University of Arkansas, Fayetteville University of Arkansas, Fayetteville

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The Eleanor Mann School of Nursing Student Works The Eleanor Mann School of Nursing

3-2021

The Effects of Administrative Support on Registered Nurse Well-The Effects of Administrative Support on Registered Nurse Well-

Being during the COVID-19 Pandemic Being during the COVID-19 Pandemic

Cassandra Fox University of Arkansas, Fayetteville

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Citation Citation Fox, C. (2021). The Effects of Administrative Support on Registered Nurse Well-Being during the COVID-19 Pandemic. The Eleanor Mann School of Nursing Student Works. Retrieved from https://scholarworks.uark.edu/nursstudent/18

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College of Education and Health Professions Eleanor Mann School of Nursing

The Effects of Administrative Support on Registered Nurse Well-Being during the

COVID-19 Pandemic

Cassandra Fox

The University of Arkansas

Eleanor Mann School of Nursing

DNP Chair: Dr. Kelly Young

DNP Team Member(s): Dr. Allison Scott

Dr. Susan Patton

Date of Submission: March 27, 2021

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Table of Contents

Abstract…………………………………………………………………………………………....5

Introduction…………………………………………………………………………………….….6

Background and Significance……………………………………………………………..6

Problem Statement…………………………………………………………………….…12

Purpose Statement………………………………………………………………………..13

Needs Assessment………………………………………………………………..………13

Objectives and Aims……………………………………………………………………..14

Review of Literature…………………………………………………………………………..…15

Theoretical Framework…………………………………………………………………………..21

Methodology……………………………………………………………………………………..26

Project Description……………………………………………………………………….26

Project Design……………………………………………………………………………27

Setting……………………………………………………………………………27

Study Population…………………………………………………………………27

Subject Recruitment…………………………………………………………...…28

Consent Procedure……………………………………………………………….28

Outcome Measures……………………………………………………………….30

Risks or Harms…………………………………………………………………...31

Study Interventions………………………………………………………………32

Subject Costs and Compensation………………………………………………...32

Project Timeline………………………………………………………………….32

Resources Needed/Economic Consideration…………………………………….32

Implementation…………………………………………………………………………………..33

Evaluation of Results………...…………………………………………………………………..38

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Data Maintenance/Security………………………………………………………………38

Data Analysis…………………………………………………………………………….38

Economic/Cost Benefit…………………………………………………………………..51

Impact on Healthcare Quality and Safety………………………………………………..49

Policy Implications………………………………………………………………………56

Dissemination……………………………………………………………………...…….56

References………………………………………………………………………………………..59

Appendices……………………………………………………………………………………….71

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Abstract

Attention to the well-being of nurses is necessary to ensure the healthcare system can operate

effectively, particularly during the COVID-19 pandemic. The workplace environment and

support from nursing leadership strongly contribute to nurses’ well-being. Currently, there is

little evidence on the effect nursing leadership has on nurses’ well-being during the COVID-19

pandemic. This DNP clinical inquiry project sought to learn more about the effects of caring

leadership behaviors on nurses’ well-being during the COVID-19 pandemic. A survey

composed of questions from previously validated and reliable surveys used in the field of

nursing was used to collect data. Neuman’s systems theory guided project implementation.

The DNP project’s goal was to increase the knowledge of how administrative support can

improve nurses’ well-being in the workplace and decrease feelings of burnout under a crisis or

contingency standard of care related to the pandemic. The results will be disseminated through

publication and presentation with the aim to improve work environments for nurses to decrease

burnout and optimize well-being during the continuing COVID-19 pandemic.

Keywords: nursing burnout, administrative support, COVID-19, mental health, well-being,

surveys, nurses

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The Effects of Administrative Support on RN Well-Being during the COVID-19 Pandemic

The purpose of this paper was to detail a DNP clinical inquiry project designed to further

knowledge of the effects of administrative support for Registered Nurses (RNs) during the

coronavirus disease pandemic (COVID-19). The paper addresses the occurrence of burnout,

poor well-being, the role of consistent administrative support, lack of knowledge on how

administrative support is affecting RNs at the bedside, and the use of surveys to assess these

topics. Concept trends, patterns, and gaps in current evidence are discussed through a review of

literature. The paper utilizes survey interventions to assess the burnout, well-being, and

administrative caring behaviors toward RNs working in Florida during COVID-19. Through

survey data analysis, outcomes were analyzed to further understand the correlations among these

topics.

Background and Significance

Burnout and Well-Being in Nurses

Burnout is a syndrome resulting from chronic workplace stress. It is characterized by

energy exhaustion, job-related cynicism, and reduced personal efficacy (World Health

Organization, 2019). Burnout results in a diminished capacity for nurses to care for

themselves and their patients, resulting in impaired patient safety (Liu et al., 2018). Burnout

also leads directly to the worsening of a nurse’s well-being through diminished physical and

mental health (Kim et al., 2019). Longer term psychological effects can result from chronic

feelings of burnout, such as anxiety and depression. Depression prevalence is also higher

among nurses compared to other United States (U.S.) professionals (Dyrbye et al., 2017).

Burnout is considered a global crisis with contributing factors related to overburdening

policies, clerical work, conflict with colleagues, inadequate staffing, unmanageable patient

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workloads, lack of time, and inadequate support of well-being (Rosen, 2015). The main

contributing factors to the high levels of burnout experienced by nurses during a pandemic

include lack of support in the work environment and fear of spreading the virus to their

families (Shahzad et al., 2019). Nurses who spend more time in direct patient care have

decreased levels of burnout and improved levels of patient safety (Liu et al., 2018). Improving

work environments, increasing nurse staffing levels, and increasing support for nurses can lead

to more direct patient care time.

Professional burnout is a well-documented experience in the nursing profession and

experienced by 16% to 43% of nurses (Dyrbye et al., 2020). Burnout has been reported as a

top reason nurses quit their jobs, which results in expenses related to recruiting and orienting

new nurses (Woo et al., 2020). The highest prevalence of burnout occurs in the intensive and

critical care specialty units (Woo et al., 2020). Furthermore, a global meta-analysis study

found that Southeast Asia and the Pacific Islands had the highest prevalence rates of nursing

burnout worldwide, which is potentially attributable to the economic status, urbanization,

aging, and the nursing shortage in these regions (Sheikh et al., 2018; Woo et al., 2020). The

prevalence of high burnout rates among nurses demands further attention and implementation

of organizational changes (Woo et al., 2020).

Aside from burnout, other contributing factors are related to overall well-being.

Factors contributing to a nurse’s well-being include levels of resilience, levels of burnout,

grateful disposition, compassion satisfaction, and job satisfaction (Kim et al., 2019). Respect

from other medical staff is one of the top variables related to an improved sense of well-being

in the workplace (Hui-Chun et al., 2020). Cohesion among staff can mitigate burnout and is

the target for many workplace interventions to prevent burnout (Eliacin et al., 2018). Notably,

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nurses’ occupational stressors can lead to poor sleep quality and somatic symptoms (Gu et al.,

2019). While the effects of the workplace certainly play a role in nurses’ well-being, other

lifestyle factors are also important. Individual attitudes, habits, and personal life stressors also

contribute to overall well-being (Hui-Chun et al., 2020). Assessing not only the personal well-

being of nurses, but also the professional well-being is necessary to ensure a comprehensive

understanding of the overall status of this population.

Administrative Support

The driving forces for leaving the nursing workforce are reported as lack of guidance,

lack of management support, conflict, and the perception of business as the greater need

compared to patient care (Tuckett et al., 2015). Yet, work environments which positively

affect nurses’ well-being directly led to improved patient care and safety (Liu et al., 2018).

Enhancing work environments, increasing staffing levels, and supporting nurses to provide

more direct patient care are beneficial means to improve patient safety (Liu et al., 2018). For

example, nurses reported feeling safe because of well-organized pre-deployment health checks

while working with Ebola patients in West Africa. Additionally, pre-deployment training,

democratic leadership styles, role models, and timely dissemination of knowledge were related

to increased feelings of personal safety when caring for Ebola patients (Holmgren et al., 2019).

The workplace has a responsibility to aid in the well-being of staff and has an interest in doing

so related to improved financial outcomes through increased productivity (DiMaria et al.,

2019).

The protection of nurses’ well-being is not the sole responsibility of the individual but

a joint effort with the organization in which the nurses work (Maben & Bridges, 2020). It is

necessary to target work culture and stress when designing organization policies (Sultana et

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al., 2020). Administrative support to staff can help reduce the risk for burnout (Maben &

Bridges, 2020). Specific interventions by nurse leaders during a pandemic have been

recommended to decrease staff anxiety, decrease burnout, and improve well-being; however,

the impact of leadership support has not been evaluated (Levin, 2019).

The organization’s attention to the psychological, physical, spiritual, and psychosocial

needs of workers is critical to reducing work stressors (Levin, 2019). Diminishing burnout and

providing workplace support were essential skills for leaders (Lown et al., 2019). During a

disease outbreak, organizational systems should be put in place to prevent burnout by limiting

overtime, incorporating mindfulness techniques, and mandating breaks (Levin, 2019).

Teamwork activities, wellness breaks, and staff appreciation should also be incorporated into

practice (Levin, 2019). These activities are targeted at reducing burnout, optimizing coping,

and improving staff resilience. Healthcare organizations are in a central position to provide

support for the well-being of their employees in the face of a pandemic.

Previous Pandemics

Previous pandemics, such as the 2003 severe acute respiratory syndrome (SARS)

pandemic, demonstrate that fear and anxiety are experienced among most members of society

(Levin, 2019). Compared to non-healthcare workers, healthcare worker SARS survivors still

reported higher levels of psychological distress one year following the SARS outbreak (Levin,

2019). Nurses treating patients during the SARS outbreak in Singapore indicated high levels

of stress, depression, anxiety, and somatization symptoms even one year after the outbreak.

During the SARS pandemic, it was found that positive administrative support resulted in the

decreased development of post-traumatic stress disorder (PTSD) and psychiatric symptoms

(Levin, 2019). These findings highlight the need to address the mental health status of

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healthcare workers during a pandemic to alleviate long-term consequences. Caring for

patients during a pandemic outbreak increases nurses’ negative emotions; however, this can be

mitigated through proper administrative support.

Similarly, with the influenza A H1N1 pandemic in 2009, health care workers reported

increases in anxiety and concern of infection of family and friends (Goulia et al., 2010).

Nurses in New Zealand reported increased patient acuity, working extra shifts, limited support,

and isolated work environments; however, despite these difficulties, nurses attributed their

positive emotions to caring for pandemic patients during the H1NI pandemic (Honey & Wang,

2012). Strong leadership communication results in reduced levels of worry among staff;

therefore, recommendations to managers should emphasize the importance of communication,

the offering of psychiatric services, and favorable work environments (Goulia et al., 2010).

Future recommendations for pandemic responses, as evidenced by the SARS and H1N1

epidemics, should encourage regular and clear updates, counseling services, and more support

for nursing staff (Levin, 2019; Honey & Wang, 2012). Working overtime, frustrations with

communication, and increased acuity were factors exacerbated by pandemics. Nonetheless,

the camaraderie associated with caring for patients in a pandemic may outweigh some of these

negative factors related to overall well-being (Honey & Wang, 2012).

COVID-19

During the COVID-19 pandemic, healthcare workers have reported higher rates of

anxiety, PTSD, and cases of suicide related to working as a healthcare provider (Occupational

Health & Safety, 2020). Data also highlights a large proportion of healthcare workers were

experiencing mood and sleep disturbances, and recommendation of timely mitigation were

stressed (Pappa et al., 2020). The prevalence of depression and anxiety is most common in

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young, inexperienced, female nurses (Pappa et al., 2020). Uncertainty related to poor

communication, infectivity, and change of policies were factors related to increased stress,

anxiety, and depression (Saxena, 2020). Nurses’ specific concerns were cited as fear of

infection to themselves and their coworkers, overtime mandates, lack of resources, consistently

changing policies, limited access to appropriate protective personal equipment (PPE), and fear

of spreading infection to their families from their workplace (Saxena et al., 2020). From the

American Nurses Association (ANA) COVID-19 survey (2020), Florida nurses reported short

staffing and mandatory quarantine as urgent staffing concerns. Eighty three percent reported

concern for keeping their families safe and 78% reported concern about having the supplies

needed to prepare for a shift. Thus far, the typical work-related stressors that lead to burnout

have only been exacerbated by the COVID-19 pandemic.

Many recommendations for nursing leadership strategies during the COVID-19

pandemic are available. Evidence-based guidelines cite the importance of communication,

visibility, and ensuring access to resources that support physiological needs (Billings et al.,

2020; Cole-King & Dykes, 2020). Despite this, a recent Gallop poll reported 78% of

healthcare workers felt the COVID-19 pandemic negatively impacted their workplace

(Rantanjee & Foy, 2020). Additionally, only 44% of healthcare workers strongly agree that

their workplace cares about overall employee well-being during the COVID-19 pandemic

(Ratanjee & Foy, 2020). Despite our knowledge from previous pandemics on the importance

of creating healthy workplace environments and providing support, a survey from Nursing

Times indicated that half of nursing staff considered the support of their mental health to be

inadequate in the workplace during the COVID-19 pandemic (Ford, 2020). While

administrative support cannot eliminate all areas of stress for the nurses, it can help by

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alleviating some specific workplace stressors (Levin, 2019).

Gap in Knowledge

Globally, addressing burnout in nurses during the current pandemic should be a

research priority (Sultana et al., 2020). Further study is needed to determine the mental health

effect of the COVID-19 pandemic on vulnerable populations, such as nurses (Holmes, 2020).

Further inquiry into the effects of administrative support on nursing mental health is needed to

improve working conditions (Hofmeyer et al., 2020). Understanding the effects of

administrative support can aid in the development of guidelines on how to properly support

healthcare workers during pandemics.

This gap in knowledge regarding how administrative support affects nurses’ well-

being, can be feasibly overcome through further research across hospitals and specialties.

Additional information on quality of life, burnout, and demographics were collected along

with administrative support to assess for trends. Surveys have been the main method of

gathering information about nurses’ well-being, burnout, and administrative support in the

studies discussed above. During the COVID-19 pandemic, many surveys have been

administered through organizations and associations to gather information on nurses’ well-

being. Therefore, usage of surveys to cover this topic is feasible. Surveys online also give

nurses some anonymity with responses which may increase the likelihood of truthful answers.

Problem Statement

The problem statement for this clinical inquiry DNP project is that the effects of

administrative support on RN well-being during the COVID-19 pandemic are unknown. The

increased acuity and communicability associated with a pandemic have assumed adverse

outcomes related to overall well-being, but these are not fully explored in the current COVID-19

pandemic crisis. Determining the factors associated with burnout, well-being, and administrative

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support is helpful to provide recommendations on how to create healthier work environments.

Purpose Statement

The purpose of this clinical inquiry DNP project was to survey Florida inpatient RNs to

determine the effect of administrative support to RNs on well-being and prevention of burnout

during the COVID-19 pandemic. The survey results were analyzed to determine the role of

administrative support on RN well-being. Results were also assessed for correlations among

demographics, burnout, and well-being. Multiple facilities and a variety of inpatient specialty

units were used to compare RN experiences. By determining possible linkages among

administrative support, burnout, and well-being, workplace policies can be designed to

optimize workplace well-being and minimize burnout. This in turn provides economic value

to the healthcare organizations by increasing productivity (de Oliveria et al., 2019).

PICOT Question

How do Florida inpatient RNs (P) working during the COVID-19 pandemic (I) perceive

their well-being, related to administrative support (O) from October 2020 to January 2021 (T)?

Needs Assessment

The effect of the COVID-19 pandemic on the well-being of RNs has not been adequately

studied. Further research could examine the effects of the positive role nursing leaders can have

on improving employee well-being. There is a strong relationship between a healthy work

environment and nurses’ satisfaction, empowerment, and retention (Wolverton et al., 2018).

Caring work environments were strengthened by caring relationships among nurses and

managers (Cara et al., 2011). Caring behaviors by managers include listening, accessibility,

maintaining safe work environments, and extending support (Wolverton et al., 2018).

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Specific to the COVID-19 pandemic, healthcare leaders should be visible and make

rounds with staff to determine needs on the ground level (Shanafelt et al., 2020). Leaders are

also called to show genuine gratitude for employees, emphasize teamwork, encourage employees

to ask for help when needed, and ensure that help is available when requested (Shanafelt et al.,

2020). As the COVID-19 pandemic continues in the U.S., healthcare workers are asking for

support from their organizations. Requests for leaders to listen, protect, prepare, support, and

care for staff and their families were the paramount concerns (Shanafelt et al., 2020). Further

evidence on the prevalence and incidence of how leadership support effects RN well-being

during the COVID-19 pandemic can help guide policies to target and improve areas with lower

levels of well-being and higher levels of burnout.

Healthcare workers have proven to be one of the most critical and scarcest resources in

the COVID-19 pandemic (Lobdell et al., 2020). Work conditions of high demand and low

control during the COVID-19 pandemic are direct factors related to increased incidence of

burnout (Lobdell et al., 2020). Moreover, international nursing leaders have stressed the

importance of mental health support and training for frontline caregivers during this pandemic

(Ford, 2020). The International Council of Nurses also highlights the potential effect of the

COVID-19 pandemic on long-term mental health and the need for governments and

organizations to support the vulnerable population of healthcare workers (Ford, 2020).

Additional information is necessary to target approaches for burnout prevention among RNs.

Understanding the contributions of leadership support on RN well-being during a pandemic can

be used to improve workplace environments and individual coping.

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Aim and Objectives

The overall aim for this study was to develop more knowledge on the effects of

administrative support on well-being of direct care RNs in Florida working during the COVID-

19 pandemic. This was accomplished by further exploring trends among inpatient RNs during

the COVID-19 pandemic and disseminating results to improve burnout and well-being. The

objectives were as follows:

• Construct a survey that demonstrates the well-being of RNs and associated

environmental factors

• Identify RNs eligible to participate in the survey

• Analyze results with the intent to provide recommendations to improve workplace

well-being

• Disseminate results to foster healthy work environments

Review of Literature

A literature review was conducted to evaluate the use of surveys that assess nursing

burnout, administrative support, workplace well-being and mental health among nurses.

Information was gathered on nurses’ well-being related to the workplace prior to COVID-19 and

healthcare worker well-being related to COVID-19. Appendix B provides an evidence grid of the

evaluated articles. The databases Google Scholar and CINAHL were used to focus on nursing-

related studies. Data was limited to a five-year search span from 2015-2020, except for

landmark studies, using English-only documents from peer reviewed journals. Search terms

include nursing burnout, administrative support, COVID-19, mental health, well-being, surveys,

and nurses. Approximately 30 results were found with these search stipulations. The inclusion

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criteria compromised healthcare surveys and international studies. Exclusion criteria for the

search included out of date articles, doctoral dissertations, and articles with a non-nursing focus.

Nurses’ Well-Being during COVID-19

Prior to the COVID-19 pandemic, research studies found nurses to be at a higher risk for

suicide attributed to work-related stressors; including, relocation, inadequacy due to incomplete

orientation, workplace conflict, workload and excessive rules (Davidson et al., 2020). In

addition, exposure to death, conflict with supervisors, and uncertainty about therapeutic effect

cause higher stress (Sarafis et al., 2016). During the COVID-19 pandemic, these areas only

intensified from nurses relocating to other units, their lack of resources, the high mortality

incidence of hospitalized COVID-19 patients, and the constantly changing policies (Sarafis et al.,

2016). Therefore, nurses are specifically at risk for increased stress due to direct workplace

changes related to the COVID-19 pandemic, in addition to other stressors felt by non-healthcare

workers during a pandemic (Levin, 2019). Additionally, the International Council of Nurses

reported a pressing need for the increased support of mental health services for nurses related to

the COVID-19 pandemic (Ford, 2020). This need was highlighted in the COVID-19: Are You

OK? campaign, a survey that found nearly all nurses were experiencing higher levels of stress

and anxiety during the COVID-19 crisis (Ford, 2020).

Qualitative research on occupational stressors during the COVID-19 pandemic and the

effect on well-being among nurses is currently lacking in the U.S. Further studies on the stress

nurses face can provide essential information to administrative systems on ways to improve

support for nurses during infectious disease pandemics (Chen et al., 2020). The rapidly evolving

information resulting in policy changes during the COVID-19 pandemic results in a knowledge

gap on the well-being effects of nurses caring for patients during the COVID-19 pandemic

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period. Despite the recommendations for administrative support to nursing staff during the

COVID-19 pandemic, there is little evidence on how administrative support is contributing to

nursing well-being in the workplace (Maben & Bridges, 2020). Specifically, the aforementioned

studies identify the need for more detailed studies into the implementation of a survey on the

stressors that nurses face in the context of administrative support during the COVID-19

pandemic.

Not only does the stress level effect overall mortality, but the perception of stress as a

negative or positive factor affects well-being as well. Keller et al. (2012) found that those with a

high level of stress and who perceived stress as a positive factor had the lowest mortality rates,

even compared to those who reported low levels of stress and perceived stress as negative to

their overall health. The findings in this landmark study indicate that mindset is an important

factor in determining the effects of stress. In another study, nurses were identified to be a high

stress and low coping group with high health risk behaviors (Jordan et al., 2016). Additionally,

perceived stress and coping ability influence the overall health of nurses (Jordan et al., 2016;

Mathis, 2017). The incorporation of mindfulness techniques has positively influenced nurses’

perceived stress in the workplace (Mahon et al, 2017). Worksite health promotion for nurses

should focus on healthy coping skills and stress reduction techniques. Understanding how nurses

appraise their stress levels is important to gauge well-being. An ANA (2011) survey found 74%

of nurses reported concern with the effects of their work stress on their well-being (ANA, 2011).

Since the ANA survey, there have been limited national surveys to gauge stress among nurses

(Tully & Tao, 2019).

Recognizing vulnerable sub-populations within the nursing population is important to

generate targeted assessments and evaluations. Sub-threshold and mild mental health

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disturbances were seen in medical and nursing staff in Wuhan, China during the pandemic (Kang

et al., 2020). A systematic review conducted in April 2020 demonstrated that female healthcare

providers and nurses experienced higher rates of affective symptoms during the COVID-19

pandemic compared to male and other medical staff (Pappa et al., 2020).

Strong social support from family, supervisors and colleagues can aid in nurses coping

and improve their quality of life (Kowitlawkul et al., 2018). Additionally, creating appropriate

work environments with strong leadership helps offset the stressful work demands in hospital

settings (Mudallal et al., 2017; Strum et al., 2019). Based on results from a Taiwanese study on

nursing stress during the COVID-19 pandemic, recommendations on creating a team atmosphere

and providing psychological assessment and care were made (Feng et al., 2020). During a

pandemic, specific attention to providing support to nurses in the workplace is essential to

maintain their well-being as many of their stressors arise from their work. In general, the long-

term impact of the COVID-19 crisis on the psychological well-being of healthcare staff has not

been established (Pappa et al., 2020).

Use of Surveys

In the literature, there was a strong support for the use of surveys assessing non-cognitive

constructs, especially workplace factors and well-being. Recently published studies on the

effects of COVID-19 on mental health have commonly used surveys to determine how

healthcare workers are coping. The impact of COVID-19 on healthcare worker’s mental health

has been studied using previously developed surveys to screen for depression, anxiety, insomnia,

and distress (Kang et al., 2020). Analysis of the use of additional surveys is needed to further the

understanding of nurses’ well-being, mental health, and workplace environments.

Burnout Assessments

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Burnout represents the emotional state after excessive and prolonged exposure to stress

and can manifest in emotional, physical, and mental exhaustion symptoms (World Health

Organization, 2019). Numerous burnout assessment surveys focused on healthcare professionals

are available. Each survey is designed with different questions and assessment objectives within

the burnout realm; however, most use Likert scales. Likert scales provide ordinal data on the

measures of emotion, with the frequent option to be “neutral” or have to “no opinion”. The

rationale for the chosen survey was not always highlighted in individual studies. The

Copenhagen Burnout Inventory (CBI) is one of the most used surveys to assess burnout in

healthcare workers (National Academy of Medicine, n.d.). This survey has proven validity and

reliability and has been incorporated in many studies exploring nursing burnout. The CBI scale,

a Likert survey consisting of 19 questions, has been used exclusively and in adaptive forms to

assess work related stress and strain (Strum et al., 2019). The survey includes sub scores of

personal, workplace, and client scales to focus on the symptoms of physical and psychological

exhaustion attributable to the work environment. Reliability has been cited at 0.91 (Grabbe et

al., 2019). Validity has been established across numerous populations and disciplines

(Papaefstathiou et al., 2019). Due to the survey’s short length, ease of use, and focus on multi-

factorial aspects related to burnouts, the CBI was the selected survey for this project.

Well-Being Assessments

Well-being and mental health assessment surveys have been integrated into many studies

focused on nurses’ workplace environment. These surveys may use depression screening tools

such as the Patient Health Questionnaire 9, General Anxiety Disorder 7, and the World Health

Organization- Five Well-Being Index. These tools were designed to screen for underlying

mental health conditions, but do not typically have a stress or physical component related

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directly to the unique stressors in the nursing workplace. The World Health Organization

Quality of Life BREF Questionnaire (WHOQOL-BREF) measure has been used to focus on

nurse specific quality of life and include measures of the impact of exhaustion on physical well-

being as well (Bazazan et al., 2018). This survey has been used in combination with other tools

to assess work engagement and burnout; therefore, the survey may assess overlapping concepts.

Bazazan et al. (2018) cites the WHOQOL-BREF survey as a valid and reliable

international tool to evaluate quality of life among nurses. The tool is composed of physical,

psychological, health, social relationships, and environmental health domains. Social support

was found to be a significant predictor within all domains of the WHOQOL-BREF survey

(Kowitlawkul et al., 2018). A Cronbach’s alpha coefficient of 0.92 was reported in a study on

nurses’ quality of life in Singapore. Initially 100 questions, this 26-item revised version is more

appealing to survey respondents. Due to the length of the survey, direct applicability to nurses,

and subscales related to holistic approaches to well-being, the WHOQOL-BREF was used in this

DNP project.

Administrative Support

Psychometric questionnaires on the level of administrative support in inpatient nursing

are not as frequently studied. The new 25 question, reduced from 96 questions, Caring

Assessment Tool focused on administrators (CAT-Adm) has been used with proven validity and

a Cronbach’s alpha of 0.98 (Wolverton et al., 2018). This survey was designed to assess staff

perceptions of the caring attitudes of the nurse managers. This tool is based off the need for

more relational approaches to leadership (Wolverton et al., 2018). Positive relationships

between nurses and managers can create supportive and healthier work environments (Cara et

al., 2011). Suggestions for further usage of the survey includes assessing if caring behaviors are

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associated with nurse job satisfaction and using results to design interventions for improved

workplace environments (Wolverton et al., 2018).

There are many questionnaires used to gauge nursing burnout, well-being, and

administrative support levels. These studies have been used in conjunction with others to answer

research questions, but this can sometimes result in lengthy surveys. There is a paucity of

quality evidence around the workplace environment and its effect on nursing well-being during

the COVID-19 pandemic. Despite the numerous recommendations for healthcare leaders during

this time, there is a lack of evidence on the implementation of those recommendations and the

effect on the nurses. As previous pandemics have demonstrated significant burden on mental

health disorders among healthcare workers, it is important to explore the situations in which

nurses feel stressed to learn how to better manage these stressors. The rationale for conducting

this DNP clinical inquiry project was to further assess the impact of administrative support on

nursing well-being during the unique circumstances of the COVID-19 pandemic. By focusing

on the administrative effects on nursing well-being, specific guidelines can be developed for

organizations to mitigate the risks of burnout, improve the workplace environment and nursing

well-being in a pandemic situation. The use of a survey is significant as it gathers data directly

from those experiencing it.

Theoretical Framework

Neuman’s Systems Theory

Neuman’s system theory is a systems model focused on the interaction of parts within a

system. It is one of the most frequently used conceptual models in nursing research (Neuman,

1996). Key concepts include viewing the client holistically and as the sum of subsystems

interacting with the environment, through stressors and lines of defense. The intervention uses

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stages to guide the client through the main concepts. Neuman’s nursing theory has been shown

to yield reliability and integrity as a suitable theoretical framework when exploring stress on

individuals (Wang et al., 2019). Consequently, Neuman’s system theory provides an appropriate

framework for the development, implementation, and evaluation of a clinical inquiry DNP

project focused on discovering more information regarding nurses’ well-being related to

administrative support during the COVID-19 pandemic through the interaction of stressors and

lines of defense.

Systems Theory Concepts

Betty Neuman developed the Neuman systems theory to focus on the holistic care for

clients who face actual or potential environmental stressors (Neuman, 1996). This model is used

to guide care, adaptability, and focuses on stressors, which affect individuals, and interventions

as a move toward stability. Neuman’s theory can be applied to individuals or groups (Ahmadi &

Sadeghi, 2017). Nurses affected by the COVID-19 pandemic represent the larger group, and

each individual nurse within this system will have different lines of defense and stressors

affecting his or her overall stability. The individual or group system is viewed as an open system

receiving and providing interaction with the environment. Each client is composed of variables

of physical, psychological, sociocultural, developmental, and spiritual variables interacting with

universal stressors. Lines of defense represent the state of well-being and adaptability of the

client (Sultan, 2018). In addition, Neuman (1996) cites lines of resistance as the internal factors

that predict how a client reacts to stressors. According to Bademli and Duman (2017), the three

levels of prevention focused on managing stressors: primary, secondary, and tertiary can be used

to achieve a comprehensive assessment on interventions and problem solving. These concepts of

stressors and environmental impact, lines of defense, and the stages of prevention directly relate

23

to this DNP project because of the focus on managing numerous stressors to increase the

development of stability through the uses of lines of defense and management of lines of

resistance and entropy. See Appendix D for concept mapping.

Stressors

Stressors in Neuman’s systems model were derived from the environment and have direct

effects on the physical, psychological, sociocultural, and environmental variables (Renato de

Oliveria et al., 2018). Nurses involved in direct patient care during the COVID-19 pandemic

have numerous stressors that affect their mental and physical health. Due to the widespread

nature of COVID-19, these nurses are also dealing with a change in sociocultural norms related

to physical distancing measures (Maben & Bridges, 2020). Additionally, some nurses are

concerned with their level of infectivity and choose to further isolate themselves from loved ones

(Maben & Bridges, 2020). This causes additional interruptions to their normal social lives

resulting in feelings of further isolation and loneliness, which produces another stressor.

Neuman’s theory highlights the importance of viewing individuals as open systems interacting

with their environments, through the feedback loop of stressors, and the effect of the variables.

Changes in the environment can affect the experience and perception of stressors, which in turn

affects the RNs interaction with the environment.

The specific dimensions of stress are interpersonal, intrapersonal, and extra personal

stressors; although, Neuman does not specifically point out which stressors are specific to which

domain (Bademli & Duncan, 2017; Renato de Oliveria et al., 2018). Interpersonal levels of

stress could be seen among coworkers and administration, specifically pertaining to the

perceived levels of support felt by nurses. Intrapersonal dimensions encompass the baseline

well-being and mental state of the nurses, as well as their perception to stressors as positive or

24

negative. Extra-personal domains, in the case of the COVID-19 pandemic, pertains to overall

social changes related to physical distancing, the closing of business and schools, and economic

changes resulting in financial strain. Currently, there is limited data on the effects of the

administrative support available to nurses during the COVID-19 pandemic and how their overall

well-being is affected by potential varying levels of support, despite the strong guidelines on the

importance of managerial support (Maben & Bridges, 2020). Additionally, during the COVID-

19 pandemic, nurses’ mental health, stress, and anxiety levels are high, and the support of their

mental health is inadequate (Ford, 2020). In relation to this project, the use of the CBI is a valid

and reliable measure which was used to assess the impact of specific stressors that nurses face in

the healthcare setting.

Lines of Defense and Lines of Resistance

The overall goal of the systems theory is to achieve stability. Stability is achieved by

regulating the system’s response to stressors through the central core (Renato de Oliveria et al.,

2018). Lines of defense and lines of resistance make up the central core of the system. The

nurses’ lines of defense during COVID-19 include individual and group protective components.

Strengthening the lines of defense includes promoting mental health and physical well-being.

Examples include practicing mindfulness, regular exercise, and spending time with loved ones.

The flexible lines of defense focus on keeping the individual’s normal balance and avoidance of

stressors (Bademli & Duman, 2017). For nurses working during the COVID-19 pandemic,

avoidance of COVID-19 is impossible, and many nurses are being relocated to COVID-19 units

(Maben & Bridges, 2020). This relocation to other units not only exposes nurses to the direct

stressor of the virus, but also creates another stressor from the relocation to an unfamiliar

environment. For personal well-being, the WHOQOL-BREF survey was used to assess the

25

impact of the COVID-19 pandemic on nursing well-being. Using Neuman’s theory to guide

survey implementation to assess the impact of stressors, assists in the furthering of clinical

knowledge related to the COVID-19 pandemic’s effect on nurses in the workplace.

Stages of Prevention

One purpose of the Systems Model is to use the stages of prevention to predict the client

system stability (Neuman, 1996). Primary prevention occurs prior to the exposure to the stressor

and involves strengthening the individual to react to stressors. The survey assessed practices in

the workplace setting that promote well-being in the time of the COVID-19 pandemic through

administrative support to nurses. The secondary stage of prevention occurs after a stressor and

includes the system’s reaction. The emphasis of this stage is to focus on strengthening the

internal lines of resistance and removing the stressor. Questions concerning the role of

administrative support were gathered to assess the potential gap in care. The COVID-19

pandemic recommendations to healthcare workplaces emphasize open and consistent

communication with staff (Billings, 2020). Tertiary prevention offers support to the system.

The main goal of this level of prevention is to keep the stressors from having negative effects on

the system. The survey was also designed to assess this level of prevention through the

assessment of administrative support during the COVID-19 pandemic. The survey related to

assessing this tertiary level of prevention, the effect of the administrative support, is the CAT-

Admin survey. Survey results can help bridge the knowledge gap as to how the system of nurses

are coping with the COVID-19 pandemic stressors and the supportive role administrative staff

can have.

Summary

The incorporation of Neuman’s systems theory assists in the evaluation of the effects of

26

administrative support on nurses’ well-being during the COVID-19 pandemic. Neuman’s theory

also assists in the evaluation of the survey by establishing known effects of stressors and the

mediating role of the lines of defense. Survey results should demonstrate an association with

nurses’ well-being and the supportive role of administrators, according to the interaction of these

concepts. Available surveys were used within the constructs of stressors, lines of defense, and

tertiary prevention. The implementation of this theory aids in the development of a survey to

further assess the current knowledge on this topic. Further knowledge assists in the

recommendation of workplace guidelines that promote administrative support of nurses and

nursing well-being during a pandemic. Additionally, the collective understanding of the impact

of stressors on nursing staff can be improved.

Methodology

Project Description

The project implemented the CBI, WHOQOL-BREF, and CAT-Adm surveys to assess

administrative support, burnout, and inpatient nursing well-being during the COVID-19

pandemic. There is currently a knowledge gap on the specific role of administrative support in

the workplace for nurses related to the novelty of the COVID-19 pandemic. Recommendations

have been provided based on previous disaster responses, but the effectiveness of these

recommendations on the impact of overall nursing well-being during the COVID-19 pandemic

have not been evaluated (Jun et al., 2020). An anonymous, online survey, conducted outside the

workplace, provides the opportunity for respondents to answer truthfully without the fear of

retaliation (Morrel-Samuels, 2002).

The aim of this project was to develop knowledge pertaining to nurses’ well-being during

the COVID-19 pandemic and the assessment of these variables helped meet this aim. Leadership

27

can help staff overcome empathetic distress, one factor related to burnout and well-being

(Shanafelt et al., 2020). Therefore, there was an expected association between strong

administrative support and positive well-being. See Appendix G for data collection sheets.

Project Design

The DNP clinical inquiry project assessed the current knowledge gap of the effect of

administrative support on the well-being of nurses working in inpatient facilities during the

COVID-19 pandemic. The project design was cross-sectional. A cross sectional study involves

measuring the exposure of study participants at the same time (Setia, 2016). For example,

measuring the effects of administrative support during the COVID-19 pandemic. The project

design was chosen to aid in meeting the objectives by assessing the well-being of nurses during

the COVID-19 pandemic. A survey provided the means for trend analysis among demographics,

administrative support, burnout, and overall well-being of nurses during the COVID-19

pandemic. The results from this survey were disseminated to provide guidance for supporting

nurses in the workplace.

Setting

The survey was conducted online for ease of access by respondents and was available for

a three-month period from October 2020-Januaray 2021. A quality check screening question

was used at the beginning of the survey to ensure only Florida RNs complete the survey.

Study Population

The study population involved RNs with an active license working in inpatient facilities

during the COVID-19 pandemic. Convenience sampling was conducted through the Florida

nursing organizations and social media. Based on data from the Florida Center for Nursing

(2018), there were 208,870 nurses working in Florida in 2016-2017. An adequate sample size of

28

at least 30 completed surveys was needed to run statistical inferential testing. The sampling size

included all respondents from the implementation period from October 2020 to January 2021.

Inclusion criteria included English-speaking, Florida RNs, with an active nursing license,

working full-time, part-time or PRN during the COVID-19 pandemic at an inpatient facility.

Exclusion criteria included non-Florida RNs, LPNs, and those not involved in direct patient care

in an inpatient facility during the COVID-19 pandemic. It was expected that most respondents

would be female, given the proportion of female nurses; however, male RNs were not excluded

from sampling. Based on the convenience sampling and word of mouth recruitment, it was also

expected that there were many respondents from the same unit of work. Specific questions were

asked of what inpatient unit nurses work on to assess for unit specialty.

Subject Recruitment

Participants were recruited through word of mouth, Florida nursing organizations and

social media after IRB approval. The survey was shared through Allnurses.com and Sigma

Theta Tau chapters. The survey link was posted on Florida nursing Facebook groups as well and

viewers were encouraged to share the survey link on their nursing units and with other nursing

colleagues. To maintain consistency and anonymity, surveys were collected online only and not

via telephone.

Consent Procedures

Consent forms were obtained prior to beginning the survey online through Qualtrics.

Without completion of the consent form, respondents were not able to progress to complete the

survey. Consent was required by RNs participating in the survey. See Appendix K for the

informed consent form.

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Study Measures

Conceptual Definitions. The main concepts for this DNP project included COVID-19,

nurses’ well-being, burnout, and administrative support. For this project, COVID-19 was

defined as the coronavirus pandemic in the United States from March 1, 2020, the date a national

emergency was declared related to COVID-19, and onward. Nurses’ well-being encompasses

the sub-systems of Neuman’s system theory: physical, psychological, sociocultural,

developmental, and spiritual variables (Ahmadi & Sadeghi, 2017). Well-being involves these

variables, as well as their interplay with the environment, and is a continuum of poor to strong

well-being. In this project, burnout was the phenomenon that occurs when stressors from the

workplace lead to compassion fatigue and the potential manifestation of other symptoms of

emotional and physical exhaustion; therefore, leading to poor well-being. Administrative

support was the role of nursing leadership, not involved in direct patient care, and the varying

levels of support provided to staff. This includes support through virtual support groups,

communication levels, and availability of leaders.

Operational Definitions. The respondents were given instructions to consider survey

questions during the COVID-19 pandemic timeline. Nurses’ overall well-being and quality of

life was assessed through the WHOQOL-BREF survey. See Appendix L for approval from the

World Health Organization to use this survey. The CBI was used to assess RN burnout during

COVID-19. This survey is available for use free of charge. To assess the role of administrative

support, nurses also completed the CAT-Adm survey. This survey was purchased as student

usage for $35. Demographic information was collected to assess for underlying correlations.

The results were compared to assess for trends related to well-being, burnout, and perceived

administrative support.

30

Outcome Measures. The main outcome measure for this project was the role of

administrative support on the well-being of RNs during the COVID-19 pandemic. This was

assessed with demographics, the CBI, WHOQOL-BREF, and CAT-Adm surveys. Results were

analyzed for demographic information related to age, gender, and race to ensure a balanced

sample size was obtained. The surveys were chosen for their applicability to the aim of this

project and brevity. The CBI scale has a Cronbach’s alpha of 0.91 (Grabbe et al., 2019). The

validity has been evaluated across numerous healthcare populations and disciplines

(Papaefstathiou et al., 2019). The components of this survey include assessing the level of

exhaustion involving the workplace and when working with clients. Bazazan et al. (2018) cites

the WHOQOL-BREF survey as a valid and reliable international tool to evaluate quality of life

among nurses. A Cronbach’s alpha coefficient of 0.92 was reported in a study on nurses’ quality

of life in Singapore (Kowitlawkul et al., 2018). Initially 100 questions, this 26-item revised

version is more appealing to survey respondents. The components involve quality of life, health

of environments, mobility, sleep, satisfaction with work, relationships, and access to resources.

These components provide a comprehensive picture of the overall well-being of nurses. The 25

item CAT-Adm has proven validity and a Cronbach’s alpha of 0.98 (Wolverton et al., 2018).

This proven instrument provides administration with information about nurse manager caring

behaviors. Components of this survey assess the caring behaviors of nurse managers toward

staff. The CBI and WHOQOL-BREF surveys are provided in Appendix H. Due to proprietary

rights, the CAT-Adm was not included in the appendices.

Process Measures. The process measure for this project was the survey completion

rates. The sample size was assessed weekly during the implementation phase. The goal

response rate was 26%. This was based on the median survey response rate of 26% for online

31

surveys (PeoplePulse, 2018). Obtaining adequate responses in healthcare surveys is difficult due

to the volume of surveys healthcare works are asked to complete in and out of their workplace

(Burke & Hodgins, 2015). The representativeness of the sample size was also compared to the

Florida RN population demographics. During the implementation phase, Plan Do Study Act

(PDSA) cycles were executed to improve respondent rates. Additionally, a run chart was used to

track response rates over time. Methods to increase respondent rates focused on accessing

gatekeepers to help distribute surveys, providing a clear and relatable rationale for the survey,

involving professional bodies, and being persistent (Burke & Hodgins, 2015). Social media and

recruitment by word of mouth through personal contacts was also be used to maintain respondent

rates.

Balancing Measures. Balancing measures reflect the potential impacts the project

results could have in the field of nursing. Significant impacts from this study could improve

work environments by improving leadership support and nurses’ well-being. Future workplace

policies could be implemented based on these results to better support nurses.

Benefits and Risks

There was a small risk of a breach in privacy and confidentiality of survey responses.

While names and specific a data were not be collected, respondent identity could be discovered

using IP addresses. To minimize this risk, no email information was collected for potential

follow up. There were no anticipated economic harms of participating in this survey aside from

the time spent completing the survey. Approximate maximum survey completion time was

projected to be twenty minutes. Average completion time based on the pilot surveys was five to

ten minutes.

Benefits of participation included reflection on well-being for the individual and

32

contribution to the furthering of knowledge to improve working conditions for nurses. A social

benefit included solidarity. Improving work environments to support nurses can result in

increases of work engagement, decreases in burnout, and overall well-being of nurses at work

(Gonzalez-Gancedo et al., 2019). Economic benefits are directly related to improvement in

workplaces support for burnout to prevent loss of productivity and sick days (de Oliveria et al.,

2019).

Subject Costs and Compensation

There were no costs to respondents for participating the survey and no compensation was

provided to respondents.

Project Timeline

See Appendix E for a Gantt chart depicting the project timeline. The implementation

phase began after IRB approval was granted. Surveys were collected from October 2020 to

January 2021. Results were analyzed during this time and after the survey closed until March

15, 2021.

Resources Needed and Economic Considerations

There was limited cost associated with the survey, related to maintenance of computer

software for administering the survey and evaluating results totaled at less than $500. The CBI

and WHOQOL-BREF surveys were publicly available; however, the CAT-Adm survey had a

$35 one-time cost for student usage. Membership with the FNA for potential listserv access was

$15 per month for four months. Resources used included a computer, internet access, excel,

Qualtrics, and the mentioned surveys.

33

Implementation

Study Intervention

An anonymous online survey through Qualtrics was implemented. The survey was

composed of demographic questions, the CBI, WHOQOL-BREF, and CAT-Adm surveys for a

total of 80 questions. These sub-surveys measured burnout, the caring attitudes of managers

toward staff, and well-being in physical, emotional, and relational domains. The implementation

process involved consistent communication with nursing organizations and the use of social

media to promote the survey to achieve an adequate response rate. Plan- Do-Study-Act (PDSA)

cycles were used throughout the implementation phase to ensure the process and outcome goals

were being met. See Appendix M for a depiction of the interventions and modifications over the

evolution of the study.

Pre-Implementation Phase

Prior to the implementation, identification of organizations with access to potentially

eligible RNs occurred. Social media, the Allnurses.com forum, the Florida Nurses Association

(FNA), and Sigma Theta Tau International (STTI) Florida chapters were identified as potential

sources to share the survey. Memberships to the FNA and STTI were paid to ensure compliance

with organizational research solicitation rules. Before the release of the survey, a small pilot test

of the survey was administered to five volunteer healthcare professionals to assess for

technological glitches, formatting, clarity of questions, and transferability of data. From the pilot

administration, the average survey completion time was 10-12 minutes. Recommendations for

spelling corrections were implemented and the flow of the survey, with a maximum of seven

questions per screen slide was kept. Recommendations to change question wording was not

implemented as this would potentially impair the previously established validity and reliability of

34

the surveys. Testing of the survey site, Qualtrics, also occurred prior to the implementation

phase to ensure ease of exporting results. Appropriate subscriptions to Microsoft Excel and

Word software were maintained to export, code, and run statistical analysis.

Implementation Phase

The survey implementation occurred from October 14, 2020 to January 31, 2021 after

IRB approval from the University of Arkansas was obtained. The survey was available online

continuously through Qualtrics and maintained respondent anonymity. Initially, the survey and

recruitment script were posted to Facebook. Respondents were asked to share the survey with

Florida nursing colleagues. Following this, individual messages were sent to potential eligible

respondents referencing the recruitment script and original social media post. Sigma Theta Tau

chapters were contacted and two chapters, Lambda Rho and Theta Epsilon, emailed the survey to

their members. Additionally, the recruitment script and survey were posted to the Florida

Nursing forum at Allnurses.com. Social media and Allnurses.com were analyzed twice weekly

for respondent questions related to the survey. The survey was not posted through the Florida

Nurses Association due to a breakdown in communication.

Data was evaluated weekly to assess for respondent rates and the need for continued

recruitment. Visual displays of response frequencies were made in Qualtrics; however, the raw

data was exported to excel to run further descriptive and inferential statistical testing. The initial

sample size of 300 would have resulted in three completed survey responses per week. This goal

was not obtained as a total of 65 surveys were completed and another 45 were attempted from

ineligible respondents.

Plan-Do-Study-Act Cycles. The proposed implementation used social media and the

FNA as the main modes to market the survey; however, due to the communication breakdown

35

with the FNA, other possibilities had to be considered for the actual implementation. Therefore,

other nursing organizations were used to market the survey. These included AllNurses.com and

Sigma Theta Tau chapter contacts. An appropriate number of survey responses was one of the

main goals of implementation. Initially a goal of 150 responses by November 6, 2020 and 300

responses by January 31, 2021 was planned. To focus on the process measures of recruitment

for the survey and ensure adequate responses were obtained, social media and communication

were key components of the implementation phase. Appendix N includes the specific PDSA

cycles.

Social Media. Due to the COVID-19 pandemic, physical distancing requirements and in-

person communication became limited and difficult; consequently, there was an increased

reliance on social media. Facebook was used as the main form of social media to market the

survey. On October 14, 2020, the survey recruitment script with the anonymous Qualtrics link

was published to the Florida State University College of Nursing 2016 group, UF Health Shands

unit 44 pediatric nursing group, and the PI’s personal Facebook page. These were chosen based

on convenience sampling and were private groups of which the PI was already a member of.

Eligible RNs were asked to encourage their nursing colleagues to complete the surveys as well.

In the first 24 hours there were five eligible survey responses and one ineligible survey response.

From October 15, 2020 to October 19, 2020 approximately 35 personal social media messages

referencing the initial post with the recruitment script and anonymous link were sent to potential

respondents to increase response rate. The purpose of this was to serve as a reminder to complete

the survey. During this time frame, 23 eligible and 11 ineligible survey responses were

completed. The personal reminder messages had the greatest percentage of participation of the

specific interventions, but this was a finite means of recruitment. Additionally, when

36

participants requested to share the survey, the PI asked the participant to share the recruitment

script to ensure all potential respondents received the same information.

Communication. For the implementation to be successful, communication was an

essential component. Weekly communication with the project chair was performed as well as

communication with the FNA. There were several breakdowns of communication with the FNA.

Unfortunately, the survey was unable to be posted by the FNA due to lack of email response,

follow up, and time restraints. Numerous attempts were made to contact the organization, but

emails were frequently lost to follow up and were sporadic in nature. To make up for this

difficulty, the survey was shared through other nursing organizations, such as the Allnurses.com

forum. To achieve approval for publishing on the website, an article for the organization was

written. The survey was published on the Florida Nursing group on November 9, 2020, using

the research request guidelines. Communication was essential in ensuring proper requirements

for posting on this site were met. Frequent inquires on review status prior to the survey posting

helped to keep the posting on track. Once the survey was posted, consistent monitoring was

necessary to answer any questions posted on the survey topic page. Seven eligible and three

ineligible survey responses were obtained from this date onward. Due to the anonymous link it

was not possible to differentiate sources of recruitment from which responses originated. At the

end of implementation, on January 31, 2021, the survey had been viewed 304 times.

Collaboration and communication with the Allnurses.com staff were important for compliance

with organizational guidelines for posting research requests on the forum.

Additionally, published contacts for fifteen Florida Sigma Theta Tau chapters were

contacted about distributing the survey. These chapter contacts were obtained from open

references online through STTI. These contacts were provided the recruitment script, the

37

anonymous survey link, and given the option to ask questions regarding the survey. The Lambda

Rho and Theta Epsilon chapters reported distributing the survey between November 2, 2020 and

November 17, 2020. During this time four eligible and four ineligible survey responses were

recorded. To ensure the survey intervention was performed correctly the recruitment script was

used when seeking survey responses. Use of the recruitment script ensured no bribing occurred

to complete the survey and that all participants were provided with the same purpose and

participation expectations.

Post- Implementation Phase

After the survey data collection period ended, data was analyzed for trends among

multiple demographic data and survey questions. The raw data was exported to excel where

descriptive and inferential statistics were used to evaluate survey response averages, frequencies,

correlations, and statistical significance. Specifically, ANOVA testing was conducted to

determine that the three sub-survey means were statistically significant, indicating the surveys

measured different aspects. Linear regression testing was conducted to determine correlations

among the variables of burnout, quality of life, and administrative caring behaviors.

The results were shared at the Sigma Theta Tau conference on creating healthy work

environments, published on social media posts where the recruitment was conducted, and on the

AllNurses.com forum post. Dissemination and professional reporting was conducted to provide

RNs at inpatient facilities with the results of the study so that workplace environments can

improve RN well-being, especially during a pandemic.

Project Timeline

Throughout the project implementation there were many changes from the proposed

timeline. The development of the survey took the same amount of time as initially proposed.

38

The proposed timeline had the survey implementation occurring shortly after the proposal

presentation. This did not consider the time to obtain IRB approval. The two-week IRB

approval period was expeditious compared to the 6-week expectation, but this still presented a

deviation from the proposed timeline. Informed consent was obtained from each individual

respondent as they complete the survey, not at the beginning of the implementation period as the

proposed timeline suggested. The survey implementation period was longer than the initial

estimate by 45 days. This was due to the flexibility achieved from rapid IRB approval. See

Appendix O for the implemented Gantt Chart and Appendix E for the proposed Gantt Chart.

Dissemination occurred at the Sigma Theta Tau conference in February, the DNP intensive in

April, and to the platforms which distributed the survey.

Evaluation of Results

Data Maintenance and Security

The data collection security process was an important element in the implementation of

the DNP project. Survey results were saved on a single password-protected computer with

access only to the principal investigator. Data were not transferred through any other devices.

Data did not contain specific contact information, names of participants, nor names of facilities

of employment. Electronic written consent was required prior to starting the survey and did not

contain names to prevent breaches of confidentiality. Four duplicate responses were found with

the same answers and from the same IP address, so these duplicate responses were deleted.

These duplicates could have been the result of a submission error on Qualtrics. After the results

were analyzed, the data was deleted from the computer system.

Data Analysis

Descriptive and inferential statistics were used to analyze the data collected from the

survey responses. Descriptive statistics were used to measure the mean of survey responses after

39

the qualitative results were converted to quantitative scores (Kaliyadan & Kulkarni, 2019).

Descriptive statistics were beneficial to assess demographic results and to evaluate single

question responses. Further descriptive statistics were used to observe distributions of

administrative support, burnout, and quality of life related to age, gender, specialty worked, and

experience. Bar charts were used to display descriptive statistics results (Hildon et al., 2011).

To analyze the process measures of response and completion rates run charts were used.

Descriptive statistics were used to measure frequency, central tendency of sub-survey score

responses, and the process outcome of response rates. In addition, inferential statistics were used

to determine correlation and statistical significance from the overall results. ANOVA testing

was used to determine that the means of each sub-survey were significantly different. ANOVA

tests were used to test if groups differ in one or more characteristics and to compare means

across multiple independent variables (Statistics Solutions, 2020). To run descriptive and

inferential statistics the nominal survey responses were converted to score scales, from 0 to 100,

using the sub-survey scoring guidelines.

40

Figure 1: Box and whisker plot of sub-survey scores

Figure 1

Box and Whisker Plot of Sub-Survey Scores

Note. Box plot demonstrates the median scores, upper and lower quartiles, range, and outlier

sub-survey scores on a 0 to 100 scale.

Due to the nature of online anonymous surveys, there were many incomplete survey responses.

A total of 52 completed surveys were used to run inferential statistical analysis. Incomplete

survey responses were likely due to the length of survey as the average length of time for

incomplete surveys was 5 minutes. This missing data led to a smaller sample size.

Outcome Measures

The main outcome measure for this project was the role of administrative support

reported on burnout and quality of life of RNs during the COVID-19 pandemic. This outcome

was assessed through the survey variables and demographics. The outcome of the survey

demonstrated statistical significance, through ANOVA testing, between burnout, quality of life,

and administrative support. Demographic trends were also evaluated within the sub-survey

41

scores.

To graphically present the survey score averages related to demographics, the qualitative

Likert scale responses had to be converted to quantitative values. This was accomplished by

using the scoring guides associated with the surveys to convert scores to a 0 to 100 scale. Some

questions were inverted so that all the data read in the same direction. For example, most of the

question responses of a higher score correlated with a more positive value or attribute; however,

some questions with a higher response score indicated a negative attribute. These question

scores were inverted to have all the responses read in the same direction to be able to run

statistical analysis and comparisons across demographics.

Histograms were used to depict frequency distributions and compare responses across the

three sub-surveys (In & Lee, 2017). Figures 2 and 3 visually display single survey question

response outcome measures. Figure 2 results show that 69% of respondents report feelings of

emotional exhaustion. This was consistent with current research on how nurses feel

overwhelmed and exhausted due to the COVID-19 pandemic (American Nurses Foundation,

2020). The COVID-19 Survey Series reported high levels of anxiety, depression, and feelings of

emotional exhaustion (American Nurses Foundation, 2020); specifically, 72% of respondents felt

exhausted in the COVID-19 Survey Series. These results were consistent with this project’s

survey reports of 69% indicating they felt emotionally exhausted often or always and 75%

feeling physically exhausted often or always.

42

Figure 2

Emotional Exhaustion and Feelings of Depression/Anxiety/Despair Survey Question

Responses

Figure 2: Emotional exhaustion and feelings of depression/anxiety/despair

Figure 3 shows a CAT-Adm question that was specifically related to recommendations for

nursing leadership during the pandemic. 62% of nurses reported feeling that their leaders kept

them informed and 55% felt safe. Communication and transparency were the top recommended

guidelines for promoting employee well-being during crisis situations (Billings et al., 2020). The

AACN essentials for a healthy work environment also site authentic leadership as a key

component for establishing and maintaining healthy work environments (American Association

of Critical-Care Nurses, 2016). This highlights the importance of the nursing leadership role to

improve burnout. The lack of respondents feeling safe could be due to the infectivity of the virus

and the well-documented lack of PPE; however, more than a third not feeling well-informed

indicates there could be improvements in communication which may lead to improved feelings

of safety through understanding.

0

5

10

15

20

25

30

35

NEVER SELDOM SOME OFTEN ALWAYS

Fre

qu

ency

Survey response

Emotional exhaustion Feelings of depression/anxiety

43

Figure 4

Sub-Survey Score Response Averages by Experience Level

Figure 3: How often does my leader keep me safe and informed?

Figure 4 displays the average sub-survey score based on experience levels. Nurses with greater

than 10 years of experience felt the lowest levels of administrative support with the highest

levels of burnout. This was not a trend identified in previous research. Specific measures to

combat burnout and increase support for experienced nurses should be targeted toward this

population.

Figure 4: Sub-survey scores response averages by experience level

Figure 3

How Often Does My Leader Keep Me Safe and Informed?

0

5

10

15

20

25

30

35

NEVER RARELY OCCASIONALLYFREQUENTLY ALWAYS

Fre

qu

ency

Survey response

Keeps me informed Makes me feel safe

40

45

50

55

60

65

70

75

0-2 years 2-4 years 4-10 years 10+ years

Sco

re a

vera

ge

Years of experience

CBI CAT-Adm WHOQOL

44

Figure 5

Average Sub-Survey Scores Based on Marital Status

40.00

45.00

50.00

55.00

60.00

65.00

70.00

75.00

Divorced Married Never Married

CBI CAT-ADM WHO-QOL

Figure 5 depicts a bar graph representing sub-survey scores and marital status. As previous

literature highlights, married individuals report higher quality of life (Azari & Rasouyar, 2016);

however, they also reported higher levels of burnout in this survey.

Figure 5: Average sub-survey scores based on marital status

ANOVA testing was used to determine if the means of the sub-surveys were statistically

different. The null hypothesis was that the means were equal and the alternative hypothesis

states that the means were not equal. When all three sub-survey means were compared the p-

value was less than 0.05. This indicated that at a significance level of 0.05 at least one of the

population means was different. Further ANOVA testing was completed to determine which

means were not equal. The p-value for burnout and administrative support sub-survey scores

was 0.68 which was greater than 0.05, resulting in a failure to reject the null hypothesis.

Therefore, testing at a significance level of 5%, we can state that the population means of

burnout and administrative support were not significantly different. With the inverted burnout

45

Table 1

ANOVA P-Values for Sub-Survey Scores

scores compared to administrative support these results were expected as we would anticipate

burnout and administrative support to behave equally. Indicated as a higher score, with more

administrative support, there would ideally be less burnout. ANOVA testing of quality of life

and administrative support sub-survey scores gave a p-value < 0.001 which indicates that we

would reject the null hypothesis. At a 5% level of significance, we can state that the sub-survey

means for quality of life and administrative support were different. The comparison of sub-

survey means of burnout and quality of life resulted in a p-value < 0.001; consequently, the null

hypothesis was rejected. The difference in means indicates variations in responses to these sub-

survey questions. These p values changed when preliminary results were analyzed with 48

surveys; therefore, a larger sample size would be necessary to develop consistent statistically

significant results.

Table 1: ANOVA p-values for sub-survey scores

CBI vs. CAT-Adm vs.

WHOQOL CBI vs. CAT-Adm CBI vs. WHOQOL

CAT-Adm vs.

WHOQOL

p-value 2.37017E-05 0.680429084 1.03226E-05 7.97894E-05

Despite the statistically significant results, there were not strong correlations between the

variables. Burnout and quality of life scores had the highest r value of 0.49 and administrative

support and quality of life had the weakest correlational r value of 0.22. No linear, exponential,

polynomial, or power regression model projected a significantly stronger correlation. The lack

of a strong correlation could be attributed to low sample size or may indicate the effect of lurking

variables. Previous research has demonstrated correlations between burnout and quality of life,

so this was an expected finding. The lack of correlation between administrative support and

46

quality of life may indicate that there were numerous other factors related to nurses’ quality of

life which may have a stronger correlation than administrative support. These could include the

nurses’ mental and physical health, personal relationships, and financial stressors.

The overall findings in this study were expected based on previous evidence has reported

the importance of healthy work environments in the reduction of burnout (Maben & Bridges,

2020). Additionally, married respondents reported higher quality of life and lower levels of

burnout, which was consistent with previous literature that marital satisfaction in nurses

correlates with burnout and quality of life (Azari & Rasouyar, 2016).

The validity and reliability of the surveys used were represented in previous studies.

Further use of these surveys in this study, with statistically significant results, enhances the

validity and reliability of the surveys. Results were considered reliable due to the limits set on

Qualtrics and data cleaning to eliminate duplicate results.

Process Measures

The process measures were the survey completion rates, attainment of adequate sample

size, and representativeness of the sample. The sample size was assessed weekly during the

implementation phase through Qualtrics. The goal response rate was 26%. This was based on

the median survey response rate of 26% for online surveys (PeoplePulse, 2018). Obtaining

adequate response rates in healthcare surveys can be especially difficult due to the high volume

of survey requests (Burke & Hodgins, 2015). During the implementation phase, Plan Do Study

Act (PDSA) cycles were executed to improve respondent rates. These PDSA cycles focused on

the use of communication through social media and email to meet the process goals of adequate

response and completion rates. Methods to increase response rates focused on accessing

gatekeepers to help distribute surveys, providing a clear and relatable rationale for the survey,

47

Figure 6

Survey Response Rate

te

being persistent, and involving professional organizations (Burke & Hodgins, 2015). Social

media and recruitment, by word of mouth, through personal contacts were also used to distribute

survey reminders to maintain response rates. A run chart was used to track response rates over

time. Appendix M displays the implementation table.

Figure 6: Run chart of survey response rate process measures

Note. An eligible survey response was a respondent who answered “yes” to the validation

question. An ineligible response was an individual who answered “no” to the validation

question. The goal survey response rate demonstrates three surveys per day to meet the original

total response of 300.

Completion rates. Completion rates were the main process goal. 102 total survey

responses were recorded; however, 80% (n = 78) of those were considered eligible responses

based on the validation question. Furthermore, 67% (n = 52) of those eligible respondents

completed 100% of the survey. Qualtrics limits were set to give one week to complete the

survey prior to finalizing results. This limit gave respondents time to go back to complete the

survey, but also recorded partially completed surveys. Due to the survey length, completion

rates were especially difficult to obtain. An anonymous link was used to distribute the survey to

0

5

10

15

20

14-Oct 21-Oct 28-Oct 4-Nov 11-Nov 18-Nov 25-Nov 2-Dec 9-Dec 16-Dec 23-Dec 30-Dec 6-Jan

Nu

mb

er o

f su

rvey

res

po

nse

s

Date

Eligible response Uneligible response Daily goal response rate

48

keep the respondent’s confidentiality. With this method, it was not possible to follow up with

specific respondents about incomplete surveys. During the first week of implementation, 57% (n

= 58) of total survey responses were obtained. The data results were cleaned of four identical

responses from the same IP address, which could be an error in data submission.

Adequate sample size. An objective during the implementation phase was to obtain as

many surveys as possible. It was necessary to determine the minimal required sample size to run

appropriate statistical tests when less survey responses were obtained. To run ANOVA testing,

statistical assumptions and a sample size of 30 had to be met. This sample size included only

eligible participants who completed all the sub-survey questions (n = 52).

Representativeness. Determining representativeness is important to extrapolate results

to the general RN population. Of those who completed greater than 70% of the survey, 95% (n =

53) were female and 5% (n = 3) were male. Total eligible survey responses indicated that 93%

(n = 63) were female and 7% (n= 5) were male. Based on surveys from 2013, 2015, and 2017

males make up 6.6%, 8%, and 9.1% of the United States RN workforce, respectively (Smiley et

al., 2019). The percentage of male RNs working in Florida is projected to be 11.5% (Florida

Center for Nursing, 2018). This survey male participant rate was lower than the projected

population. This could be due to marketing of the survey population; however, the survey could

not be marketed more to male nurses without introducing bias into the results.

The age distribution of working RNs is a well-documented topic. The age range for this

project was 21 to 67 years of age. Of the total participants, 51% (n = 52) of respondents were in

the age range of 21-30 years. This was a much greater percentage than the presumed percentage

of 10% for this age range of the total Florida RN workforce (Florida Center for Nursing, 2018).

49

Of the 64 respondents who selected a race or ethnicity, 92% (n = 59) reported identifying

as white, 3% (n = 2) reported identifying as Asian, and 3% (n = 2) reported identifying as Black

or African American. This sample has a much higher percentage of white respondents than the

Florida RN workforce of 64% (Florida Center for Nursing, 2018). A more racial and ethnically

diverse sample should be obtained to further reduce bias and to be able to generalize results.

Specialty groups could not be directly compared to the Florida RN workforce averages

due to the difference in specialty titles and lack of clarification of inpatient compared to

outpatient specialties. In this project, 31% (n = 20) of nurses work in a pediatric specialty, 23%

(n = 15) work in an adult critical care setting, and 20% (n = 13) work in an emergency

department. The varied geographical locations within Florida and 13 different inpatient

specialties represented in this survey contribute to the representativeness of the sample. The

external validity of these results should consider the demographic makeup of the survey

respondents compared to the general population. Due to the variation in these demographics, the

results should only be generalized with this caveat.

Balancing Measures

Due to the nature of this project, there were not any perceived unintended consequences

on the system. A potential benefit of the project was the contribution to the expanding field of

knowledge on how the working conditions during the COVID-19 pandemic affect nurses’ well-

being. An unexpected expense was the cost to join the FNA at $15 per month for four months.

The communication breakdown with the FNA presented an unanticipated challenge which

resulted in the use of other platforms to gain survey participants. This survey intervention is

sustainable in that it can be replicated to use in other states or with other healthcare workers.

50

Discussion

Healthcare Quality Impact

Well-being has been recommended as a leading indicator by Healthy People 2030; thus,

well-being is an essential measurement for health quality (IHI Multimedia Team, 2020). RNs

reporting poor well-being and higher levels of burnout are associated with poor patient safety

outcomes and medical errors (Hall et al., 2016). Due to the widespread nature and longevity of

the COVID-19 pandemic, nurses are at an even greater risk for burnout. They report concerns

with safety and exhaustion (American Nurses Foundation, 2020). Nurse leaders in inpatient

settings may use the results from this project to guide interventions to improve work

environments. Improving the experience of providing care has been listed as part of the

Quadruple Aim of Healthcare since 2015 (Sikka et al., 2105). This highlights the significant

role the experience of healthcare providers has on the quality and safety of care provided to

patients.

At the beginning and throughout the COVID-19 pandemic, healthcare leaders

emphasized the importance of communication, transparency and providing psychological

resources. The results of the survey found nurses reported high levels of burnout during the

pandemic. Based on these results, there is a need to enhance communication and promote RN

safety. The results also found nurses reported higher levels of quality of life. This may be

explained by personal resilience, compartmentalization, or strong coping skills.

A study on nurses’ anxiety, organizational support, and personal resilience in the Philippines

found that higher support correlated with lower anxiety during the pandemic (Labrague & De

los Santos, 2020).

The nurses in this survey reported feeling emotionally and physically exhausted. The

51

American Nurses Foundation study (2020) also reported that RNs were feeling exhausted and

overwhelmed, nationally. Due to the widespread effects of COVID-19, it is expected that

nurses in states outside of Florida feel similarly about their work during the pandemic;

however, nurses in states with higher case and mortality rates may have higher levels of

burnout. Younger, less experienced, female nurses tended to have high burnout scores which

was consistent with the literature; however, experienced nurses reported the lowest levels of

administrative support. This was an unanticipated finding. Previous research found that nurses

want to be more respected, included in communication, and want to feel cared for by nursing

managers to have higher job satisfaction (Feather & Ebright, 2013). Specific to nurses over 45

years of age, participation in decision-making, interesting work, and good working

relationships were all motivators to stay in the workplace (Fackler, 2019). Prior to the

pandemic, nurses 50 years and older also report wanting to spend more time with patients, have

shorter work hours, and to have the pace and physical demands of nursing addressed. During

the COVID-19 pandemic, the work hours, pace, and physical demand of nurses have all

increased due to the surge of patients. It is likely that these variables contribute to the lack of

more experienced nurses feeling supported in the workplace. Including experienced nurses in

unit decision making is an intervention that nurse leaders can implement to help experienced

nurses feel more supported. Improving feelings of support may result in decreased burnout and

improved patients’ outcomes overall.

While no strategic trade-offs were identified directly in this project, investing in an

improvement in one area will incur costs, which often comes from another area. This should be

considered in the strategic tradeoffs for the organization. The value of improving the work

environment and the subsequent benefit on the quality and safety of patient care should be

52

evaluated against potential costs to implement these initiatives.

Economic and Cost Benefits

Improvement of RN well-being can lead to overall enhancements in productivity and

work attendance. This can translate into benefits to the healthcare organization in terms of cost

effectiveness. Additionally, burnout prevention can promote the physical and mental health of

these essential providers, an intangible benefit that cannot be quantified (de Oliveria et al.,

2019). Preventing nurse fatigue and subsequent burnout can have positive impacts on the

retention of staff, patient outcomes, reimbursement, safety of care, infection rates, and hospital

readmissions (Chovanak, 2017). The cost of RN turnover is estimated at $37,000-$58,400 per

nurse (Nursing Solutions Inc., 2016). While there are many potential reasons for staff turnover,

burnout is listed in the top six and burnout rates have increased over the past decade (The

University of New Mexico, 2016). Additionally, healthy work cultures result in a reduction of

infection and hospital re-admission rates, a projected cost of $28.4 to $45 billion annually

(Chovanak, 2017). Therefore, improving nursing work environments can have significant

impacts on economic outcomes for an organization. Incorporating the results of this project

can help hone efforts to improve administrative support and identify those most at risk for

burnout.

Limitations

The most significant limitation of this project was the convenience sampling method,

which is a weaker sampling method, but used commonly in survey research. The subsequent

snowball sampling method used on social media potentially produced a more representative

demographic. To limit bias, there was no reward for completing the survey and the survey was

shared through various online platforms of which the PI did not know the potential participants.

53

The demographic data in this survey should be considered when evaluating response rates and

attempting to generalize results.

The demographic makeup of the sample may lead to bias as this project population had a

higher percentage of younger, white, female, pediatric nurses compared to the general RN

population in Florida. The use of social media and online platforms, which are targeted toward

younger generations, could explain the younger demographic result. It is possible that if another

method of survey distribution, such as mail, were used there would be a more representative

distribution of age. Younger female nurses have been shown to have high levels of burnout;

therefore, this may lead to higher reports of burnout than the general nursing population (Pappa

et al., 2020). This survey also had a large amount of pediatric, emergency department, and

critical care nurses respond to the survey. The high yield of pediatric nursing responses was due

to the PIs personal marketing of the survey to these groups which presents a bias. The higher

response rate from critical care nurses may also lead to increased burnout rates as these nurses

tend to experience higher burnout rates compared to other specialties.

There were also fewer male nurses in this sample than projected in the Florida RN

population. More male participants could not be included in the sample without introducing bias

from marketing more to male participants. A diverse population would be more indicative of

trends within the general nursing population and may alter the final inferential statistic results.

Additionally, a greater sample size would lead to more confident interpretation of the inferential

statistics. These factors limit transferability to the general Florida RN population. When

comparing results to other states, that state’s particular demographic makeup would have to be

considered.

Conducting this survey in one state was performed to reduce confounding variables

54

related to the various efforts to target the COVID-19 pandemic from different states. Different

caseloads, mortality rates, and governmental mandates should be evaluated when comparing

results between states. Additionally, due to the anonymity of the survey, geographic variables

such as hospital size and rural versus urban location were not evaluated. It is possible that these

variables played a role in the administrative support experiences by nurses.

Sustainability

This DNP clinical inquiry project was useful to further validate relationships and

demographic trends between burnout, quality of life, and administrative support. The

recommendations developed from this clinical inquiry project are sustainable to the vulnerable

population of nurses throughout the pandemic and beyond. With dissemination, this project

may inspire further exploration into the factors related to nursing well-being and workplace

environments during the pandemic. Inpatient organizations can implement policies and

protocols to improve workplace environments for RNs based on the findings of lack of

communication and concerns for safety. While this specific survey intervention will not

continue, this survey can be used in other states and with other healthcare workers. Further

research into the administrative support for nurses working in an outpatient setting could also

be explored using this survey.

Recommendations

Based on the results of this survey, communication between nurses and administration

should be made clear, and nurses’ safety should be prioritized in the inpatient setting. To

accomplish these goals, healthcare leaders should communicate the guidelines for PPE, PPE

allocation, and hospital contingency plans. These are conversations frequently happening at the

administrative level, but staff may not feel involved in these discussions. Administration

55

rounding with the staff to assess needs may also help increase communication and

transparency. By focusing efforts to increase support for staff, burnout may be reduced.

Administrative support should target efforts on experienced nurses, as these nurses

reported the lowest levels of administrative support and the highest levels of burnout. Input

from experienced nurses to improve unit culture and well-being should be included as these

nurses have a wealth of knowledge and experience on nursing practice. Results from the

survey demonstrated that pediatric nurses reported the highest levels of burnout but not the

lowest level of administrative support among specialties. Therefore, it is likely that there are

numerous other factors related to burnout. Many of these factors may be related to the

conditions of the pandemic, which cannot be changed. Increased mortality, infectivity, and

patient loads were sequalae of the pandemic and cannot be directly influenced by a single nurse

leader. Therefore, controllable factors, such as improvement of the work environment should

be targeted. Work conditions in which strong communication, transparency and supportive

environments are emphasized lead to a healthier and more stable work force. This contributes

positively to the overall quality and safety of healthcare provided by nurses as demonstrated by

previous research.

Further study into the effectiveness of communication and transparency on reducing

burnout should be explored to guide recommendations to leaders. It is likely that burnout is too

complex to be solved with a single intervention, but evaluation of these efforts should be done.

Follow-up projects may include more exploration into different leadership styles and their

effects on burnout, the effect of administrative support on non-nursing healthcare workers, or

comparative surveys on nurses in different states.

Practice Implications

56

Understanding how administrative support effects burnout and quality of life highlights

the important role of leadership in creating healthy work environments. Additionally, leaders

who understand how administrative support influences burnout can implement strategies to

reduce burnout. While there are numerous factors that influence burnout, leadership should use

effective strategies to mitigate risk in situations where risk for burnout is very high, such as in a

pandemic setting with high mortality, acuity, patient volumes, and anxiety. Nursing leaders

cannot change the context of the pandemic, but they can work to create and maintain healthy

work environments which promote communication, safety, and transparency. The results of

this study can be translated to inpatient facilities in states affected by the COVID-19 pandemic

similar to the way Florida was. Attention to the demographic compositions should be

evaluated when considering generalization of results.

Policy Implications

Developing and maintaining healthy work environments should be the basis for creating

workplace policies. Workplace measures, related to nursing well-being, should be

implemented to improve the risk of nursing burnout. While standards of care shifted to

contingency and crisis during the pandemic situations, specific COVID-19 research should be

used to guide local and state healthcare policies to ensure the proper measures are in place to

sustain nurses’ well-being (Maben & Bridges, 2020). Potential policies could include

mandated breaks, integration of mindfulness techniques, frequency of communication from

administration guidelines, recognition of nursing staff, and the use of an employee wellness

officer or program (Maben & Bridges, 2020). As the incidence of the COVID-19 pandemic

continues, it illuminates weaknesses in our healthcare infrastructure, particularly concerning

support for frontline healthcare workers. Policy developments related to this subject should be

57

pursued.

Dissemination

Site and DNP Committee Reporting

Participants of the survey were notified of the aggregate results through the same social

media platforms that were used to solicit participation in the survey. This includes Facebook

groups and posts, and Allnurses.com. The results were shared on these platforms to notify

participants who may be interested in the results. As a requirement of Allnurses.com, project

results were shared on the same topic thread that solicited participation. The results will also be

disseminated to the University of Arkansas Eleanor Mann School of Nursing during the DNP

intensive in April 2021.

Professional Reporting

This paper will also be shared with the scholarly community. The project was presented

as a poster at the Sigma Theta Tau International’s conference on Creating Healthy Work

Environments in February 2021. Plans for potential publication include submission to the

Journal of Nursing Management or the Journal of Clinical Nursing. These journals were chosen

based on similar topics previously published in these journals. The focus on administrative

support, workplace environments, and nursing well-being are topics frequently published in both

journals.

Conclusion

Administrative support of inpatient RNs has the potential to reduce burnout and

improve overall quality of life. The aim of this project was to develop more knowledge on the

effects of administrative support on well-being for Florida RNs working in inpatient facilities

during the COVID-19 pandemic. This project meets this aim and contributes to nursing

58

practice knowledge through statistically significant results related to administrative support,

burnout, and quality of life. Nurses reported high levels of burnout, 55% felt safe, and 62%

well-informed; therefore, recommendations should focus on improving communication and

promoting safety. As previously established, female, inexperienced, younger nurses, and

nurses working in critical care or emergency departments had higher levels of burnout;

however, pediatric nurses reported the highest levels of burnout. Additionally, nurses with the

most experience reported feeling the lowest levels of administrative support overall.

Supplementary research in this area should be pursued to provide specific guidelines for

reducing burnout in these demographics. In general, nurses reported high levels of burnout, but

not low quality of life. This demonstrates that nurses were feeling burnout but were still

managing to cope in their personal lives; however, it is essential to improve workplace

conditions to prevent further burnout from affecting quality of life. Understanding how

administrative support effects well-being, measured through burnout and quality of life, can be

used by leaders to guide workplace environment improvements. Designing healthy and safe

environments, aimed to reduce burnout, is essential to maintain sustainable nursing practice

even amid a pandemic and to improve patient safety outcomes.

59

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71

Appendices

Appendix A: Global Aims Assignment

Write a Theme for Improvement: Administrative effect on the well-being of RNs affected by COVID-19

Global Aim Statement Create an aim statement that will help keep your focus clear and your work productive:

We aim to improve: the well-being (Name the process)

In: direct care RNs in inpatient facilities in Florida (Clinical location in which process is embedded)

The process begins with: identifying eligible RNs to participate in the survey (Name where the process begins)

The process ends with: analyzing trends related to well-being among direct care RNs (Name the ending point of the process)

By working on the process, we expect: to identify the effect of administration on the well-being of RNs

during COVID-19 (List benefits)

It is important to work on this now because: the role of administration related to well-being during COVID-

19 is unknown (List

imperatives)

Create Flowchart

Specific Aim Statement

We will: improve increase decrease

The: quality of number/amount of percentage of RN well-being

(process)

From: current standards

(baseline state/number/amount/percentage)

By: understanding what contributes to workplace fatigue and stress among RNs in direct patient care during a pandemic

(describe the change in quality or state the number/amount/percentage)

By: March 31, 2021

(date)

72

Appendix B: Evidence Table

Authors Y

e

a

r

Countr

y

where

researc

h

condu

cted

Theory

guiding the

study and

identificatio

n of

variables

Independen

t or

Treatment

Variable(s)

Dependen

t or

Outcome

Variable(

s)

Design

type

Sample

(N =)

Method

Data

Colle

ction

tools

Brief

Summary of

Results

Strengt

h of

eviden

ce

Dyrbye,

L. et

al.

2

0

2

0

U.S. None listed Professiona

l burnout

Career

choice

regret

Cohort N=6,933

nurses

Randomiz

ed

convenien

ce

sampling

MBI-

HSS

surve

y

Male and

younger

nurses

indicated a

higher level

of burnout

and career

choice regret.

Career choice

regret

increased

with

emotional

exhaustion

and

depersonaliza

tion.

III

Ford, S. 2

0

2

0

U. S. None listed COVID-19 Mental

health,

well-

being,

stress,

and

support

level.

Survey N= 3,484

Convenien

ce

sampling

Surve

y

devel

oped

by the

Nursi

ng

Times

The current

support level

provided to

staff on

mental health

was reported

as

inadequate.

One third

reported they

needed

support but

did not feel

able to ask

for it.

III

No

comm

ent on

the

validit

y or

reliabil

ity of

survey.

Create

d own

survey

73

Kang,

L. e

tal.

2

0

2

0

China None listed COVID-19 Efficacy

of the

psycholog

ical care

accessed,

mental

health

status of

staff, and

psycholog

ical care

needs

Cross

section

al

N= 994

183

doctors

and 811

nurses

Convenien

ce

sampling

Self-

rated

questi

onnai

re;

PHQ-

9,

GAD-

7, ISI,

IES-R

Findings

highlight

mild and

moderate

mental health

disturbances

related to

COVID.

Recommend

supporting

frontline

workers

through

mental health

interventions

during crisis.

V

Kim, J.

S.

2

0

2

0

South

Korea

None listed Emotional

labor

strategies

Nurses’

stress and

burnout

Cross

section

al

N= 303

nurses

from 27

hospitals

Convenien

ce

sampling

Nurse

s

emoti

onal

labor

strate

gies

scale,

Expa

nded

Nurse

s

Stress

Scale

and

Profe

ssiona

l

QOL

scale

Nurse

managers

should

provide

discussion

opportunities

of emotional

labor

strategies and

promote

programs that

encourage

emotional

competence

V

Pappa,

S. et al

2

0

2

0

U.K. None listed COVID-19

outbreak

Prevalenc

e of

anxiety,

depressio

n, and

insomnia

Meta-

analysi

s

N= 13

studies

with

33,062

participant

s total. 12

studies

from

China one

from

Medli

ne,

Googl

e

Schol

ar,

PubM

ed,

Medr

vix,

Female

nurses had

the highest

rate of

somatic

symptoms.

Stressed the

need to

establish

interventions

I

74

Singapore and

SSRN

server

s

were

used.

for mental

health during

the

pandemic.

mm

Grabbe,

L. et al

2

0

1

9

U.S. Resilient

Zone

Resiliency

interventio

n focused

on sensory

awareness:

Communit

y

Resiliency

Model

Stress

tolerance

Rando

mized

Control

Trial

N= 196

nurses

Convenien

ce sample

Pre/p

ost

test

after

interv

ention

;

WHO

-5;

CD-

RISC;

STSS

; CBI;

SSS-8

CBM is

promising as

a tool to

enhance

stress

resilience and

compassion

under

working

conditions.

II

Strum,

H. et

al.

2

0

1

9

Germa

ny

None listed Perceived

working

conditions

Patient

safety and

job strain

Cross-

section

al

N=575

351 nurses

and 224

physicians

CBI,

COPS

OQ,

TLI,

HSPS

C-D

surve

ys

Sub-optimal

workplace

safety and

teamwork

concerns

correlate with

worse patient

outcomes.

Workload

measures can

be used to

assess job-

related

psychologica

l strain.

V

Bazaza

n, A. et

al

2

0

1

8

Iran Meditation

Model

Quality of

life

Mental

health

Cross

section

al

N=990

nurses

Convenien

ce

GHQ-

12;

WHO

LQO

L-

BREF

;

MFI-

20

The

WHOQOL-

BREF

domains

were strongly

related to

QOL and

suggest the

need for

interventions

to improve

V

75

fatigue.

Kowitla

wkul,

Y. et

al.

2

0

1

8

Singap

ore

None listed Surveys on

determinan

ts of QOL

QOL,

work life

balance

Descrip

tive

quantit

ative

study

N=10421

nurses

Convenien

ce

sampling

WHO

QOl-

BREF

, SoC,

WLB,

Job

satisf

action

questi

onnai

re,

Social

Supp

ort

Quest

ionnai

re

Social

support and

coherence

were

predictors of

quality of

life. Support

from

supervisors

and

colleagues

can help

individuals

cope with

stress.

Nursing

policy related

to nurses’

physical

health and

work

environment

should be

established.

V

Wolvert

on, C.

L. et

al.,

2

0

1

8

U.S. Duffy’s

Quality-

Caring

model

Psychometr

ic

properties

Caring

behaviors

of nurse

leaders

Cross-

section

al

descript

ive

N=1143 CAT-

Adm

94

items

and

CAT-

Adm

25

items

CFA was

used to

assess nurse

manager

caring

behavior.

The

Cronbach’s

alpha was

0.98 of the

25-item

survey. This

tool can be

used to

provide

information

V

76

abut nurse

manager

caring

behaviors.

77

Appendix C: Theoretical Framework

78

Appendix D: Conceptual Model

Concept Mapping

Well-being of nurses

Administrative support

Stressors

QOL, mental health,

support at home,

perceptions of stress,

stress levels

The effects of administrative support

on the well-being of RNs during

COVID-19

Goal: Disseminate

results to improve

well-being support of

RNs working in

hospitals during

COVID-19

Neuman’s

Systems

Theory Survey

Implementation

Desired outcome:

associations

discovered between

types of

administrative support

and well-being

Stressors

measured

by CBI

Lines of

Defense

measured by

WHOQOL-BREF

Tertiary

Prevention

measured by

CAT-adm

on

Feedback,

communication,

approachability,

availability of support

resources, education,

support groups

Allocation of

resources,

transferring units,

policy changes,

workload, infectivity

Contributing factors

Components

Guided by:

79

Appendix E: Proposed Gantt Chart

1-May 20-Jun 9-Aug 28-Sep 17-Nov 6-Jan 25-Feb 16-Apr 5-Jun

Proposal development

Survey development

Informed consent phase

Survey implementation

Analysis of data

Proposal presentation

Dissemination

Proposaldevelopment

Surveydevelopment

Informedconsent phase

Surveyimplementatio

n

Analysis ofdata

Proposalpresentation

Dissemination

Start date 1-May1-May1-Sep15-Sep15-Sep22-Sep1-Mar

Days to complete 901201590175330

Gantt Chart

80

Appendix F: Statement of Mutual Agreement for DNP Guidance

81

Appendix G: Data Collection Sheets

Respondent #

Gender

Race

Ethnicity

Age

Marital status

Years worked

Specialty

CBI scores

WHOQOL-BREF scores

CAT-Adm scores

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Appendix H: Copy of Questionnaires

Demographic questionnaire:

Age: (enter number)

Gender: (male, female, non-binary)

Race:

Ethnicity:

Marital status:

Years as an RN: (select range)

Specialty currently working in: Med/surg, med/surg tele, oncology, PCU, ICU, ped, ER,

psych, Women’s services (L&D, mother baby), NICU, rehabilitation

*include option: prefer not to say on each item

83

Appendix I: Copy of Surveys

Copenhagen Burnout Inventory

Part one: Personal burnout

Definition: Personal burnout is a state of prolonged physical and

psychological exhaustion.

Questions:

1. How often do you feel tired?

2. How often are you physically exhausted?

3. How often are you emotionally exhausted?

4. How often do you think: ”I can’t take it anymore”?

5. How often do you feel worn out?

6. How often do you feel weak and susceptible to illness?

Response categories: Always, Often, Sometimes, Seldom, Never/almost never.

Scoring: Always: 100. Often: 75. Sometimes: 50. Seldom: 25. Never/almost never: 0.

Part two: Work-related burnout

Definition: Work-related burnout is a state of prolonged physical and psychological

exhaustion, which is perceived as related to the person’s work.

Questions:

1. Is your work emotionally exhausting?

2. Do you feel burnt out because of your work?

3. Does your work frustrate you?

4. Do you feel worn out at the end of the working day?

5. Are you exhausted in the morning at the thought of another day at work?

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6. Do you feel that every working hour is tiring for you?

7. Do you have enough energy for family and friends during leisure time?

Response categories:

Three first questions: To a very high degree, To a high degree, Somewhat, To a low degree, To

a very low degree.

Last four questions: Always, Often, Sometimes, Seldom, Never/almost never. Reversed score

for last question.

Part three: Client-related burnout

Definition: Client-related burnout is a state of prolonged physical and psychological

exhaustion, which is perceived as related to the person’s work with clients*.

*Clients, patients, social service recipients, elderly citizens, or inmates.

Questions:

1. Do you find it hard to work with clients?

2. Do you find it frustrating to work with clients?

3. Does it drain your energy to work with clients?

4. Do you feel that you give more than you get back when you work with clients?

5. Are you tired of working with clients?

6. Do you sometimes wonder how long you will be able to continue working with clients?

Response categories:

The four first questions: To a very high degree, To a high degree, Somewhat, To a low degree,

To a very low degree.

The two last questions: Always, Often, Sometimes, Seldom, Never/almost never.

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WHOQOL-BREF Survey

1(G1) How would you rate your quality of life?

2 (G4) How satisfied are you with your health?

3 (F1.4) To what extent do you feel that physical pain prevents you from doing what you need to

do?

4(F11.3) How much do you need any medical treatment to function in your daily life?

5(F4.1) How much do you enjoy life?

6(F24.2) To what extent do you feel your life to be meaningful?

7(F5.3) How well are you able to concentrate?

8 (F16.1) How safe do you feel in your daily life?

9 (F22.1) How healthy is your physical environment?

10 (F2.1) Do you have enough energy for everyday life?

11 (F7.1) Are you able to accept your bodily appearance?

12 (F18.1) Have you enough money to meet your needs?

13 (F20.1) How available to you is the information that you need in your day-to-day life?

14 (F21.1) To what extent do you have the opportunity for leisure activities?

15 (F9.1) How well are you able to get around?

16 (F3.3) How satisfied are you with your sleep?

17 (F10.3) How satisfied are you with your ability to perform your daily living activities?

18(F12.4) How satisfied are you with your capacity for work?

19 (F6.3) How satisfied are you with yourself?

20(F13.3) How satisfied are you with your personal relationships?

21(F15.3) How satisfied are you with your sex life?

86

22(F14.4) How satisfied are you with the support you get from your friends?

23(F17.3) How satisfied are you with the conditions of your living place?

24(F19.3) How satisfied are you with your access to health services?

25(F23.3) How satisfied are you with your transport?

26 (F8.1) How often do you have negative feelings such as blue mood, despair, anxiety,

depression?

87

Appendix J: Recruitment Script

Hello, my name is Casey Fox and I am a DNP-FNP student at the University of

Arkansas. The COVID-19 pandemic has touched the lives of all nurses, whether working

directly with COVID-19 patients or not. Nurses are considered one of the scarcest resources

during this pandemic and protecting their well-being is paramount.

I am conducting a survey on the impact of administrative support on RN well-being

during COVID-19. The purpose of this research is to determine the effect of administrative

support on RN well-being during COVID-19 to improve workplace conditions for RNs working

during a pandemic. There are many recommendations for healthcare leaders during this time,

but the implementation and effect of those behaviors are unknown.

Your participation would include completion of a survey on your demographic

information, burnout, well-being, and administrative caring behaviors. The participant’s

information will be kept anonymous and results will only be shared in an aggregate form.

Participation is voluntary. Refusing to participate will not adversely affect any other relationship

with the University or the researchers.

Will you participate by completing this survey?

Contact Information:

Principle Investigator:

Casey Fox

University of Arkansas Eleanor Mann School of Nursing

606 N. Razorback Rd.

1-479-575-3904

ckenyon@uark.edu

Co-Investigator/Faculty

Chair:

Kelly Young, DNP

University of Arkansas Eleanor Mann School of Nursing

606 N. Razorback Rd.

1-479-575-3904

Kmy006@uark.edu

88

Appendix K: Consent Form

The Effects of Administrative Support and the Well-Being of RNs during the COVID-19

Pandemic

PRINCIPAL INVESTIGATOR

Cassandra Fox

University of Arkansas Eleanor Mann School of Nursing

606 N. Razorback Rd.

1-479-575-3904

ckenyon@uark.edu

FACULTY ADVISOR

Dr. Kelly Young

University of Arkansas Eleanor Mann School of Nursing

606 N. Razorback Rd.

(479)575-4914

Kmy006@uark.edu

PURPOSE OF PROJECT

You are being asked to take part in a DNP project. Before you decide to participate in this

project, it is important that you understand why the project is being done and what it will

involve. Please read the following information carefully. Please ask the principal investigator if

there is anything that is not clear or if you need more information.

The purpose of this project is to survey inpatient RNs to determine the effect of administrative

support to RNs, during the COVID-19 pandemic, on well-being to prevent workplace fatigue and

stress.

This project’s aim is to develop more knowledge related to the effects of administrative support

on the well-being of direct care RNs in Florida working during the COVID-19 pandemic.

PROJECT PROCEDURES

Participation in online survey.

RISKS

• Increase in stress from reflecting on survey response concerning well-being

• Loss of confidentiality of data

BENEFITS

Benefits to participating in this project include

89

• Contribution to furthering knowledge on nursing well-being during COVID-19

• Opportunity for reflection on experiences

CONFIDENTIALITY

Your responses to the surveys will be anonymous. Please do not write any identifying

information on your surveys.

To assure patient confidentiality, it is requested that data is de-identified when provided to the

principal investigator. The principal investigator will keep data in a computer that is password

protected. Notes, interview transcriptions, and any other identifying participant information will

be secured in a locked file cabinet in the personal possession of the principal investigator.

Participant data will be kept confidential to the extent allowed by law and University policy.

The researcher is legally obligated to report specific incidents which include, but may not be

limited to, incidents of abuse and suicide risk.

CONTACT INFORMATION

If you have questions at any time about this project, or you experience adverse effects as the

result of participating in this project, you may contact the principal investigator, whose contact

information is provided on the first page. If you have questions regarding your rights as a study

participant, or if problems arise which you do not feel you can discuss with the Principal

Investigator, please contact the University of Arkansas Institutional Review Board at 1-479-575-

2208.

VOLUNTARY PARTICIPATION

Your participation in this project is voluntary. It is your decision whether or not to take part in

this project. If you decide to take part in this project, you will be asked to sign a consent form.

After you sign the consent form, you are still free to withdraw at any time and without giving a

reason. Withdrawing from this project will not affect the relationship you have, if any, with the

principal investigator. If you withdraw from the project before data collection is completed, your

data will be returned to you or destroyed.

CONSENT

I have read and I understand the provided information and have had the opportunity to ask

questions. I understand that my participation is voluntary and that I am free to withdraw at any

time, without giving a reason and without cost. I understand that I will be given a copy of this

consent form. I voluntarily agree to take part in this project.

90

Participant's signature ______________________________ Date __________

Investigator's signature _____________________________ Date __________

91

Appendix L: Copy of Approval Letters

92

Appendix M: Implementation Table

Intervention Description Modifications Date

Development of

survey

Permission granted for use

of WHOQOL-BREF

survey and CAT-Adm.

Demographic questions

created.

Altered demographic

questions to reduce

question overload and

to analyze only relevant

data with input from

committee.

May 1, 2020-

August 1, 2020

Small pilot survey

conduction

Five healthcare

professionals completed

the survey and provided

recommendations to

change wording,

formatting, spelling, and

grammatical corrections.

Only the anonymous

link was used for

distribution to maintain

anonymity. Pilot

recommendations for

grammatical and

spelling changes were

implemented; however,

changes to question

wording were not due

to the potential change

in the survey validity,

reliability, and

reproducibility.

September 19-

20, 2020

Identification of

eligible respondents

The creation of a

validation question was

created in the survey to

confirm only those eligible

participants completed the

survey.

The validation question

remained unchanged

through the

implementation of the

survey.

October 7,

2020- January

31, 2021

Initiation of survey

implementation

Surveys were made

available to social media,

Sigma Theta Tau chapters,

word of mouth, and

Allnurses.com.

Initially, the survey was

only going to be shared

through social media

and the FNA; however,

since the survey was

not able to be shared

through the FNA

alternative sources to

distribute the survey

were used.

October 14,

2020-January

31, 2021

Monitoring of

respondents

Respondent rates were

monitored twice weekly.

Initial posting of survey

through general social

media posts resulted in

lower engagement;

therefore, potential

respondents were

contacted individual

October 14,

2020-January

31, 2021

93

with reference to initial

post to complete the

survey. This yielded a

higher respondent rate,

but it was also limited

to convenience

sampling.

Collaboration with

nursing

organizations to

share the survey

The proposed plan was to

use the FNA to share the

survey; however, there

was an initial

miscommunication related

to the cost of posting the

survey and the survey was

not shared through the

FNA.

Email communication

was used to discuss

posting the survey

through nursing

organizations. Due to

the breakdown in

communication, other

sources were needed to

post the survey. An

application to post the

research request

through Allnurses.com

was obtained and the

survey was posted on

this platform.

Additionally, by

reaching out to STTI

chapter representatives

the survey was posted

within two Florida

STTI chapters as well.

October 16,

2020-January

31, 2021

94

Appendix N: PDSA Cycles

Person

Responsible Due Date

PI 14-Oct

PI 14-Oct

PI weekly until Nov 6

PI weekly until Nov 6

Person

Responsible Due Date

PI 19-Oct

PI 19-Oct

PI 2-Nov

PI 16-Nov

Person

Responsible Due Date

PI 22-Jan

PI 19-Jan

PI 1/20/2021

PI and chair 1/22/2021

Person

Responsible Due Date

PI 31-Jan

PI 29-Jan

PI 1/31/2021

PI 1/31/2021

Study: No response to follow up email, but based on the previous communication patterns other means of survey implementation are being brainstormed.

Act: Researched other potential Florida nursing organizations to advertise survey, including the Florida Hospital Association and the Advent Healthcare System.

Do: Email the FNA director sent as a follow up reminder about implementing the survey.

Change Idea: Increase survey response rates by marketing survey through the FNA

Plan: Follow up with FNA director through email to post survey to the FNA to increase survey responses.

Do: Emailed FNA director about posting survey to website and/or email

Study: FNA director responded to email with requests to change the wording under the risk and confidentiality sections of the consent.

Act: Work with chair to respond to questions concerning consent.

FNA Partnership

Objective: Establish partnership with the FNA to post survey through the organization

Change Idea: Increase communication through email with FNA director

Plan: Follow up with FNA director through email about survey implementation

Objective: Increase the amount of survey responses

Study: Received 50 survey responses from social media. FNA requires $250 deposit to post survey

Act: Continue to reach out individually to potential respondents to increase participation rates.

Response Rates through Individual Contacts

OBJECTIVE: Increase amount of survey responses

Change Idea: Use multiple means and online platforms to reach a larger eligible population

Plan: Increase amount of individual survey recruitment to reach goal of 150 responses

Do: Individually reach out to potential survey participants and personal contacts through social media platforms to increase survey responeses

Study: Collected 62 completed responses to date. Approximately 12 more from this technique of reaching out to potential individuals

Act: Increase recruitment from other online platforms such as Allnurses.com and STTI Florida Chapters

Communication with Florida Nursing Organizations

Do: Distributed survey to social media. Reached out to director of FNA for permission to contact FNA members

Response Rates through Social Media

OBJECTIVE: Achieve 150 responses in the first 3 weeks of publishing survey on Qualtrics

Change Idea: Begin survey distribution and monitor participation percentages frequently

Plan: Start survey recruitment and monitor participation

95

Appendix O: Implementation Gantt Chart

17-Sep 6-Nov 26-Dec 14-Feb 5-Apr

IRB submitted

IRB approval

Proposal presentation

Implementation

Social media

Allnurses

STTI

Analysis of data

DNP intensive

Dissemination at…

Dissemination

IRBsubmitted

IRBapproval

Proposal

presentation

Implementation

Socialmedia

AllnursesSTTIAnalysisof data

DNPintensive

Disseminat

ion atconference

Dissemination

Series1 25-Sep7-Oct17-Sep14-Oct14-Oct8-Nov2-Nov1-Dec13-Apr19-Feb1-Apr

Duration 22210910984901203223

Implementation Gantt Chart