Reducing stress levels in undergraduate nursing students Evidence- Based Benchmark Study Spring 2018

Contents Rationale for the Project Goals Literature Review Project Stakeholders Proposed Outcomes Evaluation Design Timetable/ Flowchart Data Collection Methods Discussion of Evaluation Costs/ Benefits Analysis

A Benchmark study Justification for change

Rationale for project Nursing turnover rates continue to climb year after year, increasing the country’s nursing shortage. One in five nurses leave the profession in the first five years due to high levels of burnout and fatigue (Rudman, Gustavsson, & Hultell, 2014). The onset of stressors known to cause burnout and emotional fatigue have been identified as occurring early in undergraduate level nursing students. The presence of stressors early on in the nursing career have been linked to poor professional development, adverse patient events and deterioration of the nurses’ emotional and physical well-being (Rudman et al., 2014). The prevention of stress is better than a cure, and lends support to the effort to establish a stress management course within undergraduate nursing curricula (Suresh, Matthews, & Coyne, 2012).

Rationale Nursing Deficit by 2030 Texas 15,900 nurses New Jersey California 44,500 nurses South Carolina 10,400 nurses New Jersey 11,400 nurses Nursing turnover rates have a direct effect upon the country’s nursing shortage. By 2030, seven states are projected to have a nursing deficit exceeding 10,000 (U.S. Department of Health and Human Services [HHS], 2017). Texas, California, South Carolina, and New Jersey will have the highest nursing deficit in 2030. Providing students with knowledgeable tools to combat stress may reduce the rate of turnover in the first five years post graduation. (HHS, 2017)

Goals Generate responsiveness in nursing faculty to the detrimental effect of stress upon a nursing student’s emotional well-being and future career. Highlight specific stressors known to effect nursing students (Suresh et al., 2012). Development of a structured sixteen week stress management course, with its acceptance into an undergraduate nursing curriculum. The main goal remains thus: “to protect this valuable human resource in nursing”. (Suresh et al., 2012, p. 777)

Literature Review Within the last decade, research emerged citing higher levels of stress and an increased occurrence of mental health issues among undergraduate students (Van der Riet et al., 2015). Heavy workload, unmet clinical learning needs and combining academic demands with clinical placement are several identified stressors present among undergraduate nursing students (Suresh et al., 2012). Stress management techniques have shown to reduce anxiety, stress, depression, and regulate a person’s mood (Van der Riet et al., 2015). Mindfulness and stress management practices have been previously introduced into the clinical setting to assist medical professionals in managing the demands of their environment and to build resilience (McMeekin, Hickman, Douglas, & Kelley, 2017; Van der Riet et al., 2015).

Literature Review A stress management pilot program was implemented over the course of a few weeks within an undergraduate nursing program to assess student’s stress levels (Van der Riet et al., 2015). Researchers acknowledged that student’s reported a notable decrease in stress levels following the course (Van der Riet et al., 2015). Van der Riet et al. (2015) suggested an extension of the program over the course of a semester would allow students to retain benefits from the course for application in the coming transition from student to professional nurse. According to Rella, Winwood, and Lushington (2008), the addition of such a program within nursing curriculum “may be critical in maximizing individual capacity to sustain a long-term nursing career, by providing effective stress management skills of lifelong benefit” (p. 895).

Project outline

Project Stakeholders Upper level Texas Board of Nursing Undergraduate nursing school faculty Dean Associate Dean Undergraduate program director Course instructor(s) Stress management counselor Academic advisors

Proposed Outcomes Reported decrease in nursing student's stress levels. Reduction of stress levels noted at conclusion of course and two years post- graduation. Approval from the Texas Board of Nursing for state-wide course implementation. A stress management course will be accepted into all Texas undergraduate nursing program's curricula as a required course for graduation. A reduction in nurses’ intention to leave the profession two years post course completion.

Evaluation Design Prior to course participation, students will be required to complete both the Maslach Burnout Inventory (MBI) and the Professional Quality of Life (ProQOL) scale (Michalec, Diefenbeck, & Mahoney, 2013). The MBI is a widely used survey to determine burnout through the use of three subscales. The ProQOL scale measures a person’s compassion satisfaction and compassion fatigue levels. Students will also complete both surveys again following completion of the course. The participating educational institution would maintain contact with course participants through the use of yearly follow-up surveys up to five years post graduation. Surveys used with alumni participants would assist in further longitudinal research regarding stress management.

Timetable/ Flowchart PICO development (January) Evidence-based research (Jan./ Feb.) Reformat of PICO (March) Benchmark study formation (March) Presentation of study to institutional review board (April) In fourth semester nursing students (P), how does a stress management course (I) compared to no course (C) affect the student‘s perceived stress levels and coping behavior (O)? Proposed curriculum for a stress management course is created; samples of both surveys included for review. Research revealed the given time of eight weeks for implementation is not sufficient. Changes are made to allow for sufficient time over a sixteen week period.

Data collection method Maslach Burnout Inventory (MBI) Measures burnout through three subscales: Emotional exhaustion Depersonalization Personal accomplishment Professional Quality of Life (ProQOL) Measures compassion fatigue and compassion satisfaction Uses subscales which evaluate burnout and secondary traumatic stress Two surveys completed by students prior to course participation: Maslach Burnout Inventory (MBI) and the Professional Quality of Life (ProQOL) scale (Michalec et al., 2013). Course evaluations at the conclusion of the semester. Post course face-to-face interviews with students to evaluate student’s experience of the program (Van der Riet et al., 2015). Interviews are conducted over 60 minutes and will follow a semi-structured outline. Both surveys are completed again at the semester’s completion. Institution will be encouraged to send surveys every year for up to five years following graduation to participants. (Michalec et al., 2013)

Evaluation and conclusion

Discussion of Evaluation Evaluation of data will entail analysis of survey response pre- and post course implementation. Interview responses will be included in the analysis, and will provide valuable insight into improvements or changes needed to the program. Scoring for the MBI will be totaled and interpreted. Effective change from the intervention is determined by lower scores in the subscales of emotional exhaustion and depersonalization (Michalec et al., 2013). Scoring related to the ProQOL are based off of the summation of the subscales into one raw score. Positive outcomes are determined by scores lower than 22 in the area of compassion fatigue, with scores equal or greater than 23 in the area of compassion satisfaction (Michalec et al., 2013).

Cost Benefit Analysis Item Cost Total Office Supplies $100 Professor salary $55,580 per year ($55,580/ 2 semesters) $27,790 Stress management counselor (consultation only- curriculum dev.) $35 per hour ($35 x 8 hrs. x 20 days) $5,600 (first semester only) Follow- up surveys (printing/ postage) $2 per survey ($2 x 30 students) $60 Total projected cost (per semester) $33,550 (U.S. Bureau of Labor Statistics, 2017)

Conclusion In school, nursing students prepare to face the best and worst of life’s circumstances. If not equipped properly to negate the stressors present in the clinical setting, nursing students are prone to develop ineffectual coping mechanisms detrimental to their future careers. Protecting the future nursing workforce is a necessary step when attempting to curb the hemorrhage of nurses leaving the profession due to burnout and emotional fatigue.

References McMeekin, D. E., Hickman, R. L., Douglas, S. L., & Kelley, C. G. (2017). Stress and coping of critical care nurses after unsuccessful cardiopulmonary resuscitation. American Journal of Critical Care, 26(2), 128- 134. doi: 10.4037/ajcc2017916 Michalec, B., Diefenbeck, C., & Mahoney, M. (2013). The calm before the storm? Burnout and compassion fatigue among undergraduate nursing students. Nurse Education Today, 33, 314-320. doi: 10.1016/j.nedt.2013.01.026 Rella, S., Winwood, P. C., & Lushington, K. (2008). When does nursing burnout begin? An investigation of the fatigue experience of Australian nursing students. Journal of Nursing Management, 17, 886-897. doi: 10.1111/j.1365-2834.2008.00883.x Rudman, A., Gustavsson, P., & Hultell, D. (2014). A prospective study of nurses’ intention to leave the profession during their first five years of practice in Sweden. International Journal of Nursing Studies, 51, 612-624. doi: 10.1016/j.ijnurstu.2013.09.012 Suresh, P., Matthews, A., & Coyne, I. (2012). Stress and stressors in the clinical environment: A comparative study of fourth-year student nurses and newly qualified general nurses in Ireland. Journal of Clinical Nursing, 22, 770-779. doi: 10.1111/j.1365-2702.2012.04145.x

References U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. (2017). Supply and demand projections of the nursing workforce: 2014- 2030. Retrieved from https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/NCHWA_HRSA_N ursing_Report.pdf U.S. Department of Labor, Bureau of Labor Statistics. (2018a). Occupational employment statistics: Clinical, counseling, and school psychologists. Retrieved from https://www.bls.gov/oes/current/oes193031.htm U.S. Department of Labor, Bureau of Labor Statistics. (2018b). Occupational employment statistics: Nursing instructors and teachers, postsecondary. Retrieved from https://www.bls.gov/oes/current/oes251072.htm#(4) Van der Riet, P., Rossiter, R., Kirby, D., Dluzewska, T., & Harmon, C. (2015). Piloting a stress management and mindfulness program for undergraduate nursing students: Student feedback and lessons learned. Nurse Education Today, 35, 44-49. doi: 10.1016/j.nedt.2014.05.003