Psychiatry · Medical Literature
Non-pharmacological therapies for sleep and occupational stress regulation among nightshift nurses: a systematic review and Bayesian network meta-analysis based on randomized controlled trials.
Abstract
Nightshift nurses commonly suffer from sleep disturbances and occupational stress due to irregular work-sleep rhythms. This Bayesian network meta-analysis (NMA) compared the efficacy of non-pharmacological therapies to identify optimal interventions for improving sleep and reducing occupational stress in night/rotating-shift nurses. Cochrane, Embase, PubMed, Web of Science, and CNKI were searched up to October 24, 2025. Studies were assessed for bias via ROB2. Primary outcomes were total sleep score and sleep duration; secondary outcomes included anxiety, depression, and fatigue scores. Bayesian NMA (R 4.5.2) calculated SMD (95% CrI) and SUCRA for intervention ranking. Eighteen studies involving 1,572 nurses were included. Sleep intervention program (SIP) appeared to be effective for optimizing total sleep score (SMD -0.80, 95% CrI [-1.2, -0.41]; SUCRA = 80.71%). Mindfulness training intervention (MTI) showed relatively good effectiveness in regulating sleep duration (SMD -1.0, 95% CrI [-1.4, -0.57]; SUCRA = 95.97%). Auricular plaster therapy (APT) appeared to be effective in alleviating depression (SMD -0.60, 95% CrI [-1.0, -0.17]; SUCRA = 84.60%). Rational emotive behavior therapy (REBT) showed superior efficacy for alleviating anxiety (SMD -3.0, 95% CrI [-3.6, -2.4]; SUCRA = 100%). Pure pelargonium essential oil (PPEO) demonstrated relatively good efficacy in relieving fatigue (SMD -0.70, 95% CrI [-1.2, -0.25]; SUCRA = 94.92%). SIP, MTI, APT, REBT, and PPEO appeared to be effective non-pharmacological interventions for optimizing nightshift nurses' total sleep score, regulating their sleep duration, and alleviating their depression, anxiety, and fatigue, respectively. Future well-designed studies are warranted to further validate the role of non-pharmacological therapies, particularly SIP and MTI, in regulating sleep among nightshift nurses. However, all findings were based on indirect evidence, which formed a star-shaped network with no closed loops. Therefore, the findings should be considered exploratory and hypothesis-generating, which are intended to provide preliminary guidance for future head-to-head comparative trials rather than establishing definitive clinical evidence. Clinical decisions should be made based on a comprehensive assessment that takes into account local resources, cultural context, and individual preferences of nurses. https://www.crd.york.ac.uk/PROSPERO/view/CRD420251180760.
Clinical relevance
Among nightshift and rotating-shift nurses suffering from sleep disturbances and occupational stress, which non-pharmacological interventions most effectively improve total sleep score, sleep duration, depression, anxiety, and fatigue compared with standard care? __SNAPSHOT__ {"studyDesign":"Systematic review with Bayesian network meta-analysis (NMA) of randomized controlled trials","setting":"Not reported for individual included trials; literature search encompassed Cochrane, Embase, PubMed, Web of Science, and CNKI databases searched through October 24, 2025; senior authoring institution identified as West China Hospital, Sichuan University, China","sampleSize":"n=1,572 nurses across 18 RCTs; number per intervention arm not reported in available text","population":"Nightshift or rotating-shift nurses experiencing sleep disturbances and occupational stress; specific clinical inclusion/exclusion criteria not reported in the available abstract","intervention":"18 distinct non-pharmacological therapies evaluated, including: Sleep Intervention Program (SIP), Mindfulness Training Intervention (MTI), Auricular Plaster Therapy (APT), Rational Emotive Behavior Therapy (REBT), Pelargonium Essential Oil (PPEO), Bright Light Exposure (BLE), digital Cognitive Behavioral Therapy (dCBT), Individualized Shift Work Management (ISWM), Aromatherapy Massage (AM), Wearable Light Device (WLD), Mobile Health Program (MHP), Evening Light Exposure and Morning Light Avoidance (ELEMLA), and others","comparator":"Routine/standard care (served as the common comparator hub for all indirect NMA comparisons)","primaryOutcome":"Total sleep score and sleep duration","followUp":"Not reported","fundingSource":"Not reported"}
Key findings
Across 18 RCTs involving 1,572 nurses and 18 interventions, all comparative estimates were derived exclusively from indirect evidence via a star-shaped network with no closed loops. For the primary outcomes: (1) Sleep Intervention Program (SIP) ranked highest for total sleep score improvement (SMD −0.80, 95% CrI [−1.20, −0.41]; SUCRA = 80.71%), with the credible interval excluding zero. (2) Mindfulness Training Intervention (MTI) ranked highest for sleep duration regulation (SMD −1.0, 95% CrI [−1.40, −0.57]; SUCRA = 95.97%), with the credible interval excluding zero; this represents a large standardized effect by Cohen's convention. For secondary outcomes: (3) Auricular Plaster Therapy (APT) ranked highest for depression reduction (SMD −0.60, 95% CrI [−1.0, −0.17]; SUCRA = 84.60%), credible interval excluding zero. (4) Rational Emotive Behavior Therapy (REBT) ranked highest for anxiety reduction (SUCRA = 100%); however, the authors explicitly caution that a SUCRA of 100% in a sparse, indirect-only network does not confirm a statistically validated 'optimal' position and should not be overinterpreted. Specific SMD and CrI for REBT on anxiety were not fully reported in available text. (5) For fatigue, four studies involving 335 participants compared four interventions (WLD, MHP, ELEMLA, PPEO), with PPEO ranking highest; specific SMD and CrI for this outcome were not reported in available text. Comparators that performed poorly included dCBT and ISWM for anxiety reduction, and RSSCI for depression. Inconsistency testing was infeasible for all outcomes due to the absence of closed loops in the star-shaped network; therefore, internal validity of indirect estimates cannot be formally assessed. NNT was not calculable from the reported data. No systematic adverse event data were reported.
Practice implications
This NMA provides preliminary, hypothesis-generating rankings of non-pharmacological interventions for sleep and occupational stress outcomes in nightshift nurses, but several critical limitations must be understood before any clinical application. First, all findings are based entirely on indirect evidence from a star-shaped network with no closed loops; without direct head-to-head comparisons or closed-loop triangulation, the inconsistency assumption—fundamental to NMA validity—cannot be evaluated. The authors themselves explicitly state that findings should be considered 'exploratory and hypothesis-generating' rather than confirmatory evidence. Second, SIP and MTI demonstrated credible intervals excluding zero for the primary outcomes of sleep score and sleep duration, respectively, suggesting these may be the most promising candidates for further investigation; however, effect sizes, while nominally moderate-to-large (SMD 0.80–1.0), are derived from heterogeneous indirect chains and may be inflated. Third, APT (auricular plaster therapy), a traditional Chinese medicine intervention, ranked highest for depression, but the generalizability to non-Chinese healthcare systems and nursing contexts is uncertain. Fourth, the SUCRA value of 100% for REBT on anxiety must not be used as a standalone clinical recommendation; as the authors note, this merely reflects rank probability in a sparse network. Fifth, the population studied is exclusively nurses in shift-work settings, limiting applicability to other healthcare worker populations or the general public. Adequate representation of male nurses, nurses in low-income settings, and those with comorbid psychiatric diagnoses is unclear. Practice should not change based on this evidence alone; confirmation via adequately powered, direct-comparison RCTs is required. __LIMITATIONS__ Star-shaped network with no closed loops: all comparisons are indirect only, and formal inconsistency testing was infeasible for all outcomes—a fundamental and unresolvable methodological constraint in this dataset.,Small total sample (n=1,572 across 18 interventions): individual node sizes are likely very small, leading to imprecise estimates and unstable SUCRA rankings.,Highly heterogeneous intervention pool (18 interventions spanning behavioral, pharmacological-adjacent, light-based, and traditional Chinese medicine approaches) with variable implementation protocols; clinical interpretability of pooled SMDs is limited.,Absence of follow-up duration reporting: durability of any observed effects is unknown.,Risk of bias assessed via ROB2, but aggregate bias ratings and the proportion of high-risk studies are not reported in the available text.,No blinding of participants or personnel is feasible for most behavioral and light-based interventions, introducing performance bias.,Inclusion of CNKI (Chinese-language database) may introduce literature from a predominantly single-country research base, limiting international generalizability.,Secondary outcomes (anxiety, depression, fatigue) were measured by diverse, non-standardized instruments across studies, introducing clinical heterogeneity.,Funding source not reported; potential for publication bias cannot be excluded, and formal publication bias assessment results are not described in available text.,Only the abstract and partial full-text content were available for this summary; additional methodological detail may be present in the full publication. __BOTTOM_LINE_CATEGORY__ promising_but_preliminary __BOTTOM_LINE__ This Bayesian NMA of 18 RCTs in 1,572 nightshift nurses suggests that Sleep Intervention Programs and Mindfulness Training Interventions may be the most promising non-pharmacological approaches for improving sleep outcomes, while Auricular Plaster Therapy and Rational Emotive Behavior Therapy showed top rankings for depression and anxiety, respectively. However, all findings are derived entirely from indirect evidence in a star-shaped network without closed loops, rendering inconsistency testing impossible and all conclusions explicitly exploratory and hypothesis-generating. Clinical adoption of specific interventions based on this study alone is premature; adequately powered, direct head-to-head RCTs are needed before practice-level recommendations can be made.