Interventions to Reduce Stress and Burnout among Teachers: A Scoping Review

Abstract Background: Teaching is recognized as a highly challenging profession. Experience of chronic stress is a risk factor for poor mental and physical well-being, and burnout. There is limited knowledge regarding optimal interventions to address stress and burnout among teachers. Objective: To undertake a scoping review of the literature in the last five years to determine various psychological interventions to address stress and burnout among teachers. Method: The PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews was followed. Relevant search terms were used to determine different interventions adopted to reduce teachers’ stress and burnout. Articles published between 2018 and 2022 were identified using five bibliographic databases. Relevant articles were extracted, reviewed, collated, and thematically analyzed, and findings s were summarized. Results: Forty studies conducted in Asia, North America, Oceania, Europe, and Africa, met the inclusion criteria. Sixteen kinds of burnout and stress-reduction interventions were identified. The most popularly studied intervention were Mindfulness-Based Interventions alone or in combination with yoga or Cognitive Behavioural Therapy (CBT), followed by Rational Emotive Behavioral Therapy (REBT). Mindfulness-Based Interventions led to decreased overall Teacher Stress Inventory (TSI) and emotional exhaustion subscale scores. REBT, primarily used with special education teachers, especially in Africa, has also shown positive results. Other interventions reporting positive outcomes include Inquiry-Based Stress Reduction (IBSR), the Stress Management and Resiliency Training Program (SMART), Cyclic Meditation, Group Sandplay, Progressive Muscle Relaxation, Autogenic Training, Sport-Based Physical Activity, Emotional Intelligence Ability Models and Christian Prayer and Prayer-Reflection. Conclusions: Stress and burnout can have a negative impact on teachers and, very often, on the students they teach. Implementing suitable school-based interventions is necessary to improve teachers’ stress-coping ability, reduce the likelihood of burnout and improve general well-being. Policymakers, governments, school boards and administrators should prioritize the implementation of school-based awareness and intervention programs.


Introduction
Stress has been defined as a state of mental or emotional strain due to adverse or challenging circumstances [1]. Teaching is recognized as a high-pressure, stressful profession across the world. The term "teacher stress" was first defined by Kyriacou and Sutcliffe (1978) and refers to the experience of "negative affect (such as anger or depression) by a teacher usually accompanied by potentially pathogenic physical or biological and biochemical changes . . . resulting from parts of the teacher's job 'mediated by the perception that' demands made upon the teacher constitute a threat to his self-esteem or well-being and by coping mechanisms activated to reduce the perceived threat" [2]. scoping reviews [19], including developing the research question, searching for relevant studies, selecting articles, data charting and data extraction and collating, summarizing and reporting the results.

Identifying Relevant Studies
A systematic literature search of several electronic bibliographic databases, including the following databases: CINAHL (Cumulative Index of Nursing and Allied Health Literature) Plus with Full Text (EBSCOhost interface), PubMed (Public/Publisher MEDLINE (NLM journal articles database), APA PsycINFO (Ovid interface), MEDLINE (Medical Literature Analysis and Retrieval System Online), and Scopus Elsevier was conducted using relevant terms to identify and select articles. The search consisted of keywords representing the concepts of interventions to mitigate stress and burnout among teachers. The specific MeSH terms, keywords and descriptors included (teacher* or "school teachers" or educators or "school staff" or tutor* or schoolteacher or teach*) AND (stress or "mental exhaustion" or "psychological stress" or "emotional exhaustion" or burnout or "burn out" OR burnout) AND ("intervention*" OR therapy OR management OR treatment OR intervention OR interventions or strategies or techniques or management OR "psychological treatment" OR "teachers stress management technique" or "teacher burnout management techniques" OR "teacher stress intervention" OR "teachers burnout interventions"). Publication year restrictions were applied (2018 to 2022) to ensure only current interventions are captured. This scoping review builds on previous reviews of the literature, for instance, by Von der Embase et al., 2019 and Hagermoser et al., 2021 [13,14], extending understanding of this growing area of literature.

Articles Selection
Two researchers independently reviewed the citations during the title, abstract screening, and full-text review phase based on specific eligibility criteria. All discrepancies were resolved through discussion and consensus. Articles were eligible for inclusion only if they discussed interventions to reduce burnout or stress among classroom, special education, primary, elementary, middle, and secondary school teachers and educators. Meta-analyses, systematic reviews, case reports, opinion pieces, commentaries, editorials, or grey literature such as non-peer-reviewed graduate student theses, non-research articles or conference reports were excluded. Articles were limited to original, peer-reviewed articles written in English. Articles were excluded from the review if the study focused only on correlates of or prevalence of stress and burnout. Articles were also excluded if study participants included preschool teachers or tertiary educators working in vocational, adult or community continuing education settings, university teachers, students, or a combination of teachers and students.
We identified 63 articles for full-text review but excluded 25 articles that did not meet the inclusion criteria on closer examination. A review of the reference list from other studies was also explored and yielded two additional eligible articles, which were included in this scoping review. The PRISMA flow diagram presented in Figure 1 gives comprehensive details of this information.

Data Charting and Extraction
The research team extracted the following information from each selected article according to the following domains: author(s) name, year of publication, country of study, study design, intervention (focus and content), study procedures, participants; sample size (N), participant age range, assessment measures used, and key findings.

Collating, Summarizing, and Reporting the Results
This scoping review summarizes recent evidence regarding interventions that have been used to reduce stress and burnout among teachers. All the relevant data were organized into tables and validated by at least two team members. The characteristics and results reported in each included article were summarized.

Results
The database search was completed on 10 December 2022 and included results from 2018 to 2022. A total of 9086 records were identified through the database searches. Five hundred sixty-eight (568) duplicate records were identified and removed automatically when imported into the systematic review management software, Covidence [20]. The characteristics of the 40 articles in this scoping review are presented in Table 1. Most of the studies (n = 20, 50.0%) were non-randomized controlled trials (Non RCTs), Sixteen studies (n = 16, 40.0%) were simple RCT or RCT waitlist or group-randomized waitlist control (WLC) trials, and the remaining four were (n = 4, 10.0%) cluster RCT's. The 40 articles included a total of 4344 participants. The sample size for the individual articles ranged from 24 to 672 participants, with an age range from 21 to 70 years. Most studies (77.0%) were published between 2020 and 2022, and most of the studies were conducted in Asia (30.0%), followed by Europe (25.0%), then Africa (22.0%) and North America (15.0%), and Oceania (8.0%) as shown in Figure 2.   The remaining other studies, including Nwabuko 2020, Chesak 2019, Chirico 2020 and Song 2020, have no connections by citation with any other study included in the scoping review. Most of the visually highly connected studies were conducted in Africa with a sample of teachers who teach special needs students.

Scales Used to Measure Stress and Burnout
The Perceived Stress Scale (PSS-10) was used to assess stress in 16 articles; the Depression, Anxiety and Stress Scales (DASS-21) in six articles; the Teacher Stress Inventory (TSI) in six articles; the Single Item Stress Questionnaire (SISQ) in four articles; the Perceived Occupational Stress Scale in 2 articles; the Teacher stress questionnaire (TSQ), in one article; and the Coping Style Questionnaire and the Teacher Stress Question were used in one article each.  Burnout was assessed using the Maslach Burnout Inventory-(both the "Educators Survey" (MBI-ES) and the "General Survey" (MBI-GS) versions) in 18 articles, the Shirom-Melamed Burnout Measure (SMBM) in two articles, and the Copenhagen Burnout Inventory (CBI), Spanish Burnout Inventory and the Teacher Burnout inventory (TBI), in one article each.

Interventions to Reduce Stress and Burnout among Teachers
This scoping review identified several interventions (summarized in Tables 1-3) that have been adopted to alleviate teachers' stress and burnout. Participants were randomly assigned to the online IG or CG. Self-report scales collect pre-, and post-intervention information. CMT-T group: significant decrease in burnout from T1 to T2. WLC participants who received CMT-T showed decreases in burnout and stress. Burnout (p = 0.036) All differences reflected large effect sizes. Teachers were randomly assigned to either the IG (n =12) or WLC (n =12) group and received the intervention respectively (January to June) and the Fall (August to November) semester of 2018.).

High school teachers n = 24
Age range 25 to 70 Mean age = 42.8

Mindfulness and Mindfulness-Based with CBT or Yoga Interventions
Mindfulness is the most popularly utilized intervention studied to reduce stress and burnout among teachers, and most studies reported high efficacy [25,27,29,38], with a significant decrease in Teacher Stress Inventory (TSI) scores and emotional exhaustion subscale. However, one study reported no change in the depersonalization subscale of burnout [27]. Most mindfulness-based interventions are time intensive; Mindfulness-Based Stress Reduction (MBSR), for example, includes eight weekly 2.5 h sessions and a 7 h or full day retreat [24,32], and Compassionate Mind Training (CMT) program extends for 12 weeks [34]. Yoga-based practices for teachers complement some mindfulness-based interventions, with reported lower levels of perceived stress [32].
CBT-based interventions resulted in statistically significant improvements in perceived stress [31] and MBI-ES subscales for emotional exhaustion and depersonalization [30,31] and personal accomplishment [30]. Yoga in combination with CBT (Y-CBT) involved sessions of physical/posture exercises and meditation practices associated with reductions in perceived stress and burnout [22,28].

Rational Emotive Occupational Health Coaching (REOHC)
Rational Emotive Occupational Health Coaching (REOHC), though similar to CBT, focuses on rational thinking and positive regard for the self. It involves a 12-week of 2 h weekly stress management program and has been employed mostly among teachers of children with special needs, including children with autism [46,48,49]. REOHC significantly decreased job burnout and emotional exhaustion among special needs teachers [46,48,49].

Inquiry-Based Stress Reduction (IBSR) Intervention
This intervention is a cognitive-reframing program and includes 3.5 h weekly group meetings and weekly individual sessions with a facilitator (1 h/session) for 12 weeks [57]. The outcome of one study indicated that teachers in the intervention group showed greater improvements in emotional exhaustion (p = 0.01) and personal accomplishment (p = 0.04) compared to controls [57]. This contradicts the outcome reported by Zadok-Gurman et al., which suggested no difference in personal accomplishment scales between the intervention and control groups [60].

Other Interventions
Other interventions to decrease teachers' stress and burnout include the A+ intervention [56], sports-based physical activity program [55], the ability model of the emotional intelligence training program [54], progressive muscle relaxation with music and aromatherapy [53], Christian prayer and prayer reflection [52], Stress Management and Resiliency Training Program; SMART [51], group sandplay [58], and Autogenic training [59].
The A+ intervention had reported positive impacts on emotional well-being, occupational stress and emotional exhaustion symptoms in one study [56]. The sports-based physical activity program [55] comprises seven weeks of training in catchall, a team sport and a tournament as the culminating event. Qualitative results suggested this program helped decrease teachers' stress levels. However, quantitative results indicated no significant pre-post main effect on the Perceived Stress Scale (PSS-10) scores. The ability model of emotional intelligence [54] training program consisted of five two hours sessions for three months. The effect size was moderate to high, but the differences at Time 2 were only partially maintained at Time 3, and multivariate tests indicated only marginal significance for burnout (p = 0.06). In addition, no significant differences were found for emotional symptoms (p = 0.31). However, the intervention group experienced reduced levels of work-related stress and emotional symptoms compared to the control group. Progressive muscle relaxation with music and aromatherapy [53] included four 20 min therapy sessions over four days. Participants in the intervention group reported a significant reduction in the Teacher Stress Inventory, compared to no change in the control group. The Christian prayer and prayer reflection [52] involved two 30 min training sessions a week over two months. This intervention is a combination of individual Christian prayer and a focus group of prayer reflection. Teachers who received this intervention reported significant improvement in emotional exhaustion (p < 0.001) and depersonalization (p < 0.001) levels. SMART [51] program consists of an initial 90-min introductory session, followed by 12 online, selfpaced modules, which participants complete at their convenience and desired pace. Weekly emails were also sent to the participants during weeks 8 to 52 of the study. In addition, eight one-hour teleconferences were provided at regular intervals. This program was associated with significantly lower stress at each follow-up survey (2, 6, and 12 months) compared to baseline (p = 0.003). Group sandplay [58] engaged participants in group sandplay activities where they were given opportunities to create scenes and themes. These are then analyzed, and problems regarding work-related stress scenarios are solved while receiving social support from the other group members. This study reported significant improvement in the experimental sandplay group, with a shift from passive coping pre-test to active coping post-test, suggesting that group sandplay improved overall stress-coping abilities. The final intervention showing a reduction in work-related stressors (p = 0.05) was Autogenic training [59]. This relaxation training technique involves six progressive steps practiced for 15-20 min while concentrating on breathing and relaxing the muscles.

Discussion
Stress and burnout among teachers can negatively impact their capacity to perform job functions, productivity and their ability to build positive relationships related to their role [8,61]. This is an important global problem, given the connection between stress and burnout and the subsequent development of anxiety and depression among teachers, as highlighted in a recent scoping review [8]. Thus, interventions designed to reduce stress response, burnout, associated negative beliefs and other aspects of functioning may be essential to reducing teachers' anxiety and depression. Identifying effective interventions for addressing stress and burnout among teachers is a vital initial step in dealing with this global problem. This scoping review identified 40 studies examining interventions to reduce or mitigate teachers' stress and burnout. Moreover, effective coping, which may be improved during such programs, is an instrumental skill set that ultimately benefits the teachers' role [62]. Although most interventions intended to reduce teachers' stress and burnout have had limited success [9], this scoping review found that some interventions can potentially address stress and burnout among teachers.
Mindfulness is an attribute of consciousness and can play a critical role in promoting the psychological well-being of teachers [63,64]. Mindfulness has been used across several fields of health to prevent or reduce stress and burnout symptoms [65]. In addition, mindfulness in teachers has been reported to show a negative association with negative emotional states such as burnout (emotional exhaustion) [63]. In clinical practice, mindfulness-based interventions have been found efficacious for depression and anxiety and placed in the same category as CBT [66,67]. Mindfulness-based interventions have also shown small-to-medium positive effects on therapeutic processes and therapeutic out-comes [9] and had a medium treatment effect on teacher outcomes and an inverse relation with teachers' psychological distress [9,63]. In other professionals, such as nurses, mindfulness meditation has also decreased stress and burnout [68,69]. Most mindfulness-based interventions require time to practice and learn [24,32,34]. Teachers already experience high levels of stress associated with intense job demands even when working conditions are optimal [70], which may make these interventions challenging to access, especially during the school term. Researchers have proposed a 4-day intensive mindfulness training program [38], which may have higher acceptance and feasibility than the standard 8-week training program. A program with a shorter duration may improve engagement, and hence teachers may benefit from participating. This may be a promising way to decrease teachers' stress and improve their emotional health.
There were very few online or computerized interventions. Online interventions may be more accessible and flexible for teachers who already have busy schedules, improving feasibility. In addition, this may improve access and address the needs of those in remote areas [71]. For instance, the SMART intervention [51] was an online-based program that eliminated the face-to-face nature of other interventions and positively impacted teacher stress and burnout [32]. SMART intervention [72] has also been employed among nurses resulting in statistically significant decreases in stress and burnout and increases in resilience. However, SMART consists of 12 modules, requiring significant time to complete [51,72].
CBT is based on the theory that dysfunctional thoughts and beliefs are the main drivers of distress and that thoughts, behaviors, and emotions all impact each other. CBT has been adopted in several healthcare sectors [73], with proven benefits for various psychiatric disorders, including depression, anxiety, and personality disorders [74]. For instance, a group-based CBT program [30] reported significantly greater improvements, compared to the control condition, on the total burnout subscales scores (emotional exhaustion, depersonalization, and reduced personal accomplishment) at post-treatment, with treatment effects maintained at 6-month follow-up. REBT, similar to CBT, has also demonstrated positive impacts on stress and burnout, among special educators [46][47][48] and in the health sector, in addition to reducing depression in adults with congenital heart disease [75].
In contrast, yoga is a complementary mind-body intervention with a limited focus on cognition and yet has also been found helpful in reducing psychosomatic challenges such as stress and burnout in the clinical sample [76]. Interestingly, the combination of yoga-based CBT interventions among teachers [22,28] has been reported to be effective in reducing stress and burnout, perhaps by combining benefits derived from both cognitive and bodybased foci. Nonetheless, this intervention is also time-consuming, involving two hours weekly program for 12 weeks, which may create excess time demands, contributing to additional stress. Stress is presumed to occur when a person perceives an external demand as exceeding their capability [77]. Thus, teachers, when work or time demand exceeds their capability, then they may be stressed. Therefore, future research should therefore focus on teachers teaching different groups of students with different abilities, socioeconomic backgrounds and special needs to address the research gaps arising from differences in the effects of interventions to mitigate stress and burnout. Furthermore, some interventions involving physical activities [22,55] may be inaccessible to individual teachers with mobility or morbidity issues.
Christian prayer and prayer-reflection interventions [52] are novel and have rarely been used as a management strategy for stress or burnout in other professions. However, exploring the spirituality of physicians through a survey, respondents indicated barriers to time and training [78]. Christian prayer and prayer-reflection intervention [52] seemed to have a significant positive effect on depersonalization, unlike brief mindfulness-based interventions [12], which showed no significant effects for either the depersonalization subscale or the personal accomplishment subscale. However, not all teachers may be willing to access this intervention due to its faith-based nature. Depersonalization or cynicism is the interpersonal dimension of burnout and is associated with the negative, callous, or excessively detached response to other people [79]. Prayer/spiritual intervention may relieve teachers of the subscale depersonalization by helping them to focus on something larger than themselves and address some of the beliefs or narratives that might contribute to depersonalization. This speculation remains to be tested empirically.
Unlike Christian prayer and prayer-reflection [52], Blended Inquiry-Based Stress Reduction (IBSR) technique does not require any religious or spiritual preparation or intellectual ability but rather one's desire to deepen self-awareness [60,80]. Compared to other interventions [34,55,58], IBSR does not require a trained facilitator. IBSR [60] resulted in no change in the personal accomplishment scales in the intervention group compared to an increase in the control group. However, a contradictory report was found in another study [57], which reported improvements in emotional exhaustion and personal accomplishment. IBSR intervention also includes weekly group meetings (3.5 h per meeting) requiring teachers to set time aside. This contradiction indicates that more advanced research with a representative sample is needed to validate the impact of IBSR.
Another unique intervention is group sandplay [58], which has not been extensively researched among educators or other professionals. Sandplay has, however, been adopted among college students to improve their interpersonal sensitivity level, which was reported to be significantly lower than that before the intervention (p < 0.01) [81]. This intervention helped teachers' overall stress-coping abilities by shifting from passive to active coping [58]. However, there was no direct measurement of changes in stress or burnout levels among the teachers and therefore, the results need to be further consolidated in future research. Furthermore, the dynamics and mechanisms employed in this intervention have yet to be extensively investigated among teachers; hence future research may further explore this gap.

Implications for Policy and Practice and Future Research Directions
First, the scales used to measure stress and burnout scores in the various studies identified through this scoping review differed. However, the Perceived Stress Scale-10 and Maslach Burnout Inventory-Educator Survey (MBI-ES) were the most commonly used. The use of different scales makes an effective comparison of the efficacy of all the interventions difficult. Future systematic reviews and meta-analyses can target studies in which only specific valid and reliable scales were used for uniformity and accuracy when reporting and comparing the impact of these interventions on teacher stress and burnout.
Second, most of the interventions identified through this scoping review, although effective in mitigating teacher stress and burnout, require a considerable amount of time to complete, and this presents a barrier, as there is demand for teachers' time is already significant. Considering the busy school environment and the issue of time for most of these interventions, alternative interventions, such as mobile text-based programs to reduce stress and burnout in teachers, can be explored. Mobile text technology is an evidencebased, innovative, convenient, easily accessible, low-cost, and scalable intervention. It has been adopted as a means of delivering psychological treatments and support for the public and patients [71,[82][83][84][85]. Such innovations can easily be implemented at the school level to support teachers' psychological needs. For example, the Wellness4Teachers program, currently being evaluated in Canada, is a CBT-based supportive messaging program that delivers daily text messages and mental health literacy information to teachers [85]. If found effective, this intervention can potentially reduce the time demand and the need for face-to-face interventions [55,58]. The outcomes of the Wellness4Teachers program evaluation will have implications for the support available to teachers to reduce their stress and burnout and improve their general well-being.
Third, this scoping review summarizes currently available interventions to address teacher stress and burnout. Although most identified interventions reported positive outcomes, the methodological quality of intervention studies has yet to be explored. Therefore, a meta-analysis or systematic review of these interventions is warranted to determine the levels of evidence of the intervention's effectiveness.
Fourth, burnout has been described as an occupational illness, yet none of the interventions primarily focuses on causes such as overwork, lack of systemic support, work modifications, or specific work skills development. Future studies regarding interventions that prioritize and incorporate some of these parameters are needed.
Five, recently, Acceptance and Commitment Therapy (ACT), a 'third wave' more cognitive therapy updated version of CBT) has also been applied as an intervention for stress-related illnesses such as anxiety and depression [86]. Burnout has usually been linked with personal values related to cynicism [87]. Thus, ACT may be a better therapy than CBT or REBT, as it includes mindfulness and cognitive strategies and focuses on self-concept, values, psychological flexibility, and committed action to make a positive change, such as coping through efficacy.
Finally, given the physical stress responses inherent in burnout and the effectiveness of Progressive muscle relaxation (PMR) and autogenic training, it would be beneficial in the future to investigate other interventions that directly target the stress response, including activating the parasympathetic nervous system.

Limitations
The scoping review has some limitations. First, the search strategy was limited by the year of publication which may have excluded other potentially effective interventions. Second, only English language databases were searched; thus, some relevant studies in other languages may have been left out, impacting the interpretation of the findings. Third, the overall search strategy may have been biased towards health and sciences databases, and searching other bibliographic databases may have generated additional relevant studies. Five, the sample size for most of the individual studies included in this scoping review was small. Finally, two of the included studies, Okeke et al. 2021 [47] and Obiweluozo et al. 2021 [45] were published in the same year, utilizing the exact same study sample, sample size, study setting and intervention. The two studies also had the same study objectives, methods, flow chart and results, even though they had different authors and were published in different journals. Despite the similarities between the two manuscripts, the different authors made it impossible to determine which of the two manuscripts to exclude from the review. Notwithstanding these limitations, this scoping review offers good insight into the interventions used to reduce stress and burnout among teachers.

Conclusions
Stress and burnout in the teaching profession are widespread, and intervention to reduce these problems warrants attention both at the level of policy and practice. This review summarizes and discusses interventions that have been used to mitigate educator stress and burnout. This summary of the evidence may help inform health and education leaders to develop policies and adopt programs that are effective in addressing teacher stress and burnout. The review identified several effective interventions to address stress and burnout, although there are some shortfalls, especially regarding time constraints. Due to teachers' busy schedules, time-consuming interventions may be challenging to undertake or may even add to teachers' stress. Notwithstanding, schools need to promote and prioritize some of these interventions specifically designed to reduce teachers' stress and burnout. Implementing suitable school-based interventions at all schools is appropriate and necessary to improve teachers' stress-coping ability with the expectation that this will prevent or reduce the likelihood of burnout. Future studies need to investigate the effectiveness of teacher stress and burnout reduction programs that do not have time constraints and that are cost-effective, geographic location independent and easily scalable, such as the Wellness4Teachers program in Canada. The virtual nature of such programs may offset the need for teachers' physical presence at a particular set time. Despite both the methodological differences and variations in the interventions used in the studies included in this scoping review, each of the interventions was found to reduce educator stress and burnout. These methodological differences and the quality of the included studies make it impossible to draw conclusions about which interventions are most effective in supporting educators' mental health based on this scoping review.
Researchers need to work in partnership with governments, policymakers and school boards in the design, co-creation, implementation, monitoring and evaluation of teacher wellness initiatives to ensure their adoption. Funding: This study was supported by the Mental Health Foundation and the Douglas Harden Trust Fund. The funder had no role in the design and conduct of the study; collection, management, analysis, data interpretation; preparation, review, or approval of the manuscript; or the submission of the results for publication.