Running head: STRESS MANAGEMENT PROGRAMS FOR NURSE BURNOUT 1

Stress Management Programs for Nurse Burnout

Precious White

Cedar Crest College

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Abstract

Nurses have always been the caretakers of the sick and ill, but as time has progressed, their role

within the healthcare system has developed more which attaches more responsibility. This newly

increased responsibility may take a physical and emotional toll on the nurse. Whether it is

physical or emotional, patient outcome and the quality of care they receive will be heavily

affected. When this happens, resources should be provided by the employer to the nurse. Such

resources should include any and all types of stress management programs and techniques. For

this paper, a question was formulated to be able to guide research. Studies were then searched

and retrieved to obtain evidence for the question. The evidence was then critically appraised and

synthesized to relate its findings with the significance of the nursing practice. Recommendations

by the researchers were made and then an implementation plan was formulated based on the

recommendations.

Keywords: stress, management, nursing, burnout, programs, evidence-based practice

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Stress Management Programs for Nurse Burnout

The healthcare system is heavily relied on to maintain its fast-moving but also continuous

pace to serve patients. Healthcare workers are also expected to sustain that pace and conduct care

while accomplishing the heightened demands of such a large-scale organization (Bazarko, Cate,

Azocar, & Kreitzer, 2013). Within the organization are nurses, who are perceived as the driving

force of the hospital, steadily performing numerous tasks (Jordan, Khubchandani, &

Wiblishauser, 2016). Thus, the preservation of nurses’ health ought to be of concern to the

healthcare system (Jordan et al., 2016). This is crucial because studies have shown if nurses’

health is not kept and nurtured due to increased stress levels of working in a hospital,

unfavorable results manifests as burnout (both at home and at work), calling off from work, and

lack of contentment with the job (Bazarko et al., 2013). Bazarko et al. (2013) also stated that

stress overtime as well as poor coping abilities can be nonbeneficial both physically and

emotionally. It is detrimental when pertaining to patient care that nurses perform to the best of

one’s ability and always makes sure patient satisfaction is the focus. This can only be done when

taking care of oneself is practiced and enforced (Thacker, Stavarski, Brancato, Flay, &

Greenawald, 2016). Stress management is just one of many tools nurses have available to utilize

in their personal and professional lives, allowing for guidance on caring for oneself and

preventing burnout.

Significance

Burnout is a prevalent matter characterized by outcomes of persistent stress in the

workplace (Roberts & Grubb, 2014). According to Laschinger, Leiter, Day, and Gilin (2009)

burnout was defined by Christina Maslach as mental fatigue, doubt, and inadequacy which is

triggered by long-standing work strain. Other studies have disputed that burnout is more
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emotional than psychological (Laschinger et al., 2009). However defined, exhaustion is deemed

the foundation of burnout which impacts all aspects of working anywhere but especially in a

healthcare setting (Laschinger et al., 2009).

In nursing, what is considered ideal patient care revolves around fostering wholesome

relationships with: the patient and families, coworkers, and oneself (Thacker et al., 2016). The

latter is explained by Thacker et al. (2016) that if nurses employed self-care routines, studies

have shown an increase in: job contentment, work efficiency, self-awareness, and standard of

care. Irving, Dobkin, and Park (2009) stated that the nursing profession itself instills a goal-

oriented mindset in its nurses, causing less self-care and the inability to establish an even

proportion of work and self. Therefore, it is paramount that nurses incorporate healthy lifestyle

choices to not only physically benefit the body, but to also mentally and emotionally equip one

with coping capabilities to better assist with job related stress when such arises (Jordan et al.,

2016). This paper will address the formulated Population, Intervention, Comparison, Outcome

(PICO) question in nurses who work in the hospital, does the implementation of a stress

management program compared to no stress management program prevent the occurrence of

nurse burnout?

Literature Search

Data was collected via various databases to adequately support and answer the composed

PICO question of determining whether a stress management program would prevent burnout in

the nursing population. Google Scholar was the first and primary database used to search for the

articles. This search engine produced a great amount of results but few that pertained to the

whole PICO question. The first phrase that was used to search for articles was “nurses coping

and stress reduction.” The search generated 186,000 results. To narrow that down, the custom
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date range filter was utilized and changed from “2009-2017.” This filter brought the amount of

results down to 17,000. The advance search option was not used as it was not known about until

after the researching process was over so from the results of 17,000, titles were viewed based

upon whether they were internationally based. This was done by examining the authors’ names,

names of the journals, and the small detailed fragment of what the article included; which were

all listed and available without having to open the link to the source.

Among the results from Google Scholar was an article from a specific journal. Upon

landing on that website, keywords “stress management” and “mindfulness meditation” were

used. This generated 99 results and was brought down to 33 results once the filter of “the last 8

years” was applied. From there, titles were scanned through to determine usage.

Once again, an article from the previous search brought the research process to another

specific journal. Keywords used were “nurse fatigue,” “well-being of nurses in a hospital

setting,” “burnout,” and “nursing stress.” These keywords were all used one after another,

looking for the perfect article and producing results no greater than 20 for each keyword and

phrase. The year was changed to “2009-2017” and produced no more than 10 articles for each

keyword and phrase. This process became somewhat difficult in that free full-text PDF versions

of the articles were not always available. Fortunately, eight articles consisting of systematic

reviews and observational studies were found and chosen to support the PICO question. The

eight articles were then narrowed down to three that consisted of the best quality research and

pertaining to the entire research question.

Critical Appraisal of Evidence

The research process continued with analyzing the three chosen articles to critically

appraise the evidence.

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Bazarko, Cate, Azocar, and Kreitzer (2013)

This study took place in a large healthcare company in both Minnesota and Arizona to

determine the effect of an intervention created to increase the overall health and well-being of

nurses (Bazarko et al., 2013). It was a non-randomized pre-post eight-week intervention study

that included a total of 41 nurses with only 36 whom fully completed the tasks. The program, or

the independent variable, was called Mindfulness-Based Stress Reduction (MBSR) and included:

teaching mindfulness meditation, breathing techniques, and yoga along with other relaxation

methods. Scores, or the dependent variable, were based on three different time intervals: two

weeks before the study, after the eight-week study, and then about four months after the program

was completed. The participants showed great improvement on their mental health, self-

compassion, and overall professional burnout. Results also showed that this intervention was a

tool that was continued by the participants in their everyday lives well after the program ended

(Bazarko et al., 2013).

Some of the research variables were participation as they were offered compensation for

their time, and the timing of the intervention as some nurses were too tired after their shift to

complete the teaching. What was used to gather and organize the scores was a consolidated

online survey or questionnaire comprised of six sub-surveys including: The Perceived Stress

Scale, The Copenhagen Burnout Inventory, The SF-12v2 Health Survey, The Brief Serenity

Scale, The Jefferson Scale of Physician Empathy, and The Self-Compassion Scale. Some of the

limitations of the study were that there was no randomized control group to not have received the

intervention for a comparison to the experimental group; and, the participants may have had

prior experience with the stress reduction program already having a slight advantage over

everyone else (Bazarko et al., 2013).

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Irving, Dobkin, and Park (2009)

The purpose of this review was to examine other literature and research on a

mindfulness-based stress reduction program and its beneficial effects on healthcare

professionals, in promoting self-well-being and adequate coping strategies pertaining to work

related stress (Irving et al., 2009).

The design of the study was a systematic review of empirical studies. The sample was not

a set number of participants but rather anyone who volunteered and met the criteria of being a

healthcare professional. The variables of the study were: the mindfulness-based stress reduction

program as the independent variable, the measures of overall well-being and the ability to cope

with stress as the dependent variable, a research variable relating to adherence throughout the

intervention (the amount of time spent practicing and attending class), and another research

variable relating to the mixed population of healthcare workers rather than a specific subset

(Irving et al., 2009). The instruments used to gather the self-reporting data in this review were

various subscales (Maslach Burnout Inventory, Self-Compassion, Perceived Stress, Daily

Emotion, etc.) that created one complete questionnaire.

The results of the study were self-reported and individualized increased positive

responses to the questionnaire after completing the MBSR program. The well-being of the

participants and their ability to cope with stress was greatly impacted with the use of the

interventional tool.

Limitations included not gearing enough attention toward the aspect of adherence

throughout the program. Some of the examples already given above were: the varying amount of

time each person spent on practicing the exercises and the techniques in general, and whether

they even attended class. There was a mixed population sample in which each may have started
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at a different stress level or baseline, causing some discrepancies on the reliability of the study.

Also, the research highlighted the positive outcomes the MBSR program had on the participants

but not the negative effects (Irving et al., 2009).

Jordan, Khubchandani, and Wiblishauser (2016)

The purpose of this study was to examine both the impact of perceived stress and

perceived coping adequacy on overall health of nurses (Jordan et al., 2016).

The design of the study was a cross-sectional observational study. The sample consisted

of all full-time and part-time nurses who worked at a hospital in the Midwestern United States,

which was the setting of the study. There were no independent and dependent variables, but a

few research variables which were differences in the nurses’ baseline health status and the

number of hours each subgroup worked. Perception is individualized and viewed differently; and

so, can be difficult in measuring when one may have greater knowledge/wisdom than others (this

variable was also a limitation). It is assumed that full-time nurses endure more stress and strain

than part-time nurses; therefore, is unfair to combine the two into one sample to measure the

impact of perceived stress and perceived coping adequacy on nurses’ health (Jordan et al., 2016).

The instrument used in this study was a survey personally created by the investigators of

the research that measured: self-reported health status, current health behaviors, history of

preventative medical behaviors, level of work-related stress, self-efficacy of coping techniques,

and negative manifestations of stress. With these measurements, the researchers were able to

conclude that the associated variables of perceived stress and perceived coping adequacy greatly

impacted the nurses’ health; which in turn supported the need for workplace stress reduction

programs.
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Another limitation to this study was that the sample was comprised of nurses in one small

hospital which is not indicative of all nurses (Jordan et al., 2016).

Synthesis of Evidence

After critically appraising the evidence, it was indisputable that all three chosen articles

arrived at the same conclusion in that implementing a stress management program would in fact

prevent the occurrence of nurse burnout.

Findings

Jordan et al. (2016) concluded that when nurses were surveyed about how much stress

they endure daily, most of them answered that they were dealing with a great amount of stress;

but did not think twice about it because it became a normal “routine” to them. To allow this way

of thinking to become the typical way of thinking and by not evaluating the issue at hand,

burnout becomes inevitable (Roberts & Grubb, 2014). Roberts and Grubb (2014) mentioned that

integrating interventions, such as stress management programs, aimed towards nursing and their

particular work environment would effectively solve the problem of nurse burnout. Jordan et al.

(2016) viewed dealing with stress differently than what is stated above (but still coming to the

same conclusion) in that if nurses are going to learn to live with that amount of stress, then at

least the workplace can offer stress relieving options to aid in learning effective coping skills.

Bazarko et al. (2013) stated that stress in the workplace compared to when there is no

stress, produces negative outcomes on: the nurses, their performance, and their patients which

are all aspects of burnout. By implementing an intervention such as the MBSR program, these

negative outcomes will be resolved; but most importantly nurse burnout will decrease (Bazarko

et al., 2013). Irving et al. (2009) stated that not only is it in the best interest of the healthcare field

to execute the teachings of mindfulness training, but also that time is of the essence.
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Recommendations for Practice

The researchers of the studies provided their recommendations in implementation for the

nursing practice.

Recommendation One

Irving et al. (2009) explained that the healthcare system is only getting bigger and busier

and recommended that as that continues to happen, teaching mindfulness training to the nurses

will equip them with the tools necessary to adapt to such a growing culture. It is vital to make

sure the nurses are taking care of themselves before they are able to take care of their patients

(Irving et al., 2009).

Recommendation Two

Jordan et al. (2016) recommended that because stress and the inability to cope impact

nurses’ health and their performance, the workplace should incorporate promotions such as:

policies, networks, and a healthy lifestyle milieu to initiate the change they want to see in their

workplace. Whatever it is that advances the adaptation and continuance of the healthy lifestyle

change should be executed without hesitation, which in turn will enhance the satisfaction of both

the nurses and patients and ultimately increase nurse retention and quality of care for the patients

(Jordan et al., 2016).

Recommendation Three

Bazarko et al. (2013) recommended that providing an intervention like the MBSR

program that is cost effective will be a happy medium coming from both standpoints of the nurse

who needs the assistance, and the managers who want to help their nurses in any way they can

but have a budget to consider. It is an affordable compromise that large healthcare settings are
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able to integrate into their own system to create assurance of caring for their workers and a sense

of stability (Bazarko et al., 2013).

Implementation Plan

With any type of job, an employee wants to feel as though they are important and valued;

this is not any different for nurses. Before any change can be put into action, it needs to be

formulated first. Meaning, when a nurse voices an opinion or exhibits unspoken need for

assistance, they should be heard and acknowledged; this demonstrates compassion. Simply

recognizing the concerns of nurses and letting them know that, will start to promote a healthy

relationship in wanting to come to work every day. This is important because as burnout starts to

set in, not wanting to be at work becomes an issue. This also correlates with the workplace

teaching mindfulness training in how to effectively cope with stress. It would go a long way with

allowing nurses to feel angry, stressed, tired, and overworked but know that it will happen and

that there are ways of dealing with those situations.

First thing, would be for employers to survey their nurses to see how receptive they are to

a MBSR program and if they would attend and continue with it, should it be offered. After this is

done, a budget should be created or managed to include such a program not only to make the

nurses content within themselves but to make sure the “driving force” of the hospital is

physically and mentally able to maintain patient safety. After this, there should be a trial run of

the program to allow for the nurses to get acclimated to something new. Overtime, one would be

able to see how much the program made a difference in the attitudes of the nurses, the way they

work with each other, how they provide patient care, and the positive atmosphere of the

workplace. It cannot hurt to implement a change that has so many advantages outweighing the

disadvantages, because if it does not work at least one can say they tried.
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Conclusion

With healthcare being all that it is today, nurses will continue to endure those times of

contemplation of their life or lack thereof due to the job. Therefore, to aid in confronting the

issue, various ways of dealing with it like the MBSR program, should be implemented as studies

have shown that it helps in preventing nurse burnout. A question was formulated for research and

evidence then studies were searched and retrieved yielding to the best three analyzed and

critically appraised. All three studies concluded that a stress management program in the nursing

profession is an effective way of preventing nurse burnout. After synthesizing the evidence,

recommendations by the researchers were presented. An implementation plan on how to manage

stressors in nurses was then constructed based on the three recommendations made by the

researchers. If nurses take good care of themselves will be a good indicator on how well they

will take care of patients.

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References

Bazarko, D., Cate, R. A., Azocar, F., & Kreitzer, M. J. (2013). The impact of an innovative

mindfulness-based stress reduction program on the health and well-being of nurses

employed in a corporate setting. Journal of Workplace Behavioral Health, 28(2), 107-

133. doi:10.1080/15555240.2013.779518

Irving, J. A., Dobkin, P. L., & Park, J. (2009). Cultivating mindfulness in health care

professionals. A review of empirical studies of mindfulness-based stress reduction

(MBSR). Complementary Therapies in Clinical Practice, 15, 61-66. doi:

10.1016/j.ctcp.2009.01.002

Jordan, T. R., Khubchandani, J., & Wiblishauser, M. (2016). The impact of perceived stress and

coping adequacy on the health of nurses: A pilot investigation. Nursing Research and

Practice, 2016, 1-11. doi:10.1155/2016/5843256

Laschinger, H. K. S., Leiter, M., Day, A., & Gilin, D. (2009). Workplace empowerment,

incivility, and burnout: Impact on staff nurse recruitment and retention outcomes. Journal

of Nursing Management, 17, 302-311. doi:10.1111/j.1365-2834.2009.00999.x

Roberts, R. K. & Grubb, P. L. (2014). The consequences of nursing stress and need for

integrated solutions. Rehabilitation Nursing Journal, 39(2), 62-69. doi:10.1002/rnj.97

Thacker, K., Stavarski, D. H., Brancato, V., Flay, C., & Greenawald, D. (2016). An investigation

into the health-promoting lifestyle practices of RNs. The American Journal of Nursing,

116(4), 24-30. doi:10.1097/01.NAJ.0000482141.42919.b7

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Appendix
Evidence Summary
Study
Variables:
Author, Date, Research Independent Rating of
Measures/
Title of Study, Questions/ Methods (IV) Results/Findings Limitations Evidence/
Reliability
Journal Hypothesis/ Dependent Recommendations
Validity
Purpose (DV)
Research
(RV)
Bazarko, D., Purpose: To Design: IV: Instruments: Overall, nurses’ No Level = III
Cate, R. A., examine Nonrandomized Mindfulness- A self-report of randomized
Azocar, F., & measures of pre-post based stress consolidated health and well- control group
Kreitzer, M. J. health and intervention reduction online survey being measures to not have Quality = B/Good
(2013) well-being of survey program consisting of from baseline to received the
nurses by six sub- post-intervention intervention Recommendations:
The impact of implementing surveys- The were for a Many large
an innovative an eight- Sample: DV: Health Perceived significantly comparison healthcare
mindfulness- week stress Voluntary and well- Stress Scale, better with to the workplace
based stress reduction sampling of 41 being scores The completing and experimental environments would
reduction program that nurses of which Copenhagen maintaining the group benefit from
program on the teaches only 36 fully Burnout mindfulness implementing a
health and mindfulness completed RV: Inventory, training Participants stress reduction
well-being of meditation, Participation The SF-12v2 highly program to promote
nurses breathing (Offered Health The stress motivated to and increase
employed in a techniques, Setting: A compensation) Survey, The reduction participate mindfulness for a
corporate and yoga large healthcare Brief Serenity program is an due to culture that benefits
setting along with company in Timing of Scale, The effective and incentives both the nurses and
other both Minnesota intervention Jefferson affordable offered as the patients
and Arizona (Too tired Scale of intervention to compensation
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Study
Variables:
Author, Date, Research Independent Rating of
Measures/
Title of Study, Questions/ Methods (IV) Results/Findings Limitations Evidence/
Reliability
Journal Hypothesis/ Dependent Recommendations
Validity
Purpose (DV)
Research
(RV)
Journal of relaxation after shift to Physician use in reducing
Workplace methods complete Empathy, and stress and Participants
Behavioral teaching) The Self- burnout in nurses having prior
Health Compassion as well as non- experience
Scale nurse employees with the
stress
Methods of reduction
Data program
Collection: already
Online
questionnaire
Irving, J. A., Purpose: To Design: A IV: Instruments: Overall, the self- Greater Level = V
Dobkin, P. L., examine systematic Mindfulness- Self-reporting reported attention
& Park, J. current review of based stress scales of measures of should have
(2009) literature and empirical reduction overall well- individualized been directed Quality = B/Good
research of studies program being with well-being and toward
Cultivating how various ability to cope adherence
mindfulness in mindfulness- subscales with stress were Recommendations:
health care based stress DV: Measures (Maslach positive affects in A mixed As the demands of
professionals. reduction Sample: of overall burnout all areas population at healthcare
A review of programs can Healthcare well-being inventory, various stages professionals
empirical be beneficial professionals and the ability self- The remedial of training continue to rise,
studies of for healthcare compassion, effects of the implementing
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Study
Variables:
Author, Date, Research Independent Rating of
Measures/
Title of Study, Questions/ Methods (IV) Results/Findings Limitations Evidence/
Reliability
Journal Hypothesis/ Dependent Recommendations
Validity
Purpose (DV)
Research
(RV)
mindfulness- professionals to cope with Perceived mindfulness- (amount of mindfulness training
based stress in enhancing stress stress, daily based stress stress) is crucial in self-
reduction well-being emotion, etc.) reduction care, ultimately
(MBSR) and coping program of stress The absence improving patient
with work- RV: Methods of strongly supports of research care
Complimentary related stress Adherence Data it on the
Therapies in Collection: negative
Clinical Mixed Self-reporting outcomes the
Practice population of questionnaires stress
healthcare reduction
professionals program may
have
Jordan, T. R., Purpose: To Design: Cross- RV: Instruments: Overall, the Every nurse Level = IV
Khubchandani, examine the sectional Differences in A survey combined started off
J., & combined observational baseline created by the variables of with a
Wiblishauser, impact of study health status investigators perceived stress different Quality = B/Good
M. (2016) perceived measuring: and perceived normal of
stress and Full-time vs self-reported coping adequacy “stress” Recommendations:
The impact of perceived Sample: All part-time health status, influenced the Worksite
perceived coping full-time and current health health of nurses, Small study promotions should
stress and adequacy on part-time behaviors, supporting the just in one be utilized and
coping the health nurses history of need for hospital-not focused on the nurse
adequacy on status and employed by a preventive workplace stress representative to benefit the
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Study
Variables:
Author, Date, Research Independent Rating of
Measures/
Title of Study, Questions/ Methods (IV) Results/Findings Limitations Evidence/
Reliability
Journal Hypothesis/ Dependent Recommendations
Validity
Purpose (DV)
Research
(RV)
the health of health community medical reduction of nurses as a working
nurses: A pilot behaviors of hospital in the behaviors, programs whole environment
investigation nurses Midwestern level of work-
United States related stress,
Nursing Setting: self-efficacy
Research and Community of coping
Practice hospital in techniques,
Midwestern and negative
United States manifestations
of stress

Methods of
Data
Collection:
Surveys