Digital Repository Doctoral Projects Fall 2021 Burnout Prevention Through Teamwork and Communication for Homecare and Hospice Nurses Dawn Quada Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Quada, D. (2021) Burnout Prevention Through Teamwork and Communication for Homecare and Hospice Nurses 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. Burnout Prevention Through Teamwork and Communication for Homecare and Hospice Nurses by Dawn Quada 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 December 12, 2021 Mary Anne Hales Reynolds PhD, ARN, ACNS-BC_(signature) Faculty Advisor/Committee Chair Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE (signature) Graduate Programs Director Running head: HOMECARE & HOSPICE BURNOUT PREVENTION 1 Burnout Prevention Through Teamwork and Communication for Homecare and Hospice Nurses Dawn R Quada Weber State University Annie Taylor Dee School of Nursing November 21, 2021 HOSPICE WORKER BURNOUT PREVENTION 2 Acknowledgment I want to acknowledge the assistance and support of Dr. Melissa Neville-Norton for the advice she gave me early in my project, not to take critiques of my writing so personally, and that revisions were just part of the process. I also acknowledge and thank Dr. Mary Anne Reynolds for her unwavering encouragement, education, and direction as I navigated the challenges of writing, implementing, and evaluating this project. She provided much-needed encouragement and perspective when I was unsure and did not believe in myself. I would also like to acknowledge Dr. Kristy Baron, who challenged me to write at a graduate level. I learned a great deal in my efforts to do so. I also acknowledge the enthusiastic support and financial support of gift cards and prizes to the staff for project interventions from Wes Hansen, CEO of Applegate Homecare and Hospice. I also acknowledge the support, advice, and discussion sessions with Valarie Larkin, MSW from the same organization. This project could not have been successful without them. I would like to express my gratitude for the support and encouragement of my husband and family throughout my course of study. HOSPICE WORKER BURNOUT PREVENTION 3 Dedication I dedicate this paper to Nathan, a talented and caring homecare and hospice nurse, husband, and father. To Michele, a talented medical surgical nurse and mom. These nurses died in the struggle against substance use disorders. I also dedicate this paper to Jane, a homecare and hospice nurse who sadly ended her own life. The combined impact of their loss was the catalyst for this project. They will always be remembered. HOSPICE WORKER BURNOUT PREVENTION 4 Abstract Burnout is an epidemic problem in healthcare. Burnout among homecare and hospice nurses results from workplace demands and high-stress levels, which can lead to exhaustion. Job stress and isolation contribute to burnout in homecare and hospice nurses. This Doctor of Nursing Practice (DNP) Project aimed to prevent burnout among nurses at Applegate Homecare and Hospice using organizational interventions to improve communication and teamwork. Juran's Trilogy Model was used to design and implement a program to increase communication and teamwork among nurses. Project interventions included introducing a Kudos communication channel, initiating a monthly nurse meeting with activities that helped nurses engage personally, and a quarterly team debriefing. The program was evaluated using pre-and post-surveys and qualitative responses collected from nurses and stakeholders. Nineteen nurses participated in various interventions. One nurse left the organization prior to project completion. Pre-project interviews indicated that 17% of the nurses had signs of burnout. A comparison of pre-and post-surveys showed no significant improvement in burnout indicators. However, qualitative feedback collected from fourteen nurses indicated a positive impact on improved communication and teamwork. Comments from the Kudos channel saw a shift from focusing on individual actions to team actions. Burnout among homecare and hospice nurses can be addressed through organizational interventions to increase communication and teamwork. Continued education is needed to establish workplace practices that focus on communication and building solid teams. Keywords: burnout prevention, communication, teamwork, nursing HOSPICE WORKER BURNOUT PREVENTION 5 Homecare and Hospice Nurse Burnout Prevention Burnout among nurses has reached epidemic proportions (Reith, 2018). Worchester (2014) reported general nursing burnout at 54%. However, self-reported burnout rates have been 62% among palliative care nurses and as high as 66% among nurses in general (Kamal et al., 2016; Kavalieratos et al., 2017; Petitta, Jiang, & Hartel, 2016). Individual consequences of nursing burnout are difficult to capture. Costs of personal health and emotional exhaustion can only be estimated. Individual and organizational costs include medical mistakes, poor patient outcomes, high staff turnover, and nurses leaving jobs or nursing altogether (Barton, Bruce, & Schreiber, 2019; Harrison et al., 2017). The cost of replacing one nurse ranges from $47,000 to $85,000, based on nursing specialty (Christiansen, Wallace, Newton, Caldwell, & Mann-Salinas, 2017). Worchester (2014) estimates national burnout costs are between $250 and $300 billion annually. Homecare and hospice nurses are at particular risk for burnout. Providing care in patients' homes can cause a blurring of boundaries and a temptation to work longer hours (Barker, 2011; Guo et al., 2019: McCreary, 2020). Working alone in patient homes can be isolating, with obstacles to effective communication with team members (Slocum-Gori et al., 2011). This DNP project paper reviews critical literature to define burnout, discusses causes and outcomes related to nurses in homecare and hospice, describes the implementation, and reports an organizational solution to burnout. HOSPICE WORKER BURNOUT PREVENTION 6 Literature Review Define the Search A thorough search was conducted using the Weber State University Library’s web-based internet OneSearch, CINAHL, Google Scholar, and Cochrane databases. Search terms included nurses' stress levels, depression, burnout, suicide, nursing stress burnout, hospice nurse burnout, ICU nurse burnout, ER nurse burnout, the incidence of nurse burnout, turnover home health burnout, team nursing, teamwork, team building activities, evidence-based approaches to improve teamwork, strategies to improve teamwork, burnout, and patient safety. Approximately 196,942 articles were found. Over 70 resources are included in this literature review. Occupational Burnout Maslach and Jackson defined burnout in the 1980s as physical, emotional fatigue, and loss of motivation that results in total exhaustion and a sense of failure (Maslach & Jackson, 1981). The World Health Organization (2019) defines occupational burnout as a medical syndrome that develops when individuals are exposed to ongoing workplace stress that is not managed successfully. This syndrome is accompanied by signs of emotional exhaustion, mental depersonalization, cynical views of one's work, reduced effectiveness at one’s job, and was given a diagnosis code ICD-11, classifying it as “an occupational phenomenon” rather than a medical condition (WHO, 2019, p. 1). Burnout is preceded by long hours and high levels of job-related stress (Jacques, Ribeiro, Scholze, Galdino, Martins, & Ribeiro, 2018). According to Barker (2011), occupational stress includes heavy physical and emotionally demanding workloads, inadequate support from managers or coworkers, reduced work autonomy, and a perceived lack of support from an organization. Together such conditions are called “isostrain” and have adverse consequences on HOSPICE WORKER BURNOUT PREVENTION 7 personal health (Jacques et al., 2018, p. 484). Occupational burnout is linked to hypertension, diabetes, heart problems, gastrointestinal or respiratory issues, headaches, pain, and severe injuries. Psychological problems include depression, insomnia, and mental health issues. Burnout increases disability claims while reducing professional satisfaction and productivity (Salvagioni, Melanda, Mesas, Gonzalez, Gabani, & DeAndrade, 2017). Kavalieratos et al. (2017) describe burnout as having a “gradual and insidious onset” that is difficult to stop or reverse (p. 903). Burnout is enough of a problem that the World Health Organization (2019) is developing guidelines for mental health treatment at work. Burnout is linked with professional or job-related issues, personal factors, and organizational issues in nursing. Nurses regularly respond to life-threatening situations, address complex needs, face urgent time constraints, care for multiple patients, and have repeated exposure to trauma. The stress of making instant critical decisions builds up over time (Abellanoza, Provenzano-Hass & Gatchel, 2018; Buttenschoen, Stephan, Watanabe & Nekolaichuk, 2014; Kgosana et al., 2019; Vandevala et al., 2017). Demands include complex patients, strained working environments, increasing workloads, patients with physical or mental suffering, aggressive or violent patients, and conflicting goals of care leading to moral distress in nurses (Adib-Hajbaghery, Khamechian, & Alavi, 2012; Kavalieratos et al., 2017; Kgosana, Mamogobo, Mohtiba, & Okafor, 2019; Martins Pereira, Teixeira, Carvalho, & Hernandez-Marrero, 2016; Shoorideh, Ashktorab, Yaghmaei, & Alavi Majd, 2015). Guo et al. (2019) note that threats of physical violence are especially concerning for nurses working in patient homes or alone. Nurses are so frequently exposed to violent situations that many consider it an inherent part of the job (Vander Elst et al., 2016). HOSPICE WORKER BURNOUT PREVENTION 8 Personal factors such as communication style, confidence levels, and work ethics contribute to burnout (Harrison et al., 2017; Knupp et al., 2018; McCreary, 2020). Burnout occurs when work demands outweigh the nurse's personal resources (Petitta et al., 2016). Poor work-life balance, having multiple jobs, taking little time for self-care, and family issues contribute to burnout development (Adib-Hajbaghery et al., 2012; Guo et al., 2019; Knupp et al., 2018; Rodriguez, Santos, & Sousa, 2017). Organizational environments with a lack of communication, ineffective teamwork, or inconsistent leadership also contribute to burnout. Such environments leave nurses fatigued, with a loss of control leading to poor nurse retention (Estryn-Behar et al., 2007; Garcia et al., 2019; McCreary, 2020; Nantsupawat et al., 2016). Environments with high nurse-to-patient ratios, consistent overtime, and reduced resources add to the problem (Kamal et al., 2019; Muldallal, Othman, & Hassan, 2017). Heavy workloads correlate with additional sick days. Fewer workdays lead to inadequate staffing, higher nurse-to-patient ratios, and increased risk of unsafe care (Garcia et al., 2019; Hall, Johnson, Watt, Tsipa & O’Connor, 2016; Rodriguez et al., 2017). Organizations with inadequate structure and policies tend to have chaotic work environments that lend themselves to burnout (Harrison et al., 2017; Rodriguez et al., 2017). Once it develops, burnout can lower the organizational commitment of its nurses (Nantsupawat et al., 2016). Conversely, organizations that support nurses' decisions, offer collaboration and cohesive teamwork can generate environments that offset burnout (Estryn-Behar et al., 2007). Outcomes of Burnout The consequences of burnout can be significant for nurses, patients, and organizations. Outcomes for nurses include emotional exhaustion, depersonalization, and low personal accomplishment (de Oliveira et al., 2019). Consequences for organizations include patient HOSPICE WORKER BURNOUT PREVENTION 9 safety issues, staff turnover, and poor patient satisfaction (Garcia et al., 2019; Hall et al., 2016; Mudallal et al., 2017: Rodrigues et al., 2017; Salvagioni et al., 2017). Emotional exhaustion is a condition of being physically and emotionally exhausted by work stress. This sense of fatigue is accompanied by feeling helpless, hopeless, and depressed (Mudallal et al., 2017). This exhaustion frequently develops following signs of compassion fatigue. Compassion fatigue is an indifference that develops in response to caring for others' needs repeatedly. It is characterized by a lack of energy and a sense of dread at coming to work. Signs of compassion fatigue are noted well before burnout, and if addressed early, can prevent burnout from developing (Compassion Fatigue, n.d.; Potter et al., 2010; Sanso et al., 2015). Depersonalization is a negative coping strategy used by nurses experiencing burnout involving distancing oneself from challenging patients or issues (Shirley, 2006). This distancing includes unfeeling and cynical behaviors that result in failure to form appropriate nurse-patient relationships (Kamal et al., 2016; Mudallal et al., 2017; Vander Elst et al., 2016). Rodriguez et al. (2017) note that it leads to unsafe behaviors and clinical errors that put additional pressure on nursing teams. Low personal accomplishment includes feeling inadequate, incompetent, and negatively viewing one's work (Mudallal et al., 2016). This decline in competence is correlated with nursing turnover (Nantsupawat et al., 2016). Additional health outcomes of burnout include anxiety, depression, insomnia, alcohol, substance abuse, and increased suicide risk (Otto, Hoefsmit, Van Ruysseveldt & Van Dam, 2019; Thomas-Sabado et al., 2010). Studies note that unaddressed burnout is linked to nurses' poor health, premature death, and suicide (Alderson, Parent-Rocheleau, & Mishara, 2015; Flaskerud & Lasser, 2020). According to Davidson, Zisook, Kirby, DeMichelle & Norcross HOSPICE WORKER BURNOUT PREVENTION 10 (2018), nurses are at higher risk of suicide due to repeated exposure to stress and knowledge of lethal means. Nursing burnout is associated with patient safety and quality care issues (Rodriguez et al., 2017; Sampson, Melnyk, & Hoying, 2020; Welp, Meier & Manser, 2016). Hall et al. (2016) note that medical errors and safety issues are outcomes of burnout. Garcia et al. (2019) note that burnout is correlated with patient safety issues 66% of the time. Organizational consequences of burnout include dissatisfied nurses and high nurse turnover (Vander Elst et al., 2016). According to Worcester (2014), burnout is a solid contributor to “workforce shortages” (p.1). Studies show that nurses with burnout often complain, express intentions to leave their jobs, and negatively affect the workplace culture (Nantsupawat et al., 2016; Potter et al., 2010). The cost for organizations to hire and train new nurses is substantial. However, losing the experience and contributions of nurses due to burnout is immeasurable (Martins Pereira et al., 2016; Vander Elst et al., 2016; Worcester, 2014). Burnout for Hospice & Homecare Workers Hospice care is a program that provides end-of-life care in patient homes and encourages family members to participate in care (Hospice, n.d.). It focuses on palliative care that alleviates suffering and improves the quality of life for the terminally ill (US Department of Health & Human Services, 2017). As rates of hospice and palliative care grow, the need for nurses with this expertise grows. According to the last known recorded numbers, nearly six million Americans received palliative care in 2014. Medicare provided for 1.49 million hospice patients in 2017, an increase of 4.5% from the previous year. With a growing elderly population, increasing cancer rates, and other chronic diseases, patients will suffer from a lack of hospice HOSPICE WORKER BURNOUT PREVENTION 11 and palliative care nurses (Kamal et al., 2016; Kavalieratos et al., 2017; National Hospice & Palliative Care Organization, 2018). Nurses caring for these patients are often overburdened and continually challenged (Kavalieratos et al., 2017; NHPCO, 2018; Slocum-Gori, Hemsworth, Chan, Carson & Kazanjian, 2011; WHO, 2020). Homecare and hospice nurses face unique challenges. Working alone, poor home conditions, lack of patient resources, and even aggressive patients add to work stress (Vander Elst et al., 2016). These nurses can feel isolated from peer support or struggle with communication issues with physicians or team members (Guo et al., 2019; McCreary, 2020; Slocum-Gori et al., 2011). Hospice patients’ symptoms tend to increase in severity in the last weeks of life. Critical situations can leave the best-trained nurses feeling incapable and frustrated (McCreary, 2020; Phongtankuel et al., 2019; Slocum-Gori et al., 2011). One distinct problem homecare and hospice nurses face is inadequate compensation (McCreary, 2020). Nurses are typically paid per visit but may need to spend more than reasonable time with severely ill patients and their families. Work often completed after hours includes documentation, answering physician calls, and coordination of patient care (Barker, 2011). Nurses who work more than 8 hours per day, or more than 40 hours a week, are 46% more likely to make work-related errors. This uncompensated time leads to low job satisfaction and, subsequently, burnout (McCreary, 2020; Rodriguez et al., 2017). Providing care in patient homes can lead to intense involvement. This can result in a blurring of appropriate patient/nurse boundaries (Kavalieratos et al., 2016). Sharing personal phone numbers and taking calls after hours adds to work burdens in this population of healthcare workers (Gina Price, personal communication, January 31, 2020). Well-intentioned nurses are left coping with higher emotional loads, leaving them vulnerable to burnout (Potter et al., 2010; HOSPICE WORKER BURNOUT PREVENTION 12 Vander Elst et al., 2016). Additionally, nurses who face repeated patient deaths can have unresolved grief or feelings of failure, leading to a diminished ability to empathize with patients' grief and loss (Potter et al., 2010). The stress and challenges associated with homecare and hospice nursing make burnout a significant organizational concern (Garcia-Campayo et al., 2015; Harrison et al., 2017). High levels of burnout are linked with three times the risk of homecare nurses intending to leave their jobs (Estryn-Behar et al., 2007; Nantsupawat et al., 2016). McCreary (2020) notes that home health nursing turnover is as high as 77%. The threat of nurses leaving the field or retiring early adds to potential workforce shortages and risks inadequate end-of-life care (Barker, 2011; Kavalieratos et al., 2017; Potter et al., 2010). Solutions for Nursing Burnout Addressing burnout in nurses requires a multifaceted approach to identify those at risk, introduce healthy coping strategies, and change work environment factors. Organizational solutions for burnout include encouraging individual health strategies and making organizational changes (Cortes, 2019; Garcia-Campayo et al., 2015; Hersch et al., 2016; Jacques et al., 2017; Jones, 2005; King et al., 2008; Otto et al., 2019; Sampson et al., 2020). The first step in addressing burnout is recognizing it. Identification of burnout can be through surveys or close observation of work patterns. The Maslach Burnout Inventory is a frequently used survey to identify burnout (Maslach & Jackson, 2019). It looks at factors that can identify individual components of burnout. Organizational leaders can assess burnout by observing factors such as work patterns, the number of call-outs, increased errors, decreased productivity, and staff turnover (Estryn-Behar et al., 2007; Garcia-Campayo et al., 2015; Hall et al., 2016; Mudallal et al., 2017; de Oliveira et al., 2018; Otto et al., 2019; Rodrigues et al., 2017). HOSPICE WORKER BURNOUT PREVENTION 13 Burnout can be noted by encouraging workers to discuss feelings of stress and exhaustion or hearing how they value their work contributions (Kavalieratos et al., 2017; Pavelkova & Buzgova, 2015). Organizations can evaluate workplace factors that influence the development of nurse burnout, such as adequate staffing, nurse workloads, resource allocation, and educational opportunities (Adib-Hajbaghery et al., 2012; Mudallal et al., 2016; Nantsupawat et al., 2016). Organizations can select and support leaders who can provide a supportive work environment (Feldman, 2016; Worchester, 2014). Nurses in hospice and palliative care will inevitably face emotional challenges (Kavalieratos et al., 2017; Pavelkova & Buzgova, 2015). Jones (2005) asserts the need for daily self-awareness checks to maintain their overall health. Otto et al. (2019) note that proactive behaviors of goal-setting, mindfulness, physical activity, and adequate rest can prevent burnout altogether. Those taking vacations or time to decompress have an added protective factor against developing burnout (Kamal et al., 2019; Pavelkova & Buzgova, 2015). Healthcare workers who use mindfulness are more self-aware and thus can cope with the demands of caring for others (Perula-deTorres et al., 2019). Kavalieratos et al. (2017) addressed the need for organizations to create policies that relieve the strain of caring for hospice patients. Pavelkova & Buzgova (2015) suggested forming team assignments for challenging or heavy patients. Worcester (2014) emphasized relationship-focused leadership fostering shared goals and problem solving over task-focused leadership. Other studies note that organizational and cultural changes that support teamwork, communication, and peer-to-peer support can offset the development of burnout (Lacerenza, Marlow, Tannenbaum & Salas, 2018; Pavelkova & Buzgova, 2015). HOSPICE WORKER BURNOUT PREVENTION 14 Teamwork is the foundation of healthy staff relationships. Ideal teams utilize individual strengths and skills to focus on common goals (Cortez, 2019). Trust and peer-to-peer collaboration are features of teamwork that prevent burnout in nurses (Lacerenza et al., 2018; Pavelkova & Buzgova, 2015). Teambuilding is defined as a process to assist a group of people to work more effectively together (Teambuilding, n.d.). According to Mager & Lange (2014), teambuilding activities enhance communication and teamwork. Additionally, when team members meet outside of work duties, it positively influences the work atmosphere (Abellanoza et al., 2018). Such activities foster peer-to-peer relationships, allowing healthcare workers to be vulnerable, receive needed support, reduce stress levels, and prevent burnout (Pavelkova & Buzgova, 2015). A team debriefing is an opportunity for teams to meet and reflect on past experiences (Debrief, n.d.; Lacarenza et al., 2018). Debriefings are opportunities to discuss complex patient situations and provide feedback. Discussion of what has gone well and needs to improve should be encouraged. These meetings build emotionally connected work environments and strengthen team effectiveness through active learning. Effective teams have more significant outcomes than individual members' combined efforts working independently (Lacerenza et al., 2018). Burnout is a significant nursing practice issue found in homecare and hospice nursing. If not addressed, burnout among nursing staff can compromise care. Nurses risk patients’ health and well-being if they are not healthy themselves. Increased communication and teamwork can prevent burnout. HOSPICE WORKER BURNOUT PREVENTION 15 Quality Improvement Model Juran's Trilogy Model is chosen to guide this DNP project (DeFeo, 2019, Finkelman, 2018). This model is an improvement cycle that reduces the cost of poor quality by planning quality into improvement, focusing on the customer’s needs. The model's three main elements include quality planning, quality improvement, and quality control. Quality planning includes identifying the customers are, finding out what they need, and developing a product to meet the need. For this project, nurses are the customers facing burnout. Quality improvement uses a select process to create needed products. This includes implementing planned activities to achieve a goal. Quality control ensures that implemented processes result in the desired change. Quality control ensures sustainability by transferring the process to organizational leaders (DeFeo, 2019; Finkelman, 2018). Quality planning included asking leaders about current processes and designing interventions to offset burnout without interrupting daily nursing tasks. Quality improvement included implementing interventions that optimized communication using tools already in place. The interventions were evaluated to see if they met nurses’ needs. Quality control included the organization adopting the new process of nurses' meetings and taking the responsibility to continue its use (DeFeo, 2019; Finkelman, 2019). Project Implementation Plan Need or Gap Due to recent organizational changes, nurses and support staff in the Applegate Homecare and Hospice Ogden office face many stressors. The organization recently received a five-star rating and is at the top of the referral list at several area hospitals for homecare and hospice admissions. A subsequent increase in patient admissions caused an influx of staff, HOSPICE WORKER BURNOUT PREVENTION 16 including eight additional nurses, four new CNA’s, a chaplain, and a medical social worker. The nursing staff who provides care to hospice and homecare patients have not had time to get to know one another and have struggled with effective communication. In addition, they have coped with ongoing stressors related to the COVID 19 pandemic, including isolation restrictions not allowing staff to meet in person (CDC, 2019). Nurses were unable to meet or debrief with peers except for incidental interactions in patient homes or by way of Zoom meetings. Consequently, there was a noted lack of communication, a lack of peer-to-peer support, and a lack of teamwork. Eighteen nurses were informally asked about overall satisfaction within the company. Three out of 18 nurses indicated that they had signs of burnout. The organization did not have a formal program to address these changing needs (Lacerenza et al., 2018; Maslach & Jackson, 2019). Expected Outcomes and Goals This DNP project's overall outcome was to decrease burnout among homecare and hospice nurses at Applegate Homecare & Hospice. Goals to reach this outcome included introducing a monthly nurses meeting, implementing teambuilding activities that promote trust and increase communication, and introducing quarterly debriefing sessions to increase peer-to-peer communication and support among staff. Organization and Setting Applegate Homecare & Hospice is a family-owned company that provides home health and hospice care in Ogden, Utah. The company’s mission highlights individualized, compassionate, and quality care and focuses on treating staff equitably over profitability. The company comprises seven office locations throughout the greater Utah area. This office regularly cares for 180-200 patients, with about 15% of their patients being hospice patients and HOSPICE WORKER BURNOUT PREVENTION 17 85% homecare patients. Applegate serves patients needing post-surgical or medical homecare, including wound care, IV medication management, physical and occupational therapy, and end-of-life hospice care. Aide and private duty services are provided for families caring for elderly family members. This project was implemented in the Ogden office (Applegate HomeCare & Hospice, 2019). Population The Ogden office employs 52 staff, including 11 registered nurses (RN) as case managers, three on-call RNs, two as-needed RNs, and two RN clinical supervisors. Nurses for this organization cover homecare and hospice visits. Eleven certified nursing assistants (CNAs) help provide care for patients who need daily care. There are eight physical therapists (PT), three occupational therapists (OT), a speech therapist, a chaplain, a medical social worker (MSW), two music therapists, and a volunteer coordinator. The office staff consists of four employees. Additionally, a physician and a nurse practitioner provide hospice services. These employees are overseen and directed by a CEO located in the Ogden office. Nineteen nurses participated in the project. One nurse subsequently left the organization, and at the end of the project, 18 nurses were on staff. Nurses range in age from 25-62 years old, with 15 female and three male nurses. Years of experience among nurses are between 2 to 45 years. Practice Change Plan The DNP-FNP leader's primary role was project manager (Finkelman, 2018; Reavy, 2016). Tasks included working with organizational leaders to plan, adapt, implement, and evaluate the project's interventions. Managing the project included open communication, flexibility, and successful planning. Stakeholder feedback helped guide project adaptations to fit nurse and organizational needs. Evidence-based strategies were identified and introduced to the HOSPICE WORKER BURNOUT PREVENTION 18 team, and changes were evaluated after implementation. Project priorities were collaboration, encouraging team members, and highlighting nurses' skills. This was done while working and remaining visible within the organization. Plans included incorporating successful interventions into the organization's structure as a sustainable change (Finkelman, 2018; Reavy, 2016). Implementation Initial quality planning included obtaining leadership buy-in and completing an organization assessment. Planning with stakeholders occurred between September and December of 2020. Specific areas of improvement and organizational needs were discussed. Leadership gave input on the team's strengths and weaknesses, and several project options were considered. Additional meetings with nursing management were held to obtain buy-in on the project and input on teambuilding experiences and debriefing topics. Once restrictions on meeting in person began, support from Information Technology personnel was obtained to ensure the success of virtual interventions (Lacerenza et al., 2018). Quality improvement included the implementation of teambuilding and communication interventions from January to April 2021. Evidence-based team building and communication interventions included a monthly nurses meeting, starting a communication channel, and a quarterly team debriefing. Leadership meetings prior to each intervention allowed leaders to give suggestions and feedback that helped prepare nurses to participate. Nurse leaders supported the project by participating in interventions and encouraging nursing staff to participate in monthly meetings (Lacarenza et al., 2018). The first teambuilding activity in January 2021 highlighted each nurse in a “Getting to Know You” activity (Bell, 2020, p. 2). Before the activity, nurses were interviewed using spotlight questions in Appendix C. The nurses' meeting was held via Zoom technology and HOSPICE WORKER BURNOUT PREVENTION 19 provided a format for interacting outside work duties. Over the next six weeks, nurses played the “Getting to Know You” activity once a week. Nominal gift cards were awarded to those guessing the identity of their coworkers based on the presentation of their skills and attributes. Each of the following months had additional teambuilding activities designed to highlight individual nurses' strengths and reinforce nursing skills. The monthly nurses' meeting was designed as a team debriefing in April. This debriefing provided a format for nurses to discuss how they were coping. Additionally, a communication channel was opened and named the Kudos Channel on an encrypted Tiger Connect app. A detailed description of monthly nurse meeting interventions is included in Appendix A (Bell, 2020; Pavelkova & Buzgova, 2015; Reiners, 2020). Evaluation and Data Analysis The impact of this DNP-led program on staff burnout was assessed with collected data from various sources. Data was collected from pre-and post-burnout inventories, team meeting notes, Kudos communications, nurse debriefing session, and feedback comments. Collected data were evaluated for responses indicating an increase in trust, expression of support, changes in communication patterns, and increased teamwork. A pre-and post-project survey using Survey Monkey was designed to assess for signs of emotional exhaustion, depersonalization, or devaluing one's work contributions. The surveys were administered anonymously via Tiger Text. It included seven closed questions using a 6-point Likert scale and two open response questions. Two weeks were allowed for nurses to respond to each survey. Included in the post-project survey was how nurses felt about recent teambuilding activities. Pre- and post-survey questions are noted in Appendix B. Data and comments were collected from the Kudos channel. Additional data included peer-to-peer HOSPICE WORKER BURNOUT PREVENTION 20 interactions, general feedback, and mentions of teamwork. Feedback comments were collected and evaluated throughout the project from team members and stakeholders. The last nurse's monthly meeting was designed as a team debriefing and was facilitated by the organization’s medical social worker. Seventeen nurses met and discussed the most pressing issues affecting them. The debriefing was an open format allowing nurses to share what has been challenging to cope with, what they have been grateful for, and what they are looking forward to in the future. Comments were collected and evaluated by topics of concern for this population of nurses (Lacerenza et al., 2018). Analysis Gathered data was organized, categorized, and analyzed. Quantitative data included evaluating the number of comments noting any trend or increase in communication. A comparison of the mean of pre-and post-survey responses was also completed. Qualitative comments and observations were organized and categorized into those indicating exhaustion or burnout, or those indicating increased teamwork, and expressions of support. Pre- and post-survey data were quantitatively compared for mean responses and any changes in response to the project. Findings The pre-intervention burnout inventory was administered to all nurses, with eight nurses responding. Higher scores in the first three questions of the survey would reflect higher levels of burnout, while lower scores in questions 4, 5, and 6 indicated burnout. The pre-inventory results indicated three nurses felt emotional exhaustion, with two having potential emotional exhaustion. The post-intervention burnout inventory was administered to all nurses, with ten of them responding. Two nurses had responses indicating potential emotional exhaustion. Pre-and post-HOSPICE WORKER BURNOUT PREVENTION 21 burnout inventory responses were compared to determine the effectiveness of the quality improvement project. Nine out of ten nurses indicated that recent team building activities increased their satisfaction at work. The mean average of pre and post burnout inventory questions showed no notable differences. Pre- and post-survey responses are compared in Appendix D, Table 1. The first free text survey questions asked, “What is going well at work?” Though no questions in the survey mentioned communication or teamwork, answers to “What is going well at work?” free-text comments included topics of teamwork, communication, and work processes. When pre-and post-intervention survey responses to this question were compared, three nurses felt that communication was going well, but two fewer indicated teamwork was going well. Four nurses noted that work processes were going well. One nurse wrote feeling “less pressure to take on more work.” The comparison of pre and post-survey answers to this question are noted in Appendix D, Table 2. Answers to the second free text pre-intervention question, “What needs to improve at work?” had answers of communication, teamwork, work processes, with two nurses indicating they were unsure. Compared with the post-intervention survey responses to the same question, only two nurses indicated communication needed to improve, while teamwork did not change. An indicator of the project's impact includes that more than half of the responses indicated nothing needed to improve post-intervention. A comparison of responses from the pre-and post-intervention surveys is represented in Appendix D, Table 3. More than ninety comments were collected from the Kudos channel during the project. This data was evaluated for supportive statements directed to individuals. Initially, several employees posted positive comments about the work of their peers. Over the course of the HOSPICE WORKER BURNOUT PREVENTION 22 project, fifteen individuals were mentioned by name. In March, a change in the comments was noted. Comments shifted from individuals to positive comments about the team. These comments gradually increased in frequency. Post-project follow-up data were collected to determine if the channel was still being utilized. More than 20 comments were noted post project in June, with no indication that the Kudos channel use had slowed. This data is represented in Appendix D, Table 4. The team debriefing had 17 nurses attending the meeting. A total of 33 interactive comments were exchanged. Responses were organized according to themes. Three comments mentioned negative situations or feelings. Ten of the comments were positive. Fifteen comments included nurses sharing coping mechanisms and five comments related to an appreciation for the team. Overall, 90% of the debriefing comments freely shared were positive. One nurse who had left the company for a time specifically mentioned how the company had changed since she had returned to working there. She noted, "We were always short-staffed before. It has been good to come back, to have an abundance of nurses, and to have the help that we give each other." A representation of debriefing comments can be found in Appendix D, Table 5. Overall, qualitative feedback from staff and leadership was enthusiastic and positive. Feedback that helped evaluate the project impact includes the following comments: • “I have not even met some of these nurses. What a great way to learn about each other.” • “What a wonderful concept. Thanks for sharing.” • “Thank you for your comments today. I really needed that.” • “It is fun to see things about our nurses' personal lives. It humanizes them.” • “There has been a positive response (at the office) from the nurses to the HOSPICE WORKER BURNOUT PREVENTION 23 games at the nurses' meetings.” Evaluation of Process Overall, this quality improvement project positively impacted the nurses in this organization. Project outcomes were reviewed with organizational leaders and stakeholders, and it was determined that goals and outcomes were met. Goals to implement teambuilding activities at monthly nurses meetings and a Kudos channel successfully increased communication and promoted a team-centered focus. The primary outcome of decreasing burnout among homecare and hospice nurses was met. Discussion Implications for Practice The overall impact of this DNP project on organizational policy and population health is positive. Introducing a new policy of monthly nurse meetings has increased communication among the team and provided a format for interpersonal interaction among nurses. The staff has had time to get to know one another, and peer-to-peer communication necessary to build and maintain strong teams has increased. The Kudos channel has helped staff note coworkers' contributions and has increased positive communication and recognition. These interventions have positively affected trust and teamwork within the organization. Using evidence-based organizational practices and interprofessional collaboration can increase teamwork and communication and offset burnout. Quality control measures indicating a stronger team have led Applegate leadership to continue using the monthly nurses' meetings and Kudos channel to maintain communication. These sustainable changes have given nurses ongoing support and strengthened the team. This project contributes to NP and primary care practice by reminding providers that nurses are subject to burnout. Watching for signs of burnout in oneself and among HOSPICE WORKER BURNOUT PREVENTION 24 staff and taking steps to address it is critical for maintaining a healthy workforce. Simple interactions help maintain open communication and human connections necessary to offset the development of burnout. Recommendations This DNP project implemented teambuilding activities designed to prevent burnout by increasing communication and teamwork. Teambuilding activities helped nurses break down barriers, get to know one another better, and increase peer-to-peer communication. Creating opportunities for positive reinforcement of individuals developed into supportive statements of the whole team. Trust began to form, and 68% of the nurses were vulnerable and shared during an initial team debriefing. The strengths of this project have included organizational and stakeholder support, ease of incorporating technology into the interventions, and the willingness of staff to get to know their peers. Digital media made collecting comments and qualitative data for this project manageable. The team's strengths include a remarkable variety in skill sets and a passion for caring for their patients. Challenges included time management, with interventions needing to be efficient. Team leaders worked to select an optimal day and time for nurse meetings. Nurses were notified ahead of time, and interventions were planned and organized to be time-efficient. Leadership ensured that meetings were announced in advance, reminded nurses to arrange their schedules to participate, and made monthly nurses meeting attendance a requirement. However, patient loads kept some nurses busy and unable to participate. Adaptations to this project were necessary due to the COVID 19 pandemic. All interventions were made virtual, as social distancing regulations made it impossible to meet in HOSPICE WORKER BURNOUT PREVENTION 25 person. While activities would have been ideal in person, virtual adaptations proved effective and convenient. Planning and coordination took place over Zoom meetings. Communication about when meetings and interventions occurred in AM meetings or by way of text. Nurses needed to be encouraged to keep their cameras on and fully participate during Zoom meetings, which would have been unlikely if the team had met in person. Evaluating and addressing burnout is complicated. This DNP project indicates that organizational interventions focused on building strong teams and increasing communication can positively impact nurses. Recommendations include using organizational time to incorporate strategies that focus on personal interaction, communication, and team support to help nurses offset burnout. Incorporating debriefings can allow nurses to process difficult situations while having a teambuilding and protective effect against burnout. This organization can build on this project by offering it to their other offices in Utah. Monthly nurses meetings with a human connection component are sustainable interventions. Human Resources or office leadership within any organization can use strategies to spotlight individual employees' strengths, make connections among team members, increase communication, and work more cohesively as a team. Online and in-person activities can be adapted to meet each office or team's needs. Conclusion Burnout is a real and ongoing problem among healthcare workers. Unaddressed burnout results in signs of emotional exhaustion, depersonalization, feelings of low personal accomplishment, and poor patient outcomes. It leads to organizational problems of increased employee turnover and decreased patient satisfaction. Homecare and Hospice nursing has been identified as a field with particular risks for nurse burnout. Healthcare organizations need to HOSPICE WORKER BURNOUT PREVENTION 26 have an ongoing strategy to identify and address possible nursing burnout. Evidence-based strategies led by a DNP-prepared leader and organizational interventions that support nurses can easily be incorporated into various healthcare settings. This project allowed team members to get to know one another better, increased communication, promoted teamwork, increased peer-to-peer support, and offered an opportunity to debrief. These interventions impacted the incidence of nurse burnout in this population. Technological tools and applications offer new and unique opportunities to increase communication, foster connections among team members, and offset the development of burnout. HOSPICE WORKER BURNOUT PREVENTION 27 References Abellanoza, A., Provenzano, H. N., & Gatchel, R. J. (2018). Burnout in ER nurses: Review of the literature and interview themes. Journal of Applied Biobehavioral Research, 23(1), 1-16. https://doi-org.hal.weber.edu/10.1111/jabr.12117 Adib-Hajbaghery, M., Khamechian, M., & Alavi, N. M. (2012). 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The interplay between teamwork, clinicians' emotional exhaustion, and clinician-rated patient safety: A longitudinal study. Critical Care (London, England), 20(1), 110-120. doi:10.1186/s13054-016-1282-9 Worcester, D. (2014, Spring). Burnout and the registered nurse: The implications of leadership style. ANA-Maine Journal, 10(2), 12-16. https://link-gale-HOSPICE WORKER BURNOUT PREVENTION 36 com.hal.weber.edu/apps/doc/A369064859/AONE?u=ogde72764&sid=AONE&xid=7cd8cb6a World Health Organization (WHO). (2019). Burn-out an “occupational phenomenon”: International classification of diseases (11th ed.). https://www.who.int/mental_health/evidence/burn-out/en/ HOSPICE WORKER BURNOUT PREVENTION 37 Appendix A Quality Improvement Team Building & Debriefing. Applegate stakeholders agreed to implement a nurse's monthly meeting. Team building and team training sessions occurred once a month for one hour via Zoom or in-person as allowed by current COVID-19 restrictions (CDC, 2019). Once a month from January and April 2021, the following activities were implemented during the nurses' monthly meetings. 1. Team building - In January 2021, a “getting to know you” activity was introduced. This activity's goal was to get nurses to engage, interact, and communicate through text or email. Each nurse was introduced with an employee spotlight (Reiners, 2020). Over the following six weeks, spotlight clues were sent out about individual nurses. The first person to identify their teammate correctly won a $5.00 gift card to Starbucks or Maverick as a reward (Bell, 2020). This activity was introduced at the nurses' monthly meeting, and every nurse was highlighted during the six weeks. Discussion of things that nurses had in common and their diversity occurred during the first meeting (Cortes, 2019). These interventions are intended to increase team orientation and build trust (Kaiser & Westers, 2018). 2. Team Building and Communication – In January 2021, a communication channel was opened and named the Kudos Channel on an encrypted Tiger Connect app. This channel was made available to all staff within the organization. It was introduced as a place where encouragement, compliments from patients or families, thanks, or noting when individuals go above and beyond could be shared. HOSPICE WORKER BURNOUT PREVENTION 38 3. Team Building - In March 2021, an interactive game highlighting individual nurses' strengths was played utilizing the Kahoot app over Zoom technology (Eastern Illinois University, 2019; Jaramillo, 2020). The game was interspersed with clinical knowledge and skill reinforcement. Team members played three rounds, engaging in the game's competitive nature. Prizes were awarded to winners, and team members were encouraged to interact with one another in a relaxed atmosphere (Bell 2020: Reiners, 2020). 4. Team debriefing. In April 2021, an MSW facilitated Team Debriefing was held. The debriefing topic selected by organizational leadership was, “How well are nurses coping after a year of the COVID pandemic?” Preparatory meetings with leadership were held before the debriefing. The discussion focused on nurses’ responses to recent changes. Seventeen nurses participated, with 11 sharing some of their struggles over the past year. Response from stakeholders was encouraging, with suggestions that team debriefings be held more frequently rather than once every three months (Lacerenza et al., 2018). HOSPICE WORKER BURNOUT PREVENTION 39 Appendix B Pre-Survey and Post-Survey Burnout Inventory Questions Likert Scale 1 – Strongly Agree 2 – Agree 3 – Somewhat Agree 4 – Neither agree nor disagree 5 – Somewhat disagree 6 – Disagree 7 – Strongly Disagree Pre-Survey Questions 1. I have the materials and resources I need to do my job well. 2. I receive recognition or praise for doing my job well or picking up extra work to help out. 3. I have someone at work I can turn to when I need support or advice 4. I feel emotionally drained by my work. 5. I do not care about what happens to some patients. 6. I do not feel that the work I do is significant. 7. My supervisor or someone at work cares about me as a person. 8. What do you feel is going well at work? 9. What do you feel needs to improve at work? Post-Survey Questions 1. I have the materials and resources I need to do my job well. 2. I receive recognition or praise for doing my job well or picking up extra work to help out. 3. I have someone at work I can turn to when I need support or advice. 4. I feel emotionally drained by my work 5. I do not care about what happens to some patients. 6. I do not feel the work I do is significant. 7. How much have recent ream building activities increased your overall satisfaction at work? 8. What do you feel is going well at work? 9. What do you feel needs to improve at work? HOSPICE WORKER BURNOUT PREVENTION 40 Appendix C Informal Nurse Spotlight Interviews Before the first intervention, 16 nurses were interviewed. One of the nurses left before the beginning of the interventions, and another left mid-project. As more nurses were hired, they were included in the ongoing interventions, but no pre-project data was collected. A total of 19 nurses were interviewed by the end of the project. The following is a list of questions they were asked. Spotlight Interview Questions – Getting to Know You 1. How many years have you worked in your field? 2. What area of nursing do you feel you shine or have particular expertise in? 3. What information would you like to share about your background? 4. List 2 nursing skills you are good at. 5. What do you bring to your job that you are proud of? 6. What do you like to do to unwind after work? 7. What is your favorite food or restaurant? 8. What is one thing you cannot resist? 9. What is your greatest fear? 10. Where is the best place you have traveled to? 11. What is the weirdest job you have ever had? 12. What would you do if you were not a nurse? 13. What is something that might surprise us about you? 14. What music do you like to listen to? 15. What is something you absolutely hate doing? 16. Do you have a favorite movie or book? HOSPICE WORKER BURNOUT PREVENTION 41 Appendix D Table 1 Table 2 1.3 1.8 1.3 3.4 6.6 1.5 1.4 1.9 1.3 2.9 6.8 6.7 2 0 1 2 3 4 5 6 7 8 Q1 Q2 Q3 Q4 Q5 Q6 Q7 Pre and Post Burnout Invenory Results Pre-Survey Post-Survey 2 5 1 3 4 COMMUNICATION TEAMWORK WORK PROCESSES What is going well at work? Pre Inventory Post InventoryHOSPICE WORKER BURNOUT PREVENTION 42 Appendix D continued Table 3 Table 4 4 1 2 1 2 5 COMMUNICATION TEAMWORK WORK PROCESSES UNSURE NOTHING What needs to improve at work? Pre Inventory Post Inventory 0 10 20 30 40 50 60 70 Jan March April June Number of Comments Kudos Channel; Comment Themes Regarding Individuals Regarding Team Reinforcing Agreement CommentsHOSPICE WORKER BURNOUT PREVENTION 43 Appendix D continued Table 5