Digital Repository Doctoral Projects Fall 2022 Decreasing Public Nurse Burnout Through Mobile Technology Kaitlin M. Bird Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Bird, K. M. (2022). Decreasing Public Nurse Burnout Through Mobile Technology. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. DECREASING PUBLIC HEALTH NURSE BURNOUT 1 Decreasing Public Nurse Burnout Through Mobile Technology by Kaitlin M. Bird A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah October 3, 2022 _______________________________ ______________________________ Kaitlin M. Bird, DNP-FNP, RN Date _______________________________ _____________________________ Kristy A. Baron, PhD, RN Date Faculty Lead _______________________________ ______________________________ Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Date Graduate Programs Director Kristy A. Baron December 16, 2022 December 16, 2022 December 16, 2022 DECREASING PUBLIC HEALTH NURSE BURNOUT 2 Table of Contents Abstract ........................................................................................................................................... 4 Decreasing Public Health Nurse Burnout Through Mobile Technology........................................ 5 Background and Problem Statement ................................................................................................ 5 Diversity of Population and Project Site .......................................................................................... 7 Significance for Practice Reflective of Role-Specific Leadership ...................................................... 7 Literature Review and Framework ................................................................................................. 8 Search Methods ............................................................................................................................. 9 Synthesis of Literature ................................................................................................................... 9 Causes of Burnout .................................................................................................................... 10 Physical and Psychological Consequences of Burnout ................................................................ 12 Interventions for Burnout Reduction .......................................................................................... 13 Framework .................................................................................................................................. 15 Discussion ................................................................................................................................... 17 Implications for Practice ............................................................................................................... 18 Project Plan ................................................................................................................................... 19 Project Design ............................................................................................................................. 19 Needs Assessment of Project Site and Population........................................................................... 19 Cost Analysis and Sustainability of Project .................................................................................... 20 Project Outcomes ......................................................................................................................... 21 Consent Procedures and Ethical Considerations ............................................................................. 21 Instruments to Measure Intervention Effectiveness ......................................................................... 22 Project Implementation ................................................................................................................. 22 Project Intervention ...................................................................................................................... 23 Project Timeline .......................................................................................................................... 25 Project Evaluation ......................................................................................................................... 26 Data Maintenance/Security ........................................................................................................... 26 Data Collection and Analysis ........................................................................................................ 26 Findings ...................................................................................................................................... 27 Table 1 ........................................................................................................................................ 27 Table 2 ........................................................................................................................................ 28 Strengths ................................................................................................................................. 30 DECREASING PUBLIC HEALTH NURSE BURNOUT 3 Weaknesses ............................................................................................................................. 31 Quality Improvement Discussion ................................................................................................. 31 Translation of Evidence Into Practice ............................................................................................ 32 Implications for Practice and Future Scholarship ............................................................................ 33 Sustainability ........................................................................................................................... 34 Dissemination .......................................................................................................................... 34 Conclusion .................................................................................................................................. 34 References ..................................................................................................................................... 36 DECREASING PUBLIC HEALTH NURSE BURNOUT 4 Abstract Purpose: The project’s focus was to educate rural public health nurses in Uinta County, Evanston, Wyoming, on skills to reduce healthcare-associated burnout by learning stress management skills. The project involved implementing an evidence-based stress management mobile device app by Fifth Windows, Inc. Methodology: A pre- and post-survey were used to assess the effectiveness of the stress management app. These surveys included the Oldenburg Burnout Inventory and Perceived Stress Scale. The Oldenburg Burnout Inventory identified burnout presence and severity among participants. The Perceived Stress Scale established stress levels before and after the intervention. A follow-up survey was administered to determine the effectiveness of the Fifth Window, Inc. app. Data were analyzed through the Qualtrics surveying program. Results: Thirteen nurses participated in this study, with seven nurses completing the post-survey. Data showed that the evidence-based mobile stress management app demonstrated a self-report improvement of stress levels by participants. Implications for practice: Utilizing mobile device technology has become an ideal model for learning stress-management skills remotely due to the COVID-19 pandemic. Project findings promote the continued use of an evidence-based mobile app to learn these skills. Having sufficient stress management skills can increase coping abilities for the job demands related to nursing, thus preventing burnout. Keywords: healthcare worker, burnout, stress management, intervention DECREASING PUBLIC HEALTH NURSE BURNOUT 5 Decreasing Public Health Nurse Burnout Through Mobile Technology Healthcare provider burnout has become a significant problem in the United States, and nurses are especially at high risk. Nurses are leaving the workforce at an increasing rate, which furthers the threat of job burnout in the remaining nurses resulting from staffing reduction, longer shifts, and insufficient resources (Holman et al., 2018; Reith, 2018; Shah et al., 2021). The National Academies of Sciences, Engineering, and Medicine report Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being (2019) reiterates the importance of organizations valuing their clinical staff to increase the overall population's health. Delivering safe, high-quality, patient-centered care is impossible without a strong workforce. A weak workforce affects the public's health since public health nurses cannot provide community services without functioning at high levels. The primary purpose of this project is to recommend, implement, and evaluate evidence-based interventions via a mobile device application to teach public health nurses stress management skills and reduce the effects of job burnout on nurses working in rural communities. In Evanston, Wyoming, the Uinta County Public Health Department nurses work in a meso- and microsystem environment. These systems include clinical programs and supportive services where clients and families regularly access these resources. The project focuses on public health nurses and the stress they experience in their job roles as they work closely with patients and their needs. Background and Problem Statement Symptoms of anxiety, depression, and significant stress negatively impact thousands of lives in the United States, especially from the recent global pandemic caused by the SARS-CoV-2 virus (Bradley & Chahar, 2020; Czeisler et al., 2020). Negative stress, both acute and chronic, DECREASING PUBLIC HEALTH NURSE BURNOUT 6 contribute to poor health. Heightened stress compromises physical, mental, and emotional well-being as the feeling of strain or tension from being unable to meet demands on a personal or social level occurs (The American Institute of Stress, n.d.). Furthermore, occupational stressors add to poor health outcomes and reduce job performance (Holman et al., 2018; Ryan et al., 2017). Occupational stressors consist of environmental stimuli that decrease performance, such as poor working conditions, inadequate resources, and strained interpersonal relationships at the workplace. These unresolved issues prevent healthcare providers from performing at a high capacity and providing excellent patient care. The phenomenon of healthcare-associated burnout is not entirely understood, yet healthcare providers feel its ramifications. In 2020, the Medscape National Physician Burnout and Suicide report surveyed over 15,000 physicians nationwide and determined that the burnout rate is 43% among physicians. Additionally, 31.5% of nurses who left their jobs in 2018 cited job burnout as the reason (Shah et al., 2021). The inability to cope or handle high-stress levels contributes to burnout among healthcare workers. Job burnout is a term associated with those in "helping" professions (such as medicine, education, and other service lines) who experience extreme stress and high expectations in their roles (Institute for Quality and Efficiency in Health Care [IQEHC], 2020; World Health Organization, 2019). Burnout is different from depression, anxiety, and chronic fatigue syndrome, but experiencing burnout long-term can lead to these mental health-associated disease states (IQEHC, 2020; Maslach & Leiter, 2016). Therefore, reducing stress and increasing well-being is a public health promotion goal for all healthcare workers to prevent burnout's harmful effects (Holman et al., 2018; Ryan et al., 2017). Public health nurses are the healthcare workers who provide essential resources for community DECREASING PUBLIC HEALTH NURSE BURNOUT 7 members. Without these nurses, resources and access to services are decreased for thousands of people. Diversity of Population and Project Site The Uinta County Health Department is in rural Evanston, Wyoming. According to Uinta County statistics (2021), 20 public health workers are employed by the Health Department, which serves 20,000 people over 2,088 square miles (approximately twice the size of Rhode Island, for comparison). Most of the residents within this community are Caucasian, have a high school diploma, are aged 50 or older, and are blue-collar workers in the nearby mines. The public health nurses are Caucasian females, have an associate degree, an average of 45 years or older, and have six or more years of working experience. These public health nurses are aware of the needs of the people who reside within the area and are therefore suitable to provide appropriate health-related education and services. The responsibility of public health nurses is vast, ranging from being able to deal more effectively with workplace stressors to improving resources within this community. Implementing a stress reduction program via mobile device technology to assist public health nurses with decreasing levels of burnout may benefit all people within Uinta County, Wyoming. Significance for Practice Reflective of Role-Specific Leadership The American Association of Colleges of Nursing (AACN) updated its expectations for nurses in the new publication The Essentials: Core Competencies for Professional Nursing Education to identify domains and sub-competencies that all advanced practice registered nurses (APRN) must meet. The Doctorate of Nursing Practice (DNP) prepared APRN fulfills Domain 3: Population Health by "assessing the efficacy of a system's capability to serve a target sub-population's healthcare needs" (AACN, 2021, 3.1j, p. 33). Explicitly focusing on public health DECREASING PUBLIC HEALTH NURSE BURNOUT 8 nurses increases the efficacy of the healthcare system within this rural population by aiding nurses to experience less burnout and have increased job satisfaction and performance. Additionally, Domain 10: Personal, Professional, and Leadership Development is achieved by contributing "to an environment that promotes self-care, personal health, and well-being" (AACN, 2021, 10.1c, p. 59). Facilitating improved health and wellness for public health nurses also improves the outcomes for the entire community. Overall, interventions to promote better health within the population are implemented based on current evidence and the APRN's guidance. The selected interventions are frequently updated to reflect the pertinent needs within the healthcare system. Occupational health, specifically for public health nurses, is a concern that requires immediate attention. For APRNs to facilitate other nurses to achieve excellence, nurses must be advocated for by APRNs (AACN, 2021). If burnout goes without correction, healthcare professionals are more likely to have job dissatisfaction, pursue other career fields, and have decreased physical and mental health (Holman et al., 2018). Implementing evidence-based stress management interventions has been proven to reduce stress and improve work performance in nurses (Domes et al., 2019; Fiol-DeRoque, 2021; Hersch et al., 2016). Utilizing technology to incorporate a mobile device application into these public health nurses' daily routines can reduce stress levels and prevent burnout, ultimately improving health outcomes for the entire rural population. Literature Review and Framework This review analyzes the literature concerning healthcare worker burnout and its effects on nurses' health and ability to provide quality patient care. The adverse outcomes of burnout are apparent and affect more than the individual. Reducing burnout is essential for the well-being of DECREASING PUBLIC HEALTH NURSE BURNOUT 9 everyone, either directly or indirectly; consequently, evidence-based stress management interventions are explored to address healthcare-related burnout. Search Methods A database and web search engine (Academic Search Ultimate and Google Scholar) were searched from January 2016 to July 2021. The keywords used for the search were "burnout" OR "stress" AND "nurses," "stress management" AND "nursing," and "burnout intervention." The total academic journal search results were 5,722. The results were further refined by limiting the geography to the United States, which led to 119 results. The articles were selected to meet the inclusion criteria. All articles were published in English, contained the complete text, and reflected peer-reviewed. Moreover, exclusion criteria were studies published before 2015 and involved nursing students, nonmedical providers, hospice or palliative care settings, and non-English articles. Synthesis of Literature Although there are different conceptualizations of burnout, this phenomenon is becoming more widespread in healthcare organizations and among employees. Healthcare workers, specifically nurses, have experienced moderate to high levels of burnout within the last 12 months due to the COVID-19 pandemic (Fiol-DeRoque et al., 2021; Kelly et al., 2021; Shah et al., 2021). Organizations and employees are both negatively impacted by job burnout. According to Maslach, a highly regarded social psychologist, the psychological effects of working in the service industry can be draining. In the 1980s, Maslach observed people from various industries experiencing emotional fatigue and feeling low-spirited while performing their job duties. As Maslach and associate Jackson initially defined, burnout is a "syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment, that can occur among individuals who DECREASING PUBLIC HEALTH NURSE BURNOUT 10 work with people in some capacity" (1984, p. 134). Understanding the nature of healthcare-associated burnout is essential for preventing the distressing effects from lasting, such as understaffed organizations with remaining employees feeling overburdened to compensate, concluding in patients being underserved. Causes of Burnout The propensity to develop job burnout is related primarily to work factors and secondarily to personality characteristics. Maintaining a healthy work-life and personal life is possible when effective stress management skills are developed and utilized. Job insecurity and conflicting professional and personal roles result in a poor work-life balance. These contribute to occupational stressors and associated burnout (Ryan et al., 2017). Work and personality characteristics are interconnected; either cause cannot be disregarded. Therefore, a proper work-life balance is necessary to prevent job burnout from developing, thus affecting the worker's personal characteristics. Work risk factors consist of insufficient resources, less workforce, and few incentives and appreciation from management (Biggs et al., 2014; Dyrbye et al., 2019). Scarce resources such as budget restrictions or limited supplies add to the frustrations of job performance. Budget restrictions may also decrease the number of employees that can be hired, leading to fewer employees to do the remaining work adding to the existing stress. Finally, management that does not consistently recognize and value employees contributes to feelings of mistrust against the organization (Ozgur & Tektas, 2018), further contributing to the potential for burnout to develop in the workplace. Feeling overwhelmed with emotional exhaustion, being cynical regarding the work environment, and feeling unsuccessful are the classic components of burnout (Biggs et al., 2014; DECREASING PUBLIC HEALTH NURSE BURNOUT 11 Dyrbye et al., 2019; Hersch et al., 2016; Maslach & Leiter, 2016). Professions that revolve around helping others can become emotionally draining and exhaustive if the accumulated stress from these interactions is not dealt with effectively. Personal traits, such as neuroticism, perfectionism, and obsessive tendencies, can predispose an individual to burnout during stressful working conditions (Maslach & Leiter, 2016). Having these personality traits does not necessitate burnout will be induced in those who work under heightened stress. However, workers who do not have positive stress management skills are prone to developing chronic stress (Holman et al., 2018). Burnout is less likely if the individual has proper coping mechanisms and a positive outlook. In a literature review of 34 articles, Ryan et al. (2017) succinctly determined factors that reflect poor work-life balance, contributing to occupational stressors and associated burnout. These factors included experiencing the pressure of job security, conflicting goals, decreasing staff, and lacking time and resources. In addition to not feeling supported in the workplace, another factor that can cause further stress and burnout is not trusting the employer or organization. Ozgur and Tektas (2018) surveyed 155 nurses at a university hospital concerning their levels of burnout and trust in the hospital. They used the Organizational Trust Scale and the Maslach Burnout Inventory scale as the basis of their questionnaire. The aim was to determine a negative relationship between burnout and a staff nurse's trust in their organization. Results indicated a predictive value to the trust in the organization's administrators and the degree of burnout experienced by nurses. By improving the trust between the organization's administrators and the nurses, burnout may be decreased or overcome, enhancing job fulfillment. DECREASING PUBLIC HEALTH NURSE BURNOUT 12 Physical and Psychological Consequences of Burnout Stress has many adverse effects. The literature documented physical and psychological consequences related to burnout. Burnout leads to morbidities such as hypercholesterolemia, type 2 diabetes, coronary heart disease, musculoskeletal pain, alterations in pain, fatigue, headaches, gastrointestinal problems, and respiratory disorders as the body is compromised from insufficient care and chronic levels of increased stress (The American Institute of Stress, n.d.). Severe injuries and increased mortality below the age of 45 are associated with burnout. Job burnout left uncorrected can lead to death due to poor health and increased levels of stress (Salvagioni et al., 2017), which is considered the ultimate negative outcome of burnout on healthcare workers. In a randomized control trial (RCT) of 80 participants conducted by Domes et al. (2019), researchers determined the effects of stress on the cardiovascular and endocrine systems of a group of participants when exposed to psychosocial stressors. Participants were assigned to an internet-based stress management intervention group, an internet-based progressive muscle relaxation group, or the control. Subjective reports of stress, as well as endocrine and cardiovascular responses, were compared. Both intervention groups reported feeling decreased stress in everyday life. However, the internet-based stress management program yielded the lowest cortisol levels after six weeks. The control group had significantly higher cortisol levels in their blood in comparison. Consistently elevated cortisol levels can negatively affect the endocrine system leading to eventual adrenal insufficiency or Cushing's disease (Domes et al., 2019; Nieman et al., 2019). Additionally, Manigault et al. (2019) performed another RCT involving moderately to severely stressed individuals (n = 86) by measuring their cortisol levels after performing DECREASING PUBLIC HEALTH NURSE BURNOUT 13 cognitive-behavioral and mindfulness-based stress reduction therapies. Thirty minutes post-exposure to the stressor resulted in more significant cortisol reduction with these interventions than participants who did nothing. Therefore, not utilizing any interventions for managing stress results in poorer health outcomes. Psychological harm can also arise from stress. The toll of working in health care and providing continuous patient care can become steep as the strain negatively affects mental health. Salvagioni et al. (2017) also found that individuals with burnout commonly experienced symptoms such as insomnia, depression, antidepressant prescription use, and other psychosocially related symptoms. Further, decreased job satisfaction and absenteeism can result from unmanaged stress. In an anonymous cross-sectional survey of registered nurses (n = 812), 35.3% had the symptoms of burnout (Dyrbye et al., 2019). Sixteen percent of the survey respondents had missed at least one day of work in the past month. No major significance was found between the missed days of work and burnout. However, one in six nurses reported not working for personal health issues. Nurses missing work days due to health issues resulted in decreased staffing with higher patient-to-nurse ratios in hospitals, contributing to the strain experienced by the nurses. Although the absent nurse may not miss work from burnout directly, the remaining nurses become overwhelmed and overworked, which can cause them to develop job burnout. Interventions for Burnout Reduction Many interventions for burnout reduction exist in the literature. Aryankhesal et al. (2019) performed a systematic review of 12 RCTs to determine which stress management interventions were most effective. Based on the evidence and the complexities of mental health, combining interventions, such as meditation and mindfulness, reduced burnout for nurses and physicians DECREASING PUBLIC HEALTH NURSE BURNOUT 14 long-term. Another RCT conducted by Hersch et al. (2016) consisted of 104 hospital-based nurses. The intervention included BREATHE: Stress Management for Nurses program. This web-based program prepared healthcare workers with methods for coping with stress and reducing levels of burnout by teaching assertive communication, conflict resolution, and problem-solving strategies. However, Salyers et al. (2019) conducted a similar RCT with a larger sample size (n = 206), resulting in no apparent reduction in burnout with the BREATHE program intervention. The BREATHE participants did become more aware of early signs of burnout and intended to use better self-care strategies in the future. As a consequence of the SARS-CoV-2 virus, utilizing mobile device technology for implementing stress management interventions has become an increasingly ideal delivery method. The face-to-face constraints associated with social distancing to help minimize the spreading of this pandemic and the accessibility of smartphone applications have made the reception of stress management interventions more accepted. In a recent RCT conducted by Fiol-DeRoque et al. (2021), healthcare providers were encouraged to download an app to reduce mental health issues and prevent burnout for two weeks. Healthcare workers already receiving psychotherapy medications significantly improved their mental health status (p = 0.004). In a similar study conducted by Rung et al. (2020), women (n = 43) downloaded a mindfulness-based app on their smartphones. Women who used the app the most after thirty days were less stressed. Self-reported sleep quality and depressive symptoms were also improved. Moreover, employees at a private hospital (n = 102) used a similar smartphone app for eight weeks. The study demonstrated a significant increase in work-related well-being (p = < 0.001). The app also reduced work-related and overall stress (p = < 0.001) when used consistently (Coelhoso et al., 2019). DECREASING PUBLIC HEALTH NURSE BURNOUT 15 Organizational-level interventions have also demonstrated their usefulness in decreasing levels of burnout in healthcare workers. Modifying job characteristics, increasing communication skills, and implementing peer support groups are effective strategies for reducing stress and improving employee well-being (Holman et al., 2018). Unity and the support of coworkers reduce burnout and improve job performance. Zeytinoglu et al. (2017) completed a study involving community-based workers who perceived additional support from their organization. Those who self-reported lower work and personal stress levels had higher levels of perceived support from their organization. Further, Reitz et al. (2021) surveyed healthcare employees (n = 402) who work directly with COVID-19 patients. Perceived organizational support, burnout, and anxiety were examined. Higher perceived organizational support was significantly associated (p = < 0.001) with decreased levels of burnout and lower anxiety (p = 0.01). It is apparent that increased organizational support, such as involving the workers in making decisions and allowing schedule flexibility, significantly improves work-related stress. Healthcare workers who can effectively manage their stress levels in the workplace may be considerably more capable of caring for people without associated strain. Framework The Job Demands-Resources (JD-R) model for occupational stressors has received validity and demonstrated its usefulness for measuring employee engagement and burnout from various studies (Biggs et al., 2014; Maslach & Leiter, 2016). Every job is associated with its stressors. Job demands and job resources majorly influence stress and burnout in the workforce. Job demands have physical and psychological components, such as high work pressure and DECREASING PUBLIC HEALTH NURSE BURNOUT 16 interactions with demanding clients. Job resources are a means to achieve job goals, promote personalized learning and development, and reduce job demands (Bakker & Demerouti, 2007). The creators of this model, Bakker and Demerouti (2007), use emotional exhaustion as the basis of their concept. The model can predict employee burnout, commitment, and organizational functioning. Environmental and individual factors contribute to burnout on an organizational and personal level. Continual occupational demands cause burnout in individuals with insufficient resources to alleviate these stressors. Nurses are at an increased risk of experiencing heightened stress levels at work (Aryankhesal et al., 2019; Reith, 2018). Increased stress negatively affects nurses' ability to provide care to patients and is eventually detrimental to their health. Public health nurses serve a large population, and as such, they need additional support and resources from organizations, government agencies, and other personnel. Accessing appropriate and satisfactory healthcare levels in rural communities is an ongoing challenge. Through the Healthy People 2020 campaign, the Office of Disease Prevention and Health Promotion (ODPHP) defines health disparities as a difference in health outcomes between "race or ethnicity, sex, sexual identity, age, disability, socioeconomic status, and geographic location" (ODPHP, n.d.). These inequalities contribute to poorer health for rural populations. Conversely, urbanized areas have increased resources and working healthcare professionals compared to rural counterparts (Centers for Disease Control and Prevention, 2017; James et al., 2017). Therefore, public health nurses working in rural areas are predisposed to burnout. Having inadequate resources and insufficient support to care for the community significantly increases occupational stressors. DECREASING PUBLIC HEALTH NURSE BURNOUT 17 The JD-R model promotes positive psychological health outcomes in various occupational settings. Job resources directly impact job demands. Sufficient organizational support and resources decrease the strain associated with job demands (Bakker & Demerouti, 2007). The JD-R model also incorporates social support and motivation as factors affecting occupational outcomes. Bakker and Demerouti (2007) have developed a model that prevents occupational stress by considering job resources, demands, social support, and motivational influences. Discussion Evidence concerning occupational stress suggests that interventions for managing stress and preventing strain may be successful for staff to become more resilient to workplace stress (Biggs et al., 2014; Fisher, 2019; Holman et al., 2018; Kelly et al., 2021). Fisher et al. (2019) recommend that organizations with employees who frequently experience high levels of stress and burnout can benefit from stress reduction strategies, such as mindfulness and organizational culture changes. Mindfulness-based stress reduction is an evidence-based intervention focusing on the individual's thoughts, sensations, emotions, and environment (Baer, 2003). Stress management interventions with the most extensive research include relaxation techniques, cognitive-based therapy, meditation, and mindfulness training (Aryankhesal et al., 2019; Holman et al., 2018). Computer modules available through the internet have become progressively accepted for widened access to individuals and organizations using these stress management interventions. Internet-based stress management has had positive effects and subjective reports of reduced stress levels (Fiol-DeRoque, 2021; Hersch et al., 2016). Increasing stress management skills and improving both psychological and somatic health are essential for improving healthcare workers' well-being and reducing the effects of DECREASING PUBLIC HEALTH NURSE BURNOUT 18 burnout (Domes et al., 2019). The strategies utilized to decrease healthcare worker burnout and retain employees aim to improve their quality of life. Individual-level and organizational-level interventions to reduce burnout are effective if employees are involved in the intervention process (Holman et al., 2018). Individual interventions assist with developing coping and stress reduction skills. In contrast, organizational interventions focus on making broader organizational changes to systemically impact employees and their stress management levels (Kelly et al., 2021). Implications for Practice Reducing burnout among healthcare workers remains the organization's and employees' responsibility. The cumulative effects of overt exhaustion, a culture of cynicism, and professional inefficacy contribute to the development of employee burnout (Biggs et al., 2014; Dyrbye et al., 2019; Hersch et al., 2016; Maslach & Leiter, 2016). Employees are the life force of organizations and contribute their years of experience and individualized abilities to function within the team dynamic. Organizations benefit by having a more resilient workforce; therefore, retaining these valuable employees is imperative for the healthcare system. By implementing a no-cost intervention supported by the organization, such as a stress management mobile device app, employees can learn stress management techniques based on evidence to maintain and improve their health. Limiting or even overcoming burnout by reducing the impact of stress on the well-being of nurses can improve health and job satisfaction rates (Aryankhesal et al., 2019; Domes et al., 2019; Fiol-DeRoque et al., 2021; Fisher et al., 2019; Hersch et al., 2016; Holman et al., 2018; Ryan et al., 2017; Salyers et al., 2019). DECREASING PUBLIC HEALTH NURSE BURNOUT 19 Project Plan This project focused on educating rural public health nurses about the importance of stress management techniques and utilizing an app as the intervention. The purpose was to prevent burnout within the workforce to increase opportunities to equalize the resiliency of nurses. Healthcare workers have been forced to work harder with more challenging patients and fewer resources due to COVID-19 (Kelly et al., 2021). Nurses especially have been experiencing increased stress resulting in burnout. This consequence has worsened the workforce's situation and further decreased available staff and resources to manage complex patients in the community. The content outlined below includes the project's overall design, including the cost analysis and sustainability plan. The project outcomes involving ethical considerations and instruments to measure effectiveness are discussed. Project Design This quality improvement project aimed to teach public healthcare nurses stress management skills. Providing public healthcare nurses with a relevant evidence-based app available on mobile technology for increased convenience could improve staff resiliency. Incorporating the stress management app into daily use could equip public health nurses with techniques to combat job burnout. Needs Assessment of Project Site and Population Health equity is achieved when all people have the same opportunity to access health care to prevent diseases and promote wellness. Increasing the services provided by the Uinta County Public Health Department could improve the county's health, which impacts 20,000 people (Uinta County Statistics, 2021). Furthermore, nurses' mental and physical wellness should also be considered in achieving health equity for the county. Having sufficient stress management DECREASING PUBLIC HEALTH NURSE BURNOUT 20 skills could increase resiliency to the job demands related to public health nursing. Nurses are thus better prepared to remain in this position long-term. Rural communities have disadvantages as the geography of healthcare services is vast (ODPHP, n.d.). This disadvantage decreases the number of people with regular access to healthcare providers. Therefore, the opportunity to provide disease prevention education and health knowledge is already limited. However, an insufficient workforce of healthcare providers and community resources available also leads to these adverse health outcomes. The social determinant of health that directly impacts the project is not enough nurses to perform the duties the community needs, resulting from burnout (Kelly et al., 2021). Fewer providers interact with patients, which results in fewer opportunities to empower patients to live a healthy lifestyle. Further, lower levels of health literacy in the county led to inadequate health maintenance, which contributes to morbidities causing patient care to become more complex (ODPHP, n.d). Patients with multiple health needs require more services and care providers to have improved health. Decreasing levels of burnout among rural public health nurses helps form a stable workforce to provide resources and support to vulnerable community members (Fisher et al., 2019; Holman et al., 2018). Cost Analysis and Sustainability of Project The Fifth Windows, Inc. app was free for healthcare workers to use. The involved costs remained individualized as the participant must have a personal mobile device to use the app (see Appendices A and B for cost analysis tables). Appendix A describes the cost of the intervention with using the app daily. The table also includes nurse turnover and the current nursing burnout rates. Appendix B represents the cost of training the "coaches" using the stress management app. DECREASING PUBLIC HEALTH NURSE BURNOUT 21 After implementing these strategies, the health department budget would reflect the time staff uses the app at work, approximately 10 minutes daily. Using the app would cost the health department $22,655.58 annually for 20 full-time nurses to use the app for 10 minutes a day. However, the average cost of replacing a full-time nurse is $32,385.60 (Nursing Solutions, 2021). The rate of return is higher than the cost of the app, and the benefits of utilizing the app for a year outweigh the associated costs. After a year, the nurses may have well-developed stress management skills. These skills help combat the effects of stress, thus preventing burnout. The nurses may remain in their current positions in the health department and function professionally at high levels instead of leaving the workforce. Project Outcomes The project's short-term outcomes included public health nurses attending a training class and using the app by early January 2022. Intermediate-term outcomes were that public health nurses reported reduced levels of stress and burnout after four weeks of using the app daily by late February 2022. Long-term outcomes were that public health nurses developed lifelong stress management techniques to remain employed in the health department. Consent Procedures and Ethical Considerations All public health nurses were included in the pilot study unless they declined to participate. Being a nurse in the public health department required social justice maintenance. Gender, race, and age did not determine a nurse's worth and were not considered during the selection process. Approval was obtained through the Wyoming Department of Health and Weber State University Institutional Review Board. Project survey results remained anonymous, aggregate, and secure. DECREASING PUBLIC HEALTH NURSE BURNOUT 22 Instruments to Measure Intervention Effectiveness As the characteristics of burnout have become more identifiable, associated tools to measure its severity have been developed. A burnout-specific tool that also has credibility is the Oldenburg Burnout Inventory (OLBI). Demerouti et al. (2003) created this instrument to assess burnout's exhaustion and disengagement. The effects of burnout measure physical, cognitive, and affective symptoms. Moreover, the Perceived Stress Scale is a scale to assess the level of stress experienced by nurses. This scale measures ten stress areas and results in a total stress score. Cohen et al. (1983) assessed levels of perceived stress and created a scale to determine the effectiveness of stress-reducing interventions. The scale has been repeatedly validated and utilized as a psychological tool to measure the current perception of stress within many domains and is appropriate for the project evaluation. The Perceived Stress Scale is suitable for all groups of people currently experiencing stress (National Academy of Medicine, n.d.). The most inclusive and conclusive tools for assessing nurses' stress and burnout levels are the Perceived Stress Scales and OLBI. The Perceived Stress Scale is an acclaimed tool for measuring stress in any individual, which is pertinent to the project to establish a baseline level of stress and measure the resulting stress after the intervention. The OLBI is also ideal for determining levels of burnout before the study and measuring the app's effectiveness due to its positively and negatively worded questions, which accurately represent the dimensions of burnout (Sinval et al., 2019). Project Implementation This project involved implementing an evidence-based stress management mobile device app by Fifth Windows, Inc. to teach rural public health nurses in Wyoming to be more resistant to stress in the healthcare workforce. The app instructed nurses on stress management DECREASING PUBLIC HEALTH NURSE BURNOUT 23 techniques, including mindfulness, meditation breathing, gratitude, and guided imagery. The plan included initially using the app daily to learn stress management skills and then incorporating them into their daily routine for improved stress management abilities to reduce healthcare-associated burnout. The project was implemented on an organization-wide scale at the Uinta County Public Health Department and revolved around the piloted study. Widespread participation was essential to the project's sustainability for public health nurses to develop stress management skills. The improvement team for the project was multidisciplinary. The team consisted of the DNP student, the on-site project consultant, Weber State University faculty project lead, Uinta County public health nurses, and the provider at the rural health department. Project Intervention This quality improvement project aimed to prevent burnout by improving the stress management capabilities of public health nurses. The project's overall goal was to retain the skill set of the qualified nursing workforce at the health department. Interventions for this project were simplistic yet informative in design for greater interest and participation in the pilot study. Early planning for the stress management intervention involved collaborating with an existing evidence-based mobile app, Fifth Windows, Inc. The usability and accessibility of the app were desirable. Collaborating with the developers of Fifth Window Inc. produced additional practices created and added to the app for various evidence-based stress management techniques. To achieve greater buy-in from the rural public health nurses, I held a class for a select group of nurses to learn the information and distribute it to their colleagues. These individuals were designated as the "coaches." Their role was to teach their colleagues about stress's harmful DECREASING PUBLIC HEALTH NURSE BURNOUT 24 effects and encourage stress management techniques using the app. A class poster (see Appendix C) was created to generate interest in the pilot study and encourage the "coaches" to attend the training class in person or via Zoom. The "train the coaches" class was taught at the Uinta County Public Health Department. It was approximately an hour long. The PowerPoint presentation (see Appendix D) contained a slideshow ranging from defining stress to the project's timeline. The nurses participated in the discussion, and I answered their questions about the project. The "coaches" then taught their colleagues how to download and use the app later that week. One week before the public health nurses downloaded the app, a link to take the pre-survey through Qualtrics was emailed to participants. This survey combined the Oldenburg Burnout Inventory and Perceived Stress scales (see Appendices E and F) to assess stress and burnout in the participants. The nurses had a calendar (see Appendix G) handout to mark daily app use for the project's duration. The calendar also included the QR (query request) codes for the pre-, post-, and follow-up Qualtrics survey links. The surveys were distributed through an anonymous link, which did not collect identifying information. Study participants created a unique identifier as their username on the app to maintain anonymity. The unique identifier was created by deriving their favorite color, day of birth, and mother's maiden name (Ex: Purple25Mea). The specific username obscured identities, so no data could be related to particular individuals during or after the study. The Fifth Window, Inc. app creators requested the survey findings to improve their app. All personal information from the surveys and demographic information remained concealed. The app was designed to be user-friendly and easily accessible through mobile technology usage. A reminder prompt, or a push notification, occurred daily on the mobile DECREASING PUBLIC HEALTH NURSE BURNOUT 25 device to remind users to practice their stress management skills. The user also chose which days for notification. Study participants were encouraged to use the app daily. The app also had resources built-in containing links for Wellness Partners since a feature exists to connect to other app users or answer community questions. The app was simplistic in design and straightforward to navigate. The user first performed a "check-in" to determine how their body, mood, and thoughts were that day. Then the user-selected words (one to five) to describe their whole self. The app recommended a practice based upon these selections. Nine practices were available, ranging from two to six minutes in length. The user could choose which stress management techniques to practice regardless of their previous assessment selections for the day. Moreover, they could practice one stress management technique or multiple. The pilot study participants were also reminded to use the app daily through email for one month. The nurse educator reminded all staff to use the app throughout the week. Information technology support was available if there were technical difficulties using the app. The post-survey was administered to participants through Qualtrics two weeks after the pilot study. The follow-up survey (see Appendices H and L) was administered to participants six weeks after the pilot study's conclusion to determine the long-term effectiveness of the intervention. Project Timeline The project timeline includes the initial research and development of the intervention through the implementation phase of the pilot study to the follow-up survey. The timeline progressed through the necessary interventions to meet the implementation deadline. The project management tool (see Appendix I) informed the team of the expected pilot study course. DECREASING PUBLIC HEALTH NURSE BURNOUT 26 Project Evaluation The outcomes of this project were met by nurses experiencing less stress through using a daily mobile app. The Fifth Windows, Inc. app taught nurses numerous stress management techniques, which positively impacted the nurses in the public health department. Initially, 13 participants responded to the pre-survey and seven to the post-survey. Participants' feedback from the post-survey included that they were experiencing high levels of stress before the intervention and felt it was beneficial to learn stress management techniques to equip them for future stressful times. The nurses' perception of their stress levels after the intervention was improved. Data were collected and analyzed through Qualtrics. Findings were discussed, and their impact on health care was evaluated. Data Maintenance/Security The pre-, post-, and follow-up survey results remained anonymous. Study participants used a self-created unique identifier as their username on the app. It remained the nurse's responsibility to remember their unique identifier to log in to the app as it was not documented to retain confidentiality. Survey results were stored on a password-protected computer, which remained in one location. The Fifth Windows, Inc. app creators requested the survey findings to improve their app. The survey findings were reported in an aggregate format to keep nurses' responses unidentified. Data Collection and Analysis Three surveys were administered to study participants. The first survey was emailed to participants before the pilot study to establish a baseline for evaluation. The post-survey was given to participants two weeks after the completion of the intervention (see Appendices J and K). A follow-up survey was sent four weeks after the post-survey and contained demographic DECREASING PUBLIC HEALTH NURSE BURNOUT 27 information (see Appendices L and M). Participants were administered all surveys through Qualtrics, a platform for creating, distributing, and evaluating surveys. All quantitative and qualitative data were collected from this program. The Oldenburg Burnout Inventory and Perceived Stress scales utilized numerical answers (1-4 and 0-4, respectively) as the pre- and post-survey questionnaires. The survey results in percentages were obtained from the Qualtrics evaluation data. Findings The project outcomes were met by analyzing the survey data (see Tables 1 and 2). Of note, participants experienced moderate levels of stress and burnout before the intervention, according to the Oldenburg Burnout Inventory. Pre-survey results revealed that 76.92% of respondents found work interesting. Most respondents (61.54%) felt tired before arriving at work. Initially, only 38.46% of respondents reported tolerating their work pressure well. Nearly half (46.15%) of the participants found work to be a positive challenge and did not often feel emotionally drained (53.85%). A total of 46.15% of respondents agree that over time it is possible to become disconnected from this type of work. According to 61.54% of respondents, they did not have enough energy for leisure activities after work. Of the respondents, 76.9% did not agree that being a public health nurse was the only type of work they could see themselves doing (see Appendix J for complete survey results). Table 1 Significant Survey Findings for the Oldenburg Burnout Inventory Strongly Agree Agree Disagree Strongly Disagree 1. I always find new and interesting aspects in my work. 23.08 (0) 76.92 (100) 0 (0) 0 (0) 2. There are days when I feel tired before I arrive at work. 15.38 (14.29) 61.54 (28.57) 15.38 (57.14) 7.69 (0) DECREASING PUBLIC HEALTH NURSE BURNOUT 28 5. I can tolerate the pressure of my work very well. 38.46 (14.29) 38.46 (71.43) 23.08 (14.29) 0 (0) 6. Lately, I tend to think less at work and do my job almost mechanically. 7.69 (0) 30.77 (14.29) 53.85 (85.71) 7.69 (0) 7. I find my work to be a positive challenge. 15.38 (0) 46.15 (100) 30.77 (0) 7.69 (0) 8. During my work, I often feel emotionally drained. 15.38 (0) 23.08 (14.29) 53.85 (85.71) 7.69 (0) 9. Over time, one can become disconnected from this type of work. 15.38 (0) 46.15 (71.43) 30.77 (28.57) 7.69 (0) 10. After working, I have enough energy for my leisure activities. 7.69 (0) 30.77 (14.29) 61.54 (85.71) 0 (0) 13. This is the only type of work that I can imagine myself doing. 0 (0) 15.38 (42.86) 76.92 (42.86) 7.69 (0) Note: Pre-survey results n = 13. Post-survey results n = 7. The following findings were from the Perceived Stress Scale before the intervention. As described in Table 2, 61.54% of participants responded that they sometimes could not control the important things in their lives within the month before the intervention. Half (53.85%) of the respondents felt confident about handling their personal problems during the pre-survey, and only 38.46% felt that things were going their way over the last month (see Appendix K for complete survey results). Table 2 Significant Survey Findings for the Perceived Stress Scale Never Almost Never Sometimes Fairly Often Very Often 2. In the last month, how often have you felt that you were unable to control the important things in your life? 7.69 (0) 23.08 (57.14) 61.54 (28.57) 7.69 (14.29) 0 (0) 4. In the last month, how often have you felt confident about your ability to handle your personal problems? 0 (0) 7.69 (0) 53.85 (42.86) 30.77 (57.14) 7.69 (0) 5. In the last month, how often have you felt that things were going your way? 0 (0) 23.08 (0) 38.46 (42.86) 38.46 (57.14) 0 (0) 6. In the last month, how often have you found that you could not cope with all the things that you had to do? 0 (0) 7.69 (42.86) 61.54 (57.14) 23.08 (0) 7.69 (0) DECREASING PUBLIC HEALTH NURSE BURNOUT 29 10. In the last month, how often you felt difficulties were piling up so high that you could not overcome them? 0 (42.86) 46.15 (28.57) 15.38 (28.57) 30.77 (0) 7.69 (0) Note: Pre-survey results n = 13. Post-survey results n = 7. Study participants still had moderate stress levels after the intervention, according to the Oldenburg Burnout Inventory and Perceived Stress Scale. However, it should be noted there was progress in various categories compared to the pre-survey (see Tables 1 and 2). According to the post-survey, four respondents (57.14%) almost never felt unable to control the important things in their lives compared to pre-intervention respondents (23.08%). In addition, 57.14% felt confident fairly often in handling their problems compared to 30.77% of pre-intervention respondents. Four respondents (57.14%) sometimes felt they could not cope with the number of things they had to do compared to 61.54% of pre-intervention respondents. Further, four respondents (57.14%) felt fairly often things went their way compared to 38.46% of pre-intervention respondents (for complete survey results, see Appendix K). An improvement in several stress areas was identified after the intervention. The satisfaction with the app was positive (see Appendix L). Seven participants responded to the post-survey one month after the conclusion of the intervention. The burnout aspect of the survey results was improved. All seven respondents (100%) reported increased interest in their work post-intervention and found work to be a positive challenge. Five respondents (71.43%) tolerated the pressures of their work well, and six (85.71%) participants did not feel emotionally drained from work. Six respondents (85.71%) did not do their job mechanically and felt mentally present. However, five (71.43%) respondents agree that becoming disconnected from this work is possible. Interestingly, six respondents (85.71%) did not feel they had enough energy to enjoy leisure activities after work. However, only four respondents (57.14%) did not feel tired before DECREASING PUBLIC HEALTH NURSE BURNOUT 30 arriving at work over the last month after the intervention (see Appendix J for complete survey results). The six-week follow-up survey had minimal negative feedback about the app's effectiveness with daily use. The survey's qualitative portion included asking participants what they learned from practicing the stress management reduction techniques. Participants were also asked how they felt better equipped to handle stress (see Appendix H for complete survey questions). One participant noted, "taking time to refocus or reboot helped reduce stress in most situations." Another participant commented, "I can manage stress if I can take care of myself." A common theme emerged of the importance of taking time to learn and frequently perform stress management techniques. Seven (100%) of participants felt more knowledgeable about stress reduction and intended to take the time to use their skills daily. A setback was identified as an additional workload for the nurses during a community outbreak of COVID-19 three weeks into the pilot study. Participation rates might have been higher without the increase in community cases of COVID-19. Strengths Participation in the study was voluntary; no individual was biased towards the Fifth Windows, Inc. stress management app. Overall, the participants had decreased stress levels and valued their experience with the app. The ease of use of the app was appealing. Several participants wanted to continue to use the app daily. Another strength was the Oldenburg Burnout Inventory and Perceived Stress scales are valid and reliable instruments for the pre- and post-survey questionnaires, supporting data results. The collection method for gathering data kept identities anonymous. DECREASING PUBLIC HEALTH NURSE BURNOUT 31 Weaknesses Limitations were met throughout this study. Originally there were 13 participants, but only seven (53.8%) completed the study. The reported reason for decreasing participation was a community COVID-19 outbreak that reduced willingness to use the app daily. Implementing the project during a typical amount of workplace stress may be more productive. The findings should not be generalized to other settings. A future study might investigate if learning stress management skills through mobile technology would be as successful in other locations, having more participants. Quality Improvement Discussion This quality improvement project implements an easily accessible and practical way to learn stress reduction techniques with mobile technology, preventing the prevalent healthcare-related problem of burnout. The intervention of this project involves public health nurses at the Uinta County Health Department utilizing the evidence-based stress management app daily for four weeks created by Fifth Windows, Inc. The nurses learn evidence-based practices such as mindfulness, breath meditation, and guided imagery, among others. Previous evidence reveals that these practices effectively decrease stress levels when used consistently. In more recent studies, researchers show that incorporating the capabilities of mobile device technology is an increasingly desired delivery method for education purposes, especially during the COVID-19 pandemic. Initially, 13 nurses participated, with seven completing the post-survey. Baseline data reveals that the nurses were experiencing moderate levels of burnout and stress according to the Oldenburg Burnout Inventory and Perceived Stress Scale. Many disciplines validate these scales as practical tools for measuring burnout and stress. Outcomes are met by rural public health DECREASING PUBLIC HEALTH NURSE BURNOUT 32 nurses self-reporting less stress and prospective burnout after the intervention among the nurses who completed the project. The findings of this project propose that stress management interventions on mobile devices may be effective in learning stress management skills. Healthcare workers can acquire other essential skills through the routine use of mobile device apps, which is encouraging for future scholarship. The sustainability of this project is promising as it is no cost and is easy to use. The app sends prompts for the user to practice stress management skills as frequently as determined by the individual. The Uinta County Public Health Department nurses recognize the importance of learning positive stress management skills to protect themselves against the adverse effects of job-related stress. Moreover, the nurses are in an advantageous position to teach community members about stress management skills. This dissemination of knowledge may empower the population to desire better health by first reducing their stress. Translation of Evidence Into Practice Evidence reveals that several substantiated practices effectively decrease stress, such as mindfulness, breath meditation, and guided imagery (Aryankhesal et al., 2019; Holman et al., 2018). Evidence also demonstrates the usefulness of mobile device technology as an ideal delivery method for learning essential skills (Fiol-DeRoque et al., 2021). Mobile technology can aid in teaching stress management skills at the user's convenience to increase compliance and sustainability (Domes et al., 2019; Fiol-DeRoque, 2021; Hersch et al., 2016). The public health nurses acknowledged the mobile device app's ease of use and accessibility, which promoted continued use. The data shows a slight decrease in stress and an overall reduction in burnout according to the selected scales. By facilitating nurses with learning stress management DECREASING PUBLIC HEALTH NURSE BURNOUT 33 techniques, nurses can prevent the harmful effects of unabated stress from becoming healthcare-associated burnout. Implications for Practice and Future Scholarship A delicate balance exists between implementing an effective intervention and one that is manageable to implement into practice. The ease of use and accessibility of a mobile device app have been found to increase the acceptability of change (Coelhoso et al., 2019; Fiol-DeRoque et al., 2021; Rung et al., 2020). Future scholarship may include utilizing mobile device applications more readily for educating or training purposes. By utilizing a mobile device app, nurses can access valuable resources besides learning stress management skills. Many more skills can be taught to healthcare workers through mobile technology to increase access and participation systemically. Education-related healthcare costs may be reduced as in-person classes and conferences may not be as necessary or prevalent. Additionally, accessibility to these potential resources can decrease patient harm as healthcare workers have the means to review or practice essential skills before performing them on patients. Using validated and reliable tools to assess burnout and stress levels effectively measures the impact of learning stress management skills. These tools can be periodically used to reassess stress and burnout levels, which may implicate an individualized need for further stress reduction interventions (Cohen et al., 1983; Demerouti et al., 2007; Sinval et al., 2019). Routinely answering the Oldenburg Burnout Inventory and Perceived Stress Scale questionnaires on a personal basis may benefit all healthcare workers. These scales can help organizations or individuals properly assess coping and resiliency within the workplace. The longitudinal aspect of these routine assessments may prevent healthcare workers from the detrimental effects of unmanaged stress and job burnout. DECREASING PUBLIC HEALTH NURSE BURNOUT 34 Sustainability This quality improvement project remains sustainable as a free app for healthcare workers, which limits costs. Furthermore, stress management techniques can teach nurses life-long skills to reduce stress. The app is not necessary for daily use if the skills have been adequately developed. Until that is achieved, the app can remind users to perform the techniques according to their preferred frequency to assist with developing the skills over time. The app can be used for as many practices as desired, which increases customizability and adaptability as life circumstances change. Dissemination I am sharing the aggregated study data with the Fifth Windows, Inc. app developers to modify the app to become increasingly helpful and user-friendly. Moreover, the Uinta County Public Health Department nurses are informed about preventing stress and actively practicing stress management skills. This information regarding positive stress management skills can be disseminated to the public by the nurses at the health department. Displaying a poster at the Health Department that summarizes stress management's importance can be beneficial. Everyone can experience high-stress levels across the lifespan. Therefore, stress management skills are essential regardless of occupation. I will incorporate this knowledge into my professional practice to further educate colleagues and patients regarding stress's detrimental effects and potentially prevent burnout. Conclusion Stress and healthcare worker burnout are highly relevant concerns that are commonly experienced. Healthcare workers are at increased risk for burnout due to their type of work. The Uinta County Public Health Department nurses in Evanston, Wyoming, were recruited to DECREASING PUBLIC HEALTH NURSE BURNOUT 35 participate in the pilot study for learning stress management interventions through an evidence-based app available on mobile devices. Overall, the participants expressed an interest in using the app to incorporate stress management skills into their daily regimen. Data collection and evaluation revealed that participants had a positive experience with the intervention and intended to continue using their stress management skills (see Appendices J, K, and L). Outcomes were achieved as more than half of the public health nurses self-reported improved stress levels and increased stress management abilities. Healthcare workers who do not have positive stress management skills are prone to chronic stress, contributing to poorer health outcomes. A recommendation is to continue teaching all nurses about the importance of stress management and developing effective skills to cope with stress appropriately to prevent healthcare-associated burnout. By learning stress management techniques, nurses are better prepared to deal with potential stressors in the workplace. 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Frontiers in Psychology, 10, 338-338. https://doi.org/10.3389/fpsyg.2019.00338 DECREASING PUBLIC HEALTH NURSE BURNOUT 42 The American Institute of Stress. (n.d.). What is stress? https://www.stress.org/daily-life The Office of Disease Prevention and Health Promotion. (n.d.). Increase the health literacy of the people – HC/HIT-R01. Healthy People 2030. https://health.gov/healthypeople/objectives-and-data/browse-objectives/health-communication/increase-health-literacy-population-hchit-r01 Uinta County Wyoming. (2021). Uinta county profile. CivicPlus. https://uintacounty.com/198/Uinta-County-Profile World Health Organization. (2019). Burnout an "occupational phenomenon": International classification of diseases. https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases Zeytinoglu, I. U., Denton, M., Brookman, C., Davies, S., & Sayin, F. K. (2017). Health and safety matters! Associations between organizational practices and personal support workers' life and work stress in Ontario, Canada. BMC Health Services Research, 17(1), 427-427. https://doi.org/10.1186/s12913-017-2355-4 DECREASING PUBLIC HEALTH NURSE BURNOUT 43 Appendix A Cost of Nurse Burnout Table DECREASING PUBLIC HEALTH NURSE BURNOUT 44 Appendix B App Use Cost Analysis Table Decreasing Burnout in Public Health Nurses Train the "Coaches" Use app daily Ongoing stress management skills Total Cost $4,819 $45,311.15 $22,655.58 Number served 5 nurses 20 nurses 20 nurses Cost per Individual $963.80 $2,265.56 $1,132.78 Evaluation Findings Average cost of replacing one full-time nurse with a 6-month training period: $32,385.60 82% of nurses experiencing burnout in 2019 had moderate to high levels of burnout, which means higher rates of turnover or resignation National turnover rate is 18.70% Average cost of retaining one nurse annually after intervention: $1,132.78 Return on Investment Unknown ROI: $32,252.82 per nurse that remains at public health department ROI: $32,252.82 per nurse that remains at public health department DECREASING PUBLIC HEALTH NURSE BURNOUT 45 Appendix C Class Poster DECREASING PUBLIC HEALTH NURSE BURNOUT 46 Appendix D PowerPoint Presentation DECREASING PUBLIC HEALTH NURSE BURNOUT 47 DECREASING PUBLIC HEALTH NURSE BURNOUT 48 DECREASING PUBLIC HEALTH NURSE BURNOUT 49 DECREASING PUBLIC HEALTH NURSE BURNOUT 50 DECREASING PUBLIC HEALTH NURSE BURNOUT 51 DECREASING PUBLIC HEALTH NURSE BURNOUT 52 DECREASING PUBLIC HEALTH NURSE BURNOUT 53 Appendix E Oldenburg Burnout Inventory DECREASING PUBLIC HEALTH NURSE BURNOUT 54 Appendix F Perceived Stress Scale DECREASING PUBLIC HEALTH NURSE BURNOUT 55 Appendix G Pilot Study Calendar DECREASING PUBLIC HEALTH NURSE BURNOUT 56 Appendix H Qualtrics Follow-Up Survey DECREASING PUBLIC HEALTH NURSE BURNOUT 57 DECREASING PUBLIC HEALTH NURSE BURNOUT 58 DECREASING PUBLIC HEALTH NURSE BURNOUT 59 DECREASING PUBLIC HEALTH NURSE BURNOUT 60 DECREASING PUBLIC HEALTH NURSE BURNOUT 61 DECREASING PUBLIC HEALTH NURSE BURNOUT 62 DECREASING PUBLIC HEALTH NURSE BURNOUT 63 DECREASING PUBLIC HEALTH NURSE BURNOUT 64 Appendix I Project Management Tool DECREASING PUBLIC HEALTH NURSE BURNOUT 65 Appendix J Complete Pre- and Post-Survey Results of the Oldenburg Burnout Inventory Results of Pre- and Post-Surveys Strongly Agree Agree Disagree Strongly Disagree 1. I always find new and interesting aspects in my work. 23.08 (0) 76.92 (100) 0 (0) 0 (0) 2. There are days when I feel tired before I arrive at work. 15.38 (14.29) 61.54 (28.57) 15.38 (57.14) 7.69 (0) 3. It happens more and more often that I talk about my work in a negative way. 15.38 (0) 30.77 (42.86) 46.15 (57.14) 7.69 (0) 4. After work, I tend to need more time than in the past in order to relax and feel better. 30.77 (14.29) 30.77 (42.86) 30.77 (42.86) 7.69 (0) 5. I can tolerate the pressure of my work very well. 38.46 (14.29) 38.46 (71.43) 23.08 (14.29) 0 (0) 6. Lately, I tend to think less at work and do my job almost mechanically. 7.69 (0) 30.77 (14.29) 53.85 (85.71) 7.69 (0) 7. I find my work to be a positive challenge. 15.38 (0) 46.15 (100) 30.77 (0) 7.69 (0) 8. During my work, I often feel emotionally drained. 15.38 (0) 23.08 (14.29) 53.85 (85.71) 7.69 (0) 9. Over time, one can become disconnected from this type of work. 15.38 (0) 46.15 (71.43) 30.77 (28.57) 7.69 (0) 10. After working, I have enough energy for my leisure activities. 7.69 (0) 30.77 (14.29) 61.54 (85.71) 0 (0) 11. Sometimes I feel sickened by my work tasks. 7.69 (0) 30.77 (28.57) 46.15 (57.14) 15.38 (14.29) 12. After my work, I usually feel worn out and weary. 15.38 (14.29) 46.15 (57.14) 38.46 (28.57) 0 (0) 13. This is the only type of work that I can imagine myself doing. 0 (0) 15.38 (42.86) 76.92 (42.86) 7.69 (14.29) 14. Usually, I can manage the amount of my work well. 15.38 (14.29) 76.92 (71.43) 7.69 (14.29) 0 (0) 15. I feel more and more engaged in my work. 7.69 (14.29) 61.54 (42.86) 23.08 (42.86) 7.69 (0) 16. When I work, I usually feel energized. 0 (14.29) 38.46 (42.86) 53.85 (42.86) 7.69 (0) Note: Pre-survey results n = 13. Post-survey results n = 7. DECREASING PUBLIC HEALTH NURSE BURNOUT 66 Appendix K Complete Pre- and Post-Survey Results of the Perceived Stress Scale Results of Pre- and Post-Surveys Never Almost Never Sometimes Fairly Often Very Often 1. In the last month, how often have you been upset because of something that happened unexpectedly? 0 (0) 38.46 (42.86) 46.15 (42.86) 7.69 (14.29) 7.69 (0) 2. In the last month, how often have you felt that you were unable to control the important things in your life? 7.69 (0) 23.08 (57.14) 61.54 (28.57) 7.69 (14.29) 0 (0) 3. In the last month, how often have you felt nervous and "stressed"? 0 (0) 15.38 (0) 61.54 (71.43) 7.69 (28.57) 15.38 (0) 4. In the last month, how often have you felt confident about your ability to handle your personal problems? 0 (0) 7.69 (0) 53.85 (42.86) 30.77 (57.14) 7.69 (0) 5. In the last month, how often have you felt that things were going your way? 0 (0) 23.08 (0) 38.46 (42.86) 38.46 (57.14) 0 (0) 6. In the last month, how often have you found that you could not cope with all the things that you had to do? 0 (0) 7.69 (42.86) 61.54 (57.14) 23.08 (0) 7.69 (0) 7. In the last month, how often have you been able to control irritations in your life? 0 (0) 7.69 (0) 46.15 (42.86) 38.46 (42.86) 7.69 (14.29) 8. In the last month, how often have you felt that you were on top of things? 7.69 (0) 23.08 (14.29) 23.08 (28.57) 46.15 (57.14) 0 (0) 9. In the last month, how often have you been angered because of things that were outside your control? 0 (0) 30.77 (42.86) 53.85 (42.86) 7.69 (14.29) 7.69 (0) 10. In the last month, how often you felt difficulties were piling up so high that you could not overcome them? 0 (42.86) 46.15 (28.57) 15.38 (28.57) 30.77 (0) 7.69 (0) Note: Pre-survey results n = 13. Post-survey results n = 7. DECREASING PUBLIC HEALTH NURSE BURNOUT 67 Appendix L Results of Qualtrics Follow-Up Survey Results of Follow-Up Survey Measure n % 1. App experience Positive 7 100 2. Times app opened Daily 4-6 times a week 2-3 times a week Once a week 1 2 2 2 14.29 28.57 28.57 28.57 3. Minutes app opened <1 minute 2-5 minutes 5-10 minutes 2 3 2 28.57 42.86 28.57 4. Time of day Morning Afternoon 5 2 71.43 28.57 5. Mood Improved The same 3 4 42.86 57.14 6. Physical health Improved The same 2 5 28.57 71.43 7. Thoughts Improved The same 5 2 71.43 28.57 8. Breath meditation Slightly effective Moderately effective Very effective 1 4 2 14.29 57.14 28.57 9. Guided imagery Slightly effective Moderately effective Very effective 2 2 3 28.57 28.57 42.86 10. Gratitude Slightly effective Moderately effective Very effective Extremely effective 2 2 2 1 28.57 28.57 28.57 14.29 DECREASING PUBLIC HEALTH NURSE BURNOUT 68 Measure n % 11. Loving hands Not effective at all Moderately effective Extremely effective 1 5 1 14.29 71.43 14.29 12. Prompt Yes No 6 1 85.71 14.29 13. Likely to practice Somewhat unlikely Somewhat likely Extremely likely 1 4 2 14.29 57.14 28.57 14. Reduce stress levels Yes 7 100 DECREASING PUBLIC HEALTH NURSE BURNOUT 69 Appendix M Public Health Nurse Demographic Information Participant Characteristics Baseline characteristics n % Gender Female 7 100 Age 35-44 45-54 55-64 65+ 2 1 3 1 29 14 43 14 Ethnicity White American Indian 6 1 86 14 Level of education Associate degree Bachelor's degree Master's degree 4 1 2 57 14 29 Marital status Single Married 1 6 14 86 Employment status Employed full time Employed part-time 4 3 57 43 Employment at Health Department <1 year 2-5 years 6-10 years 11+ years 1 2 1 3 14 29 14 43