Quality improvement

FigureNURSING IS A DEMANDING profession often associated with high levels of stress due to heavy workloads, long hours, and emotional strain. Stress among nurses may lead to burnout, reduce job satisfaction, and compromise patient care. Nurse leaders play a critical role in supporting direct care nurses in ways that improve well-being. The purpose of this QI project was to introduce targeted self-care activities among nursing staff designed to alleviate stress and promote well-being. INTRODUCTION The Institute for Healthcare Improvement created a performance optimization framework, the Triple Aim, to improve three dimensions of healthcare: patient experience, population health, and healthcare costs.1 But a gap was later identified, leading to a fourth aim: providing the healthcare workforce with “care for the caregiver” support to reduce burnout.2 Workforce burnout is defined as the phenomenon of mental and physical exhaustion experienced with ongoing stress in the workplace.3 To address burnout arising from prolonged stress in the work environment, nurse leaders need to commit resources and engage nursing team members in a structured plan for self-care activities. In a Magnet®-recognized, 500-bed academic medical center, nurse leaders reviewed the shared governance councils' charters, finding a gap related to the fourth dimension of the Quadruple Aim: caring for the caregiver. This gap was the impetus for creating the Well-Being Council (WBC). The council's purpose was to partner with nurses to implement tactics focused on caregiver well-being in the work environment. As an initial step, the WBC members collaborated with a nursing graduate student (primary author/project leader) to evaluate the well-being literature and develop a bundled strategy to implement as a pilot using a quality improvement (QI) approach. This project is reported using the Squire 2.0 guidelines.4 PROBLEM DESCRIPTION Nurses working on the 38-bed intermediate care unit (IMC) at this hospital care for high-acuity patients with complex needs, including ventilator care, telemetry, and frequent assessments. Nurses on the unit face a variety of challenges, including navigating complex family dynamics, addressing patients' financial stress, overcoming cultural barriers, and managing a large physical layout that can impede communication and slow response times. A 2022 staff survey revealed low job satisfaction, poor teamwork, and dissatisfaction with access to equipment and workflow processes. Many staff indicated plans to leave within a year and criticized hospital leadership. Nurses expressed concerns about nurse-patient ratios, felt that agency nurses prioritized pay over patient care, and perceived a lack of support from the nurse manager (NM) and leadership. In a follow-up interview with the project leader, the NM attributed staff stress to high-acuity patients, heavy workloads, nurse-patient ratios of 1:4, high turnover, and a staffing vacancy exceeding 50%, which led to increased use of agency nurses (oral communication, September 8, 2022). The aforementioned factors contribute to daily stress and fall within the concerns of nurse leaders; consequently, the information was brought forward to the IMC Unit-Based Council (UBC), the organization's WBC, and nurse leaders, serving as the catalyst for this project. LITERATURE REVIEW Stress and the work environment Stressful working environments are noted as one of the top three reasons nurses leave bedside nursing for an alternate nursing position or leave the nursing profession altogether.5 Nurses experience high levels of stress when balancing care of multiple, complex, high-acuity patients and complicated care coordination.6,7 Other sources of stress reported were lack of equipment and supply availability, inadequate staffing, and working overtime.6,7 Stress related to heavy workloads precipitated by staffing challenges may lead to poor patient outcomes resulting from judgment and medication administration errors.8 Prolonged occupational stress may lead to poor physical and mental health.9 Stress symptoms such as fatigue, headaches, feelings of anxiousness, and lack of patience may affect a nurse's ability to provide quality care to patients.9 Managing stress The creation of a designated quiet space, in conjunction with offering complementary therapies such as aromatherapy, massage, or listening to music, may reduce the perceived occupational stress of nurses.10,12-17 Having a quiet space may directly contribute to nurses' well-being and consequently the effectiveness of healthcare delivery.18 A quiet space encourages nurses to take breaks, provides a refuge to escape a hectic work environment, and prioritizes the nurses' well-being, enabling a return to duties with a clear mind and enhanced concentration, supporting quality care delivery.18,19 Well-rested and rejuvenated nurses are more likely to provide effective and compassionate patient care.20 In addition, leadership support in providing designated quiet spaces is a proactive measure to decrease nurse burnout, contributing to job satisfaction, nurse retention, and staff feeling valued by the organization.18 RATIONALE The Plan-Do-Study-Act (PDSA) cycle was used to inform this QI project.21 PDSA cycles are used to test small changes; this project served as the first cycle. Data were collected throughout the project and analyzed by the project leader to determine project outcome progress. Results were discussed with the WBC, NM, and nurses to determine if modifications were needed during the project and before planned implementation on additional units. SPECIFIC AIMS This QI project's purpose was to evaluate the reported self-perceived stress of IMC nurses before and after participation in stress-reducing activities during a 12-week period, with a goal of a 10% decrease in reported perceived occupational stress. METHODS Context This project took place at a Magnet-recognized hospital known for its healthcare excellence and commitment to shared governance. UBCs play a key role, ensuring stakeholder input and driving continuous improvement through empowered accountability. The hospital has academic partnerships with regional universities, providing nursing students with clinical rotations and supporting graduate projects. These partnerships promote collaborative practice, interprofessional education, and innovation in patient care and curriculum development.22 The project leader, a former hospital employee and current faculty member at a partner university, leveraged long-standing professional relationships to successfully initiate and complete the project. The project leader proposed the project plan, and the NM, UBC, and WBC approved the plan. The project leader attended change-of-shift huddles to introduce the project. Staff voiced interest and appeared receptive; questions were answered regarding the project's time frame and how often/long the quiet room could be used. During the 3 weeks prior to project implementation, the project leader reinforced the project details at charge nurse and UBC meetings, as well as at change-of-shift huddles to elicit additional interest. Interventions The quiet space for the QI project was a private consultation room near the IMC break room, designed with no windows for privacy and dimmed lighting to reduce stimulation. It featured a recliner and a blanket, with a privacy sign to prevent interruptions. Participation was voluntary, and the charge nurse or NM arranged patient coverage. Nurses could choose among aromatherapy (lavender, rose, or clary sage oils), massage using a Shiatsu foot and leg massager, music via QR codes, or simply relaxing. The room had disinfectant wipes, and the project leader was responsible for restocking and maintaining the space. Items used were either provided by the hospital (recliner, wipes), the unit (foot massager), or purchased by the project leader (blanket and aromatherapy oils and supplies). Measures Nursing staff (N = 40) were given 2 weeks to complete the preimplementation Qualtrics survey, which also served as informed consent. The survey included demographic questions and the Perceived Occupational Stress (POS) scale, a reliable tool (Cronbach α = 0.86; P < .001) measuring work-related stress on a Likert-type scale ranging from 1 to 5.23 The survey was distributed via email, and QR codes were placed around the unit. After project completion, a similar 2-week postimplementation POS survey was conducted. Additionally, nurses rated their stress levels (0-10) before and after each stress-relief activity using a QR-coded Qualtrics survey. Surveys were distributed in a manner that ensured anonymity, and participant responses were collected without any identifying information. Electronic survey results were secured with password protection, and paper surveys were stored in a locked cabinet within a locked room, accessible only to the project manager, who held the key to both. Verbal feedback was gathered informally through unit visits and during shift huddles and UBC meetings. Modifications during implementation Aromatherapy modification. The strong earthy scent of clary sage quickly filled the room, making it uncomfortable for some nurses who were sensitive to the aroma. In response, the oils were removed, and by the following week, they were replaced with labeled bags containing a single oil-infused cotton ball. Those who were previously affected by the scent reported improved comfort, resolving the issue. Enhanced availability of survey. Informal feedback from staff and low survey completion rates pre/post activity highlighted a need for an alternative method of gathering responses. Consequently, physical copies of the survey were provided in the quiet room to encourage broader participation and feedback. Data analysis Data were collected and analyzed using simple descriptive statistics; means and standard deviations were calculated. Due to the small sample size of the postimplementation survey results (n = 3), statistical analysis of the POS scores wasn't feasible and, therefore, not recorded. A paired t test was conducted to determine statistical significance between stress levels pre and post activity in the quiet room. Qualitative data gathered informally were used to modify the project as needed. RESULTS The project leader educated 21 nurses on using the quiet room and three self-care activities. During a 12-week period, nurses used the room and activities 28 times, though qualitative data indicated more usage without completing surveys. Preimplementation, 10 nurses completed a survey; postimplementation, 3 nurses responded (see Table 1). Following self-care activities, stress scores were reduced by 43% (P < .05), with average stress levels dropping from 6.4 to 3.7 (see Table 2). Aromatherapy (lavender), the massager, and instrumental music were the most used activities (see Table 3). TABLE 1: - Participant demographics and general characteristics Variables Presurvey (n = 10) Postsurvey (n = 3) Healthcare profession Hospital-employed RN 7 3 Agency RN 3 0 Employment status Full-time 9 2 Part-time 1 1 P.r.n. 0 0 Primary shift worked 7 a.m.-7 p.m. 7 1 7 p.m.-7 a.m. 2 2 Other (3 p.m.-7 a.m.) 1 0 Average hours worked per week∗ <36 hours 1 1 36-48 hours 6 1 >48 hours 1 0 ∗Missing data; some participants didn't answer this survey question. TABLE 2: - Comparison of mean scores for self-perceived stress before and after interventions (n = 28) Preactivity stress score M (SD) Postactivity stress scoreM (SD) Pre/post stress reduction P value 6.41 (1.47) 3.67 (1.41) 43% .000 ∗Using paired t-test; P < .05 TABLE 3: - Frequency of stress-relief activities chosen by nurses Aromatherapy∗ 25 Lavender 12 Rose 10 Clary Sage 8 Massage 20 Music∗ 10 Waterfall Sounds 7 Anxiety Relief 2 Ocean Waves 1 Jazz 1 ∗The use of essential oils and music selected by participants exceeds the total activity usage because individuals chose multiple types of oils and music. DISCUSSION This QI project addressed the need to support caregivers by creating a quiet space offering three natural self-care activities. Stakeholder input guided its development, and direct care nurses' feedback prompted modifications. Both qualitative and quantitative data confirmed the space's use, and findings showed a reduction in self-reported stress levels. Participants could personalize their experience by bundling activities. The results align with studies like Zamanifar and colleagues, which measured the effects of music therapy and aromatherapy.17 Studies such as Pagador and colleagues and Zamanifar and colleagues explored similar interventions but with different methods and measurements.16,17 Methodological differences This project used anonymous self-reporting without a control group, aggregating data collectively. Although it captured usage data similar to the QI project implemented by Pagador and colleagues and Hulett and colleagues, more rigorous methods like randomized controlled trials and quasi-experiments have produced stronger results.10-17,24-27 Stress was measured before and after interventions, as recommended by prior studies, with an additional assessment of POS before and after the entire project, which most referenced studies didn't include.10-17,26,27 Tools and measurements Researchers have used various methods to measure stress, such as the Visual Analog Scale, stress questionnaires, and anxiety scales like the Beck Anxiety Inventory and Faces Anxiety Scale.10-17,24,25,27 Although this project used a 0 through 10 numeric rating scale for self-reported stress, its validity and reliability weren't tested, which may weaken the findings. Some studies also used physiologic indicators (BP, heart rate, finger temperature, serum cortisol).13,14,27 We recommend that future research combine self-report instruments with physiologic measures for a more comprehensive stress assessment. Interventions Participants could choose one, two, or all three interventions: music, mechanical massage, and aromatherapy. Music was favored in this study, unlike the instrumental music offered by Zamanifar and colleagues.17 Mechanical massage was used, similar to that offered by Hand and colleagues, Frigo and Staffileno, and Pagador and colleagues, whereas in other studies, the researchers were trained to perform the massages, and participants' awareness of this training could potentially influence their perceptions of the massage's effectiveness, introducing bias.12-16,24 Aromatherapy with clary sage, lavender, and rose was administered via inhalation, similar to Farsi and colleagues and Bahadori and colleagues.10,11 Limitations Although this project was locally successful, there were limitations. These included a small sample size; a data collection tool that was, in part, drawn from the literature and partially developed by the project leader but not formally tested for validity and reliability; and the setting of one unit in a single acute care facility. To protect confidentiality, limited demographic data were gathered. In addition, the quiet room was available at all hours, allowing nurses to use the space without engaging in any of the activities, which wasn't captured on the data collection tool. Research on the use of a quiet space might inform better understanding of additional benefits of creating a quiet room for stress management. IMPLICATIONS FOR NURSE LEADERS Knowing that nurse leaders are accountable for the milieu present within the department, it's crucial to provide the nursing team with access to a toolbox of strategies to address the stress they experience while at work. Self-care activities described in this project are examples of tools that may be helpful for nurse leaders. By supporting nursing team engagement in stress-reducing activities, the nurse leader is demonstrating a commitment to the overall health of their team. In addition to providing the team with valuable stress-reducing tactics, supporting the graduate student during the QI process enhances the academic-clinical partnership, which supports the nursing pipeline and may facilitate new nurse hires for the organization. PRIORITIZING SELF-CARE This pilot QI project revealed how self-care activities, such as aromatherapy, massage, and music therapy sessions in quiet spaces, may contribute to reducing nurses' self-reported stress levels. This project highlights the importance of offering stress-management options to nurses during work, showing that staff will use them if available. Prioritizing self-care and creating peaceful retreats within healthcare settings might not only enhance the well-being of nurses but also foster a more supportive and resilient healthcare environment. Moving forward, nurse leaders should continue exploring and implementing such projects to promote the holistic health of the nursing workforce. This article advocates for a systemic shift toward prioritizing self-care as an integral component of nursing practice, ultimately benefiting both nursing professionals and the patients they serve.