Digital Repository Masters Projects Spring 2024 Nurse Resiliency to Combat Burnout Leah Ellertson Hedin Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Hedin, L. E. 2024. Nurse Resiliency to Combat Burnout 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 Nurse Resiliency to Combat Burnout Project Title by Leah Ellertson Hedin 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 4/26/24 Ogden, UT Date Leah Ellertson Hedin BSN, RN,MSN Student 4/26/24 Student Name, Credentials (electronic signature) Date Tressa Quayle,PhD, RN 4/26/24 MSN Project Faculty Date (electronic signature) 4/26/24 (electronic signature) DNP, N, CNE MSN Program Director Note: The program director must submit this form and paper. Date 1 Nurse Resiliency to Combat Burnout Leah Ellertson Hedin, BSN, RN, MSN Student Annie Taylor Dee School of Nursing Weber State University MSN Project 2 Abstract Purposes/Aims: Nursing is a profession with high rates of burnout. This MSN project aims to identify current evidence-based research about the effects of registered nurse (RN) burnout and how resilience affects burnout. Evidence-based strategies are utilized to create an RN resiliencebuilding training program. Rationale/Background: RN burnout caused by a stressful work environment has adverse effects, including decreased quality of RN's personal and professional life, decreased patient safety, and financial burden on organizations (Bakhamis et al., 2019; Wei et al., 2018). Building resilience can help nurses better manage work stress, resulting in decreased burnout, improved patient care, and increased retention rates (Chesak et al., 2019; Low et al., 2019). Methods: This MSN project provides organizations with a clear path to implementing a resilience-building training program for RNs. This project provides the importance of combating RN burnout and offers evidence-based strategies to build resilience in RNs over six months. The implementation of this project is guided by The Model for Evidence-Based Practice Change using best evidence and systematic problem-solving approach (Melnyk & Fineout-Overholt, 2019). Results: It is anticipated that as RNs on an acute care medical-surgical unit implement a resilience-building training program over six months, their burnout rates will decrease, as measured by the Maslach Burnout Inventory (Erwan et al., 2020). Conclusions: Developing and implementing an evidence-based resilience-building training program on an acute medical-surgical unit is anticipated to decrease RN burnout significantly. The benefits can then be translated to other areas in the acute care setting. Keywords: Resilience, registered nurse burnout, resilience-building program 3 Nurse Resiliency to Combat Burnout A nurse's work environment is stressful, demanding, and constantly changing, and if unsuccessfully managed, it can lead to burnout (Cabrera-Aguilar et al., 2023). Healthcare organizations need to assist nurses in successfully managing stressors created by these challenging environments. Evidence shows that as nurses build resilience, they better manage stress and adversity created by these work environments (Chesak et al., 2019; Low et al., 2019). In contrast, when nurses are not resilient, a stressful work environment can increase burnout among nurses (Stallings Welden et al., 2021). Nursing burnout caused by a stressful work environment adversely affects a nurse's personal and professional life, patient care, organizations, and healthcare system (Jun et al., 2021). When Registered Nurses (RNs) experience burnout due to unmanaged work stress, it can negatively affect their personal and professional lives (World Health Organization, 2019). Burnout can result in physical symptoms of fatigue, anxiety, sleep disorders, headache, insomnia, frequent colds, and reduced concentration (Woo et al., 2020). These physical symptoms can affect an RN's personal and professional life. For example, impaired concentration and decisionmaking ability can lead to medication errors or near misses in patient care (Chesak et al., 2019). As RNs experience burnout, it can decrease patient safety, hinder the quality of care, and lower their commitment to their organization, resulting in increased turnover rates (Jun et al., 2021). Rising RN turnover rates caused by burnout are detrimental to individuals and organizations because they negatively affect morale, increase the workload for other nurses, and negatively impact patient outcomes (Wan et al., 2018). One outcome of RN burnout is turnover, which results in a heavy financial burden and nursing shortages (Bakhamis et al., 2019; Wei et al., 2018). Studies show that burnout 4 significantly predicts intent to leave (Bourdeanu et al., 2020; Lee et al., 2020). Intention to leave often leads to turnover, and hospitals lose $4.4 million to $6.9 million annually on nurse turnover costs. Studies show that every percent change in nurse turnover costs or saves a hospital $328,400 (Shaffer & Curtin, 2020). These costs are significant because in 2021, there was a more substantial decrease in the total supply of RNs than in the previous four decades, and the total supply of RNs decreased by more than 100,000 in one year (Auerbach et al., 2022). It is predicted that in 2025, there will be a projected shortage of 78,610 RNs (Health Resources and Services Administration, 2022). RN burnout affects the individual, the organization, and anyone they work with (Kelly et al., 2021). Evidence shows that resilience helps nurses mitigate the effects of stress and decreases burnout (Brown et al., 2018; Wei et al., 2018). Nurses with greater resilience are better at managing their response to stress and adversity, resulting in improved patient outcomes and decreased burnout (Chesak et al., 2019; Low et al., 2019). Evidence also suggests that nurses with low resilience led to burnout, low job satisfaction, decreased retention, and poor quality of work life (Mao et al., 2021). The presence or lack of resilience in nurses profoundly affects burnout. Increasing resilience in RNs is crucial to reducing burnout, and organizations play a key role in implementing strategies to help RNs accomplish this. Statement of Problem Nurses report the highest rates of burnout among healthcare workers, which presents a significant risk to the health of the United States (Shaha et al., 2021). Burnout is an occupational phenomenon added to the World Health Organization's (WHOs) International Classification of Diseases (ICD) in 2019 due to its increasing prevalence (World Health Organization, 2019). At the time, this phenomenon was added to the ICD due to its high prevalence; a third of RNs 5 reported symptoms of burnout, which was due to the pre-COVID-19 pandemic. It's alarming because post-pandemic studies show RN burnout rates have increased to 62%. Many factors contribute to RN burnout; organizations can reduce some, but some will always be present in the medical field (American Nurses Association, 2023). Organizations cannot erase all factors contributing to RN burnout; however, they need to implement programs and policies that focus on the emotional health of RNs to combat burnout. Emotional resilience is dynamic, and organizations can implement strategies to increase nurses' resilience and prevent burnout (Mintz-Binder et al., 2021; Stallings Welden et al., 2021). Research has demonstrated the importance of resilience in combating nurse burnout (Brown et al., 2018; Wei et al., 2018); however, studies have found the prevalence of low resilience in healthcare professionals, especially following the COVID-19 pandemic (Janitra et al., 2023). A recent survey showed that most healthcare professionals rate their facility as slightly ineffective or highly ineffective at helping staff address burnout (The Joint Commission, 2019). Creating and implementing a resilience-building program allows organizations to focus on factors within their control to decrease RN burnout. Therefore, this MSN project aims to develop and implement a resilience-building training program focusing on the five pillars of resilience to reduce burnout in acute care nurses. This project will be accomplished by examining current literature to determine the best strategies to create and implement a resilience-building training program for acute care nurses. Significance of the Project Creating a training program that effectively helps to increase nurse resilience will benefit many recipients, including nursing staff, patients, and organizations. Nurses benefit in their personal and professional lives as they build resilience. Evidence suggests that a higher level of 6 resilience in nurses correlates with better self-perceived physical and mental health (Stallings Welden et al., 2021). Studies also show that nurses who report higher levels of resilience often report higher levels of job satisfaction, ability to cope with stress, optimism, work engagement, autonomy, and retention (Brown et al., 2018; Chesak et al., 2019; Low et al., 2019; Wei et al., 2018). Resilience-building programs benefit RNs, and as RNs benefit, so do patients and the organizations they work for. Resilience-building programs benefit organizations because more resilient nurses decrease burnout, decrease turnover rates, and improve quality of care, all of which help maintain a healthcare organization's financial health (Wei et al., 2018). As RN burnout and turnover rates decrease, hospitals will prevent the loss of substantial amounts of money each year (Shaffer & Curtin, 2020). As nurses increase their resilience and better respond to stress, patient outcomes and patient satisfaction improve (Chesak et al., 2019; Low et al., 2019). For these reasons, many will benefit as organizations invest time and money into promoting resilience in nurses to combat the healthcare system's stressful work environment. This MSN project will use evidence-based research to create a training program for a hospital in the western United States to improve the five pillars of nurse resilience in RNs. It will explore how nurses can strengthen their five pillars of resilience, self-awareness, mindfulness, self-care, positive relationships, and purpose to help combat burnout (Ahlschlager, 2020). Review of the Literature A literature review was conducted to identify the positive effects of promoting workplace resilience in RNs and provide evidence for developing an evidence-based nurse resiliency training program focusing on the five pillars of resilience (Ahlschlager, 2020). Identifying, analyzing, and evaluating evidence-based change frameworks was also done to appraise a 7 framework selection for this project. The Model for Evidence-based Practice Change Model was selected as the framework for planning an evidence-based change associated with implementing the MSN project (Melnyk & Fineout-Overholt, 2019). This section includes a review of the Model for Evidence-Based Practice Change and a synthesis of the resilience literature. Framework The Model for Evidence-Based Practice Change guides change into practice to improve evidence-based research and healthcare quality and will be used as the framework for this project (Melnyk & Fineout-Overholt, 2019). This model is based on the change theory and the changes that are directed from a mixture of quantitative and qualitative data, clinical skills, and contextual evidence (Dustin et al., 2023). This model was chosen because it aligns with the project goal of further evidence-based research on building resiliency in nurses and implementing a training program to benefit nurses, patients, organizations, and the healthcare system. This Model for Evidence-Based Practice Change consists of 6 steps: Assess the need for change in practice, locate the best evidence, critically analyze the evidence, design practice change, implement and evaluate change in practice, and integrate and maintain change in practice (Melnyk & Fineout-Overholt, 2019). The project will follow these steps by first assessing the need to build resiliency in nurses to combat burnout. This will be accomplished by surveying nurses' baseline burnout levels in the targeted population and evaluating them against similar studies to identify benchmarked data and trends related to resilience and burnout. Next, evidence will be identified and analyzed to synthesize best practices for building nurse resilience. These practices will then be used to develop an RN resilience-building training program implemented in the targeted population. After the resilience-building training program is implemented, an evaluation will be conducted regarding the effects of resilience-building on 8 burnout. This model's focus on best evidence will guide this project's practice change and implementation. Strengths and Limitations The Model for Evidence-Based Practice Change strengths include being evidence-driven and focusing on a systematic problem-solving approach to guide new knowledge into practice (Brunt & Morris, 2023). Another strength of this model is the focus on locating and critically analyzing the best evidence (Dustin et al., 2023). This analysis helps synthesize the best evidence and assess the new practice's feasibility, benefits, and risks. Limitations of this model include the time requirements necessary to plan a rigorous systematic review of evidence and the skill and knowledge required to locate and critically analyze the best evidence (Melnyk & FineoutOverholt, 2019). Additional limitations of this model in implementing change are the lack of clear integration of patient values and preferences and in-depth instructions for evaluation (Dustin et al., 2023). Analysis of Literature A synthesis of the literature on RN resilience and resilience-building programs will be reviewed in this section. The literature review examined the available research literature on nurse burnout, nurse resiliency, resilience-building strategies, and other relevant topics. This literature review aims to explore current literature related to the question – For acute care nurses, how does implementing a training program to strengthen the five pillars of resilience affect burnout compared to those who do not have training in six months? This section will include the search strategies, literature synthesis, and the identified themes from the synthesis. Search Strategies 9 A literature search was conducted using Weber State University's Stewart Library's OneSearch and Advanced Search, which spans multiple databases. Specific databases used to identify current evidence included CINAHL, MEDLINE, Google Scholar, and Ovid. Articles from 2018 to 2023 were included in the search to keep evidence current. The search included keywords such as nurse resilience, nurse burnout, resilience building, nurse dissatisfaction, resilience experience, nurse stress, qualitative, quantitative, and nursing shortage. Various combinations of the above terminology and Boolean operators resulted in a comprehensive search of available evidence. Synthesis of the Literature Three major themes were identified in a literature search related to building resilience in acute care nurses, utilizing the five pillars of resilience to improve self-awareness, mindfulness, self-care, positive relationships, and purpose to decrease burnout. The first theme is the stressful environment nurses work in drives burnout (Cabrera-Aguilar et al., 2023; Li et al., 2021; Stallings Welden et al., 2021). The second theme is resilience helps nurses mitigate the effects of stress and decreases burnout (Brown et al., 2018; Wei et al., 2018). The third theme is resilience is dynamic and can be developed by nurses as organizations implement resilience-building strategies (Mintz-Binder et al., 2021; Stallings Welden et al., 2021; Zhai et al., 2020). Stressful Work Environment Drives Nurse Burnout Chronic occupational stress experienced by nurses drives burnout and negatively affects the quality of their lives and service provided to patients (Chesak et al., 2019; Jun et al., 2021; Li et al., 2021; World Health Organization, 2019). Research suggests that the rate of nurses experiencing burnout caused by occupational stress is high (Li et al., 2021; Shah et al., 2021). For example, in a quantitative study by Li et al. (2021), nurses (n=488) were surveyed regarding 10 burnout and stress levels. Eighty-two respondents exhibited low-stress levels, and 406 nurses exhibited high stress levels. In addition, Shah et al. (2021) conducted a secondary analysis of a cross-sectional survey with data from 3.9 million US RNs; of respondents who reported leaving or considering leaving their jobs due to burnout, 68.6% of nurses surveyed reported a stressful work environment. It should be noted that other studies did suggest additional factors contributing to burnout, including workload, poor support systems, and moral distress (Brown et al., 2018; Dall'Ora et al., 2020). However, in an integrative literature review conducted by Brown et al. (2018), the authors discovered resiliency helps combat burnout regardless of the underlying factors. Therefore, although a significant amount of nursing burnout is caused by a stressful work environment, regardless of the cause of burnout, building nurse resilience can help. Resilience Mitigates Stress and Burnout Studies suggest that nurses with greater resilience better manage their response to stress and adversity, resulting in decreased burnout (Chesak et al., 2019; Low et al., 2019). Nurses are continually confronted with stress and adversity due to the physical, emotional, and intellectual demands of caring for patients (Henshall et al., 2020). Building resilience, however, is within nurses' control and can assist nurses in successfully managing and tolerating high stress in their workplace (Andersen et al., 2021). For example, in a quantitative study by Mintz-Binder et al. (2021), the authors relate increased resilience with increased levels of stress relief as nurses implemented resilience-building interventions that could be implemented during work hours. In addition, in a randomized control trial by Mao et al. (2021), the authors also found that nurses who participated in an emotional intelligence training program to increase resilience had significantly decreased stress levels. These studies used different techniques to build resilience, but both resulted in nurses reporting lower stress levels as their resilience increased. Another 11 study concluded that the frequency and length of time nurses used resilience-building interventions increased with continued use, indicating the interventions' effectiveness in decreasing stress (Andersen et al., 2021). These studies support that building nurse resilience is worth an organization's time and money, and as nurses build resilience, it has a positive impact on their feelings of stress (Chesak et al., 2019; Low et al., 2019; Mintz-Binder et al., 2021; RosaBesa et al., 2021). Resilience Is Dynamic Resilience is dynamic, and organizations can implement strategies to increase nurses' resilience to combat nurse burnout (Mintz-Binder et al., 2021; Stallings Welden et al., 2021; Zhai et al., 2020). Research shows that many methods and strategies exist to build nurse resilience. For example, Andersen et al. (2021) concluded that resilience scores increased over time as nurses implemented inexpensive resilience-building interventions during work hours. Meanwhile, Blackburn et al. (2020) conducted a study where nurses participated in an extensive six-week program that taught self-care strategies to increase resilience. Franco and Christie (2021) used the method of a one-day self-compassion workshop for nurses to attend, which resulted in increased resilience levels. Research literature indicates that nurse resilience-building strategies are pertinent and beneficial, and many practical strategies to build resilience exist (Mintz-Binder et al., 2021; Stallings Welden et al., 2021; Zhai et al., 2020). During the literature review, five pillars were identified as commonly used to build nurse resilience (Ahlschlager, 2020; Blackburn et al., 2020; Celano et al., 2022; Lin et al., 2019; Mao et al., 2021; Wei et al., 2018). Building Five Pillars of Resilience 12 The five areas or strategies commonly used to build nurse resilience have also been referred to as the five pillars of resilience (Ahlschlager, 2020). They are emotional intelligence training to increase self-awareness, mindfulness-based interventions, facilitating social connections, encouraging self-care, and promoting spiritual well-being to increase a sense of purpose (Ahlschlager, 2020; Blackburn et al., 2020; Celano et al., 2022; Lin et al., 2019; Mao et al., 2021; Wei et al., 2018). These five pillars of resilience assist organizations in narrowing their focus on building nurse resilience. Research shows that nurses can implement strategies that focus on one or a combination of these five pillars to assist them in building resilience (Blackburn et al., 2020; Celano et al., 2022; Lin et al., 2019; Mao et al., 2021; Wei et al., 2018). Emotional Intelligence. Emotional intelligence (EI) is when one's thoughts and actions are guided by the ability to monitor one's and others' emotions and feelings (Mao et al., 2021). EI training is often used to promote self-awareness in nurses to increase resilience (Aljarboa et al., 2022; Hurley et al., 2019; Mao et al., 2021). Research shows that EI training increases EI and resilience, decreasing nurses' stress and burnout (Mao et al., 2021). Mindfulness. Mindfulness is the ability to be present in the moment with openness, receptiveness, and interest (Blackburn et al., 2020). The literature review findings noted that mindfulness-based strategies' are effective and commonly used in building nurses' resilience (Blackburn et al., 2020; Chesak et al., 2019; Lin et al., 2019; Mintz-Binder et al., 2020). Different methods for enhancing mindfulness to build resilience were identified during the literature review. For example, Chesak et al. (2019) focused on individual training to increase nurses' skills in attention and interpretation. In comparison, Lin et al. (2019) used modified mindfulness-based stress reduction group sessions to build mindfulness and increase nurses' resilience. The research literature shows that when nurses use mindfulness-based strategies, the 13 results positively affect individuals and organizations (Blackburn et al., 2020; Chesak et al., 2019; Lin et al., 2019; Mintz-Binder et al., 2020). Social Connections. Social connections have been described as the support individuals receive through their relationships with individuals, groups, and the larger community (Li et al., 2021). Evidence suggests that facilitating social connections for nurses is essential to help nurses manage work stress and build resilience (Galanis et al., 2022; Kester & Wei, 2018; Wang et al., 2018). Galanis et al. (2022) in their study focus singularly on the importance of social connections between coworkers to build resilience and other studies focus on social relationships with family, friends, coworkers, and leadership to build nurse resilience (Kester & Wei, 2018; Wang et al., 2018) The evidence suggests the more social support nurses can receive, the greater their ability to manage stress through resilience (Galanis et al., 2022; Kester & Wei, 2018; Wang et al., 2018). Self-Care. Self-care is using awareness, self-control, and self-reliance to achieve and maintain optimal health and wellness (Martínez et al., 2021). As organizations encourage selfcare strategies to promote resilience, it contributes to a culture of wellness, and nurses have improved mental and emotional balance and are better able to identify and manage stress (Blackburn et al., 2020; Kester & Wei, 2018; Mintz-Binder et al., 2021; Slatyer et al., 2018). Purpose. A sense of purpose helps nurses to feel their work is part of something bigger and encourages goal setting and development (American Nurses Association, 2023b). Spirituality is more than an individual's religious affiliation; it also includes the beliefs and practices that assist individuals in developing meaning and greater purpose in their lives (Meybodi & Mohammadi, 2020). As organizations implement strategies to promote spirituality to increase resilience and sense of purpose, nurses can experience greater personal reflection and growth. As 14 nurses experience greater purpose, resiliency, and personal growth, they can better overcome adversity in their work environment (Caton, 2021; Chiang et al., 2021). Summary of Literature Review Findings and Application to the Project The literature review demonstrated that nurses' stressful work environment drives burnout, and building resilience in RNs is possible and can mitigate this stress. The research pointed to how helping RNs mitigate stress can decrease nurse burnout. The research also indicates that helping nurses build resilience using the five pillars of resilience can aid in decreasing nurse burnout. The literature review supports establishing a resilience-building training program for acute care nurses focusing on the five pillars of resilience. This MSN project will utilize the research to develop an evidence-based resilience-building training program focusing on the five pillars of resilience for acute care nurses in a hospital in the Western United States. Project Plan and Implementation This MSN project is designed to utilize current evidence-based research to identify the effects of nurse burnout. This project also aims to explore the impact of resilience on nurse burnout and aid in the creation and implementation of a resilience-building training program to decrease nurse burnout. This section will discuss the plan and implementation of the project, the project deliverables, and the ethical considerations. Plan and Implementation Process The Model for Evidence-Based Practice Change will be utilized to implement this project in a hospital in the Western United States on an acute care medical-surgical unit. This model's evidence-driven focus and systematic problem-solving approach will guide this project's nurse resilience-building training program into practice to combat burnout (Brunt & Morris, 2023). For project approval, the project coordinator and unit manager will meet. During this meeting, the 15 project coordinator will explain to the manager the need for, the purpose of, and the project's desired outcomes through the project deliverables. For project implementation, the project coordinator will then meet with the unit manager, unit nurse educator, Employee Assistance Program (EAP) manager, and unit nurse leaders to educate these stakeholders using this MSN project's literature review on the effects of nurse burnout, the effects of resilience on nurse burnout, and the five pillars of resilience. This education will be delivered to stakeholders via a PowerPoint presentation by the project coordinator (Appendix A). During this meeting, the unit manager will review the most recent Press Ganey Caregiver Engagement survey with the stakeholders to evaluate current nurse burnout rates on the unit. After reviewing the PowerPoint presentation and caregiver engagement survey, an infographic (Appendix B) outlining the resilience-building training program created by the project coordinator will be presented in the meeting. The intended purpose of this training program is to provide the participating nurses with an infographic that explains two evidence-based resilience-building strategies for each pillar they can utilize to build resilience. Program participants will not be required to utilize every strategy but will be encouraged to select two to three strategies to implement over six months. These strategies will vary between actions they can implement at work or during personal time. After the infographic is presented, a discussion will be encouraged, and the stakeholders will voice their opinions if they feel the strategies presented are realistic for the unit nurses. The project coordinator will create a brief survey, which will be sent to all RNs on the unit to identify nurses willing to participate in the program (Appendix C). The Maslach Burnout Inventory (MBI) survey will also be utilized during this project, and all nurses on the unit will be asked to complete it before the program starts. The MBI survey completed before the program begins will be labeled pre-program MBI survey. Nurses will be asked to write participating or 16 non-participating at the top of the survey, depending on whether they are willing to participate in the program. Asking all nurses to complete the MBI survey will allow for comparing burnout rates over six months between nurses who participate in the resilience-building training program and those who do not. The MBI and participation surveys will be emailed and available on paper in the huddle room. The MBI results will be kept anonymous to encourage validity in staff answers. After the number of participating nurses is identified, the infographic and PowerPoint will be sent to all nurses' work emails by the project coordinator. The infographic will also be printed and posted in the huddle room for the duration of the program. After the infographic and PowerPoint are emailed to all nurses, charge nurses will review the infographic in the unit's huddles during the first week of implementation. Then, during the first week of each month for six months, the infographic will be reviewed in huddle as a reminder for nurses. After six months, the MBI and Press Ganey Caregiver Engagement surveys will be distributed again to all nurses. The surveys completed at the end of the program will be labeled as post-program, and nurses will again be asked to write participating or nonparticipating on the top of their survey based on their program participation. The project coordinator will compare pre and post-program survey results. A separate post-program survey will also be distributed to assess what resiliencebuilding strategies participating nurses used and how frequently they were used over the sixmonth period. All nurses will be emailed the post-program survey (Appendix D), but only participating nurses will be instructed to complete it. Interdisciplinary Team An essential attribute of an effective work environment is collaboration among healthcare providers. Higher quality of care and outcomes occur when there are higher levels of collaboration (Ma et al., 2018). Collaboration between interdisciplinary team members will be 17 essential to the success of this MSN project. For nurses to be committed to participating in the resilience-building training program, they will need to feel that unit leadership recognizes and supports this program's improved patient, nurse, and healthcare outcomes. Implementing resilience-building strategies by nurses will require a conscious effort, and the more individuals that can promote and support this project, the more participation will occur. This project's interprofessional team will include the project coordinator, unit manager, unit nurse educator, unit nurse leaders, EAP manager, and unit registered nurses. Acute Care Medical Surgical Unit Manager. The involvement of the unit manager will be essential in implementing this project for multiple reasons. The manager must first approve the implementation of this project on the unit. The manager will also play a vital role in the initial meeting with stakeholders because they consistently review caregiver survey results and will present the most recent Press Ganey Caregiver Engagement survey results during the meeting. The manager's input in choosing two resilience-building strategies for each pillar of resilience will also be beneficial because they will help identify which strategies will most likely be used by unit RNs. The manager will also assist in reviewing the Press Ganey Caregiver Engagement survey post-program results. Unit Nurse Educator. A primary responsibility of a unit nurse educator is to aid nurses in their ongoing growth and development of knowledge and skills related to their work area. Because of their expertise in educating nurses and familiarity with how unit nurses receive change, their collaboration in choosing effective resilience-building strategies for the unit will be essential. Their support throughout the program will also be fundamental because they can encourage and remind nurses to implement resilience-building strategies. The educator will also be familiar with the project deliverables to aid in answering questions throughout the project. 18 Unit Nurse Leaders. The unit nurse leaders on this acute care medical-surgical unit are the day and night charge nurses. Nurses are hired into this position for multiple reasons, including their ability to provide exemplary patient care and be outstanding team players. The nurse leaders' support of this project will be crucial because they will help to create a positive attitude on the unit surrounding the program. They are also the individuals who will interact with unit nurses the most and can aid in reminding nurses to implement the program strategies. In the initial meeting, when strategies are selected for the program, their input will also be fundamental because they are not only charge nurses but also floor nurses and know what strategies will realistically be able to be implemented. The unit nurse leaders will also review the resiliencebuilding program infographic during the initial week and first week of each month during the program implementation. Employee Assistance Program Manager. An EAP supports employees with personal or work-related issues that affect their wellness and job performance. EAPs help to improve employees' mental and emotional health (Verduyn, 2023). The manager who oversees the EAP will be utilized during the implementation of this project. Involving the EAP manager can benefit from this project because of their commitment to enhancing employee wellness, knowledge regarding policies and procedures, and experience with program implementation at the organization. Unit Registered Nurses. These will be the individuals most directly impacted by this project implementation, and their involvement is fundamental to program success. Unit RNs will need to complete the caregiver and MBI surveys pre and post-program implementation, be willing to participate in the project, and remember to implement resilience-building strategies throughout the six months. 19 Project Coordinator. The project coordinator is a medical-surgical unit champion RN responsible for this MSN project's research, development, planning, and implementation. The project coordinator will gain permission from the unit manager to implement this project. The project coordinator will create and disperse the deliverables to the unit stakeholders. The project coordinator will also evaluate the project's effectiveness and will be a resource for staff to ask questions regarding the resilience-building program. Description and Development of Project Deliverables Four deliverables will be utilized in implementing this MSN project. This section will explain the deliverables, their purpose, and their benefits to this project. Resilience to Combat Nurse Burnout PowerPoint. The first deliverable is a PowerPoint presentation that will be shown in the meeting held by the project coordinator with the unit manager to gain project approval and then in the project implementation meeting with the manager, unit nurse educator, and unit nurse leaders (see Appendix A). The presentation will aid in gaining support from stakeholders, which will be crucial in implementing a successful resilience-building training program (Ma et al., 2018). The presentation will also be emailed to all participating nurses at the beginning of the resilience-building training program. The presentation will address the following points regarding nurse burnout: what burnout is, the prevalence of burnout, what causes burnout, who burnout affects, the effects of resilience on burnout, and the five pillars of resilience. This presentation primarily aims to help stakeholders and participating nurses recognize the importance of combating nurse burnout, the effects resilience has on burnout, and the need for a resilience-building training program (Chesak et al., 2019; Jun et al., 2021; Low et al., 2019; Mintz-Binder et al., 2021). 20 Resilience-Building Training Program Infographic. The second deliverable is an infographic that outlines the evidence-based resilience-building training program created by the project coordinator (see Appendix B). The infographic will be presented in the meetings with the unit manager and stakeholders, where they will review it and approve it. After the stakeholders' approval, it will be emailed to participating nurses, printed and posted in the huddle room, and presented in the unit's huddles during the first week of the program's implementation. Then, during the first week of each month for six months, the charge nurses will review the infographic in huddle as a reminder for nurses. The infographic aims to provide nurses with a list of ten evidence-based resilience-building strategies, and nurses will be instructed to select 2 to 3 of these strategies to implement over six months (Ahlschlager, 2020; Blackburn et al., 2020; Celano et al., 2022; Lin et al., 2019; Mao et al., 2021; Wei et al., 2018). The strategies are explained in detail, and links to videos, articles, and audio recordings needed to implement the strategies are provided. This infographic is crucial in implementing this project because it is how participating nurses will learn resilience-building strategies. Nurse Participation Survey. The third deliverable developed for this project is a survey to identify nurses willing to participate in the resilience-building training program (see Appendix C). This survey will be emailed to all nurses on the floor, and printed copies will be available in the huddle room. The survey will consist of a brief description of the program, a yes or no question for whether they are willing to participate, and a space to write a reason for those unwilling to participate. Nurses will not be asked to provide their names or demographics to eliminate fear of retaliation for nurses unwilling to participate. Post-Program Survey. A post-program survey will also be emailed to all nurses at the end of the program, and printed copies will be available in the huddle room (see Appendix D). 21 Charge nurses will instruct nurses in huddle that week that the post-program survey will be emailed to everyone and available in the huddle room and that participating nurses are to complete the survey. The survey will ask participants to write down the two to three strategies they chose to implement for the program and to explain how frequently they implemented each of those strategies over the program's six months. They will also be prompted to answer if they found the program helpful and if there are any opportunities for program improvement. Timeline The project approval and implementation timeline is approximately seven months (see Appendix E). The project timeline begins when the project coordinator and unit manager meet for approval. The project coordinator and stakeholders will meet one week after the manager approval meeting. The stakeholders in this meeting will also decide on the dates for delivering the project deliverables to unit nurses. The preferred date to begin delivering project deliverables to unit nurses is one to two weeks after the stakeholder's meeting. On the agreed-upon date, all acute care medical-surgical nurses on the unit will receive an email with instructions on how to complete the pre-program MBI Survey and Nurse Participation Survey within one week. One week after the surveys have been completed, the nurses who volunteered to participate in the program will receive the Resilience-Building Training Program Infographic and Resilience to Combat Burnout PowerPoint in their work email. The week the infographic and PowerPoint are emailed to nurses will be considered "Week 1" of the program implementation. After implementing the program for six months, the postprogram surveys will be emailed to all unit nurses with instructions to complete within one week. One week after the surveys have been returned, another meeting will be held with the project 22 stakeholders to review all pre- and post-program surveys by participating and nonparticipating nurses. The estimated timeframe for gaining approval for the project implementation from the unit manager and unit stakeholders is two weeks. The delivery and return of pre-program surveys will also take approximately two weeks. The resilience-building training program is intended to be implemented by nurses for six months. Lastly, post-program surveys will take approximately three weeks to deliver, return, and review. Project Evaluation The effectiveness of this MSN project will be determined by comparing participating and nonparticipating nurses' pre- and post-MBI, Press Ganey Caregiver Engagement, and postprogram surveys. The MBI self-assessment survey explores exhaustion, depersonalization, and personal achievement. The survey uses a Likert scale ranging from 0 to 6, which rates responses from never, a few times per year, once a month, a few times per month, once a week, a few times per week, and every day. A total score is determined for each of the three sections to identify participants' risk for burnout. High scores in the exhaustion and depersonalization section and low scores in the personal achievement section can indicate burnout. The MBI survey is an effective and popular tool for measuring burnout in health professionals and has been validated through extensive research (Erwan et al., 2020). All nurses on the unit will be asked to complete the MBI survey at the beginning and the end of the resilience-building training program. The surveys will be labeled pre and post-program and will be analyzed by the project coordinator. Nurses will also be asked to write participating or nonparticipating on the top of their survey based on their program participation. Average scores for participating and nonparticipating nurses will be determined for each of the three sections. First, the project 23 coordinator will analyze participating nurses' pre and post-MBI scores. A decrease in average scores for the exhaustion and depersonalization sections and an increase in the personal achievement section in post-program surveys will indicate program success. Next, the scores of nonparticipating nurses will be analyzed and compared to those of participating nurses. The Press Ganey Caregiver Engagement survey will also be utilized to determine project effectiveness. This caregiver survey consists of a six-item index that explores an employee's intent to stay, willingness to recommend an organization (for work or care), and overall pride and satisfaction (Eagle, 2023). Based on employees' responses, a caregiver engagement index score is calculated. A higher index score indicates higher employee engagement, satisfaction, and organizational commitment. An increase in caregiver engagement index scores post-program compared to pre-program will help to determine program success. The post-program survey asks nurses to identify which resilience-building strategies they implemented, the frequency they implemented the strategy, if they found the program beneficial, and whether there are any opportunities for program improvement (see Appendix D). Assessing if nurses found the program beneficial will aid in determining the program's degree of effectiveness. The project coordinator will identify comment trends and discuss these trends with stakeholders in the post-program stakeholder meeting. The project coordinator, unit manager, educator, and nurse leaders will evaluate the data from the MBI, Press Ganey Caregiver Engagement survey, and post-program survey at an endof-program meeting. The combined data assessed from these surveys will help determine the program's success and identify future modifications. Ethical Considerations 24 There will be various ethical considerations when implementing and evaluating the resilience-building training program proposed by this MSN project. Ethical considerations included in this project are participants' privacy and honesty in results. To protect participant privacy and to encourage honesty in answers, the names and demographics of participants will not be collected, and all survey tools used as deliverables will be anonymous. Personal bias held by the project coordinator is another ethical consideration. The survey results will be reviewed by multiple stakeholders at the beginning and end of the program, which will help eliminate any bias or preferences held by the project coordinator. Additional ethical considerations included in this project are quality of patient care, participant consent, and caregiver diversity. The implementation of the resilience-building training program should not hinder patient care. To ensure this, the strategies in the program that nurses can implement during work hours were chosen because they are not time-demanding and will not distract from patient care. Participant consent is an additional ethical factor to consider. All nurses will be sent the nurse participation survey; however, participation in the program will be entirely voluntary, and nurses should not fear retaliation for lack of participation. All surveys used in this project are anonymous to help eliminate the fear of retaliation. Nurses will be asked to label their surveys as participating or nonparticipating based on their program participation to keep surveys anonymous. Caregiver diversity was also considered during the development of the resilience-building training program. Nurses' various learning styles and abilities were considered when choosing the resilience-building strategies. These considerations will assist in the ethical implementation and evaluation of this MSN project. Discussion 25 This MSN project aims to develop and implement a resilience-building training program that organizations can use to build RN resilience and combat nurse burnout and its negative effects. This section will discuss the dissemination of the project results, nursing significance, strengths, limitations, and recommendations. Evidence-based Solutions for Dissemination The results from this MSN project will be disseminated in multiple ways. After the resilience-building training program has been implemented in the medical-surgical acute care unit for six months, data collected from the pre and post-MBI, Press Ganey Caregiver Engagement, and post-program surveys will be presented to and analyzed by project stakeholders in a post-program meeting. Open discussion between stakeholders will be encouraged during the post-program meeting to evaluate the strengths, limitations, and opportunities for program improvement based on survey results. The project coordinator will also create a PowerPoint presentation to share the program results, which will be presented to unit nurses at a staff meeting following the stakeholder post-program meeting. A poster presentation will also be created to present this project to peers and faculty at Weber State University. Finally, if the program implementation is successful, the project coordinator will apply to present findings at a national conference for acute care nurses as a podium presentation. Significance to Advance Nursing Practice This project can benefit nurses, patients, and healthcare organizations by equipping nurses with evidence-based strategies to assist them in building resilience. Research suggests that nurses with higher levels of resilience are better able to manage stress and adversity, have improved physical and mental health, have improved job satisfaction and work engagement, and have lower burnout rates (Brown et al., 2018; Chesak et al., 2019; Low et al., 2019; Stallings 26 Welden et al., 2021; Wei et al., 2018). Patients and organizations also benefit as nurse burnout rates decrease and resilience increases. When nurse burnout rates decrease, patient outcomes and satisfaction increase, retention rates increase, and healthcare organizations minimize substantial money loss due to the effects of nurse burnout (Chesak et al., 2019; Low et al., 2019; Shaffer & Curtin, 2020; Wei et al., 2018). Nurse burnout also contributes to nurse shortages (Bakhamis et al., 2019; Wei et al., 2018). Organizations implementing nursing resilience programs can help combat these shortages by combating burnout. This project is significant to the advancement of nursing practice because of its positive effects on nurses, those they care for, and the organizations and systems they work within. Implications Throughout the development of this project, various strengths and limitations have been identified. Strengths include that this project provides organizations and nurses with resources to help nurses build resilience to mitigate work stress. Another strength of the project is the deliverables, which include a PowerPoint, surveys, and an infographic that meets the needs of various learning styles. Additionally, printable and electronic options for the deliverables are available for nurses to refer back to in the future. Finally, incorporated into this MSN project is the Model for Evidence-Based Practice Change (Melnyk & Fineout-Overholt, 2019). This project follows this model's six steps, which are assessing the need for change in practice, locating the best evidence, critically analyzing evidence, designing practice change, implementing and evaluating change in practice, and integrating and maintaining change in practice (Melnyk & Fineout-Overholt, 2019). Several project limitations have also been identified. Limitations include a limited number of participating nurses, staff buy-in, and barriers to implementation. The number of 27 participating nurses will be limited because this project will be implemented in a single medicalsurgical unit, and program participation is voluntary. However, this project is designed to be implemented in similar acute care units after the program's initial implementation and evaluation. Staff buy-in can also be a limiting factor to this project. For the program to be successful, it will be essential to have buy-in from the project stakeholders. Stakeholder support is essential because they must be willing to learn and understand the project deliverables to answer participating unit nurses' questions about the program. Stakeholders will also be expected to participate in the program to encourage participation by the unit nurses. If stakeholders are unwilling to accept and participate in the program, the project implementation will be limited. It will also be essential for participating nurses to be committed to implementing the resiliencebuilding strategies outlined by the program for six months. If the participating nurses are not committed, a lack of nurse participation will limit the program's outcomes. Project deliverables are intended to encourage buy-in by helping project stakeholders and unit nurses recognize the importance of combating nurse burnout and the benefits of developing resilience. Barriers to implementation include ineffective use of project deliverables. To reduce this barrier, the project coordinator will review all deliverables with stakeholders in the initial meeting to answer any questions and provide direction on presenting deliverables to participating nurses. The project coordinator will also be available via Zoom and email throughout the program for questions from the participating nurses. Limitations and barriers will be addressed by seeking staff buy-in through the use and clear understanding of project deliverables and having resources available for participants' questions. Recommendations 28 Expanding this program to other interdisciplinary team members is a recommendation for project improvement. This project focuses on building resilience in nurses. However, expanding this program to other multidisciplinary team members, such as patient care techs, occupational therapists, and physical therapists, could improve patient and staff outcomes. The literature review illustrated extensive research regarding the effects of building emotional resilience on stress and nurse burnout, but fewer studies explore the impact of increased nurse emotional resilience on patient outcomes (Chesak et al., 2019; Low et al., 2019; Mintz-Binder et al., 2021; Rosa-Besa et al., 2021). Therefore, in the future implementation of this project, research could be conducted regarding patient satisfaction and outcomes relating to nurse resilience. Conclusions Nurses work in a high-stress environment. If they unsuccessfully manage chronic work stress, it can lead to burnout (Cabrera-Aguilar et al., 2023). Nurses, patients, and healthcare organizations are negatively impacted when nurses experience burnout. Research shows that nurses can decrease burnout feelings and better mitigate stress by building emotional resilience (Chesak et al., 2019; Low et al., 2019). Nurses can build their resilience by using evidence-based strategies that have been shown to help nurses develop resilience effectively. Five areas commonly focused on to build nurse resilience are the five pillars of resilience (Ahlschlager, 2020). The five pillars of resilience are emotional intelligence training to increase selfawareness, mindfulness-based interventions, facilitating social connections, encouraging selfcare, and promoting spiritual well-being to increase a sense of purpose (Ahlschlager, 2020; Blackburn et al., 2020; Celano et al., 2022; Lin et al., 2019; Mao et al., 2021; Wei et al., 2018). Organizations can play an essential role in helping nurses build their five pillars of emotional resilience. This MSN project aims to provide organizations with a resilience-building training 29 program that focuses on these five pillars and provides nurses with evidence-based strategies to increase their resilience. 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Burnout an "occupational phenomenon": International classification of diseases. https://www.who.int/news/item/28 -05-2019-burn-out-an-occupational -phenomenon-international -classification -ofdiseases 42 Appendix B Resilience-Building Training Program Infographic https://create.piktochart.com/output/a319787c3314-resilience-strategies 43 Appendix C Nurse Participation Survey https://www.canva.com/design/DAF6k73Oit4/VrkTqxcEBZIXNvlCiMGjbA/edit?utm_content= DAF6k73Oit4&utm_campaign=designshare&utm_medium=link2&utm_source=sharebutton 44 Appendix D Post Program Survey tt :// / & _ / = F8 & /66 U _ Z2 3 = 2& / _ ? _ = = tt F8 45 Appendix E Project Estimated Timeline https://www.canva.com/design/DAF7gO3sAzo/LAslJIOYw3A4gSCfo5uWTA/edit?utm_content =DAF7gO3sAzo&utm_campaign=designshare&utm_medium=link2&utm_source=sharebutton