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Section 1: Nature of the Project
Work stress is a key issue that nurses have to manage in their work environment.
There is a need for education and prevention of work stress in the psychiatric nurse
population based on personal experience, observation of staff in the practice setting, and
review of current literature. Psychiatric nurses are at risk of developing high levels of
stress that affect their interpersonal relationships, job satisfaction, and quality of patient
care (Bang & Park, 2016). The purpose of the project was to design, implement, and
evaluate a stress management educational program focusing on work stress among
practicing psychiatric nurses to assist them in decreasing stress and absenteeism. The
goal of this project was to encourage a culture of awareness and mindfulness about work
stress in order to promote health/well-being and decrease absenteeism, which have a
significant effect on productivity and the quality of patient care (Bang & Park, 2016;
Tabaj, Pastirk, Bitenc, & Masten, 2015). The potential positive social change
implications were to strengthen the psychiatric nursing workforce at the local institution.
Social change benefits may also include creating more effective health care policies that
will help nurses to be more mindful/self-aware, increase their ability to avoid work stress,
and improve the overall quality of care provided by psychiatric nurses. Section 1 presents
the problem statement, purpose, nature of the doctoral study, significance of the project,
and summary.
Problem Statement
The local nursing practice problem that was the focus of this doctoral project
involved psychiatric nurses creating nonspecific unsuccessful coping strategies to
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manage their stress in the absence of a stress management program. Factors that
contribute to stress at the project site include high workload, staff shortages, poor
working environment, lack of support and motivation from supervisors and managers,
conflicts among treatment team members, aggressive and violent patients, and shortened
or lack of lunch breaks. Nurses at the project site are frequently absent from work due to
stress related to work, which negatively impacts patient care. When nurses are exposed to
a high level of job stress, it may lead to poor quality of patient care that can result in
lower job satisfaction, increased turnover, and reduced quality of care (Bang & Park,
2016). The significance of this project to the field of psychiatric nursing was
demonstrated at the project site by providing psychiatric nurses with a stress management
education program that was specific to their practice needs.
Local Relevance
Psychiatric nurses at the project site experience increased levels of stress without
any resource or system in place to help them manage stress. According to the assistant
director of nursing (personal communication, April 4, 2017), the facility does not have an
official process to support nurses in managing work stress. The lack of a recognized
stress management program had been reported in the Nursing Leadership Council
meeting by management staff members (SGHC, 2017). The assistant director of nursing
reported that the issue of stress management had been presented at senior management
meetings (personal communication, April 4, 2017). In a grand round presentation in
February 2017 (SGHC, 2017), the presenter acknowledged the levels of stress
experienced by psychiatric nurses and discussed an education plan for the prevention and
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management of work stress that could affect the nurses’ well-being (personal
communication, April 4, 2017). The unit manager explained that the prevention and
management of work stress education program has not been implemented at any level in
the facility (personal communication, April 4, 2017). The director of learning resources
indicated that nurse education is conducted annually, but the emphasis is on training
skills and mandatory competencies (personal communication, April 4, 2017).
Psychiatric nurses are frontline care providers, and if they are to do their jobs
effectively and efficiently, health organizations must address and support the delivery of
quality health care while protecting nurses from the effects of stress (Bang & Park, 2016).
The current levels of stress among nurses at the project site may result in reduced quality
of patient care services. Some of the potential benefits to the project site include reduced
stress levels for psychiatric nurses, increased nurse productivity, decreased rates of
absenteeism and turnover, increased workforce retention, and greater job satisfaction.
Enhanced role satisfaction may lead to the promotion of nurses’ behaviors that decrease
their levels of stress. Implementing evidence-based interventions to decrease work stress
through the development of an in-service educational program may affect positive social
change. Leadership may encourage the nurses to participate in the planned program to
decrease their stress in the work environment. Staff nurses and managers should be
encouraged to participate in such programs that may assist in building a stress-free work
environment in which nurses can perform their duties while providing high-quality care
to their patient population.
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Significance to Nursing Practice
Developing a stress management program for addressing work stress holds
significance for the field of nursing practice because the quality and performance of a
health care system are dependent on its workforce. Improving the working conditions for
psychiatric nurses may make the work more satisfying and increase the number of nurses
interested in psychiatric nursing. Through this project, nurses may be able to identify
coping strategies while working in inpatient psychiatric units. These strategies may
include social, emotional, and relaxation therapies that may help reduce tension from the
body and clear the mind, thereby improving the physical and mental health of the nurse
(Bowen, Edwards, Lingard, & Cattell, 2014).
In addition, nurses may learn how to manage conflicts with peers and other health
care professionals by using problem-solving strategies. Supervisors, on the other hand,
may learn how to use managerial strategies to improve work environments that may
increase job satisfaction and decrease absenteeism/turnover. Similarly, knowledge of
stress management can help nurse administrators create work environments that may
provide staff with access to opportunity, information, resources, and empowerment
(Bhui, Dinos, Galant-Miecznikowska, & de Jongh, 2016).
Purpose
Most research on work stress has focused on general nursing, but limited attention
has been paid to psychiatric nurses who are the largest professional group providing care
to patients in the field of mental health services (Mathew, Ram, Bhattacharjee,
Bhattacharjee, & Sharma, 2013). This current evidence-based project was designed to
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build on studies that address work stress among health care professionals (see McTiernan
& McDonald, 2015; Pereira et al., 2014; Tabaj et al., 2015; Wu et al., 2014). The goal of
this project was to decrease work stress and absenteeism among practicing psychiatric
nurses working in an inpatient mental health hospital and to develop an educational
program that would decrease stress and absenteeism. The purpose of the project was to
design, implement, and evaluate an educational program focusing on work stress among
psychiatric nurses. The implications for positive social change include minimizing stress
and improving stress management practices as well as promoting effective working
conditions that may prevent stress, enhance well-being, and decrease absenteeism.
Addressing employee stress and well-being may increase the overall health of the work
environment. In addition, positive psychological skills for work stress may have positive
spillover effects into the home, which may lead to increases in employees’ participation
in civic duties to improve social conditions.
Gap in Practice
The gap in practice was the lack of an educational program at the site or resources
to provide psychiatric nurses with stress management interventions to decrease stress.
These resources include person-focused interventions, organization-focused
interventions, and integrated stress-prevention initiatives such as mindfulness training,
meditation sessions, and peer support groups (Allen et al., 2015; Roberts, Grubb, &
Grosch, 2012). Information obtained from discussions with the admission unit managers,
long-term care units, research unit, adolescent unit, and geriatric unit at the project site
suggested that current methods for managing stress consist of nurses calling in sick and
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staying home for a number of days (Department of Nursing callout log, February, 2018).
Psychiatric patients require specialized nursing care, and nurses are expected to provide
continuous monitoring and support to these patients (Hasan, 2017). Psychiatric nurses
become tired and fatigued as they work in poor environments with increased workloads
and lack of motivation (Filgueira Martins Rodriguez, Pereira Santos, & Sousa, 2017;
Tabaj et al., 2015). Work stress is a major problem in today’s organization.
The literature showed that health care providers who deliver care to their
customers use multiple coping interventions when confronted with stressors in their
workplace. Research with health care providers such as nurses suggested stress
management interventions that target individuals and organizations (Bhui, Dinos,
Stansfeld, & White, 2012). These interventions can be categorized as preventive
interventions at primary, secondary, or tertiary levels (Bhui et al., 2012). Primary
interventions are used to prevent stress, secondary interventions are used to reduce the
severity of symptoms, and tertiary interventions are used to provide treatment and
maximize functioning among those with chronic health conditions (Bhui et al., 2012).
Individual interventions may include stress awareness training and cognitive behavioral
therapy for psychological and emotional stress. Some interventions aim at both the
individual and the organization, for example policies to secure an improved work–life
balance and peer support groups.
Practice-Focused Question
In this project, I developed, implemented, and evaluated an educational program
that would provide strategies to decrease stress among practicing psychiatric nurses. The
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practice-focused question guiding this project was the following: Can an evidence-based
stress management education program decrease stress and absenteeism among practicing
psychiatric nurses at the project site? To determine whether the intervention was
successful, I used the Perceived Stress Scale (PSS) as a pre- and posttest, and
retrospective and prospective data were collected on absenteeism.
Addressing the Practice Gap
When staff work an excessive amount of overtime, low feelings of satisfaction
and a lack of staff stress management resources can directly affect patient care, safety,
outcomes, and satisfaction (Hasan, 2017; Mazurenko, Gupte, & Shan, 2015; Sarafis et al.,
2016). The current practice of frequent absenteeism at the project site has been discussed
by senior leadership. Nurses are trained to care for other people with less emphasis on
their own health and well-being. Because nurses are an integral part of the health team,
care should be taken to ensure their well-being, including the identification of stress and
the promotion of healthy coping strategies. The evidence-based project may address the
gap in practice by synthesizing, developing, and formalizing the implementation of an
educational program that may help practicing psychiatric nurses reduce their stress. The
outcome of this DNP project may fill a gap in practice by providing an educational
program that can inform psychiatric nurses about work stress and decreasing
absenteeism. By learning interventions to decrease work-related stress, psychiatric nurses
may decrease their stress levels and improve the quality of care they provide to patients
and their families. Leadership at the facility may use the evidence and recommendations
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to develop nursing and health care policies to improve the psychiatric nurses’ abilities to
manage workplace stressors.
Nature of the Doctoral Project
The sources of evidence that were used to support and address the purpose of this
doctoral project
were obtained by
synthesizing nursing literature from the Cochrane
Library, National Guideline Clearinghouse, and the Joanna Briggs Institute EBP
Database for EBP Research. The Cochrane database can be used to identify and retrieve
systematic reviews and meta-analyses. Informative resources were also accessed from the
Walden University Center for Research Quality website, nursing white papers, and
textbooks that contain current evidence-based information on work stress. In addition,
Walden University databases such as the Cumulative Index of Nursing and Allied Health
(CINAHL) and EBSCOhost were used to obtain primary evidence from peer-reviewed
journals, and Google Scholar was used to gather evidence-based best practices. Searches
in these databases were conducted using Boolean search strings such as work stress OR
occupational stress OR job stress AND psychiatric nurses AND health; stress
management OR intervention OR rehabilitation OR prevention. I synthesized the
evidence from the literature published between 2011 and 2019.
The doctoral project was conducted with the aim of reviewing the impact of work
stress among practicing psychiatric nurses, implementing an educational program on
work stress, and identifying strategies and interventions that would decrease the
incidence of work stress. The purpose of the project was to design, implement, and
evaluate a stress management educational program focusing on work stress among
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practicing psychiatric nurses to assist them in decreasing stress and absenteeism before
and after the educational program. The PSS, an instrument that measures psychosocial
stress, its stressors, and its impact at the individual, organizational, and societal levels,
was used to measure work stress. The PSS includes questions about the respondent’s
feelings and thoughts during the last month, and questions about current levels of
experienced stress. The questionnaire is designed to reveal the level of stress of an
individual by addressing perceived psychological symptoms of stress. I used the PSS to
measure the nurses’ stress level before and after the implementation of the stress
management program.
Use of PSS to Measure Baseline
All psychiatric nurses working at the project site were asked to complete the
self-reported questionnaires to assess the stressors that nurses face on the job. The
questionnaires included questions on gender, age, educational level, and position. The
questionnaires were distributed and collected in sealed envelopes by the unit managers,
and the collected questionnaires were submitted to me for analysis using descriptive
statistics. The data collected from the completed questionnaires were then uploaded into
my computer at my home office, which was password protected, and the paper
questionnaires were stored in a locked cabinet to be destroyed or shredded after five
years.
Stress Management Program
Stress management interventions refer to a class of activities that are used by
organizations to improve employee well-being and reduce stress by addressing the causes
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of stress or by reducing the impact of stress on an individual (Czabała, Charzyńska, &
Mroziak, 2011). Information about work-related stressors and coping skills were
distributed through the hospital’s computer network. The information included details on
the identification of stressors, goal setting for stress management, cognitive behavioral
therapy, anger management training, abdominal breathing techniques, and muscle
relaxation techniques.
The approach used to decrease work stress among psychiatric nurses at the project
site was the implementation of a comprehensive stress management program. To manage
work-related stress, effective interventions applicable to the workplace are required.
Research has shown that work stress management has been focused on interventions
corresponding to secondary and tertiary prevention (Czabała et al., 2011). Secondary
interventions are intended to modify an individual’s response to stressors. Secondary
interventions are also intended to target the nurse with the underlying assumption that
focusing on individuals’ responses to stressors should be done in addition to eliminating
or decreasing stressors. Tertiary interventions are intended to minimize the effects of
stress-related problems once they have occurred, through treatment or management of
symptoms or disease. Tertiary interventions include efforts to help nurses cope with
reactions to stressful conditions, counseling, and return-to-work and other rehabilitation
programs.
The secondary and tertiary interventions focus on the individual and the
organizational levels. At the organizational level, facilitator workshops, such as group
discussions, are encouraged. The facilitators participate in a team discussion and
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encourage nurses to make an active commitment. Facilitator workshops are followed by
team-based participatory workshops. Organizational stress management strategies such as
ensuring that workloads are in line with workers’ capabilities and resources, creating a
collaborative work environment, and providing opportunities for social interaction are
encouraged. In addition, at the organizational level, job adjustment and workplace
communication activation are applied to improve the occupational context.
In the current project, data collection started with the individual baseline results of
the PSS, which helped nurses to identify their work-related stressors and strengthen their
coping skills. Individual stress management strategies included providing educational tip
sheets and flyers about stress, its causes, and reduction strategies; providing
encouragement, time, and space for yoga or other stress management activities; and
providing mindfulness training. Furthermore, at the individual level, relaxation and
cognitive behavioral techniques were applied to improve the individual’s psychological
resources and responses. Different approaches, such as encouraging nurses to exercise at
work and off the job and setting up a support group, were offered. Stress reduction
strategies were instituted, such as giving nurses flex time, arranging regular meetings to
share information, promoting job sharing, adjusting work hours considering individual
circumstances such as part-time schedules and voluntary reduced work time, extending
lunch hours, and implementing a return-to-work program. The workplace stress
management program was conducted within an 8-week period. Evaluation of the stress
management program began by examining data relating to absenteeism, presenteeism,
turnover, and nurses’ use of sick leave.
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Use of PSS to Measure Stress Post Intervention
One month after the implementation of the organizational and individual level
interventions, improved activity checks, such as adjusting work hours, considering
individual circumstances, and arranging regular meetings to share information, were
conducted by the stress management team. All of the psychiatric nurses working at the
project site were asked to complete the PSS questionnaires after the implementation of
the stress management program to assess the stressors that nurses face on the job. The
questionnaires included questions on gender, age, educational level, and position.
Identifiable personal information such as name, department, or address was not collected,
and participants were informed that their responses would be kept confidential. The
questionnaires were collected in sealed envelopes by the unit managers who forwarded
them to me. The data collected from the completed questionnaires were uploaded into my
computer at my home office, which was password protected and the paper questionnaires
were then stored in a locked cabinet to be destroyed after five years. I analyzed the data
from the questionnaires using descriptive statistics. The survey was done to assess
whether there was a reduction in the respondents’ level of work stress over a 30-day
period after exposure to the educational interventions.
A comparison of PSS scores was obtained through pre- and post-stress surveys
and was used for evaluating the intervention effect. At the organization level, active
participation of nurses in the workshops by promoting good communication techniques
and alleviating the problems caused by work-related stressors, such as interpersonal
conflicts, adverse effects to the organizational system, and deterioration of the
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organizational climate, was an indication that the interventions had decreased the stress
incidence. At the individual level, a reduction in psychological symptoms, such as
anxiety, depression, aggressiveness, sleeping problems and cognitive problems among
psychiatric nurses as measured by the PSS, was an indication that the interventions had
decreased the stress incidence.
Purpose Statement Connecting the Gap in Practice
The purpose of the DNP project was to address a gap that had been identified in
practice, which was no stress management program for practicing psychiatric nurses at
the project site. Addressing the gap was achieved by developing an evidence-based
educational program that addressed a reduction in work stress. A review of the literature
and synthesis of studies showed that work stress may lead to job dissatisfaction, increased
staff turnover, and lower quality of patient care (Bang & Park, 2016; Filgueira Martins
Rodriguez et al., 2017; Sharma, Davey Shukla, Shrivastava, & Bansal, 2014; Tabaj et al.,
2015). Primary findings indicated that nurses who care for psychiatric patients are
exposed to increased levels of stress and have a poorer health status (Adriaenssens, De
Gucht, & Maes, 2015). Secondary findings revealed that stress, when not properly
managed, can negatively impact patient care (Filgueira Martins Rodriguez et al., 2017).
Evidence-based literature also indicated that work stress can be avoided using strategies
for stress management (American Nurses Association [ANA], 2014). The DNP project
was conducted to provide psychiatric nurses with an evidence-based education program
to decrease work stress and absenteeism.
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Significance of the Project
The issue of work stress is important in the general workforce, but is especially
important in the field of nursing. Work stress and health problems constitute societal and
economic problems (Nayak et al., 2016). Stress has an impact on individuals’ health,
well-being, and job satisfaction. Stress also has a negative impact on the degree of
absenteeism and turnover that nurses and other health care professionals exhibit (Hausser,
Mojzisch, Niesel, & Schulz-Hardt, 2010). The growing increase of stress among nurses
will eventually affect the quality of services and care of patients (Sharma et al., 2014).
Regardless of the cause, nurse work stress has extensive consequences. Evidence from
the American Nurses Association (ANA) position statement addressing nurse fatigue to
promote safety and health suggested that stress from long hours at work, rotating shifts,
and infrequent breaks slows down reaction times, reduces motivation, and increases
errors, all of which can affect patient care outcomes and patient satisfaction levels (ANA,
2014; Trossman, 2015). Patient safety is a key constituent of the quality of health
services. Nurses are the largest group of professionals who care for patients, and
observing safety in nursing care should reduce injuries, disability, morbidity, and
mortality D’Souza, Umarani, & Shetty Asha, 2015). High stress can lead to a decline in
the quality of nursing care (Farzianpour et al., 2016). Safe practices are at the core of
nursing care to maintain and improve patient safety; unsafe practices can lead to legal
consequences and irreparable harm to patients (Bianchi, 2016). They may also have
negative consequences including long-term accommodation, patients suffering, additional
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costs, dissatisfaction with the hospitals, and dissatisfaction with the health system
(Kurnat-Thoma, El-Banna, Oakcrum, & Tyroler, 2017).
Stakeholders
Reduction of work stress at the project site involves the combined efforts of all
stakeholders. Stakeholders consist of nurse supervisors/managers, staff nurses, and
patients. The DNP project has the potential to impact the stakeholders in a variety of
ways. The project may assist nurse managers and staff nurses in raising their awareness
regarding the benefits of good working practices and may encourage the implementation
of strategies that focus on maintaining a healthy working environment to minimize levels
of stress. Nurse managers/supervisors may experience a positive change congruent with
their level of communication with staff nurses. These managers may also benefit from
improved coping abilities through a deeper understanding of the issues, implications, and
strategies that address work-related stress.
Staff nurses may benefit from recognizing the signs of stress in their daily work
life and developing a better understanding of how to approach it. Nurses may also benefit
from having managers who are better able to provide support and unit guidance, real-time
mentoring, and modeling of preferred behaviors for staff, as opposed to managers who
are negatively affected by stress (see Moss, Good, Gozal, Kleinpell, & Sessler, 2016). An
additional benefit for staff nurses may be increased job satisfaction and an improved
ability to focus on daily responsibilities as a result of better stress management (see
McVicar, 2015).
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Patients may benefit the most as staff nurses become more inclined to follow
directions from their supervisors/managers who design the care behaviors. According to
Loveridge (2017), managers with poor stress coping management skills are not effective
leaders. Therefore, improving supervisors/managers’ abilities to pay attention to work-
related stress and burnout may promote better patient engagement and overall patient
experience (Byron et al., 2014). In addressing these issues, the project site may benefit by
having more staff at work during any given shift as well as reducing absenteeism and its
associated costs. Addressing a local problem may improve the work environment,
thereby contributing to a healthier society.
Contributions to Practice
The goal of nursing service is to provide the patient with quality care, thereby
improving patient care outcomes. Nurses are the most important resources in every health
care institution; therefore, maintaining and supporting their health ensures their ability to
work, maintain standards, and provide quality patient care (Salilih & Abajobir, 2014).
Although work stress is a part of life, excessive stress may have an adverse impact that
decreases work output, increases absenteeism, and decreases work productivity (Bang &
Park, 2016). The current project contributed to practice through seeking to guide health
care leadership in better understanding the importance of how caring management can
promote high-quality patient care and reduce work stress, burnout, and staff nurse
turnover while improving the nurses’ overall well-being (see Vassey, 2014).
Positive coping strategies for the management of stress are of critical importance
for health care providers (McVicar, 2015). Nurse leaders can encourage a positive work
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environment through incorporating positive attitudes, demonstrating practical coping
behaviors by engaging in the support of nurses, and openly receiving and listening to
feedback from staff nurses on ways to improve the work environment. Staff nurses, on
the other hand, may benefit from nurse leaders who provide stronger support and
encouragement, coach/mentor them, and serve as role models for desired behaviors. The
educational project has the potential to contribute to nursing practice by promoting a
better life balance among practicing psychiatric nurses, thereby enhancing staff retention,
well-being, and quality of patient care.
Potential Transferability
Managing work stress and burnout is a global concern that is getting the attention
of researchers investigating best practices. The development of an evidence-based
educational program to reduce work stress levels among practicing psychiatric nurses
may provide an understanding of how work-related stress can be prevented and managed
in public health settings and businesses aiming to decrease absenteeism and increase
productivity. The comprehensive stress management program may provide the
framework to instigate similar programs at other units at the practice site. Novice
psychiatric nurses may benefit from receiving training or information on stress
management before practicing on the units. Potential transferability of this project may
also exist in organizations and professions that are trying to reduce work-related stress.
There is potential transferability for this DNP project in similar practice facilities seeking
to implement evidence-based stress management, including acute and chronic care
settings.
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Implications for Positive Social Change
The evidence-based educational project has implications for positive social
change within the selected practice environments because of the high levels of stress
currently experienced by staff nurses and nurse managers. According to Bolima (2015),
there is a significant relationship between caring supervision and increased job
satisfaction among staff nurses. Psychiatric nurses’ practice will benefit from increased
job satisfaction that translates into more focused attention and enhanced delivery of
patient care (McVicar, 2015; Moss et al., 2016). Reducing the harmful effects of stress
may also influence nursing practice through a creative ability to provide staff with
mentorship/coaching and the coordination of care delivery (Moss et al., 2016). Further
implications include continued professional growth, enhanced work-life balance, and
decreased turnover among nursing staff. Knowledge and use of effective stress
management practices may translate into more positive nursing experiences for nurses
and patients. The social effects of the project include nurses, patients, and families
benefitting from an increased understanding of the strategies that support stress reduction
as they interact with each other in more positive and productive ways.
The project may support the Walden University mission to promote positive
social change through a better understanding of psychiatric hospitals and how they can
reduce the effects of stress on the nursing staffs’ well-being and productivity. With
reduced levels of stress, nurses may be better able to provide consistent quality care while
experiencing increased job satisfaction. A direct result of this social change is that
hospital organizations may experience lower staff turnover, higher staff retention, and
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higher levels of job satisfaction among their psychiatric nursing staff, which may result in
enhanced patient care (see Filgueira Martins Rodriguez et al., 2017; Koy, Yunibhand,
Angsuroch, & Fisher, 2015).
Summary
Nursing has been identified as an occupation that has high levels of stress. Work
stress among psychiatric nurses has become a critical issue in the nursing profession.
Work stress causes hazardous impacts not only on nurses’ health, but also their abilities
to cope with work demands. Work stress affects employees and organizations and can
lead to illness, staff turnover, and absenteeism. Work stress costs organizations all over
the world millions of dollars, and on an individual level it affects the physical and
psychological well-being of nurses, which may have harmful effects on patient care.
Work stress results in an increased risk of absence from work, decreased work
satisfaction, and increased intention to leave the profession (Kurnat-Thoma, El-Banna,
Oakcrum, & Tyroler, 2017). Psychiatric nurses must have access to support systems to
help them manage their stress. Stress management education programs are absent at the
practice site, representing a gap in practice. An evidence-based stress management
program has the potential for counterbalancing work stress among practicing psychiatric
nurses. Aspects of this project may be transferable to other areas of nursing practice
because the principles guiding stress management may be beneficial to all health care
organizations and nursing administration. The DNP project included formalized
education on the techniques used to reduce psychiatric nurse work stress, which may
result in positive social change. Section 2 of this project study addresses the evidence-
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based concepts, models, and theories that were applied to the education program, and
includes relevance to nursing practice, local background and context, and my role in the
project.
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Section 2: Background and Context
Work stress is psychologically and physically challenging and may lead to high
rates of absenteeism and turnover. The nursing profession is perceived as stressful and
demanding. Psychiatric nurses promote health and wellness as they serve in indirect and
direct care roles. However, their work exposes them to a lot of stress as a result of the
physical labor, exposure to violent patients, long work hours, poor staffing, challenging
workspaces, increased paperwork, and interpersonal relationships (Hamaideh, 2011).
Stress can affect a person physically, emotionally, and behaviorally (Sugawara et al.,
2017). Psychiatric nurses adopting unhealthy lifestyle behaviors are at significantly
higher risk for developing chronic diseases and are at increased risk of experiencing
exhaustion, job dissatisfaction, and turnover (Kurnat-Thoma, El-Banna, Oakcrum, &
Tyroler, 2017). Research on work stress indicated that stress is a challenging problem for
psychiatric nurses (Sugawara et al., 2017), and exploring this issue is essential for
improving efficiency within the current U.S. health care system.
At the project site, staff nurses develop nonspecific coping mechanisms to
manage their stress because there are no resources available for staff to help manage their
stress (CHARGE NURSES, personal communication, April 4, 2017). These nurses
reported having low energy, feeling tired, and being easily fatigued. They also noted that
they are easily irritated, not motivated, and call in sick on a regular basis for several days.
These nurses feel drained without any source of replenishment. Providing psychiatric
nurses with an evidence-based comprehensive stress management education program that
addresses decreasing work stress may positively impact their work. The practice-focused
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question for the project was the following: Can an evidence-based stress management
education program empower psychiatric nurses to manage work-related stressors and
decrease stress? Strengthening psychiatric nurses’ abilities to practice healthy lifestyle
behaviors may serve as a helpful tool in preventing negative workplace stress, promote
personal well-being, and retaining qualified health care providers. The purpose of this
DNP project was to develop an evidence-based education program to help psychiatric
nurses manage their stress. This program focused on stress management that supports
nurses in experiencing more job satisfaction and decreased stress. Section 2 addresses the
concepts, models, and theories that informed this project, the relevance of the project to
nursing practice, background information and context, and the role of the project leader.
Concepts, Models, and Theories
Stress is a condition that occurs when a person recognizes that the circumstances
or strains facing them may be more than they can endure. Work stress can be defined as
the physical and emotional responses that occur when the demands of the job do not
match the capabilities, resources, or needs of the individual to meet those demands and
which, over a period of time, lead to ill health (Okita et al., 2017). Stress is a result of a
mismatch between the demands and pressures on the person and their knowledge and
abilities, which challenges their ability to cope with work (C. Wang, Yen, & Liu, 2015).
According to Milutinović, Golubović, Brkić, and Prokeš (2012), stress is a reaction to
numerous unfavorable conditions related to work content, work organization, and
working environment.
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Work stress has received a considerable amount of attention from professionals
and researchers. Many occupational health scholars have developed or contributed to
models detailing theoretical approaches to a person’s experience of stress. A single
theoretical framework was insufficient to guide this project. Theoretical models of stress
consider it to be either related to adverse life events and stressful environments or the
individual’s physiological and psychological responses to stressors, or a transactional
interaction between the individual and environment. Different theoretical models
conceptualize stress as a result of an imbalance between perceptions of external demands
and internal resources. The conceptualization of work stress is vital when developing
interventions for the workplace. However, different models of stress reveal that
psychologically significant events can translate into physiological changes that may result
in serious health problems (Seyle, 1983). Four prominent transactional theories (person-
environment fit theory [P-E fit theory], job demand-control [Support] theory, the job
demands-resources [JD-R] model, and the effort-reward imbalance [ERI] model) were
used to inform the definition of work-related stress and were used to clarify the causes
and mechanisms that underpin work stress. The key principle across these theories is an
imbalance, which is defined as a lack of balance between demands and coping resources
or between efforts and rewards (Siegrist & Li, 2016).
Transactional Model
The most commonly used model is the transactional theory
of stress and coping,
which suggests that stress, is the direct product of a transaction between a person and
their environment that may strain their resources and threaten their well-being (Lazarus &
24
Folkman, 1984). The model recognizes that stress can manifest physiologically,
psychologically, behaviorally, and socially with harmful consequences to both the
employee and the organization (Lazarus & Folkman, 1984). The model also suggests that
stress is the result of a dynamic interaction between the individual and the environment
(Cox, 1993) because stress results when the perceived demands outweigh the perceived
capability of the workers. Stressful experiences are construed as person-environment
transactions.
The transactional model suggests three types of cognitive appraisal: primary
appraisal, secondary appraisal, and reappraisal (Lazarus & Folkman, 1984). Primary
appraisal is the person’s decision about the magnitude of an event as stressful,
encouraging, convenient, difficult, or inappropriate. The second appraisal follows when
the person faces a stressor. Secondary appraisals address a person’s reaction to the
situation. Tertiary appraisal or reappraisal refers to a changed appraisal. The model
emphasizes that reciprocal processes between an individual and the environment can be
mediated by cognitive reappraisal (Lazarus & Folkman, 1984).
The assumptions of the transactional theory
of stress and coping supported this
project. The theory of stress has drawn attention to nursing job characteristics and nurses’
perceptions of stressors. The transactional model illustrates how people assess, manage,
and experience occupational stress. According to the model, the experience of stress,
coping, and the development of negative outcomes can occur at different points in the
process of work stress and coping, and can be stimulated by both psychological and
behavioral coping factors (Lazarus & Folkman, 1984). The transactional theory
25
highlights individual differences in ways of coping and examining problems, previous
experiences, and personality type, which inform and affect nurses’ workplace and their
individual stress management. Stress occurs when a person encounters an environmental
demand; the stress response depends on their cognitive appraisal, which refers to an
interpretation of the stressor based on their ability to cope with it.
Nurses appraise environmental stressors, including their level of possible threats
and expenses. Stressors assert their effects based on how a person perceives and evaluates
them (Ganster & Rosen, 2013). These experiences are mediated by the person’s appraisal
of the stressor and the social and cultural resources at their disposal. When faced with a
stressor, the nurse evaluates the possible threat (primary appraisal), which is an
assessment of the nurse’s coping resources and options. According to Folkman and
Lazarus (1984), coping has been described as any cognitive or behavioral efforts to
manage, minimize, or tolerate events that people perceive as threatening to their well-
being. When a nurse interprets the workload of the job as exceed their ability to complete
the job, they will experience a stress response. The appraisal process is subjective and
personal and depends on a nurse’s evaluation of their ability to cope with the stressor.
Nurses make potential plans to deal with stressors using known coping methods
and past experience (secondary appraisal), and then initiate coping. Reappraisal can occur
when there is new information from the environment, because of the individual’s own
reactions to the environment, and/or a result of cognitive coping efforts (Lazarus &
Folkman, 1984). Actual coping efforts aimed at regulation of the problem give rise to
outcomes of the coping process.
The way nurses perceive a specific stressor as a threat or
26
challenge can influence their coping patterns which, in turn, may impact their health
outcomes. Hence, the best management and coping strategies for nurses involves a
combination of personal coping skills, effective organizational plans and social support.
Therefore, according to the transactional model, the experienced workplace stress is
associated with exposure to particular workplace scenarios and a person’s evaluation of
their own coping difficulties.
Person-Environment Fit Theory
The Person-Environment Fit theory (P-E Fit theory) is an interactional theory of
work-related psychological distress, which signifies that work-related stress comes about
as a result of a lack of fit between the person’s skills, resources, and abilities on one hand
and the demands of the work environment on the other hand (French, Caplan, & Van
Harrison, 1982). The P-E Fit model emphasizes that interaction between the
environmental stimulus and the associated individual’s responses forms the foundation of
stress (French, Caplan, & Van Harrison, 1982). The P-E Fit theory explains the
interaction between the individual and the environment in shaping their response to work
situations and events, but also highlights the importance of the individual’s perception of
the environment and the interaction between them (French, Caplan, & Van Harrison,
1982). The core premise of the P-E fit theory is that stress arises not from the person or
environment separately, but rather by their fit or congruence with one another. The P-E
fit approach focuses on the correspondence between environmental demands and
personal skills and abilities. The lack of correspondence generates harmful psychological,
physiological, and behavioral outcomes, which ultimately result in increased morbidity
27
and mortality. A lack of fit can occur when the demands of the work environment exceed
the employee’s ability. In addition, a lack of fit can occur when the employee’s needs
consistently fail to be met by the work environment. Furthermore, a combination of the
previous two in which an employee’s needs are not being met while at the same time
their abilities are over-stretched can also create a lack of fit (French, Caplan, & Van
Harrison, 1982). According to the P-E fit theory, when a person is unable to adjust in the
prevailing environment, the environment becomes a stressor and the individual becomes
stressed.
The assumptions of the P-E Fit theory support this project.
The theory offers a
framework for assessing and predicting how characteristics of the nurse and the work
environment jointly determine nurses’ well-being, and in the light of this knowledge, how
a model for identifying points of preventive intervention may be elaborated. The P-E fit
theory focuses on the interaction between characteristics of the nurse and the work
environment, whereby the nurse not only influences his or her work environment, but the
work environment also affects the nurse. The P-E theory involves the fit between the
demands of the environment and the nurses’ abilities. Demands may include both
quantitative and qualitative job requirements, role expectations, and organizational
norms; whereas abilities may consist of aptitudes, skills, training, time, and energy the
nurse may gather to meet the demands. French, Caplan, & Van Harrison (1982) explained
that, when stressors are potentially overwhelming, some disconnection from the situation
or self may occur, which may cause some anxiety and facilitate maladaptation. The
capability of the fit between a nurse and the environment can affect the person’s
28
motivation. It can also affect the person’s behavior, and overall mental and physical
health. For example, if the fit is most favorable, the nurse’s performance may be
facilitated; if it is incongruous, the nurse may experience maladaptation.
The theory also
entails the match between the needs of the nurse and the supplies in the environment that
relate to the nurse’s needs. Supplies refer to unimportant and fundamental resources and
rewards that may fulfill the nurse’s needs, such as food, shelter, and social involvement,
(French, Caplan, & Van Harrison, 1982).
Job Demand-Control (Support) Theory
The Job Demand-Control (JDC) model (Karasek, 1979) and the Job Demand-
Control-Support (JDCS) model (Johnson & Hall, 1988) focus on psychological well-
being that accounts for the connection between job demands, job control, negative health,
and psychological outcomes. The JDCS model assumes that low levels of social support
from supervisors and peers can also contribute to job strain. The JDC theory stipulates
that work-related stress can result from the interaction between several psychological job
demands relating to workload and skill judgment (Karasek, 1979). The main assumption
of the JDCS model proposes that the highest job strain is experienced in environments
characterized by high job demands and low job control. The JDC theory suggests that
people experiencing high demands matched with low control are more likely to
experience psychological strain, work-related stress, and in the long term, poor physical
and mental health (Crescenzo, 2016). The demands component of the model is
conceptualized as time pressure due to a heavy workload (Aida, Ibrahim, & Ohtsuka,
2012), but it may be broadened to also include role ambiguity and role conflict. The job
29
control dimension involves skill discretion and decision authority, and the employees’
ability to organize their work, adopt their own initiatives, and exercise the opportunity to
make independent decisions to have a voice in what happens in the workplace.
The assumptions of the JDC and JDCS models support this project.
The JDC and
JDCS models relate the characteristics of a job to health and well-being. In the
workplace, employees are the most valuable asset of an organization. Their job
dissatisfaction will significantly affect their commitment and dedication to their work and
employer.
Stress on the job is generated when expectations are high, and employees do not
have full control of the job. Stress may also occur when employees are unable to make
informed decisions on how to manage work to achieve optimal results (Crescenzo, 2016).
The JCDS theory explains how social support may act as a buffer in high demand
situations. Social support such as advice, assistance, and feedback gained from
supervisors and senior personnel who are experienced in dealing with work-related issues
is helpful. The support provided by co-workers and their supervisor to include emotional
support such as providing care, empathy, love, and by listening to others’ personal
problems is essential to well-being. According to these models, social support can
moderate the negative impact of job strain on an employee’s physical and mental health
(Hausser, Mojzisch, Niesel, & Schulz-Hardt, 2010). The JDC and JDCS models suggest
that the most at-risk group for poor physical and mental health are those employees who
are exposed to job strain in the form of high demands and low control, coupled with low
workplace support (Aida, Ibrahim, & Ohtsuka, 2012). Nurses working in high stess jobs
30
experience the lowest well-being. However, the control can moderate the negative effects
of high demands on well-being.
Effort-Reward Imbalance Model
The ERI model posits that unsuccessful reciprocity between high efforts spent at
work and low rewards received are associated with strong negative emotions and stress
reactions with unfavorable long‐term effects on health. The ERI model assumes that
effort at work is spent as part of a psychological contract, based on the norm of social
reciprocity where effort spent at work is matched with rewards provided in terms of
money, esteem, and career opportunities (Siegrist & Li, 2016). In this model, effort can
be defined as the demands and obligations the nurse is faced with, and reward can be
explained as the money, respect/value, and career opportunities or job security, the nurse
expects in return, either from the employer or from society at large (Siegrist, 2001).
Work-related stress in the ERI model is perceived as lack of justice in the reciprocity of
efforts spent and rewards received at work (Siegrist, 2005). According to the model,
reward reflects distributive justice (Siegrist, 2005), which refers to how the employee
understands the fairness of the outcomes in relation to the job involvement.
The assumptions of the ERI model also support this project because the model
offers accepted explanations of the relationship between stressful working conditions, job
strain, psychological, and physical ill health. Siegrist and Li (2016) proposed that stress
related to the imbalance between effort and reward can arise when a nurse has a poorly
defined work contract or where the nurse has little choice concerning alternative
employment opportunities. According to the ERI model, job dissatisfaction is imminent
31
when there is an imbalance between work effort and reward, such that the effort is greater
than the reward, which may lead to a range of adverse health out-comes (Siegrist & Li,
2016). An unequal relationship between the effort spent and rewards received can result
in the emotional distress associated with stress response and an increased risk of poor
health (Eddy, Heckenberg, Wertheim, Kent, & Wright, 2016; Rugulies, Aust, & Madsen,
2017). The knowledge of a lack of reciprocity can create negative feelings in a nurse. The
negative feeling can eventually increase the susceptibility of illness due to continued
strain reactions in the autonomic nervous system (see Filgueira Martins Rodriguez et al.,
2017). When a nurse is not sufficiently rewarded with respect to their efforts, such
behavior may also signal to colleagues and superiors that the nurse has a low social
standing and little support from management. In such a scenario, nurses may accept the
imbalance for reasons such as the prospect of improved working conditions and cope
with the demands at work through an over-commitment (Kinman, 2016; Siegrist &
Wahrendorf, 2016).
These four transactional theories of work-related stress are well suited and
appropriate for the DNP project because they can be used to develop programs that seek
to improve employees’ health and well-being. The various stress models are very similar
but not interchangeable; instead they complement each other and reflect to some extent
different aspects of the psychosocial work environment (Siegrist, 2001). For example, the
Job Demand-Control model highlights task-level control, and the ERI model puts the
spotlight on the reward the employee receives (Siegrist, 2001). Both theories have helped
to clarify the causes and mechanisms that underpin work-related stress. The transactional
32
theories explicitly and implicitly recognize the central role of psychological processes
such as, perception, cognition, and emotion; in understanding how the individual
recognizes, experiences, and responds to stressful situations; how they attempt to cope
with that experience; and how it might affect their physical, psychological, and social
health. These models have attained prominence in occupational stress among researchers,
gaining recognition as the leading job stress models (Schaufeli & Taris, 2013).
Job Demands-Resources Model
The JD-R model incorporates all job demands and resources. The model explains
how job demands and resources have unique and multiplicative effects on job stress and
motivation. The model was developed based on the assumption that every occupation has
its own specific risk factors associated with job-related stress. The main assumption of
the JD-R model is that the balance between positive and negative job characteristics
influences employees’ health and well-being with positive job characteristics
representing resources and negative characteristics representing demands. In the JD-R
model job demands refer to those physical, social, and organizational aspects of the job
that require continuous physical or mental effort, and are therefore associated with
physiological and psychological cost (Demerouti & Bakker, 2016). Examples of job
demands include high work pressure, poor physical environment, longer working hours,
or emotionally demanding interactions with clients; while job resources are physical,
psychological, social, or organizational aspects of the job that may be useful in
accomplishing work goals, decrease job demands at the associated physiological and
psychological costs, encourage personal growth and development (Bakker & Demerouti,
33
2014). According to Bakker (2017), the JD-R theory postulates that job demands lead to
stress in the absence of certain resources. The model proposes that increased job demands
lead to strain and health problems and high resources lead to increased motivation and
higher productivity. The model also proposes that job resources influence motivation or
work engagement when job demands are high (Bakker & Demerouti, 2014).
The assumptions of the ERI model also support this project because the model is
useful for understanding occupational stress and it emphasizes the motivational qualities
of job resources in enhancing employees’ well-being (Bakker & Demerouti, 2014). The
model is a framework that can be used for organizations to improve employee health and
motivation, and at the same time improve various organizational outcomes. The model
incorporates many possible working conditions and focuses on both negative and positive
indicators of employee well-being. It suggests that employees are more likely to draw on
their resources under stressful conditions, including those induced by high demands
(Bakker & Demerouti, 2014). According to the JD-R model, nurses are more likely to
utilize their resources when faced with more stressful circumstances. Job resources are
the social, psychological, physical and organizational dimension of work which reduces
the negative effects of job demands, enhances the accomplishment of work goals, and
promotes personal growth and development (Bakker & Demerouti, 2014). Lack of
resources prevents the employee from meeting the job demands, which further leads to
withdrawal behavior. The end result of this withdrawal behavior is disengagement from
work (Bakker & Demerouti, 2014). Hence, providing nurses with personal resources
helps them to understand, control, and shape those aspects of work environment that
34
facilitate successful goal accomplishment and raise levels of work engagement (Bakker
& Demerouti, 2014).
Evaluation of information at the project site indicates there is a lack of resources
to manage stress; hence this educational program will focus on stress reduction. Phases of
the nursing process, including the steps of assessment, diagnosis, planning and outcomes,
implementation, and evaluation (American Nurses Association, 2016) will be integrated
with the JD-R theory. Also, the model provides a broad and flexible framework for
assessing job and personal characteristics that affect employees’ health and well-being
and their associated outcomes, including job performance. The model also provides
measures to understand stress and how to use coping strategies to encompass the
beneficial effects on health promotion, health education, and disease prevention. The JD-
R model is relevant across a wide variety of settings, because it can be tailored to the
specific needs of an organization and any given situation. Furthermore, the JD-R model
can bridge the gap between occupational health management and human resources
management (Corin & Bjork, 2016). Moreover, the JD-R model can be used to
fundamentally develop effective strategies and approaches that will improve coping and
promote physical, mental, and somatic well-being of the nurses and healthcare providers
(Azma, Hosseini, Safarian, & Abedi, 2015; Zandi, Sayari, Ebadi, & Sanainasab, 2011).
The JD-R model can help practitioners obtain an understanding of what they may expect
in particular situations and what concepts should be targeted to improve employees’
health, well-being, and performance. By applying the model’s concepts, nurses will be
able to determine how job demands and job resources work together and help to predict
35
critical organizational issues and problems. The JD-R theory can be used to expose both
the sources of occupational stress and how the nurses are using coping strategies to
process different demands (external or internal) associated with stressors (Bakker &
Demerouti, 2017).
Definition of Terms
Stress: Stress has been defined in many ways. Selye (1956) defines stress as a
non-specific response of the body to any demand made on it from the external
environment. Lazarus and Folkman (1984) define stress as any experience in which
environmental demands, internal demands, or both, exceed the individual’s adaptive
resources. Lazarus and Folkman also describe stress as a relationship between people and
the environment that is appraised as demanding or exceeding their resources and as
endangering well-being. Stress can be defined as a disturbing situation that occurs in
response to unfavorable influences from the internal or external environments
(Milutinović et al., 2012). Stress basically involves the relationships between individuals
and their environment that are considered as challenging or exceeding their resources and
jeopardizing their well-being (Okita et al., 2017). Stress can be viewed as a mismatch
between environmental demands and individual capacities or between environmental
opportunities and individual needs or goals. It is also seen as an imbalance between
perceived demand and individuals’ perceptions of their ability to meet that demand
(Wang, Yen, & Liu, 2015). With respect to the workplace, stress is seen as a negative
characteristic of the work environment that impinges on the individual.
36
Stress reactions: Stress reactions are responses in the form of physiological
response which involves rapid heart rate, increased blood pressure, and increased
respiration. The psychological response includes anger, fear, and sleep disruptions that
occur when confronted with a stressor (Papathanassiou, Tsaras, Neroliatsiou, & Roupa,
2015).
Stressors: A stressor can be defined as any incident, experience, or environmental
stimulus that causes stress in an individual (Rafati, Nouhi, Sabzehvari, & Dehgahan,
2017). These experiences are assumed as pressures or challenges to the individual and
can be either physical or psychological. Researchers have found that stressors can make
individuals more prone to both physical and psychological problems, including heart
disease and anxiety (Kivimäki, Jokela, Nyberg, Singh-Manoux, Fransson, Alfredsson &
Clays, 2015; Zandi, Sayari, Ebadi, & Sanainasab, 2011). Stressors can relate to
workplace characteristics that present a risk to individuals (Gates, Gillespie, & Succop,
2011). Stressors are substances and actions, which can be experienced from four basic
sources—environmental, societal, physiological, and mental. Stressors include poor
working conditions, work conflict, physical demands, long working hours, increased
workload, lack of resources, and rotating shifts. Stressors also include low wages,
inadequate financial rewards, lack of recognition/ appreciation, and violence or lack of
cooperation from patients and/or their families (Mehta & Singh, 2015).
Work stress: The National Institute for Occupational Health and Safety (NIOSH)
has defined work stress as a harmful physical and emotional response that occurs when
job requirements are not consistent with the employees’ abilities and needs (NIOSH,
37
2014). Work stress occurs when a job either poses demands the worker cannot meet or
fails to provide sufficient supplies the worker needs. Work stress has physical, mental,
and behavioral complications (Tearle, 2013). Physical complications include
cardiovascular and musculoskeletal disorders. Behavioral outcomes of work stress
include work absenteeism, and sleep disorders (Yaribeygi et al., 2017).
Work environment: The work environment includes an enclosed atmosphere,
time, pressures, excessive noise, sudden swings from intense to routine tasks, unpleasant
sights and sounds, and long working hours (Tuvesson, 2011; Tuvesson & Eklund, 2014;
Tuvesson, Eklund, & Wann‐Hansson, 2012). Work environment is one of the most
important resources of work stress.
Relevance to Nursing Practice
The concept of stress is highly relevant to the workforce in general and nursing in
particular. Work stress in nursing has been the focus of much research over the last 20
years, and psychiatric nursing is regarded as being one of the most stressful occupations
in the world (Zaki, 2016). Work stress in the psychiatric nurse population can have a
significant effect on nurses’ well-being, patient safety, and the health care organization.
Stressful work environments can psychologically, mentally, and physically affect staff.
Additionally, nurses working with psychiatric patients may be confronted with intense
interpersonal interactions with patients and families, dynamic changes in patients’
behaviors and emotions, emotional liability, and psychological distress that can be both
stressful and challenging (Sailaxmi & Lalitha, 2015). Nurses who are stressed are more
likely to be unhealthy, poorly motivated, less productive, and less safe at work (Kelley,
38
Fenwick, Brekke, & Novaco, 2016). When nurses are in poor physical and mental health
the provision of quality patient care, therapeutic practice, absenteeism, and workforce
retention are affected (Filgueira Martins Rodriguez et al., 2017). However, studies on
stress in mental health nursing have been slower to emerge. There is enough evidence in
health-care professions, suggesting that nursing is a stressful job (Mortaghi Ghasemi,
Ghahremani, Vahedian azimi, and Ghorbani, 2012; Sailaxmi & Lalitha, 2015; Zaki, 2016
;). Furthermore, there is a cost for these nurses in terms of health, well-being, self-
efficacy, and job dissatisfaction, as well as for the organization in terms of absenteeism
and turnover, which in turn may impact the quality of patient care (Gulavani, 2014;
Konstantinos & Christina, 2016). Al-Makhaita, Sabra, and Hafez (2014) reported that the
prevalence of occupational stress in nurses in Saudi Arabia was 45.5%. In a similar study
in Iran, 57.4% of nurses were found to be suffering from average to high occupational
stress (Hosseini, Hazavehei, Imanzad, Ghanbarnezhad, & Gharlipour, 2013).
Furthermore, Mortaghi Ghasemi et al., (2012) found that 57.4% of the nurses from
various job situations in Zanjan were reported to have high degrees of job stress.
According to the US Occupational Safety and Health Institute, the nursing
profession is ranked 27
th
among 130 studied professions regarding work-related mental
health problems; more than any other medical profession (Akbarbegloo & Valizadeh,
2011). Work-related stress among psychiatric nurses affects both the nurse and the
functioning of the organization including the provision of healthcare. Some of the
identified major stressors in hospitals include tension factors such as high work pressure
and high demands in the workplace such as longer shifts, threats, workplace violence,
39
occasional conflicts with doctors, little or no support from managers/supervisors, and the
lack of rewards and incentives (Akbarbegloo & Valizadeh, 2011). In a systematic review
conducted on the consequences and complications of work-related stress in nursing, it
was noted that occupational stress can have a significant negative impact on the
individuality of nurses compromising their abilities to accomplish tasks assigned and to
remain alert and focused. Occupational stress can also lead to musculoskeletal disorders
(Azma, Hosseini, Safarian, & Abedi, 2015; Lee, Lee, Gillen, & Krause, 2014), locomotor
diseases (Ghilan, Al-Taiar, Yousfi, Zubaidi, Awadh, & Al-Obeyed, 2013), high rates of
anxiety
(Zandi, Sayari, Ebadi, & Sanainasab, 2011), and depression (Lin, Lin, Cheng,
Wu, & Ou-Yang, 2016; Yoshizawa, Sugawara, Yasui-Furukori, Danjo, Furukori, & Sato,
2016).
Work stress and health problems also constitute both societal and economic
concerns as they influence productivity (Ganster & Rosen, 2013). Hospital environments
have the potential to increase stress levels, which can negatively affect the health and job
satisfaction of nurses as well as the welfare and health of patients, reduce job satisfaction,
increase absenteeism, and promote high turnover rates (Mosadeghrad, 2013; Sarafis et
al., 2016). The application/incorporation of effective stress management systems and
coping strategies are essential steps in supporting productive work while
addressing/reducing the level of stress among nurses.
Job-related stress also has the potential to impact employee mental and physical
health (Han, Shin, Yoon, Ko, Kim, & Han, 2018). Reducing levels of stress in everyday
work life is vital for maintaining the overall health of nurses, as it can improve their
40
mood, boost immune function, promote longevity, and allow them to be more productive.
Employers who institute measures to reduce stress among nurses benefit by having
increased staff retention and improved patient outcomes (Pino & Rossini, 2012).
Addressing employee stress and well-being raises the overall health of the work
environment. The use of an evidence-based project can demonstrate relevance to nursing
practice by offering evidence-based solutions to a well-documented challenge facing
practicing psychiatric nurses.
History
Since the 1950s our understanding of stress has deepened with Style’s (1956)
research and the connection made between stress and disease in his model. Selye first
introduced the term stress to describe physical and psychological responses to harsh
conditions or influences. Selye also used the term stressor to describe the pressure that
when acting on a body, creates stress. Numerous researchers have explored the concept
of stress in relation to the nursing profession (Sarafis et al., 2016; Sharma et al., 2014;
Tuvesson, Elund &Wann-Hansson, 2012). In the literature reviewed, surveys and articles
from the 1990s focused on the effects of stress on psychiatric nurses (Adriaenssens et al.,
2014). However, the practice of nursing has evolved since that time. McVicar (2003)
focused on identifying stress in nursing through an exhaustive literature review that
focused on organizational interventions related to managing stress from January 1985 to
April 2003. In her study, McVicar found that the emotional costs of caring have been the
main sources of distress for nurses for many years, especially when the workplace and
nursing roles were changing (McVicar, 2003). The Health and Safety Executive (HSE)
41
(2015) defines stress as an adverse reaction people have to excessive pressures or other
types of demand placed upon them. Work-related stress is thus understood to occur when
there is a mismatch between the demands of the job and the resources and capabilities of
the individual worker to meet those demands (McVicar, 2015). Work stress among nurses
is one of the core concerns in psychiatric nursing. According to the National Institute for
Occupational Safety Health (NIOSH), nursing was found to be one of the jobs that when
stress was left unconstrained and exceeded anticipated levels, it negatively impacted both
the nurses’ health and as well as their ability to cope with job demands (Adriaenssens,
2013).
Psychiatric nurses have historically assisted people in regaining a sense of
coherence over what happens to them. Their unique contribution was a simple elegance
of being there to bear witness and mitigate the negative side effects of illness alienation.
Today, psychiatric nursing is being considered a stressful specialty, with low job
satisfaction. According to Konstantinos and Christina (2016), psychiatric nurses are now
important members of the multi-disciplinary team who cater to the needs of psychiatric
patients in a therapeutic environment; however, they encounter situations in their careers
such as shortages of nurses and unpredictable patient behaviors that are uncomfortable or
distressing.
Current State of Practice
Nursing has been described as a psychologically demanding occupation with
challenges that augment levels of stress and possible exhaustion (ANA, 2014). High
levels of work-related stress experienced by psychiatric nurses have been recognized as a
42
regular event within the nursing profession (Zaki, 2016). Approaches to help psychiatric
nurses cope with stress vary within different organizations, but the accessibility to an
employee assistance program remains the same (Richmond, Pampel, Wood, & Nunes,
2017). Existing approaches have focused on encouraging personal relaxation, altering
certain factors within the work environment, and promoting mentorship for nurses, which
have produced positive outcomes (ANA, 2017). According to Happell et al. (2013),
primary interventions to reduce stress among psychiatric nurses have involved modifying
preventable stressors such as work environments according to local assessments.
Researchers investigating occupational stress for psychiatric nurses suggest
managing stress by practicing mindfulness, which can benefit mental and physical well-
being as well as reduce stress, improve focus and concentration, increase resilience, aid
creativity, and increase emotional intelligence (Allen, Eby, Conley, Williamson, Mancini,
& Mitchell, 2015). In recent years, many stress management interventions and
mindfulness-based workplace programs have come to the aid of employees (Hyland, Lee,
& Mills, 2015). When employees become overwhelmed, they may seek support from an
employee assistance program. Employee assistance programs were initially intended to
offer direction to staff members experiencing acute phases of alcohol or substance abuse,
however, today these programs have incorporated issues with the workplace as well as
home-related stress (U.S. Office of Personnel Management, 2017). Regrettably, these
programs are not fully utilized as only 4-6% of employees explored the benefits
(American Psychiatric Association (APA), 2016). Nurses may stay away from these
43
programs due to perceived stigmas regarding substance abuse or mental health issues
(APA, 2016; Richmond et al., 2017).
Filling the Gap in Practice
Psychiatric nurses trying to cope with stress in an unsupportive environment
promotes an environment of absenteeism, increased susceptibility to exhaustion, job
dissatisfaction, and staff turnover (Kurnat-Thoma et al., 2017). The DNP project filled a
gap in practice related to stress management for psychiatric nurses. The literature review
illustrated that there are increasing levels of stress among psychiatric nurses (Hosseini at
al., 2013; Mortaghi Ghasemi et al., 2012; Zaki, 2016). The project filled the gap in
practice through the development of a synthesized evidence-based education program for
psychiatric nurses. Strengthening psychiatric nurses’ abilities to engage in healthy
lifestyle behaviors can serve as a valuable tool in fighting negative workplace stress,
promote enhanced work-life balance and personal well-being, and support the retention
of competent nurses. The provision of an evidence-based educational program
synthesized from best practices has enhanced the development of improved coping skills
for this group of nurses.
Local Background and Context
Summary of Local Relevance
According to the leadership team at the project site, the issue of stress has been
addressed in several leadership meetings and recognized as a problem at both the
management and leadership levels. The absence of a formal stress management program
to minimize stress was discussed in a grand round conference by management staff
44
members (Unit Manager, personal communication, 2017). Nevertheless, no formal
interventions had been implemented. A callout checklist was created in an attempt to
monitor the rate and frequency of employee callouts per shift. Review of this list revealed
that more staff nurses call in sick every day as a result of stress related illnesses, more
than other departments in the facility indicating that unhealthy levels of stress were
present in the facility (Unit Manager, personal communication, April 2017; SGHC,
2018). No intervention has been implemented to address the issue; instead the facility has
focused on hiring more nurses to address the staff shortage and to reduce employee
overtime.
The project site, located in a metropolitan area in the Northeastern United States,
is an acute inpatient psychiatric hospital that has undergone several changes in upper
management within the past 3 years. The Chief Executive Officer (CEO) and the Chief
Operational Officer (COO) have changed once and the Chief Nursing Officer (CNO) has
changed twice. Two new Assistant Director of Nursing (ADON) positions were created
to manage/oversee staffing, coordinate patient care, strengthen healthy lifestyle
behaviors, combat negative workplace stress, promote improved work-life and personal
well-being, and reduce attrition. Changes in upper management brought changes in
organizational rules and regulations as well as new technology. The organizational
change created fear among employees, impacting job satisfaction, performance, and
productivity (ASSISTANT DIRECTOR OF NURSING, personal communication, June
2018). As a result, many nurses have lost confidence and fear the loss of job stability.
They also fear that new changes will increase their workload and that they may not be
45
capable of learning how to use the new technology. Organizational leadership has not
combated these fears or lessened their impact and as a result, several employees have
become very dissatisfied, which has led to a rise in absenteeism (DIRECTOR OF
PERFORMANCE IMPROVEMENT, personal communication, April 2018; SGHC,
2018). The nurses indicated that work stress increased because of the numerous changes
in upper management and a more corporate focus for the organization (CHARGE
NURSE, personal communication, April 2018). Organizational interventions to prevent
work stress can be implemented to alleviate psychiatric nurses suffering from different
aspect of stress with a focus on stress prevention for individuals as well as tackling
organizational issues. Implementation of a management program can equip psychiatric
nurses with skills to cope effectively with the stress (Sailaxmi & Lalitha, 2015). In
addition, profits to the facility may occur as the avoidance and reduction of stress can
diminish absenteeism, promote a less stressful work environment, impact productivity,
and improve the quality of patient care (Goulart, 2015).
State and/or Federal Contexts
Work stress is acknowledged globally as a key challenge to workers’ health and
the well-being of their organizations (Zadi, 2016). Work stress can lead to physical
illness, as well as psychological distress and mental illness (Nieuwenhuijsen, Bruinvels,
Frings-Dresen, 2010). Narrative reviews have shown consistent evidence in the literature
that work stress is linked with a variety of negative health outcomes, including
cardiovascular disease, clinical depression, and death (Ganster & Rosen, 2013). The state
and/or federal contexts such as scheduling, staffing, organizational support, increase
46
workload, interpersonal conflicts, lack of support, unfair treatment, low decision latitude,
lack of appreciation, effort–reward imbalance, conflicting roles, lack of transparency,
poor communication, and workplace violence are critical stressors in the workplace
(Confederation of British Industry, 2013). Psychiatric nurses are exposed to strong
stressors that come from the demand of their jobs (Chiang & Changa, 2012). Authors of
numerous reviews and meta-analyses have examined the health effects of individual
work-place stressors such as job insecurity (Virtanen, Nyberg, Batty, Jokela, Heikkilä,
Fransson, & Kivimäki, 2013), long work hours (Bannai & Tamakoshi, 2014),
psychological demands and job discretion (Kivimäki, Nyberg, Batty, Fransson, Heikkilā,
Alfredsson, Theorell, T. (2012). Their findings revealed that work is one of the leading
causes of stress with the physiological effects impacting cholesterol levels, the immune
system, and metabolic functioning. Additionally, psychiatric nurses are leaving the
profession due to reporting feelings of fatigue and the lack of ability to deliver quality
patient care (Chiang & Changa, 2012).
According to the HSE report (2015), work stress is more common in public
service institutions. Many state and federal settings have now realized that their
employees’ productivity is linked to their health and well-being (HSE, 2015). Most
researchers agree that job stress results from the interaction of the worker and the
conditions of work (Gulavani, 2014; Wang, 2015; Yoshizawa, 2016). The National
Institute for Occupational Safety and Health (NIOSH) is the Federal agency responsible
for conducting research and making recommendations for the prevention of work-related
illness and injury. According to the NIOSH, exposure to stressful working conditions can
47
have a direct influence on worker safety and health. NIOSH is committed to providing
organizations with knowledge to reduce stress. Many countries have laws that seek to
more rigorously control work stress. The Department of Labor encourages employers to
have an injury and illness prevention program (United States Department of Labor,
2017). The state also requires or encourages employers to have such programs (U.S.
Office of Personnel Management, 2017). In the United States, the role of the work
environment in employees’ health has drawn some awareness through research sponsored
by the NIOSH and Health Administration or the Agency for Healthcare Research and
Quality (NIOSH, 2012). Most policy discussions and resources have remained devoted to
promoting physical workplace safety and offering health promotion activities. Policies
have been created to redesign jobs and reduce or eliminate workplace practices that
induce stress (Goh, Pfeffer, & Zenios, 2015). The Occupational Safety and Health
Administration (OSHA) is the federal agency charged with monitoring the work
environment in the interest of work safety and health. Therefore, improving the
organization’s injury and illness prevention program can reduce the direct and the
indirect costs of health care such as turnover, absenteeism, and presenteeism (Goh,
Pfeffer, & Zenios, 2015).
The problem of stress in the project site is about the same as other healthcare
organizations (SGHC, 2018), although work stressors can take different forms depending
on the characteristics of the workplace and may be unique to an organization or an
industry. According to the American Psychological Association (APA) (2017), more than
one-third (36 percent) of workers in America said they typically feel stressed out during
48
their workday. Research by the NIOSH (2014) on workplace stress found that 75% of
workers think they are experiencing more stress than previous generations. Several nurses
reported that their average daily level of stress from work is an 8, 9, or 10 on a 10-point
scale (Staff nurses’ personal communication, June 2017). While the nurses’ overall stress
level remains about the same as compared to the national average, the project site nurses
continue to call in sick from work (SGHC, 2018). The nature of work is changing at
whirlwind speed, however, stress in the workplace may occur when people try to manage
their responsibilities, everyday jobs or other demands related to their jobs, and experience
some difficulties, tension, uneasiness, or become anxious as they perform their jobs
(Stranks, 2015). Nurses caring for psychiatric patients may deal with strong interpersonal
interactions, dynamic changes in patients, disturbing responsibility and psychological
distress that can be very stressful and demanding (Sailaxmi & Lalitha, 2015). Based on
the Transaction Model, stress is any stimulus that comes from the external or internal
environment and taxes or exceeds the sources of adaptation of an individual or social
system (Goulart, et al., 2015). If the mental and physical health of psychiatric nurses is
not taken care of, they may experience mental health disorders, which can add
unconstructive pressure on health care services and be a main contributor to attrition and
extensive shortages in the nursing profession (Alidosti, 2016). Stopping and/or reducing
stress in the workplace can promote the physical and mental health of workers and their
quality of life at work. In addition, advantages to organizations are anticipated as the
avoidance and reduction of stress can decrease absenteeism, promote a less stressful work
environment, and impact both productivity and quality of work (Goulart, 2015).
49
Role of the DNP Student
This doctoral project has personal relevance because I have previously worked as
a psychiatric staff nurse. Stressors experienced by psychiatric nurses are very personal
and sometimes hard to share with other professionals. Effective management of stress can
make a difference in the life of psychiatric nurses. Although I am presently not working
as a psychiatric staff nurse, many of the challenges faced by them are similar to those
challenges I encounter as a staff nurse. This project was visualized as informing a body of
nursing knowledge for psychiatric nurses and others who may benefit from stress
management.
Role in the Doctoral Project
Stress management interventions and wellness programs can help counter the
stress and exhaustion professional nurses’ experience, by promoting healthy lifestyle
behaviors and strengthening their resilience (Neville & Cole, 2013). My role in this
doctoral project is to develop an evidence-based educational program for psychiatric
nurses to minimize stress. Within this project, I assumed the role of the project manager
who compiled all the evidence-based best practices that focused on stress management.
Evidence-based literature was synthesized and incorporated into an educational program
that was presented to all the stakeholders in the organization for local relevance and
approval. Once the stakeholders approved of the evidence-based educational program, it
was presented to the nursing leadership counsel at the facility.
Being a part of this doctoral project allowed me the opportunity to work together
with a variety of nurses and staff from other disciplines within the organization. There
50
have numerous encouraging discussions about the project with both front line and
leadership/management level nurses. Interactions with these nurses boosted my level of
confidence and improved my leadership skills, which is a lifelong process of leadership
development. Participating in this project provided me with valuable teaching and
learning experiences that has allowed me to be a role model for safe patient care using
evidence-based practice. During my practicum experience, I had the opportunity to
communicate with all the members of the treatment team. I made the most of this
experience, which allowed me to build relationships with nurses and other staff members.
During this time, I collected and developed a toolbox of resources that will enable me to
take on any situation or challenge as a nurse leader. Development and evaluation of this
project assisted me in understanding current knowledge and skill levels, as well as areas
of needed improvement or reinforcement for managing psychiatric nurses work stress.
The ability to translate knowledge that can effectively benefit psychiatric nurses in their
daily demands of the practice environment provides a foundation for evolving nursing
practice (Bjørk, Lomborg, Nielsen, Brynildsen, Frederiksen, Larsen, Reierson, Sommer,
& Stenholt, 2013).
Motivations for the DNP Project
While working as a psychiatric staff nurse, I realized that psychiatric nursing is a
highly-stress profession—emotionally demanding and physically challenging (Sarafis et
al., 2016). I have recognized that some of the stressors in the workplace include poor
inter-professional relationships, increased workload, staff shortages, lack of support, or
positive feedback from nurse managers and supervisors (Yada, 2015). If psychiatric
51
nurses are not taken care of, they may experience mental health issues, which can have a
negative impact on health care services and contribute to attrition and extensive staffing
shortages (Alidosti, 2016). I was motivated by the stressful nature of psychiatric nursing
to develop a stress management program that could assist psychiatric nurses in managing
their physical, emotional, and mental exhaustion that can result from long-term
involvement in work situations that are emotionally demanding. I also believe that in
difficult and stressful working conditions, staff nurses should be motivated and supported
in a proactive way to promote healthy behaviors and prevent illnesses. A safe work
environment that enhances the quality of patient care and retains qualified nurses should
be encouraged. Furthermore, I was motivated by my own sense of personal growth and
advancement. My professional goal is to become a nurse leader who can develop and
communicate a vision that gives meaning to the work of others who have a moral duty to
treat and care for their patients in a professional way. Therefore, my goal for this project
was to create stress management interventions that enhance the nursing work
environment, a condition that is vital to the retention and recruitment of health care
professionals and the sustainability of health systems (Pino & Rossini, 2012).
Potential Biases
Detection of possible biases is hard to envisage. I have worked as a staff nurse
and I am knowledgeable regarding the challenging and diverse role of the psychiatric
nurse. Nevertheless, there is always a possibility for potential bias with any project and
therefore it is important to address. To address any potential bias, an evidence-based
literature review was conducted in the development of this project. In addition,
52
information sources included evidence-based practices from independent health care
organizations, peer-reviewed literature, and national nursing organizations. This project
was reviewed and monitored by my project chair, and any source of information that was
a potential bias was excluded from the project.
Role of the Project Team
Encouraging health promoting behaviors is a key factor in the promotion of
physical, social and psychological well-being for nurses and preventing health problems
(Chan & Perry, 2012). Promotion and use of healthy behaviors in front-line nurses can
enhance their ability cope with job stress (Wright, 2014). The focus of this project was to
develop an educational stress management program for psychiatric nurses and the
psychiatric nurses working at the project site were significant members of the project
team. The objective of this project was to encourage psychiatric nurses to participate in
the educational program and to observe the program from the standpoint of an expert.
Psychiatric nurses are professional in their everyday work stressors and how they manage
their stress (Hasan, 2017). Nurses were encouraged to attend the project presentation so
that they could appraise the educational program from their viewpoint. Psychiatric nurses
in leadership and management positions also formed a vital part of the project team.
Psychiatric nurses in leadership and management positions were encouraged to
participate in the project presentation to gain their insight for managing work stress. All
recognized stakeholders had the opportunity to evaluate the synthesized educational
program and provide comments that served to enhance the program.
53
Processes
I developed and presented a PowerPoint on the educational program to the
nursing leadership council at the project site. The stakeholders included the nurse
supervisors/managers, staff nurses, and patients and were all invited and encouraged to
attend the various sessions per their positions in the organization. Attending the
presentation was essential to ensure unfettered review of the presentation and to provide
the opportunity to ask questions in an unbiased setting. The schedules for the different
presentation times were posted in prominent areas in the facility and announcements were
made in the facility’s bulletin. The maximum number of participants was limited to 15
nurses per session to encourage participants to fully engage while providing the
opportunity to ask more personal questions. The goal was to offer approximately six
presentation sessions. Offering six different presentation times allowed the different
stakeholders to exercise the opportunity to attend at their convenience. Participation by
all team members in this evidence-based stress management educational program
enhanced the project as the team was able to contribute their knowledge, which was used
to complete the project.
Team Member Input
The team members included the executive leaders, the project leader, project
manager, the team leaders of any functional sub teams, and any critical subject matter
experts. The working project teams participating in the project were viewed as proficient
in their perception of stress. Team members had the chance to be present at one of the
educational sessions and gave their perspective on the information presented. Time was
54
provided for participants to comment on the program. Also, participants were given the
opportunity to send their comments/recommendations via emails. The idea behind
allowing team members to email their comments/recommendations was to remove the
likelihood of team members not participating or not making comments because of anxiety
in the group setting. Recommendations from psychiatric nurses, about the stress
management educational program, were integrated into the final project. Team members
were encouraged to appraise the final project after recommended changes were
incorporated.
Timelines
It was vital to establish a formal timeline for the completion of this project.
Nevertheless, it was also essential to consider the work schedules of the participants.
Invitations to participate were sent to psychiatric staff nurses, the various stakeholders,
and nurses at the leadership council. The timeline was established within two weeks of
receiving responses to the invitation. Once the established dates and times had been
fixed, a formal presentation was held with a class capacity of at least ten attendees.
Offering several presentations lessened scheduling conflicts, enhanced attendance, and
improved the opportunity for group discussion and criticism. Nurses in the lead roles who
decide to participate were asked to critique and offer recommendations for enhancement
both during the presentation and within a week of the presentation date. The timeline was
necessary as it incorporated time for a comprehensive review of the evidence, despite
individual participant’s schedule constraints.
55
Summary
Work stress is recognized throughout the world as a major challenge to workers’
health and the welfare of their organizations. Work stress arises when nurses perceive
that they cannot effectively deal with the demands being made on them or with the
pressures that impact their safety. Stressed nurses are also more likely to be unhealthy,
poorly motivated, less productive, and less safe at work. Stress at work continues to
demand attention as it becomes more and more costly for both the individual and the
institution. Educating psychiatric nurses to manage stress at work involves the
establishment of an evidence-based educational program where an individual can learn
how to cope positively with their work stressors. Coping with work stress is a learned
behavior; however, existing evidence has shown that approaches exist to help guide
nurses in this learning. Developing a synthesized educational program that enhances
psychiatric nurses coping with workplace stressors can bridge the gap that exists between
utilizing unhealthy approaches to manage work-related stress and applying evidence-
based best practices in managing work stress. In this project, I assumed the role of a
project manager and presented the evidence-based educational program to all the
stakeholders. Team members in this project served as contextual experts on their
perceptions of stress, offered recommendations for improvement, and evaluated the final
proposal and education to assess compatibility within their organization.
Section three of the project identifies the sources of evidence that address the
practice-focused questions and support the development of the project. Section three will
also elaborate on the different databases, key search terms, and methods used for the
56
comprehensive literature review. Also, section three provides an overview of the project
participants and procedures that were used to collect evidence. Furthermore, the
strategies for protecting project participants and a description of analysis and synthesis
procedures will be discussed.
57
Section 3: Collection and Analysis of Evidence
The responsibility of a psychiatric nurse in an inpatient mental health hospital has
become multifaceted and stressful because of health care dynamics (Zaki, 2016). The
dynamic changes of the patient, emotional liability and psychological distress may
include exposure to aggressive/violent behaviors, emotional responsibility, and
psychological distress that can be both stressful and challenging (Sailaxmi & Lalitha,
2015). Work stress impacts nurses’ health, well-being, and job satisfaction (Khamisa,
Peltzer, Ilic, & Oldenburg, 2016; Khamisa, Peltzer, Ilic, & Oldenburg, 2017; Sharma et
al., 2014). Work stress can also have a negative impact on the degree of absenteeism and
turnover rates among nurses (Mosadeghrad, 2013). Stressors are known to rise with the
level of demand encountered (Zaki, 2016). The literature suggested that work stress is
associated with musculoskeletal disorders
(Azma et al., 2015; Lee et al., 2014), high rates
of anxiety
(Zandi et al., 2011), depression (Lin et al., 2016; Yoshizawa et al., 2016),
reduced job satisfaction (Sharma et al., 2014), and high turnover rates (Mosadeghrad,
2013) and is negatively associated with nurses’ patient care behaviors (Sarafis et al.,
2016).
The practice at the project site involves psychiatric nurses creating nonspecific,
unsuccessful coping strategies to manage their stress without any resources or systems in
place. The purpose of this project was to design, implement, and evaluate an educational
program focused on work stress to minimize or alleviate stress among psychiatric nurses
at the project site. A single theoretical framework was insufficient to guide this project;
therefore four transactional theories were incorporated. These included P-E fit theory, job
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demand-control (support) theory, the JD-R model, and the ERI model, which were used
to inform the definition of work-related stress and to clarify the causes and mechanisms
that underpin work stress. The underlying principle among these theories is an imbalance
between the perceived demands from the work environment and the individual’s
resources to meet those demands, which is defined as a lack of balance between demands
and coping resources or between efforts and rewards (Siegrist & Li, 2016).
The staff education project was developed using Knowles’s principles of adult
learning (Kearsley, 2010), which were intended to encourage and support learners
throughout the process by helping them to recognize their thought processes and
strategies and offered a variety of options as evidence of successful learning outcomes.
Knowles’s principles were also intended to facilitate adult learning and encourage
collaborative efforts and mutual respect among the facility, practitioners, and community
partners. The project consisted of compiling and synthesizing evidence-based practices
that focused on the reduction of work stress. The staff education program plan
incorporated issues identified by the site’s nursing leadership council, and end users were
verified through a formative review using an anonymous questionnaire. The staff
education project was presented via PowerPoint to these groups, and discussions were
conducted to validate the content and ensure adoption. A second formative review was
conducted after the staff education project. My role in this project was as a project
manager. Section 3 of this project study addresses the practice-focused question, sources
of evidence, analysis, synthesis of the related evidence used to guide this project, and
summary.
59
Practice-Focused Question
Psychiatric nurses are influenced by many stressors resulting from their
responsibility to provide quality patient care (Yaribeygi et al., 2017). In the absence of an
established stress management program at the project site, patterns of excessive
absenteeism and extended sick leave had been noted (Department of Nursing callout log,
February, 2018). These nurses had received no formal stress management training, there
was no access to established evidence-based coping strategies, and the organization did
not provide any coping resources or systems. A gap in the practice and knowledge of
evidence-based coping strategies existed among this group of psychiatric nurses.
Therefore, the practice-focused question that was used to address this was the following:
Can an evidence-based stress management education program empower psychiatric
nurses to manage work-related stressors and decrease stress?
The purpose of knowledge clarification is to prepare psychiatric nurses to
understand approaches for managing work stress. This educational program was intended
to strengthen psychiatric nurses’ abilities to engage in healthy lifestyle behaviors that
may serve as a valuable tool in combating negative workplace stress and enhancing
personal well-being (see Kurnat-Thoma et al., 2017; Vassey, 2014). The educational
program included a PowerPoint presentation for the site’s nursing leadership council, end
users, and other key stakeholders. Staffs were given a pretest to determine their baseline
level of knowledge and a posttest to determine the knowledge gained. A question-and-
answer session was conducted with staff after completion of all presentations to address
any doubts or concerns. The goals of the project team and the individual team members
60
aligned with the organization’s objectives. The project was intended to close the gap in
practice through the development of an evidence-based stress management educational
program for psychiatric nurses that included a range of best practices offering nurses an
opportunity to learn about successful techniques that may be implemented in their daily
practice. Strengthening psychiatric nurses’ abilities to engage in healthy stress
management behaviors can serve as a valuable tool in combating negative workplace
stress, improving personal well-being, and retaining qualified health care providers
(Kelley et al., 2016; Khamisa et al., 2016). Promotion and the use of healthy behaviors in
frontline nurses can enhance their ability to cope with work stress (Wright, 2014).
Sources of Evidence
The DNP manual provided guidelines for staff education and the sources of
evidence to be used in the various stages of the project’s development. The databases
used for data gathering included CINAHL, EBSCOhost, ProQuest, MEDLINE, Science
Direct, Nursing & Allied Health, Google Scholar, and Ovid Nursing Journals. Public
websites such as the Centers for Disease Control and Prevention (CDC), Maryland
Department of Health, and Centers for Medicare and Medicare Services were also
referenced. The search terms and Boolean operators used were work stress OR job stress
OR occupational stress, mental health nurses OR psychiatric nurses, and stress
management OR intervention OR rehabilitation OR prevention. The years of publication
were limited to 2011 to 2019. A wide-ranging, organized, and efficient review of
literature was conducted through use of a literature review matrix.
61
The organization, analysis, and summary of the literature that focused on the
effectiveness, appropriateness, and feasibility of the best practices for this project study
were achieved through the use of Melnyk’s hierarchy of evidence decision-making
matrix (Melnyk & Fineout-Overholt, 2011). The decision-making matrix enabled me to
sort and categorize different points or informational aspects related to work stress. The
systematic review or meta-analysis of randomized controlled trials and evidence-based
clinical practice guidelines, which are considered the strongest or highest level of
evidence to guide clinical decisions (Melnyk, 2011), was used to guide this project. These
studies were critically appraised and synthesized to deepen understanding and inform the
practice-focused question. Enhanced knowledge and understanding of workplace stress
and burnout within psychiatric hospitals may be used to make recommendations that have
the potential to influence and promote higher quality patient care and decrease rates of
turnover (see Vassey, 2014). The literature review included data originally published in
English and excluded publications about work stress not related to nurses. The total
number of articles reviewed was 76. The number of articles considered for this project
was 15. I used an appropriate search strategy and appraised all articles using the
Melnyk’s hierarchy of evidence decision-making matrix, which facilitated a better
understanding of the literature needed to support and inform this project. While
appraising the articles and answering the practice focus questions, 15 articles were
selected as the most relevant articles, which provided information or context for the
project. From the relevant articles, the Melnyk’s hierarchy of evidence decision-making
matrix levels of evidence was used to choose an article that met the criteria for level I
62
evidence, which was the highest level of evidence-based research available (i.e.,
systematic reviews and meta-analysis) (Melnyk, 2011). The hierarchy of evidence matrix
ensured that the highest level of evidence was selected first from the systematic review
articles followed by articles from peer-reviewed journals in the various databases.
Stress is a vital part of our everyday challenges. It is one of the major
psychosocial work risks and a problem and concern for both employees and employers
(Tearle, 2013). Stressful situations can occur when a nurse realizes that the demands of a
job are bigger than the ability to handle those demands for extended periods (Sarafis,
Rousaki, Tsounis, Malliarou, Lahana, & Bamidis, 2016). Stress not managed can result in
high levels of employee dissatisfaction, illness, absenteeism, high turnover, decreased
productivity, and difficulty in providing quality patient care (Bang & Park, 2016; Tabaj et
al., 2015; Zaki, 2016). Analysis of evidence-based practices revealed the following
recommendations for employee assistance programs: modifying work practices through
effective interpersonal communication; redesigning the work environment to reduce
environmental stressors; using relaxation or meditation techniques; developing clear
professional roles and improving organizational climate through communication, social
support, shared vision, and feedback; reviewing the rotation of work shifts, and taking
mental breaks from the stressor (Gardner, Hailey, Nguygen, Prichard, & Newcomb,
2017; Hewko, Brown, Fraser, Wong, & Cumings, 2015; Jones, McLaughlin, Gebbens, &
Terhorst, 2015; Warshansky, Wiggins, & Rayens, 2016). Employee assistance programs
(EAPs) provide support and resources for struggling employees to ensure that they are
able to manage their stress and remain productive at work, even when faced with difficult
63
work experiences (Richmond, Pampel, Wood, Nunes, 2017). All psychiatric nurses
should be advised about the EAP and given instructions about how to access these
programs when they are stressed and need support. In addition, nurse managers can and
should refer nurses to the EAP if they are unable to resolve the stress through on-the-job
coaching and support. Essentially, these studies support the proposed project as an EAP
designed intervention program that serves to identify and help employees resolve any
stressful situation that interferes with the employee’s ability to perform his or her work
according to the organizational standards (Richmond et al., 2017). Hence, an EAP is
recommended to encourage a positive work environment, increase productivity, and
promote employee retention.
Ata and Dogan’s study (2018) evaluated the effect of the Brief Cognitive
Behavioral Stress Management Program (BCBSMP) on mental status, coping with stress
attitude, and caregiver burden on psychiatric nurses while caring for patients with
schizophrenia using a pretest/posttest control group model. The study included 61
caregivers who provided care for schizophrenia patients at a community mental health
center. The caregivers in both groups were assessed using the Demographic Data Form,
Zarit Caregiver Burden Scale, Coping Attitude Evaluation Scale, Stress Indicators Scale,
and the General Health Survey-28 before and after the program. Results showed that
stress indicators, risk of developing a psychological disorder, and caregiver burden
decreased while skills related to both the problem-oriented and emotion-oriented aspects
of stress increased in the study group after the program was completed (Ata & Dogan,
2018). The study is supportive of the proposed project as evidenced through the
64
recommendation that a psycho-educational program should be established for psychiatric
nurses to help them learn how to cope positively with their stressors. In addition, training
programs and courses on stress management can help psychiatric nurse to enhance their
stress-bearing capacity and improve their work performance.
In a qualitative study to report mental health nurses’ perspectives and experiences
in a workplace resilience program, Foster et al. (2018) showed that resilience programs
are a strength‐based preventative approach to supporting nurses in overcoming
workplace stress. Twenty‐nine registered nurses from a metropolitan psychiatric service
participated in an exploratory qualitative inquiry that utilized open‐ended responses,
semi‐structured interviews, and focus groups. The analysis found four main themes:
being confronted by adversity, reinforcing understandings of resilience, strengthening
resilience, and applying resilience skills at work. Findings illustrated that resilience
programs can help to improve nurses’ self‐efficacy and ability to realistically appraise
stressful situations and to moderate their emotional responses to others. These findings
are supportive of the proposed project as the incorporation of stress management
strategies into clinical practice may help sustain beneficial outcomes that address
workplace challenges. Crane and Searle (2016) recommended that resilience programs
are provided to promote nurses’ well‐being and resilient practices. Hence, strengthening
resilience involves understanding resilience and applying strategies such as positive
self‐talk, managing negative self‐talk, detaching from stressful situations, being aware
of and managing emotions, and showing more empathy.
65
A one group pretest and posttest design was used to test if a stress management
program can equip nurses with skills to cope more effectively (Sailaxmi & Lalitha,
2015). The study used a group pretest and posttest design in which both genders of
psychiatric nurses engaged in a stress management program that was comprised of 10
consecutive, one-hour sessions. Data was collected immediately after the intervention and
then four weeks later using the DCL Stress scale (De Villiers, Carson & Leary Stress
Scale). Results showed that preintervention stress levels were reduced significantly four
weeks after the intervention. The findings align with the proposed doctoral project
because stress management strategies positively impacted the nurses’ stress levels. The
ability to manage stress in the workplace can make the difference between success and
failure on the job. Adopting stress management programs that educate employees about
the sources of stress, effects on their health, and how they can reduce stress can be very
effective. The knowledge gain from a stress management program can also motivate
organizations to explore the stressors that are present in their own work environments,
and take steps to reduce and/or prevent stress in the workplace, thereby working to
maintain the health and well-being of the employees. The Health and Safety Executive
(2015) recommends that organizational approaches coupled with individual strategies are
the most effective way to address job stress. Adequate stress management can improve
the health of nursing professionals and the quality of care they provide to patients.
To determine the prevalence and associated factors of job stress among nurses in
primary health centers in Arar, Saudi Arabia Alanazi et al., 2019 designed a cross-
sectional study of 101 nurses covering all local primary healthcare centers (n=12). Data
66
were collected using a self-administered questionnaire including demographic
characteristics of nurses and a work stress questionnaire. Results revealed that time
pressure; boredom-induced stress, pressure on the job, work under-load stress, and
disagreement and indecision were the most common areas of work-related stress among
nurses. One-third of the nurses indicated that they experienced work-related stress.
According to Alanazi, nurses have a relatively high level of stress associated with their
work environment, resources, workload, and time—all of which have been identified as
major stressors. Sailaxmi and Lalitha (2015) suggested that management programs may
equip nurses with skills to cope effectively with the stress. Preventing and minimizing
stress at work can help the physical and mental health of nurses and their quality of life at
work. In addition, managing nurses work stress also plays a crucial role in the
organization since the prevention and minimization of stress can decrease absenteeism,
encourage a less stressful work environment, impact productivity, and affect quality of
work (Goulart, 2015). Alanazi et al.’s findings regarding the application of interventional
programs to relieve sources of stress and additional stress management training are
supportive of this project.
To evaluate the long-term effectiveness of modified brief assertiveness training
with cognitive techniques for nurses, Yoshinaga et al. (2018) used a single-group study in
which nurses received two 90-minute training sessions with a 1-month interval between
sessions. The degree of assertiveness was assessed by using the Rathus Assertiveness
Schedule (RAS) as the primary outcome, at four time points: pre- and post-training, 3-
month follow-up, and 6-month follow-up. Results showed that a total of 33 nurses
67
received the training, and the mean RAS score improved from pre-training to post-
training. These improvements were maintained until the 6-month follow-up. The pre-post
effect size was larger than the effect sizes ranging from no effect reported in previous
studies that used brief training. The study recommends that modified brief assertiveness
training is feasible and may achieve long-term favorable outcomes in improving
assertiveness among nurses Yoshinaga et al.’s findings are supportive of this project.
According to Alberts and Hülsheger (2015), awareness of thoughts, awareness of bodily
sensations and self-compassion help people to deal with stress. Hence, the
implementation of assertiveness training is important because creating an open
environment for communication leads to decreased stress, improved job satisfaction,
improved nursing care, and increased patient safety.
Yang, Tang and Zhou (2018) examined stress experienced by psychiatric nurses
by using mindfulness-based stress reduction (MBSR) therapy, which has had positive
effects on work stress and can reduce anxiety, depression, other negative emotions, and
improve mental health among psychiatric nurses. One hundred psychiatric nurses,
including 68 females and 32 males, were selected as participants from three hospitals in
the Hunan Province of China. These nurses were randomly distributed into the
intervention and control groups, with 50 respondents in each group. MBSR therapy was
used as psychological intervention in the intervention group. Before and after the
intervention, the two groups were assessed with the Symptom Checklist-90 (SCL-90)
scale, Self-Rating Depression Scale (SDS), Self-Rating Anxiety Scale (SAS), and
Nursing Stress Scale. Results indicated that after the intervention, the SCL-90 score of
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the intervention group showed a decrease in the symptom checklist. In addition, after the
intervention, the SDS and SAS scores of the intervention group also showed a decrease in
depression and anxiety respectively. Furthermore, the Nursing Stress Scale score of the
intervention group also showed a decrease in stress levels. The findings align with this
doctoral project since an effective preventive intervention may not only lead to the
maintenance of a healthy mental state in nurses, but also better quality of care for
inpatients. According to Shapiro, Wang, and Peltason (2015) mindfulness interventions
in the workplace target workplace functioning such as stress reduction and improving
decision-making, productivity, resilience, interpersonal communication, organizational
relationships, perspective-taking, and self-care. Mindfulness-based interventions have the
potential to improve nurses’ health and work engagement and as a consequence, the
quality of services provided to patients. Yang, Tang, and Zhou (2018) recommended that
mindfulness-based stress management programs are effective for reducing depression and
anxiety among psychiatric nurses. Hence, mindfulness skills may be the mediating factor
for stress reduction.
To investigate the effects of an internet-based cognitive behavioral therapy
(iCBT) program on depressive symptoms among nurses in Japan Kuribayashi et al.
(2019) designed a RCT to verify the effectiveness of the program in improving
depressive symptoms. Data was collected via online questionnaires. The iCBT program
consisted of six modules, covering different components of a cognitive behavioral
therapy (CBT), the transactional stress model, self-monitoring skills, behavioral
activation skills, cognitive restructuring skills, relaxation skills, and problem-solving
69
skills. Participants in the intervention group were asked to read the modules within 9
weeks. Results were assessed three times using the Beck Depression Inventory-II (BDI-
II). At the baseline, three, and six-month follow-ups the iCBT intervention significantly
improved occupational stress among hospital nurses. These findings suggest that work-
related stress interventions can be effective in improving depressive symptoms and other
work-related outcomes among nurses. The findings support this project as the cognitive-
behavioral therapy for stress management may be an appropriate strategy for improving
personality constructs (Kuribayashi et al., 2019). CBT focuses on how a person’s
thoughts, beliefs, and attitudes affect their feelings and behaviors. CBT can have a
positive impact on how nurses feel, act, and equip themselves with coping strategies that
help them deal with challenges.
The subjective concept of nurses’ well-being and experience of psychiatric
problems among psychiatric nurses in the United Kingdom was explored by Oates
(2018). Data were collected from a survey of 237 psychiatric nurses about their mental
health and well-being, and 27 psychiatric nurses were interviewed regarding their
personal experiences. Results showed that the nurses used strategies such as physical
exercise, mindfulness practice, spending time in nature, and listening to music to improve
their well-being. The support this doctoral project since mindfulness practices can be an
alternative and complementary therapeutic approach for stress reduction among
psychiatric nurses and opportunities to take part in activities can improve staff well-being
through shared initiatives. Mindfulness in a relationship is about observing what the other
person is doing in a non-judgmental way. Oates suggests that mindfulness practices are a
70
promising modality for stress management among healthy individuals. Hence, all stress
management programs should include mindfulness practices as one of the approaches for
stress reduction.
Evidence Generated for the Project
The participants for this project included all 61 psychiatric nurses on the 14 units.
The psychiatric nurses included all merit nurses, as well as contractual and float pull
nurses, who work 8 or 12-hour shifts. The clinical experience of the nurses ranged from
one to more than 15 years. The project exclusion criteria included nurses who were on
extended sick leave or who were absent at the time of implementation. However, staff not
present during the implementation phase received the educational information when they
returned to work. Auxiliary staff members such as the direct care assistant and patient
crisis intervention staff were not included.
Procedures
After receiving approval from the Institutional Review Board, I began the first
phase of the project. Prior to the project being developed, discussions with senior
management/leadership were conducted concerning the high rates of absenteeism and
work stress, and they requested that I develop an educational program that would
minimize stress and decrease absenteeism. Senior management encouraged nurses to
participate in the stress management program in the training phase. A project team
consisting of representatives from psychiatric staff nurses, nurse managers, nurse
supervisors, and support nurses was formed. That team was involved in the overall
program planning, implementation, follow up, and evaluation. Maximum participation
71
was encouraged through the distribution of posters and newsletters. Meetings were also
held to create greater awareness of the comprehensive stress management program. I
obtained the deidentified data regarding callouts and absenteeism for thirty-days from the
nursing administration office before the implementation of the educational intervention. I
downloaded the data into an Excel spreadsheet and stored the collected data on my
personal computer, which was password protected and kept in a private, locked office.
The nurse manager in the nursing office and the preceptor of the project manager had
access to the data.
After collecting the data, I compiled educational information for stress
management practices/techniques from the American Heart Association into educational
flyers and handouts that was presented to the nursing leadership council for feedback and
approval. The content of the handouts included stress management and how to reduce,
prevent, and cope with stress. The flyers showed pictures that were designed to increase
the understanding of how to manage and cope with stress. The handout was used during
various presentation sessions. Once the educational material was approved, the nurses
from the 14 units were informed about the project. Flyers with dates and times were
placed in all 14 units to remind nurses about the learning sessions.
A 10-point multiple-choice, perceived stress questionnaire obtained from the
American Sociological Association (Appendix A) was used to assess the nurses’
knowledge before the educational intervention. The pretest paper questionnaire and
pencils were distributed to the participants in the unit conference room prior to the
educational presentation. The participants were given 15 minutes to complete the pretest.
72
Upon completion, the participants placed their responses in an envelope labeled Pretest,
which was collected by the unit manager. The envelope was then sealed, placed, and
stored in a secure filing cabinet located in a private, locked office. The data collected
from the completed pretest questionnaires was then uploaded into the password protected
computer in my home office, which was only accessible to myself. After the data was
uploaded into an Excel file, the paper questionnaires were destroyed. All data was
analyzed by myself using descriptive statistics.
The education sessions were held during all three shifts in the unit conference
room, thus providing attendance opportunities for all of the psychiatric nurses. The stress
management educational content was presented in a PowerPoint presentation that lasted
for 30–45 minutes. During these sessions, information about stress and stress
management practices in the form of handouts was provided. After the education
sessions, a 10–15 minute question-and-answer session was conducted. The entire session
lasted 45–60 minutes. A checklist was presented at every educational presentation and
staffs were asked to sign-in. The purpose of the checklist was to ensure that all employees
were accounted for.
One month after the completion of the presentation, the PSS paper-pencil
questionnaires were once again administered as a post-test to all the staff, taking no more
than 10–15 minutes to complete. Upon completion, the participants placed their
responses in an envelope labeled Posttest, which was collected by the unit manager. The
envelope was then sealed, placed, and stored in a secure filing cabinet located in a
private, locked office. The data collected from the completed posttest questionnaires was
73
then uploaded into the password protected computer in my home office which was only
accessible to myself until the time of analysis. After the data was uploaded into an Excel
file, the paper questionnaires were then destroyed. The data was analyzed by me using
descriptive statistics.
One month after completing the educational presentation, I obtained a one-month
prospective, deidentified data set of the callouts or absenteeism for a thirty-day period
from the nursing administration office. The data was provided by the nurse manager in
the nursing administration office via confidential email. The data included the number of
callouts or absenteeism per month and was uploaded into the password protected
computer in my home office. The data was then compared to the deidentified data of the
number of callouts/absenteeism obtained for the thirty-days before the educational
intervention. The data was analyzed to assess whether there was a reduction in the
participants’ level of work stress over a 30-day period after exposure to the educational
intervention.
Instruments
The Cohen 10-item Perceived Stress Scale (Cohen PSS-10) questionnaire is the
most widely used psychological instrument for measuring the perception of stress
(Taylor, 2015). Cohen PSS-10 was developed by
Cohen and Williamson (1988). The
scale measures the degree to which situations in one’s life are appraised as stressful. The
original Perceived Stress Scale consisted of 14 items that formed a one-dimensional scale
of globally perceived stress; however, the Cohen 10-item form is more commonly
administered (Taylor, 2015), and was used as the instrument for this project. The
74
questions in the scale ask about feelings and thoughts during the last month and in each
case, respondents were asked how often they felt a certain way. The items are designed to
show how unpredictable, uncontrollable, and overloaded respondents find their lives. The
items are easy to understand, and the response alternatives are simple to grasp. The scale
also includes a number of direct queries about current levels of experienced stress (Cohen
& Williamson, 1988). The ten questions presented in the pre- and posttests were modified
to pertain specifically to psychiatric nurses and the patient population they serve. The
word at work was added at the end of each question in the scale. The modification of the
PSS questionnaires was made by myself and it did not affect the reliability and validity of
the instrument. Participants endorsed each item on a 4-point Likert scale with responses
that ranged from 0 = Never; 1 = Almost Never; 2 = Sometimes 3 = Fairly Often; 4 =
Very Often. Total stress scores were calculated by summing the responses and ranged
from 0 to 40, with higher scores reflecting higher states of perceived stress. Scores
ranging from 0–13, 14–26, and 27–40 indicate low stress, moderate stress, and high
perceived stress, respectively (Cohen, 1988). The Cohen Perceived Stress Scale is used
widely across various countries. The PSS-10 has good internal consistency and reliability
(Baik, Fox, Mills, Roesch, Sadler, Klonoff, & Malcarne, 2017; Denovan, Dagnall,
Dhingra, & Grogan, 2017). PSS-10 has been used as a valid and reliable instrument to
measure perceived stress in adults with asthma (Khalili, Sirati, Ebadi, Travallai, & Habibi
(2017). It has also been used to understand the experience of stress among older adults.
75
Analysis/Synthesis
Data collected from the Perceived Stress Scale as the pretest and the posttest was
analyzed by myself using descriptive statistics and the findings synthesized. Participants’
scores were loaded in an Excel spreadsheet to evaluate the differences in stress scores
before and after the educational presentation. The goal was to see at least a 20% decrease
in stress scores after one month of the educational presentation. The pre- and posttest
questionnaires were compiled at the end of each session to ensure that all tests were
returned and placed in a sealed envelope labeled with the appropriate Pretest or Posttest
label. Nurses on approved sick leave were eliminated from the participant population to
alleviate outliers. The deidentified 1-month retrospective callout/absenteeism data was
examined to determine the percentage of nurses identified at risk for, or experiencing,
stress out of the total number of nurses working within the one month prior to the
educational intervention. Retrospective data was obtained from the number of nurses who
called out sick or were absent a month prior to the intervention. Prospective data was also
obtained from the number of nurses who called out sick/were absent a month after the
educational intervention. Both the retrospective and prospective data were uploaded to a
Microsoft Excel spreadsheet. The number of callout/absenteeism days before and after
the educational intervention was then reviewed and compared using descriptive statistics.
The pretest and posttest scores were also uploaded to an Excel spreadsheet and
descriptive statistics were used to compare the pretest and posttest scores. The overall
mean score percentages of the nurses from the PSS pretest and posttest was also
compared using descriptive statistics.
76
Summary
Psychiatric nurses experience a significant amount of stress at the workplace,
which has a negative impact on their health and work performance (Ahanchian,
Meshkinyazd, & Soudmand, 2015). With the addition of the educational program, the
psychiatric nurses gained information and tools needed to manage the myriad of stressors
that impact their work lives. The educational presentation provided a mechanism for
them to access the intervention at times and places convenient to their busy and often
stressful schedules. Education was provided to all psychiatric nurses working in the
various units of the in-patient psychiatric hospital during a 60-minute verbal presentation.
During the presentation, psychiatric nurses were given pretest questionnaires and a month
after the presentation a posttest questionnaire was administered. Furthermore, nurses
were encouraged to participate in the discussions and a question-and-answer session was
provided to clarify any vague information. The evidence gathered from organizational
operations and the deidentified retrospective and prospective absenteeism data provided
the PSS pre- and posttest education that nurses receive as soon as they are employed to
the organization along with identifying the increase or decrease in number of
callout/absenteeism. The instrument that was used to assist in gathering this data was the
Cohen-10 Perceived Stress Scale, a classic stress assessment instrument used to measure
individual stress levels, and is considered to be a reliable and valid tool to measure
individual stress levels (Lee, & Jeong, 2019; Lee, 2012; Sun, Gao, Kan, & Shi, 2019).
Data collection consisted of the pre- and posttest questionnaires and the PSS. Analysis
and synthesis of data collected was entered into an Excel spreadsheet database on a
77
password protected computer, which was only accessible to myself, and analysis was
performed using descriptive statistics. Section 4 will discuss the project findings and
recommendations, which have the potential to influence psychiatric nurses after the
implementation of the proposed project.
78
Section 4: Findings and Recommendations
Psychiatric nursing is viewed as one of the most stressful occupations in the
world. Psychiatric nursing is physically and psychologically demanding, especially for
nurses faced with a specialized work burden and the dangers associated with job stress.
Psychiatric nurses work long hours performing physically and mentally fatiguing duties
that can affect their well-being (Omori, 2015). Work stress and successful coping tactics
have been associated with the nurses’ level of well-being (Chana, Kennedy, & Chessell,
2015). Increased levels of nurse stress impact the nursing profession and health care.
Stress has been linked to low job satisfaction; poor quality in work relationships,
collaboration, and ability to provide high-quality patient care; poor work engagement;
and increased absenteeism and turnover (Chana et al., 2015; Hall, Johnson, Watt, Tsipa,
& O’Connor, 2016).
The local problem addressed in this DNP project involved practicing psychiatric
nurses’ use of nonspecific unsuccessful coping strategies to manage their stress in the
absence of a stress management program. There had been an increase in
callouts/absenteeism and turnover at the project site, which increased from 11% to 15%
in 2016. The gap in practice addressed by this project was the lack of a recognized
educational program or resources at the project site to provide psychiatric nurses with
stress management interventions to decrease daily work-related stress. Methods used to
manage stress were often not evidence based, which led to ineffective stress management.
Additionally, some nurses reported leaving the organization as a result of excessive stress
79
caused by a high workload, understaffing, and lack of support or positive feedback from
managers and supervisors.
The practice-focused question guiding this project was: Can an evidence-based
stress management education program decrease stress and absenteeism among practicing
psychiatric nurses at the project site? Stress management interventions corresponding to
secondary and tertiary prevention have been shown to decrease stress and improve well-
being (Czabała et al., 2011). Employee assistance programs including modifying work
practices through effective interpersonal communication; redesigning the work
environment to reduce environmental stressors; using relaxation or meditation
techniques; developing clear professional roles and improving organizational climate
through communication, social support, shared vision, and feedback; reviewing the
rotation of work shifts; and taking mental breaks from the stressor have been shown to
decrease stress, encourage a positive work environment, increase productivity, and
promote employee retention (Gardner et al., 2017; Hewko et al., 2015; Jones et al., 2015;
Richmond et al., 2017; Warshansky, Wiggins, & Rayens, 2016). Psycho-educational
programs (Ata &
Dogan, 2018), resilience programs (Foster et al., 2018), assertiveness training
(Yoshinaga et al., 2018), and mindfulness-based stress management programs (Oates,
2018; J. Yang et al., 2018) have also been shown to decrease stress and provide a positive
impact on how nurses feel and act while equipping them with coping strategies to help
them deal with challenges.
80
The purpose of the project was to design, implement, and evaluate a stress
management educational program that focused on work stress among practicing
psychiatric nurses to assist them in reducing levels of stress and absenteeism. The project
sought to encourage a culture of awareness and mindfulness about work stress, facilitate
practicing psychiatric nurses’ management of their work stress to promote health/well-
being and decreased absenteeism, and has a positive effect on productivity and the quality
of patient care. Nurses’ absenteeism affects patient care outcomes and can increase
patients’ length of stay in the hospital due to high workload and low morale of the
remaining on-duty nurses.
The sources of evidence for this project included the PSS-10 questionnaire
obtained from the American Sociological Association (see Appendix A), for measuring
the perception of stress. The instrument was used for measuring nonspecific perceived
stress and for assessing the effectiveness of stress-reducing interventions. The instrument
measures the degree to which situations in a person’s life are appraised as stressful.
In addition, evidence for this project was obtained from the review of literature
that focused on the effectiveness, appropriateness, and feasibility of the best practices for
this capstone project through the use of Melnyk’s hierarchy of evidence decision-making
matrix (Melnyk & Fineout-Overholt, 2011). The decision-making matrix enabled me to
be able to sort and categorize different points or informational aspects related to work
stress. Data analysis was done using the IBM SPSS Version 25. Descriptive statistical
procedures used to analyze the data included frequency distribution for gender, age, and
pre- and poststress management education. A dependent group, paired sample t test was
81
used for the PSS to determine whether there was a statistically significant difference
between the mean pre- and posttest scores for perceived work stress assessment
questions.
Findings and Implications
After receiving approval from the Walden University Institutional Review Board,
I started the first phase of the project. Before developing the project, I had discussions
with the senior management/leadership team about the high rates of absenteeism and
work stress in the facility. They requested that I develop an educational program that
would minimize stress and decrease absenteeism. I formed a program team involving
psychiatric staff nurses, nurse managers, nurse supervisors, and support nurses who were
involved in the program planning, implementation, follow-up, and evaluation. Maximum
participation was encouraged through the distribution of posters and newsletters. I
conducted team meetings to create greater awareness of the comprehensive stress
management program and to discuss the resources and skills available for running the
program. I obtained de-identified retrospective data of the number of callouts or
absenteeism for 30 days from the nursing administration office before the implementation
of the educational intervention (see Appendix B). I downloaded the data in an Excel
spreadsheet and stored the data on my personal computer, which was password protected
and kept in a private, locked office.
Demographic Data of Respondents
Sixty-five participants attended the program, but three dropped out and provided
no reason for leaving. One direct care assistant said she was not interested in the program
82
because she did not perceive herself as experiencing work stress. A total of 61 nurses (51
females and 10 males) participated in the stress management education program (see
Table 1). Most of the participants were female, 51-60 years of age, and in the job
classification of registered nurse charge (RNC). The age range may have been the result
of older nurses being the most skilled and productive employees (see Clendon & Walker,
2015). Many older nurses favor flexible working arrangements to manage their home and
work responsibilities. In addition, older nurses take their work more seriously, and take
fewer sick days than younger nurses (Kottwittz, 2018). Nurses on approved sick leave
were eliminated from the participant population to alleviate outliers.
Table 1
Demographics of Respondents
Demographic
Number of nurses
Percentage (%)
Age range
20-30 3 4.90
31-40 8 13.11
41-50 17 27.90
51-60 21 34.42
61-70 12 19.67
Gender
Male 51 83.6
Female 10 16.4
Classification
DCA 17 27.9
LPN 5 8.2
RN 9 14.8
RNC 23 37.7
RNS 7 11.5
Note. Key: DCA-Direct Care Nursing Assistant; LPN-License Practical Nurse; RN-
Registered Nurse; RNC Registered Nurse Charge; RNS- Registered Nurse Supervisor.
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The de-identified 1-month retrospective callout/absenteeism data was examined to
determine the percentage of nurses identified at risk for or experiencing stress out of the
total number of nurses working within the one month prior to the educational
intervention. All the respondents (100%) had called out at least once in the month before
the intervention, implying that the nurses were all experiencing work stress (Table 2).
Five of the nurses had called out once in a month (8.2%). Eleven of the nurses each
called out twice in a month (18.0%). The majority of the nurses (14) had called out five
times (23.0%) in the month prior to the educational intervention. 61 respondents called
out 36 times in the month prior to the educational intervention. The total percent of
callouts in the month (100%) is an indication that nurses at the project site are very
stressed, which is one of the most common causes for unscheduled absences in the job
and organization (Gangai, 2014; Kanwal, Riaz, Riaz, & Safdar, 2013).
Table 2
Absenteeism One Month Before Educational Intervention
Number of nurses who
callout in a month
Frequency of callout in a
month
Percent of callout in a
month
5 1 8.2
11 2 18.0
13 3 21.3
8 4 13.1
14 5 23.0
4 6 6.6
4 7 6.6
2 8 3.3
Total 61 36 100.1
Most of the callouts were among the RNC who had 86 callouts and the DCA who
had 64 callouts per month before the educational intervention (Table 3). The increase
84
number of callouts among the RNC and the DCA may be the result of these nurses
having a wide area of responsibility and workload. DCAs typically spend more time
interacting with patients promoting patient safety and well-being than the charge nurses
or registered nurses, who play a pivotal role in the promotion, maintenance and
restoration of patients’ health and well-being. One hundred percent of the nurses who
participated in the project had a total of 253 callouts in the month before the educational
intervention.
Table 3
Callout per Classification One Month Before Education Intervention
Nurse classification Number of nurses Percentage of nurses Number of callout
per month
DCA 17 27.9 64
LPN 5 8.2 17
RN 9 14.8 37
RNC 23 37.7 86
RNS 7 11.5 49
Total 61 100.0 253
The design used for this project was a before and after approach, which started
with educating the psychiatric nurses to avoid work stress and decrease absenteeism. The
PSS questionnaire was administered to the psychiatric nurses from all 14 units at the
project site. A 10-point multiple-choice format perceived stress questionnaire obtained
from the American Sociological Association (Appendix A) was used to assess the nurses’
knowledge before the educational intervention. The pretest paper questionnaire and
85
pencils were distributed to the participants in the unit conference room prior to the
educational presentation. The participants were given 15 minutes to complete the pretest.
Upon completion, the participants placed their responses in an envelope labeled Pretest,
which was collected by the unit manager. The envelope was then sealed, placed, and
stored in a secure filing cabinet located in a private, locked office. The data collected
from the completed pretest questionnaires was then uploaded into the password protected
computer in my home office, which was only accessible to myself until analysis. After
the data were uploaded in an Excel, the paper questionnaires were destroyed (Appendix
C). The data was analyzed by me using descriptive statistics.
Perceived work stress was measured with a Likert scale. Individual scores on the
PSS can range from 0 to 40 with higher scores indicating higher perceived stress. Scores
ranging from 0–13, 14–26 and 27–40 are considered low stress, moderate stress and high
stress, respectively. The results from the pretest indicated that all the participants had
been very stressed and that 93.44% of respondents had high stress in the month prior to
the educational intervention (Table 4). None of the respondents had low stress, and
6.56% of the respondents were moderately stressed. The various stress levels of the
respondents may be linked to increased levels of work stress as reported by the
respondents facing challenges which were associated with their perception of having little
control, but lots of demands in the workplace.
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Table 4
Nurses’ Baseline Knowledge of Perceived Work Stress Before Educational Intervention
Perceived stress level Number of nurses with work
stress
Percentage of nurses with
perceived work stress
0–13 0 0.00
14–26 4 6.56
27–40 57 93.44
Total 61 100.00
After collecting the data, I compiled the educational information for stress
management practices/techniques from the American Heart Association (n.d) into
educational flyers and handouts that was presented to the nursing leadership council for
feedback and approval. The content of the handouts included stress management
including how to reduce, prevent, and cope with stress. The flyers showed pictures to
increase the understanding of how to manage and cope with stress. The handout was used
during the various presentation sessions. Once the educational material was approved, the
nurses from the 14 units were informed about the project. Flyers with dates and times
were placed in all 14 units to remind nurses about the learning sessions.
The education sessions were held during all three shifts in the unit conference
room, thus providing attendance opportunities for all of the psychiatric nurses. The stress
management educational content was presented in a PowerPoint presentation that lasted
for at least 30 minutes. During these sessions, information about stress and stress
management practices in the form of handouts was provided. The content of the
educational presentation was stress reduction techniques that constituted a safe and
87
effective approach for reducing stress and how nurses experiencing stress or stress-
related symptoms could benefit from the various stress management techniques. These
techniques included deep breathing exercises, which have been successfully used to
decrease fatigue and reduce anxiety in the management of acute stressful tasks as well as
meditation and relaxation techniques. These stress management techniques provide the
same benefits of maintaining inner peace, and a sense of calm and balance that can
benefit both the emotional well-being and the overall health of the nurse (Etim, Bassey,
& Ndep, 2015). The stress reduction techniques (Appendices F and G) are therapeutic for
healthcare providers, enhance interactions with patients, and improve the providers
quality of life (D’Souza, Umarani, Shetty, & Asha, 2015; Etim, Bassey, & Ndep, 2015).
After the education sessions, a 10-15 minute question-and-answer session was conducted.
The entire session lasted 45 minutes. A roster was presented at every educational
presentation and staffs were asked to sign-in. The purpose of the roster, kept by the unit
manager, was to ensure that all employees were accounted for.
One month after the completion of the presentation, the PSS paper-pencil
questionnaires were administered again as a posttest to all present staff. The posttest and
pencils were distributed on all shifts to the participants in the unit conference room. The
participants were given 15 minutes to complete the posttest. Upon completion, the
participants placed their responses in an envelope labeled Posttest, which was collected
by the unit manager. The envelope was sealed, placed, and stored in a secure filing
cabinet located in a private, locked office. The data collected from the completed post-
test questionnaires was then uploaded into the password protected computer in my home
88
office which was only accessible to myself until analysis was initiated. After the data was
uploaded in an Excel file, the paper questionnaires were destroyed. The data was
analyzed by me using descriptive statistics. The pre- and posttest questionnaires were
compiled at the end of each session to ensure that all tests were returned and placed in a
sealed envelope labeled with the appropriate Pretest or Posttest label.
When all the posttest responses on perceived work stress were reviewed, data
showed that 9.84% of the nurses had low level of perceived work stress (Table 5).
90.16% of the staff had moderate levels of perceived work stress in the month after the
educational intervention. None of the respondents had high levels of perceived work
stress in the month after the educational intervention. The results may be linked to
nurses’ awareness and involvement towards achieving a common goal, which was to
reduce stress, promote health, and well-being and a stronger affective commitment.
Table 5
Nurses’ Knowledge Gain on Perceived Work Stress After Educational Intervention
Perceived stress scores Number of nurses perceived
work stress
Percent of nurses perceived
work stress
0–13 6 9.84
14–26 55 90.16
27–40 0 0.00
Total 61 100.00
Participants’ scores were loaded in an Excel spreadsheet to evaluate the
differences in stress scores after the educational presentation. The goal was to see at least
a 20% decrease in stress scores after one month of the educational presentation. The
89
results from the comparison of the Pre-and Post-test questionnaires found that the staff
perceived an 83.6% decrease in moderate perceived work stress, and 93.44% decrease in
high perceived work stress. None of the staff experienced a high perceived work stress
after the educational intervention. The results show a remarkable improved level of low
(9.84%), medium (90.16%), and high (0%) stress after the educational intervention. The
results also show a significant difference from the original goal of 20% stress reduction
implying that most of the nurses have gained knowledge regarding the management of
work stress that can decrease absenteeism/callouts.
One month after completing the educational presentation, I obtained a one month
prospective de-identified data of the number of callouts or absenteeism for thirty-days
from the nursing administration office. The data was provided by the nurse manager in
the nursing administration office via confidential email. The data included the number of
callouts or absenteeism per month and was uploaded into the password protected
computer in my home office. The data was then compared to the de-identified data of the
number of callouts or absenteeism obtained for the thirty-days before the educational
intervention. The data was analyzed to assess whether there was a reduction in the
participants’ level of work stress over a 30-day period after exposure to educational
interventions.
The majority of the nurses to include nurses from all categories (49.2%) did not
call out one month after the educational intervention, and few nurses from all categories
(8.2%) called out more than twice in a month. The total frequency of callouts per month
after the educational intervention was 6. Among these 6 callouts, 15 nurses only called
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out once (26.2%), 10 nurses called out twice (16.4%), and only 5 nurses called out 3
times (8.2%) in the month after the educational intervention (Table 6). The reduction in
the number of callouts after the educational intervention is an indication that nurses have
gained knowledge to effectively manage their work stress.
Table 6
Callouts One Month After Educational Intervention
Number of nurses who callout
in a month
Frequency of callout in a
month
Percent of callout in a month
30 0 49.2
15 1 26.2
10 2 16.4
5 3 8.2
One month after the educational intervention, the number of callouts per nurse
classification improved (Table 7). There was no callouts from the LPN classification. The
zero callouts in the LPN classification may be attributed to their roles in the facility in
which two LPNs are assigned to only administer medications to about 24 patients.
Reducing their workload made them feel that their work is valued and flexible. RN and
RNS classifications had 6 and 7 callouts respectively. The RNC classification had the
majority (23) of the callouts per month after the educational intervention. The increase in
the number of callouts in this classification can be attributed to the fact that charge nurses
supervise and support other staff while also taking care of a limited number of patients.
Charge nurses are also responsible for maintaining a high level of patient care, evaluating
other nurses, and acting as an educational resource for other nurses. The decrease in the
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total number of callouts (from 253 callouts before the educational intervention to 51
callouts after) surpassed the initial goal of a 20% improvement, implying that the stress
management educational program provided practical information to the nurses.
Table 7
Callouts per Classification One Month After Education Intervention
Nurse classification Number of nurses Percentage of nurses Number of callouts
per month
DCA 17 27.9 15
LPN 5 8.2 0
RN 9 14.8 6
RNC 23 37.7 23
RNS 7 11.5 7
Total 61 100.0 51
There was also an overall improvement in the mean scores of the stress level and
the number of callouts. The paired samples t-test showed that there is a significant
difference in scores for the pretest and post-test (Table 8). The mean scores of the stress
level decreased to approximately half the initial score, from 33.57 one month before the
educational intervention to 17.80 one month after the educational intervention. The mean
scores for callouts also decreased significantly, from 3.87 to 0.84 one month after the
educational intervention. There was also a significant improvement between the pre-and
poststress level mean for perceive work stress. When the stress levels were high, there
was a tendency for the staff to call out more frequently, and vice versa. The association
between stress and the number of callouts shows that nurses’ stress levels likely play an
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important role in regulating the rate of callouts. Perceived work stress may also be
associated with high levels of callouts.
Table 8
Pre-and Post-Stress Scores and Callouts Before and After Educational Intervention
_______________________________________________________________________
Paired samples statistics Mean N Standard. Standard.
___________________________________________deviation__________error_______
Pair 1 Pre-Stress scores 33.57 61 5.201 .666
Post Stress scores 17.80 61 2.744 .351
Pair 2 # of Callouts before 3.87 61 1.821 .233
# of Callouts after .84 61 .986 .126
As with most callout data, there was no information on the reasons for the callout.
The lack of information for absence is consistent with published findings that identified a
positive impact related to stress management programs, coping with stress attitudes, and
caregiver burden on psychiatric nurses (Ata & Dogan, 2018). According to Sailaxmi and
Lalitha (2015), stress management programs may equip nurses with skills to cope more
effectively. Ultimately, stress management programs have the potential to positively
impact nurses’ stress levels and decrease callouts/absenteeism (D’Souza, Umarani, &
Shetty Asha, 2015). The tremendous decrease in the number of callouts after the
educational intervention may be related to the COVID-19 pandemic incentives, which
were implemented to encourage nurses to go into work. In addition, the facility had
introduced a practice of giving intangible rewards, such as posting names of nurses with
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good attendance on the bulletin board and giving credit to nurses who showed some
improvement regarding their attendance. Such behaviors also enhanced the continuance
commitment of nurses to show up for work. Of the 61 participants who attended the
stress management education program, none had previously used any specific stress
management techniques to manage their stress levels. At the completion of the program,
all participants indicated that they were using various stress management techniques.
Unanticipated Limitations/Outcomes
Some unanticipated limitations/outcomes occurred during the implementation of
the project. The number of participants was limited because many patients were on 1:1
observation for suicidal or homicidal precautions, and staff had to stay to those patients.
Although the program was offered at different times to make it easier for nurses to
participate, none of the nurse managers or assistant directors of nursing attended the
sessions. Over half of the participants were either RNCs (37.7%) or DCAs (27.9%).
Participant feedback highlighted the challenge of incorporating and attending the classes
due to busy work and personal schedules (see McCarthy, Trougakos, & Cheng, 2016; Qin
et al., 2016).
Individuals
Decreasing callouts through a stress management education program had a
number of positive implications for the participants. On an individual level, nurses had an
increased awareness of stress management techniques. Participants acknowledged that
they were able to manage their stress better as a result of the educational program, and
the PSS scores for stress level showed a significant positive difference at the completion
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of the program. Psychiatric nurses can integrate stress management techniques into their
workplace. Effectively managing work stress can improve the overall health of the nurses
and enhance productivity. This program provided the participants with the fundamental
information and skills to impact their entire work environment. One charge nurse (RN)
commented that she will begin engaging in walking exercises during her lunch break in
order to reduce stress, giving her a mental break from work. Another direct care assistant
shared that doing these walking exercises with co-workers supports both the physical and
mental benefits of socialization. According to CDC (2014), one of the goals of Healthy
People 2020 is physical activity, as any activity including walking can improve an
individual’s health, quality of life, and also reduces work stress.
Communities
Decreasing callout and absenteeism through a stress management education
program had positive implications for the community. At the community level, well
managed stress levels improved the nurses’ well-being and enhanced patient care
outcomes and patient satisfaction. Nurses with effective stress management tend to come
to work, are more productive, and provide caring behaviors in a more compassionate
manner (Chana et al., 2015).
Institutions
Decreasing callouts and absenteeism through a stress management education
program had positive implications for the institution. Organizationally, the project site
may be able to provide psychiatric nurses more opportunities for stress management
interventions in the workplace. For example, providing nurses with sufficient time for
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walking during lunch breaks can reduce work stress. Effective stress management and
higher levels of nurse well-being have been linked with better job engagement, decreased
callout/absenteeism, decreased turnover rate, improved collaboration and communication
among members of the interdisciplinary treatment teams, and fewer medical errors
(Chana et al., 2015; Hall et al., 2016). This project could encourage health care
organizations by offering nurses more stress management benefits, such as exercise
classes and additional stress reduction programs at work.
Systems
Decreasing callouts and absenteeism through a stress management education
program had a number of positive implications for the health care systems as a whole.
Assisting psychiatric nurses to manage work stress and decrease callout and absenteeism
has the potential to shift the systems’ culture to provide for the psychological and
professional well-being of the nurses as well as the quality of patient care provided.
Increased levels of stress and burnout are being experienced by practicing psychiatric
nurses and are well documented in the nursing literature (Laschinger & Fida, 2014).
Helping psychiatric nurses to manage work stress is significant by allowing nurses to be
more productive and less likely to be absent from or quit their jobs.
Positive Social Change
The project was helpful in providing education related to the recognition,
avoidance, and management of work-related stress. The pretest and posttest were useful
in assessing the nurses’ knowledge of work-related stress before and after the educational
program. Positive social change serves to improve the social and human condition
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(Walden University, 2018). Absenteeism among nurses is one of the factors related to job
dissatisfaction and nurse turnover (Mmamma, Mothiba, & Nancy, 2015). This project can
affect social change in the psychiatric nursing field. Potential implications for positive
social change include helping to ensure that the nursing workforce is healthier and more
satisfied with their job. Stress management programs such as this DNP project have been
shown to decrease nurses’ absenteeism, which affects patient care outcomes and
productivity in the healthcare institution.
Project Implementation
Implementation is critical to the success of a project because it is the necessary
step that transforms the strategic plans into action in order to achieve the goals.
Implementing a project means to carry out activities with the aim of delivering the
outputs and monitoring progress compared to the work plan (Powell, Waltz, Chinman,
Damschroder, Smith, Matthieu, Proctor, & Kirchner, 2015). During the implementation
stage, the project manager coordinates and directs project resources to meet the
objectives of the project plan (Li, Jeffs, Barwick, & Stevens, 2018). The main benefits to
implementation are the abilities to execute the tasks needed to complete the project,
identify the personnel and resources needed, and document the timeline to ensure that the
project goals are achieved (Powell et al., 2015). Before implementing the program, I
consulted with the nurses at the project site and asked for their input on the content and
goal of the program. Consulting with these nurses was very important because input from
them was valuable to ensure they understand the theoretical basis of the program being
implemented. When nurses know the goals and objectives of the program and how the
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goals are to be achieved, they are more likely to buy into the program. Nurses at the
project site gained insight about the program’s theory and how they could improve their
work. That knowledge promoted a greater buy-in and reduced the likelihood of them
creating their own modifications to manage the problem.
Secondly, I communicated the details of the program to be implemented. I
ensured that nurse supervisors were familiar and comfortable with the program so they
could share their knowledge and support the nurses as they become stressed. I asked the
nurse supervisors to monitor, for one month, both the number of callout days and work
days of all their staff and then share those observations. The reason for this was to
recognize nurses who do not call out, provide constructive feedback to nurses who do
callout, and emphasize areas for improvement. Furthermore, I established a process for
ongoing reflection for staff to share their experiences and receive feedback, including
opportunities for support and learning.
Program Evaluation
Evaluation is the final stage of the education process. It is the continuing
assessment of the staff’s learning progress during and after the program (Parkinson,
2016). The aim of evaluation involves collecting and using information to determine
whether the education provided was successful and achieved the desired learning
outcomes (Bastable, 2014). Evaluation can take many forms and can help to promote
quality in education practice (Hughes & Quinn, 2013). A comparison of the PSS scores
obtained through the pre- and posttests was used for evaluating the effectiveness of the
educational intervention. Comparing the mean scores of perceived work stress before and
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one month after the educational intervention showed a significant reduction in the levels
of stress level among the nursing staff. On the paired sample statistics, the Pre-stress
score before the intervention was 33.57 and the after intervention Post-stress score was
17.80. In addition, the mean number of callouts before the intervention was 3.87 and 0.84
afterwards, indicating a significant decrease in the number of call outs after the
intervention. The findings of the project indicated that the stress levels of the nursing
staff were reduced through the implementation of the stress management program.
Hence, the stress management program was effective in reducing work-related stress in
practicing psychiatric nurses because the numbers of callouts decreased and the nurses
felt less stressed as evidenced by the results of the post-test scores.
Recommendations
Nurses are susceptible to work stress because of the extremes in their daily
activities. The gap in practice that this DNP project sought to address was the lack of
resources provided to psychiatric nurses concerning interventions to decrease stress and
improve their well-being. Recommendations that would greatly aid in addressing this gap
in practice would be to reduce work stress among nurses by employing strategies such as
assertiveness training, establishment of fun in the work environment, shared governance,
and self-scheduling. The first recommendation is to encourage nurses to actively
participate in organizational committees and groups in connection with the nursing
leadership council. Secondly, change should be promoted as constructive and nurses
should be engaged in the change process to promote and reward positive changes in
behavior and practices. Providing the educational content in a variety of different formats
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is of the utmost importance. Participants in the project gave the impression that it was
essential that the educational information be provided to all psychiatric nurses including
the new employees’ orientation classes. Another recommendation is the establishment of
a monthly stress management program as an on-going initiative for nurses to equip them
with effective strategies. The establishment of a monthly program would include and
support the nurses in strengthening and sustaining stress reduction practices such as
meditation, yoga, and exercises as these have been proven to help reduce stress both
within and beyond the workplace (Shapiro, Wang, Peltason, 2015; Yang, Tang, & Zhou,
2018). Additionally, in using good stress management skills nurses can boost their
morale, which motivates and keeps them focused on their job and performance (Wright,
2014).
Participants’ feedback raised the idea that stress management practices should be
offered daily in the workplace to create opportunities for social interactions and
encourage open communication and participation in decision making that affects their
various roles. Furthermore, new learning experiences among nurses should be promoted.
The organization should create family-friendly policies to encourage work-life balance
and provide training for workplace stress management such as an employee assistance
program, offered by the Human Resources department, to help employees find
professional help with work and/or personal issues (Richmond et al., 2017). On the
whole, participants were very interested in having stress management programs such as
on-site and off-the-job exercise groups, relaxation techniques such as yoga, and
meditation groups that can help them manage their stress (Alberts, & Hülsheger, 2015;
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Byron et al., 2015). Participants strongly agreed that the education program was
significant in assisting them in handling their stress better, both at work and in their
personal lives.
Contribution of the Doctoral Project Team
The DNP project team, comprised of members of the nursing leadership council,
met with me before and after the implementation of the project. Team members were
very receptive to assisting with the project and carrying out their individual
responsibilities to make the project successful. Before the project was initiated, team
members were given a general idea of the project and the evidence supporting it. Team
members gave input on the course objectives, content, class design, location, time, and
directives for completing the surveys. One of the team members served as a participant in
the project. Unit managers provided snacks as incentives. Upon completion of the
program, team members were urged to appraise the entire program and make
recommendations. A team meeting was also planned to talk about the project results and
to build upon the final recommendations. Currently preparations are being made to
establish an employee assistant program, however, the ergonomically designed
workstations and a designated quiet room to relax and recharge are still under
consideration with nursing leadership (Foster, Cuzzillo, & Furness, 2018; Hyland, Lee, &
Mills, 2015; Richmond et al., 2017).
Strengths and Limitations of the Project
The strengths of the DNP project included the use of the Perceive Stress Scale,
which is a validated tool for measuring perceived work-related stress (Sun et al., 2019).
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The literature review played a significant role in providing evidence for the benefits of
the stress management program and its positive effect on nurses’ health and well-being
(Foster, Cuzzillo, & Furness, 2018; Hyland et al., 2015; Oates, 2018; Richmond et al.,
2017; Sailaxmi, & Lalitha, 2015; Shapiro, Wang, Peltason, 2015; Yang, Tang, & Zhou,
2018). The pretest scores showed a lack of information related to the identification,
avoidance, and management of work stress, while the posttest scores showed knowledge
gained when compared to the pre-test scores. In addition, the project team and
participants were very engaged, and they offered important feedback during project
development. Furthermore, the project participants were very devoted to executing the
practice activities during the presentation. The hospital fully supported the project and
encouraged nurse participation. The nursing leadership provided enough time for
participants to complete the surveys in a way that did not interrupt their workflow.
The majority of nurses who participated in the survey were RNCs and DCAs,
which is an indication that there are more charge nurses and support staff in the facility
where the project improvement initiative was conducted. Having more RNCs and DCAs
in the facility might affect the management of stressful activities or experiences since
charge nurses are expected to lead staff while managing the work systems and unit
processes to ensure that the needs of the patients are met (American Association of
Colleges of Nursing (AACN), 2013). Charge nurses are also tasked with ensuring that all
procedures run smoothly on the unit so as to provide quality patient care. In addition,
charge nurses spend additional time dealing with documentation, paperwork, treatments,
education, and communication with team members in order to effectively complete tasks
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(AACN, 2013). Charge nurses also ensure that all staff are working together to improve
the patients’ satisfaction on the unit.
Project limitations represent weaknesses within the project design that may
influence the outcomes and conclusions of the project (Wang, Bolland, & Grey, 2015).
Limitations are important to understand in order to interpret the validity of the project
findings. Project limitations included that more charge nurses volunteered to participate
in the educational program than the other nursing classifications, therefore, decreasing
the generalizability to the other nursing classification in the organization. More charge
nurses may have participated in the program because of their familiarity with me as a
charge nurse at the project site. The small number of participants from the other nursing
classifications may limit the motivation of upper leadership to expand the program. The
project, however, provided the prospect for more research on the importance of stress
management programs and its effect on reducing stress, improving health, and decreasing
callouts/absenteeism. In addition, collection of data was done only at the beginning and
end of the program. The project findings may have been stronger if additional data had
been collected 3 months after the program to see if the results had been sustained.
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Section 5: Dissemination Plan
Distribution of research and evidence-based project findings is a fundamental
constituent to advancing positive change and implementing best practices and
innovations (White, Dudley-Brown, & Terhaar, 2016). Dissemination is presenting the
research findings to specific audiences and should be outlined in a plan that focuses on
the needs of the audience that will use the knowledge (Gagnon, 2011). My plan is to
disseminate the project’s findings at the nursing team meetings, nursing leadership
council meetings, and unit staff meetings. I also plan to encourage involvement in the
implementation strategies. The purpose of engaging nurses in the project’s
implementation is to ensure widespread buy-in and to increase the odds of making an
impact on the well-being of nurses (see Edwards, 2015).
I aligned strategies with the organization’s stakeholders to increase the odds of
sustainability and commitment to success. In addition, I employed collaborative strategies
that will be a catalyst for positive change in the hospital. The collective impact
framework posits that no single entity can tackle an organization’s complex problem
effectively (Edwards, 2015). I also identified the drivers of organization health
improvement and selected strategies that may institute a practice of stress management
that becomes part of the daily workflow. Furthermore, I set goals and objectives for the
implementation strategies while considering evaluation of the project that was built into
the planning process. I collected the baseline data and compared the before and after
implementation data, making sure that the intervention made a difference.
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The primary audience for this project was nursing staff at all levels from nurse
supervisors to direct care assistants. However, improving well-being through stress
management education strategies applies to all health care workers who regularly work
with patients and their families. According to Gagnon (2011), presenting the project’s
findings at professional meetings allows for more rapid dissemination. A variety of
approaches to disseminate the project findings were made available. First, a PowerPoint
presentation of the project’s finding was submitted to the nursing leadership council, and
the program materials were distributed as flyers and handouts to the nurses on the unit.
Unit managers meet twice a week for team meetings, and they now schedule half-an-hour
every team meeting to talk about stress management strategies. The assistant director of
nursing also conducts nursing information sharing conference calls three times a week,
during which the stress management strategies are discussed. Furthermore, the director of
learning resources plans to include the stress management program in the new employee
orientation class and plans to hold stress management workshops to address and improve
the mental health of the nurses. The chief nursing officer also plans to disseminate the
information on the hospital’s website and share the information through mass emails to
all of the nurses.
Analysis of Self
My role in this doctoral project was threefold: practitioner, scholar, and project
manager. The knowledge I acquired by conducting this DNP project has developed my
leadership skills, communication skills, and ability to conduct and implement a program
(see Ulrich, Lavandero, & Early, 2014). The DNP project allowed me to experience in a
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real-life situation many of the concepts that I learned in my doctoral classes. I have
grown professionally and personally and have gained a better understanding of nursing
leadership while improving my ability to respond and address organizational issues (see
Porter-O’Grady & Malloch, 2015).
Practitioner
Presently, I work as a charge nurse directing and supervising patient care. As a
practitioner, I work with patients, families, groups, and communities assessing their
mental health needs. The knowledge gained from this DNP program has prepared me to
engage in advanced nursing practice, provide leadership for evidence-based practice,
implement evidence-based nursing practices, and lead interprofessional teams in the
analysis of complex practice and organizational issues (AACN, 2006). The knowledge
gained was in accordance with the DNP Essential VI: Interprofessional collaboration for
improving patient and population health outcomes (AACN, 2006). Graduating from the
DNP program enhanced my knowledge as a content expert in offering primary care
services to the mental health population and also contributes to policy development,
quality improvement, and evaluation of the provision of health care services as stipulated
by the DNP Essential V: Health care policy for advocacy in health care (AACN, 2006).
Scholar
Conducting this evidence-based project was a form of scholarly activity, and I
gained knowledge regarding stress management and its impact on nurses’ well-being at a
personal and organizational level. As a scholar, I acquired the skills to develop scholarly
works that will promote the nursing profession. I also learned how to identify a nursing
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practice problem; explore evidence-based literature; and plan, implement, and evaluate an
educational program (see AACN, 2006). In addition, I learned new information that has
increased my knowledge base and has helped me become a better practitioner. I learned
to work with stakeholders and translate knowledge that is meaningful and applicable to
nurses in their work environment (see AACN, 2006). Also, I acquired skills in data
collection and analysis through working with SPSS to evaluate the data and disseminate
the findings to integrate new knowledge (see AACN, 2006).
Project Manager
As a project manager, I supervised all aspects of the project ensuring that the
relevant steps were covered according to the Walden University’s Manual for Quality
Improvement Evaluation Projects (Walden University, 2018). Conducting this project has
allowed me to acquire knowledge and skills for advocating and implementing change that
will advance the nursing profession. According to Mélanie et al. (2017), change does not
occur readily; nonetheless, the stronger the leader, the better the chances that change will
take place. I have learned how to recognize a practice problem and seek resources to
conduct a project. The skills I have learned through this project will provide me with the
leadership and vision to remove roadblocks and motivate, coach, and inspire the team to
do their best work (see Porter-O’Grady & Malloch, 2015; Ulrich et al., 2014).
Completing this DNP project has helped me to build a solid network that has
fostered many positive relationships within my facility/community. Teaming up with a
more experienced mentor helped me grow and learn the skills necessary to keep up with
emerging techniques. My long-term professional goal is to merge the roles of a
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practitioner, scholar, and project manager with the knowledge gained to become an
expert in specialized areas. In completing this DNP program, I have achieved a higher
level of clinical expertise that will elevate my leadership and professionalism and lead to
more career opportunities (see AACN, 2013).
One of the challenges faced in conducting the DNP project involved participant
commitment. Despite the fact that I provided written information about the program at
staff meetings, most participants were reluctant to get involved. However, I engaged in
informal rounds on all of the units to broaden their knowledge of the benefits of
managing work stress and improving patient outcomes. By the end of each shift, most of
the nurses engaged in the program. I realized that it is important to recognize the values
of nurses, empower their participation, and encourage collaborative relationships (see
Ulrich et al., 2014). Critically appraising existing literature and other relevant evidence to
design, implement, evaluate and disseminate the project’s findings has given me insights
that will allow me to recognize relevant issues, develop quality improvement programs,
and implement evidence-based practice through interdisciplinary collaboration in the
organization to maintain the delivery of ongoing high standards of care (AACN, 2006).
In addition, I have gained the skills to contribute and develop initiatives that will advance
the nursing profession and improve patient outcomes.
Summary
Work stress is a current and future health and safety issue. Stress can damage
employee health and negatively impact the performance and productivity of the
organization. It is important to understand its effects on employees and then implement
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better solutions. Work stress is a national health crisis that must be tackled for the well-
being of all employees.
The purpose of the project was to design, implement, and evaluate an educational
program focusing on work stress among psychiatric nurses. The goal of this project was
to decrease work stress and absenteeism among practicing psychiatric nurses working in
an in-patient mental health hospital. Statistical analyses were used to determine if there
were improvements in the participants’ perception of stress. Results demonstrated that the
program participants realized that they had gained knowledge and confidence and were
better able to manage their level of stress. The project achieved its goal to assist
psychiatric nurses to manage work stress and decrease the number of callouts per month.
The project site had a total number of 253 callouts per month before the educational
intervention and 51 callouts after the educational intervention.
Hence, I believe that stress management strategies can be used within the nursing
work environment and that it can contribute to self-care. The emerging evidence from
this project supports that stress impairs the work of nurses through absenteeism. The
DNP project demonstrated that teaching stress management strategies improved the
participants perceived levels of work stress, enabled them to more effectively manage
their stress, and thereby positively impacted their well-being while it decreased
absenteeism. Nevertheless, the program will need further development in order to allow
more nurses the opportunity to participate and engage in the program. The promotion of a
hospital-wide commitment to maintaining a stress-free workforce can lead to a decrease
in absenteeism while improving the organization’s productivity.
