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Cultivating Quality

Effective Holistic Approaches to Reducing Nurse Stress and Burnout During COVID-19

Pagador, Florida MSN, CMSRN; Barone, Melanie MSN, CNML; Manoukian, Mana MSN, RN, AGCNS-BC; Xu, Wenrui MPH; Kim, Linda PhD, MSN, RN, PHN, CPHQ

Author Information
AJN, American Journal of Nursing: May 2022 - Volume 122 - Issue 5 - p 40-47
doi: 10.1097/01.NAJ.0000830744.96819.dc

FU1-20
Figure:
A serenity lounge with calming wall decorations, a recliner (at left), and a massage chair. Photo by Melanie Barone.

In landmark research published two decades ago, nurse researcher Linda H. Aiken and colleagues linked lower levels of hospital nurse staffing to higher levels of patient mortality and nurse burnout and lower levels of job satisfaction among nurses.1 What had been a chronic problem in many hospitals nationwide has only been exacerbated by the COVID-19 pandemic. More recently, a national NurseGrid survey of more than 15,000 nurses found that 61% reported high levels of burnout in December 2020, a dramatic increase from 25% in September of the same year.2 An April 2020 Feedtrail survey of 1,300 nurses found that 74% had high levels of anxiety and emotional stress, and 67% were planning to leave their current job or leave nursing, at a projected cost of $88 billion to $137 billion.3

High-stress work environments cause emotional and physical exhaustion, resulting in burnout that may lead to low-quality patient care and poorer patient outcomes, including increased medication errors, increased hospital-acquired infections, and decreased patient satisfaction.4–7 Nursing staff and leadership involvement in developing strategies to promote and identify barriers to healthier work environments may help nurses reduce anxiety, stress, and burnout; in turn, such reductions would promote improved patient safety and high-quality patient care.8–10

ANXIETY, STRESS, AND BURNOUT

According to the World Health Organization's International Classification of Diseases, Eleventh Revision,11

“Burn-out is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: feelings of energy depletion or exhaustion; increased mental distance from one's job, or feelings of negativism or cynicism related to one's job; and reduced professional efficacy. Burn-out refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life.”

There is a wealth of literature that describes the relationship between a variety of factors and nurse stress and burnout (as well as job satisfaction and intention to leave their current job) in acute care settings.9, 12, 13 For example, lower levels of nurse staffing, working the night shift, and work lasting 12 hours or longer have been linked to increased nurse burnout.12, 13 Furthermore, higher levels of burnout were reported by nurses who experienced poor interprofessional relationships, including horizontal or lateral violence and bullying by physicians as well as other members of the nursing team.9, 14

Previous studies have provided a better understanding of the common causes of nursing stress and burnout. Nonetheless, much remains to be explored on how to improve staff members' psychological function; reduce emotional exhaustion; and improve physical care, social support, work environment, and spiritual care in a highly stressful work setting, through interventions using a holistic approach.15-20

Nurses' well-being affects not only the hospital financially, but also nurses' job satisfaction and performance, as well as the quality of care nurses provide to their patients.3, 9, 21 Efforts aimed at promoting nurses' well-being, therefore, are crucial, particularly as nurses face challenges associated with a pandemic such as COVID-19.22

Programs to reduce anxiety, stress, and burnout. Being adaptive and resilient are characteristics that promote and maintain staff members' well-being during rapidly changing work conditions.22, 23 Programs such as stress management and resilience training may help nurses gain skills that enhance their adaptability and resiliency.15 Additionally, programs such as mindfulness-based trainings have been shown to be effective in improving psychological outcomes, adaptability, and resiliency, and in reducing anxiety, stress, and burnout.24-27

Environmental, social, and spiritual support. Some organizations found other strategies to be effective in reducing anxiety, stress, and burnout. Such strategies included staff recognition boards and increased leadership rounding and support to bring about cultural change.28 Other hospitals and health care institutions have brought attention to the need for self-care and peer care through peer support groups,22 as well as chaplains to provide spiritual or religious care and support.16, 29 Harris and Tao found that being “religious” or “spiritual” has a positive influence on an individual's well-being, while being “nonspiritual” has a negative influence on well-being and burnout.16

Furthermore, some hospitals have implemented “restorative breaks” in designated calm areas or “zen rooms” as a strategy to reduce stress and fatigue.17, 30 These specialized breakrooms were found to improve nurses' job satisfaction and performance17; and when equipped with a massage chair as an added intervention, they had a positive effect on perceived emotional stress, blood pressure, heart rates, and musculoskeletal overstrain, as well as pain and quality of life, while also being cost-effective.31-33

After a thorough review of the literature on such programs and approaches, including those described above, the quality improvement (QI) project team, comprising medical unit nursing staff and hospital leadership, opted to create a “serenity lounge” in our medical center equipped with a massage chair to promote staff members' rejuvenation and calmness.

Purpose of the project. The aim of this QI project was to evaluate the use of the serenity lounge and massage chair as interventions to reduce nursing staff's anxiety, stress, and burnout during the COVID-19 pandemic.

METHODS

Intervention: implementation on the pilot unit. On February 19, 2019, the first serenity lounge was opened for nursing and other staff members' use. This QI initiative was initially launched as a pilot project on one of the center's medical units. Not only was this strategy effective in reducing stress and burnout and in promoting a healthy working environment, but it also aligned well with the hospital's nursing practice model, which is based on Jean Watson's human caring theory and 10 caritas processes.34 The strategy particularly resonated with the eighth caritas process: “Create a healing environment for the physical and spiritual self that respects human dignity,” and the ninth caritas process: “Assist with basic physical, emotional, and spiritual human needs.”34

The staff agreed to share lockers in another location, and the QI project team converted the pilot unit locker room into a comfortable place for nurses and other staff members to relax and recharge during their work breaks. To promote relaxation, the team members painted the room a calming shade of blue and added zen-themed wall decorations, such as paintings of nature and inspirational quotes. The room was initially furnished with two recliners, and staff donated tables, electric percussion massagers, and a Himalayan salt lamp. Added amenities included an essential oil diffuser, table fountain, and a small audio system that played calming sounds, such as ocean waves and rain. The serenity lounge on the pilot unit had no windows, allowing for the room to be darkened to decrease stimulation. To minimize interruptions during their relaxation time, nursing staff would notify the charge nurse if they were going to use the lounge. Nurses would also give handoff to the charge nurse, assistant nurse manager, or manager, who would provide coverage for the nurses' assigned patients while the nurses were in the serenity lounge.

Before starting the pilot, the QI team developed a paper survey to measure nurses' stress levels before and after use of the serenity lounge. The survey used a Likert-like rating scale in which 0 indicated no stress and 5 indicated maximum stress. The survey results showed that the serenity lounge was used every day by eight to 10 nurses per 12-hour shift for approximately 30 minutes each. The survey results also revealed that, for 80% of the nursing staff, stress levels decreased from 4 to 5 prior to use of the serenity lounge to 0 to 1 following use of the lounge. These results indicated that the serenity lounge was a promising intervention that could promote a healthier work environment, decreasing stress levels and possibly preventing high levels of staff burnout.

The popularity of the serenity lounge, the positive outcomes found in the preliminary survey results on the pilot unit, and the increased reports of stress related to the COVID-19 pandemic prompted nursing leadership to convert additional rooms throughout the inpatient nursing units to serenity lounges in April through June 2020. The nursing research department spearheaded the spread of serenity lounges to 10 units in total, including to COVID-19 cohort units. The pilot unit's serenity lounge served as a model that facilitated expansion and implementation to the other areas.

Expansion of the project to other units. To accommodate expansion of the serenity lounge to other units, nursing leadership decided to use previously designated meditation rooms that were centrally located on each unit. Before the pandemic, patients' family members used these meditation rooms, but now since pandemic safety rules restricted family visitation, these rooms were no longer used as originally intended.

The rules of serenity lounge use varied depending on the unit. There were two main approaches: the lounge could be used on a first-come, first-served basis or via a sign-up sheet (located next to or on the door of the lounge) where staff members wrote their names and their preferred time of use. Both approaches established a workable unit-specific communication process that kept the charge nurse, the break relief nurse, and the assistant nurse manager informed so they could assist with patient care and maintain safety measures while a given nurse was in the lounge.

Supporting evidence from the QI project team's literature review described how relaxation can be enhanced by adding a massage chair to each serenity lounge.31 Based on this evidence, nursing leadership approved and allocated resources for the purchase of 10 massage chairs for use in the expanded set of serenity lounges. Each serenity lounge was then equipped with sanitizing wipes, gloves, and shoe covers in an effort to adhere to infection control protocols. The information technology, environmental safety, and infection control departments reviewed and approved all equipment and procedures to ensure that all technology was functioning properly, there were no fire hazards or safety concerns, and infection control and COVID-19 guidelines were followed.

Data collection and measures after project expansion. Data collection for this project began in November 2020 and is ongoing. Nurses responded to all preintervention and postintervention surveys electronically, via the Research Electronic Data Capture (REDCap) system, a secure, web-based software platform designed to support data capture. First, they used their smartphone to scan a QR code on a flyer posted on the door of the lounge, which allowed them to access the survey and record their responses. After staff members completed the pre-lounge-use survey, they received an automated email with an individualized REDCap link to the post-lounge-use survey. Three automated reminder emails were sent to those who didn't complete the post-lounge-use survey. The individualized link made it possible for the project team to match the preintervention and postintervention surveys of each participant. (Only the data from those who completed both pre and post surveys were included in the analysis.)

The QI project team collaborated with researchers in the nursing research department to develop all items in the pre- and post-lounge-use surveys, typically by modifying existing validated tools. This was an improvement over the pilot surveys, which were generic and unvalidated. The team used a generic demographic survey to measure participant demographics, including gender, age, ethnicity, race, job title, years of work experience, education status, marital status, and number of shifts or days missed because of illness.

Primary outcome measures, including feelings of emotional exhaustion, burnout, frustration, and being worn out, were measured using a Likert-like scale with response options ranging from 0 = “to a very low degree” to 4 = “to a very high degree,” using a modified work-related burnout subsection of the Copenhagen Burnout Inventory.35 Levels of stress and anxiety were measured on a scale ranging from 0 = “not at all” to 4 = “extremely.” Stress was measured using a modified stress item from social and behavioral domains and measures determined by the Institute of Medicine.36 We developed a single item to measure anxiety (both preintervention and postintervention) and two items related to the use of a massage chair, as no validated measurement tool was available to appropriately capture these items within the context of our project. Response options for duration of massage chair use were “< 10 minutes,” “10-20 minutes,” and “> 20 minutes.” To see the pre and post surveys, go to https://links.lww.com/AJN/A228.

Analysis. For the purposes of this project, data analysis included 67 paired responses to pre- and post-lounge-use surveys collected across all units with a serenity lounge between November 2020 and May 2021, a period with a spike (between December 2020 and February 2021) in the number of patients admitted with COVID-19. Descriptive statistics were used to describe participant demographics. Paired t tests were conducted to assess differences in primary outcome measures (feelings of emotional exhaustion, burnout, frustration, being worn out, stress, and anxiety) among survey respondents before and after use of the serenity lounge. Linear regression analysis was used to assess for relationships between the primary outcome measures and the duration of massage chair use. The clinical research specialist in the nursing research department conducted all analysis using SAS version 9.4.

Ethical considerations. This study was reviewed by the nursing research and QI council as well as the nurse scientist institutional review board (IRB) review committee, which determined this to be a QI project. After a rigorous review process, the project was deemed exempt from the need for IRB review.

RESULTS

A total of 67 paired responses were evaluated following this project's expansion to 10 units. The majority of participants were female (84.6%), Asian (63.5%), and RNs (94.2%); most had a bachelor's degree (65.4%) as their highest level of education. Approximately half of participants were married (48.1%). Mean age was 40.6 years and mean work experience was 8.2 years. (See Table 1 for detailed participant demographics.) Participants also reported that they felt emotional exhaustion, burned out, frustrated, worn out, stressed, and anxious “a lot” or at least “to some extent” and missed work on average 3.9 shifts or days in the past three months.

Table 1. - Participant Demographics (N = 67)a
Characteristic n (%) Mean (SD)
Gender
   Female 44 (84.6)
   Male 6 (11.5)
   Other 2 (3.8)
Age, years 40.6 (9.4)
Ethnicity
   Hispanic 5 (9.8)
   Non-Hispanic 46 (90.2)
Race
   White 13 (25)
   Asian 33 (63.5)
   Black/African American 1 (1.9)
   Native Hawaiian 2 (3.8)
   Other 3 (5.8)
Occupation/Job title
   RN 49 (94.2)
   Other (clinical partner, unit steward) 3 (5.8)
Department/Unit
   Medical 30 (57.7)
   Critical Care 12 (23.1)
   Other (education, research, wound care) 10 (19.2)
Work experience, years 8.2 (6.6)
Highest level of education
   High school 1 (1.9)
   Associate degree 3 (5.8)
   Bachelor's degree 34 (65.4)
   Master's degree 11 (21.2)
   PhD/DNP/Other 3 (5.8)
Marital status
   Married 25 (48.1)
   Single 24 (46.2)
   Divorced 2 (3.8)
   Widowed 1 (1.9)
Shifts or days missed in past 3 months 3.9 (14.2)
Massage chair use
   Yes 57 (85.1)
   No 10 (14.9)
Duration of massage chair use, minb
   < 10 5 (8.8)
   10-20 24 (42.1)
   > 20 25 (43.9)
   Do not remember 3 (5.3)
aTotal number of respondents may not sum to 67 because of missing data.
bTotal respondents is 57—the number who answered “yes” to massage chair use.
Note: Percentages may not sum to 100% because of rounding.

Table 2 reports the results of bivariate analysis, which show that feelings of emotional exhaustion, burnout, frustration, being worn out, stress, and anxiety were significantly reduced (P < 0.0001) following use of the serenity lounge. Table 3 shows that, compared with participants who used the massage chair for less than 10 minutes, those who used the chair for 10 to 20 minutes had significantly lower levels of emotional exhaustion (B = −1.10; 95% CI, −2.12 to −0.07, P = 0.04), feeling worn out (B = −0.98; 95% CI, −1.89 to −0.07, P = 0.03), and feeling anxious (B = −1.09; 95% CI, −1.96 to −0.23, P = 0.01). Feelings of anxiety were also significantly lower among participants who used the massage chair for longer than 20 minutes (B = −0.96; 95% CI, −1.82 to −0.10, P = 0.03) compared with those who used it for less than 10 minutes.

Table 2. - Comparison of Pre- and Post-Serenity Lounge Use on 10 Units
Survey Items Pre-Lounge Use Mean (SD) Post-Lounge Use Mean (SD) P
Feeling emotionally exhausted 2.61 (1.07) 1.36 (1.03) < 0.0001
Feeling burned out 2.51 (1.11) 1.40 (1.06) < 0.0001
Feeling frustrated 2.12 (1.15) 1.01 (1.01) < 0.0001
Feeling worn out 2.70 (1.02) 1.27 (1.02) < 0.0001
Feeling stressed 2.42 (0.86) 1.21 (0.93) < 0.0001
Feeling anxious 1.78 (1.07) 0.82 (0.97) < 0.0001
Note: Scores are based on a 0 to 4 Likert-like scale.

Table 3. - Relationship Between Duration of Massage Chair Use and Feelings of Emotional Exhaustion, Burnout, Frustration, Being Worn Out, Stress, and Anxiety
Duration of Massage Chair Use
Survey Items < 10 min (n = 5) 10-20 min (n = 24) > 20 min (n = 25)
B 95% CI P B 95% CI P
Feeling emotionally exhausted n too small to analyze −1.10 (−2.12 to −0.07) 0.04 −0.80 (−1.82 to 0.22) 0.12
Feeling burned out −0.81 (−1.81 to 0.20) 0.11 −0.68 (−1.68 to 0.32) 0.18
Feeling frustrated −0.98 (−1.98 to 0.03) 0.06 −0.68 (−1.68 to 0.32) 0.18
Feeling worn out −0.98 (−1.89 to −0.07) 0.03 −0.88 (−1.79 to 0.03) 0.06
Feeling stressed −0.21 (−1.08 to 0.66) 0.63 −0.36 (−1.23 to 0.51) 0.41
Feeling anxious −1.09 (−1.96 to −0.23) 0.01 −0.96 (−1.82 to −0.10) 0.03
B = unstandardized beta coefficient.
Note: B represents the slope of the line between the predictor variable (duration of massage chair use) and the dependent variable (feelings). This means that nurses using the massage chair for 10 to 20 minutes (or more than 20 minutes) had decreases in feelings of emotional exhaustion, burnout, frustration, being worn out, stress, and anxiety compared with nurses who used the chair for less than 10 minutes. Only four of these decreases in feelings, however, were statistically significant (shown in bold).

DISCUSSION

The results of this QI project indicate a significant reduction in all measured outcomes after use of the serenity lounge. Improvements in feeling emotionally exhausted, worn out, and anxious were also noted after using the massage chair for at least 10 to 20 minutes. A continued feeling of reduced anxiety was reported when the massage chair was used for more than 20 minutes. These findings support previous studies showing that serenity lounges and zen rooms with equipment such as a massage chair may be effective as part of a holistic strategy aimed at caring for frontline nurses' well-being.30-32 While many nurses can benefit from a week-long vacation away from the stressful work environment, even a 10-to-20-minute relaxation break on a massage chair in a serene space in a workday may be effective in preventing the long-term negative effects of chronic stress. As massage chair use was shown to be effective in improving some outcomes (feelings of emotional exhaustion, being worn out, and anxiousness), this project showed that a longer time spent in the massage chair is not always better and that staff can get some relief in as little as 10 to 20 minutes.

Additionally, there may be specific aspects or nuances of the serenity lounge other than the massage chair (such as lighting, other decor, and essential oils) that may have contributed to the reduced outcomes. Parsing these interactions wasn't within the scope of this project; however, the results shed light on the importance of comprehensive holistic interventions in helping to provide a serene environment in which staff can promote overall wellness.

Lessons learned. Many lessons were learned through the implementation of this project. One major factor that contributed to its success was staff members' involvement and engagement in creating a serene space for themselves. To make it beneficial for all, the nursing staff came together and decided on universal ground rules for using the lounge, including no food, no cell phones, and being quiet when entering and exiting. Staff volunteered their time, creativity, and personal items, including door signs, quotes, tables, a painting (made by an RN), and a Himalayan salt lamp. By creating an environment envisioned by the bedside staff nurses themselves, the nursing staff took pride in their contributions to a successful project and were happy to share the space with others. Most importantly, involving staff members early in project development, implementation, and evaluation fostered a sense of project ownership and responsibility in sustaining their improvement efforts.

Another major lesson learned was the importance of having nursing leadership committed to the nursing staff's well-being. If nursing leaders actively participate in the development and implementation of staff wellness strategies early in the process, they may be more likely to promote and encourage staff members to make use of these wellness resources. In turn, staff members may feel more empowered and comfortable when asking for the time and resources needed to promote self-care throughout the day.

On the pilot unit, where nursing leaders were actively engaged in the serenity lounge, charge nurses and other unit leaders helped to minimize patient safety concerns and operational impact by providing coverage. Staff members gave handoff reports to the nurses or nursing leaders covering them before they used the lounge, which was usually during their standard lunch breaks, to ensure that high-quality care was available to their patients. Having sufficient staffing—something that had already been a problem in many institutions, even before the onset of the pandemic—is necessary in order to make an intervention like those described here sustainable. It should be noted that, even during a surge in COVID-19 admissions between December 2020 and February 2021, we were able to maintain staffing levels of 1:4 or 1:6, depending on the shift, and use of the serenity lounge was still possible. We employed team nursing as well to ensure high-quality nursing care.

Limitations. The relationship we found between participant anxiety and the duration of use of the serenity lounges and massage chairs was based on responses to an unvalidated questionnaire developed by the project staff for the purpose of measuring outcomes following implementation of the intervention for this QI project. Furthermore, results of participant outcomes were measured only once immediately after use of the serenity lounges and massage chairs to reduce survey burden. While previous studies have shown sustainment of improved outcomes for up to 72 hours or more,31 we were unable to draw conclusions about the sustainability of improved outcomes as we lacked longitudinal data to evaluate such longer-term effects. Implications for future research include the development of a validated tool that could be used to measure preintervention and postintervention levels of burnout across settings and over multiple time periods to evaluate the sustainability of improvements.

This project was also limited in that it evaluated only one medical center's experience with staff anxiety, stress, and burnout relief. Nonetheless, the results and lessons learned from our project may guide the implementation of projects at other organizations to facilitate achievement of improved outcomes in their respective settings.

Lastly, considering that the level of burnout or other factors may have a significant impact on survey respondents, the potential exists for self-selection bias among nurses who made use of the serenity lounges and massage chairs as well as those who chose to answer the surveys. Although the purpose of our QI project was to improve outcomes based on well-established practices already in the literature, future research studies that apply rigorous methods (randomization of participants into control and intervention groups, longitudinal study design, and incentives for participating in the survey, for example) would help minimize limitations such as self-selection bias and low survey response rates and strengthen the studies' findings.

No one should expect that interventions such as those described here can completely prevent burnout. What's needed is a comprehensive, systems-level wellness initiative that includes appropriate staffing levels; a sufficient budget; and organizational policies that promote health care providers' well-being; in addition to adequate time, space, and resources, including holistic approaches to support staff members.

In caring for ourselves and our colleagues, we do well to recall the words of Jean Watson: “If one is to work from a caring-healing paradigm, one must live it out in daily life.”37

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Keywords:

anxiety; burnout; COVID-19; massage chairs; nurse burnout; serenity lounge; stress

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