MANUSCRIPT SECTION I-III

1

EXAMPLER ONLY

Create a Unique Title – see below AND REMOVE this line

Nurse Burnout Prevention Project

Student Name

Chamberlain College of Nursing

April 2024

2 Executive Summary

Purpose: The purpose of the Nurse Burnout improvement project was to implement a 30 minute

uninterrupted lunch break reduce in nurse burnout and fatigue.

Project Location: The Nurse Burnout project was completed on the hematology and transplant

clinic at a medical center.

Synthesis of Literature and Evidence: Nurses who do not take a 30-minute uninterrupted lunch

break, nurse staff satisfaction has deceased, and patient outcomes have shown a negative decline.

Further, interventions to reduce nurse burnout have been implemented at the microsystem and

macrosystem levels to ensure nursing staff take appropriate breaks.

Implementation: A nurse burnout in-service education was completed to explain the nurse

burnout intervention of an uninterrupted lunch break to the hematology and transplant clinic

nursing staff. Nursing staff utilized team nursing to take a 30 minute uninterrupted lunch break

during each shift. Weekly timesheets were used to record the 30 minute lunch breaks. A pre/post

intervention survey was completed to measure the incidence of nurse burnout, fatigue, and nurse

staff satisfaction. 35 hematology and transplant clinic nurses participated in the nurse burnout

project.

Dissemination: The nurse burnout project results were disseminated internally and externally. Internally, the nurse burnout project results were presented to the hematology and transplant clinic nursing staff, at shared governance meetings. Externally, the nurse burnout project results were presented to nursing students for the purpose of teaching the nursing g students the value of taking lunch breaks.

3

Nurse Burnout Prevention Project

Nurse burnout continues to be problematic for many healthcare organizations. As a

caregiver, nurses usually place the needs of patients before the needs of the nurse caregiver

(Roth, 2019). Also, the literature has suggested, nurses do not routinely take appropriate breaks,

including lunch breaks; because nurses decide to provide patient care, rather than take a break

(Roth, 2019). Further, not taking appropriate breaks throughout a scheduled shift can lead to

nurse fatigue and burnout, and a decrease in nurse satisfaction and patient care (Barrientos-Trigo

et al., 2018). The nurse burnout project was completed on a hematology and transplant clinic unit

of a medical center to implement a 30-minute uninterrupted meal break. The purpose of the

nurse burnout project was to reduce nurse burnout and fatigue.

Problem Statement

Many nurses would agree that break time is frequently missed (Gifkins, et al.,

2020). Nurses not taking a break during the work shift was the identified problem in a

hematology and transplant clinic unit. The purpose of the nurse burnout project was to reduce

nurse burnout and fatigue by providing staff with a 30-minute uninterrupted lunch break

(Appendix A). Currently, many nurses indicate not taking the 30 minute uninterrupted lunch

break; which means a high occurrence of nurses do not receive a lunch break. Literature has

shown the inability to take adequate breaks can lead to nurse burnout and fatigue (Gifkins et al.,

2020). Further, Gifkins and colleagues (2020) has shown a correlation between missing patient

care and compromising patient safety when nurses are unable to take breaks.

Problem Background

Nurses who do not take an adequate lunch break has been linked to patient errors, high

nurse turnover rates, and nurse burnout or fatigue (Youssef & Senbel, 2018). In contrast,

4 adequate rest breaks has been shown to improve nurse wellbeing and positive behaviors (Youssef

& Senbel, 2018). Also, the positive nurse outcomes when taking adequate rest breaks, has been

linked to a reduction of medical errors and missed patient care. Huang and colleagues (2017)

reported similar results from inadequate rest breaks; which indicated occurrence of

depersonalization that can lead to nurse burnout and fatigue. Further, the missed rest breaks can

reduce or eliminate the time to decompress during an assigned shift.

The literature indicated many factors that influence a nurse not taking a rest break. The

most common factors are: inadequate staff coverage, patient-care priority over self-care, and

consuming food quickly or while working (Johannes Wendsche, 2017). In addition, social norm

or workplace culture can alter a nurse’s decision to take a rest break (Johannes Wendsche, 2017).

Stakeholders

The nurse burnout project identified four major stakeholders, the hematology and

transplant clinic nursing staff, float pool nursing staff, unit manager and administration are the

major stakeholders. Thus, engagement of the nursing staff can influence the success of the nurse

burnout project implementation. The float pool nursing staff, who frequently supplement the

core nursing staff, will also be included in the nurse burnout project participation. Additionally,

the unit manager involvement can expedite project approval and serve as a role model for

practice change. Administration, specifically, the director of evidenced-based practice will

provide access to base line data about the current nursing staff not using rest breaks.

PICOT Question

The PICOT Model was used to formulate an improvement project PICOT question that

guided the literature search and development of an improvement project (Dang & Dearholt,

2017). The PICOT question was: Among nurses in the hematology and transplant clinic, will a

30-minute uninterrupted lunch breaks, decrease nurse fatigue and burnout, in four weeks? The

5 identified nurse burnout project population were nurses working on the hematology and

transplant clinic unit. The proposed intervention was a 30-minute uninterrupted lunch break. The

outcome was a measurement of nurse fatigue and burnout signs/symptoms, using a pre/post

intervention questionnaire.

Review of Literature

A literature search was conducted utilizing relevant databases such as CINAHL,

EBCSOhost, and PubMed. Terms and concepts from the nurse burnout PICOT question were

selected to guide the literature search. The literature search terms were: nurse burnout, nurse

fatigue, lunch break. Literature search filters were: language, articles published between 2017-

current, and peer-reviewed journals. A total of 2, 585 articles were identified. A reduction in the

number of relevant articles was achieved with addition application of filters. For example, the

additional filters were: peer-reviewed, published within last 5 years, and English language and

applied to reduce the number of articles. Non-research sources were also included such as The

Ohio Nurses Association Handbook 2020 (citation) and state legislation (citation) relavent to

employee break laws were selected as supporting evidence. The major trends identified from

the selected research were: 30 minute lunch break and decision to take a break.

FYI: BELOW is an example of literature synthesis, which provides an analysis of multiple

research studies relevant to the nurse burnout intervention. Do Not Present each research

study separately.

30 Minute Lunch Break

6 The state of Ohio law stated employee’s must be given a 30-mintue lunch break during a

shift longer than 8 hours long. In addition, The Ohio Nurses Association Handbook supported a

lunch break of 30-minute uninterrupted break time. Further, the Ohio Nurses Association stated

a staff member would be removed from the patient care area and when possible a different staff

member woul assume care of the patients. Appendix B contains details for each selected

reference.

Research articles were also included and synthesized that were related to the PICO

question. Wendsche and colleagues (2017) published a research summary of is a relevant 36

publications that explored rest break organization tactics to assure staff can receive appropriate

rest breaks. This article found that when appropriate measures are intact to allow staff to take rest

breaks, staff satisfaction is improved (Wendsche et al.,2017). The article did identify that there is

a lack of literature on the topic and further research needs to be conducted. Similar findings

about eating practices of hospital nurses was published by Monaghan & Dinour, 2017. Similar

were additional strategies were found to be needed to ensure staff can take appropriate meals

breaks. Further, identifying four themes that influence nurses eating practices on shift:

unpredictability of workload, patient care a priority over self-care, consuming what is available

quickly, and inadequate break coverage (Monaghan & Dinour, 2017). Although the identification

of these reasons can be helpful limitations of this article need to be considered including a small

sample size of 33 nurses. In contrast, Hulsegg and colleagues (2020) used a large sample size of

611 nurses and a linear regression analysis statistical test to determine further research on

interventions to assure staff take appropriate meal breaks was needed. Additionally, workplace

culture was found to be a strong factor which influenced decision to take adequate meal breaks

(Hulsegg et al., 2020). Based on the literature findings, the decision to implement a 30 minute

meal break was developed.

7 Decision to Take a Break

A synthesis of the selected research and legal evidence offered relevant findings for the

selected nurse burnout problem and 30 minute meal break intervention (Appendix B). The

problem of nurses not taking breaks was not well documented in the literature. In contrast,

research and legal evidence presented strategies to ensure nurses receive breaks during a

schedule shift. A total of 36 publications that explored rest break organization tactics to assure

staff can receive appropriate rest breaks. For example, The state of Ohio law (citation) stated

employee’s must be given a 30-mintue lunch break during a shift longer than 8 hours long. In

addition, The Ohio Nurses Association Handbook(citation) supported a lunch break of 30-minute

uninterrupted break time. Further, the Ohio Nurses Association (citation) stated a staff member

should be removed from the patient care area and when possible a different staff member would

assume care of the patients. A study by Monaghan and Dinour (2017), identified four factors that

influence nurses eating practices on shift: unpredictability of workload, patient care a priority

over self-care, consuming what is available quickly, and inadequate break coverage. The four

nursing eating practice factors provided support to develop the 30-minutes, uninterrupted meal

break.

Intervention

The nurse burnout project intervention was a 30 minute-uninterrupted meal break

(Appendix C and Appendix D). According to Ohio law (citation) and Ohio Nurses Association

(citation) nurses must be able to take a 30-minute meal break during the assigned work shift.

When staff are unable to take a meal break nurse burnout and fatigue can occur. Research has

shown nurse burnout and fatigue lead to patient errors and a high nurse staff turnover rate

(citation). Thus, the nurse burnout project goal was to decrease nurse fatigue and burnout by

8 implementing a 30-minute uninterrupted lunch break. MISSING is details about who, when

and where the intervention will be completed – REMEMBER to add the details.

Setting

The nurse burnout project was conducted in a hematology and transplant clinic. The

current workplace culture did not intervene to support nurses taking a 30-minute uninterrupted

meal break. Rather, the workplace culture fostered the nurse behavior of “eat on the go” instead

of a 30-minute meal break. Nurse turnover in the hematology and transplant clinic remained

high. Informally, nurses would describe the hematology and transplant clinic as a difficult unit

because nurses do not have the opportunity or support to take a break. The hematology and

transplant clinic manager were open to finding ways to support nursing staff, increase nurse staff

retention and nurse staff satisfaction. The hematology and transplant clinic unit council had an

objective to improve nurse staff satisfaction for the last 3 years. Therefore, readiness to change

the work culture appeared high. The nursing staff and the unit manager discussions were positive

and supportive of the 30-minute meal break.

Barriers

The nurse burnout project identified four barriers to implementation of the 30-minuites

meal break. The first barrier was the inability to find patient coverage for a nurse taking a meal

break. Patient coverage is important to ensure the meal break time would be uninterrupted.

Another potential barrier was time management to ensure all nurses take a full 30-minute meal

break. One strategy for overcoming the patient coverage and time management barriers was the

use of team nursing care delivery model. Team nursing care delivery would provide adequate

patient coverage and the management of time to achieve a 30-minute, uninterrupted meal break

for all nurses.

9 The third barrier was staffing shortages. The utilization of a float pool staff to cover

lunch breaks could overcome the staffing shortage barrier. The fourth barrier was nurses

unwilling to take a 30-minute uninterrupted meal break. A strategy to overcome the nurse

unwillingness barrier was an in-service education about the nurse burnout project and the

importance of a 30-minute uninterrupted meal break. The goal of the in-service education was

to assist staff in recognizing the link between not taking a meal break and nurse fatigue and

burnout.

Outcomes

The nurse burnout project outcome was a decrease in nurse fatigue and burnout. The

nurse burnout project outcome was measured by comparing a pre/post intervention survey score.

The pre survey was completed prior to project implementation and a post survey was completed

3 weeks after project implementation. The survey questions related to the nurse burnout project

outcome, which measured nurse burnout and fatigue. The expected outcome was a decrease in

the incidence of burnout and fatigue by participating in a 30-minute uninterrupted lunch break.

Also, the nurse timesheets were reviewed to validate nurses participated in the 30-minute lunch

break.

Action Plan

First PRESENT THE JHEBP MODEL AND NUMBER OF MILESTONES, with

appropriate citation. The nurse burnout project action plan utilized critical project milestones

(Appendix C) to achieve a successful completion of the nurse burnout quality improvement

project. The first milestone – BETTER TO DEFINE EACH MILESTONE, BEFOFE EXPLAIN

THE COMPLETED ACTION FOR EACH MILESTONE involved the pre-survey by 30 nurses

in the hematology and transplant clinic. The pre-survey was 10 questions asked the nursing staff

to rate burnout, fatigue, and staff satisfaction on a scale of 1-5. The survey data for each question

10 was analyzed, comparing the pre and post intervention survey results. The nurse burnout project

results were shared with the director of evidence-based practice and the hematology and

transplant clinic manager.

The second critical milestone-DEFINE was an in-service to the hematology and

transplant clinic nurses about the nurse burnout project goals, intervention and outcome. The in-

service included evidence about the importance of staff taking 30-minute uninterrupted breaks

and the effects of a meal break on fatigue, burnout, and nurse satisfaction. Team nursing was

explained as a strategy to allow nurses to take appropriate lunch breaks. A meeting with the float

pool manager explained the nurse burnout quality improvement project and how the float pool

staff would provide support lunch breaks for the nursing staff.

Data collection was the third milestone-DEFINE which involved documentation of the

nurses taking or not taking the 30-minute uninterrupted lunch break. Weekly meetings were

conducted with the hematology and transplant clinic manager to collect the nurse timesheets.

Meal break findings from the nurse timesheets were disseminated to the nursing staff.

The fourth and final milestone was the completion of the post-survey by the 30 nurses in

the hematology and transplant clinic. The post-survey was completed week 3 of implementation

of the project. Both, the pre and post survey questions were identical. Findings of the post-survey

were discussed with the director of evidence-based practice and the manager of the hematology

and transplant clinic to support further collaboration.

References

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14

15 Appendices, Tables, and Figures

Appendix A

Summary of Area of Interest (Sec2on I)

The purpose of the MSN project is to improve nurse burnout and fa8gue by providing staff

with a 30-minute uninterrupted lunch break (GiDins et al., 2020). The Hematology and Transplant

Clinic currently tracks the number of nurses that receive an uninterrupted lunch break. This is done

when the RN clocks out, it gives a prompt that the RN must respond to asking if they received a 30-

minute uninterrupted lunch break. As of now, many nurses are selec8ng no to this prompt, meaning

there is a high occurrence of nurses not receiving a lunch break. Literature shows that the inability to

take adequate breaks can lead to nurse burnout and fa8gue (GiDins et al., 2020). There is also a

correla8on between missing pa8ent care and compromising pa8ent safety when nurses are unable to

take breaks (GiDins et al., 2020).

Problem Statement (Sec2on I)

When nurses are unable to take a 30-minute uninterrupted lunchbreak during their shiP they are at a

higher risk for nurse burnout and fa8gue which can impact health outcomes nega8vely.

Problem Background (Sec2on I)

Currently at the center we track the number of nurses that receive an uninterrupted lunch break. This

is done when the RN clocks out, it gives a prompt that the RN must respond to asking if they received

a 30-minute uninterrupted lunch break. As of now, many nurses are selec8ng no to this prompt,

especially those RN’s that are working in infusion. Nurses being unable to take adequate meal breaks

can have a nega8ve impact on quality and safety in the clinical seRng (Roth, 2019). Studies have

shown a higher correla8on of missing pa8ent care and compromising pa8ent safety when nurses are

unable to take breaks (Roth, 2019). Incidences of medica8on errors, missed care, and falls with injury

have been proven to increase when nurses are not able to take breaks.

16 Stakeholders (Sec2on I)

• HTC staff

• Nurse Manager

• Float pool staff

• Director of Evidenced-Based Prac8ce

Clinical/Prac2ce PICO(T) Ques2on (Sec2on I)

In nurses in the Hematology and Transplant Clinic, does a 30-minute uninterrupted lunch break,

compared to no break, reduce the incidence of nurse fa8gue and burnout as measured by a pre/post

survey over a 4 week period?

17 Literature Review (Sec2on II: Include Synthesis informa2on from Module 4 assignment. In your

manuscript you will want add a bit more detailed informa2on to this sec2on)

The findings from the literature matrix table can be u8lized to help answer the PICOT ques8on stated

above by providing insight on how the workplace environment is impacted by not allowing nurses to

take adequate breaks. There are common themes that can be iden8fied throughout these ar8cles

most of which being how lack of adequate breaks effect pa8ent care and staff sa8sfac8on (Scammell,

2018). Scammell and Roth go into detail regarding the factors can contribute to nurses being unable

to take breaks. In mul8ple studies it was shown that medica8on errors and missed pa8ent care have

resulted (Skinner et al., 2018). In the ar8cles It Breaks Your Soul and ShiP Work and its Rela8on with

Meal and Snack Paderns Among Healthcare Workers prove the nurse fa8gue and burnout can occur

when nurses are unable to take adequate breaks during their shiPs.

These ar8cles answer the EBP ques8on by iden8fying that nurse fa8gue and burnout have resulted in

nurses throughout mul8ples studies when staff are unable to take a 30-minute uninterrupted lunch

break (Hulsegg et al., 2020). The ar8cles also shed light on strategies that can be implemented

throughout different levels throughout the health system to ensure staff receive appropriate meal

breaks (Cordoza, et al., 2018). From these ar8cles it can be concluded that by applying a strategy on

the microsystem level in the Hematology and Transplant Clinic at The James, there will a decrease in

the incidence of fa8gue and burnout as measured by a pre/post survey over a 4-week period.

Proposed Interven2on(Sec2on III)

The interven8on is applying team nursing to ensure that each staff member receives a 30-minute

uninterrupted lunch break. The comparison is what the staff are currently faced with which is an

inadequate in 8me, interrupted lunch break, or no break at all. The outcome iden8fied is a reduc8on

in nurse burnout or fa8gue in a 8mespan over 4 weeks as evidenced by a pre- and post-survey.

18 SeKng (Sec2on III)

From this inquiry the PICOT ques8on, in nurses in the hematology and Transplant Clinic, does a 30-

minute uninterrupted lunch break, compared to interrupted break or no break, reduce the incidence

of nurse fa8gue and burnout as measured by a pre/post survey over a 4 week period. The popula8on

iden8fied in the PICOT is nurses in the Hematology and Transplant Clinic.

Barriers (Sec2on III)

1. Inability to find pa8ent coverage

2. Time management of nurses to be able to take a full 30-minute break

3. Staffing shortages

4. Nurses not willing to take a full break

Ethical Considera2ons (Sec2on III)

Ethical implica8ons regarding this policy include beneficence (Bouveng et al., 2017). When staff have

ample opportunity to take a lunch break by providing addi8onal support it can prevent harmful

outcomes (Simpkins et al., 2016). A nurse must have awareness of how not taking adequate breaks

can affect pa8ent care and seek out strategies to help create the best outcomes for their pa8ents

(Bouveng et al., 2017).

Expected Outcomes (Sec2on III)

Staff sa8sfac8on will be improved, therefore decreasing the incidence of RN burnout. This can be

tracked using ques8onnaires for staff to fill out prior to implementa8on and then again at the end of

the 8 weeks and comparing data collected. By receiving their lunch break nurses are at lower risk for

burnout and fa8gue they func8on at a higher level and are at lower risk for cogni8ve fa8gue (GiDins

et al., 2020). Cogni8ve fa8gue can result in missed care, falls with injury, or medica8on errors (GiDins

et al., 2020). Therefore, the MSN project will impact the healthcare environment by contribu8ng to a

culture of safe, high-quality, person-centered care.

19 Ac2on Plan-Iden2fy Cri2cal Milestones and Tasks. List them below:

1. Provide educa8on to HTC staff regarding implementa8on of strategies to assure they are able to

take a 30-minute uninterrupted lunch break, including team nursing.

2. Pre-survey distributed, and data analyzed.

3.Team nursing implemented allowing staff to take adequate lunch breaks

4. Post survey distributed, and results analyzed

EBP Model ( Sec2on IV: Include your summary of your Module 3 assignment, in your manuscript

you will want to include the en2re assignment)

Applica8on of the John Hopkins Model to the PICOT ques8on above can help to guide, inform, and

support the evidenced-based prac8ce quality improvement project (Friesen et al., 2017). Applying

the first phase of the model, prac8ce ques8on, can help to determine team members that will be

involved and how educa8on on implementa8on will be disbursed to these members (Melnyk et al.,

2017). The team members iden8fied are Hematology and Transplant staff nurses and the educa8on

will be given to them regarding team nursing during the monthly team mee8ng. Another example of

how the John Hopkins model can support the clinical ques8on is during the transla8on phase when

an ac8on plan is implemented and outcomes evaluated (Melnyk et al., 2017). From the PICOT

ques8on the ac8on plan will be to implement team nursing to ensure each staff member receive an

uninterrupted lunch break. Before and aPer the implementa8on of the ac8on plan a survey will be

given to the staff regarding burnout and fa8gue. Based on those results outcomes of the ac8on plan

can be evaluated then best prac8ces can be iden8fied. Applying the John Hopkins Model to a clinical

prac8ce ques8on can encourage best prac8ces and improvements to be iden8fied and implemented

to support safe, quality, and person-centered care.

20

Appendix B

Full reference for ar2cle, including publica2on date

Popula8on t a r g e t e d a n d number of par8cipant s

Interven8o n of area of interest

S t u d y m e t h o d u s e d b y a u t h o r / authors

Summ ary of t h e finding s

Conclusions Themes S i m i l a r i 8 e s a n d differences between other studies

21 W e n d s c h e , J . ,

G h a d i r i , A . , Bengsch, A., & W e g g e , J . (2017, July 14). A nte ce d e nt s and outcomes of nurses' rest b r e a k organiza5on: A s c o p i n g r e v i e w . Interna8onal J o u r n a l o f N u r s i n g S t u d i e s . h d p s : / / www.sciencedi r e c t . c o m / s c i e n c e / a r 8 c l e / p i i / S00207489173 01530.

A literature review of 3 6 publica8on s pertaining t o r e s t b r e a k organiza8o n a n d outcomes f rest break organiza8o n.

Rest break organiza8o n to ensure s t a ff r e c e i v e appropriat e meal and w o r k breaks.

T h e a u t h o r s u 8 l i z e d A r k s e y a n d O’Malley’s framewor k t o conduct a s c o p i n g literature review

Severa l studies s h o w t h a t tempo ral and quan8 t a 8 v e w o r k deman d s , s t a ff resour c e s , a n d unplan n e d t a s k s influen ce rest b r e a k

L i t e r a t u r e supports the co rre l a8 o n b e t w e e n p a 8 e n t o u t c o m e s a n d s t a ff sa8sfac8on. But there is a l a c k o f literature on mechanisms to produce these breaks.

R e s t b re a ks improv e nurse wellbei ng and behavio r posi8ve ly

S i m i l a r i 8 e s : re st breaks improve staff sa8sfac8on.

D i ff e r e n c e s : describes a lack of l iterature on the topic.

22 Min, A., Yoon, Y. S.,

Hong, H. C., & K i m , Y. M . (2019, August 1 9 ) . A s s o c i a 5 o n b e t w e e n nurses' breaks, missed nursing c a r e a n d pa5ent safety i n K o r e a n h o s p i t a l s . Wiley Online L i b r a r y . h d p s : / / onlinelibrary.w iley.com/doi/ abs/10.1111/ jonm.12831.

399 nurses in Korean hospitals

E x a m i n e t h e rela8onshi p between a d e q u a t e breaks and m i s s e d p a 8 e n t c a r e f o r nurses.

A c ro s s - sec8onal o n l i n e s u r v e y u s i n g a l i n e a r regression to explore t h e associa8o n between b r e a k s a n d p a 8 e n t safety

M o s t nurse’s averag e d a 1 5 m i n u t e b r e a k during t h e i r s h i P . V e r y f e w h a d t h e adequ ate 30 m i n u t e break. M i s s e d nursin g care was a mediat o r betwe e n

L e n g t h o f breaks has an indirect i m p a c t o n m i s s i n g nursing care. Examples of missed care i n c l u d e p a 8 e n t s a f e t y , med i ca8 o n errors, and f a l l w i t h injury.

Sufficie n t b re a ks should b e o f t h e upmost concer n d u e to their e ff e c t o n pa8ent safety.

S imi lar i8es: Staff breaks and lack of can impact pa8ent outcomes nega8vely.

Differences: Ar8cle site falls with injury can result.

23 Cordoza, M., Ulrich,

R. S., Manulik, B. J., Gardiner, S . K . , Fitzpatrick, P. S., Hazen, T. M., … Perkins, R. S. (2018, November 1). I m p a c t o f Nurses Taking D a i l y W o r k Breaks in a H o s p i t a l G a r d e n o n B u r n o u t . A m e r i c a n J o u r n a l o f Cri8cal Care. h d p s : / / aacnjournals.o rg/ajcconline/ a r 8 c l e / 27/6/508/411 1/Impact-of- Nurses-Taking-

29 nurses o ve r a 6 w e e k period.

N u r s e s i n v o l v e d were asked to take a 30 minute, uninterrupt e d l u n c h b r e a k i n the garden opposed to indoors for 6 weeks.

A crossover trail was conducted . T h e M a s l a c h B u r n o u t Inventory a n d P r e s e n t Func8onin g V i s u a l Analogue Scale was g i ve n at t h e beginning a n d e n d of the 6 w e e k period.

T h e r e was a signific a n t improv ement i n e m o 8 o n a l exhaus 8 o n , depers onaliza 8 o n , a n d person a l accom plishm ent.

W o r k uninterrupte d, adequate, o u t d o o r breaks can help reduce t h e incidence of burnout in nurses.

Burnou t h a s b e e n associat ed with medica 8 o n errors, h i g h turnove r rates, a n d posdra u m a8 c stress.

Similari8es: Nurse b u r n o u t c a n b e linked to medica8on e r r o r s a n d h i g h turnover rates.

D i ff e r e n c e s : Depersonal iza8on c a n o c c u r w h e n nurses are unable to take breaks

Roth, E. (2019, July 2 ) . A Mul5faceted Approach to D e c r e a s i n g Burnout and I n c r e a s i n g S t a ff Engagement in Adult Cri5cal Care . Nurse L e a d e r . h d p s : / / www.sciencedi r e c t . c o m / s c i e n c e / a r 8 c l e / p i i / S15414612193 01144.

T a r g e t popula8on was nurses on 3 adult cri8cal care departmen t s . 1 3 1 n u r s e s completed t h e p r e - survey and 1 0 8 completed the post- survey.

F i r s t interven8o n w a s implemen8 n g t h e S p i r i t o f C a r i n g c o u r s e ( R S C ) . S e c o n d interven8o n w a s refl e c 8 o n r o u n d s w e r e conducted o n t h e u n i t s . Third, an increased e m p h a s i s was placed o n emo8onal s u p p o r t

M a s l a c h B u r n o u t Inventory and Areas o f Wo r k L i f e S u r v e y w e r e administer ed for a p re / p o st survey.

F r o m t h e interve n8ons applie d 88% would recom m e n d t h e R S C course . 100% bel iev e d reflec8 o n rounds encour a g e d s t a ff e n ga g ement .

T h e interven8ons resulted in a n improvemen t o f t h e o v e r a l l h e a l t h f u l c u l t u r e o f t h e u n i t s t h a t implemented them. From this study, r e fl e c 8 o n r o u n d s s h o u l d b e u 8 l i z e d i n units where p a 8 e n t d e a t h occurs.

Nurses n e e d 8me to d e c o m p r e s s a n d process when a pa8ent dies on t h e u n i t . Strategi e s should b e implem e n t e d t o provide addi8o n a l support d u r i n g t h e s e

Similari8es: Nurses n e e d 8 m e t o d e c o m p r e s s a n d p r o c e s s w h e n trauma8c situa8ons occur on the unit.

24 Hulsegg, G., Loef, B.,

Benda, T., van der Beek, A., & P r o p e r , K . (2020). ShiL work and its rela5on with m e a l a n d snack paMerns a m o n g h e a l t h c a r e w o r k e r s . Scandinavian j o u r n a l o f w o r k , environment & h e a l t h . h d p s : / / pubmed.ncbi.n l m . n i h . g o v / 31046127/.

611 nurses ages 28-31.

N u r s e s were asked t o complete a food diary f o r 3 consecu8v e days >1 work days and 1 work free day.

Covariates w e r e measured b y standardiz e d ques8onn a i r e s ’ . L i n e a r regression a n a l y s e s w e r e u8lized to determine number of meals and quality of meals.

Nurses in the s t u d y c o n s u m e d m o r e snacks during w o r k d a y s t h a n w o r k f r e e d a y s . O n w o r k d a y s m a n y nurses stated t h e y d i d n o t have a m e a l b r e a k j u s t s n a c k breaks oppos e d to w o r k f r e e d a y s w h e n a meal w a s taken.

F r o m t h i s study it was determined that further interven8ons needs to be implemented t o e n s u r e staff feel able t o t a k e a meal break during their shiP.

Nurses f e e l t h e y a r e unable to take a meal b r e a k d u r i n g t h e i r s h i P a n d instead s n a c k through o u t w h e n able.

Similari8es: Further interven8ons need to be implemented to ensure nurses take meal breaks.

Differences:

T h e w o r k p l a c e culture plays a role in staff feeling they are unable to take a break.

25 Monaghan, T. , &

D i n o u r , L . (2017). Factors Influencing the E a 5 n g P r a c 5 ce s o f H o s p i t a l Nurses During Their ShiLs - T i n a M o n a g h a n , Lauren Dinour, Doreen Liou, M e l a n i e Shefchik, 2018. SAGE Journals. h d p s : / / journals.sagep ub.com/doi/ 10.1177/2165 079917737557 .

20 nurses in a New J e r s e y H o s p i t a l that have b e e n a nurse for at l e a s t 1 year.

Inter v iew t h e 2 0 n u r s e s regard ing factors that i n fl u e n c e their ea8ng p r a c 8 c e s d u r i n g their shiPs.

A n interview o f 3 3 s e m i - structured ques8ons w a s conducted v i a telephone , v i d e o chat, or in person.

4 theme s emerg e d f r o m t h e s t u d y t h a t influen c e t h e i r ea8ng prac8c e s : u n p re dictabi lity of worklo a d , pa8en t care a priorit y over s e l f - c a r e , c o n s u m i n g w h a t i s availab l e quickly ,

A d d i 8 o n a l s u p p o r t i s needed by management t h r o u g h s t a ffi n g , c o v e r a g e , a n d educa8on to ensure staff rece ive an appropriate meal break.

Addi8o n a l strategi es need t o b e implem e n t e d at the manage m e n t level to ensure s t a ff a r e able to take an approp r i a t e m e a l b r e a k d u r i n g t h e i r shiP.

S i m i l a r i 8 e s : Strategies need to be i m p l e m e n t e d t o ensure staff are able to take appropriate meal breaks.

Differences:

Strategies should be implemented at the management level.

26 Allan, J. L., Johnston,

D. W., Powell, D . J . H . , Farquharson, B., Jones, M. C., Leckie, G., & Johnston, M. (2019, April). C l i n i c a l decisions and 5me since rest b r e a k : A n a n a l y s i s o f d e c i s i o n f a 5 g u e i n nurses. Health psychology : official journal of the Division o f H e a l t h P s y c h o l o g y, A m e r i c a n Psychological A s s o c i a 8 o n . h d p s : / / www.ncbi.nlm. n i h . g o v /

150 nurses at NSH

T o inves8gate i f n u rs e s suffer from d e c i s i o n fa8gue due to lack of a d e q u a t e r e s t a n d m e a l breaks.

A n observa8o n a l , repeated- measures study was conducted from 4000 c a l l s worth of data.

F o r e v e r y c a l l t a k e n s i n c e l a s t b r e a k t h e o d d s of the n u r s e sufferi n g f r o m decisio n fa8gue increas ed by 5.5%.

D e c i s i o n s nurses are m a k i n g further from t h e i r l a s t b r e a k b e c o m e m o r e conserva8ve a n d l e s s r e s o u r c e - efficient.

Cogni8 v e fa8gue i s experie n c e d w h e n n u rs e s a r e unable to take adequa t e b re a ks through o u t t h e i r shiP.

Similari8es: Decision making is effected w h e n s t a ff a r e u n a b l e t o t a k e breaks.

D i ff e r e n c e s : Cogni8ve fa8gue can occur.

Scammell, J. (2018, May 11). Do you take your breaks? How to influence change in the w o r k p l a c e . Bri8sh Journal o f N u r s i n g . h d p s : / / www.magonlin elibrary.com/ d o i / a b s / 1 0 . 1 2 9 6 8 / bjon.2018.27.9 .514.

N u r s e managers t o implement strategy to encourage s t a ff t o t a k e a d e q u a t e m e a l breaks.

Implement a 8 o n o f r e s t , rehydrate, and refuel ini8a8ve by the Royal College of Nursing

E x t e r n a l a n d i n t e r n a l f a c t o r s t h a t influenced m e a l b r e a k s w e r e t a k e n using the P E S T L E tool

T h e r e w e r e poli8c a l , econo m i c , social, techno logical, l e g a l , a n d enviro nment a l factors influen c i n g m e a l breaks

N u r s e m a n a g e r m u s t b e a w a r e o f these factors a n d i m p l e m e n t strategies to c o m b a t them so staff are able to t a k e a d e q u a t e breaks.

Workpl a c e culture has had a n impact o n n u rs e s n o t takin g m e a l breaks.

S i m i l a r i 8 e s : Workplace culture has an impact on nurses feeling that they are able to take meal breaks.

Differences: Rest, rehydrate, refuel ini8a8ve

27 Barrientos-Trigo, S.,

Vega-Vázquez, L . , D i e g o - Cordero, R. D., B a d a n t a - Romero, B., & Porcel-Gálvez, A. M. (2018, January 11). Interven5ons t o i m p r o v e w o r k i n g condi5ons of nursing staff in a c u t e c a r e h o s p i t a l s : S c o p i n g review. Wiley Online Library. h d p s : / / onlinelibrary.w iley.com/doi/ full/10.1111/ jonm.12538.

Registered N u r s e Forecas8ng p r o j e c t i d e n8 fi e d t h a t b u r n o u t , j o b dissa8sfac8 on have a n e g a 8 v e impact on p a 8 e n t outcomes. Study used to iden8fy interven8o ns that can b e implement e d t o c o m b a t these.

Interven8o n s w e r e a n a l y z e d f r o m s t u d i e s that can be implement e d t o d e c r e a s e b u r n o u t a n d j o b dissa8sfac8 on.

A scoping review of 7 0 5 papers. 21 p a p e r s were then analyzed.

Interve n8ons can be applie d a t t h e macro manag ement l e v e l , m e s o manag ement l e v e l , a n d m i c r o manag ement l e v e l . Interve n8ons on the macro a n d m e s o l e v e l t e n d t o produc e beder

Pa8ent-nurse ra8o has the g r e a t e s t i m p a c t o n burnout and j o b sa8sfac8on.

Nurse- pa8ent r a 8 o s c a n have an impact o n a b i l i t y to take adequa t e breaks.

Similari8es: Nurse- pa8ent ra8os effect nurses ability to take breaks

D i ff e r e n c e s : Interven8ons on the macro management l e v e l h a v e t h e greatest impact on allowing staff to take breaks.

28 Skinner, N., Dijk, P. V.

van, Stothard, C., & Fein, E. C. (2018, January 1). "It breaks your soul": An i n - d e p t h explora5on of w o r k p l a c e i n j u s 5 c e i n n u r s i n g : S e m a n 5 c S c h o l a r . u n d e fi n e d . h d p s : / / www.seman8c s c h o l a r. o rg / p a p e r / %E2%80%9CIt- breaks-your- soul%E2%80% 9 D % 3 A - A n - in%E2%80%90 d e p t h - explora8on-of- Skinner-Dijk/ f1325e4b6b8d

24 nurses w o r k i n g full 8me in t h e Australian N u r s e s Union.

Inter v iew nurses to get an idea o f t h e i r experience w i t h workplace injus8ce.

A qualita8ve study was conducted with semi- structured interviews . That data col lected w a s a n a l yze d u s i n g c o n t e n t analysis.

W h e n nurses percei v e d injus8c e o r unfa ir n e s s t h e i r perfor mance w a s nega8 v e l y impact ed.

T h i s s t u d y can help to d e t e r m i n e what nurses perceive as injus8ce or unfairness.

Nurses see the inability to take a n adequa t e b r e a k d u r i n g t h e i r shiP as u n j u s t a n d u n f a i r becaus e they l e ga l l y should be able to.

Similari8es: Nurses have a legal right to take an adequate meal break.

Differences: Nurses view the inability to t a ke a b r e a k a s unjust and unfair.

Binks, H., Vincent, G. E., Irwin, C., H e i d k e , P. , Vandelanode, C., Williams, S. L., & Khalesi, S. (2020, August 1 5 ) . A s s o c i a 5 o n s between sleep and lifestyle b e h a v i o u r s a m o n g A u s t r a l i a n n u r s i n g s t u d e n t s : A cross-sec5onal s t u d y . C o l l e g i a n . h d p s : / / www.sciencedi r e c t . c o m / s c i e n c e / ar8cle/abs/pii/ S13227696203 00342.

4 7 0 n u r s i n g students in Australia

Ques8onna i r e t h a t a s s e s s e d sleep and l i f e s t y l e behaviors

C r o s s - sec8onal d e s i g n , m u l 8 p l e regression t e s 8 n g u s e d t o determine rela8onshi p s b e t w e e n variables

Inadeq u a t e s l e e p follow ed by irregul a r ea8ng habits w e r e m o s t stated finding s . Irregul a r l u n c h intake was a contr i bu8ng variabl e t o t h e s e finding

From these fi n d i n g s , s t r a t e g i e s need to be implemented to address t h e inadequate s l e e p a n d e a 8 n g behaviors

P o o r lifestyle behavio r s include infrequ e n t l u n c h b re a ks a n d p o o r nutri8o n a l habits.

Inf requent lunch i n t a ke h a s b e e n associated with bad s leep habits and p o o r l i f e s t y l e choices.

29 Johannes Wendsche,

W. H. (2017). Understaffing and registered n u r s e s ' turnover: The m o d e r a 5 n g role of regular rest breaks - J o h a n n e s W e n d s c h e , W i n f r i e d Hacker, Jürgen Wegge, 2017. SAGE Journals. h d p s : / / journals.sagep ub.com/doi/ a b s / 10.1177/2397

80 German g e r i a t r i c n u r s i n g teams

A n n u a l t u r n o v e r r a t e s , s t a ffi n g r a 8 o s , produc8vit y r a t e s assessed

C ro s s - s e c 8 o n a l , m u l 8 - m e t h o d study design

Correla8 o n between understa ffing and posi8vel y predicte d turnover

W o r k condi8ons a n d i r r e g u l a r rests breaks h a v e a n impact on t u r n o v e r rates

Impleme n t a 8 o n o f regularly schedule d r e s t b r e a k s c a n improve reten8on of nurses

Understa ffing can contribut e t o inab i l i ty t o t a k e b r e a k s . Inab i l i ty t o t a k e b r e a k s can result i n h i g h s t a ff turnover

H u a n g , B . , Cu l tbertson, A., Connor, T., & Looker, S. ( 2 0 1 7 ) . A l t e r n a 5 v e O u t p a 5 e n t Chemotherapy S c h e d u l i n g M e t h o d t o I m p r o v e Pa5ent Service Q u a l i t y a n d N u r s e S a 5 s fa c 5 o n . J o u r n a l o f o n c o l o g y p r a c 8 c e . h d p s : / / pubmed.ncbi.n

M u l 8 p l e p r a c 8 c e s e R n g s w i t h i n a s p e c i fi e d healthcare system

A n a l y z e d e x i s 8 n g manageme nt models on units

Alternate model was app l ied to o u t p a 8 e n t chemotherapy unit

The new m o d e l reduced s t a ffi n g viola8on s b y a l m o s t 5 0 % . Nursing sa8sfac8 on was increase d.

U8lizing a n u r s i n g r e s o u r c e can balance w o r k l o a d a n d i m p r o v e s p a 8 e n t s e r v i c e quality and s t a ff sa8sfac8on

A resource n u r s e c a n b e u 8 l i z e d to allow staff to t a k e appropri a t e breaks

Assuring staff are a b l e t o t a k e appropria te breaks c a n increase s t a ff sa8sfac8o n a n d i m p ro v e s t a ff turnover.

Youssef, A., & Senbel, S. (2018). A Bi- level heuris5c solu5on for the n u r s e s c h e d u l i n g problem based o n s h i L - swapping. IEEE X p l o r e . h d p s : / / ieeexplore.iee e.org/abstract/ d o c u m e n t / 8301623.

Implement a8on of a solu8on to the nurse scheduling problem

A p p l y i n g s h i P s wa p p i n g to sa8sfy the nurse scheduling problem

Simula8on created to demonstrate implementa8on of solu8on

Solu8on sa8sfies b o t h h a r d and soP constrai nts

Implemen8 n g t h e solu8on to t h e s imula8on d i d demonstrat e a sa8sfactory outcome

N u r s e s b e l i e v e they are n o t b e i n g t r e a t e d fair when they are n o t guarante e d breaks

S h i P swapping c a n a s s u r e staff are a b l e t o t a k e appropria te breaks

30

Appendix C

1. Complete the following activities to ensure successful translation:

31

⬛ Secure a project leader.

⬛ Identify change champions.

⬛ Consider whether translation activities require different or additional members.

⬛ Schedule time to complete milestones.

⬛ Identify critical milestones and related tasks.

⬛ Identify observable pre or post measures.

2. Identify barriers to the success of the change, and then identify strengths that can be leveraged to overcome barriers.

Barriers Resources or Strengths Plan to Overcome Barriers by

Leveraging Strengths as Appropriate

Inability to find patient coverage High level of teamwork, float pool staff Implementation of team nursing, utilization of float pool staff to aid in lunch coverage

Time management of nurses to be able to take full 30-minute break

High level of teamwork, float pool staff Implementation of team nursing, utilization of float pool staff to aid in lunch coverage

Staffing shortages Float pool staff Utilization of additional staff from the float pool to act as resource staff to encourage staff to take lunch breaks

Nurses not willing to take full break In-service prior to implementation of project

In-service can highlight importance of staff taking appropriate breaks

Nurses wanting to receive pay instead of taking unpaid lunch

Hematology and Transplant Manager The Hematology and Transplant is highly motivated to cut down to nurses clocking out that they did not take a lunch including a required reason for why they are clocking out that way.

3. Consider whether or how this change will affect the following:

☐Electronic health record ⬛ Workflow ⬛ Policies and/or procedures

4. Confirm support and/or availability of funds to cover expenses. (Check all that apply)

☐ Personnel costs

☐ Supplies/equipment

☐ Technology

☐Photocopying

☐ Education or further training

☐ Content or external experts

⬛ Dissemination costs (conference costs,

travel)

☐ Other: Enter test

32

5. Identify critical milestones and related tasks:

Pre-survey In-service on Quality Improvement Project

Data collection Post-survey

Ta sk s

Pre-survey conducted by 35 nurses on the Hematology and Transplant Clinic

Inservice provided prior to implantation of project

Meet with Hematology and Transplant Manager weekly to get time sheets

Post survey completed week 5 of project implementation

Findings of Pre-survey analyzed Importance of staff taking 30-minute uninterrupted lunch breaks provided.

Disseminate findings of timesheets to determine rate of nurses inputting they received a 30-minute uninterrupted lunch break

Finding of post survey analyzed

Incidence of burnout and fatigue identified among staff

Explanation of team nursing provided

Task Incidence of burnout and fatigue identified among staff

Staff satisfaction determined Collaboration with Float Pool Manager to determine availability of resource nurse to cover lunches

Task Staff satisfaction determined

Collaboration with Director of Evidence-Based Practice and Hematology and Transplant Clinic Manager

Task Task Collaboration with Director of Evidence Based Practice and Manger of the Hematology and Transplant Clinic

33

Appendix D

Action Plan Milestone/Task

Resources Needed Forecasted Cost Source of Funding

Additional Staff to provide lunch breaks to staff

Float pool staff Additional cost to have float pool staff come break nurses for their lunch break

Float pool staff resources

Team nursing Plan implemented to ensure team nursing is carried out when able

No additional cost n/a

Additional Staff from Hematology and Transplant Clinic

HTC staff Additional staff member will be an additional FTE

HTC staff resources

34 Appendix E

Pre-Survey/ Post-Survey

Please rate the following responses to the best of your ability on the scale provided by circling your response.

In the past 30 days I have experienced fatigue

Agree Somewhat Agree Neutral Somewhat Disagree Disagree

In the past 30 days I have experienced nurse burnout

Agree Somewhat Agree Neutral Somewhat Disagree Disagree

I am overall satisfied working on the Hematology and Transplant Clinic

Agree Somewhat Agree Neutral Somewhat Disagree Disagree

I am consistently able to take a 30-mintue uninterrupted lunch break during shifts

Agree Somewhat Agree Neutral Somewhat Disagree Disagree

35 Figures

Figure 1

Figure 2

Figure 3

36

Figure 4.