Collection and Analysis of Evidence on Nurse Mentorship
The role of a nurse manager in the acute care hospital has become increasingly
complex and stressful because of changing health care dynamics (Miyata et al., 2015).
Stressors are noted to increase based on the level of demand a manager faces (Miyata et al.,
2015). At the project site, practices involved managers relying on personal coping
mechanisms to handle their stressors in the absence of resources for individual stress
management (HRC, 2016). The purpose of this DNP project was to develop an evidence-
based education program to guide nurse managers in coping with work-related stressors.
This project was guided by the job demands-resource theory, which was used to
focus on a job demand leading to stress on an individual in the absence of resources. A
literature review of the topic of nurse manager stress revealed that stress is not a new
element of the manager role, and that coping methods vary (Advisory Board, 2017;
AONE, 2018; Cairaki, McKey, Peachey, Baxter, & Flahterty, 2014; Frankel, 2018; Kelly,
Wicker, & Gerkin, 2014; Keys, 2015). Analysis of the current state of practiced revealed
recommendations for employee assistance programs, modifying work environments,
obtaining advice from administrators, and taking mental breaks from the stressor
(Advisory Board, 2017; Gardner, Hailey, Nguygen, Prichard, & Newcomb, 2017;
Hendren, 2018; Hewko, Brown, Fraser, Wong, & Cumings, 2014; Jones, McLaughlin,
Gebbens, & Terhorst, 2015; Warshansky, Wiggins, & Rayens, 2016). The role of the
DNP student in this project was project manager. This project consisted of compiling and
synthesizing evidence-based best practices focusing on stress and burnout reduction,
designing an educational program that was presented to a stakeholder group using a
PowerPoint presentation, and presenting to all managers who elected to attend.
Section 3
includes the practice-focused question, sources of evidence, and the analysis and
synthesis plan.
Practice-Focused Question
A changing health care environment has resulted in the expansion and
modification of roles, including the nurse manager. In the acute care hospital setting, a
change in dynamics has resulted in expansion of the nurse manager role adding
complexity and stress (Miyata et al., 2015). A correlational relationship between job
demands and stress on the nurse manager develops, in which an increase in demands
results in an increased level of stress (Miyata et al., 2015). Stress management practices
identified at the project site have resulted from an absence of resources for individual
stress management. Managers are not using evidence-based coping mechanisms in
response to their stressors (HRC, 2016). These coping mechanisms lack a specific
outcome to foster continued stress management. Nurse managers who become
overwhelmed may elect to seek private assistance from the employer in the form of a
crisis helpline, but this resource focuses on the recovery following an event as opposed
to primary intervention (HRC, 2014). Low manager-peer engagement combined with
minimal support systems contribute to an environment primed for burnout (HRC, 2016).
A gap in practice existed in the knowledge base of evidence-based coping
mechanisms used by nurse managers to navigate daily stressors (Dyess et al., 2016).
Insight from nurse managers at the project site revealed that current methods for coping
with stress levels consisted of relying on personal stress-reducing behaviors. Primary
resources for stress management at the project site are focused on direct patient care roles
because the topic has been studied more frequently (Kath et al., 2013). Employers may
offer these resources in the form of person-focused interventions, organization-focused
interventions, and integrated stress prevention initiatives including employee assistance
facilitators, meditation sessions, and peer support groups (Roberts et al., 2012). Stress is
experienced at all levels of practice, and when stress exceeds coping thresholds, eustress
is exhausted and distress can ensue (Quick & Henderson, 2016). Continued exposure to
distress without intervention may lead to manager burnout (Cieslak et al., 2014).
Alignment
This project closed the gap in practice through the development of synthesized
evidence-based best practice stress education for nurse managers. The practice-focused
question for this project was the following: Can developing an evidence-based stress
reduction education program empower nurse managers to better handle work-related
stressors and reduce burnout? The purpose of synthesizing evidence-based best practices
was to develop an education program that may enhance nurse managers’ ability to cope
with role-related stressors. The objective aligned with the practice-focused question
through development of an education program that encompasses a variety of best
practices, offering nurse managers an opportunity to learn about successful techniques
that may be implemented in their daily practice.
Operational Definitions
The project included terms with generally accepted meanings in nursing practice.
Sources of Evidence
Evidence was collected from a variety of sources, including peer-reviewed
publications from professional journals, nursing management/professional
organizations, and published studies. Examples of peer-reviewed professional journals
included the Journal of Nursing Administration, Nursing Management, Journal of
Nursing Management, and the Journal of Nursing Research. Examples of professional
organizations included the American Organization of Nurse Executives, the American
Nurses Association, and the Organization of Nurse Leaders. Published studies were
reviewed for appropriateness to the topic and transferability of the findings. Data were
not collected from unpublished sources, unverifiable studies, or participant interactions.
The project purpose was to develop an evidence-based education program to guide nurse
managers in coping with role-related stressors. The sources used to address the practice-
focused question met criteria regarding evidence base and relevance to the project.
A synthesis matrix was used to organize and analyze each source of evidence. The
synthesis matrix allowed for evidence to be sorted and categorized based on different
outcomes or management techniques (see Parris & Peachy, 2013). Sources were arranged
by theme using the matrix. In addition, sources were rated using The Johns Hopkins
Nursing Evidence-Based Practice Rating Scale (Johns Hopkins University, n.d) to
evaluate and synthesize the literature based on evidence level and quality.
Analysis and Synthesis
A comprehensive, systematic literature review was completed to synthesize
evidence for this project and assembled on a literature review matrix. Databases included
EBSCOhost, ProQuest, CINAHL, MEDLINE, and Science Direct. I also used the
Google Scholar search engine. I also researched professional nursing organizations such
as the American Organization of Nurse Executives, the American Nurses Association,
and the Organization of Nurse Leaders. Key search terms included nurse manager stress,
nurse manager burnout, nurse leader stress, nurse leader burnout, nursing leadership
stress, nursing leadership burnout, and evidence-based stress coping techniques. The
scope of this review consisted of a four-year look-back, starting in 2014 until present.
Sources were limited to peer reviewed, evidence based, and published documents or
programs. Evidence integrity was demonstrated by documenting and grading all
reviewed sources on the literature review matrix.
Summary
The practice-focused question for this project was the following: Can developing
an evidence-based stress reduction education program empower nurse managers to better
handle work-related stressors and reduce burnout? Databases included EBSCOhost,
ProQuest, CINAHL, MEDLINE, and Science Direct. I also used the Google Scholar
search engine and professional organization publications to obtain evidence for this
project. The sources of evidence were organized using a literature review matrix, rated
using The Johns Hopkins Nursing Evidence-Based Practice Rating Scale, and
synthesized to develop an education program for nurse managers. Sources that were not
evidence based or peer reviewed were not included in this project. Section 4 provides
findings and recommendations from this synthesis.
Findings and Recommendations
The purpose of this DNP project was to develop an evidence-based education
program to guide nurse managers in coping with role-related stressors. This program may
enable nurse managers to experience enhanced role engagement and decreased burnout.
A gap in practice existed in the knowledge base regarding coping mechanisms used by
nurse managers to navigate daily stressors. Methods used for stress management were
often not evidence based, leading to ineffective coping strategies. This DNP project
addressed this gap in practice by identifying evidence for the synthesis, development, and
implementation of an education program designed to reduce stress and minimize burnout
for nurse managers. The practice-focused question guiding this project was the
following: Can developing an evidence-based stress reduction education program
empower nurse managers to better handle work-related stressors and reduce burnout? To
answer the project question, I conducted a literature review of evidence-based practices
to reduce nurse manager stress and burnout. This literature review included articles and
resources published from 2014 until the present. The sources of evidence were organized
using a literature review matrix, rated using The Johns Hopkins Nursing Evidence-Based
Practice Rating Scale, and synthesized to develop an education program for nurse
managers.
Findings and Implications
The focus of this DNP project was to decrease nurse manager stress and burnout
through the development of a synthesized evidence-based education program. The sources
of evidence were organized using the Walden University literature review matrix
and rated using the Johns Hopkins Nursing Evidence-Based Practice Rating Scale
(Appendix A). This matrix was assembled to organize sources based on evidence
strength, evidence quality, management technique, outcomes, and implications for future
practice.
Grading evidence based on strength and quality was achieved using the Johns
Hopkins Nursing Evidence-Based Practice Rating Scale. This scale outlines strengths of
evidence from Level I through Level V (Johns Hopkins University, n.d.). Level I
consists of experimental study/randomized controlled trial or meta-analysis. Level II
consists of quasi-experimental study. Level III is a nonexperimental study, qualitative
study, or meta-synthesis. Level IV is an opinion of nationally recognized experts or an
expert consensus panel. Level V is an opinion of an individual based on nonresearched
evidence. The quality of evidence is ranked from A = high, B = good, and C = low
quality or major flaws (Johns Hopkins University, n.d.). Each of these rankings includes
criteria for reviewing research, summative reviews, organizational reviews, and expert
opinions.
A total of 31 evidence-based peer-reviewed sources were included in the literature
review. These sources met the inclusion criteria of peer reviewed, evidence based, and
published documents or programs accessed via multiple search engines and limited to date
range of 2014 until present. Of the 31 sources, nine met Level I criteria, 11 met Level II
criteria, nine met Level III criteria, and two met Level IV criteria of strength scoring. Quality
overview revealed 27 sources rated A or high quality, and four sources rated B or good
quality. Sources receiving a C rating were excluded from the project.
Multiple themes were identified in the literature analysis (see Appendix B),
including manager-initiated methods of stress reduction, modification of workplace
environment, peer support, roles of senior leadership in stress reduction, and fostering
future leadership development. The predominant theme or stress management
technique was leadership development. This development was identified across all
experience levels. The transition from staff member to nurse manager was identified as
a crucial point for mentoring or modeling, experiencing stress, and learning how to
manage management stressors (Frankel, 2018). Training and developing leaders early
in their career has been demonstrated to be a positive pathway for success during the
management transition (American Organization of Nurse Executives [AONE], 2018).
Effects of early training have been reported to influence a nurse manager’s stress levels
and ways in which the nurse manager copes with unanticipated stressors (Advisory
Board, 2017; AONE, 2018; Cairaki, McKey, Peachey, Baxter, & Flahterty, 2014;
Frankel, 2018; Kelly, Wicker, & Gerkin, 2014; Keys, 2015).
Modification of work environment was the next recurring theme. These
modifications could include a physical change to the environment or culture setting.
Culture setting encompassed aspects of delegation, manager empowerment from senior
leadership, reduction of scope creep, and ability to disconnect from the workplace
(Advisory Board, 2017; Gardner, Hailey, Nguygen, Prichard, & Newcomb, 2017;
Hendren, 2018; Hewko, Brown, Fraser, Wong, & Cumings, 2014; Jones, McLaughlin,
Gebbens, & Terhorst, 2015; Warshansky, Wiggins, & Rayens, 2016). Peer-to-peer
mentorship and networking were identified as effective methods for managers to share
their experiences and facilitate mutual development (AONE, 2018). This type of stress
reduction technique was linked to an overall increased personal fulfillment in position
and enhanced nurse leader retention (Lamonica et al., 2016).
Nurse managers participating in peer-to-peer mentorship reported that the support
and problem-solving insights shared differed from their primary employers were more
effective at enhancing situational coping (AONE, 2018; Cairaki et al., 2014; Lamonica et
al., 2016). Identifying areas that contributed to stress and burnout became a key
component in planning coping techniques (Ellis, 2016). The act of acknowledging the
presence of stress is essential to planning an intervention, which will determine effective
or ineffective outcomes (Ellis, 2016; HcPro, 2017; Van Bogaert, Timmermans et al.,
2014). Positive stress management techniques correlated with greater nurse manager
tenure but required nurse managers to examine their coping habits and group them into
positive or negative techniques (Laal, 2016).
Unanticipated Limitations
The primary unanticipated limitation of the project was the exclusion of
ineffective stress management techniques in the literature. This project was focused on
use of evidence-based stress management techniques. A strong evidence base supported
the use of identified techniques, but the education program would have been strengthened
by an evidence base for ineffective techniques.
Individuals, Communities, and Institutions
The implications of the project include providing nurse managers with initial and
ongoing education related to stress management and coping techniques. At the time of
study, formal training sessions focused on stress management were neither readily
available nor evidence based. Through the presentation of synthesized techniques offered
in a convenient setting, nurse managers will be able to access education beneficial to
career development and personal needs. Educational programs serve a driving force to
improve nursing practice (Savage et al., 2015). Institutions electing to implement a
synthesized stress education program for nurse managers would receive benefit from
peer-to-peer management interactions, increased nurse manager retention levels, and
management teams capable of coping with challenges or stressors as they present.
Positive Social Change
Implications for positive social change include nurse managers’ ability to better
handle stressful situations. A nurse manager who is overwhelmed by stressors cannot
fully meet the needs of departments, staff members, and patients. Through the use of
stress management education, the nurse manager will have the tools necessary for
effective coping. When effective coping techniques become habitual, nurse managers will
be able to fulfill their role requirements to their patients and staff through staff
mentorship, real-time coaching, and coordination of care delivery (Moss et al., 2016).
Recommendations
Although stress is often present in nursing management, effective methods of
coping with stress are not. The gap in nursing practice that was the focus of this DNP
project was a lack of knowledge of evidence-based techniques for stress reduction. The
results of this DNP project indicated that evidence-based stress management and coping
techniques are available, and when used result in positive outcomes for nurse managers
related to their stress levels. The recommended solution to fill the gap in nursing practice
includes implementation of an educational program that synthesizes evidence-based
stress management and coping techniques. This educational program would be directed to
the needs of nurse managers and delivered through PowerPoint, lecture, collaborative
group interactions, and handouts when appropriate. The educational program could be
tailored to meet the needs of individual facilities or health systems. This program would
be conducted in a formalized workshop setting at a time convenient to the nurse
managers. Components of the recommended program (see Appendix C) consist of a
pretest to assess baseline knowledge, delivery of the education via methods outlined in
the education plan, and a posttest to assess whether learning has occurred on the topic
presented.
Learning objectives for the education program include aspects beneficial to nurse
managers’ development of stress coping skills. The learning objectives were designed to
be cumulative, as different aspects of stress management are introduced during the
education (see Appendix C). The transformational learning theory for adult learners
supported development of objectives through perspective transformation and integrated
approach to promote competency (Taylor, 2017).
Educational Product
The educational product (see Appendix C) is a formalized educational program
presented in the style of a workshop delivered through PowerPoint and lecture. The
program was broken down into five sessions presenting aspects of stress management
over a period of one business week. Course Objectives 1 through 3 will be covered
during each session, focusing on the different aspects of stress management. Each
subsection contains individual objectives and learning outcomes specific to the topic
covered during that session. This methodology allows for the presentation to occur during
daily manager meetings or leadership forums. Time required for each presentation is 5 to
10 minutes, allowing for questions following material presentation.
Recommendations for Implementation and Evaluation
The recommendation to meet the gap in practice is supported by evidence-based
stress management practices. This project demonstrated that evidence-based practice
coping techniques covering a variety of stressors are available for nurse managers. Each
stress management technique was presented in a different format to accommodate the
needs of participants. The American Organization of Nurse Executives (2018) indicated
that programs for manager development can be held in a variety of ways suited to the
busy manager schedule including multiday intensives, session workshops, and online
interactive courses. Options for synthesized education offered by the Advisory Board
(2017) occur in the forms of workshops offered either on-site or online depending on
participant needs. Formulating the best setting and delivery for education is as important
as the education itself (Lockheart, 2006). Focusing the efforts of this educational program
to meet the time constraints of busy nurse managers led to the use of the empowering
education model (Chaghari, Saffari, Ebadi, & Ameryoun, 2017) as a design platform. The
empowering education model is a new model matching the needs of nurses with the
desirability of learning. All training was developed with a focus of self-direction and
practicality.
Building on these practices would lead to the creation of an educational product
that introduces the concepts from the literature. Implementation of the evidence-based
education program would provide nurse managers with guidance and knowledge related
to managing work-related stressors. The nurse manager would have an opportunity to
attend educational sessions with other nurse managers and build on previous experiences
while learning evidence-based techniques. Recommendations for the program include
holding sessions during daily morning manager meetings or daily forums as defined by
the facility (see Advisory Board, 2017; AONE, 2018; Lockheart, 2006). Presenting in
the identified forums would ensure that all managers could attend, the education would
not conflict with other responsibilities, and collegial dialogue would occur. Upon
conclusion of the education program, an evaluation process would occur as means of
assessing learning and program effectiveness.
Evaluation of the effectiveness of the education program would occur in the
form of a pretest/post-test. The pretest was designed to assess the nurse managers
baseline knowledge of stress management and coping techniques. The posttest was
designed to assess learning on the topics presented. Questions from each subsection
were developed based on the content presented. Questions in the posttest mimic those
presented in the pretest, which was purposeful and will aid in determining whether nurse
manager learning has occurred (see Advisory Board, 2017). Additionally, nurse
managers will be provided the opportunity to offer senior leadership feedback on
methods of enhancing daily organizational working conditions.
