Digital Repository Masters Projects Spring 2024 Self-Care Practices for Pediatric Oncology Nurses Natalie Lancaster Mason Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Mason, N.L. 2024. Self-Care Practices for Pediatric Oncology Nurses 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 Self-Care Practices for Pediatric Oncology Nurses Project Title by Natalie Lancaster Mason 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 26 April 2024 Ogden, UT Date Natalie Lancaster Mason, BSN, RN, MSN Student 26 April 2024 Student Name, Credentials (electronic signature) Date 26 April 2024 MSN Project Faculty (electronic signature) Date 26 April 2024 (electronic signature) DNP, N, CNE MSN Program Director Note: The program director must submit this form and paper. Date 1 Self-Care Practices for Pediatric Oncology Nurses Natalie Lancaster Mason, BSN, RN, MSN Student Annie Taylor Dee School of Nursing Weber State University MSN Project 2 Abstract Purposes/Aims: Nursing in a specialized unit, such as pediatric oncology, has unique challenges and stressors. Burnout is prevalent among nurses, leading to job dissatisfaction and low retention. This project aims to educate pediatric oncology nurses on evidence-based self-care techniques and other mental health resources to increase resilience and decrease turnover. Rationale/Background: The Immunocompromised Unit at Primary Children's Hospital has a high turnover rate. More than fifty percent of the nurses on that unit have been there less than one year ((N. Dennis, personal communication, August 10, 2023). Occupational stress and dissatisfaction are significant factors that contribute to turnover (Bae, 2022). A nurse's health impacts patient care, which is why self-care and overall well-being are essential (Williams et al., 2022). Educating nurses on evidence-based self-care techniques is crucial in increasing job retention and satisfaction. Methods: Nurses will be given a pre-survey assessment regarding self-care techniques and the employee assistance program. Educational materials explain the problem, solution/project, rationale, and implementation. Educators on the unit make resources available to the nurses on bulletin boards and in the breakroom, including mental health resources (support group, employee assistance program website, and others), along with self-care techniques. A follow-up survey assessment will be completed six months after the implementation of the project to gauge learning and assess for any gaps. Retention will be monitored quarterly. Results: The survey will be given to 105 nurses. Based on the survey, nurses will be educated to address any gaps found in hopes that there will be an increase in the utilization of the employee assistance program and self-care techniques. Overall retention will be increased as well. 3 Conclusions: Research has shown that nurses who invest in themselves, practice self-care techniques, and have support, are healthier and happier (Williams et al., 2022). Emotional resilience can lead to better outcomes for nurses and patients. Keywords: burnout, self-care, resilience, mental health 4 Self-Care Practices for Pediatric Oncology Nurses The work environment of nurses involves many stressors, including workload, lack of administrative support, exposure to terminally ill patients, unit-based stressors, lack of education, and lack of preparedness for the emotional and physical impact of the job itself (Al Sabei et al., 2022). Other systemic factors, including poor work environment, understaffing, and low pay, also contribute to burnout and nurses' quality of life (Khatatbeh et al., 2021). Burnout among nurses is a multilevel, system-wide problem. Nursing in a specialized unit, such as pediatric oncology, has unique challenges and stressors. Nurses working in an oncology unit may be more susceptible to burnout due to specific factors such as direct contact with death, pain, and suffering by patients and their families, and a perceived lack of social support (De La Fuente-Solana et al., 2020). Despite continuous advances in medicine, one in five children with cancer will die from the disease (Boyle & Bush, 2018). The loss of a patient can cause emotional vulnerability among nurses due to the intense needs of patients and family members. Not only that, but nurses take on numerous roles, including care provider, educator, facilitator, translator, supporter, and advocate (Boyle & Bush, 2018; Zarenti et al., 2021). Thus, occupational stress, burnout, compassion fatigue, moral distress, and grief are prevalent among pediatric oncology nurses (Boyle & Bush, 2018). Without intervention, occupational stress over a long period can lead to burnout (Slater et al., 2018). According to Maslach's model, burnout includes emotional exhaustion, depersonalization, and diminished personal accomplishment (Boyle & Bush, 2018; Slater et al., 2018). Burnout among nurses leads to job dissatisfaction and low retention. Nurses must care for themselves because they work in stressful conditions (Williams et al., 2022). Not only does 5 stress impact the nurse, but it also impacts the patient and their care. Stress and burnout reduce the productivity of the nurse and diligence to their patients (De La Fuente-Solana et al., 2020). Evidence-based self-care techniques can make a difference in a nurse's quality of life, all while improving job satisfaction and retention (Williams et al., 2022). Nurse health and wellbeing should be a priority. One way to do this is by educating nurses about evidence-based selfcare techniques (Williams et al., 2022). Some of these techniques include attending a support group, practicing mindfulness, deep breathing exercises, and cognitive behavioral therapy. Some nurses make few or no attempts to share their grief outside the workplace due to a lack of understanding by peers in their social circles (Boyle & Bush, 2018). By excluding family and friends from their work experiences, nurses deprive themselves of a possible source of support (Boyle & Bush, 2018). Self-exclusion is even more of a reason why self-care techniques available in the workplace must be prioritized. Primary Children's Hospital offers mental health resources through the Employee Assistance Program (EAP). However, the EAP needs to be utilized more through education. Statement of Problem The Immunocompromised Unit at Primary Children's Hospital has had an increase in turnover rate over the past two years. More than 50% of the nurses on that unit have been there less than a year (N. Dennis, personal communication, August 10, 2023). Constantly training new staff burdens the senior staff, leading to burnout and low retention. Nursing stress and dissatisfaction are significant factors contributing to turnover (Bae, 2022). Nursing turnover compromises quality patient care. Thus, the nurse's health impacts patient care, so self-care is essential (Williams et al., 2022). 6 Turnover is also costly for the employer. Training a new nurse costs $21,514 to $88,000 (Bae, 2022). Educating nurses and encouraging evidence-based self-care practices is crucial in increasing job retention and satisfaction (Williams et al., 2022). Improving job retention will, in turn, require the unit to train fewer nurses. If fewer nurses are being hired and trained, more money is saved by the employer. Therefore, this MSN project aims to educate pediatric oncology nurses on evidence-based self-care practices to increase resilience. Emotional resilience can help prevent burnout (Slater et al., 2018; Williams et al., 2022). Practicing self-care is a concept that has been introduced previously, but it needs to be utilized and is often overlooked by busy nurses. By examining the current evidence and best practices related to self-care techniques for nurses, the goal is to implement educational resources for nurses to reference, utilize, and practice self-care. Techniques must be flexible and diverse and acknowledge the personal nature of coping and resilience (Slater et al., 2018). Using these resources and increasing self-care practice will increase resiliency and job satisfaction, decreasing turnover. Along with providing nurses with self-care techniques, providing additional resources for nurses to utilize can help with burnout and retention issues. For example, creating a group of nurses on the unit to help those struggling could be a great resource. A "comfort crew" would be trained on end-of-life patients and the frequently asked questions from parents on what to expect when their child is dying, as well as ways to support staff who are assigned to those patients. High levels of support from work significantly influence nurses' intent to stay (Sanner-Stiehr et al., 2022). Having more than one resource available for nurses to utilize will significantly impact their well-being. 7 Significance of the Project Self-care practice may be the key to helping nurses develop self-efficacy and manage their health despite stressors and obstacles at work (Melnyk, 2020; Zarenti et al., 2021). Evidence shows that nurses often ignore emotions related to negativity, irritability, and anger to get through their shift (Boyle & Bush, 2018). However, this is not sustainable over time. One evidence-based self-care technique is mindfulness. Mindfulness is something that has been researched for many years. When utilized, it can improve nurses' well-being, leading to reduced anxiety and depression, improved communication, and increased empathy (Williams et al., 2022). It also improves stress and emotion that is perceived in any given situation. Mindfulness exercises, such as guided imagery, meditation, deep breathing, or even a mindful walk, can take as little as five minutes. Mindfulness can improve work performance and increase job satisfaction, thus increasing job retention (Melnyk, 2020; Williams et al., 2022), Another self-care technique is cognitive-behavioral therapy. This technique has also been researched for years and has shown remarkable results when combined with mindfulness (Williams et al., 2022). Cognitive-behavioral therapy focuses on the idea that thoughts, behaviors, and emotions are interconnected. Changing behavior positively improved perceptions of well-being (Williams et al., 2022). A few strategies involved in this therapy include goal setting, problem-solving, and focusing on the positive in a situation (Williams et al., 2022). Other ways for nurses to receive support are support groups and meetings with counselors, social workers, or chaplains. Emotional support for pediatric oncology nurses has two goals. First, it counters the emotional "wear and tear" from exposure to stressful events. Second, it reduces the situational hardship and the feeling that they are alone in what they think 8 (Boyle & Bush, 2018). Realizing that others feel similar can decrease some of that emotional hardship. Leadership, managers, and others must encourage nurses to invest in self-care just as they invest in caring for their patients. Leadership has a responsibility to its staff. When nursing leadership is engaged and informed about the strategies available, they can become an advocate for their nursing staff (Boyle & Bush, 2018). When leadership takes care of their staff, the staff can then care for their patients. Research has shown that when nurses invest in themselves, practice self-care techniques, and have support while doing so, they are healthier and happier (Williams et al., 2022). Increasing job retention and satisfaction can be as simple as utilizing a five-minute mindfulness exercise. Framework Spradley's Change Theory was the theoretical framework chosen for this project after consideration of the various factors involved. Spradley's Change Theory is a modification of Lewin's three-step change theory. However, it focuses on the continuous change process with constant evaluation over eight steps compared to three. The review that is part of each step aids in the success rate (ANA, n.d.). The eight steps include recognizing a need for change, diagnosis of the problem, alternative solutions to the problem, and selecting, planning, implementing, evaluating, and stabilizing the chosen change (ANA, n.d.; Kassean & Jagoo, 2005). The theory allows multiple solutions to the problem to be addressed and discussed. It is also a theory that can enable social change to start from the bottom up or corporate change from the top down (Kassean & Jagoo, 2005). The focus of Spradley's Change Theory is evaluation. Evaluation is found in every step. Almost two-thirds of all change projects fail due to different reasons, such as poor planning, 9 unmotivated staff, or lack of communication (Barrow et al., 2022). After every step of Spradley's Change Theory, the team evaluates each step before moving on to the next. Change is constant in healthcare and must be constantly monitored (ANA, n.d.). Change must be managed realistically, without false hope and expectations (ANA, n.d.). It is vital to emphasize enthusiasm for the future. Spradley's change theory, which focuses on evaluating each step of the change process, does just that. It manages change realistically, focusing on improved mental health for nurses and enthusiasm for the future. Nurses' mental health is critical to job satisfaction, affects patient care, and has been a focus of extensive research. On a unit-specific basis, evaluating each step of Spradley's change theory will be doable and achievable. Applying Spradley's Change Theory to implement evidence-based self-care techniques for pediatric oncology nurses is essential. Mental health and the effectiveness of self-care strategies will differ for every nurse involved. Evaluating each stage of this project will be paramount in guiding its success. Step one is to recognize that there is a need for change. In the Immunocompromised Unit at Primary Children's Hospital, there has been an increase in job dissatisfaction and turnover. Step two is to diagnose the problem. Fifty percent of the staff in that unit have been there for less than a year, which impacts the senior staff and patient care. Working in pediatric oncology has its stressors and mental demands. Next is to analyze the different solutions to the problem. Examining various methods to increase job satisfaction and retention for the unit provided the information to focus on self-care for the nurses. Educating nurses on evidence-based self-care techniques is the driving force for the project, followed by educating staff on the resources available through the Employee Assistance Program (EAP). The following steps include 10 selecting the change, planning the change, implementing the change, evaluating the change, and stabilizing the change. Strengths and Limitations Spradley's Change Theory is straightforward to follow. Following the eight steps and incorporating evaluation within each step helps aid in the success of this theory (ANA, n.d.). An easy-to-follow step-by-step plan keeps things organized and empowers the individuals involved in the change (Kassean & Jagoo, 2005). Change theories, including Spradley's, are affected by many internal and external factors; therefore, success cannot be guaranteed (Barrow et al., 2022). Little literature exists on Spradley's Change Theory, which is based on Lewin's Change Theory, indicating it needs to be studied more extensively. Information is lacking, therefore limiting this change theory. With this theory being based on eight steps, each can lead to the change taking longer to implement and losing interest from those involved. Analysis of Literature A thorough literature review was completed to explore self-care techniques for pediatric oncology nurses. Caring for vulnerable patients, like those with cancer or immunocompromised, can be stressful and challenging for nurses. This category of patients includes those with a cancer-related diagnosis (solid tumors, brain tumors, hematologic malignancies, and others), hematologic disorders such as anemia, autoimmune diseases, and congenital immunodeficiency syndromes. Each with its own set of complications, stressors, and prognosis. The emotional toll it takes can have lasting effects on nurses. Evidence was identified to support the MSN project question: Does educating hospital nurses in a pediatric oncology unit about self-care practices (mindfulness, cognitive behavioral 11 therapy, exercise, and others) improve job retention and satisfaction over one year? Evidence shows a lack of support, inadequate education, and insufficient coping techniques related to nursing in this specialty (De La Fuente-Solana et al., 2020). Increasing knowledge and coping strategies in this field can lead to greater nurse retention and improved patient outcomes. This literature review explores current literature regarding evidence-based self-care techniques for pediatric oncology nurses. Search Strategies A literature search was conducted to identify current evidence using Weber State University's Stewart Library's OneSearch (which spans multiple databases), PubMed, and Google Scholar. Articles from 2017 to 2023 were included in the search to keep information current. However, articles covering ten years from 2013 were also included in the search. The search included keywords of oncology, bone marrow transplants (BMT), hematopoietic stem cell transplant (HSCT), nursing, occupational stress, coping strategies, evidence-based, mindfulness, guided imagery, deep breathing, complications, pediatrics, support, patient outcomes, mental health, dying, death, self-care, nurse retention, and job satisfaction. Various Boolean combinations of the above terminology resulted in a comprehensive search of available evidence. Synthesis of the Literature Stress, quality of work, and retention were found throughout the literature, indicating the value of addressing needs within healthcare organizations. The need for evidence-based self-care techniques among pediatric oncology nurses is evident throughout research. The literature identified three themes: occupational stress impedes patient-centered care, effective self-care techniques for nurses, and years of experience lead to lower stress levels. These themes will be presented and discussed in greater detail. 12 Occupational Stress Impedes Patient-Centered Care Occupational stress is common in many industries. Working in pediatric oncology can be rewarding but comes with unique challenges. Work-related stress can lead to burnout and job dissatisfaction, impeding patient care. Several studies found that the stressors related to oncology nursing, although not only associated with these specialties, are prevalent (Gallagher & Gormley, 2013; Ko & Kiser-Larson, 2016; Morrison & Moris, 2017; Zamanzadeh et al., 2013). Gallagher and Gormley (2013) performed a descriptive, non-experimental qualitative study (n=30), reporting that the most significant stress came from short staffing, rotating shifts, scheduling, acuity of patients, dying patients, and demanding families. However, critical illnesses and high acuity were the most stressful factors, with long hours being the least stressful factor. Additionally, a qualitative study (n=24) by Morrison and Morris (2017) found that the most common stressors were insufficient workplace training and lack of support for dying patients. Coping with and caring for a dying patient was a common theme found in several studies. Ko and Kiser-Larson (2016) mentioned that the stress related to dying patients was associated with the lack of time available for end-of-life care. Comparatively, in another study by Gallagher and Gormley (2013), the stress related to death and dying was mainly due to the little education provided to prepare them to care for and cope with these patients. Additionally, a qualitative study by Zamanzadeh et al. (2013) explores the emotional labor involved with dying patients. De La Funete-Solana et al. (2020) explained that there is a perceived lack of social support for dying patients. This type of stress can be divided into five categories, which include witnessing suffering, struggling mentally, hurting emotionally, feeling drained of energy, and escaping grief. Emotional labor describes how someone suppresses their feelings to care for others. Dealing with dying patients can lead to depersonalization. 13 Along with depersonalization, compassion fatigue, moral distress, and diminished personal accomplishment were common outcomes related to stress commonly found in pediatric oncology nurses (Boyle & Bush, 2018; De La Fuente-Solana et al., 2020; Williams et al., 2022). In a qualitative study by Boyle and Bush (2018), moral questioning and guilt were common among pediatric oncology nurses due to frustration and anger regarding nursing care for their patients. Additionally, in a systematic review by De La Fuente-Solana et al. (2020), six studies mentioned that emotional exhaustion exhibited by nurses can lead to negative behaviors toward patients. Nurses can become less sensitive to patients' needs while developing cynicism and indifference. Not only that, but low personal accomplishment can lead to decreased interest in one's work and impaired permanence. Williams et al. (2022) explain that nurses report and deal with emotional distress independently without management's support. Effective Self-Care Techniques for Nurses Navigating a stressful work environment affects mental health and overall job satisfaction. Self-care and utilizing coping strategies are two ways to decrease burnout. In a literature review by Ko and Kiser-Larson (2016), the research found that coping strategies fall into two categories: functional and dysfunctional. Lack of boundaries and colleague support contributed to dysfunctional coping patterns and poorer mental health outcomes. Dysfunctional coping had a negative effect overall on the physical and mental health of pediatric oncology nurses. Coping strategies are influenced by unit support or the lack thereof. Rivaz et al. (2017) also conducted a qualitative study at five teaching hospitals to examine job satisfaction and retention. Nurse retention and patient safety is a global concern. The study showed that having appropriate support and resources increases job satisfaction and retention. 14 Self-care techniques need to be flexible and diverse. In a qualitative study by Slater et al. (2018), the research found that self-care techniques need to focus on each person's individuality to build resilience among nurses. They need to focus on the personal nature of coping and resilience and how it can differ from person to person. Additionally, a qualitative study (n=24) by Mills et al. (2018) explains that self-care needs to be intentional. It must be proactive, holistic, and personalized to promote health and well-being. If self-care is effective, it will enhance one's capacity to care for oneself, their patients, and their families (Mills et al., 2018; Slater et al., 2018). Mindfulness has been researched for many years and found to be an effective strategy to reduce and manage stress. In a study by Williams et al. (2022), mindfulness was shown to reduce anxiety and depression, increase empathy, and increase job satisfaction. Melnyk (2020) also performed a study showing that mindfulness can improve work performance. Comparatively, in a qualitative study by Slater et al. (2018) on the effectiveness of mindfulness among hospital nurses, results showed that 94% of nurses who participated in a mindfulness session agreed that it positively impacted their well-being. The study also showed that nurses applied mindfulness principles outside the training session. Mindfulness resulted in improved self-awareness and resiliency and prompted nursing staff to seek support from trusted colleagues (Slater et al., 2018). Evidence shows that nurses can cope better with critical incidents, interact better with their patients, and handle the stresses of work by implementing mindfulness (Melnyk, 2020; Slater et al., 2018; Williams et al., 2022). Cognitive-behavioral therapy, another self-care technique, positively impacts nurses' mental health when utilized independently or with mindfulness. Cognitive behavioral therapy focuses on the concept that thoughts, behaviors, and emotions are interconnected. Research by 15 Williams et al. (2022) showed that cognitive behavioral therapy should be considered part of career development. This therapy includes goal setting, problem-solving, and focusing on the positive in a situation. Comparatively, a qualitative study by Hofmeyer et al. (2020) showed that negative self-talk and self-criticism activate the sympathetic nervous system, stimulating the stress response. Kind self-talk leads to self-compassion. Additionally, in the same study, Hofmeyer et al. (2020) states that nurses need to be aware of their own needs before they can help others with theirs. Talking kindly about oneself can strengthen communication skills between patients, families, and colleagues. Cognitive behavioral therapy and self-compassion are selfless acts that can help nurses cope with work-related stress. Adequate sleep, healthy eating, and exercise are also effective self-care techniques. Stimpfel et al. (2019) performed a quantitative study (n=1,568) demonstrating that sleep deprivation, or short sleep duration, was statistically associated with lower ratings for quality of care and patient safety. Nurses who sleep less than the recommended seven hours before work, impacted not only their health but job performance as well (National Institute for Occupational Safety and Health [NIOSH], 2020). Comparatively, Marko et al. (2023) performed a systematic review showing that nurses under stress have more barriers to eating healthily. Additionally, Mohebbi et al. (2019) showed that nurses who do aerobic exercises had significantly less occupational stress than nurses who do not exercise. Lack of awareness of workplace stress and how to handle it will result in irreparable complications in patient care and nurses' overall health and well-being (Mohebbi et al., 2019). Employee Assistance Programs (EAP) are also beneficial for nurses if utilized. EAPs are to be used for workplace issues, including education, mental health and wellness, safety, performance improvement, fitness, and incident response (Doran, 2022). Additionally, The U.S. 16 Department of Health and Human Services (HHS, 2022) mentions that EAPs should provide short-term counseling and be available 24 hours a day, 365 days a year. However, the utilization rate is relatively low. The National Business Group on Health found that only 5.5% of staff members used EAPs in 2018 (Doran, 2022). The lack of program awareness and insufficient time were reasons that were given as to why the EAP was not utilized (Doran, 2022). The EAP at Primary Children's Hospital has numerous resources for employees. One resource included is the 'Caregiver Well-being Center,' an online resource where nurses can find resources on feeling well and staying well at work and home. It covers mental, physical, financial, and workplace well-being. The EAP at Primary Children's Hospital also offers Care Sessions, mindfulness resources, counseling services, care coaching, and financial and legal assistance. Code Lavender, also known as Lavender Response, is another resource available. When nurses are experiencing prolonged periods of stress, the death of a patient, complex patients or families, unexpected events, or even a significant crisis, a Lavender Response can be called. Any member of the healthcare team can call a Lavender response. When one is called, a chaplain or social worker comes to the unit and brings additional resources for staff to utilize during stressful times. Years of Experience Leads to Lower Stress Levels When a person is constantly stressed, job satisfaction and retention decrease. However, in a systematic review by Zarenti et al. (2021), 23 studies mentioned that relieving some stress burden increased job satisfaction and retention. In contrast, oncology nurses, in particular, experienced lower stress levels related to patients' critical conditions as years of nursing experience increased. Comparatively, a quantitative study by Hierlmeier et al. (2018) gathered data on bone marrow transplant pediatric patients over ten years. Bone marrow transplant 17 patients require chemotherapy to be given by an oncology nurse. Two hundred twenty-nine patients had received a transplant, and 74% suffered from early and late complications. It is not a matter of if; it is a matter of when a patient starts experiencing complications, whether a nurse feels ready to navigate and treat those complications, and whether they feel supported while doing so. Patients will have complications, and experienced nurses can better navigate and respond to those changes (Hierlmeier et al., 2018; Zarenti et al., 2021). Additionally, Rivaz et al. (2017) explain that having well-qualified nurses is essential in ensuring patient safety. Unstable work environments and low nurse retention can increase mortality rates and medication errors. To increase job retention, better training, greater support, and improved coping strategies must be taught. This will then lead to improved patient safety. Despite the risk of burnout, working in healthcare can be a transformative experience. Nurses can become more self-aware, reflect, and learn to sustain themselves through robust coping mechanisms and self-care strategies (Slater et al., 2018). Emotional resilience can lead to better outcomes for nurses and patients. Summary of Literature Review Findings and Application to the Project A thorough review of current literature on self-care techniques for pediatric oncology nurses revealed a need for improved education on self-care and mental health resources. Nurses are impacted due to occupational stress, and patient care is greatly affected. Literature suggests that evidence-based self-care techniques are flexible and diverse (Slater et al., 2018). They can be short and straightforward. Mindfulness, cognitive behavioral therapy, adequate sleep, healthy eating, and exercising, along with a hospital employee assistance program, are all supported by evidence to show an improvement in a nurse's ability to work through stress (Melnyk, 2022; Mills et al., 2018; Slater et al., 2018; Stimpfel et al., 2019; Williams et al., 2022). This 18 information has helped substantiate this MSN project's potential to improve pediatric oncology nurse retention and job satisfaction. Project Plan and Implementation There is a great need for mental health resources to be made available or for pediatric oncology nurses to be educated on them. Implementation will occur in a conference room near or on the unit. The unit manager, assistant managers, social workers, educators, support group representative, and a member of the resource council will be at the planning and implementation meeting. After discussing the different self-care resources available to nurses, the ones that are not available will be discussed, along with how to implement them. First, the resource council will discuss implementing a "comfort crew" while working with the social worker. Individuals who want to be part of that crew must work alongside social workers to be trained on end-of-life patients and how to better help their coworkers cope. Nurses will discuss who would be a good fit for this role, and then the recommended individuals will be invited to be part of the comfort crew. Nurses with varying experiences will be chosen and asked to be a part of this group in hopes that they can reach and help every nurse when needed. Next, QR codes will be designed for each nurse's station and breakroom. These codes will take nurses to the EAP website and provide simple directions on self-care techniques such as mindfulness. Having QR codes is an easy way to direct nurses to credible resources in seconds. Afterward, social work will explain the purpose of Lavender Response and how it can be better utilized as a resource in the unit. The educators will help design a bulletin board for either the breakroom or the hallway explaining all the different resources that are and will be available for nurses to utilize. The comfort crew, EAP, self-care techniques, support group with date and times listed, Lavender 19 Response, and QR codes to additional resources will be on the bulletin board for nurses to read. The educators will email monthly highlighting a self-care technique to help decrease burnout and increase resiliency. The educators will also send out more information on the support group in monthly emails. Interdisciplinary Teamwork Teamwork and collaboration are essential parts of implementing a new idea. The World Health Organization (WHO) defines a team as a group of two or more individuals who work dynamically, independently, and adaptively toward a goal or mission (Bendowska & Baum, 2023). Each team member should be assigned specific roles or functions to carry out the plan. Expertise, knowledge, and skills will significantly impact the project's success and outcomes. Managers, social workers, educators, a support group representative, and a member of the resource council provide a broad spectrum of individuals for interdisciplinary teamwork. Managers Managers can significantly influence intent to stay by consistently implementing supportive measures (Sanner-Stiehr et al., 2022). Implementation of the plan needs to start at the top. The unit and assistant managers can explain the changes, support the staff while the change is implemented, and encourage staff. They can create a working environment where nurses and other healthcare team members are ready to participate and actively contribute to the changes. Social Workers Social workers will provide information on the Lavender Response and everything it entails. Anybody can call a Lavender Response, which should be encouraged when individuals have received education regarding the protocol. Social workers can also provide more information on end-of-life patients, resources available for parents, and even resources for staff. 20 Hence, they feel more equipped and ready to take on complex patients. They will help educate the comfort crew on how to best interact with parents who have a child who is dying. Educators The educators will send out the monthly education email explaining in greater detail what resources will be available to the staff regarding their mental health and self-care. They will also design a bulletin board in the breakroom with information on those resources, QR codes, and information on the monthly support group. The educators will also be responsible for keeping information on the bulletin board current. Support Group Representative The support group representative and the assigned social worker from the EAP will continue to hold monthly support groups where staff can attend virtually. The support group representative will continue to encourage staff to attend. An email is sent out each month reminding staff of the date and time of the next meeting, which patients will be honored, and patients who have recently passed away will be discussed, along with other important information. Resource Council The resource council is responsible for meeting together monthly or bi-monthly. The council talks about changes that need to be made, policy changes, and ideas for improving the unit. The resource council will work together to design a comfort crew and develop the specifics for that role. They will be responsible for determining who would be a good fit for this new role. The assistant manager who runs the resource council will then reach out to those individuals and see if they would be willing to join the comfort crew. Description and Development of Project Deliverables 21 This MSN project will utilize six deliverables to aid in the implementation. This section will go through all deliverables in detail and explain their role and importance in ensuring the project is successful. Each deliverable will educate the interdisciplinary team and nursing staff on the problem and available solutions. Various media will be utilized, including PowerPoint, surveys, QR codes, and flyers. Self-Care for Pediatric Oncology Nurses: PowerPoint The first deliverable is a PowerPoint that will be presented at the implementation meeting (see Appendix A). The PowerPoint aims to explain, in simplified detail, the project's premise. It defines the problem and the plan to alleviate that problem. It goes step by step into what the change is all about. The PowerPoint presentation is concise, keeping the audience engaged. This same PowerPoint will be presented to the staff at the fall meeting to help roll out the change being implemented in the unit. Pre- and Post-Survey The second deliverable created for this project is a pre- and post-survey (see Appendix B). The pre-and post-survey will contain information that is being taught. The pre-survey will be used as a starting point to gauge where the unit is before education begins. Education will then be introduced and implemented, and a follow-up survey will be utilized. It will be used as a tool to analyze learning among the nurses on the unit. It will help bridge gaps, if there are any, and help aid in evaluating the project. The survey consists of seven simple questions that provide detailed feedback. The questions range from yes/no, short answer, and scale-like questions based on utilizing mental health resources. QR Code for the EAP 22 A QR code directly to the EAP website is included (see Appendix C). Self-care tools must be flexible, diverse, and easily obtainable (Mills et al., 2018; Slater et al., 2018). Having a QR code that takes nurses directly to the EAP website will be an excellent resource for them to utilize. It only takes seconds to scan a code. This code will be available for nurses in the breakroom during breaks or when heading home after their shifts. The EAP website is full of resources for nurses to utilize. It is a center for caregiver well-being where nurses can access information about mental, physical, financial, and workplace assistance. Utilization of the EAP is relatively low; however, with the help of a QR code and the ability to access it more quickly, utilization may increase (Doran, 2022; HHS, 2022). Monitoring the website’s use before and after implementation will help provide feedback on whether or not a QR code is deemed an effective strategy for getting staff to visit the website. Evidence-Based Self-Care Techniques An example of an evidence-based self-care technique is mindfulness (see Appendix D). The goal is to have simple, easy-to-read techniques that nurses can utilize throughout their shifts. Research reveals that by implementing self-care techniques in the workplace, nurses can cope better with critical incidents, handle the stresses of work, and interact better with their patients (Melnyk, 2020; Slater et al., 2018; Williams et al., 2022). The unit educators will design infographics, such as this one, to hang on a bulletin board and post in the breakroom for nurses to look at and utilize. There will also be resources that nurses can pull off the bulletin board and take home. Self-care techniques can and should be used outside of work, too. Comfort Crew, Lavender Response, Support Group The fifth deliverable will be a flyer about the peer support group (see Appendix E). Selfcare and mental health resources go beyond things that can be done individually. Sometimes, a 23 person needs support from those around them who are going through things similar to them. The peer support group is a unit-based support group where coworkers can collaborate in a virtual setting and support each other. Depersonalization, moral distress, questioning, and guilt are common feelings among pediatric oncology nurses (Boyle & Bush, 2018; De La Fuente-Solana et al., 2020; Williams et al., 2022). These feelings can be addressed with a licensed social worker in a group setting. Other flyers, like the peer support group, will be made regarding comfort crew and lavender response. Self-care techniques can be utilized as a group or in a group setting. Timeline A detailed timeline will help guide the implementation of this project (see Appendix F). Having a clear vision will help aid in the organization of the project. The project's implementation begins with collaboration with the unit manager and assistant managers. Then, a short meeting with the rest of the team (social workers, educators, support group representatives, and resource council members) will be held to review the deliverables and the project's logistics before educating the rest of the unit. The educators will meet over the next two to three months to assemble the visual aid tools on the bulletin board and in the breakroom. Meanwhile, the resource council and assistant managers will solidify the staff in the comfort crew. They will be trained with the help of the social workers. Next, the support group representative will continue to gain knowledge about the peer support group. They will find a day and time each month that can be recurring to hold the meeting. After the details are in place, the plan will be presented to the rest of the unit at the fall festival. Fall and spring festivals are mandatory meetings each year. New skills, education, and policies are discussed at this meeting. The pre-survey will be taken here before the PowerPoint is presented. After the fall festival, the planning committee will have a short meeting to evaluate 24 how the presentation went. During the following week, the educators will set up bulletin boards with the new information presented for the nurses to utilize. The post-survey will be given five to six months later to gauge understanding and learning at the spring festival. Based on the results of that survey, the managers and educators will meet together and make changes to bridge any gaps. Follow-up will continue to happen after that. With the help of deliverables, the project will follow an organized timeline and be implemented accordingly. Mental health resources will be available and encouraged for staff to utilize. Nurses should be cared for while they are caring for their patients. Project Evaluation The effectiveness of this project will be determined in a few ways. First, results from the post-survey will be compared to the pre-survey results. Comparing the results from each survey will assist in determining if nurses gained knowledge on self-care techniques and available mental health resources. An increase in retention could correlate with the education taught directly or indirectly. This project aims to increase retention and resiliency among nurses in the Immunocompromised unit at Primary Children's. Third, monitoring the EAP webpage and how many visits the site gets before the QR codes and education are rolled out and comparing it to how many visits the site receives afterward will help determine if the education was effective. Increased site visits could mean that nurses are utilizing or at least exploring the mental health benefits available to them. Ethical Considerations Various ethical considerations will be discussed for this project. Ethical considerations help to ensure project accountability and avoid error and bias. Ethical considerations include patient care and safety, diversity, learning abilities, and nurse consent. First, research has shown 25 that burnt-out or emotionally exhausted nurses can lead to negative behaviors toward their patients (De La Fuente-Solana et al., 2020). Nurses become less sensitive to their patients' needs as well. Emphasis will be placed on nurses to utilize self-care techniques and resources during downtime or a break to prevent interruption of care. Patient-centered care is still a top priority while the project is being implemented. Next, diversity is something that is considered and discussed in great detail. Different learning styles and reading abilities will be considered when making educational tools for this project. Written material will be at an appropriate reading level. The resources will also be available in English and Spanish. Having a variety of techniques and tools is a top priority because nursing is not a one-size-fits-all field. Nurses have differing mental health needs, and the effectiveness of the techniques will vary. There will be printed-out and technology-based resources for nurses to utilize on the go or at their convenience. Nurses' consent and privacy regarding surveys and feedback are also considered. All surveys will be anonymous to protect the nurse. They will be encouraged to answer openly and honestly. These considerations will assist in ensuring the ethical implementation of this project. Discussion There needs to be a shift in healthcare with a greater focus on nursing well-being and mental health. Burnout among nurses is multifactorial. The work environment for nurses involves many stressors, including but not limited to workload, lack of administrative support, exposure to terminally ill patients, lack of education, and lack of preparedness for the emotional and physical demands of the job (Al Sabei et al., 2022). Some of these stressors can be combatted with better education, a greater focus on self-care, mental health support, and support from management. This project will be implemented at Primary Children's Hospital and start in 26 the Immunocompromised Unit (ICS). However, spreading awareness, educating nurses, and providing better resources can and should be adapted to the rest of the hospital. This section will discuss the dissemination of the project's results, nursing significance, implications, and recommendations. Evidence-based Solutions for Dissemination The results from the project will be disseminated in several ways. After the data is collected and analyzed after the first six months of implementation, and then at the year's mark, a report will be made to show whether or not retention has improved and if mental health resources are being utilized. Informatics and charts will be utilized to make the report. This report will be shared with the unit manager, educators, and hospital administrators to see if this education has yielded the desired results. The report and information can be shared with other unit managers if a hospital-wide implementation occurs. Then, results from using the QR codes to access the employee assistance program will be shared with hospital administrators. Results will be used to change, adapt, and help drive people to the website. There are numerous steps can be taken with that data as well. Data can be collected on the website views as a whole and can go even further to include clicks to different aspects and resources found on the website. Data can be collected on what resources are being looked at the most. Based on the project’s results and data, further projects can be inspired or even driven on a unit or hospital-wide basis. The mental health and well-being of nurses are not just a unit problem. Other units and hospitals within Intermountain Health can benefit by focusing on their well-being. However, it is a multifaceted problem. Significance to Advanced Nursing Practice 27 Nurses, although undervalued, have a significant impact on their patients. They provide direct care and support. Their attitude about their job directly affects patient health outcomes and safety (Chang et al., 2020). When nurses have a positive attitude and outlook regarding their jobs, nursing care improves while turnover and healthcare costs are reduced (Chang et al., 2020). For these reasons, hospital administrators and even unit managers should understand the factors associated with nurse's job satisfaction and overall well-being. Unit managers should encourage nurses to develop resiliency and positive work motivation (Chang et al., 2020). A nurse's happiness is closely related to their work life, so focusing on self-care and mental health is essential (Boyle & Bush, 2018; Change et al., 2020). Not only that, but stress and burnout reduce a nurse's productivity and diligence to their patients (De La Fuente-Solana et al., 2020). Happy nurses are more likely to set new goals at work and work towards them actively (Change et al., 2020). They can become immersed in their professional practice, perform their work more efficiently, and positively affect their organization (Boyle & Bush, 2018; Chang et al., 2020; De La Fuente-Solana et al., 2020). First, take care of the nurses, and they will take care of the patients and the organization. Implications Several strengths and limitations have been identified for this project. Strengths include various deliverables and educational materials, evaluation methods, and the framework. Education will be taught using multiple media such as PowerPoint, email, printed material, and QR codes. Information will be available in English and Spanish to accommodate the diversity of nursing staff. The self-care techniques taught are evidence-based and effective at lowering stress and increasing resiliency. This project incorporates Spradley's Change Theory as the framework for change. This theory focuses on evaluation during every step and enables social change to 28 start from the bottom up and corporate change from the top down (ANA, n.d.; Kassen & Jagoo, 2005). Evaluation will happen multiple times throughout the project. Limitations for this project have also been identified. Limitations include barriers to learning, staff buy-in, organizational support, and small sample size. Improper implementation and utilization of the educational material by staff could lead to skewed results. Surveys will be conducted to gauge learning and provide feedback to help evaluate and reduce these barriers. Having organizational support from management will help with staff buy-in as well. Staff need to feel supported by management to aid their mental health efforts (Williams et al., 2022). This project will be implemented in the immunocompromised unit, with a small sample size compared to the rest of the hospital. However, implementation in other units in the hospital can happen later. Recommendations While this MSN project utilizes many resources to create an effective plan, recommendations are indicated for further improvement of this subject. Advances in medicine are happening every year, but advances in the care of nurses still need to be made. Since COVID-19, research on burnout, compassion fatigue, and nurse anxiety is abundant. However, research on the solution still needs to be done. The literature review illustrated extensive research regarding evidence-based self-care techniques and how to utilize them in nursing. However, the solution is not as simple as providing and educating nurses on available mental health resources. Support from management, better scheduling, improved patient ratios, increase in wages, debriefing sessions, and others may be beneficial in preventing burnout and increasing nurse satisfaction and retention. Findings from this project may help improve nurse satisfaction, but it is just the beginning. 29 Conclusions Working in healthcare can be a transformative and fulfilling experience but challenging. Being a nurse is not getting any easier, and occupational stress is paramount. This project aims to improve the resilience of nurses by educating them on evidence-based self-care techniques and resources available to them through the employee assistance program. There are many opportunities for nurses to take care of their mental health, which they have been missing. Research has shown that when nurses invest in themselves, practice self-care techniques, and have support while doing so, they are healthier and happier (Williams et al., 2022). 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Article e981. https://doi.org/10.14806/ej.26.1.981 35 Appendix A Educational PowerPoint 36 37 38 39 Appendix B Pre-survey and post-survey. 40 Appendix C QR Code that connects staff with the Employee Assistance Program (EAP) at Primary Children's Hospital. 41 Appendix D Self-Care Techniques Reference: Wellmark, 2024. https://www.wellmark.com/blue/ healthy-living/how-to-be-more-mindful 42 Appendix E Support Group, Comfort Crew, Lavender Response 43 Appendix F Timeline Summer 2024 The next few months will consist of solidifying the visual aid tools. Members of the comfort crew will be selected and trained. Support group will finalize a date and time to meet each month. Next 2 to 3 Months Fall Festival 2024 The educators will set up the bulletin boards with educational materials regarding the things discussed at fall festival. The nursing staff will start to carry out the change. The plan will be implemented among the rest of the unit at this required education meeting for the nurses. A pre-survey will be done to gauge learning among the nurses over the next few months. Next 4 to 6 months Spring Festival 2025 Follow-up and continual evaluation and education will occur. The bulletin boards will continue to be updated with new information. Implementation meeting with the planning committee. Continuing forward The post-survey will be given to the nurses to gauge understanding and learning. Based on the results, the managers and educators will meet and make changes based on any gaps.