Digital Repository Masters Projects Spring 2023 Stress Management for Nurses in Skilled Nursing Facilities Kaylynn Gorman Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Gorman, K. 2023. Stress management for nurses in skilled nursing facilities. Weber State University Masters Projects. https://dc.weber.edu/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 scua@weber.edu. WSU REPOSITORY MSN/DNP Stress Management for Nurses in Skilled Nursing Facilities Project Title by Kaylynn Gorman Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY April 2, 2023 Ogden, UT Date Kaylynn Gorman, RN, MSN 4/2/2023 Student Name, Credentials Date (electronic signature) Tressa Quayle, PhD, RN 4/21/2023 MSN Project Faculty Date (electronic signature) 05/25/2023 Melissa NeVille Norton (electronic signature) DNP, APRN, CPNP-PC, CNE Graduate Programs Director Note: The program director must submit this form and paper. Date 1 Stress Management for Nurses in Skilled Nursing Facilities Kaylynn Gorman, BSN, RN, MSN Student Weber State University Annie Taylor Dee School of Nursing 2 Abstract Nursing is a mentally and physically demanding job, causing stress in the lives of many registered nurses. Extreme stress is often disregarded due to the demands of the job and the increasing shortage of nurses in the field. Evidence indicates that nurses in skilled nursing facilities are at significant risk for stress-related adverse outcomes. Stress negatively impacts physical and mental health, nurse burnout, and compassion fatigue, compromising the well-being of the nurse and the patients they care for. This project aims to implement a stress management program for registered nurses within a skilled nursing facility. Two resources will be included to help nurses identify stress and manage its effects in and out of the workplace. The first resource is a PowerPoint Presentation that explains common outcomes of stress and provides coping strategies to utilize at any time. The second resource is a readily available handout to all nurses that provides quick references on the effects of stress and serves as a reminder for nurses to check in with their current mental and physical state. The provided education will assist nurses in recognizing the signs of stress and offer suggestions for reducing the risks of excessive stress. Nurse managers will also benefit from this project by maintaining a healthier nursing staff and increasing nurse and patient satisfaction. Overall, this project aims to raise awareness of stress and its overall effects on nurses in skilled nursing facilities and provide those nurses with resources to assist them in managing their stress. Keywords: stress, burnout, compassion fatigue, mental health, physical health 3 Stress Management for Nurses in Skilled Nursing Facilities Stress is one of the most underappreciated yet impactful concerns in the field of nursing. It affects many aspects of a nurse's work and private life. The emotional burdens are endless, and the physical demands can affect nurses' mental and physical health (American Nurses Association, 2022; Feliciano, 2022; Ling et al., 2020). The ethical pressures of the job are also in the back of nurses' minds. This stress often disturbs the health of nurses and sometimes even results in poor patient care. Furthermore, it increases the risk of burnout, which harms the organizations in which they work (American Nurses Association, 2022). Despite research showing overwhelming evidence that high-stress levels in nurses negatively affect patient outcomes and increase burnout rates, stress management programs within skilled nursing facilities are not standard (Dimino et al., 2021; Feliciano, 2022). A significant association exists between the nursing practice environment and nursing outcomes related to patient care (Feliciano, 2022; Jun et al., 2021; Ling et al., 2020; Rivaz et al., 2021). Even under ideal circumstances, nursing is a physically and emotionally demanding job. Nurses work long hours and are responsible for maintaining constant vigilance to ensure the safety of their patients. The toll of continual stress often leads to nurse burnout. Nurse burnout is a significant determinant of the quality of care in skilled nursing facilities (Eltaybani et al., 2021). Nurse managers can take high-stress levels among their nurses seriously and help them succeed by implementing workplace stress management techniques (American Nurses Association, 2022; Mudallal et al., 2017). Stress is an unavoidable hazard in nursing, so stress management is critical. Administrators play a significant role in the working environment of nurses. Their management style and strategies can add to or alleviate stress from the nurses they charge. By implementing stress management techniques and encouraging self-care, factors 4 contributing to stress and burnout among nurses can be reduced (Slemon et al., 2021). Nurse managers who recognize the importance of stress management for staff create a safer workplace and a more effective care team. Statement of Problem Burnout is an occupational risk affecting nurses, patients, and healthcare organizations (Jun et al., 2021; Ling et al., 2020). Nurse burnout is associated with reduced safety and quality of care and decreased patient satisfaction (Shah et al., 2021). Burnout is often caused by chronic emotional and interpersonal stressors on the job (American Nurses Association, 2022; Betka et al., 2021). Nurses in skilled nursing facilities report acute and chronic stress as contributing factors to burnout (Kelly et al., 2021). These nurses are exceedingly susceptible due to their large workload and increasing acuity of patients. Steinheiser (2018), using Heidegger's interpretive phenomenological approach, analyzed stress among registered nurses in skilled nursing facilities. Most participants reported high-stress levels due to the number of daily tasks, staffing ratios, and lack of support from nurse administrators. This MSN project aims to implement an evidencebased stress management program for nurses at a skilled nursing facility in northern Utah to reduce the stress of the nursing staff and ultimately decrease burnout rates within the facility. Ways Project Contributes to Intended Recipients The psychological toll of caring for patients and their families, who are often experiencing grief, anger, or fear, is taxing for nurses (Rivaz et al., 2021; Shah et al., 2021; Steinheiser, 2018; White, 2020). Nurses often feel these overwhelming feelings but must disguise them to show compassion for their patients during difficult times. Psychological stress can contribute to physical ailments such as insomnia, anxiety, depression, and high blood pressure. In addition, these mental and emotional stressors on nurses contribute to the likelihood 5 of medical mistakes (Betka et al., 2021). Therefore, implementing a stress management program at a skilled nursing facility benefits the staff, patient population, and organization. Reducing the stress nurses experience makes them more likely to work efficiently and produce better patient outcomes. They are also more likely to have higher job satisfaction, which leads to better work performance and long-term retention (Rivaz et al., 2021). Rationale for the Importance of Project Nurses are considered one of the most formidable professions and risk developing stressrelated outcomes (American Nurses Association, 2022; Betka et al., 2021; Eltaybani et al., 2021; Kelly et al., 2021; Nurse Journal, 2022; Purdue University Global, 2021; Wijn et al., 2022). These outcomes involve negative mental and physical health impacts, compassion fatigue, and burnout. Risk factors that often lead to stress-related outcomes include shiftwork, extended work hours, rotating schedules, and interaction with the loss and grief of patients. In addition, nurses often work with limited resources and staffing shortages (Wijn et al., 2022). Nurses employed at skilled nursing facilities are at significant mental and physical risk due to job demands. Self-care can decrease that risk; it involves deliberate activities that improve an individual’s physical and psychological well-being. Nurses spend their careers caring for others and are especially vulnerable to physical and mental exhaustion. Self-care replenishes their capacity to have empathy and continue to care for others at their highest potential (Pagador et al., 2022; Purdue University Global, 2021; van Mol et al., 2015; White, 2020). In addition, stress management is self-care that directly assists an individual exposed to prolonged stress. Therefore, it is vital that professionals, such as nurses, participate in stress management activities regularly. 6 An expanding problem among nurses in this field is compassion fatigue. Although compassion fatigue is not new, it is increasing among nursing staff with overwhelming responsibilities to care for patients with advanced needs (Steinheiser, 2018). Studies show a direct correlation between the decreased quality of care with compassion fatigue (American Nurses Association, 2022; Eltaybani et al., 2021). For example, a 2021 study showed that higher emotional exhaustion among nursing staff was associated with higher rates of patients with pneumonia and pressure ulcers in their facilities (Eltaybani et al., 2021). Higher emotional and physical exhaustion among nurses has continually shown a decrease in the quality of care in patients. Nursing burnout is a direct result of increased stress levels in the workplace, and it is becoming more relevant with higher patient demands. Regular stress management techniques improve overall burnout rates, which improves patient outcomes. As an aspect of holistic nursing, research has shown that stress management programs significantly reduce nurse burnout (Slemon et al., 2021). Nurse managers can be a great asset in maintaining a healthy workplace by implementing a stress management program for their team. Aligning the facility's goals with its workforce's health ensures that the best level of care is provided. Nurses are at an increased risk of social isolation due to long hours, shiftwork, and increased stress levels. Some researchers compare social isolation to an accelerator for disease. Opposing this, having a sense of purpose from connection with others enhances the health of immune cells and strengthens the body (Wijn et al., 2022). Camaraderie and teamwork are vital to wellness in the nursing field. Camaraderie does not simply mean being around other people. Having opportunities to participate in enjoyable, productive activities with others matters. The interaction's benefit creates a sense of connection (Carpenter, 2022). 7 Self-care is a critical component of stress management in nursing. According to data collected from a survey by the American Nurses Association (2022), improving nurses' health is imperative. It emphasizes the need to focus on self-care in physical activity, nutrition, rest, safety, and quality of life. In the survey, 70% of nurses said they put their patients' well-being above their own (Purdue University Global, 2022). This phenomenon is a prime example of why nurses must focus on their health to continue functioning at their best to care for patients. Literature Review and Framework A literature search was conducted to identify and explore evidence regarding the effects of stress on nurses in skilled nursing facilities. The literature examined included effective stress management programs to reduce stress-imposed effects in the workplace, such as adverse mental and physical health effects, burnout, and compassion fatigue. Research and non-research types of evidence were reviewed during the search. In addition, evidence-based frameworks were identified, reviewed, and evaluated for information on selecting a framework for this project. Framework The Iowa Model-Revised (IMR) was selected as the framework for planning the evidence-based changes associated with implementing this MSN project. The IMR assists in making decisions about nursing and administrative practices that affect healthcare outcomes. It utilizes a change process with multiple stages and feedback loops to identify issues and opportunities to continuously improve practices within a facility (Melnyk & Fineout-Overholt, 2019). By identifying triggering issues, the IMR identifies prospects of improvement using scientific knowledge, leading to improved practice standards. Nurses in leadership positions can utilize IMR to create a system that supports evidence-based care (Melnyk & Fineout-Overholt, 2019). 8 The steps of the Iowa Model Revised include identifying current issues of practice, stating the purpose of change, forming a team, assembling the body of evidence, designing the practice change, integrating the practice change, and distributing the results (Mudderman et al., 2020). Within the IMR, the three points to assist in guiding the improvement process are a) the priority of the topic, b) the presence of sufficient evidence, and c) the appropriateness of implementing change. If yes cannot be answered for these three points, the feedback loop requires more work before the process continues (Mudderman et al., 2020). The IMR applies to this project because it begins with identifying a question and guides the administration of practices that improves the triggering issue through continuous feedback (Melnyk & Fineout-Overholt, 2019). The change aims to reduce the damaging effects of stress on nurses within the facility. Following the steps of IMR, feedback loops will be utilized to continue asking critical questions to improve the implemented changes. Strengths and Limitations A clearly stated purpose is one of the strengths of IMR. IMR focuses on high-risk and high-cost topics, which this project involves. Stress reduction to improve nursing outcomes and reduce burnout is the purpose of this project. Occupational stress in healthcare profoundly impacts the nurse, the patient, and the facility (Behzadi et al., 2022). A topic with such overreaching consequences should be prioritized. Another strength of IMR is the feedback process. Feedback is critical to effective change. High-quality change is implemented when the results are carefully reviewed and transformed to fit the purpose as needed (Melnyk & FineoutOverholt, 2019). A limitation of the IMR is that evidence is being produced at an increasing rate, and continuous updating of facility practices presents time and monetary barriers (Duff et al., 2020). 9 Continuous improvement can be a context barrier within the facility. Another limitation of the IMR is that it requires interdisciplinary collaboration (Duff et al., 2020). These limitations are strengths of the IMR model in more extensive facilities with multiple training resources; however, they can pose potential constraints in a skilled nursing facility. The strengths outweigh the limitation, and this model is still the best fit for this MSN project. Analysis of Literature Even under ideal circumstances, nursing is a physically and emotionally demanding job. Nurses work long hours and are responsible for maintaining constant vigilance to ensure the safety of their patients. Unfortunately, the toll of continual stress often leads to nurse burnout which can be a significant determinant of the quality of care in skilled nursing facilities. (Eltaybani, et al., 2021) Nurse managers play a significant role in the workplace. Their management style and strategies can add to or alleviate stress from the nurses they supervise. By implementing stress management techniques and encouraging self-care, they can reduce factors contributing to stress among nurses (Slemon et al., 2021). In nursing, stress is an unavoidable hazard, so management is critical. A significant association exists between the nursing practice environment and nursing outcomes, such as burnout (Rivaz et al., 2021). Nurse managers who recognize the importance of stress management for their staff create a safer workplace and a more effective care team. The literature review revealed three themes resulting from high levels of occupational stress: negative mental and physical health impacts, compassion fatigue, and burnout. Search Strategies A literature search was conducted to identify current evidence of the effects of stress on nursing and the results of implemented stress management techniques using Google Scholar, 10 Weber State University's Stewart Library's OneSearch, The Cochrane Library (which spans multiple databases), and CINAHL to direct initial exploration. Articles from 2018 through 2022 were included in this literature review to keep the information current. The search had keywords of nursing burnout, skilled nursing facilities, stress management, management support, health impacts, and compassion fatigue. The literature review identified three themes. First, prolonged workplace stress decreases mental and physical well-being. Second, high levels of stress in healthcare increase rates of compassion fatigue. Third, the effects on the nurse's well-being and risk of compassion fatigue increase overall burnout (American Nurses Association, 2022). Impacts of Stress on Nurse’s Mental and Physical Health Nurses working in skilled nursing are exposed to extreme stressors, including high patient proportions, heavy workloads, patients with complex needs, physical and mental strain, and role ambiguity (American Nurses Association, 2022). Stress affects all body systems, including the nervous, musculoskeletal, cardiovascular, endocrine, gastrointestinal, respiratory, and reproductive systems (American Psychological Association, 2018). In addition, nurses spend their careers caring for others and are especially vulnerable to physical and psychological exhaustion. The psychological toll of caring for patients and their families, often experiencing grief, anger, or fear, is profound for nurses (Rivaz et al., 2021). Nurses may also feel these overwhelming feelings but often must disguise them and show compassion for their patients. In addition, psychological stress may contribute to physical ailments such as insomnia, anxiety, depression, and high blood pressure (ANA, 2022). This stress often affects the health of nurses and sometimes even the outcomes of patients and patient care. Furthermore, it compromises nurse retention rates and can even harm the financial status of healthcare organizations (Purdue 11 University, 2021). Research has shown that prolonged exposure to work-related stress harms nurses. Therefore, it is in their best interest to interrupt and reduce the amount of stress exposure for nurses. Stress reduction can be achieved through stress-management programs specific to the nurses in their department (Pagador et al., 2022). Compassion Fatigue An expanding problem among nurses is compassion fatigue. In nursing, compassion fatigue manifests when a nurse gradually becomes less compassionate about their patient’s medical challenges (White, 2020). It is increasing among nursing staff with overwhelming responsibilities to care for patients with advanced needs (Steinheiser, 2018). An Eltaybani study in 2021 shows a direct correlation between the decreased quality of care with compassion fatigue. In addition, higher emotional and physical exhaustion among nurses has continually demonstrated a decrease in the quality of care in patients (Dimino et al., 2021). Depending on the setting, compassion fatigue could lead to errors that could be a matter of life or death for patients (White, 2020). Healthcare professionals devote a significant amount of effort and time toward providing patients with optimal quality of care, so it is essential to look at both sides when understanding compassion fatigue in nursing, including what it is and why it happens (White, 2020). Compassion fatigue consists of two parts. The first part contains concerns such as exhaustion, frustration, and depression. The second part is the negative feeling driven by problems such as hyper-vigilance, avoidance, fear, and mental disturbances (van Mol et al., 2015). Due to the potential consequences of compassion fatigue, it can be an occupational hazard that should be promptly dealt with when recognized (White, 2020). Nurse Burnout 12 Nurse burnout is a pervasive occurrence characterized by a decline in nurses' energy that exhibits emotional exhaustion, lack of motivation, and feelings of defeat that may negatively affect work ethic and efficacy (Mudallal et al., 2017). Burnout is a typical result when the stress of the job causes physical, mental, and emotional fatigue. Most nursing professionals experience nurse burnout at some point in their careers. For example, a 2017 Kronos study found that 63% of hospital nurses reported experiencing burnout (as cited in NurseJournal, 2022). When managers of skilled nursing facilities encourage stress management techniques, nursing burnout rates decrease, and patient outcomes improve (American Nurses Association, 2022). Research has shown that self-care, such as stress management programs, as an aspect of holistic nursing, significantly reduces nurse burnout (Slemon et al., 2021). Nurse managers can be a great asset in maintaining a healthy workplace for their staff. Aligning the facility's goals with its workforce's health ensures the best level of care. The Importance of Education Since the literature indicates that occupational stress poses many adverse effects for nurses, examining the type of support they need to deal with stress is essential. Stress management, when used correctly, can be a beneficial tool for reducing the adverse effects of stress (Purdue University, 2021). In addition, nurses need support from management and peers, safe patient ratios, and adequate break times. However, a stress management program will emphasize the nursing staff's wellness and provide them with additional resources to combat the hazards of their occupation. Summary of Literature Review Findings and Application to the Project For nurses, poor mental and physical health, compassion fatigue, and burnout result from demanding jobs, frequently exposing them to human suffering (NurseJournal, 2022). Nurses deal 13 with people in pain and agony every day. Additionally, nurses often work 12 or more hours within one day. These factors can lead to adverse effects on their health and well-being. Furthermore, workplace circumstances such as inadequate support or leadership can exacerbate burnout (American Nurses Association, 2022). The literature review has shown overwhelming evidence that prolonged exposure to large amounts of stress, such as that in the nursing profession, negatively impacts an individual's overall well-being. Therefore, this project finds it essential to reduce stress by providing nurses in skilled nursing facilities with stress management techniques. Project Methodology This MSN project aims to prepare nurses employed in skilled nursing facilities to manage stress in the workplace. This will be accomplished by providing education and documentation to support nursing staff understanding. Three deliverables have been created to promote this project’s introduction and implementation with the skilled nursing facility. In this section, the deliverables are described in detail, and a timeline for completion is provided. Description and Development of Project Deliverables Three items were created to aid in the implementation of this project, with the intent to educate and assist nurses in managing stress and encouraging nurses to communicate with their supervisors to get the support they need. Furthermore, an elucidation of the importance of each deliverable is included. The deliverables include an RN PowerPoint presentation, which outlines teaching points regarding the importance of stress management in nursing. The second will be a staff handout that outlines stress reduction techniques. Third, a feedback form will be distributed for nurses to utilize as a method to communicate their needs with their supervisors. Lastly, a 14 timeline will be provided that outlines pertinent details of the timetable for the implementation of the project. The Importance of Stress Management in Nursing PowerPoint The first item is a PowerPoint presentation (Appendix A). The presentation aims to prepare nurses to recognize the effects of stress on their well-being and provide them with tools to manage stress in the workplace. The presentation includes common signs of distress and coping strategies (Centers for Disease Control and Prevention, 2019). The presentation will help nurses recognize the signs of stress on their well-being and how to implement interventions when necessary. This deliverable will represent a stress management program for nurses working in a skilled nursing facility that encourages discussion and valuable information for the welfare of the nurses. Stress Reduction Handout The second deliverable is an educational handout for nurses (Appendix B). The handout contains information gathered from current literature regarding the catalysts and effects of stress on nurses (Nurmine, 2022; Steinheiser, 2018). The handout will provide nurses in the skilled nursing facility with a visually engaging source of information that can be easily referenced and accessed. Additionally, this deliverable will remind nurses to periodically check in with themselves and better understand how their job affects their well-being and work performance. Nursing Feedback Form A third deliverable is a feedback form available to nursing staff to check in with their supervisors regarding their concerns (Appendix C). This is designed so that nurses can communicate with supervising staff concerning their current state of mind and express their needs. Hard copies of the forms will be available at each nursing station and can be turned into 15 the supervisor’s receiving box. QR codes that correlate with electronic versions of the documents will be posted throughout the facility and be automatically submitted when completed. Timeline The timeline for the implementation of the project can be found in Appendix D. This includes all pertinent details of the project, such as a graphic that assists the nursing staff in visualizing the implementation plan process. This timeline will benefit the team by helping them plan accordingly and promoting full participation. The implementation planning will begin in the year's first quarter, with the stress management program beginning in the second quarter. Throughout the third and fourth quarters of the year, the plan will continue to be implemented and reevaluated as needed. After the first year of program implementation, the goal is for the program to be fully functional and beneficial to the nursing staff. Plan and Implementation Process This MSN project will be implemented by the second quarter of the year. A nursing project implementation team will be created to collaborate on the project alongside management. Monthly meetings for the first year and quarterly after that will be conducted between the project team and the nursing staff. The deliverables (Appendix A, B, C) will be discussed and dispersed in these meetings. These meetings will take place in the conference room at the facility. During the meetings, long-term care nurses can give input on the project and its deliverables and ask questions. This project will be an ongoing project within the facility to continually assess and address the needs of the nursing staff regarding workplace stress and its consequences. Interdisciplinary Teamwork Highly effective healthcare teams are dependent on mutual respect and shared ideas. (Betka et al., 2021). Effective teamwork can directly and positively affect patient safety and 16 outcomes (Babiker et al., 2014). With the implementation team, management, and nursing staff working closely together throughout the implementation process, the nursing stress management project has an improved chance of success. Director of Nursing. The director of nursing (DON) will review and approve the project plan and deliverables. In addition to approving the project plan, the DON will schedule time for the implementation team to work on and disseminate the plan. They will also be responsible for reviewing the nursing feedback forms (Appendix C) and addressing the needs and concerns of the nurses. The DON will approve the budget, allowing time to work on the project and materials to produce the deliverables. Project Team Leader. The project team leader is an RN who will lead the project planning, implementation, and review. They will present the plan to the director of nursing before implementation and make any necessary planning changes. The team leader will correspond closely with the nursing staff, record results, and concerns, and address them collaboratively with the director of nursing at quarterly meetings. Registered Nurses. The facility’s registered nurses will be responsible for attending meetings and participating in the stress management program. Registered nurses are the intended recipients due to their risk of workplace stress, and their participation is vital to a successful program. The nurses will also be accountable for providing input to the program to assist in tailoring the training and deliverables to the facility’s specific needs. Plan for Evaluation of Project This MSN project will be evaluated pre- and post-implementation. Nursing staff will complete a knowledge survey on the implications of work-related stress. This will give the implementation team a starting point for the knowledge base and deficits that must be addressed. 17 The project's success will be determined by comparing the pre-and post-evaluation results with a scoring system of 1-10. The higher the scores, the more effective the program is in educating nurses on stress management. The questionnaires will also have an input section at the end, allowing nurses who have specific ideas on what will help them most with stress management skills a chance to provide feedback. Ethical Considerations Two ethical considerations must be addressed in this project. First, the nurses’ behavioral and mental health details must remain confidential. The nurses will have the right to choose or refuse to use the feedback forms. Feedback forms will be kept anonymous. If a nurse decides to disclose their name, the information is reviewed only by the director of nursing and the project director overseeing the project. Second, nurses have heavy caseloads and stressful work environments that already place them at a greater risk for increased stress (White, 2020). The additional time and work needed to make this project successful will add to the nursing staff and project implementation team’s workload. To combat that potential concern, the biweekly meetings for the implementation team will be during scheduled workdays. The monthly meetings for the nursing staff will be paid for training hours, and they may use the training in place of one monthly online training required by all staff. Participation in the stress management project is encouraged but is elective. The nurses participating in monthly meetings will be rewarded with quarterly incentives. These gifts will promote vitality, such as gift cards to spas and bookstores and extra PTO hours. Non-participants of the meetings will still have access to the deliverables and are welcome to start participating in the project at any time. 18 Discussion Stress is inevitable in nursing, and managing it is crucial. High-stress levels and related obstacles can threaten the well-being of nurses and their patients. Psychological concerns increase the probability of medical mistakes. The real implications of nursing stress are only sometimes visible, but the need for proper management is more significant than ever (AdventHealth University, 2020; Shah et al., 2021). Nurses need to understand the consequences of stress on their health and their patient’s welfare (White, 2020). The implications of this project are to educate on the effects of stress and assist nurses in a skilled nursing facility in northern Utah with stress management techniques. The strengths and limitations of this program, along with additional research references, will be discussed. Information regarding the program will be disseminated orally in meetings, and with deliverables previously discussed. Evidence-based Solutions for Dissemination Following the first quarter, the results of this project will be disseminated in three ways. First, the project implementation team at the skilled nursing facility will present a group discussion during a scheduled nurses’ meeting. The PowerPoint presentation and the preimplementation questionnaire will be presented at the meeting. Second, the results of the preimplementation questionnaire will be disseminated among the implementation team and management to determine the base level of knowledge and stress level among the nurses in the facility. This will assist the team in leading the main-level presentation at the implementation start date. Third, this project will be shared with Weber State University faculty and peers as a poster presentation at the end of the final semester. Significance to Advance Nursing Practice 19 A stress management project for nurses can benefit nurses in all settings. It allows the topic to be discussed in detail and removes the stigma of weakness among the pressures of a nursing career (Pagador et al., 2022; Yuan et al., 2020). This project will also benefit facilities by educating and preparing nursing staff for the demands that come with the profession. Additionally, this project will enhance the quality of care given to the patients within the facility where it is implemented. Implications This project educates and prepares nurses for the mental and physical demands of the job. It allows for open communication among peers and supervisors with stressors and solutions for those stressors. Training nurses on their personal mental and physical health will enable them to enhance the care they give to their patients. Finally, patient outcomes will improve as the nursing staff’s knowledge and experience with self-care improves. This project’s limitations include its limited size within a 40-bed skilled nursing facility. Conversely, once this project is implemented, it may be utilized to spread to other facilities. The lack of participation of nursing staff may also be a limiting factor. Staff orientation and monthly meetings will highlight stress management's importance. It will also be emphasized in the inservices posted at the nursing stations. Nurses impact patients' lives by caring for them in their most vulnerable and stressful situations. Working long hours and doing physically demanding work, all while maintaining constant awareness in making decisions for the betterment of other human beings, lead to an alarming increase in stress levels. For these reasons, nurses must understand the risks of their work-related stress and methods to decrease those risks (AdventHealth, 2020). Recommendations 20 The literature review indicated an overwhelming sense of urgency regarding the need for nurses to manage their stress levels (Advent Health, 2020; Dimino et al., 2021; Feliciano et al., 2022). However, few facilities implement stress management programs for their nurses. It is recommended that stress management be a focal point for training among new and experienced nurses alike. It is also recommended that research be conducted regarding policies that lessen the mental and physical stressors placed upon nurses in the healthcare field. Conclusions Nurses in skilled nursing facilities work with various patient diagnoses and situations, from providing preventive care and surgical recovery services to treating pandemic recovery patients. While stress factors can manifest in any setting, nurses are especially vulnerable to the adverse effects of stress. Nurses should be given the skills they can use to cope with and recover from stress to continue to provide their patients with the optimal level of care (Regis College, 2021; Wijn et al., 2022). Stress management techniques can help nurses rejoin the evocative purpose that brought them to the field and improve their occupational satisfaction (Betka et al., 2021; Regis College, 2021). This project aims to give nurses the advance they need to recognize signs of stress in their professional lives and provide them with the means to manage it. 21 References Advent Health University. (2020, July 31). Managing Nurse Stress: Mental Health Tips and Resources. https://www.ahu.edu/blog/managing-nurse-stress American Nurses Association. (2022, October 22). Combating Stress. https://www.nursingworld.org/practice-policy/work-environment/healthsafety/combating-stress/ American Psychological Association. (2018, November 1). Stress effects on the body. https://www.apa.org/topics/stress/body Babiker, A., El Husseini, M., Al Nemri, A., Al Frayh, A., Al Juryyan, N., Faki, M. O., Assiri, A., Al Saadi, M., Shaikh, F., & Al Zamil, F. (2014). Health care professional development: Working as a team to improve patient care. Sudanese journal of paediatrics, 14(2), 9–16. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4949805/ Betka, K., Baskinka, M., & Andruszkiewicz, A. (2021). Nurses' sense of coherence and stress management strategies against the types of health status. NursingOpen, Article 8, 34033410. https://doi.org/10.1002/nop2.886 Carpenter, H. E. (2022, October 3). The power of camaraderie: How socialization strengthens nurse well-being. Healthy Nurse Healthy Nation. https://engage.healthynursehealthynation.org/blogs/8/4255 Centers for Disease Control and Prevention. (2019, September 13). Taking Care of Your Emotional Health. https://emergency.cdc.gov/coping/selfcare.asp de Wijn, A. N., & van der Doef, M. P. (2022). A meta-analysis on the effectiveness of stress management interventions for nurses: Capturing 14 years of research. International Journal of Stress Management, 29(2), 113-129. https://doi.org/10.1037/str0000169 22 Dimino, K., Learnmonth, A. E., & Fajardo, C. C. (2021). Nurse managers leading the way: Reenvisioning stress to maintain healthy work environments. Critical Care Nurse, 41(5), 52-58. https://doi.org/10.4037/ccn2021463 Eltaybani, S., Yamamoto-Mitani, N., Ninomiya, A., & Igarashi, A. (2021). The association between nurses' burnout and objective care quality indicators: A cross-sectional survey in long-term care wards.BMC Nursing, 20(1), Article 34. doi: 10.1186/s12912-021-00552-z Feliciano, A. Z., Feliciano, E. E., Al-Asiry, S., Magtubo, J. D., Reyes, W. S., Bautista, E. C., Santiango, B. M., T., & Gumabon, R. G. (2022). Nurses’ stress, anxiety, depression, and burnout in the workplace: A correlational study. International Journal of Advanced and Applied Sciences, 9(9), 96-104. http://www.science-gate.com/IJAAS.html Jun, J., Ojemeni, M. M., Kalamani, R., Tong, J., & Crecelius, M. L. (2021). Relationship between nurse burnout, patient and organizational outcomes: Systematic review. International Journal of Nursing Studies, 119, Article 103933. https://doi.org/10.1016/j.ijnurstu.2021.103933 Kelly, L. A., Gee, P. M., & Butler, R. J. (2021). Impact of nurse burnout on organizational and position turnover. Nursing Outlook, 69(1), 96-102. https://doi.org/10.1016/j.outlook.2020.06.008 Ling, K., Xianxiu, W., & Xiaowei, Z. (2020). Analysis of nurses’ job burnout and coping strategies in hemodialysis centers. Medicine, 99(17), Article e19951. doi: 10.1097/MD.0000000000019951 Melnyk, B., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Wolters Kluwer. Mudderman, J., Nelson-Brantley, H., Wilson-Sands, C., Brahn, P. & Graves, K. (2020). The 23 effect of an evidence-based practice education and mentoring program on increasing knowledge, practice, and attitudes toward evidence-based practice in a rural critical access hospital. The Journal of Nursing Administration, 50(5), 281-286. doi: 10.1097/NNA.0000000000000884. Nurmine, Kairi. (2022). Work Stress among Registered Nurses in Health Care Services. LAB University of Applied Sciences. https://www.theseus.fi/bitstream/handle/10024/745565/Nurmine_Kairi.pdf?sequence=2N urse Journal Staff. (2022, September 1). What Is Nurse Burnout? https://nursejournal.org/resources/nurse-burnout/ Pagador, F., Barone, M., Manoukian, M., Xu, W., & Kim, L. (2022). Effective holistic approaches to reducing nurse stress and burnout during COVID-19. American Journal of Nursing, 122(5), 40-47. doi: 10.1097/01.NAJ.0000830744.96819.dc Purdue University Global. (2022). What is Self-Care? . Retrieved from Purdue University : https://www.purdueglobal.edu/blog/nursing/self-care-for-nurses/ Purdue University Global. (2021, April 28). The importance of self-care for nurses and how to put a plan in place. Purdue University Global: Nursing. https://www.purdueglobal.edu/blog/nursing/self-care-for-nurses/ Regis College. (2021, April 21). 5 Stress Management Techniques for Nurse Leaders. https://online.regiscollege.edu/blog/stress-management-for-nurses/ Rivaz, M., Tavakolinia, M., & Momennasab, M. (2021). Nursing professional practice environment and its relationship with nursing outcomes in intensive care units: A test of the structural equation model. Scandinavian Journal of Caring Sciences, 35(2), 609–615. https://doi.org/10.1111/scs.12877 24 Shah, M. K., Gandrakota, N., & Cimiotti, J. P. (2021). Prevalence of and factors associated with nurse burnout in the US. JAMA Network, 4(2), Article e2036469. doi:10.1001/jamanetworkopen.2020.36469 Steinheiser, M. (2018). Compassion fatigue among nurses in skilled nursing facilities: Discoveries and challenges of a conceptual model in research. Applied Nursing Research, 44, 97-99. doi: 10.1016/j.apnr.2018.10.002 van Mol, M., Kompanje, E., Bemoit, D., Bakker, J., Nijkamp, M., & Seedat, S. (2015). The prevalence of compassion fatigue and burnout among healthcare professionals in intensive care units: A systematic review. PlosOne, 10(8), Article e0136955. https://doi.org/10.1371/journal.pone.0136955 White, W. (2020, November 30). Compassion fatigue in nursing: What it is and how to deal with it. Incredible Health. https://www.incrediblehealth.com/blog/compassion-fatigue/ Wijn, A. N., & van der Doef, Margot P. (2022). A meta-analysis on the effectiveness of stress management interventions for nurses: Capturing 14 years of research. International Journal of Stress Management, 29(2), 113-129. https://doi.org/10.1037/str0000169 Yuan, L., Yumeng, C., Z., Jinbo, F. (2020). Analyzing the Impact of Practice Environment on Nurse Burnout Using Conventional and Multilevel Logistic Regression Models. Sage Journals. https://doi- org.ezproxy.saimia.fi/10.1177%2F2165079919900796. 25 Appendix A THE IMPORTANCE OF STRESS MANAGEMENT IN NURSING Image from PowerPoint Office 365 Stress ¡ Stress amongst nurses is one of the most THE PROFESSION OF NURSING underappreciated yet impactful issues nurses face. ¡ It surfaces in many aspects of a nurse’s work and personal life. ¡ The emotional demands are limitless, and the physical demands/fatigue can be burdensome. ¡ The ethical/moral stresses of the job are also in the back of nurses’ minds. (American Nurses Association, 2022) 26 WHAT HAS BROUGHT US ALL HERE TODAY? “Our committed mission and vision are to assist its patient facilities in their continuing quest to achieve and maintain quality health. And that its patient facilities be immediately recognized as the preeminent nursing and rehab centers offering a compassionate clinical system of care in a warm, inviting, and comfortable environment..” - Skilled Nursing Facility NOTES FROM ADMIN ¡ 100% Confidentiality ¡ Your Well-being is our Top Priority ¡ Participant’s Behavior is Vital to the Success of this Program Image from PowerPoint Office 365 27 Workplace ¡ There's always deadlines to meet ¡ Mistakes to make right WORK & PRESSURE ALWAYS SEEM TO FOLLOW ONE ANOTHER ¡ Many demands to meet ¡ Targets to reach ¡ Problems to fix ¡ Challenges to rise to IMPACTS OF STRESS ON NURSE’S MENTAL AND PHYSICAL HEALTH ¡ Increased blood pressure and heart rate ¡ Tension in muscles creates stiffness and pain. ¡ Insomnia ¡ Anxiety ¡ Depression ¡ Weakened immune system Image from PowerPoint Office 365 (American Psychological Association, 2018) 28 Good Stress DIFFERENT KINDS OF STRESS Bad Stress ¡ Your patient recovers. ¡ Dangerous workload. ¡ The patient has supportive ¡ Lack of support from family members. ¡ You have strong emotional bonds with colleagues and supervisors. coworkers. ¡ Long work hours with a lack of appropriate breaks. Images from PowerPoint Office 365 WHAT ARE SIGNS OF STRESS ¡ What you can see: Nail-biting, twitching of the eye or brow, and lip-licking or biting regularly ¡ What you can hear: Hitting desks with fists, phones, papers, or slamming of doors ¡ What you can feel: Sweaty, clammy, heated, tense, annoyed, and enraged Image from PowerPoint Office 365 29 If you decide to take no notice of it: ¡ You lose the ability to adapt. GAINING SUCCESS AND UNDERSTANDING THE IMPACT OF STRESS ¡ The issues deteriorate ¡ The pressures grow worse. So as a result: § You experience increased tension. § The circumstance gets trickier. § Finding assistance get harder. § It takes a lot of time and work to return to the "norm." POSITIVE RESPONSES TO WORKPLACE STRESS ¡ Prepare in advance for known workload increases. ¡ Lessen your need for perfection ¡ Start delegation or improve delegation. ¡ Work more productively. ¡ Organize your workload and concentrate on one thing at a time. ¡ Become more proactive as opposed to reactive. ¡ Speak with someone to gain an alternative viewpoint. Image from PowerPoint Office 365 30 LOWERING THE STRESS § Asking questions about what you don’t understand § Being as tolerant as you can with others and the tasks at hand § Adapting with the shift of things as quickly as possible § Talk to others about your worries Image from PowerPoint Office 365 HOW TO MANAGE STRESS AND LIFESTYLE CHANGES TO HELP EAT A HEALTHY DIET. PARTICIPATE IN REGULAR PHYSICAL EXERCISE. REACH OUT FOR SUPPORT FROM FRIENDS, COWORKERS, AND FAMILY. 31 THE IMPORTANCE OF HELP Discussing your situation with someone can: ¡ Clarify what you mean ¡ Get it out of your system. ¡ Adjust your perspective. ¡ Sort out the genuine from the imagined problems ¡ Give you a fresh viewpoint ¡ Reduce the feeling of loneliness that pressure might cause. (Mayo Clinic, 2023) Image from PowerPoint Office 365 PROMOTING AN ENVIRONMENT OF LOW STRESS ¡ Accept accountability ¡ Discuss your stress and be open about it. ¡ Keep your self-worth separate from your income/success at work. ¡ Try to gain as much knowledge as possible about stress, then use it. ¡ Communicate and inform others. ¡ Co-operate ¡ Offer and accept assistance ¡ Recognize and embrace change (Peart, 2019) 32 References American Nurses Association. (2022, October 22). Combating Stress. https://www.nursingworld.org/practice-policy/workenvironment/health-safety/combating-stress/ YOUR FUTURE IS BRIGHT American Psychological Association. (2018, November 1). Stress effects on the body. https://www.apa.org/topics/stress/body Mayo Clinic. (2023). Stress Basics. https://www.mayoclinic.org/healthy-lifestyle/stressmanagement/basics/stress-basics/hlv-20049495 Peart, Natalie. (2019, November 05). Making Work Less Stressful and More Engaging for Your Employees. Harvard Business Review. https://hbr.org/2019/11/making-work-less-stressfuland-more-engaging-for-your-employees 33 Appendix B Stress Reduction Handout STRESS MANAGEMENT GUIDE FOR NURSES Did you know that not all stress is harmful? Research shows that there are certain levels of stress that are “optimal” and enhance performance. When you are under-stressed, you will feel your motivation is low. On the other hand, if your stress levels are too high, your performance could suffer and be impaired due to high anxiety (Kariuki, 2021). IN WHAT WAY CAN THIS INFORMATION HELP ME? Find a level of stress that works better for you. What works for your coworkers might not necessarily work for you. Everyone works best under different levels of stress. What may feel optimal for someone else, could feel extremely high-stress and debilitating for you. USE STRESS MANAGEMENT TECHNIQUES Stress is unavoidable in nursing, so managing it is critical to avoid stress-related health problems, compassion fatigue, and burnout (Advent Health University, 2020). There are several techniques you can use to manage stress, including: • • • • Breathing exercises Grounding techniques Mindfulness exercises Meditation • • • • Exercise Prioritization of tasks Engaging in hobbies Increasing your free time • • • • Taking breaks Talking to peers Setting boundaries Asking for help 34 Appendix C NURSING FEEDBACK FORM Use this form if you are experiencing workplace-related stress. Turn it in to your supervisor. You may remain confidential if you prefer. What is the CAUSE of your STRESS? What incidents/events lead to this? What SOLUTIONS have you tried? As your leader, HOW CAN I HELP YOU be successful? Take a 20-minute break and practice stress management techniques that are from the STRESS MANAGEMENT HANDOUT posted in the breakroom. 35 Appendix D