided data to address the efectiveness in the systematic reviews, and (3) insufcient information to appraising methodologic quality.

Selection of Articles.
Articles meeting the inclusion criteria were uploaded to EndNote X9 (Clarivate Analytics, PA, USA) for article screening.Two independent reviewers assessed eligibility by titles and abstracts followed by full text review of eligible studies.Reasons for the exclusion of papers that did not meet the inclusion criteria were recorded.Any disagreements between the two reviewers were resolved through discussion with a third reviewer.After relevant studies were retrieved, the JBI system for the unifed management, assessment, and review of information (JBI SUMARI) (JBI, Adelaide, Australia) was applied to integrate fndings.

Quality
Appraisal.Te methodology's quality was evaluated using the JBI SUMARI's systematic review instruments, consisting of the JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses (JBI CACSRRS) [24].Te appraisal of systematic reviews or meta-analyses is guided by 11 questions.Te answers are rated as "yes," "no," "unclear," "or not applicable."Two independent reviewers used the instruments to appraise eligible studies.A third reviewer was consulted to facilitate discussion and resolve any issues.

Data Extraction.
Te JBI SUMARI was used to extract data from the included reviews.Te information extracted included frst author's name and country, published year, and review objectives.Te details of included studies in each review were extracted and included the number of studies, number of included participants, country, study design, strategies, outcome measurement, and conclusions.

Search Process.
A total of 2424 articles were retrieved from six databases.After removing duplicate records (n � 1130) and screening by title and abstract, 52 full-text articles were reviewed.Articles were excluded due to the following: the outcome did not include burnout (n � 10), subjects included non-nursing staf (n � 25), and the article did not present a systematic review (n � 8).Nine articles from six databases were retained.Two additional articles were obtained using a citation search.Eleven articles were included in the analysis (Figure 1).

Characteristics of Included Articles.
Te articles were published between 2012 and 2021, with two of the eleven systematic reviews including meta-analyses (Table 1).Te number of studies synthesized with the systematic review ranged from 6 to 25, encompassing a total of 467 to 6,055 subjects.Researchers were represented from Germany (n = 4), Canada (n = 2), and one each from Taiwan, Korea, Australia, Malaysia, and Iran.Te included studies in the review encompassed a global perspective, covering Europe (with countries such as the Netherlands, Spain, Italy, Germany, Ireland, the UK, Portugal, Denmark, Sweden, Norway, Greece, and France), the Americas (the USA, Canada, and Brazil), the Middle East (Iran and Israel), Asia (India, Japan, Turkey, China, Taiwan, Malaysia, Hong Kong, and Korea), and Oceania (Australia).Te RCT was the most researched design within the reviews.Te outcome indicators represented three categories: mental perception (e.g., stress, burnout, depression, and life satisfaction), physical symptoms (e.g., muscle pain and insomnia), and work-related (e.g., patient care and job satisfaction).

Quality Appraisal.
Te quality of the eleven included articles was evaluated using the JBI CACSRRS.In the eleven systematic reviews, 10 (90.9%) achieved a yes score on 8 of the 11 questions (Table 2).All articles met of 100% for questions 1, 7, 8, 10, and 11.Four questions (Q2, Q3, Q4, Q5, and Q6) were met between 64% and 91%.Question 9, "the likelihood of publication bias," was answered for only one review due to the low number of studies in the other reviews.All eleven systematic reviews were included for qualitative integration.

Strategies and Interventions for Reducing Burnout.
Among the 11 selected systematic reviews, a total of 145 studies were included.After removing duplicates, 131 remained, of which 64 studies discussed the three strategies for the outcome indicators of burnout or occupational stress.Within these 64 studies, the strategies employed included combinations in 6 studies (four mental health + physical activities and two mental health + professional education) and single strategies in 59 studies (25 for mental health, 24 for physical activities, 9 on professional education).Among the 64 studies, the distribution of strategies applied was as follows: mental health (n � 31, 44%), physical activities (n � 28, 40%), and professional competences (n � 11, 16%).In the 31 studies focused on mental health strategies, three types of interventions were included: mindfulness-based stress reduction (MBSR), stress and relaxation management, and resilience and cognition training.Two studies combined two approaches (stress and relaxation management + resilience and cognition training; MBSR + resilience and cognition training).Tus, in these 31 Journal of Nursing Management mental health strategy studies, the distribution of the interventions was MBSR (48%), stress and relaxation management (27%), and resilience and cognition training (24%).In the 28 studies related to the strategies of physical activities, two types of interventions were yoga and general physical exercise, with their distribution being yoga (71%) and general physical exercise (29%).Among the 11 studies on professional competences strategies, two types of interventions were competence education (73%) and coworker supervision (27%) (Figure 2).

Discussion
An umbrella review included a comprehensive evaluation of evidence derived from eleven systematic reviews of 131 diferent research studies focused on reducing nurse burnout.Strategies formed three main categories: mental health, physical activity, and professional competence.Te interventions which positively contributed on burnout were MBSR, resilience and cognition training, and stress and relaxation as well as yoga in occupational stress.

Enhancing Mental
Health.MBSR is the most frequent mental health strategy applied to reduce burnout based on the study fndings.Nurses face a high workload and poor working conditions [29] and are at risk of developing psychological distress [30].Many studies have documented the efectiveness of MBSR in reducing stress [13,14].For physical mechanism, MBSR practices can be crucial for the body's defense against infections and improving health [31,32].MBSR practices cultivate self-compassion, helping individuals to face adversity without succumbing to selfcriticism or negative self-evaluation, which are key factors in burnout [33].When conducted in group settings, mindfulness practices strengthen interpersonal connections among nurses, providing a network of emotional support that is vital for managing work-related stress and reducing the risk of burnout [34].
A typical MBSR program consists of two to three hours of instruction per week for eight weeks and requires regular practice to reap its full benefts.However, some factors should be considered for the individuals [35,36].(1) Time commitment: a typical MBSR program consists of two to three hours of instruction per week for eight weeks; it may be challenging for some individuals to commit this amount of time.(2) Requires practice: MBSR requires regular practice to reap its full benefts; a busy schedule may make this difcult for some individuals.( 3) Not a substitute for professional help: the MBSR program should not be regarded as a substitute for professional medical or psychological care.In cases involving mental or physical illness, it is essential to seek professional assistance.

Increasing Physical Activity.
Increasing physical activity was the second most frequently strategy for mediating nursing burnout, with yoga being the most common activity.Physical activity infuences hormone levels, including the stress hormones.Maintaining physical activity provides a positive contribution to human psychoneuroimmunology and improved mental health [37].Te systematic review of Dutta et al. [38] described the physical and psychological benefts of yoga.However, yoga practitioners must be cautious of (1) musculoskeletal injuries: injuries to the musculoskeletal system are caused by the improper position,  which can lead to muscle, bone, and joint problems [39]; (2) overstretching: an individual who overstretches their body or pushes it beyond its limits can lead to both pulled muscles and torn ligaments as a result of overstretching or pushing the body beyond its maximum ability [40]; and (3) physical exhaustion: for beginners or individuals with underlying health conditions, intense yoga sessions can sometimes result in physical exhaustion [41].

Improving Professional
Competence.Professional competence was the third strategy, and professional competence education and coworker supervision were the important interventions in the current systematic reviews.Te nurses' professional competence is refected in their attitudes, knowledge, and psychosocial and psychomotor skills [42].Nursing professional competence refers to the ability of nurses to demonstrate various abilities such as personal characteristics, professional attitudes, values, knowledge, and skills as they carry out their professional responsibilities [43].Some researchers emphasized the signifcance of professional values on nursing competence and found the negative relationship between professional values and burnout [44,45].On the other hand, work-related stress occurs when people are expected to perform tasks beyond their abilities which requires coping mechanisms.Improving professional competence can provide confdence which can lead to a sense of mastery and control.Situational control reduces the stress associated with uncertainty and ambiguity for a decrease in burnout [45,46].Nurses possessing high levels of professional competence are typically well-equipped with the necessary knowledge, skills, and experience to adeptly handle challenging situations and workloads [47].
Additionally, nurses with higher levels of professional competence reported stronger relationships with their colleagues, likely because they are more likely to be seen as competent and trustworthy [48].Many research studies have indicated that good interpersonal relationships are an important factor in combating burnout [49,50].Terefore, higher professional competence can positively contribute to good interpersonal relationships and self-confdence at work, which can then reduce stress and burnout.

Implications for Managers.
Te umbrella review highlighted the importance of manager facilitation in addressing nursing burnout through individual-based strategies.Key recommendations include routine assessment of burnout level, ofering MBSR and yoga programs, fostering workplace social support networks, and organizing professional competence development programs.
First, regular assessment of the burnout level is necessary because the efectiveness of interventions would be inefective after 6 months [11].Managers can tailor the schedule for burnout assessments to align with the organization's culture and the individual characteristics of employees.Tis approach allows for a thorough evaluation of burnout levels, taking into account diferences across various professional nursing tiers and considering signifcant occurrences like hospital accreditation or personal milestones.Second, managers can arrange the MBSR and physical activities such as yoga or general physical exercise training for nurses.Before the nurses practice the MBSR or yoga activities by themselves, well-trained instructors can provide comprehensive training and prevent the adverse events of MBSR and yoga.On the other hand, the instructors can suggest the appropriate period of MBSR or skill of yoga according to individual 10 Journal of Nursing Management characteristics.Tird, resilience improvement is also an important factor.Studies indicate that resilience can combat burnout [15,26].Health organizations need to improve the well-being of nurses and the managers can implement training courses such as resilience training to prevent the incidence of cumulative burnout [51].Fourth, nurse leaders can mitigate the negative impact of burnout on their professional values by strengthening and improving their professional value education through seminars and nursing inservice education programs [52].In addition, nurse managers can provide continuing education opportunities based on the working unit or level of professional capacity to enhance professional competence among nurses [53].Te competence improvement education can teach nurses to determine for themselves how to handle their problems and how to improve their situation through meaningful dialog and engagement with nurse leaders concerning their work-life issues.Finally, the peer support and supervision system is necessary.A network fosters a sense of belonging and security, enhancing individuals' ability to cope with stress and burnout.Designing leisure activities for nurses can contribute to interpersonal relationships and decrease stress [54].

Strengths and Limitations
An umbrella review systematically compiled and synthesized evidence on individual-based strategies for reducing stress and burnout among nurses in hospital-based settings.Te review marks a signifcant step in collating evidence and identifying the research on the most frequently used strategies.Te review was limited by only including published systematic reviews and omitted grey literature or unpublished studies.Overlapping sources across the systematic reviews led to inconsistent outcomes and may have rendered burnout metrics inaccurate.Additional mental health indicators, such as anxiety or depression, may have confounded burnout fndings.Te umbrella review revealed that while numerous interventions are commonly used, many have not been thoroughly tested.More research is needed for in-depth analysis of these interventions.

Conclusion
Strategies for reducing nurse burnout are focused on mental health, physical activity, and professional competence.Nurses can adopt personal preference strategies and selfhelp interventions to reduce burnout.
Reducing Burnout.Among the 64 studies reviewed, 23 mentioned the efectiveness of interventions on emotional exhaustion (EE), with 17 (74%) reporting a signifcant reduction in EE.Among these 17 studies, the interventions most frequently efective in reducing EE included MBSR mentioned 5 times, competence education 4 times, resilience and cognition training 3 times, stress and relaxation management 2 times, coworker supervision 2 times, and yoga once.19 studies addressed the impact of interventions on depersonalization (DP), with 11 (58%) reporting efective reductions.Te most frequently efective measures for reducing DP included MBSR 4 times, resilience and cognition training 3 times, competence education 2 times, stress and relaxation management once, coworker supervision once, and yoga once.20 studies discussed intervention efects on low personal accomplishment (LPA), with 10 (50%) achieving signifcant reductions.Te interventions most efective in reducing LPA were MBSR, resilience and cognition training, and competence education, each mentioned 3 times, followed by coworker supervision 2 times, stress and relaxation management once, and yoga once.42 studies examined the efectiveness of interventions on work stress, with 32 (76%) noting substantial stress reductions.Te most frequently efective strategies to reduce work stress were yoga 17 times, MBSR 6 times, stress and relaxation management 5 times, competence education twice, and general physical activities twice (Figure3).

Figure 2 :
Figure 2: Te strategies and interventions for reducing nurse burnout.

Figure 3 :
Figure 3: Te efectiveness of interventions for reducing emotional exhaustion, depersonalization, low personal accomplishment, and occupational stress.
OR (staf * OR employee * OR ofcer * OR personnel * OR practitioner * OR profess * OR provider * OR specialist * OR worker * ) NEAR/6 (nurs * OR health * OR hospital * OR medical))] AND *

Table 2 :
(11)ity appraisal of included systematic reviews using JBI (n � 11).Were the inclusion criteria appropriate for the review question?(3)Was the search strategy appropriate?(4)Were the sources and resources used to search for studies adequate?(5)Were the criteria for appraising studies appropriate?(6)Wascriticalappraisalconducted by two or more reviewers independently?(7)Were there methods to minimize errors in data extraction?(8)Were the methods used to combine studies appropriate?(9)Was the likelihood of publication bias assessed?(10)Wererecommendationsforpolicy and/or practice supported by the reported data?(11)Were the specifc directives for new research appropriate?