beatleyweb.simmons.edubeatleyweb.simmons.edu/.../original/6fafcbc6f2f7b676fba… · web...

Running Head: Self-Care Among Nurses

Developing Self-Care Practices Among Nursing Staff on In-Patient Acute Care Units

Denise Corbett-Carbonneau

Simmons College

For the Degree Doctorate of Nursing Practice

© 2018 Denise A. Corbett-Carbonneau

Self-Care Among Nurses

Signatures Page

Self-Care Among Nurses iii

Abstract

Within the healthcare delivery system there has been an increasing focus on understanding

the essential components necessary to obtain optimal patient care outcomes. The level of

engagement of care providers plays an important role in the delivery of care and attaining

these outcomes. The prevention of burnout and compassion fatigue among nurses is pivotal

in this regard. Self-care for nurses is an important contributor to this prevention and to the

attainment of optimal engagement levels. Krietzer (2015) validates the importance of self-

care for nurses through the inclusion of caregivers’ health and wellbeing as a major principle

in the Integrative Nursing framework. Additionally, the role of nurse leaders in establishing

a healthy work environment which supports the care of self as well as the care of others is

articulated in the American Nurses Association’s (ANA) Standards for Nursing

Administration (2016).

There is a need for more knowledge around what practices are specifically meaningful for

nurses and how to effectively promote these practices within the work environment. The

purpose of this study was to add to the body of knowledge around self-care as it relates to

nursing staff in an acute care hospital setting, the identification of meaningful self-care

opportunities within the hospital setting and the benefit of these practices to levels of

engagement. Both Registered Nurses (RN’s) and Patient Care Technicians (PCTs)

participated in the program. The literature review focused on this topic as it related primarily

to the registered nurses.

This program development project utilized a mixed methods design including a pre and

post intervention survey developed by the principal investigatory (PI) and pre and post

intervention focus groups. The project involved four units – two study units and two control

Self-Care Among Nurses iv

units. A self-care program was designed and implemented on the two study units for a

period of one month.

While there were no statistically significant results from the study, trends were identified

which warrant further study. These trends included an increase in engagement levels in the

intervention group. It is unclear whether confounding variables impacted this outcome and

the trend can only be understood further through additional study.

Self-Care Among Nurses v

Acknowledgements

I would like to express my sincere appreciation to several people who had an important role

in this Capstone project:

Capstone Committee: Dr. Rebecca Koeniger-Donohue (Chair) and Dr. Susan Gordon

DNP Capstone Faculty: Dr. Eileen McGee, Dr. Patricia Reid Ponte, Dr. Patricia Rissmiller

and Dr. Shelley Strowman.

Study Collaborators: Dr. Susan DeSanto-Madeya and Barbara Donovan, NS

Self-Care Program Contributors: Leslie Ajl, CNS, Alice Bradbury, ND, Jodi Dean

LICSW, Jed von Freymann, RN, and Tsering Ngoup Yodsampa, ST

BIDMC Nursing Leadership and Staff

Simmons DNP Colleagues

Family Members: William, Sarah, and Timothy Carbonneau

Self-Care Among Nurses vi

Dedication

This Capstone project is in loving honor of William, Sarah, and Timothy Carbonneau. I

thank each of them for their love and support in this endeavor, and in all things.

This Capstone Project is also in loving memory of John and Dorothy Corbett.

Self-Care Among Nurses vii

Table of ContentsAbstract....................................................................................................................................iii

Acknowledgements....................................................................................................................v

Dedication.................................................................................................................................vi

List of Tables.............................................................................................................................x

Introduction/Problem Statement..............................................................................................11

Purpose and Practice Inquiry Questions:.................................................................................12

Significance of the Problem.....................................................................................................12

Literature Review....................................................................................................................14

Introduction..........................................................................................................................14

The Importance of the Work Environment’s Influence on Nursing Care............................15

Further developments in understanding optimal work environments..................................19

Exploring the Concept of Self-Care within Nursing............................................................20

Identifying Effective and Valuable Self-Care Practices Among Nurses.............................22

Definition of Terms..............................................................................................................27

Conceptual Framework........................................................................................................27

Methods...................................................................................................................................28

Design..................................................................................................................................28

Setting..................................................................................................................................29

Sample Population...............................................................................................................29

The Intervention...................................................................................................................29

Data Collection....................................................................................................................31

Data Analysis...........................................................................................................................32

Survey Quantitative Data Analysis......................................................................................32

Survey Qualitative Data Analysis........................................................................................33

Focus Group Data Analysis.................................................................................................33

Rigor.....................................................................................................................................35

Cost Analysis.......................................................................................................................35

Human Subjects Protection..................................................................................................36

Results......................................................................................................................................36

Recruitment of Participants..................................................................................................36

Self-Care Among Nurses viii

The Sample..........................................................................................................................36

The survey sample............................................................................................................36

Demographics of participants......................................................................................37

The focus group sample...................................................................................................39

Demographics of participants......................................................................................39

Quantitative Survey Findings...............................................................................................41

Open-ended and Multiple Response Survey Findings.........................................................45

Focus Group Qualitative Outcomes.....................................................................................56

Discussion............................................................................................................................73

Limitations...........................................................................................................................76

Conclusion...........................................................................................................................77

Plan for Dissemination.........................................................................................................78

Appendix A..............................................................................................................................79

Pre-Survey............................................................................................................................79

Demographics...................................................................................................................79

Questions:.............................................................................................................................79

Appendix B..............................................................................................................................81

Post Survey..........................................................................................................................81

Demographics...................................................................................................................81

Questions:.........................................................................................................................81

Appendix C..............................................................................................................................83

Focus Group Questions........................................................................................................83

Pre Intervention................................................................................................................83

Appendix D..............................................................................................................................84

Focus Group Questions........................................................................................................84

Post Intervention...............................................................................................................84

Appendix E..............................................................................................................................85

Email Invitation to Nursing Staff to Participate In Study....................................................85

Part 1: Email for Study Units Farr 2 and Farr 7...............................................................85

Part 2: Email for Control Units Rosenberg 7 and Stoneman 8........................................87

Appendix F..............................................................................................................................89

Focus Group Information Sheet...........................................................................................89

Self-Care Among Nurses ix

Appendix G..............................................................................................................................90

Self-Care Program Outline...................................................................................................90

Appendix H..............................................................................................................................91

Email for Nursing Staff on Farr 2 and Farr 7 Regarding the Self-Care Program................91

Appendix I...............................................................................................................................93

Farr 2 and Farr 7 Self-Care Program: January, 2018...........................................................93

Appendix J...............................................................................................................................95

Wellness Corner on Farr 7...................................................................................................95

Wellness Corner on Farr 2...................................................................................................96

Appendix K..............................................................................................................................97

IRB Approvals.....................................................................................................................97

Beth Israel Deaconess Medical Center IRB Exempt approval.........................................97

Simmons College IRB Performance/Quality Improvement approval..............................98

References................................................................................................................................99

Self-Care Among Nurses x

List of Tables

Table 1: Pre-Survey Group Demographics............................................................................37

Table 2: Post-Survey Group Demographics...........................................................................38

Table 3: Focus Group Demographics....................................................................................40

Table 4: Frequencies: How satisfied are you with your current job?....................................42

Table 5: Frequencies: What is your level of engagement in the workplace?.........................42

Table 6: Frequencies: How committed do you feel to your job?............................................43

Table 7: Pre vs. Post Crosstabulation: Do you feel able to care for yourself in the workplace?...............................................................................................................................43

Table 8: Pre vs. Post Crosstabulation: How satisfied are you with your current job?..........44

Table 9: Pre vs. Post Crosstabulation: What is your level of engagement in the workplace?.................................................................................................................................................44

Table 10: Summary of Study and Survey Questions with Related Staff Verbatims................53

Table 11: Summary of Focus Group Outcomes and Related Verbatims................................66

Self-Care Among Nurses 11

Developing Self-Care Practices Among Nursing Staff on In-Patient Acute Care Units

Introduction/Problem Statement

Nurses’ well-being in the workplace has been demonstrated to relate to levels of

engagement. The level of nurses’ engagement significantly impacts patient outcomes and the

overall patient experience. Job satisfaction and commitment are key elements of employee

engagement. (Macy, & Schneider, 2008). Reimbursement models have moved toward

patient care outcomes as opposed to specific processes and points in service. The benefits of

high levels of engagement among nursing staff include economic benefits related to retention

as well as reimbursements and patient care outcomes. The importance of self-care practices

among nurses, and the contribution of these practices to wellbeing, is evident in the literature,

but, specific recommendations around what practices and approaches are most effective are

lacking. The increasingly complex practice environment within inpatient acute care units

may present challenges to nurses’ ability to carry out self-care practices.

The study was conducted on inpatient general medical units within a major tertiary

medical center in New England. The target population is the nursing staff, which includes

both RN’s and PCT’s, employed on these units. The desired outcome of the study was to

promote self-care practices among the nursing staff within the work environment and to

develop a set of recommendations around self-care practices in the work environment that

healthcare leaders can adopt in their practice settings. The project aimed to foster a work

environment which supports the importance of self-care practices for the nursing staff and

successfully encourages staff to incorporate these practices into their daily routines.


Purpose and Practice Inquiry Questions:

The purpose of this study was to add to the body of knowledge around self-care as it

relates to nursing staff in an acute care hospital setting, the identification of meaningful self-

care opportunities within the hospital setting and the benefit of these practices to levels of

engagement.

The central question of this study:

What is the experience of nursing staff on an acute care general medicine unit in practicing

self-care behaviors at work?

Related questions:

What work based self- care practices have the greatest value to the nursing staff

on an acute care general medical unit?

What are the barriers to practicing self-care in the workplace?

What impact does a program of self-care practice opportunities have on levels of

engagement?

How can the unit-based leadership best support the development of a culture of

self-care on the inpatient unit?

Significance of the Problem

This is a very important topic within nursing. The current healthcare system is under

great pressure to deliver care which is high quality, of high value to the patient, and cost

effective.

The systems of reimbursement are increasingly focused on these outcomes. The literature

has established the importance of nurses’ engagement to the patient experience and patient

outcomes. The role of self-care in nurses’ wellbeing and levels of engagement has received


increasing attention in recent years. Concern for compassion fatigue and burnout, which

have a negative impact on engagement, add to the urgency to further understand the

challenges nurses face in terms of their ability to care for self while caring for others.

Compassion fatigue is a state of exhaustion, incurred through caring and exposure to

secondary trauma, in which coping abilities are compromised. This compromise can manifest

itself through physical and emotional symptoms as well as a state of disconnection in the

caregiver. Burnout is often referred to as a sequela to compassion fatigue (Nolte et al, 2017).

Burnout is “...associated with feelings of hopelessness and difficulties in work or in doing

your job effectively” (Stamm, 2010, p.13). Self-care is identified as one way of buffering the

impact of compassion fatigue (Nolte et al, 2017).

The importance of developing resiliency among health care professionals is evident in

the literature (McAllister and McKinnon, 2008). Resiliency is the ability of an individual, or

group, to positive adapt to adverse circumstances. Due to the challenging conditions within

which nurses work, the development of resiliency is an important consideration. Self-care is

an important element of resiliency (Jackson, 2008). These considerations support the

imminent need for a greater understanding of the self-care practices that would be most

effective for nurses in the work environment, the barriers to sustaining the ability to apply

these practices, and how to create a culture which supports practices of self-care and

encourages the development of these practices among nursing staff.

Leadership within nursing and health care organizations can play a pivotal role in

identifying, establishing and supporting the optimal work environment for nurses.

Professional nursing organizations, including the American Association of Critical-Care

Nurses (AACN) and the American Nurses Association (ANA), have put forth agendas which


promote self-care among nurses. The AACN’s Healthy Work Environment (2005)

campaign, as well as ANA (2017) Year of the Healthy Nurse, advocate for these practices to

be valued and incorporated into the practice environment. Nurse leaders within health care

organizations are called upon to provide the leadership necessary to prioritize the wellbeing

of caregivers and to help transform the practice environment within which nurses provide

care. Dyess et al (2018) discuss the importance of self-care among nurse leaders in the acute

care environment as well as staff nurses. Nurse leaders “…require clear minds to focus on

the domain of caring necessary to create and support patient-centered safe healing

environments” (Dyess et al, 2018, p. 79).

There is a historical legacy to overcome of self-sacrifice among nurses as the care of

others has been seen as more important than the care of self. The development of knowledge

has provided insight into the importance of maintaining one’s own well-being in order to

optimally support the well-being and care of others.

Literature Review

Introduction

One may wonder why the topic of self-care among nurses is pertinent now as nursing is a

well-established profession with a proud history. There is a confluence of circumstances

within healthcare which make this topic very pertinent. It is important to understand the

developments within healthcare, and nursing, in the last two decades in order to provide a

framework within which the importance of self-care among nurses can be fully appreciated.

In 1999, the Institute of Medicine (IOM) published, To Err is Human: Building a Safer

Health System which provided a comprehensive report on the quality and safety concerns

within hospitals in the United States and the devastating effects of medical error. This


publication was followed by the IOM publication, Crossing the Quality Chasm (2001), which

called for fundamental reforms within the healthcare system in the United States in order to

assure the delivery of safe, effective, patient-centered, timely, efficient, and equitable care

(IOM Executive Summary, 2001, p. 5-6). The IOM also published Keeping Patients Safe:

Transforming the Work Environment of Nurses in 2003. This report highlighted the

important role nurses play in the provision of high quality, safe patient care.

Recommendations issued by IOM in this report focused on the work environments and

organizational cultures within which nurses provide care and the characteristics necessary to

support an environment which would support and promote patient safety. These reports were

influential in ushering in the current era of healthcare within which the provision of high

quality and safe care and the attainment of improved patient outcomes are paramount. These

priorities are upheld by consumers and society as there is a movement for these standards to

be met. Within this context, the importance of self-care among nurses and the impact nurses’

well-being has on the delivery of optimal patient care emerges.

The Importance of the Work Environment’s Influence on Nursing Care

When considering the role of self-care among nurses, the importance of the work

environment and organizational culture are important to understand. In the early 2000’s the

influence of the IOM report on the importance of nurses’ role in the attainment of quality

health care, and concerns of a nursing shortage, fueled interest in developing greater

understanding about factors influencing the delivery of nursing care and the organizational

characteristics which may ultimately promote, or negatively impact, patient outcomes.

Vahey, Aikens, Sloane, Clarke and Vargas (2004) examined the impact of nurse burnout

on patients’ satisfaction with their care. Vahey et al (2004) conducted cross-sectional


surveys of 820 nurses and 621 patients from 20 different hospitals across the United States.

In this study, burnout was assessed using the Maslach Burnout Inventory (MBI) which

includes three established characteristics: emotional exhaustion, depersonalization and

personal accomplishment. The nurse work environment was assessed using 3 subscales of

the Nursing Work Index, NWI-R. This has been shown to have a high degree of reliability

and validity. A 21-item version of the La Monica-Oberst Patient Satisfaction Scale (LOPSS)

was used to assess patient satisfaction. The authors state that they “…demonstrated

empirically…that nurse burnout, as measured by feelings of emotional exhaustion and lack

of personal accomplishment, is a significant factor influencing how satisfied patients are with

their care” (p. 1162). Vahey et al (2004) state that the emotional exhaustion subscale of the

MBI has the strongest predictive validity. Additionally, Vahey et al (2004) advised that

further research was needed to identify how particular qualities of organizations affect the

delivery of nursing care.

Laschinger and Leiter (2006) in their study, The Impact of Nursing Work Environments

on Patient Safety Outcomes, succeeded in identifying qualities in the work environment

which ultimately impact patient safety outcomes. The Nursing Worklife Model was the

theoretical framework used for the study. This model describes how nursing work life

factors, burnout, and nurse and patient outcomes relate to one another. This model identified

five work life factors of great importance in terms of impact on nurse levels of burnout vs.

engagement and patient outcomes. The five work life factors are effective nursing

leadership, staff participation in organizational affairs, adequate staffing for quality care,

support for a nursing (versus medical) model of patient care, and effective nurse/physician

relationships (p. 260). Measures of work life of 8,597 nurses were assessed using the


Practice Environment Scale of the Nursing Work Index. The Maslach Burnout Inventory –

Human Service Scale was used to assess burnout. Both of these tools are reported to have

validity and reliability. Nurses also reported the frequency of adverse patient events. The

authors suggest a longitudinal study to assess changes over time and also suggest replication

of the study with different samples of staff nurses to validate the findings. Laschinger and

Leiter (2006) conclude “….the results suggest that when nurses perceive that their work

environment supports professional practice, they are more likely to be engaged in their work,

thereby ensuring safe patient care. The results also support the key role of strong nursing

leadership in creating conditions for work engagement and, ultimately, safe, high-quality

patient care (p. 265).”

The American Association of Critical Care Nurses (AACN), in 2001, made their

commitment to fostering healthy work environments wherever acute and critical care nurses

practice. These healthy work environments would support and foster excellence in patient

care. In 2005, AACN issued AACN Standards for Establishing and Sustaining Healthy Work

Environments: A Journey to Excellence. AACN established the following six standards as

being the core of healthy work environments:

Skilled Communication – Nurses must be as proficient in communication skills as

they are in clinical skills.

True Collaboration – Nurses must be relentless in pursuing and fostering true

collaboration

Effective Decision Making – Nurses must be valued and committed partners in

making policy, directing and evaluating clinical care, and leading organizational

operations


Appropriate Staffing – Staffing must ensure the effective match between patient

needs and nurse competencies

Meaningful Recognition - Nurses must be recognized and must recognize others for

the value each brings to the work of the organization

Authentic Leadership – Nurse leaders must fully embrace the imperative of a healthy

work environment, authentically live it, and engage others in its achievement (AACN

Executive Summary, 2005, p.2)

With this increased national focus on quality and safety of patient care, effective and

efficient care, and increasing value to the patient, reimbursement patterns began to change

(IOM, 2001; Porter, 2010). Following the recommendations of the IOM, healthcare began to

try to move from fee for service reimbursement models to reimbursements for a cycle of care

which took into account patient outcomes. Reimbursements are increasingly related to

hospitals’ performance in quality outcome measure including the Medicare Hospital

Consumer Assessment of Healthcare Providers and Systems (HCAPS) categories, several of

which relate to patient satisfaction and outcomes of patient care (Medicare, 2016). All of

these trends reinforced the need to study factors related to successful outcomes in these areas

and to understand what nursing environments seemed to be more successful than others (in

terms of meeting newly established goals, standards, and expectations around value and

cost).

Further developments in understanding optimal work environments

Optimal patient outcomes are supported by the delivery of excellent nursing care

(IOM, 2004; Laschinger and Leiter, 2006). Healthy work environments promote nurse


engagement which has been demonstrated to positively impact patient outcomes (AACN,

2005, Laschinger and Leiter, 2006). Strong nursing leadership is needed to support the

development of healthy work environments which include the promotion of self-care for

nursing staff thus increasing wellness and engagement (Shirey, 2006). “Beyond the

requirement to provide a healing and aesthetic physical work environment for patients is the

more contemporary assumption that the healing environments must also extend to the nurses

who care for patients” (Shirey, 2006, p.258). Shirey validates that optimal engagement of

nurses in the work environment is the most important element in preventing the build-up of

chronic stress and ultimately burnout.

Hunsaker et al (2015) studied compassion fatigue (cf), compassion satisfaction (cs), and

burnout in emergency department (ED) nurses. “Compassion satisfaction is the positive

aspects of helping others (Stamm, 2010, p.10)”. “Compassion satisfaction is about the

pleasure you derive from being able to do your work well” (Stamm, 2010, p. 12). Hunsaker

et al’s study included a survey using the Professional Quality of Life Scale version 5 which

was distributed to 1,000 ED nurses in the United States. There was a 28% response rate.

The results of a multiple regression analysis of the variables studied showed that the

strongest predictor of the level of CS, CF and burnout among the nurses studied was manager

support.

The American Association of Nurse Anesthetists reinforces the importance of building a

culture of safe and healthy work environments for nurses. “Healthy work environments

optimize patient safety, enhance staff’s physical and mental well-being and help

organizations sustain financial stability” (AANA, 2014, p.1). Shirey (2006), in her work,

Authentic Leaders Creating Health Work Environments for Nursing Practice, provides a


detailed literature review on this topic and articulates the key components of authentic

leadership. Shirey states that, “...building healthy work environments which achieve optimal

levels of nurse engagement as well as patient outcomes requires skilled, authentic nursing

leadership” (p. 256).

Given the importance of the healthy work environment and the impact on nursing

practice, Shirey (2006) posits we need to build the science of authentic leadership. Shirey

points to the work of Avolio and Gardner (2005), who have begun to build a theoretical

model which links authentic leadership to the attitudes, behavior, and performance outcomes

of staff. Shirey states,

“On the basis of this proposed model, a healthy work environment (distal or long-term

outcome) may logically be assumed to result from a process of employee engagement in

which authentic leadership is configured to be the input (or antecedent). The

psychological engagement (proximal or immediate outcome) of employees by authentic

leaders may be a key mechanism by which the healthy work environment is created.” (p.

263).

Exploring the Concept of Self-Care within Nursing

“For someone to develop genuine compassion towards others, first he or she must have a

basis upon which to cultivate compassion, and that basis is the ability to connect to one’s

own feelings and to care for one’s own welfare…Caring for others requires caring for

oneself.” (Dalai Lama, 2003, p. 125).

Mills, Wand and Fraser (2014) point out that self-care, within the traditional culture of

nursing, may have been seen as selfish. The relationship of self-care to one’s ability to care

for others was not necessarily a shared value and concept among nurses. Rather, norms and


social enculturation within nursing promoted selflessness and martyrdom. Mills et al state

that nurses’ ability to care for self and others is interdependent and supported by Watson’s

Theory of Human Caring (2008). Based upon the importance of self-care among nurse and

its relationship to the provision of high quality care as previously discussed, Mills et al

suggest that the nursing practice culture needs to condone self-care and reinforce the

importance of self-care practices.

Orem (1991) defines self-care as “…activities that individuals personally initiate and

perform on their own behalf in maintaining life, health and well-being” (p. 365). Dorothea

Orem’s theory of self-care incorporates the principles of health promotion as outlined by

Pender (Hartweg, 1990). Pender includes the following in her definition of health,

“….evolving life experience…actualization of inherent and acquired human potential

through goal-directed behavior, competent self-care, and satisfying relationships with others”

(Pender, 2011, p.3). Orem’s definitions of two main concepts – health and well-being share

the same characteristics as Pender’s concepts of stability and actualization. These theoretical

frameworks are utilized in the literature pertaining to self-care and nursing. Pender’s Health

Promotion Model and associated validated tools were utilized by many of the studies

reviewed including McElligott, Seimers, Thomas and Kohn (2009), McElligott, Capitulio,

Morris and Click (2010), Nevins and Sherman (2016) and Stark, Manning-Walsh, and

Vliem (2004).

Kreitzer (2015) clearly articulates the importance of self-care among nurses in her

Integrative Nursing framework which “…focuses on improving the health and wellbeing of

caregivers as well as those they serve (p.1)”. The detrimental effects of lack of self-care

among nurses impact the individual caregiver, patients and entire organizations.


Identifying Effective and Valuable Self-Care Practices Among Nurses

The literature strongly supports the importance of self-care and the relationship of self-

care practices among nurses to desired outcomes - including higher levels of engagement and

patient outcomes. However, there is a lack of information around recommendations and

practices specific to nursing and the particular challenges that nurses experience.

Three studies reviewed focused on the self-care of nursing students (Stark et al, 2005;

Blum, 2014; Nevins and Sherman, 2016). Although the experience of nursing students

differs from that of the clinical nurse, there are points of consideration which pertain to this

discussion. The overall goal of these studies was to promote knowledge and awareness of

the importance of self-care among the students. The researchers seemed to share the hope

that the instruction on self-care would ultimately benefit the student’s nursing practice as

well as their ability to effectively promote these behaviors in patients. Starke et al (2005)

and Blum (2014) incorporated course content on self-care into the curriculum for the nursing

students. Both studies found that the content was beneficial and contributed to the

cultivation of healthy self-care practices among the students. Limitations included the

heightened focus that accompanies required course content and the challenge to sustaining

the focus once it is not required. Nevins and Sherman (2016) conducted a survey of self-

care practices among nursing students in order to assess the value of health promotion

behaviors in this group. Their results also pointed to support for the incorporation of content

into the curriculum for nursing students.

Four studies were reviewed which explored self-care practices among practicing nurses.

Kravits, K., McAllister-Black, Grant, M. and Kirk, C. (2010) studied self-care strategies for

nurses. They discussed burnout and its three main symptoms of emotional exhaustion (EE),


depersonalization (DP) and decreased perception of personal accomplishment (PA). Kravits

et al (2010) utilized Lazarus and Folkman’s Cognitive Model of Stress and Coping and the

Transtheoretical Model of Change as their conceptual framework. The study used an

educational program as an intervention to teach positive self-behaviors to nurses. There were

248 course participants. The Maslach-Burnout Inventory-Human Services Survey (MBI-

HSS) was used to assess the three components of burnout. This tool has established validity

and reliability. An art evaluation tool which was early in the stages of development, Draw-a-

Person-in-the-Rain Art Assessment (PIR), was used to supplement the information from the

MBI-HSS. The interventions presented in the class included relaxation and guided imagery,

art exploration of proactive coping strategies, and creation of personal wellness plans. The

most significant result from the study was the positive effect of the class on emotional

exhaustion levels in the nurses as well as the level of depersonalization. The authors

identified the limitations which create the challenge in attracting nurses to participate in a

self-care program as well as the need for a longitudinal study.

McElligott et al (2009) assessed health promoting lifestyle behaviors in acute care nurses

and found that areas of weakness included stress management and physical activity. Health-

promoting behaviors were assessed using the Health-Promoting Lifestyle Profile II survey

which the authors stated had proven validity and reliability. There were 149 respondents to

the survey. The authors conclude there are opportunities for self-care in the workplace

including education programs and utilization of stress reducing modalities. McElligott et al

state, “….as health is multifaceted, health promotion interventions for nurses should be

comprehensive, incorporating a holistic wellness approach, and fostered in the workplace”

(p. 214). Massage, reflexology, and imagery were among the recommended modalities. The


authors recognized that their sample size was relatively small and that further studies are

needed to validate their findings and recommendations.

The development of resiliency among new nurses was studied by Chesak et al (2015). In

this study a stress management program was incorporated into the orientation period of 55

new nurses. In this randomized controlled study, the new nurses were randomly assigned to

either the study group or the control group. The study group attended two educational

sessions, the first session was ninety minutes long and the second session was an hour long.

During the sessions a model of stress management and resiliency was presented. The

intervention group also received instructional materials biweekly. The control group

participated in the routine nursing orientation lecture which incorporated content related to

stress management along with other topics related to adaptation to the new role. The

Perceived Stress Scale, the Mindful Attention Awareness Scale, the Generalized Anxiety

Disorder 7-item scale and the Connor-Davidson Resilience Scale were all used as

measurement tools. T-tests were used in analyzing the data. Though not statistically

significant, the intervention group showed improved mindfulness and resiliency scores and

decreased stress and anxiety scores compared to the control group. The need for protected

time for nurses to participate in this type of program was among the future recommendations

of the investigators, as it had been one of the challenges for study participants who did not

complete the program.

McElligott et al (2010) studied the effect of a holistic educational program, the

Collaborative Care Model, as well as development of a self-care plan, on the practice of

health promoting behaviors among nurses in a large academic medical center setting. The

Health Promoting Lifestyle Profile II instrument was used in this study. There were 185


surveys returned and 73 care plans completed. In comparison to a control group, who did not

participate in the education program or self-care planning, the experimental group had

increased health promoting lifestyle scores. They showed sustained improvement in

spirituality, interpersonal relationships, and nutrition over time. A limitation of this study

was the small sample size with further studies recommended.

Lubinska-Welch (2016) conducted a study of self-care practices of nurses in a rural

hospital setting. This was a cross-sectional, descriptive study which utilized a structured

questionnaire to collect data. The sample was comprised of 45 participants. Participants

indicated a high level of engagement in self-care activities such as walking, reading,

spirituality, music, healthy sleep and humor. There was an indication that participants would

be interested work based programs in fitness and nutrition as well as job stress management

and health education. Limitations included a small, homogeneous convenience sample from

one hospital setting. Additionally, the structure of the questionnaire did not include open

ended question(s).

Reid Ponte and Koppel (2015) implemented a pilot program in mindfulness which was

available to all nursing and clinical staff in a comprehensive cancer center. This program had

structured education sessions as well as practice sessions in mindfulness techniques. The

techniques utilized in this curriculum included meditation, body scan exercises, mindful body

movement such as yoga, and walking meditation. The program also guided staff in

incorporating mindfulness activities into their daily practice and routine. The application of

mindfulness techniques was presented as an important part of self-care. The participants

reported very favorable outcomes including increased resilience, increased levels of calm,

and enhanced awareness and clarity. Due to voluntary participation and reliance on


descriptive evidence the study results are not generalizable. Reid Ponte and Koppel strongly

encourage further research into the relationships between mindfulness, nursing practice and

patient care outcomes.

Crane & Ward (2016) offered a continuing education program for nurses on self-healing

and self-care. Crane and Ward provided instruction on seven self-care techniques –

breathing exercises, body awareness, relaxation techniques, meditation, physical affection,

exercise and nutrition (Crane and Ward, p. 390-391). Crane and Ward discuss conscious

leadership and the importance of the nurse leader attending to individual and systemic issues

which may be barriers to a work environment conducive to self-care among the nurses.

Crane and Welch also encourage nurses to practice positive psychology techniques, thought

techniques which promote emotional balance, and spiritual connection.

The commonality in the studies of nursing students and practicing nurses is the support of

work based programs which encourage self-care. Many of the studies used an educational

program. There is a need for further study around specific recommendations of self-care

practices which are sustainable in the daily practice environment and have the most impact

on managing the day to day stress of the inpatient nurse. There is adequate literature around

the optimal environment and leadership characteristics needed to promote an environment

which encourages self-care among nurses.

Definition of Terms

For the purposes of this study, the definition of self-care provided by the World Health

Organization (WHO) will be used. The WHO (1983) states “…Self Care in health refers to

the activities individuals, families and communities undertake with the intention of

enhancing health, preventing disease, limiting illness, and restoring health”(p. 2). Kreitzer


(2015) states, “...Self-care is the most sustainable health care practice and comprises

attentiveness to lifestyle behaviors (including healthy eating, exercise, sleep, and stress

management), and may include the use of integrative therapies, such as meditation, yoga,

energy therapies, and massage” ( p. 5).

Dempsey and Reilly (2016) offer the following definition of nurse engagement:

“...The concept of nurse engagement is often used to describe nurses’ commitment to and

satisfaction with their jobs. In reality, these are just two facets of engagement. Additional

considerations include nurses’ level of commitment to the organization that employs them,

and their commitment to the nursing profession itself “(p. 1).

Conceptual Framework

Kreitzer’s (2015) Integrative Nursing framework will be used as the conceptual

framework for this study. Kreitzer states that the principles of integrative nursing are

compatible with major nursing theories and associated paradigms. There are six major

principles of Integrative Nursing:

Human beings are whole systems inseparable from their environments.

Human beings have the innate capacity for health and wellbeing

Nature has healing and restorative properties that contribute to health and wellbeing

Integrative nursing is person-centered and relationship-based

Integrative nursing is informed by evidence and uses the full range of modalities to

support/augment the healing process, moving from least intensive and invasive to

more, depending on need and context

Integrative nursing focuses on the health and wellbeing of caregivers as well as those

they serve (Kreitzer, 2015, p. 2-5).


Kreitzer (2015) also points out that integrative nursing is aligned with the triple aim goals

in health care within the United States which are the improvement of the patient experience,

the improvement of the health of populations, and the reduction of the cost of care.

Kreitzer’s emphasis on the importance of the well-being of caregivers has been reinforced by

a proposal from the healthcare community to make the triple aim of health care the quadruple

aim of health care. In the quadruple aim, the fourth goal is focused on the care and well-

being of the provider/caregiver. The ability to achieve the other three aims is tied to this

essential component. (Bodenheimer, T. & Sinsky, C., 2014).

Methods

Design

This study was a program development project. A mixed methods approach was utilized

for data collection. These methods included surveys and focus groups. (See Appendices A-

D). In the first phase of this project, both of these methods were used to assess the present

state of self-care practice among the population as well as the barriers to self-care and

preferred self-care practice opportunities. This information informed the second phase of the

project which was the program development and implementation. The third phase was the

evaluation phase in which survey and focus group methods were used to evaluate the impact

of the program on self-care practices among the population and the effectiveness of the

program in meeting overall project goals.

Setting

This study took place in a tertiary care academic medical center in a major urban area.

The population is the nursing staff who works on inpatient acute care general medical units.

Two general medical units with similar characteristics and patient population were studied.


There were few barriers to implementation of the pilot program. The first and most

considerable barrier was time for staff to carry out identified self-care activities, due to the

rigor of the practice environment. The second barrier was optimal space for self-care

activities as open space on the units was very limited. Monetary requirements were not

included because the study did not have a budget.

Sample Population

The sample population included the nursing staff, RN’s and PCT’s, who work on the

identified unit(s). The survey was open to all the nursing staff who work on the identified

unit(s). The focus group included representatives from the sample population. The program

was open to all the staff, though it was utilized primarily by those working on the unit at the

time the structured opportunities were available. All program activities were offered to all the

nursing staff on the study units. Participation in the surveys, focus groups, and program

activities was strictly voluntary. (See Appendices E and F.)

The Intervention

The intervention and its design were guided by the information obtained through the

initial survey and focus groups. The intervention was a month long self-care program. The

program had two components. The first component was a series of self-care practice

sessions. The second component was a creation of a Wellness Corner on each of the two

units. The program components and chosen topics were informed by the pre-intervention

data collection and analysis. An outline of the program can be found in Appendix G.

The self-care program took place during the month of January on the two study units. The

program included sessions on Silent Meditation, Chair Yoga, At Your Fingertips: Self-care

Apps, and Mindfulness/Meditation Techniques. Content experts employed at the medical


center facilitated the topics. There was a weekly session for each topic throughout the month

and sessions were held on Tuesday, Wednesday and Thursday each week. The times for the

sessions were 12:30p, 1p, 5p, or 5:30 p. This schedule was decided upon taking into

consideration the facilitator’s availability, the nursing staff schedules and the workflow on

the units. The program content was disseminated to the study unit nursing staff through

email (see Appendix H) and the schedule of sessions was posted on the conference room

doors (see Appendix I).

The Wellness Corner was created in response to pre-intervention data indicating that some

staff members may prefer individual time and a dedicated space for self-care activities. The

Wellness Corners consisted of information on the sessions, including a visual poster on each

topic. Written material on each topic, included step by step instruction on related exercises,

and was provided in the Wellness Corner. The corners were decorated to distinguish them

and provide a therapeutic environment. Furniture was arranged to provide a quiet corner

near a window. The windows on these units look out at a wooded riverway area. Photos of

the Wellness Corners can be found in Appendix J. Each conference room was reserved for

30 minutes per shift for use only by nursing staff members and this reservation was posted on

each conference room door.

Data Collection

A pre and post survey developed by the PI was administered through Survey Monkey.

The focus groups took place on site and were coordinated by the PI along with the

collaborators. As the PI has a managerial role on one of the units, one collaborator was the

facilitator and the second collaborator supported the data collection and took notes during the

focus group discussion. The notes did not include any identifying information. An


information sheet was distributed to staff who attended the focus groups (see Appendix F).

The collaborators collected de-identified demographic information from the participants.

The focus group discussions were audio recorded by the collaborator. The audio recordings

were transcribed verbatim by an outside transcriptionist and participants were de-identified.

The program development was guided by the information gathered through the survey and

focus groups. The post study survey and focus groups were used to evaluate the success of

the program in meeting project goals. There were five pre-intervention focus groups and

four post-intervention focus groups. However, one of the post-intervention focus groups was

not utilized as the sole participant in that group disclosed her identity to the PI. The content

of the remaining three post-intervention groups was analyzed. In two instances, participants

inadvertently identified themselves in a transcribed statement; those passages were removed

from consideration.

The focus groups were held in conference rooms on the two study units. Nursing staff

from both units were welcome at all the focus groups. Each focus group was scheduled to

last 30 to 45 minutes. Nursing leadership on the two units supported staff attendance at the

focus groups by caring for the patient and unit needs during the 30 to 45 minute period. The

timing of the focus groups was such that staff working between the hours of 7a.m. and

11p.m. had the opportunity to participate. Staff who were not scheduled to work were

welcome to attend. There were questions pertinent to the pre-intervention and post-

intervention discussions which served as a guide for the facilitator. Similar to semi-

structured interviews, focus group discussions were guided by a list of planned topics or

questions (Polit and Beck, 2016). See Appendices D and E.


The PI developed survey was administered via Survey Monkey. The pre-survey remained

open to staff for 18 days. The post-survey remained open to staff for 26 days. The post-

survey period was extended due to an initial slow response rate. The survey content was

developed in consultation with academicians with expertise in nursing research. See

Appendix B and C.

Data Analysis

The data analysis will be a segregated design in which the survey data and focus group

data will be analyzed separately. After the two data sets are analyzed, the findings will be

synthesized (Sandelowski et al, 2006).

Survey Quantitative Data Analysis

The pre and post survey data were analyzed using IBM SPSS Version 24 (IBM,

Armonk, NY). In the pre-survey, twelve subjects were removed from the data set as they did

not answer any questions except demographic information. In the post–survey, three subjects

were removed from the data set as there was no unit identified in each case and, therefore,

there was no way to know if the subject belonged to the intervention or the control group.

After this cleaning of the data, the pre-survey sample size was 71. The post-survey sample

size was 64. The participants were not matched in the pre and post surveys.

The survey contained quantitative and qualitative, open-ended items. The qualitative

data were coded into themes and entered numerically in SPSS in order to be analyzed using

counts and percentages. Descriptive statistics included frequencies and percentages reported

separately for the pre and post survey samples.

Chi-square statistical tests were conducted comparing pre vs. post survey responses

on three categorical dependent variables, separately for the intervention and control groups.


The dependent variables were: whether one felt able to care for oneself in the workplace, job

satisfaction, and engagement in the workplace. A bivariate analysis was not possible on the

variable of commitment to one’s job as the data were too skewed. Respondent satisfaction

and engagement were asked using five-point scales. In order to have enough cases to meet

the chi-square test assumption of at least five expected cases per cell, respondent satisfaction

and engagement were each collapsed into two categories. For both variables, the two

categories were Not Very/Slightly/Somewhat vs Very/Extremely.

Survey Qualitative Data Analysis

The qualitative survey data, obtained through the open ended questions, was analyzed

using conventional content analysis. As stated, open ended survey questions were coded

according to identified themes and entered into SPSS allowing for counts and frequencies.

Key staff verbatims were included as they related to study and survey questions.

Focus Group Data Analysis

Focus groups have been utilized in the social sciences as a research method since the early

twentieth century. In a focus group, the data is generated in the setting of an interactive

discussion. This unique dimension of focus groups provides access to data which is not

accessible through individual interviews (Hennink, 2014). The focus group data was

analyzed using conventional content analysis. In conventional content analysis codes and

themes are not predetermined but arise from immersion in the data and are identified during

data analysis (Hsieh and Shannon, 2005). The pre-intervention focus group transcripts were

reviewed until codes emerged and categories were developed. The notes taken during the

focus groups by the study collaborator were also reviewed to validate content. From the

categories established for each question in each focus group, a cross-group analysis was


conducted to identify themes and patterns. Study collaborators, both of whom were present

at all focus groups, reviewed corroborated, and validated the findings and emerging themes.

The themes which emerged from the focus group data analysis are as follows:

Theme 1: The nursing staff struggle to meet basic self-care needs in the work environment.

The main support they experience in trying to do so comes from their peers.

Theme 2: The desired self-care practice of greatest value to the nursing staff is the ability to

attend to self-care needs by having uninterrupted time for meals and breaks. The nursing

staff finds value in a variety of self-care practices as well as the ability to seek out desired

spaces and environments in which to care for self.

Theme 3: Lack of time and lack of resources to support staff’s self-care needs and practices

are the main barriers nursing staff experience in their ability to carry out self-care in the

workplace.

Theme 4: There is consensus among the nursing staff that opportunity to practice self-care in

the work environment has a positive impact on engagement levels.

Theme 5: The unit based nursing leadership can best support staff efforts in self-care by

promoting awareness and mutual respect among the staff about the importance of self-care,

providing the support and resources necessary for uninterrupted, covered opportunities for

self-care practices, and organizing structured, facilitated self-care technique sessions on the

unit.

Rigor

Rigor, also referred to as validity and reliability, is essential to establishing the

trustworthiness of qualitative research (Merriam and Tisdell, 2016). The data analysis

process was supported through consults with content experts in qualitative and quantitative


nursing research. The survey was reviewed by survey content researchers and experts.

Changes in the survey were made in response to their input. The PI, along with study

collaborators, validated that qualitative data collection continued to the point of saturation.

The establishment of the audit trail as described, the audio transcripts and written notes of the

focus group content, as well as the use of peer review and multiple sources of data,

contributed to the establishment of appropriate rigor in the study. Please see Appendix K for

related IRB approvals.

Cost Analysis

The costs associated with the project included transcriptionist fees and materials needed

for the program implementation. There were no costs in terms of facility use. The content

experts involved in the program activities were functioning within their job scope in

supporting the program. Nursing staff’s time in filling out surveys and participating in focus

groups is a consideration, but, no additional costs were associated with this.

The impact of the program has potential cost savings for the organization. If a culture

which promotes and supports self-care among the nurses positively affects the levels of

engagement, the resulting positive effects on retention levels as well as patient care outcomes

may have major cost savings associated with them.

Human Subjects Protection

This is a program development project which has more of an orientation towards a quality

improvement project. Exemption applications were submitted to the Beth Israel Deaconess

Medical Center IRB as well as to the Simmons IRB and approved.

Results

Recruitment of Participants


Recruitment of participants for the survey and focus groups was primarily through email

messages sent to the nursing staffs on the study and control units by the PI and study

collaborator. The initial email inviting staff to participate in the study can be found in

Appendix A. Members of the Nursing leadership teams on the study units supported staff

participation in the focus groups and the surveys. Participation remained voluntary and there

was no consequence related to whether one participated or not.

The Sample

The survey sample.

Demographic information collected in the pre and post surveys included role (RN vs.

PCT), unit, number of years of PCT practice, number of years of RN practice, number of

years on present unit, age range, and gender. As the participants in each survey were not

matched pre to post, the demographic results are reported separately for each time period (see

Table 1 and 2).

Demographics of participants.Table 1:

Pre-Survey Group Demographics

Intervention (n = 32) Control (n = 39)Variable n Percent n Percent

Role

PCT 7 21.9 9 23.1

RN 25 78.1 30 76.9

Age Range21 and below (Gen Z) 3 9.4 1 2.6

22-40 (Millennial) 20 62.5 31 79.5


41-52 (Gen X) 5 15.6 7 17.9

53-71 (Baby Boomer) 4 12.5 0 0.0

GenderFemale 30 93.8 34 87.2

Male 2 6.3 5 12.8

Experience n Mean (SD) n Mean (SD)# years of PCT practice 26 2.42 (5.85) 33 2.66 (5.04)

# years of RN practice 28 9.98 (10.78) 32 7.41 (6.96)

# years on present unit 32 6.01 (6.65) 38 3.30 (3.86)


Table 2:

Post-Survey Group Demographics

Intervention (n = 21) Control (n = 40)Variable n Percent n PercentRole

PCT 5 23.8 8 20.0

RN 16 76.2 32 80.0

Age Range21 and below (Gen Z) 0 0.0 2 5.0

22-40 (Millennial) 15 62.5 33 82.5

41-52 (Gen X) 5 20.8 4 10.0

53-71 (Baby Boomer) 4 16.7 1 2.5

GenderFemale 20 83.3 34 85.0

Male 4 16.7 6 15.0

Experience n Mean (SD) n Mean (SD)# years of PCT practice 14 6.60 (5.36) 22 3.87 (8.00)

# years of RN practice 19 12.03 (11.56) 32 6.73 (7.96)

# years on present unit 22 7.39 (7.49) 40 3.41 (4.74)

The percentages of RN’s and PCT’s in the pre-survey group as compared to the post-

survey group were relatively similar. Of note, three participants did not identify their role.

The main difference in this variable pre-survey to post-survey was the number of registered

nurses in the intervention group which decreased from 25 to 16. The predominant age group

in both the pre-survey group and post-survey group was 22 to 40 years of age. Compared to

the intervention group, the control group had a larger percentage in this category in both the


pre-survey and the post-survey. Both the pre-survey group and the post-survey group were

predominantly female.

There was variation in years of experience within each role as indicated by the standard

deviations. With the exception of the number of years of PCT practice in the pre-survey

group, the means demonstrate that the control group had less experience in all categories of

these variables as compared to the intervention group, both pre-group and post-group. This

difference in years of experience could be a confounding variable, particularly in terms of

employee engagement, satisfaction, and commitment to one’s job. Note that years of

practice as a PCT includes the time that some RN’s spent in the PCT role before becoming

licensed. The data in the years of experience of PCT practice, RN practice and years of

experience on the unit were too skewed to support statistical tests.

The focus group sample.

Demographics of participants. The focus groups included staff from the intervention units. Demographic information

collection in the focus groups included role (RN vs. PCT), unit, # of years of PCT practice, #

of years of RN practice, # of years on present unit, age range, and gender. Due to the low

number of PCT participants, with the exception of PCT vs. RN pre to post survey,

demographics on the entire focus group sample are reported together. This was done in order

to protect the anonymity of participants. (See Table 3).


Table 3:

Focus Group Demographics

Pre-Intervention Post-Intervention

Variable n Percent n PercentRole

PCT 2 10.5 1 7.7

RN 17 89.5 12 92.3

Pre and Post Focus Groups Combined DemographicsAge Range n Percent

21 and below (Gen Z) 0 0

22-40 (Millennial) 28 87.5

41-52 (Gen X) 3 9.4

53-71(Baby Boomer) 1 3.1

Gender

Female 30 93.7

Male 2 6.3

Experience Level n Mean (SD)

# years of PCT practice 11 4.32(5.85)

#years of RN practice 29 5.78(5.51)

#years on present unit 29 4.20(4.19)

The percentages of RN’s and PCT’s in the pre and post focus groups are relatively similar

with both groups having a large percentage of RN’s. The pre focus groups had more

participants than the post focus groups. The focus group sample is predominantly female and

of the age range of 22 to 40 years of age. There was variation in years of experience in the

PCT, RN, and years on unit as indicated by the standard deviations. The means suggest that


the RN group has more experience overall than the PCT group. The data in the years of

experience of PCT practice, RN practice and years of experience on the unit were too skewed

to support statistical tests.

Quantitative Survey Findings

The central study question is, “What is the experience of nursing staff on an acute care

general medicine unit in practicing self-care behaviors at work?” The survey question, “Do

you feel able to care for yourself in the work place?” provides important information related

to this central question. One of the study questions pertains to engagement. “What impact

does a program of self-care practice opportunities have on levels of engagement?” As

mentioned previously, satisfaction and commitment are elements of engagement (Macy &

Schneider, 2008).

The Pearson chi-square test statistic was used to test whether pre vs post differences

varied between the intervention group and control group

The frequencies and percentages for the three Likert scale variables - satisfaction with

current job, level of engagement in the workplace, and commitment to job- were compared

pre vs post for the intervention and control groups separately (see Tables 4-6). The

percentages are displayed for all response choices and not for the collapsed versions of

satisfaction and engagement which are shown later. Chi-square tests were not conducted for

these variables because the data did not meet the test assumption of five expected counts per

cell.


Table 4:

Frequencies: How satisfied are you with your current job?

Intervention ControlHow satisfied are you with your current job?

Pre Post Pre Postn Percent n Percent n Percent n Percent

1. Not very satisfied

0 0.0 2 8.7 0 0.0 0 0.0

2. Slightly satisfied

2 6.3 1 4.3 2 5.1 5 12.5

3. Somewhat satisfied

12 37.5 9 39.1 11 28.2 14 35.0

4. Very satisfied

15 46.9 10 43.5 22 56.4 19 47.5

5. Extremely satisfied

3 9.4 1 4.3 4 10.3 2 5.0

Table 5:

Frequencies: What is your level of engagement in the workplace?

Intervention ControlWhat is your level of engagement in the workplace?


1. Not very engaged

1 3.1 0 0.0 0 0.0 1 2.5

2. Slightly engaged

0 0.0 0 0.0 1 2.6 1 2.5

3. Somewhat engaged

9 28.1 5 21.7 5 12.8 9 22.5

4. Very engaged

15 46.9 13 56.5 26 66.7 22 55.0

5. Extremely engaged

7 21.9 5 21.7 7 17.9 7 17.5


Table 6:

Frequencies: How committed do you feel to your job?

Intervention ControlHow committed do you feel to your job?


1. Not at all committed

0 0.0 0 0.0 0 0.0 0 0.0

2. Slightly committed

0 0.0 0 0.0 2 5.1 2 5.0

3. Somewhat committed

4 12.5 2 8.7 0 0.0 3 7.5

4. Very committed

18 56.3 12 52.2 21 53.8 28 70.0

5. Extremely committed

10 31.3 9 39.1 16 41.0 7 17.5

Tables 7 through 9 contain the Crosstabulations for each of the three variables analyzed.

The results of the Chi-square tests are stated below each table.

Table 7:

Pre vs. Post Crosstabulation: Do you feel able to care for yourself in the workplace?

Intervention ControlDo you feel able to care for yourself in the workplace?


1.Yes 6 18.8 4 17.4 15 39.5 13 33.32. No 9 28.1 7 30.4 9 23.7 6 15.43.Sometimes 17 53.1 12 52.2 14 36.8 20 51.3

There was no significant association between the ability to care for self between the pre

and post intervention group. (χ2(2, N=55) = .040, p =.980). The data suggests that the control

group was more likely to say ‘yes’ to this survey question in both the pre and post survey

groups.


There was no significant association between the ability to care for self between the pre

and post control group. (χ2(2, N=77) = 1.789, p =. 409).

Table 8:

Pre vs. Post Crosstabulation: How satisfied are you with your current job?

Intervention Control

Satisfaction (collapsed)


1. Not very/Slightly/Somewhat

14 43.8 12 52.2 13 33.3 19 47.5

2. Very/Extremely 18 56.3 11 47.8 26 66.7 21 52.5

There was no significant association between the level of satisfaction in one’s current job

between the pre and post intervention group. (χ2 (1, N=55) = .381, p = .537).

There was no significant association between the level of satisfaction in one’s current job

between the pre and post control group. (χ2 (1, N= 79) = 1.645, p =.200).

Though not statistically significant there is a trend that satisfaction was lower in the post-

survey for both the intervention and control groups.

Table 9:

Pre vs. Post Crosstabulation: What is your level of engagement in the workplace?

Intervention ControlCollapsedEngagement


1. Not very/Slightly/Somewhat

10 31.3 5 21.7 6 15.4 11 27.5

2. Very/Extremely

22 68.8 18 78.3 33 84.6 29 72.5

There was no significant association between the level of engagement in the workplace

between the pre and post intervention group. (χ2 (1, N= 55) = .610, p =. 435).


There was no significant association between the level of engagement in the workplace

between the pre and post control group. (χ2 (1, N=79) = 1.716, p = .190).

Though not statistically significant, there is a trend that engagement levels were higher in the

post-survey for the intervention group and lower in the post-survey for the control group.

In summary, the bivariate analysis did not show any statistically significant impact of the

program on the ability to care for oneself in the workplace, satisfaction or engagement. The

variable of commitment, as stated, did not meet the criteria for analysis.

In terms of being able to participate in any of the structured self-care opportunities

offered on the unit during the program, 44.0% of staff responded that they were never able to

attend, 29.6% attended infrequently (less than 1x per week), 18.5% attended intermittently

(1-2x/week), and 7.4% always attended. The bivariate analysis was also run without the

respondents who had indicated that they were never able to attend a structured self-care

session in order to see if the analysis results were any different. The results of that analysis

were all nonsignificant as well.

Open-ended and Multiple Response Survey Findings

The open-ended and multiple response survey questions also provided information

pertinent to the capstone questions. The outcomes of the pre-survey and post-survey will be

discussed as they relate to the study questions. The multiple response questions asked

respondents to check all that apply. Open-ended questions were coded by themes and some

respondents’ answers contained more than one theme. Therefore, the responses to multiple

response and open-ended questions had total percentages which were more than 100%.

When reporting the results of these items, the number of the respondents will be reported


instead of percentages. The denominator for these items will be the number of respondents

who answered the particular survey question.

The information gathered through these items on the survey continue to build information

and insights around the central study question, “What is the experience of nursing staff on an

acute care general medicine unit in practicing self-care behaviors at work?”. See Table 10

for a summary of study and survey questions which relate to key staff verbatims from the

qualitative survey data.

In the pre-survey, 46.5% of staff stated their ability to practice self-care in the work

environment was infrequent (less than 1x/week) or never. On the post-survey, 38.7% of staff

reported the same. Staff provided open ended answers to the follow-up question, “Why do

you not feel able to care for yourself?” Staff quotes included the following:

• “...No time, too much stress, never able to leave unit…

• “Rushed at work, need to take care of patients first.”

• “The floor can get very hectic and busy and often you put the patients’ needs and

your coworkers before your own. It becomes easy to forget to take care of yourself.”

• “...too busy to have time to reflect on practice, too busy to eat at times, high stress…”

• “We are constantly needed…”

Several survey items provided information related to the study question, “What work

based self- care practices have the greatest value to the nursing staff on an acute care general

medical unit?”


The pre-survey data provided an important baseline about the current state of self-care

practice among study participants. In a multiple response item, the self-care activities

identified as having the greatest value to the nursing staff in the workplace were as follows:

1. relaxation exercises (43 of 71 respondents),

2. yoga (38 of 71 respondents) and

3. silent meditation (32 of 71 respondents).

In another multiple response question, staff who were practicing self-care in the

workplace prior to the intervention period identified silent meditation (28 of 71 respondents)

and relaxation exercises (17 of 71 respondents) as the most frequently utilized strategies in

which they engaged at least once per week.

In an open-ended item, 52 respondents reported a self-care activity which they were

currently incorporating into their work day. Of note, some respondents seemed to consider

the work day as including the time preparing for work and the time following the completion

of work as a part of the overall work day. . These activities included the following:

1. breathing exercises (16 of 52),

2. breaks and lunch (14 of 52),

3. meditation (12 of 62),

4. relaxation (5 of 52),

5. walks (4 of 62)

6. hydration (3 of 62), and

7. music (3 of 62).


Identification of the self-care practices staff would like most to incorporate into their

work day was another open-ended item. Reponses included:

1. lunch and breaks (20 of 43),

2. meditation, reflection, breathing and relaxation exercises (15 of 43),

3. walks and fresh air (9 of 43),

4. yoga (8 of 43), and

5. exercise (5 of 43).

When asked for additional suggestions for ways to incorporate self-care practices into the

work environment, an open-ended question, staff responses included:

1. scheduled self-care time (6 of 36)

2. meditation/mindfulness/reflective opportunities (5 of 36 respondents)

3. support for staff (4 of 36)

4. staffing model adjustments (4 of 36)

5. dedicated space (3 of 36 respondents) and

6. decrease in noise and pages (2 of 36).

Responses to whether staff would find value in having structured opportunities within

the work day to carry out self-care practices revealed both staff interest and concern. Value

in having opportunity for structured self-care activities was responded to affirmatively by 38

of 51 respondents. However, staff expressed concerns about the ability to participate due to

lack of time (10 of 51 respondents) and workflow demands (11 of 51 respondents). Self-care

opportunities were identified as having value in managing stress (9 of 51 respondents) and

providing opportunities for self-care for the caregivers (9 of 51 respondents). Mutual support


and respect for personal preferences among the staff were identified as important

considerations (5 of 51 respondents).

In the post survey, 16 respondents participated in self-care program activities. These

included:

1. meditation (6 of 16 respondents)

2. chair yoga (4 of 16 respondents), and

3. self-care apps (2 of 16 respondents).

One off-shift staff member noted, “....Using the self-care room for my own practice.”

The most commonly identified benefits from the self-care activities were:

1. time to relax and refocus (9 of 16 respondents)

2. quiet time and quiet space (5 of 16 respondents), and

3. improved stress management (4 of 16 respondents).

. Quotes from staff regarding what was most valuable about the self-care activities include

the following:

• “Taking time in a quiet space allowed me to gather myself and reset my mind on a

hectic shift.”

• “...pager off/quiet time without worry to answer lights as someone covered me…”

• “...able to relax/destress for 15 minutes although unfinished work was often

lingering in the back of my mind.”

• “The deep breathing made me feel relaxed and centered. I can do that anywhere,

anytime and achieve some level of peace even in the most stressful situation.”

In answering how the self-care program helped with self-care during the work day, staff

identified the following ways in which the program helped:


1. the building of a self-care mindset (5 of 19 respondents)

2. ability to relax and refocus (3 of 19 respondents),

3. the benefit of having structured opportunities (3 of 19 respondents), and

4. quiet time/quiet space (3 of 19 respondents).

Staff shared the following in terms of how the program helped with self-care:

• “Made me aware of taking time for myself to eat, get a coffee, take a break, etc., and

to help my colleagues do so.”

• “The fact that there was a designated time and a designated place helped a lot.”

• “I wasn’t on day shift so the program didn’t have a huge impact but it did provide a

space to perform self-care which therefore encouraged self-care activities.”

• “Allowing me to clear my mind and prioritize my patient’s needs.”

Of 32 respondents to the question of whether staff were engaging in any new self-care

activities in the workplace since the self-care program, 17 responded ‘no’. A positive impact

on self-care practice was reported by 8 respondents. Staff quotes included the following:

• “Although I wasn’t able to attend the self-care activities on the unit I have been more

proactive and intentional about self-care on my days off, which has helped me stay

engaged when I am at work.”

• “More aware of need to eat, drink, take a minute for myself to re-energize.”

• “No. No time - patient acuity high and needs too great - orders constantly requiring

attention.”

• “Taking quiet time in the conference room, breathing exercises.”

• “I am trying.”


The survey data provides information related to the study question, “What are the

barriers to practicing self-care in the workplace?”

In the pre-survey, the multiple response question was, “What barriers do you experience

or anticipate to being able to carry out self-care practices during your work day? “The

identified barriers, experienced or anticipated, included:

1. not enough time (65 of 71 respondents)

2. lack of support for these opportunities (33 of 71 respondents)

3. lack of knowledge (11 of 71 respondents)

4. guilt (2 of 71 respondents)

5. lack of motivation (1 of 71 respondents).

Three of 71 respondents indicated that they did not experience barriers.

In the post-survey, the multiple response question was, “What barriers, if any, did you

experience to participating in the self-care program?” The barriers identified to participating

in the self-care program were:

1. not enough time (19 of 32 respondents).

2. working at a time when the program was not offered (4 of 32 respondents

3. lack of support for these opportunities (3 of 32 respondents)

4. no interest (2 of 32 respondents) and

5. lack of knowledge (1 of 32 respondents).

Three of 32 respondents indicated that they did not experience barriers.

Staff quotes about barriers from the surveys included the following:

• “...feelings of guilt when I take time out of my day for myself because partly I feel

like I should always put my patients first.”


• “No one to care for patients while off floor - need RN who comes in to cover just

breaks…”

• “Nurses feel guilty for handing off their pager to another nurse who already has a

heavy workload.”

• “...too busy on unit to be able to practice self-care…”

• “A break nurse and proper breaks would allow for greater care.”

. Survey data also provides information related to the study question, “What impact does

a program of self-care practice opportunities have on levels of engagement?” The related

open-ended survey question, “Did you feel more engaged in your work after participating in

the self-care program? Why or why not?” had 16 respondents. Eleven of the 16 responded

affirmatively. There were three negative responses. The responses included themes related to

the chance to relax and refocus and to improved stress management. Staff quotes included

the following:

• “...Yes, makes me stop and think during stressful situations.”

• “Yes. It was helpful to see what and how you can care for yourself at work during

your busy day.”

• “...no felt like it was more difficult to go back to work floor.”

• “No...I think because my practice isn’t developed. I’m not yet able to bring that

clam and presence into our chaotic environment.”

• “Yes, glad it’s on the radar, but getting a lunch break free of interruption and not

having PACU transfers, discharges interrupt (and) make you stay late would be more

meaningful.”


Table 10:

Summary of Study and Survey Questions with Related Staff Verbatims

Study Questions Survey Question Verbatims from Survey

Central Study Question: What is the experience of nursing staff on an acute care general medicine unit in practicing self-care behaviors at work?

Why do you feel unable to care for yourself?

“The floor can get very hectic and busy and often you put the patients’ needs and your coworkers before your own. It becomes easy to forget to take care of yourself.”

“Rushed at work, need to take care of patients first.”

“...No time, too much stress, never able to leave unit…”

“The acuity and busyness of the floor prevents me from being able to perform self-care at work.”

“...too busy to have time to reflect on practice, too busy to eat at times, high stress…”

“We are constantly needed…”

Related Study Question 1: What work based self-care practices have the greatest value to the nursing staff on an acute care general medical unit?

Survey Question:What did you find most valuable/beneficial about the self-care activities?

“The deep breathing made me feel relaxed and centered. I can do that anywhere, anytime and achieve some level of peace even in the most stressful situation.”

“Taking time in a quiet space allowed me to gather myself and reset my mind on a hectic shift.”

“...pager off/quiet time without worry to answer lights as someone covered me…”

“...able to relax/destress for 15 minutes although unfinished work was often lingering in the back of


my mind.”

Survey Question:

How did the self-care program help you with self-care during your work day?

“Made me aware of taking time for myself to eat, get a coffee, take a break, etc., and to help my colleagues do so.

“The fact that there was a designated time and a designated place helped a lot.”

“I wasn’t on day shift so the program didn’t have a huge impact but it did provide a space to perform self-care which therefore encouraged self-care activities.”

“Allowing me to clear my mind and prioritize my patient’s needs.”

Survey Question:Are you engaging in any new self-care practices in the workplace since the self-care program?

“Although I wasn’t able to attend the self-care activities on the unit I have been more proactive and intentional about self-care on my days off, which has helped me stay engaged when I am at work.”

“More aware of need to eat, drink, take a minute for myself to re-energize.”

“No. No time - patient acuity high and needs too great - orders constantly requiring attention.”

“Taking quiet time in the conference room, breathing exercises.”

“I am trying.”

Related Study Question 2:What are the barriers topracticing self-care in theworkplace?

Survey Question:What barriers, if any, did you experience to participating in the self-care program?

“...feelings of guilt when I take time out of my day for myself because partly I feel like I should always put my patients first.”


“No one to care for patients while off floor - need RN who comes in to cover just breaks…”

“Nurses feel guilty for handing off their pager to another nurse who already has a heavy workload.”

“...too busy on unit to be able to practice self-care…”“A break nurse and proper breaks would allow for greater care.”

Related Study Question 3: What impact does a program of self-care practice opportunities have on levels of engagement?

Survey Question:Do you feel more engaged in your work after participating in the self-care program?

“Yes, glad it’s on the radar, but getting a lunch break free of interruption and not having PACU transfers, discharges interrupt (and) make you stay late would be more meaningful.”

“Yes. It was helpful to see what and how you can care for yourself at work during your busy day.”

“...no felt like it was more difficult to go back to work floor.”

“No...I think because my practice isn’t developed. I’m not yet able to bring that clam and presence into our chaotic environment.”

“...Yes, makes me stop and think during stressful situations.”

Focus Group Qualitative Outcomes

The focus group outcomes will be presented as they pertain to the study questions. See

Table 11, found at the end of this section, for a summary of the focus group data analysis

outcomes.


The central question of this study: What is the experience of nursing staff on an acute care

general medicine unit in practicing self-care behaviors at work?

The first theme of the analyses articulates a state of profound struggle for the nursing staff

in meeting self-care needs in the work environment. In the current state, the main support the

staff experience in trying to take care of themselves comes from their peers. Peer recognition

of periods of distress and the support offered to one another in such times was found to be of

great importance in the staff’s ability to cope within the work environment. Participants’

comments included the following quotes:

“If someone’s having a bad day it’s like okay what can I do to help….come in the

backroom and just take a breather, talk to me, what’s happening.”

“People notice when people are having a really bad day.”

“We’re able to go and speak to one another and sort of vent to one another if a

problem arises or we’re frustrated with...whether it be a patient, a situation or

whatever it may be, we’re able to sort of vent to one another. I think that’s self-care.”

The difficulty in tending to basic needs such as eating, hydrating and eliminating was

apparent throughout the focus group discussions. There is widespread acknowledgement of

the need to be able to step away from the practice setting in order to refocus and regroup.

This need was seen to be of greatest import during the periods when it is most difficult to

fulfill such as a very chaotic day on the unit or in the face of caring for a very challenging

patient. When there is opportunity to practice self-care, whether it is an adequate meal break

or a walk outside, there is consensus about the benefits of this time. One participant stated,

“I know when I’m getting aggravated I remove myself. Sometimes you have a really trying


frustrating patient and I just try to step away for a little while and figure out how to bring it

back in.”

The nursing staff describes a work environment characterized by heavy demands related to

patient care, interdisciplinary communication, unpredictable activity, i.e., the arrival time of

admissions, and unrelenting noise and alarms. Participant had the following descriptions

related to taking breaks:

“…I didn’t want to leave the floor because I was like as soon as I leave, that’s going

to happen, (an admission), and, I was waiting until eight, and, then I was like alright,

I’m going to run outside and grab myself a dinner and as soon as I went to leave the

floor my admission came up, and, I was like of course…You wait for something to

happen and the minute you go to do something for yourself it’s like. oh, now it’s time

to do that.”

“So for example when we have lunch, we still have our pager and then when we hear

the bed alarm we leave our lunch or whatever breakfast time even, to run to the alarm

that’s going off and then when we finish we come back. If we had an uninterrupted

lunch sometimes it would be so great.”

“...I find that if you’re constantly thinking about all the things that continue to happen

and you continue to be interrupted for things that I don’t mind doing but after years of

it happening you realize that I think your stress levels...I don’t think that helps stress

levels at all.”

The first related study question is: What work based self-care practices have the greatest

value to the nursing staff on an acute care general medical unit?


The second theme informs us that the desired self-care practice of greatest value to the

nursing staff is the ability to attend to self-care needs by having uninterrupted time for meals

and breaks. The nursing staff clearly expresses the need to have this type of time in order to

adequately care for self and to maintain the energies necessary for optimal patient care. The

nursing staff finds value in a variety of self-care practices as well as the ability to seek out

desired spaces and environments in which to care for self. Most study participants who were

able to take advantage of the opportunities available through the self-care program

experienced positive results in terms of having time to relax and refocus. The discussions in

the post-intervention focus groups suggest a keener interest in self-care opportunities and the

importance of self-care in the workplace. Staff quotes related to this are as follows:

“I think I would be open to any new things because you don’t really know what

works for you especially in this environment. Like I know it works for me outside in

my personal life when it’s not so stressful, but, you don’t really know what works for

you without practicing right?”

“Like you said you went to the chair yoga, that was nice. Like little things

throughout the day…if things like that were kind of offered because I feel like we

have difficulties…I don’t know leading. Like, if there’s someone there to lead us

through then we’ll do it.”

In addition to the articulated need related to uninterrupted time for meals and breaks,

nursing staff expressed interest in having structured, facilitated opportunities for self-care.

Staff seemed to want to learn a variety of techniques in order to ultimately know what

worked best, and, in what circumstance. The self-care activities discussed included

meditation, (chair) yoga, pet therapy, breathing and relaxation exercises, and music. As


stated by one participant, “It’s building our tool box. All these tools …we know how to take

care of …patients, but we got to…take care of us too.” In general, staff feels that any

technique that mitigates the stress of the environment is advantageous. Staff suggestions also

include having the harpist visit the unit and providing visual cues for nursing staff to

remember to breathe.

The nursing staff also found value in having a designated space for self-care practice.

Focus group discussions included characteristics of such a space as being quiet, colorful,

calming and protected from interruption. The Wellness Corners which were built in each of

the conference rooms were noted to be helpful in this regard. Along with the articulated

desire for a dedicated space, there was common interest in being able to leave the unit for a

therapeutic break and, in particular, to go outside for a walk or fresh air. The following

quotes from participants relate to this component.

“My ideal is that I can…go out on a nice day. I always get very jealous of (other

discipline) eating their lunches out on a sunny day, and, I’m always like, ah, that

would be so good to do.”

“I think it would be so healthy if everybody could just step out and maybe go take a

ten minute walk outside. That would be so beneficial. Sometimes I just come to the

solarium and look out the window for thirty seconds and open the window and I

immediately feel so much better.”

“…Going outside and getting fresh air would be huge.”

One staff member also pointed out the availability of the chapel as a calm environment

which may be underutilized.


The second related question of the study is: What are the barriers to practicing self-care in

the workplace?

The third theme identifies that lack of time and lack of resources to support staff’s self-

care needs and practices are the main barriers nursing staff experience in their ability to carry

out self-care in the workplace. These barriers were consistent and marked in the focus group

discussions. These challenges, as discussed by the staff, relate to the demands of the practice

environment, staffing and assignments, and the rising acuity of the patient population. There

was a frequent suggestion to have a dedicated nurse whose only responsibility is to cover

patients during staff lunch breaks. In describing the challenge of taking meal breaks, or any

break, staff spoke often of feeling guilty and worried. The guilt was about the patients and

about their colleagues. Staff expressed worry about something happening to their patients if

they were on break, about patients being upset if they are not responded to in a timely

manner and about the burden that covering additional patients puts upon colleagues who are

already very busy with their own patients. Contributions to this topic include the following:

“If you take time, like ten minutes away, it’s like, oh, there’s four people that you’re

supposed to be responsible for. It gives you anxiety just thinking about…they

probably need me, I should go check on them before you even finish having time to

yourself.”

“You’re always needed or it feels like you’re always needed by a patient, a doctor, a

family member, coworkers. Sometimes you feel kind of guilty at times when you see

your coworkers are struggling and drowning.”

“I would say I would like there to just be less guilt about taking time for yourself

because if you’re not feeling well mentally or whatever, then you’re not going to take


good care of people, but, I still think there’s a lot of guilt for a lot of people about

taking a break.”

The presence of a designated resource nurse, at certain times of the day, was

acknowledged. Staff express that the resource nurse, although very helpful and supportive, is

also quite busy responding to the daily demands on the unit and is not in a position to cover

all the lunch breaks.

Nursing staff addressed the shared concern about interruptions and intrusions when they

do try to take a break. In the current state, most breaks take place on the unit and the pager

remains with the staff member while they take a break. The pagers ring very frequently and

include pages for bed and chair alarms, other members of the team wanting to talk to the staff

member, calls from family members and patient calls. In addition, other health care team

members, with regularity, enter the staff room while the staff member is trying to take a

break, in order to speak with the staff member about patient care issues which may or may

not be of an urgent matter. In the words of one participant, “If there was a way we could get

uninterrupted lunch because that would be so nice but I know…it’s frustrating when you go

into the backroom and…someone’s on the phone and you’re like I’m trying to eat, it’s like

nothing urgent really that calls you out of your lunch. It’s just little grievances and I think

that would personally help me.” The staff is clear in stating that workplace demands are

constant and are the reason the staff feel strongly that the need to have a break, a period of

time, without interruption is paramount.

Some nursing staff expressed a concern about taking time for self-care as it creates other

challenges for them. If one takes time for self-care, upon returning, to the unit there is a

backlog of work which needs to be done. This can add stress as opposed to removing it.


Additionally, taking time for self in the work environment can impede the ability to meet

other priorities. These other priorities include patient care and safety as well as the ability to

finish one’s work day in a timely manner. One participant stated, “I think from a nurse’s

perspective in the course of our day there’s a lot of different priorities, but the biggest are our

patients survive and that we get to leave on time….we’re more likely to deny ourselves the

time that we need to make sure that those two needs are attended to.”

Nursing staff who work the between 7p and 7a express a shared concern about the lack of

resources during this time period to support self-care practices.

The third related study question is: What impact does a program of self-care practice

opportunities have on levels of engagement?

The fourth theme informs us that there is consensus among the nursing staff that

opportunity to practice self-care in the work environment has a positive impact on

engagement levels. Focus group participants varied in their ability to take advantage of

opportunities offered through the self-care program. Among those who did participate, there

was very favorable feedback on the positive impact of the experience. One staff member

expressed her/his surprise at the benefit of participating in a brief meditation exercise.

“Sometimes I feel like when we do the meditation before rounds, I think I won’t be able to

turn my brain off and I won’t be able to relax and then usually by the end I’m like oh, I

wasn’t thinking about work for five minutes.”

Some focus group members noted making use of the Wellness Corner and the benefit of

having both a place and information on techniques available to use. Whether focus group

participants had utilized the self-care program or not, there was a consensus that having the

ability to practice self-care opportunities in the workplace would positively impact


engagement. Benefits to patient care, nurses’ attitudes about work, and the prevention of

burnout were all noted in the discussions. Staff comments related to this include the

following quotes:

“Not doing the self-care is apt to burn out a lot (of staff).”

“I think it (self-care opportunities) would make you feel more engaged in work.”

“I think I would be better at my job.”

“I think if we were able to give ourselves even just five minutes of time for what we

need to do it would completely change how we are carrying (ourselves) in front of

patients. I think we could provide better care.”

“Anything that I can do to help myself to never burn out would be helpful.”

Most focus group participants responded favorably in terms of their level of engagement.

Despite the challenges to self-care, many staff expressed a love for their job, pride at being in

nursing, and a commitment to their patients and colleagues. Some verbatims from the staff

on their level of engagement are included here.

“I mean, I love my job.”

“I mean, I think we’re all pretty committed to our patients and we like caring for

patients.”

“I feel like we have a pretty strong community that I feel engaged with.”

“I am really proud to say I’m a nurse and I’m proud of the profession.”

Some participants expressed their level of engagement waning over time. In a couple of

instances the staff related this to changing personal circumstances and external commitments.

However, discussion also pointed to a cumulative frustration around the stressors in the work

environment. Rising patient acuity, the strained ability to meet patient care expectations, and


limited resources seemed to negatively impact the staff’s perspective about work and

engagement.

“It feels like we have to do more with less.”

“…So I’ve noticed over my time here when I first started I was super engaged…then

over time I’ve kind of pulled back because I feel like when things go wrong or bad

things happen I get stressed out.”

“I’d say that I’m moderately engaged in my profession only because personal,

family…I’m kind of stepping back from it personally by choice.”

The fourth related study question is: How can the unit based leadership best support the

development of a culture of self-care on the inpatient unit?

The fifth theme puts forth the elements of leadership identified by staff as being most

important: the unit based nursing leadership can best support staff efforts in self-care by

promoting awareness and mutual respect among the staff about the importance of self-care,

providing the support and resources necessary for uninterrupted, covered opportunities for

self-care practices, and organizing structured, facilitated self-care technique sessions on the

unit.

Discussions about self-care on the units included concerns about potential conflict as

not all staff have the same attitude about self-care activities and the importance of these

opportunities. Comments from staff included the following:

“So I actually put that under what support is most helpful. Education about why it’s

(self-care) needed and then kind of the teamwork approach.”

“…We all know…people who are reluctant to do new things...”

“It’s hard but we can encourage each other.”


Leadership can help to build this level of mutual respect and regard, as well as openness to

try new things. Nursing staff recognize the positive impact of leadership presence,

particularly when the support and care of the leadership around staff self-care needs is

evident.

“They (unit based nursing leadership) do a good job just checking in and making sure

that you’re okay and touching base to see if they can help in any way.”

“People do take care of each other and it comes from the top down.”

Having uninterrupted time and resources for coverage of patient care during staff

breaks was the most prominent need articulated throughout the focus groups. While staff

recognize that unit based leadership may have limitations in this regard, this type of time is

seen as imperative for any ability to care for self in the workplace. Beyond meeting basic

needs, staff have two main areas of interests related to self-care opportunities. One, noted

previously and expressed more clearly in the post-intervention focus groups, is the

opportunity for structured, facilitated self-care sessions which provide guidance and

education around a variety of different techniques. Staff were able to articulate that they

need leadership in these efforts as it helps to promote the practice and provide consistency.

While content experts in the organization may be the facilitators of these sessions, unit based

leadership can oversee the organization of sessions and participation. Secondly, staff express

great interest in the ability to access spaces – the types of spaces include a dedicated space

such as the Wellness Corner, quiet places like the Chapel or an outside space where one can

walk, breathe, or reflect. Self-care activities can be applied individually in this type of

context.


One participant offered the following on the matter of leadership and self-care, “You

got to find those little moments where you…in part it’s everyone’s responsibility to…take

time for yourself and it’s great that leadership is building these workshops and things like

that. That’s fantastic because I think without that support, I wouldn’t be as open to it because

it’s turned my brain onto a whole other…trying to learn mindfulness practices and things like

that.”

Table 11:

Summary of Focus Group Outcomes and Related Verbatims

Study Questions Themes Verbatims from Focus Groups

Central Study Question: What is the experience of nursing staff on an acute care general medicine unit in practicing self-care behaviors at work?

Theme 1: The nursing staff struggle to meet basic self-care needs in the work environment. The main support they experience in trying to do so comes from their peers.

“If someone’s having a bad day it’s like okay what can I do to help….come in the backroom and just take a breather, talk to me, what’s happening.”

“People notice when people are having a really bad day.”

“We’re able to go and speak to one another and sort of vent to one another if a problem arises or we’re frustrated with...whether it be a patient, a situation or whatever it may be, we’re able to sort of vent to one another. I think that’s self-care.”

“I know when I’m getting aggravated I remove myself. Sometimes you have a really frustrating patient and I just try to step away for a little while and figure out how to bring it back in.”


“…I didn’t want to leave the floor because I was like as soon as I leave, that’s going to happen (an admission) and I was waiting until eight and then I was like alright I’m going to run outside and grab myself a dinner and as soon as I went to leave the floor my admission came up and I was like of course...You wait for something to happen and the minutes you go to do something for yourself it’s like oh, now it’s time to do that.”“So for example when we have lunch, we still have our pager and then when we hear the bed alarm we leave our lunch or whatever breakfast time even, to run to the alarm that’s going off and then when we finish we come back. If we had an uninterrupted lunch sometimes it would be so great.”

“...I find that if you’re constantly thinking about all the things that continue to happen and you continue to be interrupted for things that I don’t mind doing but after years of it happening you realize that I think your stress levels...I don’t think that helps stress levels at all.”

Related Study Question 1: What work based self-care practices have the greatest value to the nursing staff on an acute care general medical unit?

Theme 2:The desired self-care practice of greatest value to the nursing staff is the ability to attend to self-care needs by having uninterrupted time for meals and breaks. The nursing staff finds value in a variety of self-care practices as well as the ability to seek out desired spaces and environments in which to care for self.

“I think I would be open to any new things because you don’t really know what works for you especially in this environment. Like I know it works for me outside in my personal life when it’s not so stressful, but you don’t really know what works for you without practicing right?”


“Like you said you went to the chair yoga, that was nice. Like little things throughout the day…if things like that were kind of offered because I feel like we have difficulties…I don’t know leading. Like if there’s someone to lead us through that we’ll do it.”

“It’s building our tool box. All these tools…we know how to take of…patients, but we got to…take care of us too.”

“My ideal is that I can…go out on a nice day. I always get very jealous of (other discipline) eating their lunches out on a sunny day and I’m always like ah, that would be so good to do.”

“I think it would be so healthy if everybody could just step out and maybe go take a ten minutes’ walk outside. That would be so beneficial. Sometimes I just come to the solarium and look out the window for thirty seconds and open the window and I immediately feel so much better.”

“Going outside and getting fresh air would be huge.”

Related Study Question 2: What are the barriers to practicing self-care in the workplace?

Theme 3: Lack of time and lack of resources to support staff’s self-care needs and practices are the main barriers nursing staff experience in their facility to carry out self-care in the workplace.

“If you take time, like ten minutes away, it’s like oh there’s four people that you’re supposed to be responsible for. It gives you anxiety just thinking about…they probably need me, I should go check on them before you even finish having time to yourself.”


“You’re always needed or it feels like you’re always needed by a patient, a doctor, a family member, coworkers. Sometimes you feel kind of guilty at times when you see your coworkers are struggling and drowning.”

“I would say I would like there to just be less guilt about taking time for yourself because if you’re not feeling well mentally or whatever, then you’re not going to take good care of people, but I still think there’s a lot of guilt for a lot of people about taking a break.”

“If there was a way we could get uninterrupted lunch because that would be so nice but I know…it’s frustrating when you go into the backroom and…someone’s on the phone and you’re like I’m trying to eat, it’s like nothing urgent really that calls you out of your lunch. It’s just little grievances and I think that would personally help me.”

“I think from a nurse’s perspective in the course of our day there’s a lot of different priorities, but the biggest are our patients survive and that we get to leave on time…we’re more likely to deny ourselves the time that we need to make sure that those two needs are attended to.”


Related Study Question 3: What impact does a program of self-care practice opportunities have on levels of engagement?

Theme 4: There is consensus among the nursing staff that opportunity to practice self-care in the work environment has a positive impact on engagement levels.

“Sometimes I feel like when we do the meditation before rounds, I think I won’t be able to turn my brain off and I won’t be able to relax and then usually by the end I’m like oh, I wasn’t thinking about work for five minutes.”

“Not doing the self-care is apt to burn out a lot (of staff).”

“I think it (self-care opportunities) would make you feel more engaged in work.”

“I think I would be better at my job.”

“I think if we were able to give ourselves even just five minutes of time for what we need to do it would completely change how we are carrying (ourselves) in front of patients. I think we could provide better care.”

“anything that I can do to help myself to never burn out would be helpful.”

“I mean I love my job.”

“I mean I think we’re all pretty committed to our patients and we like caring for patients.”

“I feel like we have a pretty strong community that I feel engaged with.”


“I am really proud to say I’m a nurse and I’m proud of the profession.”

“It feels like we have to do more with less.”

“…So I’ve noticed over my time here when I first started I was super engaged…then over time I’ve kind of pulled back because I feel like when things go wrong or bad things happen I get stressed out.”

“I’d say that I’m moderately engaged in my profession only because personal, family…I’m kind of stepping back from it personally by choice.”

Related Study Question 4: How can the unit based leadership best support the development of a culture of self-care on the inpatient unit?

Theme 5: The unit based leadership can best support staff efforts in self-care by promoting awareness and mutual respect among the staff about the importance of self-care, providing the support and resources necessary for uninterrupted, covered opportunities for self-care practices, and organizing structured, facilitated self-care technique sessions on the unit.

“So I actually put that under what support is most helpful. Education about why it’s (self-care) needed and then kind of the teamwork approach.”

“…We all know…people who are reluctant to do new things…”


“It’s hard but we can encourage each other.”

“they (unit based nursing leadership) do a good job just checking in and making sure that you’re okay and touching base to see if they can help in any way.”

“People do take care of each other and it comes from the top down.”

“You got to find those little moments where you…in part it’s everyone’s responsibility to…take time for yourself and it’s great that leadership is building these workshops and things like that. That’s fantastic because I think without that support, I wouldn’t be as open to it because it’s turned my brain onto a whole other…trying to learn mindfulness practices and things like that.”

Discussion

The study does offer information and insight into the experiences of the nursing staff

who participated in the survey and focus groups. There are no statistically significant

findings in the study and the results are not generalizable. The results of the data collection

demonstrate solid strengths in the experience of the inpatient nursing staff on a general

medical unit but also endemic concerns. While the program itself did not have a statistically

significant impact on engagement levels, the existing level of engagement among the nursing

staff is encouraging. As stated earlier, engagement is closely linked to patient care outcomes

and self-care is an important element of engagement. A high degree of engagement among


the nursing staff is necessary to achieve and uphold in order to deliver optimal patient care.

(AACN, 2005; Laschinger and Leiter, 2006; Shirey 2006).

The challenges described by the nursing staff in taking care of oneself in the work

environment are concerning as they pose a threat to the sustainment of the level of

engagement. A healthy work environment, which includes the wellbeing of the staff, is an

important mediator in preventing compassion fatigue and burnout. (Vahey et al, 2004;

Stamm 2010; Nolte, 2017). The struggle of the nursing staff to attend to even basic self-care

needs in the work environment warrants attention. In the current healthcare climate, which

is driven by the need to fulfill goals related to patient care outcomes, value based payments

and reimbursements, efficiency in utilization of resources, and containment of costs, the

inpatient environment is pressured. This is evident in the descriptions offered by the nursing

staff about their work environment.

Nursing leadership has an important role to play in the development and sustainment of a

healthy work environment (AACN 2005; Laschinger and Leiter, 2006; Shirey, 2006; Crane

and Ward, 2016, Dyess, 2016). The focus group data offers rich reflection from the nursing

staff on the ways in which unit based leadership can support self-care efforts among the

nursing staff. Given the importance of self-care, and its ultimate relationship to the quality of

care delivered and outcomes achieved, it seems that all levels of leadership in an organization

need to be committed to innovations and resources necessary to provide the ability for self-

care among the nursing staff in the workplace.

The nursing staff, although challenged to carry out self-care in the work environment, are

interested in the opportunity. It seems that Maslow’s Hierarchy of Needs (Maslow, 1943) is

applicable to the situation of the general inpatient nurses in the study. Before a self-care


program, such as that offered through the study, can be successful, there needs to be an

infrastructure which supports the fulfillment of basic self-care needs. In this particular study,

the participants were clear in their need for breaks, optimally uninterrupted, which allow for

basic self-care, i.e., eating and hydration. It is the opinion of this author that this need must

be fulfilled before nursing staff will feel able to incorporate further self-care opportunities

into their work day.

The types of opportunities which are of interest to the nursing staff are similar to those

practices which have been studied by others, albeit in varying practice areas (McElligott et al,

2009; Kravits et al, 2010; Reid Ponte & Koppel, 2015; Lubinska-Welch, 2016; Crane &

Ward, 2016). Though the results of this study are not generalizable, there is suggestion that

opportunities which include meditation, breathing and relaxation exercises, and yoga would

be very welcome by the staff if there are adequate supports in place. It is important that this

support include coverage of patient care so that the nursing staff are assured that patient care

needs are met while they pause to care for self. There also was consensus among study

participants that having a designated space for staff which can be used for brief periods of

quiet and self-care is valued.

Engagement was an important concept in the study. The qualitative data from the focus

groups suggests that there is a trend among those who participated in the self-care program

toward enhanced engagement. Also, participants speculate that engagement would be

positively impacted if nursing staff have more ability to care for self in the work

environment. This focus group trend is also noted in the quantitative survey data. While it is

not statistically significant, the percentage of respondents in the intervention group who

describe their level of engagement as ‘very’ and ‘extremely’ changed from 68.3% in the pre-


survey (n=32) to 78.3% in the post-survey (n=23). Conversely, the same engagement item

among the control group showed a decrease in the percentage of respondents who described

their level of engagement as ‘very’ and ‘extremely’. The pre-survey percentage in this item

was 84.6% (n =39) and in the post-survey was 72.5% (n =40).

As noted previously, however, the control group was less experienced in both the RN and

PCT roles in the post-survey group as compared to the intervention group. Additionally, the

control group had fewer years of experience on the present unit in the post-survey group as

compared to the intervention group. This factor of less experience overall in the control

group in the post-survey creates a question of whether this may have been a confounding

variable which impacted the engagement levels. The changes in the engagement levels are

not statistically significant. They are of interest, however, and present additional possibilities

for study. In order to understand more fully the importance of self-care among the nursing

staff on the general inpatient unit, its contribution to the level of engagement, and its

relationship to the attainment of optimal patient care and outcomes, further study on this

topic is warranted.

Limitations

There are several limitations to the study. As stated, the quantitative bivariate analysis

showed no statistically significant results. The sample size was small.

The PI was also the Nursing Director of one of the units. This dual role may have created

some confusion in terms of the response to the pre-intervention data collection. The staff

were very clear in their concerns about the difficulty of taking breaks, particularly lunch

breaks. In the capacity of student and PI, the Nursing Director concentrated on the self-care

program but felt it was not possible to effect changes on the infrastructure surrounding breaks


as a part of this study. The lack of this response, coupled with the added self-care program

sessions, may have created some negative reaction among the staff. This may possible have

had an impact on participation rates. Additionally, the dual role limited the ability of the PI

to engage with staff about the program. Also, the PI was not able to neither participate in the

focus groups nor attend program sessions.

Several initiatives came through the involved units during the study period. Staff were

asked to complete several surveys and participate in some interviews related to other

projects. These requests, along with other quality and safety initiatives, may have contributed

to initiative fatigue among the staff in terms of participation.

The medical center where the study took place had a very busy month at the time the

program took place. There was a very high census level in the hospital, high acuity, and

several code helps. A code help involves urgent decompression of the emergency

department and necessitates patients’ admission to hallways spaces on the inpatient units.

This adds to the demand on staff and may have also been a factor which impacted

participation rates.

The other limitation of note involves confounding variables. As noted, the level of

experience in the post-survey control group may have been a confounding variable which

impacted response, including engagement levels. Additionally, there were other programs

and disciplines interested in doing mindfulness work with nursing staff during this time

period. When the interest was known to the PI, there was a request to wait until after the

study period. However, there may have been activities unknown to the PI which might have

been carried out, particularly on the control units. Additionally there may have been other,

unstudied, factors in the work environment impacting staff participation and staff responses.


Conclusion

This study begins to build more knowledge and insight among the self-care practices on

the general medical units involved in the study. The importance of self-care among nursing

staff is clearly demonstrated in the literature. Nursing leadership, as well as organizational

leadership, is called upon to build and sustain healthy work environments which include self-

care for nursing staff. Optimal patient care, safety and outcomes depend upon an engaged

nursing staff. This study suggests there is work to be done in this regard. It is the hope of

this author that further studies on this topic will be pursued in order to enhance our ability to

provide the work environments which optimize engagement of nursing staff and, ultimately,

attain the goal of optimal patient care.

Plan for Dissemination

Upon completion, the project results will be presented to the staff on the units involved in

the study, the BIDMC Nursing Leadership Council and the BIDMC Nursing Research and

Education Council.


Appendix A

Pre-Survey

Demographics

What is your role? _____PCT _____RN

What unit do you work on? _____Farr 2 _____Farr 7

# of years of PCT practice _____

# of years of RN practice _____ # of years on present unit _____

Which age range are you in? _____53-71 _____52-41 _____40-22 _____21 or below Questions:

Engagement in the workplace is characterized by one’s commitment to and satisfaction with one’s job. Additionally it pertains to one’s level of commitment to the organization and to your profession. Using the following scale please describe your level of engagement in the workplace.• ___ Not very engaged• ___ Somewhat engaged• ___ Very engaged

Of the following, what self-care practices are of greatest interest to you? Please rate with 1 being of greatest interest to 5 being of least interest.• ___ Silent Meditation • ___ Meditative Walking • ___ Yoga• ___ Reflective Readings• ___ Relaxation Exercises


Do you feel able to care for yourself in the work place? • ___Yes• ___No

Using the following scale how would you describe your ability to practice self-care in your work environment? • ___1 = never• ___2 = infrequently (i.e. less than 1x/week) • ___3 = intermittently (1-2x/week) • ___4 = routinely (>2x/week)

What self-care activities do you presently incorporate into your work day?

What self-care practices would you like to incorporate into your day which are presently not part of your routine?

What barriers do you anticipate to being able to carry out self-care practices?

What barriers do you experience when trying to carry out self-care practices?

Do you have any additional suggestions for meaningful self-care practices to consider for incorporation into the work environment?

Would you find value in having structured opportunities within the work day to carry out self-care practices? Please provide comment as to why or why not.


Appendix B

Post Survey

Demographics

What is your role? _____PCT _____RN

What unit do you work on? _____Farr 2 _____Farr 7

# of years of PCT practice _____

# of years of RN practice _____ # of years on present unit _____

Which age range are you in? _____53-71 _____52-41 _____40-22 _____21 or below

Questions:

Engagement in the workplace is characterized by one’s commitment to and satisfaction with one’s job. Additionally it pertains to one’s level of commitment to the organization and to your profession. Using the following scale please describe your level of engagement in the workplace.• ___ Not very engaged• ___ Somewhat engaged• ___ Very engaged

Do you feel able to care for yourself in the work place? • ___Yes• ___No


Using the following scale how would you describe your ability to practice self-care in your work environment? • ___1 = never• ___2 = infrequently (i.e. less than 1x/week) • ___3 = intermittently (1-2x/week) • ___4 = routinely (>2x/week)

What self-care activities do you presently incorporate into your work day?

What self-care practices would you like to incorporate into your day which are presently not part of your routine?

What barriers do you experience when trying to carry out self-care practices?

What barriers did you anticipate to being able to carry out self-care practices?

Have you been able to participate in the structured self-care practice opportunities on the unit?(Can further define once interventions are decided upon based upon pre data collection)• ___1 = never• ___2 = infrequently (i.e. less than 1x/week) • ___3 = intermittently (1-2x/week) • ___4 = routinely (>2x/week)

What value do you find in having structured opportunities within the work day to carry out self-care practices? Please provide thorough comment.


Appendix C

Focus Group Questions

Pre Intervention

What is your experience in carrying out self-care practice in the work environment?

What would you like your experience to be in terms of self-care practices in the work environment?

What barriers do you anticipate or experience in terms of carrying out preferred self-care activities?

What structured opportunities for self-care are you most interested in having available to you?

What support (from unit based leadership) do you think is most helpful to you in terms of incorporating self-care practices into your work day?

Engagement in the workplace is characterized by one’s commitment to and satisfaction with one’s job. Additionally it pertains to one’s level of commitment to the organization and to your profession. How would you describe your present level of engagement? How do you think opportunity for self-care in the work environment impacts your level of engagement?


Appendix D

Focus Group Questions

Post Intervention

What is your experience in carrying out self-care practice in the work environment?

What would you like your experience to be in terms of self-care practices in the work environment?

What barriers have you experienced in terms of carrying out preferred self-care activities?What barriers did you anticipate but not experience?

What structured opportunities for self-care are you most interested in having available to you?What support (from unit based leadership) do you think is most helpful to you in terms of incorporating self-care practices into your work day?

Engagement in the workplace is characterized by one’s commitment to and satisfaction with one’s job. Additionally it pertains to one’s level of commitment to the organization and to your profession. How would you describe your present level of engagement? How do you think opportunity for self-care in the work environment impacts your level of engagement?


Appendix E

Email Invitation to Nursing Staff to Participate In Study

Part 1: Email for Study Units Farr 2 and Farr 7

Hello!

You are invited to participate in the capstone project related to my DNP program through

Simmons College focused on self-care. The topic of this research study is, “Developing Self-

Care Practices Among Nurses on In-Patient Acute Care Units.” The project is taking place

on Farr 2, Farr 7, Rosenberg 7 and Stoneman 8, all medical units at BIDMC. Farr 2 and Farr

7 will be actively involved in a self-care program through the study while Rosenberg 7 and

Stoneman 8 will be control units. As control units, they will contribute to our pre and post

data collection but will not be involved in the self-care program during the study period. The

self-care program will be available to the control units when the study is over. All members

of the nursing staff on each of these units are invited to participate. This includes all RN’s

and PCT’s.

Participants may benefit from participation. If so, this study will provide a model for a self-

care program which other units may choose to implement.

Participation in this study is completely voluntary. There are no consequences related to

your decision to participate or not to participate. Participation in this study, or lack of

participation in this study, will not affect evaluations nor will any data collected be used in

evaluations. As participation is strictly voluntary, your participation is considered as your

consent to participate.

This study is a program development project. I will use an online anonymous survey and

focus groups to collect data before and after program implementation. The staff on all four

units will receive the survey online. Staff on Farr 2 and Farr 7 will also have an opportunity


to register for one of several focus groups. The information gathered through the initial

survey and focus groups will inform the design of the self-care program.

A pre and post survey will be administered via Survey Monkey. The survey is strictly

anonymous. The focus groups will take place on site. As the Principal Investigator (PI) has a

managerial role, the PI will not attend the focus groups nor will the PI be informed as to the

identification of participants. The study collaborator, Nurse Scientist Susan DeSanto-

Madeya will be the facilitator. Focus group discussion will be audio recorded. The audio

recordings will be transcribed by an outside transcriptionist and any identifying information

will be removed. The program development will be guided by the information gathered

through the survey and focus groups. The results of the project will be shared with all staff

on the involved units. As a reminder, all participation is voluntary. If you have any

questions re recruitment, please send questions and/or responses to Susan DeSanto-Madeya,

[email protected].

If you have any questions about participation or concerns about the project design please

contact Susan DeSanto-Madeya, Nurse Scientist, BIDMC at 617-667-2739 or the Human

Subjects Protection Office (HSPO) at 617-667-0469. You may also contact Rebecca K.

Donohue, Simmons Capstone Chair at 617-521-2131.

Thank you for your time and consideration.

Denise Corbett-Carbonneau, Principal Investigator (PI)

Nursing Director, Farr 2; DNP candidate Simmons College

[email protected]; 617-632-7871


Part 2: Email for Control Units Rosenberg 7 and Stoneman 8

Hello!

As a member of the nursing staff on Rosenberg 7 or Stoneman 8, I am contacting you to

ask you to complete two surveys on my area of study, self-care. The topic of my research

study is, “Developing Self-Care Practices Among Nurses on In-Patient Acute Care Units.”

The project is taking place on Farr 2, Farr 7, Rosenberg 7 and Stoneman 8, all medical units

at BIDMC. Farr 2 and Farr 7 will be actively involved in a self-care program through the

study while Rosenberg 7 and Stoneman 8 will be control units. As control units, you will

contribute to our pre and post data collection but will not be involved in the self-care

program during the study period. The self-care program will be available to Rosenberg 7 and

Stoneman 8 when the study is over. All members of the nursing staff on your unit are

invited to complete the pre and post surveys. This includes all RN’s and PCT’s. We may

learn through the study that participants benefit from participation. If so, this study will

provide a model for a self-care program which other units may choose to implement.

Participation in this study is completely voluntary. There are no consequences related to

your decision to participate or not to participate. Participation in this study, or lack of

participation in this study, will not affect evaluations nor will any data collected be used in

evaluations. As participation is strictly voluntary, your participation is considered as your

consent to participate.

This study is a program development project. I will use an online anonymous survey and

focus groups to collect data before and after program implementation. The staff on all four

units will receive the survey online. Staff on Farr 2 and Farr 7 will also have an opportunity

to register for one of several focus groups. The information gathered through the initial

survey and focus groups will inform the design of the self-care program.


A pre and post survey will be administered via Survey Monkey. The survey is strictly

anonymous. The focus groups will take place on site. As the Principal Investigator (PI) has a

managerial role, the PI will not attend the focus groups nor will the PI be informed as to the

identification of participants. The study collaborator, Nurse Scientist Susan DeSanto-

Madeya will be the facilitator. Focus group discussion will be audio recorded. The audio

recordings will be transcribed by an outside transcriptionist and any identifying information

will be removed. The program development will be guided by the information gathered

through the survey and focus groups. The results of the project will be shared with all staff

on the involved units. As a reminder, all participation is voluntary. If you have any

questions re recruitment, please send questions and/or responses to Susan DeSanto-Madeya,

[email protected].

If you have any questions about participation or concerns about the project design please

contact Susan DeSanto-Madeya, Nurse Scientist, BIDMC at 617-667-2739 or the Human

Subjects Protection Office (HSPO) at 617-667-0469. You may also contact Rebecca K.

Donohue, Simmons Capstone Chair at 617-521-2131.

Thank you for your time and consideration.





Appendix F

Focus Group Information Sheet

Thank you for participating in this focus group. Participation is strictly voluntary. Your

decision to participate is considered as your consent to participate. This session is being

facilitated by study collaborator, Susan Desanto-Madeya. The session is being recorded and

will be transcribed by an outside transcriptionist. All information will be de-identified and

the Principal Investigator (PI), Denise Corbett-Carbonneau, will not have access to

identifying information. The data collected through the focus group will not be used in any

formal evaluation and your participation will not affect any evaluation. As a participant you

are asked to respect the privacy of the participants and not discuss the identity of participants

outside of the focus group. Thank you again for your participation.




Appendix G

Self-Care Program Outline

The Self-Care program takes place on Farr 2 and Farr 7 during the month of January. The

program consists of a series of instructional sessions on self-care techniques. The

information provided by the nursing staff on the study units guided the choice of techniques

included in the program. The location of the instructional sessions will alternate between the

two units. Nursing staff from both units are welcome to attend any and all sessions. Topics

to be included in the program are listed below. The sessions will be led by BIDMC staff who

are content experts in the areas noted. Participation is voluntary and the identity of

participants will not be available to the PI due to her role at BIDMC.

Self-Care Sessions will include the following topics:

Silent Meditation

Meditation and Relaxation Techniques

Chair Yoga

Use of Self-Care Apps

There will be a Wellness Corner on each unit. This area will include instructional material

shared by the presenters on the topic areas. This area will also be available intermittently

throughout the day for any member(s) of the nursing staff on Farr 2 and Farr 7 who wishes to

use the space for self-care activities.


Appendix H

Email for Nursing Staff on Farr 2 and Farr 7 Regarding the Self-Care Program

Hello!

Thank you for your participation in the capstone project related to my DNP program

through Simmons College. This research study is titled, “Developing Self-Care Practices

Among Nurses on In-patient Acute Care Units”. Based upon the information which you all

provided during the preliminary data collection phase, a program of self-care has been

developed which will take place on Farr 2 and Farr 7 during the month of January. The areas

of self-care which the data showed to be of most interest to the nursing staff who responded

included the following: meditation, relaxation techniques, and yoga. Some participants

indicated an interest in structured activities while others would like to learn techniques that

can be applied individually. My goal in developing the program is to support both of these

preferences.

There will be a series of instructional sessions which will run on the two units throughout

the month. The presenters will be BIDMC staffs who are content experts in the topics being

presented. The location of the sessions will alternate between Farr 2 and Farr 7. The topics

of the sessions will include the following:

Silent Meditation

Meditation and Relaxation Techniques

Chair Yoga

Use of Self-Care Apps.

The schedule of sessions will be sent out to all of you via email once it is finalized. It will

also be posted on the Farr 2 Conference Room door and the Farr 7 Solarium door.


There will be a Wellness Corner on each unit. This area will include instructional material

shared by the presenters on the topic areas. This area will also be available at designated

times throughout the day for any member(s) of the nursing staff on Farr 2 and Farr 7 who

wishes to use the space for self-care activities. The designated times will be posted on the

door of the Farr 2 conference room and Farr 7 solarium where the Wellness Corners will be

housed.

Participation in the sessions is completely voluntary. There are no consequences related

to your decision to participate or not to participate. Participation in the sessions, or lack of

participation in the sessions, will not affect evaluations. As participation in the sessions is

strictly voluntary, your participation is considered as your consent to participate. The

Principal Investigator (PI) will not be present at the sessions nor will the PI utilize the

Wellness Corner during the designated times. The identity of the staff members who choose

to participate in the sessions will not be provided to the PI.

Thank you for your consideration of this project. I hope that you enjoy the January Self-

Care Program!





Appendix I

Farr 2 and Farr 7 Self-Care Program: January, 2018

Silent Meditation with Tsering Yodsampa (BIDMC – Spiritual Care) - Tuesdays 10:00 a.m.

to 10:30 a.m.

Location: January 2 – Farr 2 Conference Room

January 9 – Farr 7 Solarium

January 16 – Farr 2 Conference Room



Chair Yoga with Leslie Ajl (BIDMC – Psych Nurse Specialist)

Wednesdays – Alternating 12:30 p.m. to 1 p.m. and 5:30 p.m. to 6 p.m.

Location: January 3 – 12:30 p.m. to 1 p.m., Farr 7 Solarium

January 10 – 5:30 p.m. to 6 p.m., Farr 2 Conference Room


January 24 – 5:30 p.m. to 6 p.m., Farr 7 Solarium


At Your Fingertips – Use of Self Care Apps with Jed von Freymann (Farr 2 CN III) and

Alice Bradbury (Nursing Director Farr 9)

Wednesdays – Alternating 12:30 p.m. to 1 p.m. and 5:30 p.m. to 6 p.m.

Location: January 3 – 5:30 p.m. to 6 p.m., Farr 2 Conference Room






Mindfulness, Meditation and Relaxation Techniques with Jodi Dean (BIDMC – Social

Work)

Thursdays 1:30 p.m. to 2 p.m.

Location: January 4 – Farr 7 Solarium





Appendix J

Wellness Corner on Farr 7


Wellness Corner on Farr 2


Appendix K

IRB Approvals

Beth Israel Deaconess Medical Center IRB Exempt approval.


Simmons College IRB Performance/Quality Improvement approval.


References

American Association of Critical Care Nurses. (2005). AACN standards for establishing

and sustaining healthy work environments: a journey to excellence. Retrieved

September 30, 2016 from http://www.aacn.org

American Association of Nurse Anesthetists. (2014). Promoting a culture of safety and

healthy work environment. Retrieved September 30, 2016 from http://www.aana.com

American Nurses Association. 2017: Year of the Healthy Nurse. Retrieved September 30,

2016 from http://www.nursingworld.org

Avolio, B.J. and Gardner, W.L. (2005). Authentic leadership development: getting to the

root of positive forms of leadership. Leadership Quarterly, 16: 315-338.

Awa, W.L., Plaumann, M. and Walter, U. (2010). Burnout prevention: a review of

intervention programs. Patient Education and Counseling, 78: 184-190.

Blum, C. (2014). Practicing self-care for nurses: a nursing initiative.

The Online Journal of Issues in Nursing, 19(3): 1-16.

Bodenheimer, T. & Sinsky, C. (2014). From triple to quadruple aim: care of the patient

requires care of the provider. Annals of Family Medicine, 12:573-576.

Chesak, S.S., Bhagra, A., Schroeder, D.R., Foy, D.A., Cutshall, S.M., & Sood, A.

(2015). Enhancing resilience among new nurses: feasibility and efficacy of a pilot

intervention. The Ochsner Journal, 15:38-44.

Crane, P.J. & Ward, S.F. (2016). Self-Healing and Self-Care for Nurses. AORN Journal,

104(5): 387-397.

Dalai Lama. (2003). Transforming the mind: Teachings on generating compassion.

London: Thorsons.


Dempsey, C. and Reilly, B. (2016). Nurse engagement: what are the contributing factors for

success? The Online Journal of Issues in Nursing, 21(1): 1-12.

Dyess, S.M., Prestia, A.S., Marquite, D., Newman, D. (2018). Self-care for the nurse leaders

in acute care environment reduces perceived stress. Journal of Holistic Nursing,

36(1): 79-90.

Hartweg, P.L. (1990). Health promotion self-care within Orem’s general theory of nursing.

Journal of Advanced Nursing, 15: 35-41.

Hennink, M. M. (2014). Focus group discussions. New York: Oxford University Press.

Hsieh, H. & Shannon, S. (2005). Three approaches to qualitative content analysis.

Qualitative Health Research, 15, 1277-1288.

Hibbard, J.H. and Greene, J. (2013). What the evidence shows about patient activation: better

health outcomes and care experiences, fewer data on costs. Health Affairs, 32(2):

207-214.

Hunsaker, S., Chen, H., Maughan, D. & Heaston, S. (2015). Factor that influence the

development of compassion fatigue, burnout, and compassion satisfaction in

emergency department nurses. Journal of Nursing Scholarship, 47(2):186-194.

Institute of Medicine. (2001). Executive Summary: Crossing the quality chasm: a new health

system for the 21st century. Committee on quality of health care in America.

Retrieved September 30, 2016 from http://www.nap.edu/catalog/20017.html

Institute of Medicine (2003). Keeping patients safe: transforming the work environment of

nurses. (Ann Page, Editor). Committee on the work environment for nurses and

patient safety. Retrieved September 30, 2016 from http://www.nationalacademies.org

Institute of Medicine. (2000). To err is human: building a safer health system. Committee on


quality of health care in America. Retrieved from http://www.nationalacademies.org

Jackson, D., Firtko, A., & Edenborough, M. (2007). Personal resilience as a strategy for

surviving and thriving in the face of workplace adversity: a literature review. Journal

of Advanced Nursing, 60(1), 1-9.

Kravits, K., McAllister-Black, R., Grant, M., and Kirk, C. (2010). Self-care strategies

for nurses: A psycho-educational intervention for stress reduction and the prevention

of burnout. Applied Nursing Research, 23: 130-138.

Kreitzer, M.J. (2015). Integrative Nursing: application of principles across clinical settings.

Rambam Maimonides Medical Journal, 6(2): e0016.

Laschinger, H.K. S. and Leiter, M.P. (2006). The impact of nursing work environments on

patient safety outcomes: the mediating role of burnout/engagement. Journal of

Nursing Administration, 36(5): 259-267.

Lubinska-Welch, I., Pearson, T., Comer, L., and Metcalfe, S. (2016). Nurses as instruments

of healing, self-care practice of nurses in a rural hospital setting. Journal of Holistic

Nursing, 34(3): 221-228.

Macey, W.H. & Schneder, B. (2008). The meaning of employee engagement. Industrial and

Organizational Psychology, 1:13-30.

Maslow, A.H. (1943). A theory of human motivation. Psychological Review, 50: 70-396.

McAllister, M. & McKinnon, J. (2008). The importance of teaching and learning resilience

in the health disciplines: a critical review of the literature. Nurse Education Today,

29: 371-379.

McElligott, D., Seimers, S., Thomas, L., & Kohn, N. (2009). Health promotion in nurses: is

there a healthy nurse in the house? Applied Nursing Research, 22: 211-215.


McElligott, D., Capitula, K.L., Morris, D.L., and Click, E.R. (2010). The effect of a holistic

program on health-promoting behaviors in hospital registered nurses. Journal of

Holistic Nursing, 28(3): 173-183.

Merriam, S.B. and Tisdell, E. J. (2016). Qualitative research, a guide to design and

implementation. San Francisco: Jossey-Bass, A Wiley Brand.

Mills, J., Wand, T., and Fraser, J. (2015). On self-compassion and self-care in nursing:

selfish or essential for compassionate care. International Journal of Nursing Studies,

52: 791-793.

Nevins, C.M. and Sherman, J. (2016). Self-care practices of baccalaureate nursing students.

Journal of Holistic Nursing, 34(2): 185-192

Nolte, AGW, Downing, C., Temane, A. & Hastings-Tolsma, M. (2017). Compassion

fatigue in nurses: a metasynthesis. Journal of Clinical Nursing, 26:4364-4378.

Pender, N.J. (2011). The health promotion model manual. Retrieved April 20, 2018 from

http://deepblue.lib.umich.edu

Polit, D.F. and Beck C.T. (2017). Nursing research, generating and assessing evidence for

nursing practice. Philadelphia: Wolters Kluwer.

Porter, M.E. (2010). What is value in health care? New England Journal of Medicine,

363: 2477-87.

Reid Ponte, P. and Koppel, P. (2015). Cultivating Mindfulness to Enhance Nursing Practice.

American Journal of Nursing, 115(6): 48-55.

Sandelowski, M., Voils, C., & Barroso, J. (2006). Defining and designing mixed research

synthesis studies. Research in the Schools, 13, 29.


Shirey, M. (2006). Authentic leaders creating healthy work environments for nursing

practice. American Journal of Critical Care, 15(3): 256-267.

Staff, B.H. (2010). The concise ProQOL manual (2nd ed). Pocatello, ID. Retrieved

March 24, 2018 from http://www.proqol.org/uploads/ProQOL_Concise_2ndEd_12-

2010.pdf

Stark, M., Manning-Walsh, J., and Vlien, S. (2004). Caring for self while learning to care for

others: a challenge for nursing students. Journal of Nursing Education, 44(6): 266-

270.

The Official United States Government Site for Medicare. Hospital Compare (2016).

Retrieved September 30, 2016 from http://www.Medicare.gov

Vahey, D., Aikens, C., Sloane, D., Clarke, S. & Vargas, D. (2004). Nurse burnout and

patient satisfaction. Medical Care, 42(2), 1157-1166.

Watson, J. (2008). The philosophy and science of caring. Boulder, CO: University Press of

Colorado.

World Health Organization (1983). Health education in self-care: possibilities and

limitations. Retrieved April 20, 2018 from http://apps.who.int

beatleyweb.simmons.edubeatleyweb.simmons.edu/.../original/6fafcbc6f2f7b676fba… · web...

Documents