Digital Repository Doctoral Projects Spring 2021 Addressing Burnout in Intermountain Homecare and Hospice Nurses Heather Clark, MSN, RN Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Clark, H. (2021). Addressing Burnout in Intermoutain Homecare and Hospice Nurses Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Addressing Burnout in Intermountain Homecare Nurses by Heather Clark A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah April 20, 2021 Ann Rocha PhD, APRN, FNP-BC Faculty Advisor/Committee Chair (Ann Rocha PhD, APRN, FNP-BC) Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Graduate Programs Director Running head: ADDRESSING BURNOUT 1 Addressing Burnout in Intermountain Homecare and Hospice Nurses Heather Clark, MSN RN Annie Taylor Dee School of Nursing, Weber State University ADDRESSING BURNOUT 2 Acknowledgments I would like to thank the following individuals for their overwhelming support and guidance with this DNP project. Their knowledge and expertise were monumental in the implementation of this project. Dr. Ann Rocha, a professor with the Annie Taylor Dee school of Nursing at Weber State University, was vital in the writing and collaboration portions of the project. Her wisdom and research into burnout added depth to the project and this paper. Dr. MaryAnne Reynolds is also a professor at the Annie Taylor Dee School of Nursing at Weber State University. Her collaboration with the writing and implementation of this project and paper was exceptional. Next, I would like to thank Dr. Perry Gee, a Nurse Scientist with Intermountain. His expertise and mentorship during the implementation of this project were unparalleled. Without the support of these individuals, as well as Intermountain Healthcare, I would not have been able to address burnout and create interventions that could be used to improve the well-being of healthcare workers. Last, but not least, I would like to thank my husband and children for their support and encouragement throughout this program. ADDRESSING BURNOUT 3 Abstract Burnout is a significant concern for healthcare professionals. Job-related stress is a contributing factor for burnout. The purpose of the DNP project was to decrease burnout for nurses within Intermountain Homecare and Hospice by providing education and resources. A pre-test survey by twenty-four nurses working at a regional Intermountain Homecare and Hospice was utilized to evaluate knowledge and resources about burnout. In this survey, 79% of the nurses reported they had experienced burnout, 8% reported they may have, and 12% reported they had not experienced burnout in their career. From these responses an eLearning module was created and implemented utilizing Articulate Storyline. The module was twelve slides in length and incorporated interactive concepts to keep the learners engaged. Mindfulness minute topics were presented and discussed during the monthly meetings. Following the project implementation, 87% of the nurses stated their burnout symptoms decreased over the twelve months. All found at least two new mindfulness techniques, 87% indicated they would use mindfulness in the future, and all stated they wanted Intermountain to continue with the burnout module. This DNP project increased awareness of burnout and coping skills to combat burnout. Changes in healthcare practices are unavoidable but improvements within organizations and the understanding of resources can combat the rising levels of burnout. Education on burnout and prevention techniques can improve mental wellness and coping mechanisms for nurses. ADDRESSING BURNOUT 4 Addressing Burnout in Intermountain Homecare and Hospice Nurses Burnout has become a significant concern for healthcare professionals (Gelinas, 2019). Job-related stress is a major contributing factor to the risks of burnout. The following literature review discusses the healthcare nurse's well-being, the stress in the workplace, and the effects in the workplace as they relate to Intermountain Homecare and Hospice nurses. The literature review highlights current research findings for a scholarly project to improve Intermountain Homecare and Hospice nurses' well-being. The purpose of this project was to determine the knowledge of and experience with burnout by nurses employed with Intermountain Homecare and Hospice. Through education and resources, the goal of this project was to decrease burnout among this population. Literature Review Biksegn, Kenfe, Matiwos, and Eshetu (2016) defined burnout as the physical and psychological stress reaction to long term exposure to intense emotional and interpersonal pressures. Shanafelt and Noseworthy (2019) describe burnout as a syndrome characterized by exhaustion, cynicism, and reduced effectiveness. Assessments of burnout have been completed in several different areas of healthcare, with similar findings noted. Descriptions of the healthcare workplace often include stressful, long hours, rotating shifts, weekends and holidays, and exhausting (Gelinas, 2019). These variables can take a toll on healthcare nurses' physical, mental, emotional, and spiritual well-being, which can be burnout factors. While the concern for the physical safety of healthcare professionals has existed for a substantial amount of time, the focus on their emotional well-being emerged into the spotlight over the last decade and focused on how this correlates with burnout rates. Organizations have ADDRESSING BURNOUT 5 emphasized physical and emotional well-being by offering resources such as educational modules and courses and healthy living incentives (Perlo et al., 2017). The Joint Commission (n.d.) provides required mesures of accountability including research. The Joint Commission defines research as performing evidence-based care processes to improve health outcomes (either directly or by reducing the risk of adverse outcomes). Symptoms of burnout could cause adverse consequences, as well as effect accuracy and adverse effects, which are two other measurements from the Joint Commission. The lack of focus on the effects of emotional trauma, exhaustion, or burnout may have led to increased depression, substance abuse, and suicide among healthcare professionals (Dyrbye et al., 2017, Melnyk, 2019). Job demands, including workload, emotional needs, and client-initiated aggression, were also identified as creating negative effects on nurses (Elst et al., 2016; Viotti & Converso, 2016; Melnyk, 2019). The mental well-being of caregivers directly affects their ability to focus and think clearly. Lee, Tzeng, and Chiang (2019) found a significant prediction between caregivers' good mental health and their ability to perform quality care and ensure patient safety. Additionally, Johnson et al. (2017) identified higher depressive symptoms in healthcare staff than in the general public and overlapped with burnout. The concept of depression encompasses a more holistic sense of low mood and psychological distress and exists on a continuum ranging from low to high depression. Fausto- Vitorino et al. (2018) discuss that burnout syndrome is a professional disease related to physical and/or mental overload and excessive stress in the work environment. Hall, Johnson, Watt, Tsipa, and O'Connor (2016), in a systematic review, found twenty-one out of thirty articles reported a positive correlation between clinician well-being and patient safety. Additionally, poor well-being was associated with moderate to high levels of burnout. ADDRESSING BURNOUT 6 Maslach Burnout Inventory (MBI) assesses burnout through work-related exhaustion, specifically including emotional exhaustion (EE), depersonalization (DP), and reduced personal accomplishment (PA). Several other scales have been used in the assessment of well-being and burnout in healthcare professionals. They include the Shirom-Melamed's Burnout Scale, Copenhagen Burnout Inventory (CBI), Physician Well-Being Index, General health Questionnaire, Harvard National Depression Screening Scale (HANDS), and Quality Life Scales (Hall et al., 2016; Trockel et al., 2018). Burnout is often overlooked in the homecare setting and focused more on critical care settings such as the Emergency Departments and the Intensive Care Units. Little research has been completed on burnout in homecare employees. However, Hall et al. (2016) reported that 21 out of 30 articles from a systematic review noted a significant correlation between poor well-being and decreased patient safety. It was also pointed out that poor well-being was associated with moderate to high levels of burnout. Shanafelt and Noseworthy (2019) found the challenges and unprecedented changes within the healthcare system. Some of these challenges include increasing price competition, narrowing insurance networks, and a more significant proportion of patients with noncommercial insurance. Along with these changes, the requirement for meaningful use of electronic health records resulted in substantial capital expenditure and increased staff clerical burden. In an attempt to compensate for these increased costs, productivity expectations increased for healthcare nurses. Caregivers in outpatient settings experience different stressors than inpatient settings. Intermountain Homecare nurses have identified some of these as limited access to technology during patient visits (i.e., bladder scanners, vein finders, patient lifts). Other stressors include the ability to access inpatient charting systems, communicate with providers via messaging systems, ADDRESSING BURNOUT 7 drops in communication from hospital discharge planners, and their safety in patient's homes. Hanson, Perrin, Moss, Laharnar, and Glass (2015) discussed the findings of homecare workers who reported negative events that they had personally experienced. These events included verbal aggression, workplace aggression, workplace violence, sexual harassment, and sexual aggression. Some effects noted from these events included increased stress, fear, burnout, depression, and sleep problems. Over a decade ago, the publication To Err Is Human (IOM, 2010) highlighted the staggering number of medical errors and the decreasing quality of care in hospitals. The emphasis on patient-centered care and the importance of the patient experience and patient satisfaction scores placed pressure on healthcare workers, which has increased stress (McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011). Examining the caregiver satisfaction scores is another aspect of burnout that was addressed throughout the literature. McHugh et al. (2011) surveyed nurses in both nursing homes and acute hospitals. It was noted that 36% of hospital nurses, 47% of nursing home nurses, and 21% of nurses in other settings reported that their workload caused them to miss significant changes in their patient's conditions. Similar findings of nurses feeling their workload led to the failure to convey critical information at shift change (p. 206). Johnson et al. (2017) emphasize that improving patient safety remains a priority in acute settings, in light of recent research indicating that clinical errors affect approximately 10% of hospital inpatient episodes. Hall et al. (2016) highlighted that one in twenty prescriptions contains an error resulting in litigation costs at an estimate of 1.6 billion dollars. Both latent and active burnout factors at the system and individual levels cause patient safety incidents. ADDRESSING BURNOUT 8 Several common factors were noted as causes to increase burnout rates. Utilizing the Epworth Sleepiness Scale (ESS), Kaliyaperumal, Elango, Alagesan, and Santhanakrishanan (2017) observed 69% of shift-working nurses reported poor sleep qualitiy. In addition, there was a 32% increase in mathematical errors on the night shift compared to the day shift, and Kaliyaperumal et al. (2017) indicated that cognitive performance was found to be impaired among shift working nurses due to poor sleep quality and decreased alertness during wake state. Gelinas (2019) discussed the correlation between burnout and turnover rates. It was also found that 43% of inpatient nurses had a high degree of emotional exhaustion. The National Solutions Inc (2018) discovered the average turnover rate for nurses was 18.2% and rising. Estimates of the cost of a bedside nurse leaving a unit were $82,500, and for each percent change, it would cost or save the average hospital $337,500 (Dyrbye et al., 2017). Project Setting and Population The goal of this project was to present an eLearning module and mindfulness resources to nurses within a regional homecare and hospice office. The overall outcomes were to increase knowledge, increase resources, decrease turnover and sick call, and decrease burnout rates. This project took place within Intermountain Healthcare, specifically the Intermountain Homecare and Hospice-Logan office. This homecare and hospice office provides services to approximately 175 to 200 patients each month in either the home, assisted living, or skilled nursing facilities in Northern Utah, specifically Cache and Box Elder counties. As an organization, Intermountain had a corporation-wide goal to address caregiver burnout and implement interventions and tools to mitigate burnout. Within the Logan office, there are approximately 35 caregivers, including nurses' assistants, registered nurses, physical therapists, occupational therapists, speech therapists, social workers, and a chaplain. Of these team members, nurses were included for this ADDRESSING BURNOUT 9 DNP project in assessing burnout, implementing burnout reduction tools, and evaluating the effectiveness of the tools and resources. This population is diverse and unique in that neither ambulatory nor homecare nurses has been a focus of burnout prevention. Barriers and Issues Barriers to implementing this project were anticipated to be minimal because Intermountain had a specific goal to address burnout organization-wide. The education department's time requirements within homecare were limited to the eLearning module's review and final approval. Time requirements on the part of the staff were limited to monthly staff meetings and daily huddles that were currently in place and required. The eLearning module was initially presented via Articulate Storyline to the Intermountain Homecare and Hospice leadership and Intermountain education teams for approval. Some limitations were noted within this project and included the small sample of nurses from a rural homecare office. The participants in the project also worked in the same office that the DNP student was working as a nurse. Participants may have been inclined to refrain from reporting negative results within burnout. The creation of an eLearning module was completed utilizing Articulate Storyline, the required platform used throughout Intermountain Healthcare for education. The module was twelve slides in length and incorporated interactive concepts to keep the learners engaged. Intermountain did not have the ability to offer personalized training and instructions for this program; therefore, the DNP student acquired knowledge through Articulate online training resources, which were offered through the Articulate program, as well as a social media blog. Discussing signs and symptoms of burnout, as well as negative coping mechanisms, may cause increased anxiety in some people. The eLearning module addressed the risks associated ADDRESSING BURNOUT 10 with participation in this project, which discussed the signs and symptoms of burnout but also focused on the individual and organizational resources that are available to caregivers. Internal approval of this project ensured that subjects were protected from harm. Approval from the IRB committee within Weber State University was completed to ensure that the Qualtrics survey met the university's standards and guidelines. The information from this survey was utilized to monitor for effectiveness of the eLearning module and to identify if the goal of increasing awareness of resources was achieved. Implementation of Project Carayon, Cassel, and Dzau (2019) identified critical strategies for health care organizations to develop, pilot, implement, and evaluate to reduce the risk of burnout and foster professional well-being. One of these key strategies encourages organizations to routinely measure clinician burnout, and a second was to improve the learning environment and support professional well-being. The second strategy of an effective eLearning modules is to ensure that the participant is engaged with fun and interactive actions that can be completed on a mobile device (Zahraa-Jabbar, 2016). This project addressed both of these points and allowed clinicians to begin receiving the educational training of burnout and resources available. Before offering the education program to the nurses, data on burnout knowledge and the experience was gathered through informal discussions during monthly staff meetings for the Logan homecare and hospice teams and an anonymous Qualtrics survey disseminated prior to the eLearning module distribution. During staff meetings, the discussions included questions about feelings of burnout, ideas to assist in preventing burnout, and ideas for tools and resources to create and implement to combat burnout. The Qualtrics survey obtained data regarding the caregiver's current role, age, years in the field, experience with burnout, knowledge of signs and ADDRESSING BURNOUT 11 symptoms of burnout, perception of ability to prevent burnout at the individual and organization level, and understanding of resources available through Intermountain Healthcare. The second phase of this project was creating an eLearning module for homecare nurses that addressed the causes for burnout and resources available, both on an individual and organization level, to combat burnout. At the time, an education learning module was not available, nor was an emphasis placed on monitoring for burnout in employees. There was an acknowledged need and commitment to the creation and implementation of both processes throughout Intermountain Healthcare. Organizations, including Intermountain, needed to focus on physical and emotional well-being by offering resources such as educational modules and courses as well as healthy living incentives (Perlo et al., 2017). All healthcare organizations nationwide have a commitment to patient safety and have regulations to ensure these safety measures are being met. Lee et al. (2019) assessed nurses' perceptions of the correlation between patient safety and the quality of care and practice. This study noted a significant prediction between the two variables and subsequently that the individual nurse's mental health status plays an important role in patient safety and quality of care. The role of the DNP student for this project included reviewing literature and resources to present to staff in the monthly staff meetings, to identify and outline the mindfulness minute strategy that was practiced for each time period, and developing and delivering to the Intermountain education department of the eLearning module for review and revisions as needed. Project Timeframe The implementation of the project was planned for the third and fourth quarters of 2020. The first phase was to survey homecare and hospice nurses from the Logan office about their ADDRESSING BURNOUT 12 knowledge, perceptions, and experience with burnout. Following that was the implementation of the mindfulness minutes during monthly staff meetings and daily huddles. The final part of the implementation was the development of and approval for the use of the learning module prior to the fourth quarter of 2020. Evidence-Based Practice Change Theory To address this concern, the Adult Learning Theory was utilized. The essence of this theory is that adults can have a self-directed approach to their learning (O'Neill, 2019). Adults use their previous experience as resources for learning. In the case of burnout, staff may be able to reflect on instances where this has occurred or is currently happening and be motivated to increased knowledge of this phenomenon and resources available to assist. This learning module was applicable to them and created a motivation to learn about the signs and symptoms of burnout and how to recognize it in themselves and others. Adult learners need control of when and where they learn. An online module that has a due date to be completed, but no other time stipulations, gave them the freedom to complete the learning module when and where convenient—the format of the eLearning module allowed for viewing on computers, phones, and tablets. Adult learners also want to know, "How can I use this information now?" This module gave them the information they needed to assess burnout in themselves, monitor for signs and symptoms of burnout in others, and awareness of the resources that they have available to them through their employer. A second theory, Havelock's theory, focuses on the management of change, including planning and monitoring change (Finkelman, 2018). The first step of the project, using this theory, was to build relationships with the team, both the staff and the administration. The ADDRESSING BURNOUT 13 second step was to determine the need for a change. This came through a review of the survey findings regarding the prevalence of burnout among IHC Homecare and Hospice nurses. The third step was to gather resources for the change, including literature review, collaboration with employee assistance program representatives, and the review of data revealed in the second step. The fourth step was to select the best option to provide information based on the adult learning theory; this was the use of an eLearning module. The fifth step was to establish and accept the change. This step was achieved once staff had learned about burnout prevention and had been able to utilize the learning module. The final step was to evaluate, maintain, and stabilize by keeping current with literature regarding burnout and resources that can be used. Steps within the process of implementation of the project included the assessment of nurses' perception and understanding of burnout, followed by the implementation of the learning module as a quarterly education requirement, and then the surveys to nurses about their new level of understanding and prevalence of burnout and what resources are available for Intermountain employees. Another final follow-up tool was the ability to obtain data regarding the number of employees that accessed resources within employee assistance programs before and after the implementation of this module. This would indicate a change in the level of awareness and utilization of resources as a healthy coping mechanism to combat burnout. Evaluation and Data Analysis Plan The evaluation of improvement from this project came from a pre-and post-implementation survey regarding knowledge of burnout, coping skills used, and knowledge of resources available through Intermountain Healthcare. The frequency, mean, and percentage for survey questions were analyzed via Qualtrics. There were twenty-four nurses that responded to the pre-and post-surveys that were delivered via Qualtrics. These surveys assessed for level of ADDRESSING BURNOUT 14 both knowledge and understanding of burnout as well as resources to cope and combat burnout that is available through Intermountain. Before implementation of the mindfulness minutes and the burnout module, the nurses were asked if they had personally experienced burnout. Nineteen of the twenty-four nurses reported they had, two reported they may have, and three reported they had not. Twenty of the nurses reported they felt like they could approach their supervisor regarding feelings of burnout, one of them felt they may be able to, and three of them felt they could not. When asked if nurses felt Intermountain offered resources to prevent burnout, fourteen of the nurses stated “few resources”, eight responded “some resources”, and two nurses indicated several resources”. 19 20 0 5 10 15 20 25 Have you expereinced burnout Can you approach your supervisor about burnout symptoms Intermountain Homecare Nurses and Burnout Yes Maybe No ADDRESSING BURNOUT 15 The effectiveness of this project was also assessed through the number of nurses that accessed the eLearning module, including resources, and the outcomes to increase knowledge, increase resources, decrease turnover and sick call, and decrease burnout rates for the Logan office. Turnover rates within the Logan homecare and hospice office, as well as homecare Intermountain wide, seem to have increased over the past decade. However, within the years of 2019-2021 only two nurses left the Logan office, one due to retirement. There were also only three nurses added to the homecare and hospice teams, despite nurse's concerns of being understaffed and overworked. To measure the level of improvement, the DNP student used the project-level analysis tool. This assessed the level of improvement of burnout each month as new mindfulness topics are delivered and the implementation of the eLearning module on burnout. Qualitative data was gathered to assess levels of improvement as well. The definition for burnout was the number of nurses that report higher than 6, on a Likert scale of 1-10 compared to the total number of nurses in the Logan office. The baseline was gathered from a Qualtrics survey that asked participants to 14 8 2 0 2 4 6 8 10 12 14 16 Intermountain has resoucres to combat burnout Resources to Combat Burnout A few resources some resources several resources ADDRESSING BURNOUT 16 identify their experience with burnout, their awareness of signs and symptoms of burnout, and their awareness of resources on the individual and organizational level. The data collection was completed by the DNP student utilizing Qualtrics surveys via email that anonymously collected data from clinicians within the Logan Homecare and Hospice office. This data was collected before starting the mindfulness minutes and eLearning module and then again after. Each month in staff meetings, a different concept of mindfulness was introduced, followed by a group discussion about the benefits of that tool. All staff from the Logan office were included in mindfulness minutes; however, only the nurses were included in the surveys for this project. The sampling of participants was done via judgment sampling because the project was initially implemented in the Logan homecare and hospice office. Participants included nurses from the homecare and the hospice teams because all are exposed and at risk for burnout. As indicated in the table above, the overall mean of the participants showed an improvement in burnout with both the mindfulness minutes and the eLearning module. All 21 24 21 24 3 0 3 0 0 0 0 0 0 5 10 15 20 25 30 Did your level of burnout decrease over the past 12 months Did you find at least two new mindfulness techniques Will you utilize mindfulness in the future Should Intermountain continue with the mindfulness minutes and burnout module Post Assessment of Burnout Yes Maybe No ADDRESSING BURNOUT 17 participants also indicated a need and desire for the continuation of these interventions within Intermountain Homecare, therefore reinforcing the need to address burnout and the quality improvement that this DNP project provides. Results and Outcomes After implementation of the mindfulness minutes and preventing burnout module, a group discussion was conducted in a staff meeting to assess the overall impression of the project and if it had an impact on burnout prevention. Eighteen nurses were present in this meeting, and all indicated an increase in awareness and coping skills to mitigate burnout. Qualtrics survey concluded that all nurses felt like their knowledge of burnout and coping skills had increased over the year. Discussion & Recommendations This project was successful in addressing burnout for Intermountain Homecare nurses from the Logan office. The feedback following the implementation was positive and showed a desire and need for sustaining the module and the mindfulness minutes. Education on burnout, including resources available to combat it, should follow the standard annual requirement to readdress the importance of good mental health and coping skills, risk factors for burnout, and the resources and tools that employees can access. By addressing burnout, healthcare organizations can mitigate the negative consequences discussed within this paper. It can also improve patient and caregiver satisfaction and improve the quality of care. Conclusion This paper reviewed several important contributing factors of burnout. The DNP prepared nurse leader had acquired the knowledge and skills to present, evaluate, and manage this project ADDRESSING BURNOUT 18 implementation. Experts continue to agree that changes in healthcare practices are unavoidable but that changes within organizations and the awareness of resources can combat the rising levels of burnout. Input from Intermountain homecare and hospice leaders and educators was utilized as resources to assist in the development of a learning module on burnout awareness for Intermountain homecare and hospice employees. This learning module highlighted the significance of good mental health and coping skills, mindfulness, and the resources that Intermountain has available for employees both on the individual and organizational level. Education on burnout, including resources available to combat it, should follow the standard annual requirement to readdress the importance of mental health, burnout, and the resources and tools that can be accessed by employees. ADDRESSING BURNOUT 19 References Alenezi, A., McAndrew, S., & Fallon, P. (2019). Burning out physical and emotional fatigue: Evaluating the effects of a programme aimed at reducing burnout among mental health nurse. International Journal of Mental Health Nursing, 28, 1045-1055. Biksegn, A., Kenfe, T., Matiwos, S., & Eshetu, G. (2016). Burnout status at work among health care professionals in a tertiary hospital. Ethiopian Journal of Health Sciences, 26(2), 101- 108. Carayon, P., Cassel, C., Dzau, V. J. (2019). Improving the NaNe system to support clinician well-being and provide better patient care. Journal of the American Medical Association, 322(22), 2165-2166. Drybye, L. N., Shanefelt, T. D., Sinsky, C. A., Cipriano, P. F., Bhatt, J., Ommaya, A., & Meyers, D. (2017). Burnout among health care professionals a call to explore and address this underrecognized threat to safe, high-quality care. States News Service. Retrieved from https://link-gale-com. hal.weber.edu/apps/doc/A500357929/AONE?u=ogde72764&sid=AONE&xid=b3ae 9bc0 Elst, T. V., Cavents, C., Daneels, K., Johannik, K., Baillien, E., Van den Broeck, A., & Godderis, L. (2016). Job demands-resources predicting burnout and work engagement among Belgian home health care nurses: A cross-sectional study. Nursing Outlook, 64(6), 542-556. Fausto-Vitorino, M., Dantas Rodrigues, M., Braz Evangelista, C. B., Guimaraes, A. L., Vidal Batista, J. B., Fonseca, A. G., Araujo, A. L., & Melo, M. (2018). Burnout syndrome: Knowledge of neonatal nursing team. Journal of Nursing UFPE, 12(9), 2308-2314. ADDRESSING BURNOUT 20 Finkleman, A. (2018). Quality improvement: A guide for integration in nursing. Burlington, MA: Jones and Bartlett Publishing. ISBN: 978-1-284-10554-4 Gelinas, L. (2019). Promoting clinician well-being: Staying emotionally healthy is important to personal and patient safety. American Nurse Today, 14(4), 4. Retrieved from https://link-gale-com. hal.weber.edu/apps/doc/A584601979/AONE?u=ogde72764&sid=AONE&xid=d4d4 eda7 Hall, L. H., Johnson, J., Watt, I., Tsipa, A., & O'Connor, D. B. (2016). Healthcare staff well-being, burnout, and patient safety: A systematic review. PLoS ONE, 11(7). Retrieved from https://link-gale-com. hal.weber.edu/apps/doc/A457357855/PPNU?u=ogde72764&sid=PPNU&xid=2a961 6d3 Hanson, G. C., Perrin, N. A., Moss, H., Laharnar, N., & Glass, N. (2015) Workplace violence against homecare workers and its relationship with workers health outcomes: A cross-sectional study, BMC Public Health, 15(11). https://doi.org/10.1186/s12889-014-1340-7 Institute of Medicine. (2010). The future of nursing: Focus on education. Retrieved from http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2010/The- Future-of-Nursing/Nursing%20Education%202010%20Brief.pdf Johnson, J., Louch, G., Dunning, A., Johnson, O., Grange, A., Reynolds, C., Hall, L. & O'Hara, J. (2017). Burnout mediates the association between depression and patient safety perceptions: A cross-sectional study in hospital nurses. Journal of Advanced Nursing, 73(7), 1667-1680. ADDRESSING BURNOUT 21 Kaliyaperumal, D., Elango, Y., Alagesan, M., & Santhanakrishanan, I. (2017). Effects of sleep deprivation on the cognitive performance of nurses working in shift. Journal of Clinical & Diagnostic Research, 11(8), 1–3. https://doi-org. hal.weber.edu/10.7860/JCDR/2017/26029.10324 Lee, T., S-H., Tzeng, W-C., & Chiang, H-H. (2019). Impact of coping strategies on nurses' well-being and practice. Journal of Nursing Scholarship, 51(2), 195-204. McHugh, M. D., Kutney-Lee, A., Cimiotti, J. P., Sloane, D. M., Aiken, L. H. (2011). Nurses' widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Affairs, 30(2), 202-210. Melnyk, B. M. (2019). Making an evidence-based case for urgent action to address clinical burnout, The American Journal of Accountable Care, 7(2), 12-14. O'Neill, E. (2019, April 25). What is Adult Learning Theory? [blog]. Retrieved from https://www.learnupon.com/blog/adult-learning-theory/ Penque, S. (2019). Mindfulness to promote nurses' well-being. Nursing Management (Springhouse), 50(5), 38–44. doi: 10.1097/01.NUMA.0000557621.42684.c4. Perlo J., Balik B., Swensen S., Kabcenell A., Landsman J., & Feeley D. (2017). IHI framework for improving joy in work. IHI white paper. Institute for Healthcare Improvement. Cambridge, Massachusetts. Shanafelt, T. D. & Noseworthy, J. H. (2019). Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clinic Proceedings, 92(1), 129-146. The Joint Commission (n.d.) Measures Retrieved from https://www.jointcommission.org/measurement/measures/ ADDRESSING BURNOUT 22 Trockel, M., Bohman, B., Lesure, E., Hamidi, M. S., Welle, D., Roberts, L. & Shanafelt, T. (2018). A brief instrument to assess both burnout and professional fulfillment in physicians: Reliability and validity, including correlation with self-reported medical errors, in a sample of resident and practicing physicians. Academic Psychiatry, 42(1), 11- 24. Viotti, S. & Converso, D. (2016). Buffering effect of job resources in the relationship between job demands and work-to-private-life interference: A study among healthcare workers. Safety and Health at Work, 7(4), 354-362. Zahraa-Jabbar, Q. A. (2016). Enjoyable e-learning modules: Developing and evaluating. International Journal of Computer Applications, 145(7), 42-47.