Digital Repository Doctoral Projects Spring 2022 Implementing a Resiliency Coaching Program to Descrease Burnout in Front-line Nurses Jamie D’Ausilio Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON D’Ausilio, J. (2022). Implementing a resiliency coaching program to decrease burnout in front-line 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. Implementing a Resiliency Coaching Program to Decrease Burnout in Front-line Nurses by Jamie D’Ausilio 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 April 7, 2022 Jamie D’Ausilio DNP, MSN, RN, CRRN, NEA-BC (signature) Faculty Advisor/Committee Chair Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE (signature) Graduate Programs Director Note: If the thesis/project is submitted by the faculty member, please have the student sign this form as well. IMPLEMENTING A RESILIENCY COACHING 1 Implementing a Resiliency Coaching Program to Decrease Burnout in Front-line Nurses Jamie D’Ausilio Weber State University Annie Taylor Dee School of Nursing Doctorate of Nursing Practice Project Faculty Project Lead: Dr. Melissa Neville Norton Project Consultant: Dr. Luanna Schmelter Date of Submission: March 18, 2022 IMPLEMENTING A RESILIENCY COACHING 2 Abstract Nationally, front-line nurses report increased workplace burnout and decreased resiliency due to factors such as poor management, lack of teamwork, staffing, mandatory overtime, and lack of resources (Bakhamis et al., 2019). A gap analysis at Intermountain Healthcare identified a need for a Doctorate in Nursing Practice (DNP) project that addressed resiliency skills and early identification of workplace burnout of front-line nurses. This process improvement project involved front-line nurses and nurse managers from the six rehabilitation units at Intermountain Healthcare. Front-line nurses participated in a 20-minute training on recognizing low resiliency and self-care measures. Nurse managers participated in a two-part training on resiliency coaching. In addition, front-line nurse participants were asked to complete baseline and follow-up surveys that measured resiliency and burnout. A resiliency coaching program can positively impact a front-line nurse's resiliency, engagement, confidence, and knowledge. However, a focus on resiliency does not necessarily equate to improved burnout symptoms and decreased turnover. Keywords: Burnout, resiliency, coaching, joy, healthy work environment, nurse, nurse manager, front-line nurse. IMPLEMENTING A RESILIENCY COACHING 3 Table of Contents Introduction ......................................................................................................................................6 Background and Problem Statement ....................................................................................8 Diversity of Population and Project Site ..............................................................................8 Significance for Practice Reflective of Role Specific Leadership .......................................9 Literature Review...........................................................................................................................10 Framework .........................................................................................................................10 Search Methods ..................................................................................................................12 Synthesis of Literature ...................................................................................................................13 Burnout ..............................................................................................................................13 Causal Factors of Workplace Burnout ...............................................................................13 Strategies to Decrease Workplace Burnout .......................................................................19 Finding Joy in the Workplace ............................................................................................19 Promoting Employee Resiliency in the Workplace ...........................................................21 Coaching ............................................................................................................................22 Discussion ..........................................................................................................................25 Implications for Practice ....................................................................................................26 Project Plan ....................................................................................................................................26 Project Design ....................................................................................................................26 Needs Assessment of Project Site and Population .............................................................27 Cost Analysis and Sustainability of Project .......................................................................29 Project Outcomes ...............................................................................................................30 Consent Procedures and Ethical Considerations................................................................30 IMPLEMENTING A RESILIENCY COACHING 4 Instruments to Measure Effectiveness ...............................................................................32 Project Implementation ..................................................................................................................35 Intervention ........................................................................................................................35 Project Evaluation ..........................................................................................................................42 Data Maintenance/Security ................................................................................................42 Data Collection and Analysis.............................................................................................42 Findings..............................................................................................................................51 Quality Improvement Discussion ..................................................................................................77 Translation of Evidence Into Practice ................................................................................78 Implications for Practice and Future Scholarship ..............................................................79 Conclusion .....................................................................................................................................83 References ......................................................................................................................................84 Appendix A. Strength, Opportunities, Weaknesses, and Threats (SWOT) Analysis ....................95 Appendix B. Cost Analysis, Budget, and Return on Investment ...................................................96 Appendix C. Weber State and Intermountain IRB Approval ........................................................97 Appendix D. Resiliency Menu .......................................................................................................98 Appendix E. Single Item Burnout Survey ...................................................................................100 Appendix F. Brief Resiliency Scale .............................................................................................102 Appendix G. Team STEPPS® – ASTD Coaching Self-Assessment Form ..................................104 Appendix H. Approval Email ......................................................................................................106 Appendix I. Press Ganey® Engagement Survey ..........................................................................107 Appendix J. Intermountain Training Questionnaire (Pre and Post) .............................................114 Appendix K. Intermountain Team Caregiver Rounding and Index-3 Leader Assessment .........116 Appendix L. Resiliency Coaching Program – Step by Step ........................................................118 IMPLEMENTING A RESILIENCY COACHING 5 Appendix M. Coaching Guide .....................................................................................................119 Appendix N. Resiliency Coaching Program Booklet ..................................................................121 Appendix O. Timeline .................................................................................................................122 Appendix P. Survey Request Email .............................................................................................127 IMPLEMENTING A RESILIENCY COACHING 6 Implementing a Resiliency Coaching Program to Decrease Burnout in Front-line Nurses The National Academies of Sciences, Engineering, and Medicine [NASEM] (2019) estimates that between 34% and 54% of nurses experience burnout symptoms. Nurse burnout remains a priority for healthcare organizations because it affects nurses' health, workforce turnover and poses a potential detriment to patient health outcomes (Bakhamis et al., 2019). A nurse manager has 24-hour responsibility for the supervision and management of front-line nurses to ensure high-quality patient care delivery (Press Ganey, 2017). Personal and organizational factors, which have been shown to increase nurse manager burnout, include staffing concerns, legislative changes, family concerns, budget fluctuations, and an inability to shut off work in their personal lives (Kelly & Adams, 2018). When a nurse manager is experiencing Burnout, it can deleteriously affect front-line nurse engagement, which leads to more accidents, increased healthcare costs, and poor patient experience (Seichter, 2018). The Institute of Healthcare Improvement's (IHI) Quadruple Aim of Healthcare intends to change the healthcare system by improving workforce engagement and supporting joy in the workplace (Sikka et al., 2015). The nurse manager plays a vital role in creating an engaging work environment where the front-line nurse feels supported as a human being to provide safe patient care (Labrague et al., 2017). Nurse managers support the IHI Quadruple Aim by promoting a healthy work environment, advocating for patient-centered care, and acting as a change agent (Batcheller et al., 2017). However, a nurse manager experiencing Burnout may be less effective in their job responsibilities through lowered emotional intelligence and poor decision-making (Kelly et al., 2019). Nurse managers have an essential role in creating the work environment that supports front-line nurse engagement (Press Ganey, 2017). Engagement is the nurse's commitment and satisfaction with their job, organization, and profession (Dempsey & IMPLEMENTING A RESILIENCY COACHING 7 Reilly, 2016). Low front-line nurse engagement correlates with safety, quality, and patient experience outcomes and can affect the nurses' perception of safety and nurse managers' effectiveness (Press Ganey, 2020). Nurse managers should be competent in the early identification of job-related Burnout in themselves (Kelly & Adams, 2018). Evidence demonstrates that the early identification of job-related Burnout is essential because chronic exposure to Burnout can lead to stress, job dissatisfaction, and turnover (Membrive-Jimenez et al., 2020). A burnt-out nurse manager is a flawed role model for front-line nurses, puts the work environment at risk, and increases front-line nurses' likelihood of experiencing Burnout (Kelly & Adams, 2018). When the nurse manager recognizes job-related Burnout, they can decrease the front-line nurse experience with Burnout. Coaching is a way to develop others to achieve more through education, goal setting, and guidance (Milner et al., 2020). Coaching is a tool that can improve nurse managers' competency in the early identification and management of nurse burnout for themselves and those they lead (Warshawsky, 2018). Nurse managers can use coaching to promote change by ensuring front-line nurses are similarly trained in the early identification of burnout and resiliency. Front-line nurse burnout has been associated with increased care costs, poor health outcomes, and lower patient satisfaction (Bodenheimer & Sinsky, 2014). Monetary investment in developing coaching competency in nurse managers leads to improved patient satisfaction, better staff engagement, and decreased turnover (Seitcher, 2018). This doctoral project aims to create an evidence-based educational and coaching program for nurse managers on Inpatient Rehabilitation Units (IRU) at Intermountain Healthcare. Creating and implementing a coaching program on the early identification and management of nurse burnout will support the IHI Quadruple Aim initiative to help nurse managers and front-line nurses identify and manage job-related Burnout. IMPLEMENTING A RESILIENCY COACHING 8 Background and Problem Statement Burnout is considered a healthcare crisis that affects nurse managers, front-line nurses, and patient outcomes (NASEM, 2019). Nurse manager burnout is the fourth most common reason for leaving their position (Warshawsky & Havens, 2014). The decreased effectiveness from nurse manager burnout leads to decreased job satisfaction, poor financial management, decreased front-line nurse engagement, and poor clinical outcomes (Kelly et al., 2019). The prevalence of Burnout among front-line nurses ranges from 10% to 70% (Lyndon, 2016). A 2013 study of front-line nurses found that 51% thought their job affected their health and 35% felt like leaving their position (Young et al., 2016). Patient health outcomes, such as hospital-acquired infections, are at risk of increasing when front-line nurses are burnt out (Membrive-Jimenez et al., 2020). Burnout is associated with fatigue, exhaustion, inability to concentrate, and detachment, leading to increased patient care errors or omissions (Bakhamis, 2019). Creating and implementing a coaching program directly affects nurse managers because they will have the tools to recognize Burnout in themselves and the front-line nurse. Likewise, a nurse manager coaching program will directly affect the front-line nurses because their leader will have the tools needed to identify and respond to Burnout. As a result, patient health outcomes will improve by addressing nurse manager and front-line nurse burnout. Diversity of Population and Project Site Creating and implementing a resiliency coaching program will benefit multiple stakeholders, including nurse managers, front-line nurses, and IRU patients. This project focuses on the organizational role of the nurse manager, which indirectly affects patient care. By supporting nurse managers through coaching, they will utilize what they learn to support their front-line nurses leading to improved job satisfaction and joy in the workplace (Godfrey et al., IMPLEMENTING A RESILIENCY COACHING 9 2014). As a result, staff engagement should increase, improving patient safety, quality of care, and patient satisfaction. An IRU differs from a medical-surgical unit because the patients' admission is to learn mobility, daily living activities, cognitive, and medical skills to be independent at home. The atmosphere is one of teamwork and collaboration amongst the different disciplines. The stress that staff experience is maintaining a patient's therapy schedule and still meeting the patients' medical needs. This project will meet the diverse needs of nursing staff, nurse managers, and locations. Front-line nurses and managers working in the IRUs come from various backgrounds and can experience Burnout at any time. Nurse managers will receive education on recognizing Burnout in themselves and others. To ensure that nurse managers can assist a front-line nurse through a burnout crisis, they will obtain coaching training. While the IRU sites are across the state of Utah, each nurse manager will receive the same education. Local adaptations will be encouraged to ensure that the diverse needs of the front-line nurse are addressed. The resiliency training will incorporate protective factors from different cultures, and the coaching training will include cultural norms of communication, such as preferred distance, eye contact, and physical touch. By implementing this program, front-line nurses will feel supported, committed, and satisfied, while nurse managers will feel connected, empowered, and engaged. Significance for Practice Reflective of Role-Specific Leadership The Association of American Colleges of Nursing [AACN] (2006) Essential VI: Interprofessional Collaboration for Improving Patient and Population Health Outcomes provides the foundational skills of collaboration and communication needed to build relationships and coach others on their journey. A doctorally prepared nurse leader's responsibility is to ensure the translation of evidence into practice (AACN, 2006). As a nurse leader and regional director, it is IMPLEMENTING A RESILIENCY COACHING 10 critical to ensure that nurse managers' education is incorporated into their practice. Additional leadership skills, such as consultation and facilitating change, will be essential to incorporate into the coaching program (AACN, 2006). This project provides a foundation for future practice scholarship by teaching leaders to utilize coaching and implement what they have learned. Literature Review and Framework This section will review the evidence-based practice framework and literature search methods used to develop this DNP project. Topics explored in the literature synthesis include Burnout, joy, resilience, and coaching. Finally, a critical analysis of the evidence, supporting nursing practice, and applying it to this DNP project will be discussed. Framework The John Hopkins Nursing Evidence-Based Practice (JHNEBP) Model provides the framework for creating and implementing a resiliency coaching program to decrease Burnout in nurses (Dang et al., 2018). The JHNEBP's purpose is to ensure the latest research and best practice is incorporated at a systems level (Dang et al., 2018). Best practice integration is accomplished through problem-solving, teamwork, and constant inquiry and modification of processes (Dang et al., 2018). The JHNEBP framework begins with an inquiry, followed by a cadence of practice and learning, resulting in best practice implementation. Step one, inquiry, starts with curiosity about a specific problem or evidence-based practice (Dang et al., 2018). Inquiry is the catalyst to the second step, which involves practice and learning. Step two is called the Practice Question, Evidence, and Translation (PET) process and is where a majority of the framework is detailed. During the practice question phase, the team is identified, the problem is clarified, the team's responsibilities explained, and meetings scheduled (Dang et al., 2018). Research is conducted IMPLEMENTING A RESILIENCY COACHING 11 during the evidence phase, the evidence is appraised, summarized, synthesized, and practice recommendations are created (Dang et al., 2018). The project's feasibility is evaluated during the translation phase, and an action plan is created. The action plan is then implemented, evaluated, and modified. During implementation, a pilot site is chosen to trial the recommendations and provide feedback about the process (Dang et al., 2018). Then the change is evaluated for positive outcomes and progress towards goals (Dang et al., 2018). Feedback is utilized to modify the action plan, and then the change is implemented on a broader scale if appropriate (Dang et al., 2018). Communication to key stakeholders includes the project implementation, results of change, and outcomes obtained (Dang et al., 2018). These two steps involve insight into a practice problem, identifying evidence-based practice, and translating evidence into practice (Dang et al., 2018). Once best practice has been identified and implemented, nurses should be encouraged to challenge the status quo, question practices, and implement creative solutions (Dang et al., 2018). Inquiry launches the JHNEBP model into another round of practice questions, evidence, and translation processes to incorporate best practice (Dang et al., 2018). The JHNEBP framework is the foundation to create and implement a resiliency coaching program to decrease Burnout in front-line nurses and nurse managers. The DNP student inquired about utilizing coaching to improve resiliency and decrease Burnout in front-line nurses and nurse managers. The JHNEBP Model will guide the DNP student utilizing the PET Process. During the Practice Question phase, the DNP student will define the problem, refine the EBP question, identify key stakeholders. Having a team focus ensures that multiple perspectives are engaged and ensures robust answers to problem questions. The DNP student, the project leader, will form a team of nurse managers and schedule meetings. During the Evidence Phase, IMPLEMENTING A RESILIENCY COACHING 12 the DNP student will collect, appraise, summarize, and synthesize the evidence related to resiliency, coaching, Burnout, and joy in the workplace. This evidence summary is the foundation for recommending a practice change. During the Translation Phase, the DNP student will guide nurse managers to create an action plan and secure needed resources. A pilot unit will implement the recommendations. After implementation, feedback from front-line staff and nurse managers will be obtained and outcomes evaluated. Outcomes and findings will be disseminated to key stakeholders and identified next steps. This framework also allows for ongoing assessment of processes that ensure that practice recommendations are the most current evidence recommendations even after the change is initiated. Search Methods The Weber State Library allowed for a robust and comprehensive evidence search. Numerous databases such as PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane library, MEDLINE, Gale One File, and The Directory of Open Access Journals (DOAJ) were utilized to search for peer-reviewed journal articles and research. Keywords and phrases in this search included, "burnout", "job stress", "occupational burnout", "nurse manager", "nurse", "work-life balance", "engagement", "joy", "intent to leave", "inpatient rehabilitation", "coaching", "nurse leader", "satisfaction", "resilience", "hospital", "manager as coach". The initial search for Burnout in nurses resulted in 43,081 results. Inclusion criteria for this search included articles in English, Burnout, resilience, nursing, and management. Exclusion criteria for this search included non-English articles, nursing students, and specific self-care research. The remaining 48 articles were reviewed for relevancy to this DNP project's topics and evaluated for research design, level of evidence, strengths, weaknesses, and outcomes. IMPLEMENTING A RESILIENCY COACHING 13 Synthesis of Literature Burnout Burnout is a long-term reaction to work-related chronic emotional and interpersonal stressors that manifests as emotional fatigue, depersonalization, and a lack of personal achievement (Maslach et al., 2001). A recent Gallup poll revealed that 76% of US workers had experienced Burnout sometimes and 26% often at work (Wigert, 2020). In addition, this survey showed the top five reasons for burnout: unfair treatment, unmanageable workload, unclear communication from managers, lack of support, and excessive time pressures (Wigert, 2020). Burnout can go unnoticed and have severe consequences for health and job satisfaction (NASEM, 2019). Cańadas-De la Fuente et al. (2015) performed a qualitative study of front-line nurses (n = 676) in Spain and surmised that burnout could manifest as anxiety, depression, hostility, aggressiveness, isolation, apathy, distrust, and irritability. Other changes related to burnout included attitudinal, emotional, and behavioral (Cańadas-De la Fuente et al., 2015). Occupational injury, problematic substance use, and the risk of suicide are some of the personal repercussions of Burnout (NASEM, 2019). Burned-out staff can also feel career regret and inadequate professional growth due to their behavior (NASEM, 2019). In addition, burnout-related stressors often challenge integrity, the fundamental ethical principles central to clinicians' professional fulfillment (NASEM, 2019). Burnout can have severe implications and threaten staff members' health and well-being if left unnoticed. Causal Factors of Workplace Burnout The reasons for front-line nurse burnout are varied. The qualitative meta-synthesis by Bakhamis et al. (2019) identified numerous reasons for Burnout amongst nurses, including poor management, lack of teamwork, staffing, mandatory overtime, and lack of resources. The IMPLEMENTING A RESILIENCY COACHING 14 hospital's high-stress environment is a significant reason for nurses' Burnout (Bakhamis et al., 2019; Cańadas-De la Fuente et al., 2015). Exhaustion in nurses occurs from the high demand of the workload and a feeling of being overwhelmed and fatigued, leading to disengagement (Bakhamis et al., 2019). Depersonalization manifests as cynicism towards the organization's services, a lack of empathy, increased pessimism, and uncaring attitudes towards patients and coworkers (Cańadas-De la Fuente et al., 2015). Three factors are often associated with Burnout, including emotional exhaustion, depersonalization, and reduced personal accomplishment (Maslach et al., 2001). Emotional exhaustion is described in the literature as being emotionally and physically drained and tired (Cańadas-De la Fuente et al., 2015; Zhang et al., 2020). Signs and symptoms of emotional exhaustion include loss of control, feeling "stuck" in a situation, poor sleep, decreased motivation, and lack of energy (Bakhamis et al., 2019). Emotional exhaustion is a frequent manifestation of Burnout and has been shown to stimulate the body's stress response (Maslach et al., 2001). Whether environmental or psychological, a stressful situation can activate stress hormones that produce physiological changes such as high blood pressure, gastric ulcers, poor sleep, and decreased immune response (Chu et al., 2020). Chronic exposure to stress can lead to stroke, depression, and heart disease (Chu et al., 2020). Emotional exhaustion, a chronic stress response, should be identified early to minimize these adverse effects and proactive measures implemented. Proactive measures help bring about change rather than expecting it. Proactive measures help mitigate the harmful effects of emotional fatigue and chronic stress. Depersonalization involves feeling distant or indifferent towards others or the organization (Maslach et al., 2001). Bakhamis et al. (2019) identified excessive job demands as a core reason for depersonalization development. The burnout resulting from depersonalization IMPLEMENTING A RESILIENCY COACHING 15 develops from the person's attempt to adapt to the situation and relieve the stress he or she is experiencing at work (Membrive-Jimenez et al., 2020). A person experiencing depersonalization feels detached from the person or thing causing stress and will start to express cynical or negative behaviors (Bakhamis et al., 2019). This indifferent attitude can manifest as decreased interactions with peers, a lack of empathy, and negativity towards others (Maslach et al., 2001). Depersonalization can lead to serious insensitivity issues towards others, impacting relationships and degrading both the work environment and the quality of work performed (Membrive-Jimenez et al., 2020). Depersonalization results from feeling detached and can lead to severe interpersonal problems in the work environment. The feeling of reduced personal accomplishment has resulted in long-standing depersonalization and exhaustion (Maslach et al., 2001). Signs and symptoms of reduced personal accomplishment include an inability to express happiness, feel joy, or express pleasure (Bakhamis et al., 2019). Employees who experience reduced personal accomplishment may experience physical symptoms such as insomnia, pain, and gastrointestinal issues (Mealer et al., 2016). This stage of Burnout is characterized by a feeling of low self-worth, poor self-esteem, and insufficient ability to perform one's job (Maslach et al., 2001). Reduced personal accomplishment can lead to turnover and decreased staff satisfaction (Mealer et al., 2016). Reduced personal accomplishment is the culmination of depersonalization and exhaustion and can lead to a feeling of low self-worth and turnover. Burnout in Nursing Nurse burnout is a phenomenon experienced by nurses across the United States (NASEM, 2019). Burnout affects the nurses caring for patients daily and the leaders in charge of IMPLEMENTING A RESILIENCY COACHING 16 ensuring efficiency of care and patient safety. This section will cover how front-line nurses and nurse managers experience Burnout differently and the associated consequences. Front-line Nurse Burnout Front-line nurse burnout as a national problem has a prevalence that ranges from 10% to 70%, and studies report that it is steadily increasing (Lyndon, 2016). Shah et al. (2021) performed a national cross-sectional study (n = 50,273) that discovered that 35% of nurses reported Burnout as a reason for leaving their job. In addition, this study revealed that the prevalence of burnout in nurses in the Western United States was 16.6% compared to 30% in the Southeast United States (Shah et al., 2021). Utah nurses are also experiencing Burnout. A 2016 workforce survey of nurses across Utah (n = 1203) showed that 1.7% of the respondents identified burnout as a reason for leaving their position permanently (Nagelhout, 2016). In addition, 14% of respondents reported experiencing burnout in their work with nursing students due to the increased workload and misconceptions by nurse managers that a student decreases workload (Nagelhout, 2016). The IRUs at Intermountain Healthcare are experiencing a problem with front-line nurse burnout. Yearly, Intermountain Healthcare contracts with Press Ganey Incorporated to administer a staff engagement survey that includes 120 questions measured on a Likert scale from one to five. In 2020, the IRUs front-line nurse response to the question "I rarely experience burnout from my work" (n = 191) indicated an increase in burnout (μ = +0.70) and a decrease in resilience (μ = -0.23) from 2019 results. Specifically, Burnout scores from 2019 to 2020 decreased from 3.17 to 2.47, revealing a more burned-out staff. Moreover, resilience scores from 2019 to 2020 decreased from 4.29 to 4.06, indicating that this team has a decreased ability to recover and remain engaged even in challenging work circumstances. This team's overall engagement scores dropped dramatically (μ = -0.44) from 2019 to 2020, from 4.36 to 3.92, and IMPLEMENTING A RESILIENCY COACHING 17 moved from the highest engagement to a lower tier. Teams in the lower engagement tiers require significant support throughout the improvement process and may need additional training and coaching to effect change and improvement. Front-line nurse burnout has serious consequences that affect all aspects of healthcare. Nurse burnout leads to poorer patient outcomes, increased healthcare costs, and dissatisfaction (Bakhamis et al., 2019). A 10% increase in burnout scores is associated with increased hospital-acquired infections (Bakhamis et al., 2019). There is also a direct relationship between burnout to nurse turnover, lateral violence, compassion fatigue, and decreased engagement (Bakhamis et al., 2019). Nurse Manager Burnout Nurse managers are subject to demanding conditions and stress daily, resulting in long workdays and difficulty balancing work and family life (Membrive et al., 2014). A cross-sectional study by Warshawsky & Havens (2014) of nurse managers (n = 291) found that 62% reported an intent to leave their positions in the next five years, and 30% of those respondents reported burnout as the primary reason. The authors recommended professional development and workload management to ensure this group is resilient to burnout (Warshawsky & Havens, 2014). In 2020, the IRU nurse managers (n = 6) response to the question "I rarely experience burnout from my work" showed an increase in burnout (μ = +0.56) and a decrease in resilience (μ = -0.21) from 2019 results. Specifically, Burnout scores from 2019 to 2020 decreased from 3.06 to 2.50, revealing a more burned-out leader. Furthermore, resilience scores from 2019 to 2020 decreased from 3.94 to 3.73, indicating that this leadership team's ability to rebound and stay involved in challenging work situations is impaired. From 2019 to 2020, this team's overall engagement scores decreased from 4.81 to 4.61 but remained in a high-tiered engagement group. Being in a higher tier and having high engagement scores means that this IMPLEMENTING A RESILIENCY COACHING 18 team has pride in the organization, intent to stay, willingness to recommend, and workplace satisfaction. The evidence shows that causal factors for nurse manager burnout are varied, involving reports of time pressures, conflict management, lack of resources, decreased interactions with staff and patients, inability to turn off work at home, and regulatory changes (Kelly & Adams, 2018; Warshawsky & Havens, 2014). The demands of the nurse manager's job can lead to burnout. Nurse managers are susceptible to exhaustion from increasing workload, responding to staffing concerns, and perceiving a lack of support (Membrive-Jimenez et al., 2020). This increased workload creates a problematic situation for nurse managers in which they may not have time for personal reflection and cannot recognize that they are burned out (Warshawsky, 2018). Kelly et al. (2019) performed a mixed-methods study (n = 672) among nurse leaders in the hospital environment and identified emotional drain as one of the significant burnout themes in this population of nurse leaders. Higher burnout in nurse managers was predicted by less experience in leadership (p = 0.022), low collaboration (p = 0.035), and membership in a professional organization (p = 0.013) (Kelly et al., 2019). The literature reveals that nurse managers experience emotional exhaustion, depersonalization, and reduced personal accomplishment. Membrive-Jimenez et al. (2020) performed a meta-analysis (n = 11) on the levels, risk factors, and burnout prevalence in nursing managers. The analysis revealed that nurse managers (n = 780) are susceptible to high emotional exhaustion due to work overload, with an identified prevalence of 29% (Membrive-Jimenez et al., 2020). The study also showed that depersonalization is less severe than emotional exhaustion in this population of nurse leaders (Membrive-Jimenez et al., 2020). When depersonalization occurs, it manifests as insensitivity toward coworkers and patients, jeopardizing manager-employee relationships (Membrive-IMPLEMENTING A RESILIENCY COACHING 19 Jimenez et al., 2020). Both exhaustion and depersonalization lead to a lack of personal accomplishment and feeling overwhelmed, rejected, and disconnected (Membrive-Jimenez et al., 2020). Leaders shape the environment through their interactions with their employees, their knowledge of their team's dynamics, their accessibility, and their authority to make important decisions (Kelly & Adams, 2018). A burnt-out nurse manager cannot meet the needs of the patients or their staff, leading to lower staff engagement, poor patient satisfaction, increased healthcare costs, and unsafe work environments (Seichter, 2018). Nurse managers are subject to demanding conditions and stress daily and are susceptible to burnout. Strategies to Decrease Workplace Burnout Current research is filled with articles on how to combat burnout in nursing. This section will focus on current research regarding the relevance of joy, resilience, and coaching in the workplace. Finding Joy in the Workplace Employees who experience joy in the workplace feel physically and mentally healthy, understand the importance and intent of their job, have choice and control over their time, have a sense of camaraderie with their coworkers, and believe that their work-life is equal and equitable (Perlo et al., 2017). Joy in work is more than the absence of burnout. A recent Harvard Business Review poll of employees worldwide (n = 500) revealed that joy derives from unity, influence, and acknowledgment in the team setting (Liu, 2019). Employees who experience joy in the workplace are more likely to contribute intellectually, emotionally, and behaviorally to an organization's mission and direction (Perlo & Feeley, 2018). Better coordination, less waste, higher patient satisfaction, and increased employee productivity benefit from promoting joy in the workplace (Perlo & Feeley, 2018). In 2004, the IHI introduced the Triple Aim to optimize IMPLEMENTING A RESILIENCY COACHING 20 the healthcare system by prioritizing health outcomes, patient experience, and lower costs (Valentine, 2018). Barriers to implementing the IHI Triple Aim included the obesity and diabetes epidemics, widening income gaps, rising healthcare costs, and a disengaged healthcare workforce (Bodenheimer & Sinsky, 2014). In addition, rising administrative, regulatory, and professional pressures contributed to clinician burnout, which directly opposed the goals of the IHI Triple Aim (Valentine, 2018). In 2014, the IHI overhauled its approach, introducing the Quadruple Aim to address clinician burnout issues. The IHI Quadruple Aim ensures that any healthcare system improvements benefit the entire system, including individual patients, communities, and healthcare practitioners (Valentine, 2018). To meet the Quadruple Aim, healthcare organizations and leaders must foster environments where healthcare workers may find pleasure and value in their jobs. Leaders can support joy in the workplace by supporting an environment of psychological safety, meaning, recognition, autonomy, teamwork, resilience, and continuous improvement (Perlo et al., 2017). Front-line nurses obtain joy from helping patients succeed, from connecting to others, and through the nature of their work (Kelly & Adams, 2018). Alternatively, nurse managers obtain joy through supporting staff, mentoring others, educating, and leading change to create positive outcomes (Kelly & Adams, 2018). When joy is missing, patient satisfaction declines, productivity decreases, workplace accidents increase, and staff engagement suffers (Perlo et al., 2017). A qualitative, correlational study by Deetz et al. (2020) of nurse managers (n = 35) found no correlation between front-line nurse engagement and nurse manager joy in work (s = 0.227). Higher engagement scores were attributed to the front-line staff perceptions of their nurse manager (p < 0.001), and researchers recommended nurturing joy in work through the development of strong relationships and healthy work environments (Deetz et IMPLEMENTING A RESILIENCY COACHING 21 al., 2020). Promoting joy in the workplace can create a healthy work environment where staff can thrive. Promoting Employee Resilience in the Workplace Resilience is the ability to rapidly recover from setbacks and positively respond to stress and change (Perlo et al., 2017). Robertson et al. (2016) performed a literature review of quantitative and qualitative studies (n = 13) to define resilience in healthcare providers and found resilience, high persistence, high self-directedness, and low avoidance of challenges were strongly correlated. Social support, physical activity, and outside interests were all positive influences on healthcare providers' resiliency (Robertson et al., 2016). The adverse effects of low resiliency in front-line nurses for patients are similar to those experiencing Burnout. To have joy in work and experience less Burnout, front-line nurses need a healthy work environment to practice resiliency skills. To create a healthy work environment, a nurse manager must help front-line nurses succeed, grow, and feel supported (Everly, 2011). This can be accomplished through encouragement, providing interpersonal support, ensuring teams have training on managing stress and creating opportunities for collaboration (Everly, 2011). Resiliency skills that promote personal and team resiliency include self-awareness and knowledge of abilities (Seitcher, 2018). Other interventions to improve resiliency include stress management, gratitude practices, work/life balance, and mental well-being (Perlo et al., 2017). Research focusing on interventions for improving workplace resiliency is found in the literature. Carpio et al. (2018) carried out a cross-sectional study of nurse managers (n = 48) to identify appropriate interventions to improve resilience. The results of the Resilience at Work (RAW) scale showed areas of concern for resilience in the nurse manager population were maintaining perspective (p = 0.03) and staying healthy (p = 0.04) (Carpio et al., 2018). The recommended interventions IMPLEMENTING A RESILIENCY COACHING 22 included resiliency as a core competency, professional development for nurse managers to develop resiliency skills, and the RAW scale to measure progress (Carpio et al., 2018). Workplace resilience can be cultivated by focusing on education and intervention programs. Vanhove et al. (2016) performed a meta-analysis of resilience-building programs (n = 37), identifying the effect of these programs to be small (d = 0.21) and decrease over time (d = 0.07). Vanhove et al. (2016) found that programs that employed coaching as part of the program (d = 0.59) were the most effective, and computer-based delivery (d = 0.16) was the least effective. Song et al. (2020) performed a mixed-methods study to measure burnout and resiliency factors of surgical interns (n = 17). The participants participated in a year-long resiliency program with a coaching focus. They found a significant increase (p = 0.002) in the Brief Resilience Scale score, suggesting that coaching provided the coachee with skills to be more resilient (Song et al., 2020). Quality improvement projects also provide insight into successfully implementing resiliency in the workplace. A quality improvement project on a cardiac and rehabilitation unit saw increased engagement and decreased turnover after implementing joy and resiliency education and interventions (Kelly and Hawkins, 2019). The research suggests that developing resiliency is a crucial component of decreasing Burnout. Coaching Coaching is a structured process that focuses on collective goal setting to create strategies and use goal attainment to facilitate the client's ongoing self-directed learning and personal growth (Mühlberber & Traut-Mattausch, 2015). Coaching is a structured process where the coachee comes to the coach with specific goals and agendas. The coach then provides feedback, guides the coachee, and holds them responsible for meeting objectives (Kowalski, 2020). This process helps people learn and grow professionally, embrace change, and advance in the IMPLEMENTING A RESILIENCY COACHING 23 workplace (Kowalski, 2020). Coaching helps others achieve personal or organizational goals, improve interpersonal skills, and lead to better relationship skills (Kowalski, 2020). In contrast to coaching, mentoring is typically a long-term relationship where the mentor is experienced and guides the mentee on career development (Jones et al., 2016). Experience in the coachee's work field is unnecessary because coaching aims to help the coachee meet objectives that require a different skill set (Jones et al., 2016). Benefits of Coaching in the Workplace Coaching has many benefits, including goal attainment, improved satisfaction, and a feeling of support. The coaching relationship is rooted in meeting goals. The coach helps the coachee work through goal attainment and guides to ensure the coachee moves forward in their endeavors (Mühlberber & Traut-Mattausch, 2015). Multiple randomized studies have shown that participants reported better goal attainment and motivation in the individual coaching groups (Mühlberber & Traut-Mattausch, 2015; Losch et al., 2016). The nature of coaching is a mutually beneficial relationship built on trust and resulting in satisfaction in work and life. Losch et al. (2016) performed a randomized control study (n = 84) among students from the University of Salzberg and demonstrated higher life satisfaction in individual (p < 0.001) and group coaching (p = 0.009) compared to the control group (p = 2.08). Additionally, Wescott (2019) performed a mixed-methods study (n = 21) of hospital nurse managers and demonstrated that the managers who engaged in coaching developed resilience, decreased stress, and improved relationships. Finally, the coaching relationship ensures that the coachee feels supported. Godfrey et al. (2014) performed a mixed-methods study (n = 382) of adult participants enrolled in a coaching program and demonstrated a positive relationship with the coach (p = 0.01); the coach was helpful in learning (p < 0.001), and the coach helped guide and support the team (p = IMPLEMENTING A RESILIENCY COACHING 24 0.02). In addition, participants reported feeling their coach helped them and their team improve (Godfrey et al., 2014). This research concludes that coaching can positively affect the coach and the person being coached, decreasing burnout and improving engagement. Coaching cultures are nurturing environments in which working relationships thrive, and everyone is focused on enhancing individual and organizational success (Milner et al., 2020). For coaching cultures to exist, everyone from the front-line staff to the organization executives needs to believe in the benefits of coaching and learning the principles (Gormley & Nieuwerburgh, 2014). Establishing an organizational coaching culture is a way to show commitment to front-line staff development; it can increase performance and improve attitudes (Gormley & Nieuwerburgh, 2014). A nurse manager needs to be trained in coaching and creating a supportive environment for front-line staff. Godfrey et al. (2014) suggest that nurse managers receive basic training, guidance, and feedback when learning to coach and are provided with resources and help when needed. A coaching culture has benefits for front-line nurses and nurse managers. Jones et al. (2016) performed a meta-analysis (n = 17) of studies in which a coaching culture was the objective of generating affective, cognitive, skill-based outcomes at work and demonstrated that all outcomes improved with coaching (d = 0.36). Additionally, Milner et al. (2020) performed a survey-based qualitative study (n = 580) and identified six themes associated with a coaching culture: empowerment, inclusiveness, ownership, collaboration, innovation, and learning. Woods (2016) reported that after implementing a coaching culture at a psychiatric hospital in Kentucky, patient safety improved, a steady increase in staff satisfaction, a successful Joint Commission survey, and employee development was noted. Developing and implementing a coaching culture benefits front-line staff and manager engagement and can decrease burnout. IMPLEMENTING A RESILIENCY COACHING 25 Discussion The coaching literature lacks quantitative research, a small sample size of studies, instrument validity and reliability, and a lack of healthcare perspective (Jones et al., 2016; Milner et al., 2020; Mühlberber & Traut-Mattausch, 2015). The most common limitation was the lack of quantitative data, limiting the replicability of findings (Gormley & Nieuwerburgh, 2014; Godfrey et al., 2014; Jones et al., 2016). These findings support the need for additional quantitative research on coaching cultures in healthcare. The gaps related to nurse manager Burnout research involve expectations and competencies. Nurse managers are expected to fix their burned-out staff to improve engagement scores, even if they are burned out. Low engagement scores reflect poorly on the nurse manager's performance and the organization. For nurse managers to improve burnout in their units among their nurse teams, they must first evaluate the extent of workplace Burnout (Kelly & Adams, 2018). Tools to evaluate burnout in front-line nurses are not readily available. Annual engagement surveys evaluate concepts such as burnout, joy, and resilience, which are not administered frequently enough to measure progress and change. These expectations often require specific competencies. Nurse managers are expected to recognize when others show signs of burnout with little to no training and practice. Nurse managers are not taught to be coaches unless they attend an ongoing learning opportunity. To improve leader retention, the organization invests in leadership skills and competency development (Laschinger & Finegan, 2008; Parsons & Stonestreet, 2003; Warshawsky, 2018). To accomplish this, nurse managers need education on Burnout and related topics with a structured program to practice the newly learned skills, like coaching. In addition, more research is needed that evaluates how nurse managers identify and respond to front-line nurses' burnout. IMPLEMENTING A RESILIENCY COACHING 26 Implications for Practice The evidence supports implementing a resiliency coaching program to decrease Burnout in front-line nurses and nurse managers. The literature supports addressing joy and resilience in the workplace to decrease burnout in nurse managers and front-line nurses (Perlo et al., 2017; Robertson et al., 2016). In addition, the literature supports coaching to improve relationships, develop trust, and help others meet personal and organizational goals (Godfrey et al., 2014; Gormley & Nieuwerburgh, 2014; Milner et al., 2020; Westcott, 2016). These findings support the need and purpose of creating a resiliency coaching program. Nurse managers will be trained on coaching and then taught how to recognize burnout and coach resiliency in their front-line staff. Weekly follow-up and practice with the DNP student will ensure nurse managers feel comfortable coaching their team. During monthly one-to-one check-in sessions with front-line staff, nurse managers will evaluate for burnout and coach resiliency if needed. Alternatively, if a nurse manager identifies that a front-line nurse may become burned out, they can employ the coaching concepts to help them build resiliency. This reciprocal relationship will help both front-line nurses and nurse managers build resiliency and decrease burnout through trust, mentoring, and accomplishment. The resiliency training will provide a culturally sensitive knowledge base on recognizing burnout, goal setting, and self-care measures. As nurse managers learn about coaching and resiliency, front-line nurse burnout should decrease, patient outcomes will improve, engagement will increase, and safety events will decrease. Project Plan Project Design This process improvement project intends to decrease burnout in front-line nurses by implementing a resiliency coaching program modeled after a mixed-methods study design. A IMPLEMENTING A RESILIENCY COACHING 27 mixed-methods study design collects and analyzes quantitative and qualitative data to answer a clinical question (Reavy, 2016). Quantitative data collected from surveys and questionnaires will evaluate levels of burnout, resiliency, and coaching skills. This data will be analyzed collectively for primary themes, and the results will be utilized to measure training effectiveness and inform future education topics. In addition, formative feedback from participant interviews or following training will be collected through direct quotations to get additional perspectives about participants' experiences and attitudes. This type of data collection provides objective data, which provides a rich understanding of the problem and whether improvement is occurring. Finally, the quantitative and qualitative data collected will be summarized and used to improve the future training of nurse managers and front-line nurses at Intermountain Healthcare. Needs Assessment of Project Site and Population The participants for this process improvement project include the front-line nurses and nurse managers that work in Rehabilitation at Intermountain Healthcare. Across Intermountain Healthcare, there are potentially 106 front-line nurses and six nurse manager participants with varied backgrounds and experience. Inclusion criteria for this project include being a nurse or nurse manager on one of the rehabilitation units and volunteering to provide data. The role of participants is to learn, participate in discussions, and apply what they learned to improve their resiliency. The six Intermountain Healthcare Rehabilitation sites chosen for this project include the following: • the Transitional Care Unit at Logan Regional Hospital • the Inpatient Rehabilitation Unit at McKay-Dee Hospital • the Inpatient Rehabilitation Unit at Intermountain Medical Center • the Inpatient Rehabilitation Unit at Utah Valley Medical Center IMPLEMENTING A RESILIENCY COACHING 28 • the Garfield County Nursing Home in Panguitch, Utah • the Inpatient Rehabilitation Unit at St. George Regional Medical Center These sites, located across Utah, represent a diverse population of rehabilitation nurses. Three types of rehabilitation nursing represented include skilled nursing, inpatient rehabilitation, and long-term care. All sites have rigorous regulatory requirements for patient safety and have a multi-disciplinary approach to care. A needs assessment was performed pre-implementation to establish a baseline and understand rehabilitation nurses' issues. In January 2021, the DNP student interviewed 56 front-line nurses and six nurse managers who voluntarily answered questions utilizing the Index-3 Leader Assessment and The Intermountain Team Caregiver Rounding Tool. No identifying information was collected; only direct quotes were collected. This information, coupled with data from the 2019 and 2020 Press Ganey Caregiver Engagement Survey results, the DNP student identified burnout as a problem that staff were facing that needed to be addressed (see Appendix A) Stakeholders The stakeholders for this project include ancillary staff and system directors. The ancillary staff are team members who work daily with the nursing staff, including physical therapy, occupational therapy, speech therapy, social work, and physicians, whose role is to support the nursing staff as they work to improve their resiliency. The system directors include rehabilitation and medical surgical nursing leadership, who can help provide resources and support to improve resiliency. IMPLEMENTING A RESILIENCY COACHING 29 Social Determinants of Health (SDoH) The nursing-related work environment can lead to health disparities in the nurse population as a result of cumulative workplace stress, including high stress, lack of sleep, long working hours, emotional drain from patients, incivility, violence, and lack of support from management (University of St. Augustine for Health Science, 2021). The coaching culture and promotion of professional resiliency that this project aims to create will provide a nurturing environment where working relationships thrive and are supported. If this can be achieved, it will help everyone focus on enhancing individual and organizational success (Milner et al., 2020). The SDoH that may influence this project includes the nurses' knowledge of resiliency, gender, support systems, and levels of occupational stress. In addition, these SDoH can influence an individual’s reaction, assessment, and management of their burnout. Cost Analysis and Sustainability of Project The cost of this project is projected to be approximately $1,880, which includes the salaries of participants and training handouts. The cost of replacing one nurse is estimated to be between $28,000 and $51,700 (NSI Nursing Solutions, 2021). The projected cost savings in reduced turnover, improved resiliency, and workplace engagement exceeds the project’s cost. The return on investment of implementing this program in preventing one nurse from leaving the organization is 2,019%. An analysis of the financial data provides detail, breakdown of costs, payers, and time required to implement (see Appendix B). To ensure the sustainability of this project into the future, the DNP student will provide the initial training to front-line staff to emphasize the importance of the topic and ensure consistency of implementation. Next, a workgroup of nurse managers and front-line nurses will identify and create additional educational materials and topics. This team will also work to IMPLEMENTING A RESILIENCY COACHING 30 incorporate education into onboarding and annual education activities. Finally, the nurse managers will need to sustain this project in the future. The nurse managers will be involved early in creating education, goals, and implementation. The resiliency coaching provided to nurse managers in one-to-one coaching sessions after front-line resiliency education will reinforce the importance of building resiliency in others. Project Outcomes The long-term aims of this project include, by December 2022, improving the Press Ganey question, “I rarely experience burnout from my work,” by one point for front-line nurses. A one-point change in this question equates to decreased perceived burnout and can show improvement over time. In addition, front-line nurse turnover will be reduced by 5% by December 2022. To meet these program goals, the following short-term initiatives will need to be met including: • During November 2021, train 90% of front-line nurses on resiliency. • During December 2021, train 100% of nurse managers on resiliency coaching. • By December 2022, 100% of nurse managers will receive 12 coaching sessions for resiliency. • During January 2022, form a team to create and provide additional resiliency education to front-line nurses. • In 2022, collect burnout and resiliency data every three months from 50% of nurse managers and front-line nurses. Consent Procedures and Ethical Considerations Institutional Review Board (IRB) review ensures that participants of a project or study are not harmed or at risk for harm (Reavy, 2016). Weber State University and Intermountain IMPLEMENTING A RESILIENCY COACHING 31 Healthcare IRB approved this project as a process improvement project that does not meet the criteria for human research (see Appendix C). All participants will receive the resiliency education and resources but providing survey data will be voluntary. Staff who volunteer to complete surveys will provide the project's purpose and data utilization. Full informed consent will not be collected as it would disregard the participant's anonymity. Ethical Considerations This project will meet ethical standards of privacy and confidentiality while upholding social justice. No identifying information will be collected to protect the privacy and confidentiality of those participating in this project. Microsoft Forms will be utilized to collect quantitative data, and the name of respondents will not be collected to ensure anonymity. This will ensure that the participants can be open and honest when answering personal questions about their burnout and resilience. For qualitative data collection, staff will volunteer to answer one-on-one interview questions, understanding that it is not anonymous. Names of staff answering questions will not be written down, only direct quotes. If the DNP student notices aggregate trends, the nurse manager will be informed of collective responses, not individual reports. This is important because leaders should help and provide staff with additional resources and training if there is a trend of distressed staff members. Participants, who may be experiencing burnout, will be provided with resources during the training. The “Resiliency Menu” includes instructions on accessing the Employee Assistance Program and other Intermountain Healthcare resiliency resources (see Appendix D). This ensures that a participant who may need additional help has immediate resources. In addition, to ensure social justice is upheld, resiliency education will be shared with all staff working in the rehabilitation units, such as patient care technicians, therapists, and physicians. All IRU team IMPLEMENTING A RESILIENCY COACHING 32 members should be treated fairly and provided with the same level of high-quality training to decrease burnout and improve resiliency. Instruments to Measure Effectiveness Seven instruments will be utilized in this project to measure effectiveness. These surveys will evaluate a participant’s knowledge, feelings, or coaching style. This section will review the Single Item Burnout Survey, Brief Resilience Scale, ASTD Coaching Self-Assessment, Press Ganey Engagement Survey, Intermountain Training Survey, Index-3 Leader Assessment, and Intermountain Team Caregiver Rounding Tool. Single Item Burnout Survey The Single Item Burnout Survey (SIBS) prompts the participant to define their burnout (Knox et al., 2018). The SIBS was a question administered by the American Medical Association to physicians and was a component of the Physician Worklife Study (Linzer et al., 2002). The SIBS has since been a validated tool to measure burnout (Knox et al., 2018). The SIBS is a one-question survey with five answers that describe a person who is not burnt out to a very burnt-out person. The participant answers the question based on their definition of burnout. The score is noted, and scores less than or equal to two indicate no symptoms of burnout, while scores greater than three indicate one or more symptoms of burnout (see Appendix E). This survey is non-proprietary and free to the public as long as the authors are cited. Brief Resilience Scale The Brief Resiliency Scale (BRS) measures a person’s ability to bounce back and recover from a stressful event (Smith et al., 2008). Developed by Smith et al. (2008), the BRS is a valid and reliable assessment for measuring resilience. Fung (2020) performed a cross-sectional study of Chinese students (n = 511) to evaluate the consistency and validity of various resiliency IMPLEMENTING A RESILIENCY COACHING 33 scales. The BRS showed good internal consistency (a = 0.71), consistent with other BRS validation studies. Additionally, Smith et al. (2008) administered the BRS to four groups that consisted of undergraduate students (n = 128 and n = 64), cardiac rehabilitation patients (n = 112), and women with fibromyalgia (n = 50) to assess the ability to bounce back or recover from stress. The BRS demonstrated good internal consistency and test-retest reliability. The BRS is a simple tool that takes five minutes to complete. The BRS includes six questions that the participant will answer on a five-point Likert scale. The higher point value denotes that the participant strongly agrees, while the lower point value denotes that the participant strongly disagrees with the statement. The values of the participant's answers are added together and divided by six. The scores are interpreted by the following: • BRS Score 1.00-2.99 indicates low resilience • BRS Score 3.00-4.30 indicates normal resilience • BRS Score 4.31-5.00 indicates high resilience (Smith et al., 2008) This survey is non-proprietary and free to the public as long as the authors are cited (see Appendix F). Team STEPPS® - ASTD Coaching Self-Assessment The ASTD Coaching Self-Assessment form created by the Agency for Healthcare Research and Quality (AHRQ) will be utilized to assess the participant's knowledge in different coaching competencies. The ASTD Coaching Self-Assessment form is part of the AHRQ Team STEPPS® program, a series of evidence-based teamwork tools to improve collaboration between patient outcomes and healthcare staff (AHRQ, 2021). Participants are provided with a coaching competency and are asked to rate their comfort level from "one of my strengths" to "lacking this skill" (see Appendix G). The information obtained from this self-assessment is used to create a IMPLEMENTING A RESILIENCY COACHING 34 plan to improve coaching skills. This is a proprietary program, and permission to utilize this form in a performance improvement project was obtained via email (see Appendix H). Press Ganey® Engagement Survey The Press Ganey® Engagement Survey is a 77-question engagement survey administered to all staff to gather information about the staff’s perception and experience working for Intermountain (Intermountain Healthcare [IHC], 2021). The Press Ganey® survey is validated and a best practice tool for measuring staff engagement (IHC, 2021). The survey is administered yearly at Intermountain Healthcare to provide internal and national benchmarking data used to improve the work environment. It is a simple tool that takes 10 to 15 minutes to complete (IHC, 2021). Survey participants are provided with a question and asked to answer on a five-point Likert scale. The higher point value denotes that the participant strongly agrees, while the lower point value indicates that the participant strongly disagrees with the statement (see Appendix I). The scores from the survey provide insight into the engagement level of staff. Intermountain Training Survey The Intermountain Training Survey is a best practice tool utilized to measure the knowledge and confidence gained by an education session. This tool created by Intermountain Healthcare has not been validated but has been used in the Rehabilitation service line to evaluate training. The Intermountain Training Survey evaluates the participant's knowledge and confidence of a topic before and after the education. The participants are provided a statement and asked to answer on a five-point Likert scale. The higher point value denotes that the participant strongly agrees, while the lower point value indicates that the participant strongly disagrees with the statement (see Appendix J). The data obtained from this survey will identify what the participants learned from the education and inform any program changes. IMPLEMENTING A RESILIENCY COACHING 35 Index-3 Leader Assessment and The Intermountain Team Caregiver Rounding Tool The Index-3 Leader Assessment and the Intermountain Team Caregiver Rounding Tool are best-practice qualitative interview questions used to obtain information from front-line staff and nurse managers. This tool created by Intermountain Healthcare is not validated but has been used in the Rehabilitation service line to obtain qualitative information about engagement. The qualitative data obtained from these surveys will provide anecdotal information about engagement and burnout (see Appendix K). This information will be utilized pre-implementation to complete a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis needed for the gap analysis. All information from these Intermountain surveys will be anonymous, de-identified, and reported as aggregate data. Project Implementation This project aims to decrease burnout and turnover in front-line nurses through a robust education and coaching program. The John Hopkins Nursing Evidence-Based Practice (JHNEBP) provided the framework to create and implement a resiliency coaching program (Dang et al., 2018). This section will review the timeline and implementation of this project (see Appendix O). Interventions In January 2021, the DNP student identified project outcomes that guided the creation of interventions for this project. The first outcome was to decrease burnout for front-line nurses. This is assessed every September through a partnership with Intermountain Healthcare and Press Ganey®, where all staff is sent the Caregiver Experience Survey to evaluate the employee experience (see Appendix I). Results from September 2020 revealed that front-line nurse response to the question "I rarely experience burnout from my work" (n = 191) indicated an IMPLEMENTING A RESILIENCY COACHING 36 increase in burnout (μ = +0.70) and a decrease in resilience (μ = -0.23) from 2019 results. Specifically, Burnout scores from 2019 to 2020 decreased from 3.17 to 2.47, revealing a more burned-out staff. Moreover, resilience scores from 2019 to 2020 decreased from 4.29 to 4.06, indicating that this team has a decreased ability to recover and remain engaged even in challenging work circumstances. This team's overall engagement scores dropped dramatically (μ = -0.44) from 2019 to 2020, from 4.36 to 3.92, and moved from the highest engagement to a lower tier. Teams in the lower engagement tiers require significant support throughout the improvement process and may need additional training and coaching to effect change and improvement. In response to these findings, the project outcome was established to improve on the previously asked question “I rarely experience burnout from my work” by one point on a five-point Likert scale by December 2022. From January 2021 to July 2021, the DNP student performed a gap analysis and developed training in the planning phase. The gap analysis resulted from in-person interviews of front-line nurses (n = 56) and nurse managers (n = 6) and analysis of Press Ganey® Engagement (PGE) survey results from 2020 and 2019. Staff was voluntarily interviewed in person by the DNP student utilizing the Index-3 Leader Assessment and The Intermountain Team Caregiver Rounding Tool (see Appendix K). Themes extracted from these interviews and the PGE survey were categorized in a SWOT format (see Appendix A). Burnout was identified as an opportunity, and a threat, which provided a focus for the project. In addition to the gap analysis, a quality improvement team was formed to provide feedback on the project's interventions and plan. This committee included nurse managers (n = 3) and front-line nurses (n = 2) from across the IRUs at Intermountain Healthcare. The team approach is valuable to a quality improvement project because people with diverse perspectives and knowledge are needed for lasting improvement IMPLEMENTING A RESILIENCY COACHING 37 (Grant et al., 2020a). This team analyzed the gap analysis provided valuable front-line knowledge and feedback on the education created by the DNP student. Additionally, a team approach ensures a commitment and can help champion an intervention (Grant et al., 2020a). This team was valuable throughout the entire project plan. In the implementation phase, this team was supportive, encouraged staff to attend training, and helped follow up with those that did not attend. The gap analysis provided a clear focus and the Quality Improvement (QI) improvement team valuable insight and support for this project’s success. Studies have shown that providing education can increase the development of resiliency and decrease burnout in nurses (Carpio et al., 2018; Everly, 2011; Vanhove et al., 2016). Project interventions designed to decrease burnout focused on educating front-line nurses on identifying burnout and developing resiliency through an interactive PowerPoint presentation. The training program taught front-line nurses to identify and manage low resiliency. As part of the training program, a resiliency menu was created to reinforce learning and ensure that participants have resources outside of the education and training program (see Appendix D). Developing resiliency can only be done by the person, not anyone else (Perlo et al., 2017). The Resiliency Menu is a one-page, menu-style handout with Intermountain Healthcare resiliency resources and self-help tips provided to all participants. The Resiliency Menu and resiliency education are interventions for front-line nurses to build their resiliency skills and decrease burnout. The second project outcome was to reduce front-line nurse turnover by December 2022 by 5%. Front-line nurse turnover can result from burnout (Nagelhout, 2016; Shah et al., 2021). Interventions designed to meet this outcome focused on creating a supportive environment that cultivates resiliency (Everly, 2011). The resiliency coaching program for nurse managers focused on resiliency and coaching education (see Appendix L). Coaching is a tool that can improve nurse managers' IMPLEMENTING A RESILIENCY COACHING 38 competency in the early identification and management of nurse burnout for themselves and those they lead (Warshawsky, 2018). With this new knowledge, nurse managers can use coaching to build relationships, trust, and a positive environment for front-line nurses (Warshawsky, 2018). The resiliency coaching program provides the nurse managers with the tools to recognize burnout and intervene with a coaching conversation, thus creating a supportive environment where nurses do not leave. The success of this project was contingent on increasing the nurse manager's knowledge of resiliency so that they can train and coach their staff. The train-the-trainer framework is utilized to prepare future teachers or subject matter experts to train others in their organizations (Kalisch et al., 2013). Kalisch et al. (2013) performed a quasi-experimental study to determine if the train-the-trainer framework would improve teamwork and missed interventions from nursing staff (n = 242) working in med/surgical units. Results indicated that the train-the-trainer framework was successful in improving teamwork (p = 0.001), decreasing missed interventions (p = 0.03), and improving nursing staff satisfaction (Kalisch et al., 2013). The train-the-trainer framework is a way to provide sustainability of the process, and create internal mentors, change champions, and opinion leaders (Kalisch et al., 2013). The DNP student did the initial front-line staff training with the nurse manager in attendance. This exposed the nurse manager to a repetition of the information, increasing their knowledge of resiliency. All nurse managers were optimistic about the front-line nurse training and agreed to repeat the presentation with those who did not attend. The train-the-trainer framework is a valuable tool to create subject matter experts who can sustain a change into the future. The resiliency coaching program prepares the nurse manager to identify and assist staff struggling with low resiliency. The three parts of this program include education on resiliency, IMPLEMENTING A RESILIENCY COACHING 39 hands-on coaching education, and ongoing coaching practice. In October 2021, a 60-minute education was presented by the DNP student to six nurse managers. The education reviewed topics such as recognizing low resiliency in others, modeling self-care, and cultivating a supportive environment. After the training, nurse manager participants voluntarily completed the Brief Resilience Scale and Single Item Burnout Survey (see Appendix F; see Appendix E). The nurse manager's survey comments gathered themes that included gratefulness, current burnout, and hope. First, the theme of gratefulness was identified from comments (n = 3) that express thankfulness and appreciation for the education and training. Next, the theme of current burnout was identified from comments (n = 2) that suggested the current battle with burnout and how the training helped address it. Finally, the theme of hope was identified from comments (n = 2) that stated the training provided tools to help others build resiliency. This training provided essential knowledge of resiliency, burnout, and joy in the workplace that the nurse managers can utilize when engaging in a coaching conversation with front-line nurses. In December 2021, the DNP student presented a 60-minute, interactive education session on conducting resiliency coaching conversations (see Appendix M). Before the training, participants were asked to complete the Team STEPPS® - ASTD Coaching Self-Assessment Form, which assesses competencies in coaching (see Appendix G). This education reviewed topics such as the benefits of coaching, having resiliency conversations, and asking coaching questions. The participants were given scenarios and were paired with a partner to practice asking coaching questions. This training provided essential knowledge and practice on coaching. The last part of this resiliency coaching program focused on practicing resiliency coaching skills. From January 2022 to December 2022, nurse managers met monthly with the DNP student to review challenging resiliency issues, practice resiliency coaching, and build competencies (see Appendix L). These meetings were IMPLEMENTING A RESILIENCY COACHING 40 problem-solving sessions that reinforced key concepts and continued learning. The education and follow-up embedded in this program provided the nurse manager with the tools and knowledge to identify and assist staff struggling with low resiliency. This manager program was initially planned to be rolled out before the front-line training. However, the manager training implementation timeline was moved to after the front-line nurse training due to pilot results and the train-the-trainer framework. In August 2021, a 20-minute education was presented to the front-line nurses (n=7; 78%) at the Garfield County Nursing Home. A pilot project is a small-scale test of the intervention (Grant et al., 2020b). A pilot can provide the DNP student with data about the intervention, ensure practicality, obtain feedback, and help define the roll-out of a broader project (Barker, 2018). This training differed from the nurse manager's education because it focused on recognizing low resiliency and taking personal actions, not identifying it in others, and coaching for improvement. The education and training program reviewed topics such as recognizing low resiliency for front-line nurses, evidence-based interventions that improve resiliency, and resiliency resources available from Intermountain Healthcare (see Appendix D). After the training, participants voluntarily completed the Brief Resilience Scale (BRS), the Single Item Burnout Survey (SIBS), and the Intermountain Training Questionnaire (ITQ) (see Appendix F; see Appendix E; see Appendix J). Comments made to the DNP student after the presentation and from surveys were overwhelmingly positive. The themes gathered from comments included hope, optimism, courage, and confidence. As a result of this pilot, the DNP student decided to roll out the resiliency training to all IRUs across Intermountain Healthcare. The pilot also informed sustainability and system-wide practice change from a micro and mesosystem perspective. First, the clinical microsystem is a small group of experts regularly collaborating to IMPLEMENTING A RESILIENCY COACHING 41 offer treatment to specific patient groups (Likosky, 2014). Nurses in the clinical microsystem must work together to provide quality and safe care to patients. Staff experiencing burnout symptoms may feel exhausted or depersonalized that they do not work well with their peers to provide positive patient outcomes or may not provide high-quality care themselves. The pilot revealed that there needs to be a continued focus on resiliency with the front-line staff. The nurse managers were trained to recognize low resiliency and intervene with coaching conversations. Next, the front-line staff will be sent the BRS and SIBS every three months to evaluate the program's effectiveness. Finally, all resources, videos, and educational materials were uploaded to the Rehabilitation Microsoft Teams website for access by all staff members. The pilot also impacted the mesosystem. The mesosystem is the glue that links the microsystems together (Likosky, 2018). The entire program has been consolidated into one booklet, and additional education will be added as needed (see Appendix N). This booklet can be used by other service lines that want to improve front-line resiliency and decrease burnout. Next, in December 2021, a front-line staff workgroup was formed to discuss future resiliency topics, incorporate resiliency into mandatory education, and assist in future education. These microsystem and mesosystem interventions can provide a foundation for success and implementation across all medical-surgical units at Intermountain. Front-line nurse resiliency training was implemented across all IRUs from August 2021 to November 2021. All IRUs (n = 6) participated, with n = 60 (56.6%) front-line nurses receiving training. All training was taught in-person to facilitate discussion and questions. The nurses that did not attend were given the link to the Microsoft Teams site to access the recorded education and handouts. In addition, the nurse managers for each of the units agreed to follow up with staff who did not attend to review the information with them. IMPLEMENTING A RESILIENCY COACHING 42 This project can potentially impact front-line nurses, nurse managers, patients, and the system. First, nurses can be impacted by decreased burnout and increased joy in work by creating a supportive work environment (Everly, 2011). Next, nurse managers can be impacted by improved relationships with their staff and decreased burnout. Then, patients can be affected by this project because decreasing burnout can improve patient outcomes (Seichter, 2018). Finally, this project can affect the system through cost savings from decreased turnover and improved retention. Project Evaluation Evaluation of a Quality Improvement (QI) initiative is essential for understanding the impact of a quality improvement project. The following section will review data maintenance, analysis methods, demographics, and survey response rates. Additionally, project findings will be analyzed, and strengths and weaknesses identified. Data Maintenance/Security Data security protects information from unwanted access, manipulation, or theft (International Business Machines [IBM], n.d.). Breaches such as cyber threats and human error are concerns for maintaining the security and privacy of data (IBM, n.d.). The DNP student implemented various measures to ensure data was maintained and safe. First, confidential data were stored on workplace servers, which required two-person authentication and multiple passwords to access. In addition, these workplace servers require a virtual private network to access and run the latest antivirus software. These measures ensure that personal data collected for this project was secure from third parties trying to access or corrupt data. Next, data access was limited to only the DNP student and only for this project. In the event that project data was lost, a copy of the data was saved on a different workplace drive only accessible to the DNP IMPLEMENTING A RESILIENCY COACHING 43 student. Finally, privacy was maintained to ensure participants’ anonymity. No personal identifying information was collected or recorded with any survey or conversation. This allowed for open and honest feedback when participants answered personal questions about resiliency and burnout. The DNP student collected and analyzed data after the data security measures were in place. Data Collection and Analysis This project aimed to improve burnout and decrease turnover by implementing a resiliency coaching program. To do this, demographics about the front-line nurses and nurse managers were gathered and examined. The John Hopkins Nursing Evidence-Based Practice (JHNEBP) provided the framework to create and implement a resiliency coaching program (Dang et al., 2018). The JHNEBP framework is organized into three phases: practice question, evidence, and translation (Dang et al., 2018). The practice question and translation phases involve data collection and analysis in an evidence-based practice project (Dang et al., 2018). This section will review these phases and their relation to data collection and analysis. Practice Question The team is identified during the practice question phase, and the problem is clarified (Dang et al., 2018). To do this, the DNP student performed a SWOT analysis and reviewed Press Ganey® Caregiver Engagement results (see Appendix A). Front-line nurses and nurse managers were selected as participants, particularly nurses experiencing more burnout year over year from these analyses. Therefore, the plan for this project was twofold: (a) teach front-line nurses resiliency skills and (b) teach nurse managers how to coach direct reports for resiliency. Demographic data for both populations were collected through manual extraction of data internally available on the Intermountain Healthcare intranet. Data were transcribed onto an IMPLEMENTING A RESILIENCY COACHING 44 excel worksheet, and descriptive statistics, such as frequencies and percentages, were calculated. Next, data about the front-line nurse and nurse manager populations were examined. Intermountain Healthcare employs N=106 front-line nurses in rehabilitation who were eligible to participate in the performance improvement project. Demographic variables for front-line nurses are presented in Table 1. The majority of this population were female, highly educated, with more than five years of experience at Intermountain Healthcare. This data was important to understand as gender roles and tenure could affect burnout. According to research by Templeton et al. (2019), female nurses are more likely to experience burnout (p = 0.016), and for each year of tenure, burnout increases (p = 0.004). Therefore, these demographics provided an understanding of the potential population for this project. Unfortunately, sample demographics were not obtained for the participants in the project or individual project sites. This oversight was a limitation that interfered with identifying sample characteristics that could relate to project outcomes. Meanwhile, demographics were collected for nurse managers in the practice question phase of this project. Intermountain Healthcare employs N=6 nurse managers in rehabilitation who were eligible to participate in the performance improvement project. Nurse manager demographics are detailed in Table 1. In contrast to the front-line nurse population, there is an even mix of males and females in the nurse manager population. However, this population has an even higher tenure with Intermountain Healthcare, which could be a factor in increased burnout (Templeton et al., 2019). With an understanding of the populations involved, the DNP student moved to the evidence phase. IMPLEMENTING A RESILIENCY COACHING 45 Table 1 Participant Demographics Variable Front-line Nurses Nurse Managers n % n % Gender Female 87 82.1 3 50.0 Male 19 17.9 3 50.0 Scheduled Work Hours Full Time (0.75 to 1.0 FTE) 77 72.6 6 100.0 Part Time (0.30 to 0.74 FTE) 24 22.7 Per Diem (0.1 to 0.29 FTE) 5 4.7 Highest Level of Education Licensed Practical Nurse 5 4.7 Associates Degree 41 38.7 Bachelor’s Degree 56 52.8 2 33.0 Master’s Degree 4 3.8 3 50.0 Doctorate Degree 1 17.0 Tenure at Organization 0 to 2.0 Years 22 20.8 2.1 to 5.0 Years 22 20.8 1 16.5 5.1 to 10.0 Years 23 21.7 1 16.5 >10.1 Years 39 36.7 4 67.0 Translation An action plan is implemented during the translation phase, and project outcomes are evaluated (Dang et al., 2018). To do this, the DNP student gathered and analyzed project data. Accordingly, the DNP student identified validated surveys, completed training, and gathered data from participants. The resiliency coaching program was implemented in two phases. The first phase involved training front-line nurses on resiliency. The DNP student recorded attendance IMPLEMENTING A RESILIENCY COACHING 46 and calculated frequencies for each training (see Table 2). A total of n = 60 (56.6%) front-line nurses attended the initial training across all sites. However, variability was noted in the attendance at each site and could be attributed to different expectations from nurse managers about staff meeting attendance. Table 2 Training Attendance Variable Front-line Nurses Training Attendance n % Garfield County Nursing Home 8 88 St. George IRU 17 65 Utah Valley IRU 26 26 IMED IRU 29 21 McKay-Dee IRU 18 100 Logan TCU 8 75 The DNP student identified and administered five surveys to project participants to evaluate project outcomes adequately. The first survey was the Intermountain Training Questionnaire (ITQ). This survey was administered to front-line nurses to measure knowledge and confidence before and after resiliency training. The knowledge section of the ITQ measured the participant’s knowledge of resiliency, burnout, and resources provided by Intermountain Healthcare. The ITQ knowledge items were arranged in a 5-point, Likert-type format describing responses based on agreement (1 – very poor, 2 – poor, 3 – neutral, 4 – good, 5 – very good). The ITQ knowledge section was treated as a one-factor scale where items were summed and divided by three, yielding a mean score that ranged from 1 to 5. In addition to knowledge, the ITQ assessed the participant’s confidence in identifying low resiliency and implementing self-IMPLEMENTING A RESILIENCY COACHING 47 care actions. The ITQ confidence items were arranged in a 5-point, Likert-type format describing confidence levels (1 – not very confident, 2 – not confident, 3 – neutral, 4 – confident, 5 – very confident). The ITQ confidence section was treated as a one-factor scale where items were summed and divided by two, yielding a mean score that ranged from 1 to 5. Subsequent surveys were administered to understand participants’ resiliency, burnout, engagement, and coaching skills. The next survey, the Brief Resilience Scale (BRS), was administered to front-line nurses and nurse managers to assess their ability to bounce back and recover from stress. The BRS items were arranged in a 5-point, Likert-type format describing responses based on agreement (1 – strongly disagree, 2 – disagree, 3 – neutral, 4 – agree, 5 – strongly agree). The BRS was treated as a one-factor scale where items were summed and divided by six, yielding a mean score that ranged from 1 to 5. The total mean was used to categorize samples as low resiliency (1.00 – 2.99), normal resiliency (3.00 – 4.30), and high resiliency (4.31 – 5.00). Meanwhile, the Single Item Burnout Score (SIBS) was administered to front-line nurses and nurse managers to measure how participants defined burnout. The SIBS items were arranged in a 5-point, Likert-type format describing responses based on agreement (1 – strongly disagree, 2 – disagree, 3 – neutral, 4 – agree, 5 – strongly agree). The SIBS was treated as a one-factor scale where items were summed and divided by five, yielding a mean score that ranged from 1 to 5. Unlike the BRS, the SIBS did not have a score interpretation scale. As a result, additional means were calculated to understand further whether participants were experiencing or not experiencing burnout symptoms. The following survey administered measured the participant’s coaching skills. Additionally, the Team STEPPS® - ASTD Coaching Self-Assessment (ASTD) was administered to nurse managers to understand their coaching knowledge and identify future educational topics. The ATSD items were arranged in a 4-point, Likert-type format describing responses based on skill IMPLEMENTING A RESILIENCY COACHING 48 level (1 – lacking skill, 2 – need to develop, 3 – doing okay on this, 4 – one of my strengths). The ASTD was treated as a one-factor scale where items were summed and divided by four, yielding a mean score that ranged from 1 to 4. Finally, caregiver engagement was evaluated through the Press Ganey Caregiver Engagement survey (Press Ganey, 2020). This survey is administered directly from Press Ganey via email to all staff members who work at Intermountain Healthcare every October. Descriptive statistics, such as means, are calculated and reported by Press Ganey®. In addition, filters allow for different views of the data. Surveys for measuring outcomes were administered to front-line nurses after resiliency training. The DNP student administered the initial survey to front-line nurses after resiliency training. The BRS, SIBS, and ITQ were built into one form in Microsoft Teams for ease of completion. In addition, a qualitative question was included to gather resiliency topics for future training. The survey was designed using a matrix rating scale question which allowed the respondent to evaluate one or more row items using the same column choices. The DNP student sent each attendee an email with a survey link and a request to complete the survey (see Appendix B). The average time for survey completion was five and a half minutes. No changes were made in the survey design or delivery throughout the project. Microsoft Teams grouped all the responses into one excel sheet, which allowed response rates for front-line nurses to be calculated. Response rates provide information about the accuracy of the collected data. A total of n = 24 (40%) of front-line nurses completed the initial survey, including the BRS, SIBS, and ITQ (see Table 3). A higher attendance at staff meetings correlated with higher survey return rates. Low response rates can be attributed to delayed survey administration, related to late IRB approval, at McKay-Dee, St. George, and Garfield County Nursing Home. No changes were IMPLEMENTING A RESILIENCY COACHING 49 made to correct the low response rates. The DNP student should have addressed this limitation, which could have increased survey response rates. In addition, surveys were readministered to the same sample of front-line nurses to see if the training had increased resiliency and burnout over time. Table 3 Response Rates Variable Initial Survey Follow-up Survey % % Garfield County Nursing Home 29 14 St. George IRU 64 45 Utah Valley IRU 25 42 IMED IRU 33 17 McKay-Dee IRU 50 39 Logan TCU 17 The BRS and SIBS surveys were readministered to front-line nurses in January 2022. A total of n = 19 (32%) of front-line nurses completed the follow-up survey (see Table 3). In addition, an email with the survey link and request to complete the survey was sent to front-line nurses (see Appendix B). The average time to complete the survey was two and a half minutes. The low survey response rate for all units could be attributed to the COVID-19 Omicron surge that resulted in increased sick calls and required mandatory overtime. Therefore, no changes were made to correct the low response rate. Response rates were also analyzed for nurse managers. The second phase of this project involved training nurse managers on resiliency coaching. Two different pieces of training were provided to nurse managers. In October 2021, 100% of nurse managers attended a didactic training that reviewed resiliency coaching. In IMPLEMENTING A RESILIENCY COACHING 50 December 2021, 100% of nurse managers attended training on how to coach. After the second training, the DNP student sent each attendee an email with a survey link and a request to complete the survey (see Appendix B). The BRS and SIBS were combined into one form for ease of completion. The average time to complete all three surveys was four minutes. The surveys were designed using a matrix rating scale question which allows the respondent to evaluate one or more row items using the same column choices. No changes were made in the survey design or delivery throughout the project. A total of n = 3 (50%) nurse managers completed the surveys. The low response rate could be related to the COVID Omicron surge in which some nurse managers were sick, and others worked floor shifts to help with decreased staffing. There was no effort by the DNP student to improve low response rates. Once both front-line nurses and nurse managers returned surveys, the data were analyzed. A review of the data included a quantitative and qualitative analysis. When a participant completed a survey in Microsoft Forms, the data were gathered into an excel sheet with no identifying information. The DNP student inspected data for completeness, outliers, and errors. All data fields were complete, and no errors in the data were identified. Additionally, data in the excel sheet were coded for Likert scores utilizing the rankings noted by the Likert scale of each survey. This allowed for ease of calculation of descriptive and inferential statistics. Descriptive statistics were calculated for demographic and survey data, including frequencies, percentages, means, and standard deviations. Inferential statistics such as the t-test was calculated to compare the means of initial and follow-up surveys for front-line nurse survey results. Analysis began by comparing descriptive and inferential statistics of pre-and post-surveys, aggregate data, and specific unit data. Qualitative data was also collected and analyzed for this project. IMPLEMENTING A RESILIENCY COACHING 51 Qualitative data for this project included a comment question built into the front-line nurse’s initial survey and statements collected by the DNP student after training. A total of n = 9 (37.5%) of participants provided survey comments, and n = 6 (10%) spoke with the DNP student. The comments were recorded in Excel and themes extracted. Findings This project aimed to improve the resiliency of front-line staff through education and coaching. Data from this project were gathered and analyzed. The following section will review project findings related to front-line nurses, nurse managers, and outcomes. In addition, the strengths and weaknesses of the project design will be discussed. Front-line Nurses Pre-Intervention. Three surveys were administered to the front-line nurses: the ITQ, BRS, and SIBS. Data from these surveys were analyzed for the front-line nurse sample and each unit. The first survey administered to the participants was the ITQ which has two portions. The knowledge portion of the ITQ assessed what the participant understood about resiliency, burnout, and resources before the training. Results from this survey are listed in Table 4. Results show that the front-line nurse sample had average knowledge before training. However, the mean for the variable, “Your knowledge of resiliency resources offered by Intermountain,” stood out to the DNP student as unusually low related to the other variables. This data represents the sample as having knowledge about resiliency and burnout but not knowing where to get help within the organization. The confidence portion of the ITQ measured the participant’s confidence in recognizing and implementing actions to improve resiliency. Confidence is important for problem-solving, developing coping skills, and achieving personal goals. Results show that the front-line nurse sample had above-average confidence before training (see Table 5). This data IMPLEMENTING A RESILIENCY COACHING 52 represents a sample that does not lack confidence which will help them continue building their resiliency. In addition to knowledge and confidence, a baseline assessment of resiliency was collected and analyzed. Table 4 Knowledge Scores for Front-line Nurses Variable ITQ Pre a ITQ Post b M SD M SD Your knowledge of resiliency 3.50 1.14 4.58 0.58 Your knowledge of burnout 4.04 0.86 4.67 0.48 Your knowledge of resiliency resources offered by Intermountain 2.83 1.24 4.50 0.59 Note. ITQ = Intermountain Training Questionnaire a n = 24 b n = 24 Table 5 Confidence Scores for Front-line Nurses Variable Pre a Post b M SD M SD Your confidence in recognizing low resiliency in yourself. 3.50 0.98 4.33 0.70 Your confidence in implementing actions to become more resilient. 3.38 0.97 4.42 0.65 Note. ITQ = Intermountain Training Questionnaire a n = 24 b n = 24 IMPLEMENTING A RESILIENCY COACHING 53 Resiliency skills can be developed through self-care, strong relationships, problem-solving, and commitment (Perlo et al., 2017). To understand the participant’s baseline resiliency skills, the BRS was administered. Data for the BRS was collected and analyzed for the front-line nurse sample. Results showed that the front-line nurse sample is not highly resilient (see Table 5). Specifically, the BRS interpretation categorized this sample as “low resiliency” (M = 2.98). Overall, this sample is not highly resilient but is not lacking skills. Furthermore, data from the BRS was analyzed by the project site. Front-line nurses from the six IRU units participated in the BRS survey. Unfortunately, three sites had meager response rates, and statistics could not be calculated (see Table 3). Therefore, BRS results from the St. George IRU, Utah Valley IRU, and McKay-Dee IRU were analyzed. The first site where the BRS was administered and data analyzed was the St. George IRU. Initial BRS results showed a sample that was not highly resilient and categorized as “low resiliency” (M = 2.93) (see Table 9). While the BRS score was similar to the front-line nurse sample, the St. George IRU sample reported a better ability to bounce back and get over setbacks (see Table 7). This sample is not highly resilient but does have some resiliency skills. The next site where the BRS was administered and data analyzed was the Utah Valley IRU. Results revealed a sample with moderate resiliency and categorized as “normal resiliency” (M = 3.17) (see Table 8). Unfortunately, the initial survey response for the Utah Valley IRU was n = 3 (25%), which could have been attributed to higher means. However, the means for making it through stressful times, snapping back, and getting over setbacks were higher than other sites (see Table 8). This data reflected a sample with more agreement to those variables, which signified less resiliency. The last site where this analysis was completed was the Mckay-Dee IRU. Results showed a sample that was not highly resilient and categorized as “low resiliency” (M = 2.92) (see Table 9). The McKay-Dee IRU BRS results were lower than the IMPLEMENTING A RESILIENCY COACHING 54 other sites signifying a sample lacking resiliency skills. The final survey administered in the preintervention stage to front-line nurses provided insight into participants’ perceived burnout level. Table 6 Resiliency Scores for Front-line Nurses Variable BRS Initial Survey a BRS Follow-Up Survey b M SD M SD I tend to bounce back quickly after hard times. 3.83 0.76 3.79 0.98 It does not take me long to recover from a stressful event. 3.46 0.83 3.47 0.96 I usually come through difficult times with little trouble. 3.50 0.83 3.47 0.84 I have a hard time making it through stressful events. 2.42 0.88 2.47 0.90 It is hard for me to snap back when something bad happens. 2.42 0.97 2.79 1.13 I tend to take a long time to get over setbacks in my life. 2.29 0.81 2.21 0.98 Note. BRS = Brief Resilience Scale a n = 24 b n = 19 IMPLEMENTING A RESILIENCY COACHING 55 Table 7 Resiliency Scores of Front-line Nurses at St. George IRU Variable BRS Initial Survey a BRS Follow-Up Survey b M SD M SD I tend to bounce back quickly after hard times. 4.14 0.69 4.40 0.55 It does not take me long to recover from a stressful event. 3.43 0.98 4.20 0.45 I usually come through difficult times with little trouble. 3.71 0.76 3.80 0.45 I have a hard time making it through stressful events. 2.14 0.69 1.80 0.45 It is hard for me to snap back when something bad happens. 2.29 0.95 2.60 0.89 I tend to take a long time to get over setbacks in my life. 1.86 0.69 2.20 0.45 Note. BRS = Brief Resilience Scale a n = 7 b n = 5 IMPLEMENTING A RESILIENCY COACHING 56 Table 8 Resiliency Scores of Front-line Nurses at Utah Valley IRU Variable BRS Initial Survey a BRS Follow-Up Survey b M SD M SD I tend to bounce back quickly after hard times. 4.00 1.15 3.40 1.34 It does not take me long to recover from a stressful event. 3.67 0.58 3.00 1.00 I usually come through difficult times with little trouble. 3.67 0.58 3.00 1.22 I have a hard time making it through stressful events. 2.67 3.20 1.10 It is hard for me to snap back when something bad happens. 2.67 1.15 3.00 1.22 I tend to take a long time to get over setbacks in my life. 2.33 0.58 2.80 1.30 Note. BRS = Brief Resilience Scale a n = 3 b n = 5 IMPLEMENTING A RESILIENCY COACHING 57 Table 9 Resiliency Scores of Front-line Nurses at McKay-Dee IRU Variable BRS Initial Survey a BRS Follow-Up Survey b M SD M SD I tend to bounce back quickly after hard times. 3.67 0.73 3.71 0.95 It does not take me long to recover from a stressful event. 3.22 0.83 3.43 0.98 I usually come through difficult times with little trouble. 3.33 0.71 3.57 0.79 I have a hard time making it through stressful events. 2.44 0.71 2.29 0.76 It is hard for me to snap back when something bad happens. 2.33 0.71 2.29 0.95 I tend to take a long time to get over setbacks in my life. 2.56 0.73 2.00 1.00 Note. BRS = Brief Resilience Scale a n = 9 b n = 7 The early identification of burnout is essential to decrease stress, improve job satisfaction, and decrease turnover (Membrive-Jimenez et al., 2020). The SIBS was administered to understand the participant’s baseline perception of burnout. Data for the SIBS was collected and analyzed for the front-line nurse sample. Means were calculated for the two categories of variables: (a) not experiencing burnout symptoms and (b) experiencing burnout symptoms. Inspection of the no burnout symptoms category showed mixed results and a mean of 3.02 (see Table 10). In addition, the experiencing burnout symptoms category showed results that skewed IMPLEMENTING A RESILIENCY COACHING 58 towards disagreement with a mean of 2.54. The importance of the results found from the front-line nurse sample is that this group is experiencing burnout. Early intervention such as resiliency training could prevent this sample’s burnout from going from mild to crisis levels. Furthermore, data from the SIBS was analyzed by the project site. Front-line nurses from the six IRU units participated in the SIBS survey. Unfortunately, three sites had meager response rates, and statistics could not be calculated (see Table 3). Therefore, SIBS results were analyzed from the St. George IRU, Utah Valley IRU, and McKay-Dee IRU. The first site where the SIBS was administered and data analyzed was the St. George IRU, and the results are listed in Table 11. Means were calculated for the two categories of variables: (a) not experiencing burnout symptoms and (b) experiencing burnout symptoms. Inspection of results from the no symptoms category showed mixed results and a mean of 3.35. In addition, results from the experiencing symptoms category showed results skewed towards disagreement with a mean of 2.33. Inspection of specific variables provided insight into the burnout experienced by this sample. The variable, “I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion,” showed a mean of 2.86, which is skewed towards agreement. The St. George IRU sample is experiencing burnout, and early identification can help prevent further crisis. The next where the BRS was administered and data analyzed were the Utah Valley IRU, and results are listed in Table 12. Means were calculated for the two categories of variables: (a) not experiencing burnout symptoms and (b) experiencing burnout symptoms. Inspection of results from the no symptoms category showed a mean of 3.67. In addition, results from the experiencing symptoms category showed results skewed towards disagreement with a mean of 2.22. However, the initial survey response for the Utah Valley IRU was n = 3 (25%), which could have been attributed to skewed means. Inspection of specific variables provided IMPLEMENTING A RESILIENCY COACHING 59 insight into the burnout experienced by this sample. The variable, “I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion,” showed a mean of 3.00, which was higher than the St. George IRU sample. The Utah Valley IRU sample is experiencing burnout, and early identification can help prevent further crisis. The final site where the SIBS was administered and data analyzed was the McKay-Dee IRU (see Table 11). Means were calculated for the two categories of variables: (a) not experiencing burnout symptoms and (b) experiencing burnout symptoms. Inspection of results from the no symptoms category showed mixed results and a mean of 2.72. In addition, results from the experiencing symptoms category showed results skewed towards disagreement with a mean of 2.88. Inspection of specific variables provided insight into the burnout experienced by this sample. The variable, “I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion,” showed a mean of 3.67, which is skewed towards agreement and the highest of all the sites. These scores illustrate a sample that is experiencing more burnout than their peers. With baseline data collected for the front-line nurses and specific subgroups, the data collection moved to the intervention phase. IMPLEMENTING A RESILIENCY COACHING 60 Table 10 Burnout Scores in Front-line Nurses Variable SIBS Initial Survey a SIBS Follow-Up Survey b M SD M SD No Burnout I enjoy my work. I have no symptoms of burnout. 2.63 1.01 3.37 0.83 Occasionally I am under stress, and I don’t always have as much energy as I once did, but I don’t feel burned out. 3.42 1.06 3.63 0.90 Burnout I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion. 3.17 1.17 2.58 0.77 The symptoms of burnout that I’m experiencing won’t go away, I think about frustration at work a lot. 2.42 1.10 1.84 0.76 I feel completely burned out and often wonder if I can go on. I am at the point where I may need some changes or may need to seek some sort of help. 2.04 0.95 1.47 0.70 Note. SIBS = Single Item Burnout Scale a n = 24 b n = 19 IMPLEMENTING A RESILIENCY COACHING 61 Table 11 Burnout Scores of Front-line Nurses at St. George IRU Variable SIBS Initial Survey a SIBS Follow-Up Survey b M SD M SD No Burnout I enjoy my work. I have no symptoms of burnout. 2.71 1.11 3.40 0.89 Occasionally I am under stress, and I don’t always have as much energy as I once did, but I don’t feel burned out. 4.00 0.82 3.20 0.84 Burnout I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion. 2.86 1.21 2.40 0.55 The symptoms of burnout that I’m experiencing won’t go away, I think about frustration at work a lot. 1.71 0.98 1.60 0.55 I feel completely burned out and often wonder if I can go on. I am at the point where I may need some changes or may need to seek some sort of help. 2.43 0.76 1.40 0.55 Note. SIBS = Single Item Burnout Scale a n = 7 b n = 5 IMPLEMENTING A RESILIENCY COACHING 62 Table 12 Burnout Scores of Front-line Nurses at Utah Valley IRU Variable SIBS Initial Survey a SIBS Follow-Up Survey b M SD M SD No Burnout I enjoy my work. I have no symptoms of burnout. 3.33 0.50 3.60 1.14 Occasionally I am under stress, and I don’t always have as much energy as I once did, but I don’t feel burned out. 4.00 3.80 1.30 Burnout I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion. 3.00 1.00 3.00 1.00 The symptoms of burnout that I’m experiencing won’t go away, I think about frustration at work a lot. 1.67 2.00 1.00 I feel completely burned out and often wonder if I can go on. I am at the point where I may need some changes or may need to seek some sort of help. 2.00 0.58 1.40 0.55 Note. SIBS = Single Item Burnout Scale a n = 3 b n = 5 IMPLEMENTING A RESILIENCY COACHING 63 Table 13 Burnout Scores of Front-line Nurses at McKay-Dee IRU Variable SIBS Initial Survey a SIBS Follow-Up Survey b M SD M SD No Burnout I enjoy my work. I have no symptoms of burnout. 2.44 0.73 3.29 0.49 Occasionally I am under stress, and I don’t always have as much energy as I once did, but I don’t feel burned out. 3.00 1.00 3.57 0.53 Burnout I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion. 3.67 0.87 2.57 0.79 The symptoms of burnout that I’m experiencing won’t go away, I think about frustration at work a lot. 2.44 0.88 2.00 0.82 I feel completely burned out and often wonder if I can go on. I am at the point where I may need some changes or may need to seek some sort of help. 2.56 0.88 1.71 0.95 Note. SIBS = Single Item Burnout Scale a n = 9 b n = 7 Intervention. Resiliency training was provided to front-line nurses from August 2021 to December 2021. After training, the ITQ was collected to understand the effect on knowledge and IMPLEMENTING A RESILIENCY COACHING 64 confidence related to the topic. In addition, comments from the survey and those made to the DNP student were collected and analyzed. This section will review ITQ and qualitative results. Post-intervention surveys can be useful in comparing and measuring a change in participants' thoughts, behaviors, or processes (Dimitrov et al., 2003). To do this, the ITQ was administered after training to measure the participant’s knowledge of resiliency, burnout, and Intermountain Healthcare resources after attending the resiliency training. Data from the knowledge portion of the ITQ survey are presented in Table 4. There was a significant increase in knowledge from the pre to post ITQ survey (t = -5.47; p = <0.00001). In addition, all post-training results indicated a population with above-average knowledge of resiliency, burnout, and resources after receiving resiliency training. These results point to the training as a factor in improving the samples’ knowledge. In addition, the ITQ measures the participant's confidence in identifying and implementing measures to address low resiliency. Results for the confidence portion of the ITQ showed similar results as the knowledge portion. Data for the confidence portion of the ITQ survey are presented in Table 5. There was a significant increase in confidence from the pre to post ITQ survey (t = -2.30; p = <0.01). In addition, all post-training results indicated a population with above-average confidence in recognizing low resiliency and implementing actions. These results point to training as a factor in improving the confidence of the sample. Qualitative data were also examined in the intervention phase. Qualitative data provides meaningful information to identify patterns and themes (Lobiondo-Wood & Haber, 2018). Nurse manager and front-line nurse feedback regarding burnout and the training program's impact offered valuable insights regarding the impact of the program and opportunities for program improvement. The qualitative analysis included open-ended answers from various surveys and comments after the training program. The qualitative IMPLEMENTING A RESILIENCY COACHING 65 data was stored on an excel sheet through an automatic download from Microsoft Forms and manual entry. The data was then analyzed for themes and topics. Initially, the front-line nurses suggested future education topics, including coping, where to start with resiliency, burnout, resiliency, helping others with their burnout, implementing resiliency, mindfulness, decreasing stress, and taking time off. Comments from the open-ended question in the initial survey included, “I think any education in-services would be appreciated. I wouldn’t mind if the one I attended was repeated every 3-6 months.” Additionally, the DNP student collected comments from front-line staff after completing the training. Example comments included, “You [management] always tell us to be more resilient, but we didn’t know where to start. You gave us a great place to start.”; and “I enjoy in-services that reiterate the importance of our work, acknowledge the good work being done, and how to value & love self.” The themes extracted from these comments were resiliency, burnout, thankful, grateful, where do we start, and resources. These qualitative results are significant because they showed that resiliency training was needed and appreciated. Follow-up Surveys. A follow-up survey was sent to front-line nurses to understand if the training they attended had lasting results on resiliency and burnout. The survey, which included the BRS and SIBS, was sent on January 3, 2022. Unfortunately, three sites had very low response rates, and statistics could not be calculated (see Table 3). Data from the front-line and subgroup samples, means, and standard deviations were compared to the initial surveys, and t-test and p values were calculated. In addition, data from the BRS and SIBS were analyzed, and results will be discussed in this section. The BRS survey can provide insight into a person’s ability to bounce back and recover from a stressful event (Smith et al., 2008). A follow-up BRS survey was sent to the front-line IMPLEMENTING A RESILIENCY COACHING 66 nurse sample, and results showed a slight improvement in resiliency (see Table 5). The BRS interpretation categorized the front-line nurse sample as “normal resiliency” (M = 3.03; +0.05). There was a numerical trend towards improvement in the variables of snapping back and getting over setbacks with the follow-up survey; however, all other variables worsened. Additionally, the initial to follow-up resiliency survey results showed no significant improvement (t = -0.61; p = 0.27). These results suggest that the resiliency training had minimal effect on improving front-line nurse resiliency. Data from the BRS was further analyzed by project site. The first site where the follow-up BRS was administered and data analyzed was the St. George IRU (see Table 7). Results showed an increase in resiliency skills. The BRS interpretation categorized the St. George IRU sample as “normal resiliency” (M = 3.17; +0.25). However, the initial to follow-up resiliency survey results showed no significant improvement (t = -1.29; p = 0.11). These results suggest that the nurse sample at St. George IRU are resilient but may be experiencing stress challenging them. The next site where this analysis was completed was at the Utah Valley IRU, and results showed a worsening of all BRS variables (see Table 8). The BRS interpretation categorized the Utah Valley IRU sample as “normal resiliency” (M = 3.06; -0.11). One reason for the decrease in resiliency scores could be the improved response rate which may be more representative of the sample. However, the initial to follow-up resiliency survey results showed no significant improvement (t = 0.60; p = 0.28). This survey suggests that this sample of front-line nurses has decreased resiliency over the past couple of months, and training did not help. The last site where this analysis was completed was the McKay-Dee IRU, and the results are listed in Table 9. Results showed an improvement in all BRS variables. The BRS interpretation categorized the McKay-Dee IRU sample as “low resiliency” (M = 2.88; +0.04). The initial to follow-up resiliency survey results showed no significant improvement (t = -1.29; p = 0.11). IMPLEMENTING A RESILIENCY COACHING 67 These results suggest that the nurses at McKay-Dee IRU are resilient and have built resiliency skills. Overall, follow-up BRS survey results showed an improvement in resiliency. The second survey administered in the post-intervention stage to front-line nurses provided insight into whether the training helped to decrease perceived burnout. The SIBS survey can provide meaningful information on the experience of burnout in front-line nurses (Knox et al., 2018). The SIBS was the second survey administered to the front-line nurse sample in the post-intervention phase. Means were calculated for the two categories of variables: (a) not experiencing burnout symptoms and (b) experiencing burnout symptoms. Inspection of results from the no symptoms category showed an improvement with a mean of 3.5 (+0.47) (see Table 10). In addition, results from the experiencing symptoms category showed results that skewed towards agreement with a mean of 2.94 (+0.61). The initial to follow-up burnout survey results did not show significant improvement (t = 1.33; p = 0.09). These results suggest that the experience of burnout varies among front-line nurses. The data from the follow-up SIBS was further analyzed by project site. The first site where the follow-up BRS was administered and data analyzed was the St. George IRU (see Table 7). Results revealed an improvement in the experience of burnout in front-line nurses. Means were calculated for the two categories of variables: (a) not experiencing burnout symptoms and (b) experiencing burnout symptoms. Inspection of results from the no symptoms category showed a slight worsening of the mean (M = 3.3; -0.05). (see Table 11). In addition, results from the experiencing symptoms category showed results that skewed more towards disagreement (M = 1.8; -0.53). The initial to follow-up burnout survey results showed no significant improvement (t = 1.33; p = 0.09). These results reveal a group of front-line nurses who experienced decreased burnout symptoms. The next site where this analysis was completed was at the Utah Valley IRU, which showed IMPLEMENTING A RESILIENCY COACHING 68 improved burnout symptoms. Means were calculated for the two categories of variables: (a) not experiencing burnout symptoms and (b) experiencing burnout symptoms. Inspection of results from the no symptoms category showed a slight improvement of the mean (M = 3.7; +0.03) (see Table 12). In addition, results from the experiencing symptoms category showed results that skewed more towards disagreement (M = 2.13; -0.09). The initial to follow-up burnout survey results showed no significant improvement (t = 0.17; p = 0.43). These results reveal a group of front-line nurses who experienced decreased burnout symptoms. The McKay-Dee IRU was the final site where this analysis was completed, which showed a dramatic improvement in burnout symptoms. Means were calculated for the two categories of variables: (a) not experiencing burnout symptoms and (b) experiencing burnout symptoms. Inspection of results from the no symptoms category showed a dramatic improvement of the mean (M = 3.42; +0.70). (see Table 12). In addition, results from the experiencing symptoms category showed results that skewed more towards disagreement (M = 2.09; -0.79). The initial to follow-up burnout survey results showed no significant improvement (t = 1.24; p = 0.12). These results reveal a group of front-line nurses experienced decreased burnout symptoms. Overall, the results from this survey showed varied results from dramatic to no improvement in burnout. Nurse Manager The second phase of the project involved training nurse managers on resiliency coaching to provide skills in helping others through life challenges and build resiliency skills. The nurse manager training was completed in late 2021, and the follow-up survey is not planned until the second quarter of 2022. This section will report the preintervention survey results from the nurse manager phase of this project. Preintervention. During the pre-intervention phase of this project, three surveys were IMPLEMENTING A RESILIENCY COACHING 69 administered to obtain baseline data. The first survey administered to the nurse managers was the BRS, and the results showed a sample with moderate resiliency skills (Table 14). The BRS interpretation categorized the nurse manager sample as “normal resiliency” (M = 3.22). The initial survey response for nurse managers was n = 3 (50%), which could have been attributed to higher means. Compared to the front-line nurse sample, nurse managers have better resiliency skills in bouncing back, recovering, and making it through difficult times. However, the nurse manager sample had a higher mean for the variable, “I have a hard time making it through stressful events,” suggesting this sample lacks skills to deal with stress. The next survey measured the nurse manager's perception of burnout. Table 14 Resiliency Scores for Nurse Managers Variable BRS Initial Survey a M SD I tend to bounce back quickly after hard times. 4.00 1.00 It does not take me long to recover from a stressful event. 4.00 1.00 I usually come through difficult times with little trouble. 3.67 0.58 I have a hard time making it through stressful events. 3.00 1.00 It is hard for me to snap back when something bad happens. 2.33 0.58 I tend to take a long time to get over setbacks in my life. 2.33 0.58 Note. BRS = Brief Resilience Scale a n = 3 Identifying and managing burnout nurse managers can improve staff engagement, patient satisfaction, and safety in the workplace (Seichter, 2018). The SIBS was administered to measure burnout in nurse managers, and the results are detailed in Table 15. Means were calculated for the two categories of variables: (a) not experiencing burnout symptoms and (b) experiencing IMPLEMENTING A RESILIENCY COACHING 70 burnout symptoms. Inspection of results from the no symptoms category showed high results and a mean of 3.55. In addition, results from the experiencing symptoms category showed results skewed towards disagreement with a mean of 2.77. However, the initial survey response for the nurse managers was n = 3 (50%), which could have been attributed to skewed means. Inspection of specific variables provided insight into the burnout experienced by this sample. The variable, “The symptoms of burnout that I’m experiencing won’t go away, I think about frustration at work a lot,” showed a mean of 3.33, which is skewed towards agreement. This result suggests that the nurse manager sample is experiencing more severe burnout symptoms such as depersonalization or reduced personal accomplishment. The third survey administered in the post-intervention stage to nurse managers evaluated their training needs related to coaching. IMPLEMENTING A RESILIENCY COACHING 71 Table 15 Burnout Scores for Nurse Managers Variable SIBS Initial Survey a M SD No Burnout I enjoy my work. I have no symptoms of burnout. 3.00 1.00 Occasionally I am under stress, and I don’t always have as much energy as I once did, but I don’t feel burned out. 4.00 Burnout I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion. 3.00 1.00 The symptoms of burnout that I’m experiencing won’t go away, I think ab