MANUSCRIPT PART VI

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,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).

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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 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

The literature review that follows discusses evidence-based practices to minimize burnout in nursing staff. A systematic search was conducted on databases such as PubMed, CINAHL, and PsycINFO using keywords such as "nursing burnout," "relaxation techniques," and "educational interventions." The search was filtered for peer-reviewed articles from 2021 to 2025.

Burnout Prevalence

Current studies have reconfirmed that burnout remains a critical issue among nursing professionals. Han & Yeun's (2023) systematic review identifies nurses' burnout levels as 35% to 55%, depending on healthcare settings and work pressure. The study observes that stress extends emotional exhaustion, depersonalization, and decreased personal accomplishment, finally impacting patient care outcomes.

Educational Interventions

Education programs and training sessions have been shown to enhance nurses' coping strategies and awareness. Burleson et al. (2023) reviewed a scoping study that identified cognitive-behavioral training and education through peer support as effective interventions. The review revealed that formal education sessions not only enhanced nurses' knowledge regarding burnout but also helped reduce symptoms of stress.

Relaxation Techniques

Meditation, mindfulness-based stress reduction (MBSR), and progressive muscle relaxation (PMR) have effectively reduced burnout symptoms in healthcare workers. Wong et al. (2024), conducting a systematic review of randomized controlled trials, identified that nurses undergoing relaxation training experiences showed significant psychological well-being and job satisfaction improvement. The interventions also positively affected cortisol levels as well as sleeping habits.

Outcome Measurement

Quantifying the performance of burnout interventions is necessary for validation and further development. A systematic review by Lee & Cha (2023) assessed various intervention results based on pre- and post-intervention questionnaire surveys. Their findings showed evidence of intervention impacts through programs that measured self-reported stress levels, heart rate variability, and burnout scales. The review emphasizes the need for long-term follow-ups so benefits will be maintained.

Synthesis of Evidence

The evidence from the literature is overwhelmingly in favor of using educational interventions and relaxation strategies to minimize burnout in nurses. Cognitive-behavioral training and peer education efficiently increase awareness and knowledge, while mindfulness-based approaches such as guided meditation and progressive muscle relaxation reduce stress levels and improve well-being. Based on available evidence, using these interventions to inform nursing practice will likely yield beneficial effects in workforce maintenance and patient care quality.

Proposed 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 implementing a 30-minute uninterrupted lunch break

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.

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

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 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 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 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 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.

Introduction to Model

“The Johns Hopkins Nursing Evidence-Based Practice Model (JHNEBP) is the guiding model for the practicum project and practice change. The model provides high-quality patient care through a systematic process of integrating evidence-based practice in clinical decision making (Dang et al., 2021). It works best in addressing problems in healthcare institutions by enabling nurses to go through a guided process of finding, evaluating, and implementing evidence-based solutions.

“The three elements of the JHNEBP Model are practice, evidence, and translation.” The practice element is drawn from solving a problem or a clinical question that requires a solution. The evidence element deals with the collection, critique, and synthesis of best available research and non-research evidence (Brunt & Morris, 2023). The translation element implements the evidence and evaluates the outcomes of the change.

It has a methodical nineteen-step process that evolves in three stages. The practice question stage begins with organizing an interprofessional team, developing the practice question, and making a search plan. The evidence stage involves searching for the relevant literature, “its strength and quality critique, summarizing findings, and establishing evidence-based recommendations” (Dang et al., 2021). The translation stage determines whether the change is ready to be implemented, complete an action plan, secure organizational endorsement, implement the change, evaluate outcomes, report outcomes, establish next steps, disseminate findings, implement the practice change, sustain it in the long term, and conduct periodic re-assessments.

Use of Model to Support Project

The “JHNEBP Model” was the model used for the nurse burnout project that aimed to reduce fatigue and enhance nurse satisfaction through the implementation of a 30-minute unbreakable lunch break. “In the practice phase, the project team set the issue of nurse burnout in the hematology and transplant clinic and formulated the PICOT question, where the question was whether an unbreakable lunch break would decrease nurse burnout and fatigue for four weeks.”

The process of translation involved the use of evidence-based change. The action plan included staff education, utilization of team nursing practices, and collection of data using pre- and post-surveys. Support was received from “unit managers and the director of evidence-based practice to ensure easy implementation.” The efficacy of the project was measured using nurse fatigue and burnout levels before and after the intervention. Results were internally reported to clinic staff and externally to nursing students to emphasize the importance of organized breaks in avoiding burnout.

Implementation

Implementation of the project is a significant process to achieve evidence-based practice to clinical change. As per the evaluation of the evidence, the practice recommendation of the project is implementing a “30-minute uninterrupted lunch break for nurses in the hematology and transplant clinic to reduce burnout and fatigue.” Implementation process is directed through “the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) Model” and is made up of a series of organized steps (Brunt & Morris, 2023).

Phase one involves the formation of an interprofessional team that includes nursing staff, the unit manager, and a float pool representative. Once the team is formed, an in-service educational session will be conducted to introduce the project, highlight break periods' importance, and present the benefits to staff health and patient care (Liu et al., 2021). Following training, the intervention will be implemented by booking uninterrupted lunch breaks through the use of a team nursing approach. Rotating responsibility for coverage will be assigned to staff to allow all nurses to have their allotted break without compromising patient care. Weekly Nurse Timesheets will be checked to ensure compliance.

Feasibility and organizational appropriateness are facilitated through matching the intervention with existing staffing models and securing leadership support. Resources include educational materials, time-tracking software, and administrative resources. The project will be piloted over a four-week duration with pre- and post-survey assessments of burnout levels. Continuous feedback will be obtained to overcome challenges and customize the approach.

References

Brunt, B. A., & Morris, M. M. (2023). Nursing professional development evidence-based practice. In  StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK589676/

Dang, D., Dearholt, S. L., Bissett, K., Ascenzi, J., & Whalen, M. (2021).  Johns Hopkins evidence-based practice for nurses and healthcare professionals: Model and guidelines. Sigma Theta Tau. https://books.google.com/books?hl=en&lr=&id=m4k4EAAAQBAJ&oi=fnd&pg=PP1&dq=Johns+Hopkins+Nursing+Evidence-Based+Practice+(JHNEBP)+Model&ots=pVMsCJwdB8&sig=lTz2VpF081o1Qu7Mv1HQLmljMoI

Burleson, S., Thomas, L., & DeBoor, S. (2023). Effective interventions for nursing student burnout: a scoping review.  Nurse Educator,  48(3), E85-E89. https://journals.lww.com/nurseeducatoronline/fulltext/2023/05000/effective_interventions_for_nursing_student.25.aspx

Han, S. J., & Yeun, Y. R. (2023, December). Psychological intervention to promote resilience in nurses: A systematic review and meta-analysis. In  Healthcare (Vol. 12, No. 1, p. 73). MDPI. https://www.mdpi.com/2227-9032/12/1/73

Lee, M., & Cha, C. (2023). Interventions to reduce burnout among clinical nurses: systematic review and meta-analysis.  Scientific Reports,  13(1), 10971. https://www.nature.com/articles/s41598-023-38169-8.pdf

Liu, M., Lin, Y., Dai, Y., Deng, Y., Chun, X., Lv, Y., ... & He, F. (2021). A multi-dimensional EBP educational program to improve evidence-based practice and critical thinking of hospital-based nurses: development, implementation, and preliminary outcomes.  Nurse Education in Practice,  52, 102964. https://www.sciencedirect.com/science/article/pii/S1471595320310507

Wong, K. W., Wu, X., & Dong, Y. (2024). Interventions to reduce burnout and improve the mental health of nurses during the COVID‐19 pandemic: A systematic review of randomized controlled trials with meta‐analysis.  International journal of mental health nursing,  33(2), 324-343. https://onlinelibrary.wiley.com/doi/abs/10.1111/inm.13251

Appendices, Tables, and Figures

Appendix A: John Hopkins Action Planning Tool

Appendix B: Financial Table

Appendix C: Pre- and Post-Intervention Survey

Appendix D: Consent Form

Tables

Finance Table

Budget