The Journal of the New York State Nurses Association, Volume 48, Number 2

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THE

JOURNAL of the New York State Nurses Association

VOLUME 48, NUMBER 2

n E ditorial: Roles

by Anne Bové, MSN, RN-BC, CCRN, ANP; Audrey Graham-O’Gilvie, DNP, ACNS-BC; Meredith King-Jensen, PhD, MSN; Alsacia L. Sepulveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN; and Coreen Simmons, PhD-c, DNP, MSN, MPH, RN

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Nursing Students’ Experiences on NCLEX-RN Preparation by Susan Joseph, PhD, RN, CNE

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Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 4: Promoting Quality Nursing Care Through Better Self-Care Pilot Study Results by Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD; Lucille Contreras Sollazzo, MSN, RN-BC, NPD; and Christina Singh DeGaray, MPH, RN-BC

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Adaptation to Motherhood for Rural Women With Newborn(s) in the Neonatal Intensive Care Unit by Donna Tomasulo West, PhD, RN, FNP-BC; Pamela Stewart Fahs, PhD, RN; Geraldine R. Britton, PhD, RN, FNP; and Carolyn Pierce, PhD, RN

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What’s New in Healthcare Literature

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CE Activities: Nursing Students’ Experiences on NCLEX-RN Preparation; Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 4: Promoting Quality Nursing Care Through Better Self-Care Pilot Study Results; Adaptation to Motherhood for Rural Women With Newborn(s) in the Neonatal Intensive Care Unit



THE

JOURNAL of the New York State Nurses Association

Volume 48, Number 2

n E ditorial: Roles ................................................................................................................................................................................ 3 by Anne Bové, MSN, RN-BC, CCRN, ANP; Audrey Graham-O'Gilvie, DNP,

ACNS-BC; Meredith King-Jensen, PhD, MSN; Alsacia L. Sepulveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN; and Coreen Simmons, PhD-c, DNP, MSN, MPH, RN

n Nursing Students’ Experiences on NCLEX-RN Preparation................................................ 5 by Susan Joseph, PhD, RN, CNE

n Nurses Unions Can Help Reduce Stress, Burnout, Depression, and

Compassion Fatigue During the COVID-19 Pandemic, Part 4: Promoting Quality Nursing Care Through Better Self-Care Pilot Study Results................... 13 by Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD; Lucille Contreras Sollazzo, MSN, RN-BC, NPD; and Christina Singh DeGaray, MPH, RN-BC

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A daptation to Motherhood for Rural Women With Newborn(s) in the Neonatal Intensive Care Unit.................................................................................................................................... 34 by Donna Tomasulo West, PhD, RN, FNP-BC; Pamela Stewart Fahs, PhD, RN; Geraldine R. Britton, PhD, RN, FNP; and Carolyn Pierce, PhD, RN

n What’s New in Healthcare Literature............................................................................................................... 43 n CE Activities: Nursing Students’ Experiences on NCLEX-RN Preparation; Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 4: Promoting Quality Nursing Care Through Better Self-Care Pilot Study Results; Adaptation to Motherhood for Rural Women With Newborn(s) in the Neonatal Intensive Care Unit.................................................................................................................................... 45


THE

JOURNAL

of the New York State Nurses Association

n

The Journal of the New York State Nurses Association Editorial Board

Anne Bové, MSN, RN-BC, CCRN, ANP Clinical Instructor New York, NY

Alsacia L. Sepulveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN Registered Nurse III New York-Presbyterian Adult Emergency Department New York, NY

Audrey Graham-O’Gilvie, DNP, ACNS-BC Assistant Professor Touro College School of Nursing Hawthorne, NY

Coreen Simmons, PhD-c, DNP, MSN, MPH, RN Professional Nursing Practice Coordinator Teaneck, NJ

Meredith King-Jensen, PhD, MSN, RN Quality Management Specialist Veteran’s Administration Bronx, NY

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Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD, Co-Managing Editor Lucille Contreras Sollazzo, MSN, RN-BC, NPD, Co-Managing Editor

Christina Singh DeGaray, MPH, RN-BC, Editorial Assistant

The information, views, and opinions expressed in The Journal articles are those of the authors and do not necessarily reflect the official policy or position of the New York State Nurses Association, its Board of Directors, or any of its employees. Neither the New York State Nurses Association, the authors, the editors, nor the publisher assumes any responsibility for any errors or omissions herein contained. The Journal of the New York State Nurses Association is peer reviewed and published biannually by the New York State Nurses Association. ISSN# 0028-7644. Editorial and general offices located at 131 West 33rd Street, 4th Floor, New York, NY, 10001; Telephone 212-785-0157; Fax 212-785-0429; email info@nysna.org. Annual subscription: no cost for NYSNA members; $17 for nonmembers. The Journal of the New York State Nurses Association is indexed in the Cumulative Index to Nursing, Allied Health Literature, and the International Nursing Index. It is searchable in CD-ROM and online versions of these databases available from a variety of vendors including SilverPlatter, BRS Information Services, DIALOG Services, and The National Library of Medicine’s MEDLINE system. It is available in microform from National Archive Publishing Company, Ann Arbor, Michigan.

©2021 All Rights Reserved  The New York State Nurses Association

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Journal of the New York State Nurses Association, Volume 48, Number 2


n EDITORIAL Trust Children’s author George MacDonald (1824–1905) wrote, “To be trusted is a greater compliment than to be loved.” This issue of the Journal contains articles in which each central theme involves trust. As nurses, we may take for granted that our profession is regularly considered to be among America’s most trusted professions. How does this trusted status operate in our day-to-day work? What do patients and families gain through therapeutic, trust-based relationships with nurses? Words such as confidence, faith, energy, assurance, and safekeeping come to mind. There is power in trust. Students invest time and finances on accredited academic programs to gain entry, through licensure, into the healthcare workforce as registered nurses. In “Nursing Students’ Experiences on NCLEX-RN Preparation” the author demonstrates how addressing the unique learning styles of students strengthens a student’s chance to successfully pass the NCLEX-RN examination. Accreditation, which requires adequate NCLEX-RN pass rates, is a public and professional affirmation of trust in a school to provide nursing education, according to standards established by the nursing academic community. In this way, nursing upholds its contract with society to provide the public with adequately trained and competent nurses. Utilizing educational practices that incorporate students’ learning styles enables the nursing program to fulfill assurances to both students and accreditation body. In “Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue, Part 4: Promoting Quality Nursing Care Through Better Self-Care Pilot Study Results,” the element of trust is activated at many levels. Peer leaders learned from NYSNA educators about the potential for self-care techniques to reduce workplace stress for themselves and among their recruited peers. Trust, placed in their union, colleagues, and themselves empowers nurses to risk change and potential failure. Nurse peers willingly depend on their informal leaders’ plan and formal leaders’ support for a program in which application of self-care methods improves nurses’ lives and indirectly helps patients thrive. The article, “Adaptation to Motherhood for Rural Women With Newborn(s) in the Neonatal Intensive Care Unit” most clearly discerns the capacity for trust to enhance life changes. Here, mothers who live far from their newborns for a time, positively adapt to their new roles as they trust in those caring for their babies. This essential adaptation is life-enhancing for mother, baby, families, and society at large. The ongoing pandemic demonstrates with every successive wave how trust, and conversely breach of trust, entwine large governments and personal relationships, influencing life and death through COVID-19. Trust is a thread woven into humanity’s pursuit for better tomorrows. We hope you enjoy this issue. Meredith King-Jensen, PhD, MSN, RN Alsacia L. Sepulveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN Coreen Simmons, PhD-c, DNP, MSN, MPH, RN Audrey Graham-O’Gilvie, DNP, ACNS-BC Anne Bové, MSN, RN-BC, CCRN, ANP

Journal of the New York State Nurses Association, Volume 48, Number 2

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Nursing Students’ Experiences on NCLEX-RN Preparation Susan Joseph, PhD, RN, CNE

n A bstract Nursing educators have a crucial responsibility for maintaining first-time National Council of Licensing Examination for Registered Nurses (NCLEX-RN) pass rates and reducing the impact of a national nursing shortage. A qualitative multiple case study was conducted to explore nursing students’ experiences on NCLEX-RN preparation, including learning styles and approaches. Data were collected from nine associate degree nursing (ADN) graduates as three cases defined by years of graduation from 2011 to 2013. Kolb’s Learning Style Inventory (LSI) was used to explore the learning styles. Eight major themes emerged from the study, including learning approaches and learning styles that were used by students for NCLEX-RN preparation. Nursing students that passed NCLEX-RN on their first attempt had a deeper learning approach. Also, the specific Kolb’s learning styles of diverging, converging, and assimilating were helpful to students in passing the NCLEX-RN on their first attempt. This study provides information for nurse educators and leaders that can be used to improve NCLEX-RN pass rates. Keywords: First time NCLEX pass rate, student nurse learning style, Kolb's learning style, nurse education

Introduction Maintaining first-time National Council of Licensing Examination for Registered Nurses (NCLEX-RN) pass rates at or above the national average is a major challenge for nursing schools nationally. Both a school’s first-time pass rate and accreditation status of their nursing program are affected when a nursing student becomes unsuccessful on the NCLEX-RN (Hinderer et al., 2014; Homard, 2013). Studies have shown that most strategies to improve the NCLEX-RN outcome are the result of data gathered from the perspectives of faculty members rather than data that explore how students prepare for the licensure examination (Koestler, 2015; Schroeder, 2013). Student perspectives are fundamental aspects for program effectiveness and can be different from faculty perspectives in many areas, especially in preparation for the licensure examination. Given the problem of low NCLEX-RN pass rates and its contribution to ineffective program outcomes and the subsequent jeopardization of accreditation status, nursing shortage increases, and a weakened workforce, attention needed to be given to exploring nursing students’ experiences on preparation for licensure, including their learning styles and approaches. The chosen research location was a hospital-based nursing school in the Northeastern region of the United States with five consecutive years

of low NCLEX-RN pass rates, beginning from 2008, that jeopardized its accreditation status. Though the reason for the low pass rates was unclear, educators had implemented changes in different areas such as increasing the passing grades, reducing student enrollment, and offering remediation for students. A multiple case study was undertaken to explore NCLEX-RN preparation experiences from the students’ perspectives. Two research questions (RQs) guided the study: RQ1. What are the perceptions and experiences of associate degree nursing (ADN) graduates with learning approaches used to prepare for the NCLEX-RN? RQ2. What are the perceptions and experiences of ADN graduates with learning styles used to prepare for the NCLEX-RN?

Method Literature Review To identify the preferred learning styles and explore the students’ experiences on NCLEX-RN preparation, a comprehensive literature review was conducted for peer-reviewed articles categorized by main themes into NCLEX-RN examination, nursing workforce, strategies to promote

Susan Joseph PhD, RN, CNE Montefiore School of Nursing, Mount Vernon, New York Journal of the New York State Nurses Association, Volume 48, Number 2

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Nursing Students’ Experiences on NCLEX-RN Preparation

Student perspectives are fundamental aspects for program effectiveness and can be different from faculty perspectives.

NCLEX-RN success, predictors of NCLEX-RN success, and student learning styles. A study conducted by Chen and Lo (2015) on student satisfaction, affirmed the importance of studying students’ experiences for better program accountability. According to past studies, various external factors, including academic and non-academic issues, affect the NCLEX-RN outcome (Homard, 2013; Taylor et al., 2014); however, very limited inquiries have been done to explore nursing students’ experiences that include learning approaches and styles regarding NCLEX-RN preparation. None of the studies predominantly explored nursing students’ learning styles and learning approaches used in preparation for the NCLEX-RN (Andreou et al., 2014; Frantz & Mthembu, 2014). Moreover, Kolb (1981) endorsed the need for further discipline-specific studies to confirm students’ learning style preferences for improvement of academic disciplines. Furthermore, there are no studies existing to confirm specific learning styles used by ADN students for NCLEX-RN preparation. Nursing accreditation agencies such as the Accreditation Commission for Education in Nursing (ACEN) and the Commission on Collegiate Nursing Education (CCNE) set standards for the nursing programs to measure program efficiency and evaluate program mission and goals (Serembus, 2016; Yeom, 2013). First-time NCLEX-RN success is crucial to students, faculty, and accrediting agencies as a benchmark for nursing program quality (Salvucci, 2015; Serembus, 2016). It’s a challenge to prepare nurses to be successful on the NCLEX-RN at the first attempt with the increasing passing standards necessary to meet the minimum competencies for an entry-level registered nurse (RN) (Salvucci, 2015). According to statistics from the National Council of State Boards of Nursing (NCSBN) (2014), of 89,032 candidates who took the NCLEX-RN in the United States, only 85.54% passed the examination on their first attempt. In 2014, among 157,372 first-time, U.S.-educated graduates, 86,377 were from an ADN program and took the NCLEX-RN (NCSBN, 2014). The AACN reported that the current nursing shortage in the United States is expected to increase by 2025 and predicted the nation will require more nurses (AACN, 2014). When nursing students are unsuccessful on the NCLEX-RN, there are fewer RNs added to the workforce, exacerbating the nursing shortage as demand exceeds supply (Yeom, 2013). Teaching can be more efficient if faculty know the learning style of students (Lockie et al., 2013). The learning style is how a student grasps new information and the process to understand it, whereas a learning approach is how a student approaches a learning situation to study a new concept (Tsingos et al., 2015). To support nursing students’ success in the program and on their boards, awareness of student learning styles and learning approaches is essential. Nursing students are also unique, each with unique learning styles. Tsingos et al. (2016) claimed that a preferred learning style might affect academic performance positively if the style fits with the learning environment. 6

Nevertheless, learning approaches are methods that reveal how a student moves toward studying, whether by using superficial or in-depth learning (Tsingos et al., 2016). Howie and Bagnall (2013) analyzed Biggs and Tang’s (2007) model of learning approach and affirmed that there are two types of learning approaches comprised of surface and deep. In a surface approach to learning, students learn only the bare minimum, learning concepts required to complete the course and used a lower cognitive level while learning (Howie & Bagnall, 2013). There are many rationales why a student might use a surface learning approach, including (a) planning to achieve only a minimum grade, (b) having other priorities in life, (c) not having enough time to study, (d) having confusion over course materials and requirements, (e) taking grades too lightly, (f) having anxiety, (g) having too much to handle, or (h) lacking an ability to learn (Howie & Bagnall, 2013). A deep approach to learning is when students study meaningfully and significantly to comprehend using a superior cognitive level of learning (Howie & Bagnall, 2013). Students use a deep approach to learning by (a) focusing on the course materials in-depth, (b) relating learned concepts to one another to get the entire perspective, (c) showing an interest in the subject matter to comprehend the details, (d) feeling optimistic about the subject, and (e) being challenged to be successful (Howie & Bagnall, 2013). Some students learn in a systematic way by planning, organizing, and following a study schedule. Approaches to learning aren’t wholly responsible for students’ comprehension of new information, however a preferred learning style assists students with comprehending, grasping, and processing new information for knowledge. Li et al. (2014) acknowledged that a student’s preferred learning style is a way of obtaining new knowledge and arranging and holding on to it consistently. There are different learning style inventories (LSIs) in existence, and educators need to identify and understand different learning styles of students in order to guide their learning process (Frantz & Mthembu, 2014). Li et al. (2014) recommended Kolb’s LSI as an authentic and reliable tool to assess the ways in which a student receives and processes information. Kolb’s LSI is a self-scored assessment of 9–12 items, which identify four different learning styles, including abstract conceptualization (AC), concrete experience (CE), active experimentation (AE), and reflective observation (RO) (Lockie et al., 2013; Fogg et al., 2013; Ponto et al., 2014).

Theoretical Framework David Kolb’s (1984) experiential learning theory (ELT) was used in the study to explore nursing students’ experiences of NCLEX-RN preparation, including learning styles and learning approaches. Kolb proposed in ELT that “Learning is the process whereby knowledge is created through the transformation of experience” (Kolb, 1984, p. 38). Kolb’s ELT has been used in some education studies; however, it has rarely been used to identify nursing students’ experiences and learning styles for NCLEX-RN preparation (Poore & Cullen, 2014; Witt et al., 2013).

Research Method A qualitative research method was appropriate for this study since there is no form of quantification needed to answer the research questions. Rather, an exploration of students’ experiences and perceptions was needed to interpret the meanings of their beliefs and practices (Baškarada, 2014). A case study design is recommended by Robert Yin (2014) when an inquiry is done to comprehend profound experience,

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Nursing Students’ Experiences on NCLEX-RN Preparation

such as a school performance, small group behavior, and an institutional practice by focusing on a case to find out real-world viewpoints. “A multiple case design is a study that involves more than a single case” (Polit & Beck, 2014, p. 476). In this study, the cases were three groups of nursing students, each from a different graduating class (2011, 2012, and 2013), and the context was the nursing school. The target population was 239 ADN graduates who successfully completed the nursing program at the research location from 2011 to 2013. Since the nursing students graduated between 2011 to 2013, a period of time in which the NCLEX-RN first-time pass rate dropped at this location, they were appropriate for the study. The selection criteria for the study sample included students who successfully completed the ADN program between the spring and the fall semesters of 2011 to 2013 and who had attempted to take the NCLEX-RN at least once. A strategic and purposive sampling was used to focus on the cases’ unique context as an effective method of recruitment in this study (Miles et al., 2014). In a case study, it is typical to choose a minimum number of cases for a deep exploration of a significant phenomenon in order to get in-depth meaning of real-life events (Yin, 2014). There are qualitative studies that used sample sizes mostly ranging from five to 18 (McFarquhar, 2014; Ozturk & Guven, 2016). Therefore, this study selected nine participants who met the criteria for the study. Additionally, when the participants were interviewed, data saturation also occurred that determined the nine participants were adequate for the study.

Materials, Instruments, Data Collection, and Analysis The study instrumentation was open-ended, semi-structured interview questions to guide the interview process with research participants. The school performance report from 2011 to 2013, in particular the NCLEX-RN first-time pass rates, were collected from school’s archival data. Kolb’s LSI was purchased for each participant and the questionnaire was used before the interview to explore their preferred learning styles. By interviewing the participants, the researcher had an opportunity to gather detailed information and explanations from students, including “personal views, attitudes, perceptions, and meanings” (Yin, 2014, p. 106). Triangulation of data collected from interview, verbal, and nonverbal cues, LSI, and school documents determined the consistency of findings (Yin, 2014). The collected data were arranged and organized with the help of NVivo 11 software and other computer tools, such as word processing and Microsoft Excel, to help identify themes and patterns in the statements of the participants (Mills et al., 2014; Yin, 2014). There were three cases defined by the students’ years of graduation (2011, 2012, and 2013) and three participants in each case. Frequencies and percentages for demographic characteristics are presented in Table 1.

Findings Learning Approaches and Themes The study construct of learning approaches was explored in RQ1 and five major themes were found (Table 2).

A Study Plan Is an Important Learning Approach for NCLEX Eight participants reported they had an organized study plan, including setting aside time to practice questions, taking breaks in

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Table 1 Demographic Characteristics

Frequency (n)

Percentage (%)

Male

4

44.4

Female

5

55.6

Black

4

44.4

Latino

2

22.3

Asian

3

33.3

32

1

11.1

33

1

11.1

35

1

11.1

37

2

22.2

41

2

22.2

42

1

11.1

45

1

11.1

Married

5

55.6

Unmarried

4

44.4

Worked while in school

4

44.4

Did not work while in school

5

55.6

Passed NCLEX on first attempt

8

88.9

Passed NCLEX after multiple attempts

1

11.1

2011

3

33.3

2012

3

33.3

2013

3

33.3

Characteristic Gender

Ethnicity

Age

Marital status

Work

NCLEX-RN

Year of graduation

between, and planning for a specific number of hours to study, exercise, eat, shop, and sleep. This was illustrated by Participant 1, who said, “I had a plan for studying daily, set aside a lot of time, and I did not work during the preparation, and had a plan for studying 5 hours a day for 5 days a week.” In addition, Participant 2 stated, “I had a schedule for studying, practiced question and answers, planned for days to rest before the exam to take a mental break, and I wanted to be alone and not add anything to my life 48 hours before that exam.” Participant 6 also stated, “I had a plan to separate 4 to 5 hours for studying daily, planned to take a practice test after studying each system and then go back to the rationale for each answer before studying again. I looked at the NCLEX-RN blueprint and template from NCSBN to make my study schedule. I would

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Nursing Students’ Experiences on NCLEX-RN Preparation

Table 2 Major Themes for Research Question 1

Theme

Frequency (n)

Percentage (%)

1. A study plan is an important learning approach for NCLEX-RN.

8

88.89

2. C onstant practice of NCLEX-RN-style questions and answers is a helpful learning approach.

7

77.78

3. N ote-taking and summarizing is an effective learning approach for NCLEX-RN.

6

66.67

4. S taying focused is a learning approach for NCLEX-RN preparation.

6

66.67

5. Commitment to study is crucial while preparing for NCLEX-RN.

6

66.67

Note-Taking and Summarizing Is an Effective Learning Approach for NCLEX-RN

Note. N = 9 say today I should get through this section and these many questions. I also planned and took a break to go to the mall in between studying.” Moreover, Participant 7 reported, “Before I started studying, I set a date to take the exam, if you don’t have a date for the exam; it’s hard for me to study with a plan.”

Constant Practice of NCLEX-Style Questions and Answers Is a Helpful Learning Approach Seven participants reported that they practiced taking NCLEX-style questions either from a review book or online resources. For example, Participant 2 said, “I was a full-time employee; I did 250 to 300 questions per day during the week. On weekends, Saturdays and Sundays, I will sit at Barnes and Noble and I put all the questions that I got wrong together and review each topic, focus on area of wrong questions, and Monday again start over with practicing questions. I also practiced questions during work since I had understanding people and a good work place.” Similarly, Participant 4 stated, “I used a review book, and after reviewing contents of each systems initially for first two weeks, then I take practice exams; studying and practicing questions and answers helped me.” And Participant 5 said, “I did too much questions, finished the book, and did same questions again and again.” In addition, Participant 6 said, “I started doing questions from the beginning, sometimes it made me panic and thinking, ‘Oh my God, many hours have passed reviewing topics and I didn’t understand much.’ Then I will decide to go to practice questions and then come back to review the contents again. It can be overwhelming, especially when you are tackling a subject you are not good [at]. You don’t know even if you read it 10 times, you may still think you are not getting it. So, I hit pause on it and do the practice questions and then come back to contents. Especially with the NCLEX, you can be a good student but a bad test taker. NCLEX is a type of standardized test, so the more test questions you practice, the more you [get] used to how they are going to ask you the questions.” Similarly, Participant 7 said, “I did 120 to 150 questions and answers per day. The more I did the 8

questions, the more comfortable I was…. I also had an app on my cell phone and I used it everywhere to practice questions, at supermarket while shopping and during laundry, as I was continuously practicing and preparing for NCLEX.” Likewise, Participant 8 stated, “Practicing tests by doing questions [was] very helpful, I did 100 to 200 questions per day, and when I do the questions, I went back to text book to review the contents on the questions that I got wrong.” Participant 9 said, “I did a lot of online practice questions, rationales, and felt that the anxiety level can decrease with doing more practice questions.”

Participant 1 stated, “Just reading was not helpful for me to study. I had to take notes, a lot and lots of notes. I wrote in the books and the side of the PowerPoint notes, then I studied referring [to] my notes and I had to write repeatedly that it just stuck.” Also, Participant 2 and 8 said, “Taking notes were helpful while preparing,” and Participant 5 said, “I took notes while I was reading and that was helpful to summarize at the end.” Likewise, Participant 6 said, “While reading and reviewing, I take notes in the book so I will come back to review that topics. Also, just reading the topics is very passive to me, so I use the strategy of writing and highlighting to make it [a] more active learning experience.” In addition, Participant 7 stated, “I used a lot of writing on index cards and summarizing a lot of important lines.”

Staying Focused While Preparing for NCLEX-RN Is a Very Important Learning Approach Participant 1 stated, “I just focused on reviewing questions, not getting distracted with other life issues.” Participant 2 and 3 said, “Focusing is important. You need to focus when you study; focusing is the key that I passed NCLEX.” In addition, Participant 5 said, “I focused on reading review books, on practicing to prepare for NCLEX.” Participant 6 said, “I needed to focus on studying while preparing for NCLEX, I even got out of my house to avoid distraction, rented a hotel the night before the exam to stay focused on preparation. I ate well, relaxed, and went straight from [the] hotel to take the exam.” In a like manner, Participant 8 stated, “I tried staying focused and don’t get distracted while preparing.”

Commitment to Study Is Crucial While Preparing for NCLEX-RN. Participant 1 stated, “I had some form of commitment in studying. It is not easy, and you need the same commitment that used for the program in nursing school to be used for NCLEX too. You can do everything, but having a commitment to be prepared well is a must; otherwise you will not be successful. My theme was the school is not over until I pass NCLEX.” Likewise, Participant 3 said, “I had a commitment in preparing for NCLEX by balancing work and studies.” Participant 4 stated, “I had a commitment to study a full month by my own, not taking any review class, [I] only used review books.” And Participant 5 recommended, “Don’t take the NCLEX light; have a form of commitment to study.” Participant 7 and 9 stated, “I had a commitment and determination to pass at first time. I wanted to take NCLEX only once and pass.”

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Nursing Students’ Experiences on NCLEX-RN Preparation

Table 3 Major Themes for Research Question 2

Frequency (n)

Percentage (%)

Students need to watch and think (assimilating) while learning for NCLEX-RN.

7

77.77

Students learn by doing and thinking (converging) for NCLEX-RN.

7

77.77

Students learn by feeling and watching (diverging) while preparing for NCLEX-RN.

6

66.66

Theme

Note. N = 9

Learning Styles and Themes Three major themes emerged for RQ2 (Table 3).

Students Need to Watch and Think (Assimilating) While Learning for NCLEX-RN Participant 1 said, “For me, I did two things: watched a lot of videos, especially after clinical I go home, and watch YouTube videos and think again to make sure that what I learned is right.” Similarly, Participant 2 stated, “I recorded all my lectures, reviewed and listened [to] all my recorded lectures, and I listened [to] the lectures again and again.” Also, Participant 4 said, “I mostly watch an interactive video, animations, and cartoons to think and understand the material.” In contrast, Participant 4 stated, “I didn’t like YouTubes, but only used it to learn procedures.” Similarly, Participant 5 said, “I used interactive case studies like patient is coming with something and what I should do to take care of those patients and such scenarios.” In addition, Participant 6 said, “I learned through simulation specifically on how to put protective equipment and there was question about it on NCLEX.” Participant 8 said, “I am a visual learner. I have to watch to learn.” Likewise, Participant 9 said, “I watched a lot of YouTube video clips and online medical clips that were available.”

Students Learn by Doing and Thinking (Converging) for NCLEX-RN Participant 1 said, “In order to understand the information while learning, I used critical thinking strategies and I had a good anatomy and physiology foundation that helped me to know the basic information, and think critically. You need a solid, basic knowledge to understand the nursing concepts.” Participant 3 stated, “To gather and understand information, I did a lot of thinking and recalling what I learned in medical-surgical and basics nursing courses, to understand why my answer is right or wrong and the rationale. I also tied what I am reading to procedures.” Likewise, Participant 4 said, “To gather information for learning, I focused on what I need to concentrate especially on each system, reviewing the class materials and notes, thought different ways to get information on topics.” Participant 5 said, “I concentrated on books for gathering information and do lots of critical thinking exercises from the book.” Additionally, Participant 6 stated, “In terms of actually understanding what to learn…doing [a] care map

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was a great resource for me. And I used critical thinking to connect the dots and think why I am putting different parts of a care map.” Similarly, Participant 7 said, “I had to think why my answer is wrong when I do practice question.” Participant 9 stated, “Though I used practice questions, I gathered information from different books and went to the explanations and rationales for answers to think why my answers were wrong.”

Students Learn by Feeling and Watching (Diverging) While Preparing for NCLEX-RN Participant 2 said, “When I don’t understand, I will look at the information with imaginations and watch more information from YouTubes or interactive simulation videos. [I] also gathered information from coworkers who were more experienced.” Similarly, Participant 3 said, “When I don’t understand things, I think an alternate way of gathering more information on the topic such as visualizing the topics and solve the confusion.” Participant 5 said, “I gathered information from books mainly, and when I have problems to understand, I used interactive videos.” Similarly, Participant 6 said, “When I need additional information, I googled, went to text books, videos, and websites to see detailed information.” Participant 7 stated, “I tried to gather information from different sources. Also, I watched people during my externship on the medical-surgical floor. I spoke to different people to know different points of view.” Similarly, Participant 9 said, “When I don’t understand something, I asked my doubts to peers, teachers, and friends. And my experience in medical-surgical clinical rotation helped me to imagine the practical aspects. I also watched YouTubes, video clips on various medical contents when I needed more information.”

Limitations This study was a multiple case study at a single ADN program; therefore, the findings may not be generalized to other programs including bachelor’s degree in nursing because of the use of various teaching and learning strategies and diverse student population in other nursing programs. This study focused on the participants’ experience on NCLEX-RN preparation, including specific learning styles and approaches of the graduates that will not take in to account any other variables that may have affected their NCLEX-RN outcomes.

Implications and Recommendations The implications of the study results may be important to nursing educators in providing future students the necessary guidance, advice, remediation, and recommendations on NCLEX-RN preparation. This study filled a gap in the literature through participant perceptions on learning approaches and learning styles used by ADN students for NCLEX-RN preparation. The theoretical lens used to analyze RQ2 was Kolb’s theory of experiential learning that proposed that learning is the process whereby knowledge is created through the transformation of experience (Kolb, 1984, p. 38).

Learning Approach Implications The implications of having a study plan and schedule allowed nursing students to become more organized to study by using a deep approach to learning and reinforced student success in the program and on the

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Nursing Students’ Experiences on NCLEX-RN Preparation

NCLEX-RN by improving study and time management skills (Maile & Akir, 2012). The nursing students who practiced NCLEX-style questions regularly became familiarized with the type of questions, increased their language skills, alleviated fear and test anxiety, improved test-taking abilities, comprehension, confidence, and knowledge inorder to pass the NCLEX-RN (Blozen, 2015; Davis, 2016; Homard, 2013; McFarquhar, 2014). Note-taking and summarizing the concepts while studying helped nursing graduates to be successful on the NCLEX-RN (Nelson, 2016; Nugent & Vitale, 2016). The nursing students who used note-taking and summarizing techniques as a key learning approach improved critical thinking skills, learning performance, and helped them to understand the concepts clearly for success on the NCLEX-RN (Chan, 2012; Nelson, 2017; Nakayama et al., 2017). Staying focused on academic goals decreased students’ barriers to NCLEX-RN success. Though the students needed to make modifications in their life routines inorder to focus on course material in depth, learning was meaningful and active (Davis, 2016; Sandvik et al., 2014). The commitment of nursing students to studying was critical to balancing the demands of their professional education, made a better academic outcome, and helped to pass the NCLEX-RN on a first attempt (Clements et al., 2016; Sandvik et al. 2014).

Learning Style Implications The three major themes that emerged from RQ2 supports the ELT model that the main process of learning is by grasping and transforming experience into knowledge (Kolb, 1984). The nursing students prepared for the NCLEX-RN using an assimilating learning (watching and thinking) style that included grasping the information by watching and transforming it into knowledge by thinking (Kolb, 1984). The students who used a converging learning style passed the NCLEX-RN when they used problem-solving and decision-making skills through a thinking and doing learning style (Chan, 2012; Kolb, 1984). The students with diverging style rationalized the information using their judgment, practical explorations, and different viewpoints during preparation to pass the NCLEX-RN (Andreou et al., 2014); and when students rationalized the information using their judgment and explorations, they were combining practice and reflection (Kolb, 2000; Kolb & Kolb, 2005). Nursing students in this sample showed a deeper approach to learning and specific learning styles helped them pass the NCLEX-RN on their first attempt. Research shows that nursing educational leaders and educators need to

10

The Kolb’s learning styles of diverging, converging, and assimilating were helpful to students in passing the NCLEX-RN on their first attempt.

encourage and support nursing students to take a deeper approach to learning during the program and in preparation for the NCLEX-RN. When students used a deep learning approach they studied meaningfully and significantly to comprehend the concepts using a higher cognitive level of learning (Howie & Bagnall, 2013). The research also shows that nursing education leaders should plan mandatory study strategy seminars that include training students in effective learning approaches.

Recommendations and Summary Recommendations for nursing education are: (a) provide study strategy seminars, (b) begin an NCLEX-RN Review Center that would provide opportunities for students to practice unlimited NCLEX-RN-style questions, (c) include higher cognitive level questions that use application, analysis, and evaluation levels on the course examinations, and (d) imitate NCLEXstyle questions on course exams to increase student confidence levels for passing NCLEX-RN (Blozen, 2014; Davis, 2016; Homard, 2013; McFarquhar, 2014). Additional recommendations to improve the first-time pass rate are: (a) extend NCLEX-RN support for graduating students until they pass the NCLEX-RN, and (b) identify the students’ preferred learning styles (D’ Amore et al., 2012; Ponto et al. 2015). Further, identifying the preferred learning styles of students using Kolb’s (1984) ELT will surely assist nursing students in grasping the concepts well and transforming them into new knowledge for passing the NCLEX-RN (Lockie et al., 2013; Ponto et al., 2015). The findings of this study indicate that the Kolb’s learning styles of diverging, converging, and assimilating were helpful to students in passing the NCLEX-RN on their first attempt. Additionally, nursing students need to use a deeper approach to learning when preparing for NCLEX-RN because students who passed the NCLEX-RN on their first attempt employed a deep-learning approach.

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Kolb, A. Y., & Kolb, D. A. (2005). Learning styles and learning spaces: Enhancing experiential learning in higher education. Academy of Management Learning & Education, 4(2), 193–212. https://doi. org/10.5465/AMLE.2005.17268566 Kolb, D. A. (1981). Learning styles and disciplinary differences. The Modern American College, 232–255. Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development. Prentice-Hall. Kolb, D. A. (2000). Facilitator’s guide to learning. Hay/McBer. Li, Y., Yu, W., Liu, C., Shieh, S., & Yang, B. (2014). An exploratory study of the relationship between learning styles and academic performance among students in different nursing programs. Contemporary Nurse: A Journal for the Australian Nursing Profession, 48(2), 229–239. https://doi.org/10.5172/conu.2014.48.2.229

Clements, A. J., Kinman, G., Leggetter, S., Teoh, K., & Guppy, A. (2016). Exploring commitment, professional identity, and support for student nurses. Nurse Education in Practice, 16, 20–26. https://doi. org/10.1016/j.nepr.2015.06.001

Lockie, N. M., Van Lanen, R. J., & Gannon,T. M. (2013). Educational implications of nursing students’ learning styles, success in chemistry, and supplemental instruction on NCLEX-RN performance. Journal of Professional Nursing, 29(1), 49–58. https://doi.org/10.1016/j. profnurs.2012.04.003

D’Amore, A., James, S., & Mitchell, E. K. (2012). Learning styles of firstyear undergraduate nursing and midwifery students: A cross-sectional survey utilizing the Kolb Learning Style Inventory. Nurse Education Today, 32, 506–515. https://doi.org/10.1016/j.nedt.2011.08.001

Malie, S., & Akir, O. (2012). Bridging the gaps between learning and teaching through recognition of students’ learning approaches: A case study. Research in Education, 87(1), 75–94. https://doi.org/10.7227/ RIE.87.1.6

Davis, J. H. (2016). Faculty roles and processes for NCLEX-RN outcomes: A theoretical perspective. Teaching and Learning in Nursing. https:// doi.org/10.1016/j.teln.2016.07.001

McFarquhar, C. (2014). Lived experiences of failure on the national council licensure examination—registered nurse (NCLEX-RN): Perceptions of registered nurses. International Journal of Nursing Education, 6(1), 10–14. https://doi.org/10.5958/j.0974-9357.6.1.003

Fogg, L., Carlson-Sabelli, L., Carlson, K., & Giddens, J. (2013). The perceived benefits of a virtual community: Effects of learning style, race, ethnicity, and frequency of use on nursing students. Nursing Education Perspectives, 34(6), 390–394. https://doi.org/10.5480/11526.1 Frantz, J., & Mthembu, S. (2014). Learning styles among nursing students, the implications for higher education institutions: A systematic review. South African Journal of Higher Education, 28(6), 1814–1829. Hinderer, K. A., Dibartolo, M. C., & Walsh, C. M. (2014). HESI admission assessment (A2) examination scores, program progression, and NCLEX-RN success in baccalaureate nursing: An exploratory study of dependable academic indicators of success. Journal of Professional Nursing, 30(5), 436–442. https://doi.org/10.1016/j. profnurs.2014.01.007 Homard, C. M. (2013). Impact of a standardized test package on exit examination scores and NCLEX-RN outcomes. Journal of Nursing Education, 52(3), 175–178. https://doi.org/10.3928/0148483420130219-01

Miles, M. B., Huberman, A. M., & Saldaña, J. (2014). Qualitative data analysis: A methods sourcebook (3rd ed.). Sage. Nakayama, M., Mutsuura, K., & Yamamoto, H. (2017). The possibility of predicting learning performance using features of note-taking activities and instructions in a blended learning environment. International Journal of Educational Technology in Higher Education, 14(1), 1–14. https://doi.org/10.1186/s41239-017-0048-z National Council of State Boards of Nursing. (2014a). Exam statistics and Publication. https://www.ncsbn.org/1232.htm National Council of State Boards of Nursing. (2014b). NCLEX-RN Pass Rate. https://www.ncsbn.org/Table_of_Pass_Rates_2014.pdf Nelson, A. E. (2017). Methods Faculty Use to Facilitate Nursing Students’ Critical Thinking. Teaching and Learning in Nursing, 12, 62–66. https://doi.org/10.1016/j.teln.2016.09.007 Nugent, P., & Vitale, B. (2016). Test success: Test-taking techniques for beginning nursing students (7th ed.). F.A. Davis Company.

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Ozturk, T., & Guven, B. (2016). Evaluating students’ beliefs in problem solving process: A case study. Eurasia Journal of Mathematics, Science & Technology Education, 12(3), 411–429. https://doi. org/10.12973/eurasia.2016.1208a Polit, D. F., & Beck, C. T. (2014). Essentials of nursing research: Appraising evidence for nursing practice (8th ed.). Wolters Kluwer Lippincott Williams & Wilkins. Ponto, M. M., Ooms, A., & Cowieson, F. (2014). Learning styles and locus of control in undergraduate medical, nursing, and physiotherapy students: A comparative study. Progress in Health Sciences, 4(1), 172–178. Poore, J. A., Cullen, D. L. (2014). Featured article: Simulation-based interprofessional education guided by Kolb’s experiential learning theory. Clinical Simulation in Nursing, 241–247. https://doi. org/10.1016/j.ecns.2014.01.004 Salvucci, C. (2015). A comparison of associate degree nursing students’ Kaplan diagnostic examination® scores to first time NCLEX-RN outcomes. Teaching and Learning in Nursing, 10112–10117. https:// doi.org/10.1016/j.teln.2015.04.002 Sandvik, A., Eriksson, K., & Hilli, Y. (2014). Becoming a caring nurse: A Nordic study on students’ learning and development in clinical education. Nurse Education in Practice, 14(3), 286–292. https://doi. org/10.1016/j.nepr.2013.11.001

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Schroeder, J. (2013). Improving NCLEX-RN pass rates by implementing a testing policy. Journal of Professional Nursing, 29(1), 43–47. https:// doi.org/101016/j.profnurs.2012.07.002 Serembus, J. F. (2016). Improving NCLEX first-time pass rates: A comprehensive program approach. Journal of Nursing Regulation, 6, 38–44. https://doi.org/10.1016/S2155-8256(16)31002-X Taylor, H., Loftin, C., & Reyes, H. (2014). First-time NCLEX-RN pass rate: Measure of program quality or something else? Journal of Nursing Education, 53(6), 336–41. https://doi.org/10.3928/0148483420140520-02 Tsingos, C., Bosnic-Anticevich, S., & Smith, L. (2015). Review article: Learning styles and approaches: Can reflective strategies encourage deep learning? Currents in Pharmacy Teaching and Learning, 7, 492–504. https://doi.org/10.1016/j.cptl.2015.04.006 Witt, J., Colbert, S., & Kelly, P. J. (2013). Training clinicians to be preceptors: An application of Kolb’s theory. The Journal for Nurse Practitioners, 9, 172–176. https://doi.org/10.1016/j.nurpra.2012.07.031 Yeom, Y. (2013). An investigation of predictors of NCLEX-RN outcomes on the first-attempt among standardized tests. Nurse Education Today, 33(12), 1523. https://doi.org/10.1016/j.nedt.2013.04.004 Yin, R. (2014). Case study research: Design and methods (5th ed.). Sage Publishing.

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Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue, Part 4: Promoting Quality Nursing Care Through Better Self-Care Pilot Study Results Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD Lucille Contreras Sollazzo, MSN, RN-BC, NPD Christina Singh DeGaray, MPH, RN-BC

n A bstract

Background: Workplace stress contributes to nurses’ adverse health, burnout, depression, and compassion fatigue. Better quality of nursing care may be achieved through better self-care. Objective: We aim to contribute to a better understanding of the impact of stress on nurses while testing a peer-led stress-reduction program of self-care exercise. We sought to discern how participation in self-care exercises influences the experience of stress on nurses within their work environment. Design: A quantitative descriptive survey design with a qualitative component was utilized. Nurses participated in a conference on alternative stress-reduction modalities, held by the New York State Nurses Association in December 2019. These leaders returned to hospital units, recruited colleagues to incorporate self-care exercises such as aromatherapy, deep-breathing, self-Reiki/ therapeutic touch/ crystals, meditation, yoga, and stretching into the daily routines of nurses during a 4-week, self-care exercise pilot program. Participants: Nineteen registered nurses, including six nurses’ union leaders, from various nursing specialty units in private and public sector hospitals in New York State participated. Measurements: The NYSNA Promoting Quality Nursing Care Through Better Self-Care Pilot Study Survey included a 38-item self-report questionnaire, completed prior to and following program participation. Weekly journal entries tracked the exercise modality used and the frequency of utilization. Self-reflection journal entries documented the impact of self-care on stress, and the impact on work productivity. Findings: The Wilcoxon signed-rank test produced a statistically significant difference in the number of days mental health was “not good” between the pre- and post-intervention periods (z = -2.38, p = .017), indicating that self-care exercise usage may have contributed to improved mental health. However, limitations due to small participant number, short-term study duration, and instrument specificity restrict data interpretation and generalizability of results. The most commonly reported symptoms among those who experienced adverse health effects due to job stress were headaches and/or body aches and sleep disruption. Conclusion: Reduced stress may be achieved through simple, peer-led self-care exercises. This pilot study demonstrates the positive influence of self-care on well-being, and calls for further randomized controlled trials and studies, with a particular focus on the mental health variables for hospital-based nurses. Keywords: stress, pilot study, stress-reducing intervention, work-stress impact on nurse health, contractual agreement, peer-led hospital intervention, nurse self-care

Carol Lynn Esposito, EdD, JD, MS, RN-BC, NP; Lucille Contreras Sollazzo, MSN, RN-BC, NPD; and Christina Singh DeGaray, MPH, RN-BC Nursing Education and Practice, New York State Nurses Association, New York, New York Journal of the New York State Nurses Association, Volume 48, Number 2

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n Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue, During the COVID-19 Pandemic, Part 4 Self-Care Dynamic relationship[s] among union, nurse, employer, and patients places frontline nurse member leaders in the unique position to identify, prioritize, and tackle workplace challenges which, in turn, improve work life for themselves, their unit, the bargaining unit, the organization, and patients served.

The World Health Organization defines self-care as “the ability of individuals, families, and communities to promote, maintain health, prevent disease, and to cope with illness with or without the support of a health care provider” (World Health Organization, 2014, p. 15). Coping behaviors can significantly improve occupational stress and mental health (Mark & Smith, 2012). Thus, self-care strategies can help nurses reduce stress and live happier, healthier lives. There are a number of factors which may be facilitators or barriers to nurses’ participation in self-care (Ross et al., 2019).

Background and Significance

Introduction The authors have been studying and reporting on workplace stress among New York State Nurses Association (NYSNA) member participants (Contreras Sollazzo & Esposito, 2020; Esposito et al., 2020). This article is the fourth in a series to address this serious challenge and opportunity to improve nurses’ experiences dealing with stress. In this segment, we report methods and results of a member-driven pilot project which sought to reduce workplace stress and its many consequences utilizing self-care exercises that can be implemented on the job.

Nursing Practice Environment, Staffing, and Staff Mix Certain characteristics form the complex web of nurses’ work life within hospitals. The nursing practice environment is “the organizational characteristics of a work setting that facilitate or constrain professional nursing practice” (Lake, 2002, p. 178). The most commonly used measure (Swiger et al., 2017) of the nursing practice environment is the Practice Environment Scale of the Nursing Work Index (PES-NWI) (Lake, 2002). The scale consists of 31 items encompassing five subscales. The five subscales are Nurse Participation in Hospital Affairs; Nursing Foundations for Quality of Care; Nurse Manager Ability, Leadership, and Support of Nurses; Staffing and Resource Adequacy; and Collegial Nurse-Physician Relations (Lake, 2002). The nurse practice environment is an arena where nurse, organization, and patients experience various phenomena such as varied nurse sleep quality and wellness (Hong et al., 2020), perceptions of quality of care (Gensimore et al., 2020; Zuniga et al., 2015), and quality end-of-life care (Lasater et al., 2019). The blend of the kinds of healthcare providers, along with nurses who care for patients, is known broadly as staff mix. There is wide variation of staffing and staff mix (Sharma et al, 2016). Sufficient nurse staffing contributes to lower nurse stress (Wheelock et al., 2015) and allows for better patient outcomes and reduced healthcare costs (Lasater et al., 2021).

Workload There are a number of definitions for the concept of nursing workload (Alghamdi, 2016; Morris et al., 2006). That proposed by Swiger et al. (2016), “the amount of time and physical and/or cognitive effort required to accomplish direct patient care, indirect patient care, and non-patient care activities,” seems applicable. Excessive workload acts as a stressor for nurses (Turan et al., 2020; Wheelock et al., 2015) and can lead to fatigue (Han et al., 2014) and intention to leave the profession (Huiyun et al., 2017). 14

Nurses’ unions fundamentally support the well-being of nurses in many ways. Collective bargaining strives to secure fair compensation and quality work environments. Nurses’ bargaining unit involvement within their facilities and within the larger NYSNA organization offers nurses meaningful avenues for personal and professional growth. Members are encouraged to grow through continuing education, political action, and advocacy for vulnerable patients and communities. This dynamic relationship among union, nurse, employer, and patients places frontline nurse member leaders in the unique position to identify, prioritize, and tackle workplace challenges which, in turn, improve work life for themselves, their unit, the bargaining unit, the organization, and patients served. Staff nurses are exposed to stressful circumstances. The blend of circumstances include physical workload and psychological stress (Hämmig, 2020), work demands, emotional pressure, and interpersonal relations (Ueno et al., 2017). Several large studies examine the presence of nurse occupational stress, studying determinants and consequences for the nurse, organizations, and patients. Prevalence of stress among nurses working in hospital-based settings prior to the COVID-19 pandemic was high (Dong et al., 2017; Gu et al., 2019). Nearly one-third of nurses have experienced psychological symptoms from stress, including depression, anxiety, and sleep disturbances during the COVID-19 pandemic (Al Maqbali, et al., 2021; Wu et al., 2021) that have affected their quality of life (Çelmeçe & Menekay, 2020). Simply working as a nurse, particularly in acute care, is associated with poor psychological (Obročníková et al., 2015), physical health (Weyers et al., 2005), and sleep disruption (Dong et al., 2017; Hämmig et al., 2020). These impairments to health often manifest themselves as depression, anxiety, somatic symptoms (Gu et al., 2019), musculoskeletal injury (Hämmig, 2020), and bodily damage at the cellular level through oxidative processes (Biganeh et al., 2021). Experiences of acute stress disorder may lead to post-traumatic stress for many nurses. If left unchecked, damage to individuals and nursing staff lead to reduced job satisfaction (Muhawish et al., 2019), burnout (Rudman et al., 2020), compassion fatigue, impaired work performance, impaired personal relationships, resignation, and leaving the nursing profession. Consequences of workplace stress are not limited to the nurse. Workplace stress is consistently found to indirectly threaten patient safety. Nurses’ experience of emotional demands and emotional abuse are risk factors which lead to cognitive stress symptoms and consequent difficulties with concentration and decision-making (Elfering et al., 2017). Nursing role stressors such as excessive patient load and stressed interpersonal relations

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Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue, During the COVID-19 Pandemic, Part 4

were found to correlate with reported adverse events (Kakemam et al., 2019). Operational within an organization, and seemingly self-perpetuating in nature, this stress leads to high nurse turnover (Halter et al., 2017; Yang et al., 2017), absenteeism, high vacancy rate, chronic staff shortages, and associated costs to employers. Fortunately, much can be done to effectively prevent or mitigate workplace stress. Systematic review on the effectiveness of interventional stress-management programs for nurses determined that interventional programs reduce nurse stress and promote stress-coping strategies (Alkhawaldeh et al., 2020). Coping self-efficacy (Shahrour & Dardas, 2020) and self-care protect against the effects of stress. Improvements in quality of work life for nurses enhances quality health outcomes and reduces health system costs (Horrigan et al., 2013). Stress-reduction strategies include brief personal intervention, such as diaphragmatic or deep breathing (Hopper et al., 2019), mindfulness (Lin et al., 2019; Rodriguez-Vega et al., 2020), and meditation (Rangasamy et al., 2019). Support from coworkers and supervisors may reduce fatigue (Han et al., 2014) and buffer against the burnout-depression link (Weigl et al., 2016). The purpose of this study was to examine whether peer-led stressreduction practices could improve self-reported measures of stress among acute care nurses. Additionally, we wanted to measure the relationship, if any, between participation in a stress-reduction program and self-reported physical and mental health.

Study Aims The purpose of this pilot study was to ask: 1. Do brief exercises practiced by nurses (aromatherapy, deep-breathing, self-Reiki/therapeutic touch, crystals, meditation, yoga, and/or stretching) on the job decrease stress, emotional, and/or physical experiences of the working nurse? 2. What are the top-3 stressors nurses face on a daily basis on the job? 3, What did practice focus group (PFG) leaders describe as barriers to nurse engagement in stress-reduction exercises? 4. Was there a change in symptoms attributed to work-related stress and their prevalence before and after stress-reduction participation?

Methods Participants and Design of Study This study employed a non-experimental descriptive design with informal qualitative analyses. “Qualitative-naturalistic-phenomenological field methods of inquiry or a combined qualitative-quantitative inquiry are in keeping with the Theory of Human Caring” (Watson, 1985 as cited in Fawcett & DeSanto-Madeya, 2013, p. 411).

n

Improvements in quality of work life for nurses enhances quality health outcomes and reduces health system costs.

Six attendees volunteered to become PFG leaders. These leaders returned to their units and recruited 13 additional nurses, bringing the total number of participants in this convenience sample to 19. Leaders discussed the implementation of a stress-reduction program using these techniques and secured permission for the project from their unit’s supervisor. As participation was voluntary, consent was implied through participation. Prior to and after implementing the program, nurses completed the NYSNA Staffing and Job Stress Survey (Appendix 1). A 38-item survey created by the New York State Nurses Association included descriptive statistics as well as items from the NIOSH Quality of Work Life Survey (NIOSH, 2013), survey by Lake (2002), and survey by Aiken, et. al, (Aiken et al., 2010; Aiken, 2010). During the 4-week program, participants filled out weekly questionnaires (Appendix 2), indicating which technique(s) were utilized and providing some qualitative feedback to open-ended questions. Participants were asked to describe the impact self-care exercises had on stress and anxiety for each modality used. They were asked about their overall experience of self-care sessions as well as how the sessions impacted their work at the hospital on the same day. To evaluate staff mix, workload and nursing practice environment characteristics, and impact on health prior to and following intervention, frequencies and means were calculated for study variables. Simple frequency data is reported for self-care utilization. Differences in percentages were calculated for symptom prevalence, causes of stress on participants’ units, and actions taken to protest inadequate staffing. Descriptive statistics were tabulated. Data were analyzed using the IBM Statistical Package for the Social Sciences software, Version 26. The difference between pre- and post-intervention for the “number of days physical or mental health was not good” was computed using the Wilcoxon signed-rank test. It is a non-parametric test for group differences between variables measured at least at the ordinal level, appropriate for the small sample size with non-normal distribution. It takes the numerical data by participant and identifies the pairs of pre- and post-intervention responses as +, -, or = to each other. It sums the positive and negative ranks and generates a test statistic. Then it tests whether there is a statistically significant difference between pre- and post-intervention scores for the number of days, in the past 30 where the participant felt their physical or mental health was “not good.” Participants in this study received no compensation for participation. Consent was implied through voluntary participation.

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n Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue, During the COVID-19 Pandemic, Part 4

Results Table 1 Description of Study Participants

Demographics (n) = 19

Pre-intervention % (n)

Mean (SD), range

Post-intervention % (n)

Gender Female

94.7 (18)

Male

0.0 (0)

Non-binary

5.3 (1)

Age, y

41.1 (10.3), 25–61

Length at present job, y

5.3 (6.2), < 1–24

Educational degree

789.0

Associate

31.6 (6)

Bachelor’s

52.6 (10)

Master’s

15.8 (3)

Shift worked Day

73.7 (14)

66.7 (12)

Evening

10.5 (2)

16.7 (3)

Night

5.3 (1)

5.6 (1)

Other

10.5 (2)

11.1 (2)

8 hours

36.8 (7)

27.8 (5)

10 hours

15.8 (3)

16.7 (3)

12 hours

47.4 (9)

50.0 (9)

0.0 (0)

5.6 (1)

Shift length

Other Extra hours beyond usual schedule per week Pre-intervention

5.1 (6.2), 0–24

Post-intervention

6.1 (6.8), 0–24

Study Participants

Staff Mix, Workload, Practice Environment

The majority of participants (Table 1) were baccalaureate-educated (52.6%) females (94.7%), mean age 41 years, ranging from 25 to 61 years of age. The average length at present job was 5.3 years, ranging from less than 1 year to 24 years. Most participants worked 12-hour (47.4%) day shifts (73.7%). Nurses worked an average of 5.1 hours pre- and 6.1 hours post-intervention beyond their usual work schedule.

Responses depicted in Table 3 indicate that frequently, staffing is inadequate and did not facilitate doing everything well, and was a source of stress for most nurses. Following intervention, more nurses agreed that their workload caused them to miss changes in patients’ conditions. Not having a full complement of staff remained a source of stress for most nurses, but to a lesser degree.

Characteristics of the Staffing Process A review of Table 2 shows there was no overall change in the description of staffing grids or nurse-to-patient ratios following the intervention. Approximately half of the participating nurses had a staffing grid or nurse-to-patient ratio on their unit that was upheld 29.4% of the time. The majority of nurses did not know whether there was a process for modifying the staffing grid or ratio to account for census and acuity changes. It was reported that hospitals do not fill vacancies promptly. Orientation and preceptorship for newly hired staff is generally reported as adequate. 16

Impact on Health (Physical, Mental, Sleep) The percentage of nurses who often experienced trouble falling or staying asleep (Table 4) improved, dropping from 21.1% to 5.6%. The Wilcoxon signed-rank test (Table 7) showed that there was a statistically significant difference between the pre- and post-intervention periods (z = -2.38, p = 0.017) for mental health. This shows that the intervention was worthwhile, possibly improving mental health. However, the Wilcoxon signed-rank test indicated no significant change in physical health.

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Table 2 Staffing Process Prior to and Following Intervention

Variable Do you have a staffing grid or nurse-to-patient ratio on your unit?

Is the ratio or staffing grid upheld?

Is there a process for modifying agreed upon staffing grids or nurseto-patient ratios to account for census and acuity changes?

The hospital fills all vacancies promptly.

Is there a process to adequately orient newly hired staff?

Is there a process to adequately precept newly hired staff?

Response

Pre-intervention % (n) Post-intervention % (n)

Yes

50.0 (9)

43.8 (7)

No

50.0 (9)

56.3 (9)

Yes

29.4 (5)

25.0 (4)

No

17.6 (3)

18.8 (3)

N/A

52.9 (9)

56.3 (9)

Yes

6.3 (1)

5.9 (1)

No

18.8 (3)

41.2 (7)

Don’t know

75.0 (12)

47.1 (8)

Yes

16.7 (3)

23.5 (4)

No

77.8 (14)

52.9 (9)

Don’t know

5.6 (1)

23.5 (4)

Yes

78.9 (15)

94.4 (17)

No

15.8 (3)

5.6 (1)

Don’t know

5.3 (1)

0.0 (0)

Yes

72.2 (13)

83.3 (15)

No

22.2 (4)

11.1 (2)

Don’t know

5.6 (1)

5.6 (1)

Table 3 Staff Mix, Workload, Practice Environment Prior to and Following Intervention

Variable

I have too many patients to do everything well.

How often are there not enough RNs to get all work done?

How often are there not enough ancillary staff to get all work done?

How often are there not enough MDs to get all work done?

Response

Pre-intervention % (n)

Post-intervention % (n)

Strongly agree

15.8 (3)

6.3 (1)

Agree

36.8 (7)

50.0 (8)

Disagree

42.1 (8)

37.5 (6)

Strongly disagree

5.3 (1)

6.3 (1)

Often

36.8 (7)

33.3 (6)

Sometimes

47.4 (9)

38.9 (7)

Rarely

10.5 (2)

22.2 (4)

Never

5.3 (1)

5.6 (1)

Often

58.8 (10)

47.1 (8)

Sometimes

23.5 (4)

23.5 (4)

Rarely

5.9 (1)

5.9 (1)

Never

11.8 (2)

23.5 (4)

Often

11.1 (2)

5.6 (1)

Sometimes

38.9 (7)

38.9 (7)

Rarely

38.9 (7)

27.8 (5)

Never

11.1 (2)

27.8 (5)

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n Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue, During the COVID-19 Pandemic, Part 4 Table 3 Continued

Variable I usually receive enough help to get my job done.

Adequate ancillary staff allows me to spend enough time with my patients.

I have enough time and opportunity to discuss patient care problems with other nurses and physicians.

Not having a full complement of staff is a source of stress for me.

There are enough RNs on my unit for quality patient care.

My workload sometimes causes me to miss changes in patients’ conditions.

Is being floated off your unit a cause of stress?

Is having staff floated onto your unit a cause of stress?

18

Response

Pre-intervention % (n)

Post-intervention % (n)

Strongly agree

5.3 (1)

5.9 (1)

Agree

52.6 (10)

47.1 (8)

Disagree

31.6 (6)

29.4 (5)

Strongly disagree

10.5 (2)

17.6 (3)

Strongly agree

63.2 (12)

50.0 (8)

Agree

31.6 (6)

43.8 (7)

Disagree

5.3 (1)

0.0 (0)

Strongly disagree

0.0 (0)

6.3 (1)

Strongly agree

10.5 (2)

16.7 (3)

Agree

42.1 (8)

38.9 (7)

Disagree

36.8 (7)

38.9 (7)

Strongly disagree

16.1 (2)

5.6 (1)

Strongly agree

42.1 (8)

17.6 (3)

Agree

42.1 (8)

64.7 (11)

Disagree

15.8 (3)

11.8 (2)

Strongly disagree

0.0 (0)

5.9 (1)

Strongly agree

10.5 (2)

11.8 (3)

Agree

47.4 (9)

52.9 (11)

Disagree

42.1 (8)

29.4 (2)

Strongly disagree

0.0 (0)

5.9 (1)

Strongly agree

0.0 (0)

0.0 (0)

Agree

26.3 (5)

56.3 (9)

Disagree

57.9 (11)

25.0 (4)

Strongly disagree

15.8 (3)

18.8 (3)

Often

5.6 (1)

6.3 (1)

Sometimes

22.2 (4)

25.0 (4)

Rarely

27.8 (5)

31.3 (5)

Never

44.4 (8)

37.5 (6)

Often

5.6 (1)

5.9 (1)

Sometimes

27.8 (5)

35.3 (6)

Rarely

27.8 (5)

17.6 (3)

Never

38.9 (7)

41.2 (7)

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Table 4a Impact on Health (Physical, Mental, Sleep) Prior to and Following Intervention

Variable My stress level at work has negatively affected my health.

Have you experienced adverse health effects due to job stress? During the past 12 months, how often have you had trouble falling asleep or staying asleep?

Response

Pre-Intervention % (n)

Post-Intervention % (n)

Strongly agree

21.1 (4)

16.7 (3)

Agree

52.6 (10)

50.0 (9)

Disagree

26.3 (5)

33.3 (6)

Strongly disagree

0.0 (0)

0.0 (0)

Yes

63.2 (12)

55.6 (10)

No

36.8 (7)

44.4 (8)

Often

21.1 (4)

5.6 (1)

Sometimes

31.6 (6)

33.3 (6)

Rarely

42.1 (8)

50.0 (9)

Never

5.3 (1)

11.1 (2)

Table 4b Impact on Health: The Number of Days Participants Felt Unwell During 30 Day Periods Prior to and Following Intervention

n

Pre-Intervention Mean (SD), Range

n

Post-Intervention Mean (SD), Range

Thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 was your physical health not good?

19

5.4 (8.3), 0–30

17

5.7 (6.8), 0–30

Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 was your mental health not good?

19

4.8 (4.4), 0–15

17

3.9 (4.4), 0–10

Variable

Table 5 Stress Reduction, Actions Taken

Variable Is there a nurse stress-reduction program at your workplace? If yes, have you participated in it?

Table 6 Self-Care Exercise Utilization

PrePostResponse intervention intervention % (n) % (n) Yes

22.2 (4)

23.5 (4)

No

77.8 (14)

76.5 (13)

Yes

23.5 (4)

25.0 (4)

No

11.8 (2)

18.8 (3)

Not applicable

64.7 (11)

56.3 (9)

Self-care exercise

Week 1 Week 2 Week 3 Week 4 Total

Aromatherapy

4

3

4

5

16

Deep breathing

17

15

9

9

50

Self-Reiki/ therapeutic touch/ crystals

0

1

2

6

9

Meditation

5

5

8

4

22

Yoga

0

5

1

3

9

Stretching

9

15

9

8

41

Total

35

44

33

35

147

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n Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue, During the COVID-19 Pandemic, Part 4 Stress-Reduction, Actions Taken

Participants Engaging in Self-Care Exercises by Week

There was no change in the number of stress-reduction programs or participation when programs were offered by the employer (Table 5).

The number of exercises utilized by the group remained steady through the 4 weeks ranging from 33 to 44 exercises per week (Figure 4). Individuals utilized approximately two exercises per week, over 4 weeks, ranging from zero to four exercises in a single week. All participants utilized deep breathing at least once during the study.

Table 6 shows participants’ utilization of self-care exercise by item and week. Deep breathing was the top exercise choice each week, followed by stretching, meditation, and aromatherapy. Yoga and self-Reiki/therapeutic touch/crystals were equally utilized, but less frequently than the others.

Practice Focus Group Leader Evaluation Symptom Prevalence Among Those Who Experienced Adverse Health Effects Due to Job Stress The most commonly reported symptoms among those who experienced adverse health effects due to job stress were headaches and/ or body aches and sleep disruption. Gastrointestinal distress and appetite suppression or overeating were even as the third most common symptoms. Least common were tachycardia and depression and/or anxiety. Sleep disruption, gastrointestinal distress, and hypertension were less frequently reported following self-care exercises (Figure 1). Unchanged were headaches and/or other body aches, depression, and/or anxiety, tachycardia, and other symptoms. Slightly increased were appetite suppression or overeating and extreme or chronic fatigue (Figure 1).

Action Taken to Protest Inadequate Staffing While the reported protest action taken against inadequate staffing postintervention stress-reduction techniques appeared reduced in most categories, participation in union action increased post-intervention stress-reduction activities, along with actions taken in the “other” category (Figure 2).

All managers embraced the idea of bringing stress-reduction exercises to their units (Figure 5). The majority provided support for time and space to teach nurses on the unit the stress-reduction techniques (Figure 6). Several barriers to nurse engagement in stress-reduction exercises were identified by PFG leaders (Figure 7). Leading barriers included age, lack of motivation among nurses, lack of dedicated space for the project, and “other.” One leader identified the timing of the study, performed near the

Table 7 Wilcoxon Signed-Rank Test Result

Wilcoxon signed-rank test result

Post-mental health not good during past 30 days? Pre-mental health not good during past 30 days? -2.384a

Z Asymp. Sig. (2-tailed)

.017

a. Based on positive ranks

Table 8 Qualitative Results

Theme Time

20

Sub-theme

Comments

Length of time taken to perform activities

 “The amount of time I took was enough for what was going on in the moment.”  By fourth week, “It takes less time to perform the exercise.”

Time of day when best or worst to perform activity

 Best done “before day got busy.”  “I was able to perform exercise during downtimes.”  “My coworker and I did this prophylactically before shift.”  “ I tried to start these exercises at the beginning of my shift. It’s really a challenge to get people together to do it since we have different assignments and acuity of patients.”

Time management

 “Self-care gave me more time to focus on patients.”  “I accomplished more in less time.”

Thoughts slowed

 “After deep breathing, brain slowed down and became focused.”  “Deep breathing resets the clock in your mind.”  Meditation helped me to “slow down.”

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Table 8 Qualitative Results

Theme

Sub-theme Self-consciousness

 “To meditate, I didn’t want to close eyes and be accused of sleeping...”  “Felt more effective when I had privacy otherwise would feel self-conscious.”  “My husband noticed I was less tense.”

Interrelation with coworkers, patients

 “Helped my coworkers’ morale and communication.”  “Help others with a positive attitude, this in return decreased coworkers’ stress.”  “I left lavender lotion at the nurses’ station to bring a sense of calmness in the atmosphere.”  “Seemed benefits stretched beyond myself and into the atmosphere of the unit.”  “When one person is less stressed, the whole unit and coworkers are less stressed.”  “Before work I stretched. This caused my coworkers to stretch too.”  “Noticed aromatherapy being used by many other staff members in the OR.”  “With difficult patients and family, I was able to stay calm and positive. In return my patient was calm too.”  “My interactions with coworkers are better.”  “This is the first time I tried to use therapeutic touch exercises. One day somehow my aches were relieved without medication. I shared that personal experience with my fellow nurses and the next day when we worked together, we were hugging each other prophylactically. Best exercise to relieve stress put a lot of smiles on peoples’ faces.”  “Effects of deep breathing yoga and stretching works. It increased relaxation, decreased stress, and is more calming, allowing me to not react too harshly to negativity from coworkers.”

Reminders/pairing

 “Paring exercise with... ‘reminder,’ ‘handwashing,’ or ‘other exercise’ such as deep breathing and meditation or yoga.”  “Easier to do when I set reminders,” makes it “quick, needing little thought.”

Location matters (ambient sounds, visibility while doing exercise)

 Better when “less interruptions,” “peaceful space,” “locker room,” “breakroom,” “bathroom,” “off unit,” “outdoors,” “on way home,” and “before bed.”  “Tried various times throughout day and locations for performing activities.”  Many chose “to go to the bathroom because it was easy to say you’re “going away for 10–15 minutes,” “easier to meditate,” however, “limited yoga positions.”  Better when quiet.

Others

Activity feasibility

Positivity/negativity

Focus/perspective

Comments

 When done at start of shift, “positive start to the day.”  “Difficult week that ended with positivity.”  “Helped counter negativity such as conflict with coworker, others’ negative attitudes and behaviors, own negative thoughts.”  “With low staffing and negative attitudes at work, this is needed so you don’t take work stress home.”  “Helped cope with negative coworkers or situations.”  “Helped me stay positive and productive.”  “Helped keep a positive work environment.”  “I feel more positive at work, deal with difficult people better.”  Helped nurses focus on “self,” “surroundings,” “patient,” “tasks,” and “coworkers.”  “Able to focus on my patient and not on the frustrating situation.”  The exercises “help me step back and see bigger picture that not all problems can be solved.”  “Doing deep breathing exercises during a stressful moment at work assisted me to focus back on the care of my patients. It allowed me to relax and resolve the issue to the best of my ability.”

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n Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue, During the COVID-19 Pandemic, Part 4 Table 8 Continued

Theme

Sub-theme

Comments

Emotions

 “I’m in a better mood.”  “I feel less frustration.”  “I have better control of my emotions.”  “My more careful reactions to situations and coworkers was more desirable.”  “I am less reactive.”  “More confidence in handling tasks at hand and in general.”  “Feel more in control.”  “Also improves stress at home and in personal life.”  “Taking time for deep breathing in an empty patient room helped me relax when feeling overwhelmed about a large number of early admissions.”

Bodily experience

 “My muscles were less sore. I didn’t have to take Motrin this whole week.”  “I am falling asleep faster at night.”  “Have more energy.”

Impact at work

 “More enjoyable, nice to share techniques and interact with colleagues. Felt more productive able to process more.”  “Helped deal with frustration when I had too many patients.”  “I remained calm despite greater than usual workload.”

Progression through program

 “At first I was hesitant.”  “I was confused about which exercise to do.”  “At first it caused stress because it was another item on my to-do list.”  “Trying to perform (exercise) at this point brings its own level of anxiety.”  “Once I realized when to meditate it was great.”  “Deep breathing has become a part of my day.”  “Overall, after four weeks of the self-care sessions I value the limited time it took to do the self-care exercises. It has given me insight that caring for oneself allows one to care for others better.”  “The first day I was reminding myself to do it often. The second shift I did it basically every hour and the next two shifts I was able to use my exercise when I felt stressed. At the beginning it was just awkward and then it became very easy and I love it. ”  “Since I had such a positive outcome from self-care exercises such as deep breathing exercises, stretching, and therapeutic touch exercises, I told myself I should include something such as essential oil therapy.”

winter holidays, as a barrier because their clinic was closing for weeks during that time. Regarding space, leaders described that their break room was not conducive to these self-care activities while there was not a break room at all on one unit.

Discussion Aim 1

Qualitative Feedback

Although we cannot distinguish which exercise(s) may have contributed most toward improving stress, deep breathing and stretching were utilized most frequently (Figure 4). Frequent journal comments link these two exercises to positive emotional, mental, and physical experiences (Table 8).

While a formal qualitative analysis was not a method for this study, certain themes emerged from respondents’ feedback. Themes of time, others, positivity/negativity, activity feasibility, focus/perspective, emotions, impact on work, bodily experience, and progression through program are depicted in Table 8.

While there was a statistically significant improvement in mental health following the exercises (Table 7), the symptom prevalence for depression and anxiety remained unchanged. Coworker interrelation was described in the qualitative data as more appreciated and improved (Table 8). This improvement positively addressed the quantitative data, where

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Figure 1 Symptom Prevalence Among Those Who Experienced Adverse Health Effects Due to Job Stress Extreme or chronic fatigue Appetite suppression or overeating Other

Tachycardia Depression and/or anxiety Headaches and/or body aches Gastrointestinal distress Sleep disruption Hypertension -2

-1

0

1

2

3

4

Pre-intervention

5

6

7

8

Post-intervention

9

10

11

12

Percentage change

Figure 2 Action Taken to Protest Inadequate Staffing 16 14

15

14

12 10 8

8

7

6

5

4

4

6

5

2

1

2

0 Filed a POA

Signed a letter or petition protesting Participated in a union action inadequate staffing to protest inadequate staffing

Pre-intervention

Participated in contract negotitations to fight for improved staffing levels

Other

Post-intervention

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n Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue, During the COVID-19 Pandemic, Part 4 Figure 3 Top Causes of Stress on Participant Unit Inadequate staffing Conflict between coworkers Other Lack of adequate supplies or equipment Pressure to carry out duties out of scope of practice Conflict with managers Excessive number of hours worked Conflict with doctors Inadequate training Inadequate policies Harrassment due to race, gender, sexual orientation... 0

1

2

3

4

5

8

7

6

Pre-intervention Figure 4 Participants Engaging in Self-Care Exercises by Week

18

9

10

11

12

13

Post-intervention

17

16

15

15

14 12 10

9 9

8 6 4

4

3

4

6

5

2 0

1 Aromatherpay

Deep breathing

5 5

4

9

8

5 3

2

1

Self-Reiki/ therapeutic touch, crystals

Week 1 24

9

8

Week 2

Meditation

Week 3

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Yoga

Week 4

Stretching

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Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue, During the COVID-19 Pandemic, Part 4

Figure 5 PFG Leader Evaluation of Managerial Support for Bringing Idea of Stress-Reduction Exercises Onto the Unit

n

Figure 6 PFG Leader Evaluations of Managerial Support for Time and Space to Teach Nurses on Unit the Stress-Reduction Techniques

No

No

Yes

Yes

100% 0%

10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 7 PFG Leader Evaluation of Barriers to Nurse Engagement in Stress-Reduction Exercises 4 3 2 1

3

2

3

2

2

1

10%

20%

30%

40%

50%

60%

70%

80%

90%

While there was no statistically significant reduction in the number of days participants experienced physical unwellness, participants seemed to perceive a reduction in stress-caused adverse health effects (Table 4) following the intervention.

Aim 2

1

Oth e

r

0 Nur ses Age not Too m ma otiv ny ate d eno patie u n g t Not h n s an eno urse d no s t my ugh su coll ppo e r Not agues t from fr enou Unh om ma gh su n p eal thy agme port w Ded ork nt icat sch ed edu spa les ce n ot p rov ide d No ene rgy

0%

83.3%

While not having a full complement of staff remained a source of stress for most nurses, it is possible to conclude that it may have been to a lesser degree (Table 3). Small sample size and study design leave this observation open to further study. Among several factors, this result may be attributed to nurses’ described improvements in their emotions, focus, and positivity (Table 8). Use of self-care may have improved coping self-efficacy (Shahrour & Dardas, 2020), and may have also improved the nurses’ facility with handling the stressful event. More rigorous study design may help clarify this indeterminate observation.

4

3

16.7%

The three greatest causes of stress on participant’s units prior to and following intervention (Figure 3), include inadequate staffing, conflict between coworkers, other, and lack of adequate supplies/equipment. While the causes of stress may have remained the same, nurses indicated they more carefully reacted to difficult situations, felt less frustrated, and improved their time management (Table 8).

Aim 3

coworker interrelations were noted as one of the greatest causes of stress on the unit (Figure 3). Positive changes in factors such as happiness, anger, and frustration operational among work-related stress and well-being (Turan et al., 2020; Vallone et al., 2020) may have contributed to nurses reporting fewer unwell mental health days.

Leading barriers included age, lack of motivation among nurses, and lack of dedicated space for the project. Regarding age, older nurses or nurses who were on the unit “a long time” were said to have little interest in participation. As PFG leaders identified lack of motivation or “other” reasons, they described staff, particularly veteran staff, as having little confidence in the interventions’ feasibility or potential for success. Staff frequently said they had “too many tasks to complete.” Interestingly, participants also identified some of these challenges while undertaking the program. They were able to overcome self-consciousness by figuring out when and where

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n Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue, During the COVID-19 Pandemic, Part 4 particular exercises worked best for them (Table 8). Nurses may have been accustomed to the perceived failure of previous efforts to reduce stress or to “make things better” on the unit, calling for a comprehensive cultural shift and managerial prioritization and support on the unit.

Use of familiar or easily trained self-care exercises may promote program sustainability, particularly during the early phase.

Aim 4 The three most common symptoms attributed to work-related stress were headaches/body aches, sleep disruption, and appetite suppression or overeating paired with gastrointestinal distress. Although these symptoms ultimately were not reported as greatly improved, there were some small variations, with reduced sleep disruption being the most improved symptom. One meta-analysis of 53 studies on nursing staff sleep quality found the pooled prevalence of poor sleep to be 61% (Zeng et al., 2020). The percentage of nurses who often experienced trouble falling asleep or staying asleep in our study went from 21.1% to 5.6% (Table 4). While it appears that improvement in sleep quality may have factored into improved reported mental health, small participant size limits interpretation, leaving results inconclusive.

Stress-Reduction Exercises Ranked More than one participant stated that “deep breathing” (the most popular exercise) helped them “cope with short staffing and feelings of being overwhelmed and frustrated. Deep breathing was the most frequently used modality, followed by stretching (Table 6). Exercise selection may have been due to the participants’ familiarity, confidence for using each, timing factors, and location requirements (Table 8). The interventions most commonly utilized by participants, deep breathing and stretching, were likely associated with the reported improvements in sleep quality and in reported mental health; however, a direct correlation remains inconclusive. Further study of these interventions and their potential is therefore warranted.

Thematic Findings Respondents identified differences in the duration of the effect from the exercise. Some nurses described effects which were short-term (few minutes, temporary) following an exercise, to long-term (rest of shift). The “time” theme included comments on the “length of time taken to perform activities,” and “time of day” when best or worst to perform an activity. “Time management,” and the sense that thoughts “slowed down from a racing pace, allowing clarity of thought” is particularly interesting in that it identifies factors which could potentially improve the burden of workload and facilitate cognitive processes which may, in turn, improve patient safety. Long-term adoption of self-care behavioral changes and therapeutic response duration is another area for future studies. Self-consciousness appears to have been a barrier to self-care usage, prompting some nurses to seek privacy. However, encouragement from peers or observations from others who recognized that the nurse appeared “less stressed” may have encouraged utilization. Exercise triggers, private location, quiet ambient sound, frequency of exercises, and pairing exercise with “something else,” also served to facilitate use of self-care as nurses

26

incorporated exercises into their day. The positive experiences of emotional and physical responses to exercise, positivity, and perceiving benefits beyond themselves for their coworkers and patients may also have fostered the program’s success. This may have incentivized nurses to increase selfcare frequency or to select certain exercises or to attempt use of the less familiar exercises (Table 8). Insight gained from the qualitative component of this is study is very helpful for future participant recruitment, instructional, and planning purposes. It is plausible that various processes, highlighted within the themes were operational as the program progressed.

Study Limitations The present study has several limitations, restricting data interpretation and the ability to generalize results. Small participant size reduced our ability to study relationships among variables utilizing parametric statistical analysis. The population sample from this study was comprised of registered nurses from various clinic care settings with insufficient size for betweengroup comparison of nurses or individual effects from exercise modality. The short study duration during the winter holiday season may have introduced confounding factors such as personal stress and distraction, and variable staffing patterns and patient mix. Repeat studies should rely on longitudinal research design, ideally incorporating a control group. The use of standardized tools to measure specific phenomenon such as stress, job demand, workload, burnout, sleep quality, depression, mental health, well-being, and compassion fatigue would facilitate result analysis, enabling data comparison across similar studies.

Conclusion Multimodal (Sallon, et al., 2017), creative workplace stressreduction and well-being promotion programs should be designed with consideration for the unique needs (Oates, 2018) of nursing staff. Broad participation and effectiveness of such programs may rely on utilizing what works best for the nurses. Use of familiar or easily trained self-care exercises may promote program sustainability, particularly during the early phase. Building confidence in the program’s potential for success, through motivational marketing (Raney & Van Zanten, 2019) prior to program implementation may bolster participation across age groups and levels of experience. This study contributes to the understanding of how union-sponsored, peer-led self-care may benefit nurses, patients, and healthcare organizations. By demonstrating associations between nurse self-care and improved number of mental health days, we support efforts to promote favorable work environments.

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n References Aiken, L. (2010). Safety in numbers. Nursing Standard, 24(44), 62–63. https://doi.org/10.7748/ns.24.44.62.s55 Al Maqbali, M., Al Sinani, M., & Al-Lenjawi, B. (2021). Prevalence of stress, depression, anxiety and sleep disturbance among nurses during the COVID-19 pandemic: A systematic review and meta-analysis. Journal of Psychosomatic Research, 141, 110343. https://doi.org/10.1016/j. jpsychores.2020.110343 Alkhawaldeh, J. F. M. A., Soh, K. L., Mukhtar, F. B. M., & Ooi, C. P. (2020). Effectiveness of stress management interventional programme on occupational stress for nurses: A systematic review. Journal of Nursing Management, 28(2), 209–220. https://doi.org/10.1111/ jonm.12938 Biganeh, J., Ashtarinezhad, A., Behzadipour, D., Khanjani, N., Tavakoli Nik, A., & Bagheri Hosseinabadi, M. (2021). Investigating the relationship between job stress, workload and oxidative stress in nurses. International Journal of Occupational Safety and Ergonomics, JOSE, 1–7. https://doi.org/10.1080/10803548.2021.1877456 Çelmeçe, N., & Menekay, M. (2020). The effect of stress, anxiety and burnout levels of healthcare professionals caring for COVID-19 patients on their quality of life. Frontiers in Psychology, 11, 597624. https://doi.org/10.3389/fpsyg.2020.597624 Contreras Sollazzo, L., & Esposito, C. L. (2020). Nurses’ unions can help reduce stress, burnout, depression, and compassion fatigue part 1: The background. Journal of the New York State Nurses Association, 47(1), 18–44. Daigle, S., Talbot, F., & French, D. J. (2018). Mindfulness-based stress reduction training yields improvements in well-being and rates of perceived nursing errors among hospital nurses. Journal of Advanced Nursing, 74(10), 2427–2430. https://doi.org/10.1111/jan.13729 Elfering, A., Grebner, S., Leitner, M., Hirschmüller, A., Kubosch, E. J., & Baur, H. (2017). Quantitative work demands, emotional demands, and cognitive stress symptoms in surgery nurses. Psychology, Health & Medicine, 22(5), 604–610. https://doi.org/10.1080/13548506.201 6.1200731 Esposito, C. L., Contreras Sollazzo, L., & DeGaray, C. (2020). Nurses unions can help reduce stress, burnout, depression, and compassion fatigue, part 2: NYSNA 2020 staffing and job stress survey results. Journal of the New York State Nurses Association, 47(2), 32–44. Evaluating and improving nurses’ health and quality of work life. (2013). Workplace Health & Safety, 61(4), 173–177. https://doi. org/10.3928/21650799-20130327-18

Hämmig, O. (2020). Work- and stress-related musculoskeletal and sleep disorders among health professionals: A cross-sectional study in a hospital setting in Switzerland. BMC musculoskeletal disorders, 21(1), 319. https://doi.org/10.1186/s12891-020-03327-w Han, K., Trinkoff, A. M., & Geiger-Brown, J. (2014). Factors associated with work-related fatigue and recovery in hospital nurses working 12-hour shifts. Workplace Health & Safety, 62(10), 409–414. https:// doi.org/10.3928/21650799-20140826-01 Hopper, S. I., Murray, S. L., Ferrara, L. R., & Singleton, J. K. (2019). Effectiveness of diaphragmatic breathing for reducing physiological and psychological stress in adults: A quantitative systematic review. JBI Database of Systematic Reviews and Implementation Reports, 17(9), 1855–1876. https://doi.org/10.11124/JBISRIR-2017-003848 Huiyun, Y., Jingwen, L., Xi, Z., Huitong, L., Baibing, M. (2017). Validation of work pressure and associated factors influencing hospital nurse turnover: A cross-sectional investigation in Shaanxi Province, China. BMC Health Services Research, 17, 1–11. https://doi.org/10.1186/ s12913-017-2056-z Kakemam, E., Kalhor, R., Khakdel, Z., Khezri, A., West, S., Visentin, D., & Cleary, M. (2019). Occupational stress and cognitive failure of nurses and associations with self-reported adverse events: A national crosssectional survey. Journal of Advanced Nursing, 75(12), 3609–3618. https://doi.org/10.1111/jan.14201 Lake, E. T. (2002). Development of the practice environment scale of the nursing work index. Research in Nursing and Health, 25(3), 176–188. https://doi.org/10.1002/nur.10032 Lin, L., He, G., Yan, J., Gu, C., & Xie, J. (2019). The Effects of a Modified Mindfulness-Based Stress Reduction Program for Nurses: A Randomized Controlled Trial. Workplace Health & Safety, 67(3), 111–122. https://doi.org/10.1177/2165079918801633 Muhawish, H., Salem, O. A., & Baker, O. G. (2019). Job related stressors and job satisfaction among multicultural nursing workforce. Middle East Journal of Nursing, 13(2), 3–16. https://doi.org/10.5742/ mejn.2019.93635 National Institute for Occupational Health and Safety (2013). Quality of work life questionnaire. https://www.cdc.gov/niosh/topics/stress/ qwlquest.html Oates, J. (2018). What keeps nurses happy? Implications for workforce well-being strategies. Nursing Management–UK, 25(1), 34–41. https://doi.org/10.7748/nm.2018.e1643

Fawcett, J., DeSanto-Madeya, S. (2013). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (3rd ed.). F.A. Davis Company.

Obročníková, A., Magurová, D., Majerníková, L’., Kaščáková, M., & Harčariková, M. (2015). Psychological strain between nurses. Central European Journal of Nursing & Midwifery, 6(4), 352–359. https://doi. org/10.15452/CEJNM.2015.06.0027

Gu, B., Tan, Q., & Zhao, S. (2019). The association between occupational stress and psychosomatic well-being among Chinese nurses: A crosssectional survey. Medicine, 98(22), e15836. https://doi.org/10.1097/ MD.0000000000015836

Raney, M., & Van Zanten, E. (2019). Self-care posters serve as a low-cost option for physical activity promotion of hospital nurses. Health Promotion Practice, 20(3), 354–362. https://doi. org/10.1177/1524839918763585

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n Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue, During the COVID-19 Pandemic, Part 4 Rangasamy, V., Thampi Susheela, A., Mueller, A., F. H. Chang, T., Sadhasivam, S., & Subramaniam, B. (2019). The effect of a onetime 15-minute guided meditation (Isha Kriya) on stress and mood disturbances among operating room professionals: A prospective interventional pilot study. F1000Research, 8, 335. https://doi. org/10.12688/f1000research.18446.1 Rodriguez-Vega, B., Palao, Á., Muñoz-Sanjose, A., Torrijos, M., Aguirre, P., Fernández, Amador, B., Rocamora, C., Blanso, L., Marti-Esquitino, J., Ortix-Villabos, A., Alonso-Sanudo, M., Cebolla, S., Curto, J., Villanueva, R., de la Iglesia, M. J., Carracedo, D., Casado, C., Vidal, E., Trigo, D., Iglesias, N., Cabanas, D., Mellado, L., Garcia, D., FernandezEncinas, C., Navarro, R., Mediavilla, R., Vidal-Vilegas, M. P., BravoOrtiz, M. F., Bayón, C. (2020). Implementation of a mindfulness-based crisis intervention for frontline healthcare workers during the COVID19 outbreak in a public general hospital in Madrid, Spain. Frontiers in Psychiatry, 11, 562578. https://doi.org/10.3389/fpsyt.2020.562578 Rudman, A., Arborelius, L., Dahlgren, A., Finnes, A., & Gustavsson, P. (2020). Consequences of early career nurse burnout: A prospective long-term follow-up on cognitive functions, depressive symptoms, and insomnia. EClinicalMedicine, 27, 100565. https://doi.org/10.1016/j. eclinm.2020.100565 Sallon, S., Katz-Eisner, D., Yaffe, H., & Bdolah-Abram, T. (2017). Caring for the caregivers: Results of an extended, five-component stressreduction intervention for hospital staff. Behavioral medicine, 43(1), 47–60. https://doi.org/10.1080/08964289.2015.1053426 Shahrour, G., & Dardas, L. A. (2020). Acute stress disorder, coping selfefficacy and subsequent psychological distress among nurses amid COVID-19. Journal of Nursing Management, 28(7), 1686–1695. https://doi.org/10.1111/jonm.13124 Souza Ueno, L. G., Cescatto Bobroff, M. C., Trevisan Martins, J., Bueno Rezende Machado, R. C., Ghiraldi Linares, P., & de Godoy Gaspar, S. (2017). Occupational stress: Stressors referred by the nursing team. Journal of Nursing UFPE / Revista de Enfermagem UFPE, 11(4), 16321638. https://doi.org/10.5205/reuol.9763-85423-1-SM.1104201710

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Turan, N., & Ançel, G. (2020). Examination of the psychological changes in nurses due to workload in an intensive care unit: A mixed method study. Contemporary Nurse: A Journal for the Australian Nursing Profession, 56(2), 171–184. https://doi.org/10.1080/10376178.2020.1 782762 Vallone, F., Smith, A. P., & Zurlo, M. C. (2020). Work-related stress and wellbeing among nurses: Testing a multi-dimensional model. Japan Journal of Nursing Science, 17(4), 1–17. https://doi.org/10.1111/ jjns.12360 Weigl, M., Stab, N., Herms, I., Angerer, P., Hacker, W., & Glaser, J. (2016). The associations of supervisor support and work overload with burnout and depression: A cross-sectional study in two nursing settings. Journal of Advanced Nursing, 72(8), 1774–1788. https:// doi.org/10.1111/jan.12948 Weyers, S., Peter, R., Boggild, H., Jeppesen, H. J., & Siegrist, J. (2006). Psychosocial work stress is associated with poor self-rated health in Danish nurses: A test of the effort-reward imbalance model. Scandinavian Journal of Caring Sciences, 20(1), 26–34. https://doi. org/10.1111/j.1471-6712.2006.00376.x World Health Organization, Regional Office for South-East Asia. (2014). Self-care for health. https://apps.who.int/iris/handle/10665/205887 Wu, T., Jia, X., Shi, H., Niu, J., Yin, X., Xie, J., & Wang, X. (2021). Prevalence of mental health problems during the COVID-19 pandemic: A systematic review and meta-analysis. Journal of Affective Disorders, 281, 91–98. https://doi.org/10.1016/j.jad.2020.11.117 Zeng, L.-N., Yang, Y., Wang, C., Li, X.-H., Xiang, Y.-F., Hall, B. J., Ungvari, G.S., Li, C.-Y, Chen, L.-G., Cui, X.-L., An, F.-R., Xiang, Y.-T. (2020). Prevalence of poor sleep quality in nursing staff: A meta-analysis of observational studies. Behavioral Sleep Medicine, 18(6), 746–759. https://doi.org/10.1080/15402002.2019.1677233

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Appendix 1

NYSNA Job Stress and Staffing Survey 1. How long have you worked in your present job? ____ years 2. Which of the following best describes your usual work schedule? ____ Day shift

9. During the past 12 months, how often have you had trouble falling asleep or staying asleep? ____ Often ____ Sometimes

____ Evening shift

____ Rarely

____ Night shift

____ Never

____ Weekends only

10. Have you experienced adverse health effects due to job stress?

____ Rotating shift

____ Yes ____ No

Other:

If yes, what adverse health effects have you experienced? Check all that apply:

3. How long is your typical shift?

____ Headaches and/or other body aches

____ 8 hours

____ Hypertension

____ 10 hours

____ Sleep disruption

____ 12 hours

____ Gastrointestinal distress

Other:

____ Appetite suppression or overeating

4. How many extra hours do you work beyond your usual schedule in a typical week? ____

____ Extreme or chronic fatigue

5. How often do you find your work stressful?

____ Tachycardia

____ Depression and/or anxiety Other (please specify):

____ Always

11. I have too much work to do everything well.

____ Often

____ Strongly agree

____ Sometimes

____ Agree

____ Hardly ever

____ Disagree

____ Never

____ Strongly disagree 12. How often are there not enough RNs to get all the work done?

6. My stress level at work has negatively affected my health.

____ Often

____ Strongly agree

____ Sometimes

____ Agree

____ Rarely

____ Disagree

____ Never

____ Strongly disagree 7. Thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good? 8. Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

13. How often are there not enough ancillary staff (LPNs, PCAs, PCTs, CNAs, clerks, transporters, etc.) to get all the work done? ____ Often ____ Sometimes ____ Rarely ____ Never

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Appendix 1 Continued 14. How often are there not enough MDs to get all the work done? ____ Often ____ Sometimes

____ Strongly disagree 21. Is being floated off your unit a cause of stress?

____ Rarely

____ Often

____ Never

____ Sometimes

15. I usually receive enough help to get the job done. ____ Strongly agree ____ Agree

____ Rarely ____ Never 22. Is having staff floated onto your unit a cause of stress?

____ Disagree

____ Often

____ Strongly disagree

____ Sometimes

16. Adequate support services allows me to spend enough time with my patients. ____ Strongly agree ____ Agree

____ Rarely ____ Never 23. Have you ever taken any of the following actions to protest inadequate staffing? Check all that apply:

____ Disagree

____ Filed a protest of assignment form (POA)

____ Strongly disagree

____ Signed a letter or petition protesting inadequate staffing

17. I have enough time and opportunity to discuss patient care problems with other nurses. ____ Strongly agree ____ Agree ____ Disagree ____ Strongly disagree 18. Not having a full complement of staff is a source of stress for me. ____ Strongly agree ____ Agree

____ Participated in a union action to protest inadequate staffing ____ Participated in contract negotiations to fight for improved staffing levels Other: 24. Is there a nurse stress-reduction program at your workplace? ____ Yes ____ No 25. If yes, have you participated in it? ____ Yes ____ No 26. What are the 3 greatest causes of stress on your unit? Please check 3:

____ Disagree

____ Inadequate staffing

____ Strongly disagree

____ Conflict with managers

19. There are enough registered nurses on my unit to provide quality patient care.

____ Conflict with doctors ____ Conflict between coworkers

____ Strongly agree

____ Pressure to carry out duties out of scope of practice

____ Agree

____ H arassment due to race, gender, sexual orientation or identity, age, country of origin

____ Disagree ____ Strongly disagree 20. My workload causes me to miss changes in patients’ conditions.

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____ Disagree

____ Excessive number of hours worked ____ Lack of adequate supplies and/or equipment ____ Inadequate policies

____ Strongly agree

____ Inadequate training

____ Agree

Other (please specify):

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27. How many patients are routinely assigned to you?

n

33. What can be done to reduce the stress you experience at work?

28. Do you have a staffing grid or nurse-to-patient ratio for your unit in your contract? ____ Yes ____ No If yes what is it?

34. What do you do to decrease your stress level?

Is this currently upheld? ____ Yes ____ No 29. Is there a process for modifying agreed upon staffing grids or nurse-topatient ratios to account for census and acuity changes? ____ Yes

35. What techniques have you found helpful in reducing your stress level?

____ No ____ Don’t know If yes, describe: 36. What is your age? ____ 30. Does the hospital promptly fill all vacancies?

37. What is your gender?

____ Yes

____ Female

____ No

____ Male

____ Don’t know

____ Non-binary

31. Is there a process to adequately orient newly hired staff? ____ Yes

Other: 38. What is the highest degree you have received?

____ No

____ AD

____ Don’t know

____ BSN

32. Is there a process to adequately precept newly hired staff? ____ Yes

____ MSN Other:

____ No ____ Don’t know

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Appendix 2

Weekly Questionnaire and Journal Entry Instructions: You are invited to participate in a pilot survey study about the effects of self-care exercises on nurses’ stress levels in the workplace. Your participation will require doing a 5–10 minutes self-care exercise of your choice each day that you work in a four (4) week period. In addition, your participation will require you to fill out one (1) pre-self-care exercise survey, one (1) post-self-care exercise survey, and one (1) self-care exercise packet. This self-care exercise packet contains 9 pages. Please fill out 2 pages at the end of each week for four (4) consecutive weeks.  Use pages 2 and 3 for week 1  Use pages 4 and 5 for week 2  Use pages 6 and 7 for week 3  Use pages 8 and 9 for week 4  There are three questions/statements on pages 2, 4, 6, and 8.  There is one page for you to write your personal reflections regarding that week’s self-care exercise’s effect on you on pages 3, 5, 7, and 9. Please answer all questions on pages 2, 4, 6, and 8. Please respond with sentences; do not use one/two word responses. Please write a paragraph statement after each self-care exercise session on pages 3, 5, 7, and 9. Your personal reflections page should describe how the self-care exercise session impacted you. You may describe emotions, thoughts, or visuals that may have occurred. Please take the pre-self-care exercise survey before you begin your self-care exercise packet. Please take the post- self-care exercise survey after you complete your self-care exercise packet. WEEK 1 The self-care exercises I used this week were (check all that apply): ____ Aromatherapy ____ Deep breathing ____ Self-Reiki/Therapeutic Touch/Crystals ____ Meditation ____ Yoga ____ Stretching Q1: What impact did the self-care exercise have on your stress and anxiety levels? Please describe the impact of EACH modality used.

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Appendix 2 Continued Q2: What was your overall experience of your self-care sessions?

Q3: How did the self-care sessions impact your work at the hospital today? Please be specific in your description.

WEEK 1: Personal reflections on my self-care experience. Please describe how your self-care exercise session impacted you. You may describe emotions, thoughts, or visuals that may have occurred. Please also describe when you were able to do the exercises during your shift, how many times you did the exercises per shift, and describe whether it was easy or difficult to do your self-care exercises. My Reflections:

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Adaptation to Motherhood for Rural Women With Newborn(s) in the Neonatal Intensive Care Unit Donna Tomasulo West, PhD, RN, FNP-BC Pamela Stewart Fahs, PhD, RN Geraldine R. Britton, PhD, RN, FNP Carolyn Pierce, PhD, RN

n Abstract The Roy adaptation model (Roy, 2009) serves as a framework for this qualitative descriptive study. Participants resided in rural areas of Upstate New York and had given birth within the last month to a baby who was admitted to the neonatal intensive care unit (NICU). Through semi-structured interviews, they expressed their needs, concerns, and experiences. The purpose was to gain an understanding of the experience of how women from rural areas adapt to motherhood when their newborn requires care in the NICU. In total, seven themes emerged. The meta-theme was trust, found to be an integral part of their adaptation to motherhood. The findings have implications for nursing, as they will help inform the best care at a crucial developmental time in the lives of this vulnerable group of women. This aligns with the goal of nursing, which is assisting to promote a state of integrated adaptation, which is health according to Roy (2009). Keywords: Roy adaptation model, qualitative study, trust, therapeutic relationship

Background The purpose of this qualitative descriptive research was to gain an understanding of the experience of adapting to motherhood for rural women when they have a newborn in the neonatal intensive care unit (NICU). Becoming a mother is generally considered a normative transition for many women in adulthood (Aber et al., 2013). Adaptation to the role of mother, while challenging, is not considered unusual. However, when a newborn’s condition warrants admission to the NICU, mothers often have limited opportunities for physical contact with them, thus interfering and delaying adaptation to the role of mother. Moreover, there are serious health concerns, often unanticipated, for their babies. Consequently, many mothers experience distress, which contributes to symptoms of anxiety and depression, potentially limiting their ability to care for their newborns and leading to less desirable outcomes (Rossman et al., 2015). Thus, when a non-normative transition to motherhood occurs, it is fraught with additional challenges to adaptation to motherhood.

Providers who treat newborns in the NICU are also engaged in a therapeutic relationship with the parents of their patients.

A newborn’s admission to the NICU has been described as a very stressful (Heinemann et al., 2013; Heydarpour et al., 2017) and even traumatic event for the parents (Aftyka et al., 2017). Regardless of the reason for admission to a NICU, it is an experience accompanied by many challenges to adaptation for a parent (Park & Chung, 2015; Rossman et al., 2015). Providers who treat newborns in the NICU are also engaged in a therapeutic relationship with the parents of their patients, assisting them in adapting to parenting their newborn who is in critical condition.

Donna Tomasulo West, PhD, RN, FNP-BC; Pamela Stewart Fahs, PhD, RN; Geraldine R. Britton PhD, RN, FNP; and Carolyn Pierce, PhD, RN Binghamton University, Decker College of Nursing and Health Sciences, Binghamton, New York 34

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Adaptation to Motherhood for Rural Women With Newborn(s) in the Neonatal Intensive Care Unit

Rurality adds its own challenges to the transition process. Distance from healthcare access and other factors common to rural dwellers uniquely affect health outcomes and experiences of adaptation. While rural mothers have resources, such as the familiarity and sense of community that often exists in rural communities, they face susceptibilities unique to their places of residence (Winters & Lee, 2018). Rural mothers encounter many obstacles. Since most NICUs exist in metropolitan areas, their newborns often need to be transported a long distance for treatment. Mothers from rural places must adapt to two foreign environments: the urban area where the hospital is located and the NICU. At the same time, they are recovering from childbirth, are concerned about their babies who are in critical condition, and are adapting to taking on the role of mother. Prior research has shown that rural dwellers often have certain vulnerabilities that are not the same for people who live in urban areas, simply because of the place where they live. Residents of rural areas experience healthcare disparities that may be impacted further by social determinants of health. These include vulnerability factors such as race and ethnicity, socioeconomic status, geographic isolation, and residence in medically underserved areas (Gonzalez et al., 2018). Therefore, understanding how mothers from rural places adapt to having a newborn in the NICU can add knowledge to the discipline about how to best assist mothers, improve care provided to babies, and ultimately, improve family functioning. In the Roy adaptation model (RAM) (Roy, 2009), the environment is known to have three types of stimuli: focal, contextual, and residual. Focal stimuli are those that are most immediately affecting the person, which in this study means having a newborn in the NICU. Contextual stimuli are those that contribute to the effect of the focal stimuli. Contextual stimuli which have been previously measured include variables such as age, race, parity, type of delivery, planned vs. unplanned pregnancy, severity of the newborn’s condition, support of the newborn’s father, family support, financial situation, ability to be with the newborn while in the NICU, and feeding method (Bailey et al., 2014; Chen et al., 2016; Chourasia et al., 2013; Foster et al., 2016; Heydarpour et al., 2017; Korukcu et al., 2017; Premji et al., 2017; Roque et al., 2017). There was, however, found to be a dearth of research that focused specifically on NICU experience and the contextual stimulus of rural residency. Residual stimuli are present in the environment, but they are not measurable in the particular study or situation, are often unknown, and their effects are unclear (Roy, 2009). Roy (2009) described four modes of coping in her model. The physiologic mode of coping refers to physical response to stimuli and is inextricably involved in the postpartum period as mothers are recovering from labor and birth. There are physiologic responses to emotional and social stressors as well. The self-concept mode of coping signifies how a person views themselves. Coping in the role-function mode connotes the knowledge of how one functions within societal roles or categories in relation to others – in this case their newborn, their partner, and the medical professionals. The fourth coping mode, interdependence, represents the subjects’ relationships with significant people in their lives. Roy (2009) further explicated the levels of adaptation to be integrated, compensatory, or compromised. Adaptation level is “a changing point influenced by the demands of the situation and internal resources” (p. 31). During periods of great stress and change, the level of adaptation is not

n

While rural mothers have resources, such as the familiarity and sense of community that often exists in rural communities, they face susceptibilities unique to their places of residence.

likely to be integrated for some time. Integrated adaptation “describes the structures and functions of the life process working as a whole to meet human needs” (p. 37). At the compensatory level of adaptation, the modes of coping “have been activated by a challenge to the integrated processes” (p. 37), such as having an infant who requires care in the NICU. A person is noted to be in the compromised level, and adaptation problems are seen, when an individual’s integrated and compensatory processes are not adequate to effectively respond to the environmental stimuli. The care nurses provide is directed at promoting adaptation (Roy, 2009), either by changing the stimuli of the environment or by aiding one’s coping processes. In their review of the literature, Romero and colleagues (2012) looked at research articles pertaining to components of the RAM (Roy, 2009), specifically, coping and adaptation, and the puerperium, which is a time requiring great coping and adaptation by the woman and the whole family unit. They concluded that activities that promote maternal adaptation also, consequently, enhance the maternal-child bond and enhance all family adaptation. In Roy’s model, this refers to the interdependence mode of coping, which involves those relationships that are closest to people and which “…satisfy needs for affection and development of relationships” (Roy, 2009, p. 385). Interdependent relationships, according to Roy, may also be with support systems, such as the healthcare professionals caring for a high-risk infant. There is much research about NICU and postpartum adjustment (Cleveland & Bonugli, 2014; Hawes et al., 2016; McGowan et al., 2017; Northrup et al., 2013; Roque, et al., 2017;), but little relating the RAM to the experience, nor any specifically focused on rural mothers’ experiences within the NICU environment. People living in rural areas have different strengths and vulnerabilities that contribute to their healthcare experiences (Brown & Schafft, 2019; Winters & Lee, 2018), presumably including their experience of having a newborn in the NICU. Information about the NICU experience for rural mothers provides new insight to better enable nurses and other healthcare workers to assist them in adapting to parenting their newborn in the NICU. Theory-based interventions may be developed to promote rural mothers’ adaptation. That, in turn, can promote more effective parenting and family functioning at this critical time and moving forward.

Methods Theoretical Framework Sandelowski (2010) suggested that qualitative descriptive studies utilize a theoretical framework to guide the initial interview focus and questions. The RAM (Roy, 2009) was found to be well suited to guide nursing research in this subject area because it addresses human adaptation. As a nursingbased model, the Roy model provided a framework for the structure of

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Adaptation to Motherhood for Rural Women With Newborn(s) in the Neonatal Intensive Care Unit

inquiry, leading to results that may expand nursing science. It is a systems model which reflects incoming stimuli, modes of coping, and outcomes of varying levels of adaptation, which in turn may reenter the system as additional stimuli. Persons are described holistically as biopsychosocial beings who are continuously adapting to internal and external stimuli, i.e., their environment, to maintain an integrated level of adaptation, which Roy defines as health. The goal of nursing, according to Roy (2009), is the promotion of adaptation.

mothers also had additional, follow-up phone interviews after they were discharged because their babies had not yet been in the NICU for the required (inclusion criteria) 3 days at the time of their first interview. One mother gave her entire interview via telephone. One mother’s infant had been discharged 2 days prior, but she returned to the hospital for the interview. The babies were born at gestational ages ranging from 31 weeks and 3 days to 40 weeks. Interviews ranged in time from 20 to 90 minutes, with an average time of 45 minutes.

Design

An open-ended leading prompt was asked of participants: Tell me about your experience as a new mother to this newborn. Participant interviews also included open-ended prompts guided by the Roy model’s modes of coping (physiologic, self-concept, role function, and interdependence):

The philosophy of qualitative descriptive research is naturalistic inquiry with the goal of “…describ[ing] individuals’ experiences in their own words” (Willis et al., 2016, p. 1193). Sandelowski (2000) provided the seminal literature on this mode of inquiry. She stated that while certainly also interpretive, ultimately “the description in qualitative descriptive studies entails the presentation of the facts…in everyday language” (p. 336). Findings are presented in a “comprehensive thematic summary” (Willis et al., 2016, p. 1193). In other words, the common ideas from multiple individuals are grouped together as themes and re-presented in the findings.

Sample A purposive sample of women were interviewed for this study. Inclusion criterion were mothers over the age of 18, who had given birth to a baby who was admitted to the NICU for a minimum of 3 days, within the last 3 months. The 13 women were all Caucasian and ranged in age from 18–39 years old, with a mean age of 25.4 years. All were in a supportive relationship both emotionally and financially with the father of their newborn or other significant man. Three of the women were married. Seven were first-time mothers. First-time motherhood was one of the most important contextual stimuli identified in this study. Among the 13 participants, three had given birth to twins, all via planned primary cesarean section, and all between 32- and 36-weeks’ gestation. In total, the 13 participants gave birth to 16 babies. There were nine premature (less than 37 weeks + 6 days gestation) deliveries of 12 babies (three sets of twins) and four more newborns who were admitted to the NICU for reasons not related to prematurity. Because there are several different ways of defining rural, participants were chosen first if they self-identified as living in rural areas using their own socially constructed definition. Their residence location was then confirmed via an objective measure of rural taken from the Am I Rural? tool. Those areas designated as “Not located in an Urbanized Area or Urban Cluster” were considered rural (Rural Health Information Hub [RHIhub], n.d.).

 Tell me as much as you can about how you are feeling/adjusting physically.  Tell me as much as you can about how you are feeling about yourself at this time.  Tell me as much as you can about how your life roles have changed.  Tell me as much as you can about your relationships. Additional probes by the researcher were utilized to increase the depth of descriptions provided by the subjects (Sandelowski, 2000).

Data Analysis Qualitative content analysis-synthesis was conducted using methods described by Parse (2001). Interviews were audio recorded and later transcribed. There were 135 pages of transcripts generated, the shortest was 4 pages and the longest was 26 pages in length. The transcripts were reviewed multiple times by the researcher in order to discern major ideas and common themes. Themes were then related to the RAM and presented in the findings. Review of the data, by other researchers (PhD prepared nurses in this case) was employed to ensure internal validity and credibility (Willis et al., 2016, p. 1194). After 13 interviews, many of the same ideas were repeated by most of the mothers. When no new ideas emerged, saturation was reached, thus capping the sample at 13 women. Demographic information was used to examine and consider the possibility that those contextual factors were in some way related to the adaptation process. Expressed in a different way, demographics were collected to be potentially useful in the understanding of the participants’ experiences. Themes were also interpreted as they relate to the theoretical framework of Roy’s model.

Results Procedures Hospital Institutional Review Board approval was obtained prior to recruiting participants through purposive sampling. The 13 rural mothers were recruited from a level three NICU located in a hospital in the Southern Tier of New York State. Flyers introducing the study were posted and distributed in the NICU and the maternity unit within the hospital. After informed consent was obtained, participants were interviewed. The interviews took place between 1 day and 3 weeks after giving birth. Data were obtained by digital, audio-recorded, semi-structured interviews, which took place in a private location within the hospital. Three of the 36

After thoroughly reviewing the transcripts and considering their content, both verbal and nonverbal, the major ideas women spoke about were sorted into seven common themes that emerged. If all or most mothers talked about those themes, then they were considered by the researchers to be of importance. The themes were then summarized once more into one overarching theme that permeated every interview – the meta-theme. Every mother talked, to some extent, about transportation issues related to getting back and forth to the NICU to be with their newborn. As they talked, every mother spoke optimistically and focused on the positive of their situation. Twelve mothers talked about it being difficult to go home

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and not bring their baby or babies with them. Twelve mothers expressed feeling guilty about their baby needing to be in the NICU. Twelve mothers talked about their uncertainty, specifically not knowing what was going to happen next or when they would be taking their baby home. Identifying as a mother was another universal theme and it was distinctly different for multiparous versus primiparous mothers and for mothers under the age of 21 versus those who were older. A fascinating theme that emerged was that new mothers already identified some things about their babies’ attributes. Finally, and remarkably, an overarching metatheme emerged that was addressed by all the mothers, although it was not articulated by name by most of them. After several weeks immersed in the interviews, the overarching theme of trust was identified. Although not all mothers used the term trust, every mother expressed trust in those caring for their newborn(s).

Seven Themes Transportation Issues Given that the participants were rural mothers, not surprisingly, having a significant commute to get back to the NICU to be with their babies was common to all. The average driving time was 60 minutes one way. Driving themselves was not always an option, especially for those who had a cesarean section. Many did not have a car. Public transportation was not available in their rural areas. Additionally, the cost of gas for a long daily drive was reported as a financial concern. The most remarkable transportation story was told by the mother who delivered precipitously en route to the hospital. She had financial, childcare, and transportation difficulties. The father of the newborn was not able to go to the hospital with her because he needed to stay at home to watch their other young children. Mother and newborn were transported to the hospital without another family member for support. Two days later, her infant was moved to a higher level NICU, even farther away. She had no idea when she would be able to get a ride to go see her baby. In light of Roy’s model, this theme can be viewed as a contextual stimulus, part of the physical/physiologic and interdependence modes of coping, as well as a level of adaptation. Women who solved the problem of getting to and from the hospital were acting at an integrated level of adaptation in the matter of transportation. Those who relied on others could be said to be at a compensatory level, while those who had not yet figured out how they were going to manage would be at a compromised level.

Focus on the Positive The mothers were all going through a very stressful life event, but their optimism was remarkable. They talked about counting their blessings. One mother viewed having the newborn stay in the NICU after she [the mother] was discharged as “the best thing for his health, so I can get better and he can get better at the same time.” There was also a feeling of pride in knowing that they were doing the best they could to help their baby, for example, one mother said: I love providing breastmilk because I know I’m helping contribute to her health…. I know I’ve done my best to make her progress better. I knew that she was getting the right medicine, the right treatment she needed to help her feel better. It was scary, but I handled it so well.

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Mothers reassured themselves by focusing on the positives: It’s kind of reassuring, when you’re holding them skin-to-skin, [what] they do just calm to you. That kind of helps with the whole emotional separation part with them. You don’t really think of being able to hold your baby as a huge milestone, but in the NICU, it is. In RAM terms, providing breastmilk, an obviously physical act, was a positive coping method and way for mothers to physically care for their newborn, if not always in person, then via the milk they provided. Their milk created an alternate means of interdependence with their newborn; additionally, skin-to-skin contact is a physical act which enhances interdependence. Both actions influenced mothers’ self-concept and rolefunction modes.

The Difficulty of Going Home Without Baby Most mothers interviewed expressed decidedly negative feelings about going home while having to leave their newborn in the hospital. The women described this aspect of their experience as “hard,” “stressful, and “draining.” One mother stated, “I go home, and I feel bad.” It was a refrain expressed by every mother. One of the first-time mothers lamented, “I’m not pregnant anymore, but I can’t take him home. And it’s not something you usually think about when you have a baby.” In Roy’s model, closely and naturally related to the physical mode of coping, is the interdependence mode. One can understand how the physical act of going home without baby disrupts the interdependence between mother and newborn, as well as the self-concept and role function of the mother.

Feeling Guilty The theme of feeling guilty reflects our societal notion that motherhood is often fraught with feelings of guilt. Although none of the mothers intended to have their newborn require NICU treatment, they still felt somehow, and to some degree, to blame for that admission. One mother said, “You feel like it’s your fault.” A mother of premature twins said, “Just wish I could have carried them longer. You can’t help it; you get a little like, ‘Did I do something? Did I do too much?’” On a different note, and possibly related to being a rural woman, one mother said, “I hated the thought of getting food stamps because I’m not one to want help from the government. But then I realized – there is a difference between going to social services because you’re lazy and you don’t want to work, as opposed to you can’t work because of the high-risk pregnancy.” Literature (Rasmussen et al., 2018) supports that rural dwellers, while not usually accepting of help from people outside of their community, are much more accepting of outside services when children need care. Guilt feelings relate to Roy’s coping modes of role function, interrelationship, and self-concept. Heydarpour and colleagues (2017) and Korukcu et al. (2017) discussed feelings of guilt as an interfering factor in women’s adaptation to motherhood in the NICU environment as well.

Uncertainty Mothers stated uncertainty about many aspects of their experiences. Mothers of preterm babies did not expect to deliver as early as they did: “It just

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Trust was a vital, primary element of the NICU experience for all the mothers.

happened so fast; I didn’t have time to absorb any of it. It was shocking. I think she just wanted out.” One mother explained what she said the nurses referred to as the NICU Shuffle, a dance that babies do: progressing, regressing, and then progressing again. She was informed that it is uncertain which babies will do what, but it is expected that most NICU babies will have that sort of pattern. Most notably, when asked about discharge, not one mother knew for certain when that would be and that was especially stressful. In RAM terms, uncertainty about circumstances or the unknown, such as the big question of “When would baby be coming home?” was a major residual stimulus for all participants. It was a weight on all their minds.

Identifying as a Mother Adapting to the role of motherhood was different, depending on whether they already had children or not. Mothers’ ages were also identified as influencing their readiness to take on the role. Multiparous mothers’ perspectives. Some multiparous women were unfazed by adding another child to their mothering role, despite the implications of that newborn’s stay in the NICU. A mother of three had this to say, “It’s not like new baby overwhelming. It’s not like she’s my first, so I have to get used to doing everything.” Multiparous mothers had the perspective of experience. That seemed to help them cope in a more understanding way. One mother of premature twins, whose first child is a teenager, spoke from that perspective: We’ll get out of debt later. Spend time with the babies now.… When I started out with my first child, I wanted to do this and that, but you start seeing the days go by, and I’m like – no, I am going to spend time with him, and I will work out the rest later. Looking back, it went so quick! And I’m sure it will go quick with these babies. Primiparous mothers’ perspectives. In contrast, the women who were becoming mothers for the first time spoke about the difficulty of taking on that role in relation to their newborn’s NICU admission. One mother stated how she felt her situation was surreal: It’s set in that I’m a mom, but it’s like, not really that I’m a mom yet, because other people are taking care of my child…. I know I gave birth to a child and I know that he’s here, but I’m only here a couple hours a day because we do live so far.

Feeling too young and unprepared. Four of the first-time mothers were under the age of 21. In contrast with the older mothers, every one of them commented on their age as a concern. “I asked for a lot of advice because I am a young mom. I found out when I was 19 and had her when I was 20, so it’s definitely different from somebody who is having a baby at 27 and has been working and has a lot of money saved up.” All of the young mothers credited their own mothers with being their biggest supporters and helping them cope with their unplanned pregnancies for which they felt so unprepared. They said they would not have been able to do it without their moms. The contextual stimuli of parity and age affected both identifying as a mother and feeling prepared to adopt that new role. These can be viewed as affecting the coping modes of self-concept and role function in the Roy model. This finding was not surprising, as many other researchers have viewed age and parity as contextual stimuli in adaptation to motherhood (Chen et al., 2016; Chourasia et al., 2013; Foster et al., 2016, Northrup et al., 2013; Roque et al., 2017).

Identifying Baby Attributes Due to the NICU admission, these mothers had spent relatively limited time with their babies since birth. It seems notable that never-the-less, they had definite opinions about some of their newborns’ traits. They already deemed them to be “angel babies” and “a little trooper” and “healthy.” One said, of her son who had been receiving care in the NICU for over a week at the time that “he’s never needed a lot of help.” One mother assured me that her baby has bettered her life and she is certain the baby “will be bettering a lot of other people’s lives.” This identification of newborns’ attributes is coping in the interrelationship mode. It can also be seen as relating to Mercer’s (2006) stages of acquaintance and increasing attachment, or part of the process of attaining maternal identity which is similar to the coping modes of selfconcept and role-function in Roy’s model.

Meta-Theme After lengthy reflection on the words of these mothers, an overarching meta-theme became apparent in every encounter. While only three mothers used the actual word trust; it was implicit in every interview. Trust was a vital, primary element of the NICU experience for all the mothers. It was implied by every mother in their statements and certainly by their actions. Speaking with a nurse researcher during such a stressful time of their lives required trust. Leaving their precious newborns in the care of other people and going home without them required the utmost trust.

In some interviews with first-time mothers, the language they used indicated that their maternal identity was in the process of forming. It was interesting to hear one mother talk about the support her friends gave via Facebook, “They told me how awesome I’m going to be as a mother…” – as though she had not yet become a mother.

Many mothers reported that they called the NICU several times daily, during the day and night, from their home. Updates from the nurses reaffirmed that their trust was well placed. One mother explained, “Me being able to actually call and ask how she’s doing makes me kind of be able to tolerate not being able to come back all the time.”

It was also evident that first-time mothers were amazed and marveled at their own abilities to mother. Taking on the identity of mother meant that their priorities had changed and they were surprised, as well as pleased with that: “I never had to worry about anyone but myself and now it feels good that I have someone who needs me.”

In Roy’s model, trust can be viewed as a contextual stimulus. It also is involved in all four of the coping modes. For example, coping in the interrelationship mode certainly changed as mothers adapted to the implications of having a newborn in the NICU. Interactions with the NICU nurses and doctors became new significant relationships that necessarily,

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were navigated with trust and mutual respect. Trust can also be viewed as a mediator of level of adaptation in the circumstance of adapting in the NICU.

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Nurses were not aware of where their patients lived.

Discussion While conducting this research, it was evident that the experience of adaptation to motherhood could readily be related to Roy’s model, just as another researcher has endorsed (Romero et al., 2012). The RAM is well suited to nursing studies of mothers and newborns, because its focus is adaptation, which is a process mothers and newborns are actively engaged in. When trying to recruit participants for this study, it became apparent that nurses were not aware of where their patients lived. Location of residence was not part of what was considered when planning care for their patients and required a computer search to find. Given the significance of rurality to the experience of adaptation to motherhood, having that information readily available to the nurses would be beneficial to them in providing care to newborns and mothers. This information must not be used to stereotype, but rather to address the unique challenges that mothers who live in a rural place experience. Knowledge of rural nursing theory and awareness of mothers who are from rural places has implications for the extra significance that health teaching may have for those mothers. “If the nurse can provide adequate health knowledge, the rural dweller’s desire for self-reliance may lead to health-promotion behaviors” (Long & Weinert, 1989, p. 124). Considering the distance from emergency healthcare providers, health-promotion behaviors are even more consequential to rural dwellers, especially with a neonate at home who began life with health problems. The value that these mothers expressed in being able to care for their own newborns by providing breastmilk, having skin-to-skin contact with their infants, and even something as ordinary as changing diapers is knowledge that nurses should possess. Nurses’ encouragement and support of mothers in those activities can have a profoundly positive impact on a mothers’ self-concept and role function, thus aiding their self-efficacy and consequent adaptation to motherhood, even under the extreme conditions of the NICU. That support in activities can also build the trust that is so necessary for integrated adaptation. Knowing that their newborn was safe and well cared for was essential for these mothers. The finding that trust was an integral part of maternal adaptation has relevance in nursing education and practice. Nurses must be worthy of that trust. The importance of this needs to be emphasized in nursing education. While teaching the necessary skills and factual knowledge, we cannot overemphasize the importance of building trusting relationships.

Limitations A limitation of this study is that, although the selection of participants was purposive, it was also a convenience and self-selected sample. While this study provides insight into the experiences of these women, it cannot

provide that same information about the women who were excluded from the research, either by their own choice or by exclusion criteria. Conducting this research has led to many more questions. Most pressing is what about the women who were less inclined to talk and those who did not participate in the study at all? There were many more mothers who did not participate during the 3 months of data collection. All of them certainly hold information that would benefit nurses’ knowledge in providing the best possible support for mothers of babies in the NICU. Only mothers were interviewed for this research because it was an inquiry specifically into adaptation to motherhood. Future research should involve interviews with rural fathers to understand their process of adaptation when a newborn is in the NICU. It would be beneficial to understand fathers’ experiences so that nurses could best support their adaptation. When reviewing the nursing literature, there was a noticeable lack of recent research on adaptation to motherhood in general. Society is continuously changing and cultural norms change with it. Research on adaptation to motherhood needs continuous updating to more fully understand that experience as time passes. The experience of NICU nurses and their view of how their patients’ parents adapt would also be revealing information. What do they see as the barriers and enhancers of providing care to their high-risk patients while supporting the mothers of those babies as they adapt to their new roles? Lastly, since trust was found to be an overarching theme for these mothers, there is a need for research into what factors enhance trust between families and those they encounter in health care. Knowledge of those factors would provide important information to nurses to enable better interaction with the public, especially with their patients and patients’ families. Building trust will enhance nurses’ abilities to help parents to cope with whatever stimuli they are facing and thus promote their adaptation.

Conclusion The experience of adaptation to motherhood for rural women in the environment of the NICU was the focus of this study. The contextual stimulus of residing in a rural area was germane for all participants. Important themes found were transportation issues, uncertainty, age, and parity. Mothers coped in all four coping modes and the modes were shown to overlap with each other as well as with stimuli and level of adaptation, just as Roy (2009) described in her model. Information from this study can benefit nursing, practice, and education, making it possible to provide better care for rural mothers whose babies are in the NICU. This is in sync with the goal of nursing, which according to Roy (2009) is assisting persons in their coping behaviors to promote a state of integrated adaptation or health.

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Aftyka, A., Rozalska Walaszek, I., Rosa, W., Rybojad, B., & Karakuła Juchnowicz, H. (2017). Post-traumatic growth in parents after infants’ neonatal intensive care unit hospitalisation. Journal of Clinical Nursing, 26(5–6), 727–734. https://doi.org 10.1111/jocn.13518

Long, K. A. & Weinert, C. (1989). Rural nursing: Developing the theory base. Scholarly Inquiry for Nursing Practice: An International Journal, 3(1), 113–127.

Bailey, B. A., McCook, J. G., & Chaires, C. (2014). Burden of elective earlyterm births in rural Appalachia. The Southern Medical Association, 107(10), 624–629. https://doi.org/10.14423/smj.0000000000000176 Brown, D. L. & Schafft, K. A. (2019). Rural people and communities in the 21st century, (2nd ed.). Polity Press. Chen, E. Y., Enright, R. D., & Tung, E. Y. (2016). The influence of family unions and parenthood transitions on self-development. Journal of Family Psychology, 30(3), 341–352. http://dx.doi.org/10.1037/ fam0000154 Chourasia, N., Surianarayanan, P., Adhisivam, B., & Bhat, B. V. (2013). NICU admission and maternal stress levels. Indian Journal of Pediatrics, 80(5), 380–384. https://doi.org/10.1007/s12098-012-0921-7 Cleveland, L. M. & Bonugli, R. (2014). Experiences of mothers of infants with neonatal abstinence syndrome in the neonatal intensive care unit. Journal of Gynecological and Neonatal Nursing, 43(3), 318–329. https://doi.org/10.1111/1552-6909.12306 Foster, M., Whitehead, L., & Maybee, P. (2016). The parents’, hospitalized child’s, and health care providers’ perceptions and experiences of family-centered care within a pediatric critical care setting: A synthesis of quantitative research. Journal of Family Nursing, 22(4), 6–73. https://doi.org/10.1177/1074840715618193 Gonzalez, K. M., Shaughnessy, M. J., Kabigting, E-N. R., West, D. T., Robinson, J. F. C., & Fahs, P. S. (2018). A systematic review of the health of vulnerable populations within U.S. rural societies. Online Journal of Rural Nursing and Health Care 18(1),112–147. http://dx.doi. org/10.14574/ojrnhc.v18i1.507 Hawes, K., McGowan, E., O’Donnell, M., Tucker R, & Vohr, B. (2016). Social emotional factors increase risk of postpartum depression in mothers of preterm infants. Journal of Pediatrics, 179, 61–67. https:// doi.org/10.1016/j.jpeds.2016.07.008 Heinemann, A., Hellström Westas, L., & Nyqvist, K. H. (2013). Factors affecting parents’ presence with their extremely preterm infants in a neonatal intensive care room. Acta Paediatrica, 102(7), 695–702. https://doi.org/10.1111/apa.12267 Heydarpour, S., Keshavarz, Z. & Bakhtiari, M. (2017). Factors affecting adaptation to the role of motherhood in mothers of preterm infants admitted to the neonatal intensive care unit: A qualitative study. Journal of Advanced Nursing, 73(1), 138–148. https://doi.org/10.1111/ jan.13099

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McGowan, E. C., Du, N., Hawes, K., Tucker, R., O’Donnell, M., & Vohr, B. (2017). Maternal mental health and neonatal intensive care unit discharge readiness in mothers of preterm infants. The Journal of Pediatrics, 184, 68–74. https://doi.org/10.1016/j.jpeds.2017.01.052 Mercer, R. T. (2006). Nursing support of the process of becoming a mother. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 35(5), 649–651. https://doi.org/10.1111/j.1552-6909.2006.00086.x Northrup, T. F., Evans, P. W., & Stotts, A. L. (2013) Depression among mothers of high-risk infants discharged from a neonatal intensive care unit. Maternal Child Nursing, 38(2), 89–94. https://doi.org/10.1097/ nmc.0b013e318270f8b8 Park, H. J., & Chung, G. H. (2015). A multifaceted model of changes and adaptation among Korean mothers of children with disabilities. Journal of Child and Family Studies, 24(4), https://doi.org/10.1007/ s10826-014-9902-y Parse, R. R. (2001) Qualitative inquiry: The path of sciencing. Jones and Bartlett. Premji, S. S., Pana, G., Currie, G., Dosani, A., Reilly, S., Young, M., & Lodha, A. K. (2017). Mother’s level of confidence in caring for her late preterm infant: A mixed methods study. Journal of Clinical Nursing, 27(5–6), e1120–e1133. https://doi.org/10.1111/jocn.14190 Rasmussen, A., O’Lynn, C., & Winters, C. A. (2018). Beyond the symptomaction-timeline process: Explicating the health-needs-action process. In C. A. Winters & H. J. Lee (Eds.), Rural nursing: Concepts, theory, and practice (5th ed., pp. 215–230). Springer. Rossman, B., Greene, M. M., & Meier, P. P. (2015). The role of peer support in the development of maternal identity for “NICU moms.” Journal of Obstetric, Gynecologic, and Neonatal Nursing, 44(1), 434–445. https://doi.org/10.1111/1552-6909.12527 Romero, A. M. O., Rodriguez, L. M., & Cárdenas, C. H. R. (2012). Coping and adaptation process during puerperium. Columbia Médica, 43(2), 168–175. Roque, A. T. F., Lasiuk, G. C., Radünz, V., & Hegadorn, K. (2017). Scoping review of the mental health of parents of infants in the NICU. Journal of Gynecological and Neonatal Nursing, 46(4), 576–587. http:// dx.doi.org/10.1016/j.jogn.2017.02.005 Roy, C. (2009). The Roy adaptation model (3rd ed.). Pearson Prentice Hall Health. Rural Health Information Hub (n.d.) Am I rural? tool. https://www. ruralhealthinfo.org/am-i-rural

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Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing and Health, 23(4), 334–340. https://doi.org/10.1002/1098-240X(200008)23:4%3C334:AIDNUR9%3E3.0.CO;2-G Sandelowski, M. (2010). What’s in a name? Qualitative description revisited. Research in Nursing & Health, 33(1), 77–84. https://doi. org/10.1002/nur.20362

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Winters, C. A. & Lee, H. J. (Eds). (2018). Rural nursing: Concepts, theory, and practice. (5th ed.). Springer. Ziegler, K. A., Paul, D. A., Hoffman, M., & Locke, R. (2016). Variation in NICU admission rates without identifiable cause. Hospital Pediatrics, 6(5), 255–260. https://doi.org/10.1542/hpeds.2015-0058

Willis, D. G., Sullivan-Bolyai, S., Knafl, K., & Cohen, M. Z. (2016). Distinguishing features and similarities between descriptive phenomenological and qualitative description research. Western Journal of Nursing Research, 38(9), 1185–1204. https://doi. org/10.1177%2F0193945916645499

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THE

JOURNAL of the New York State Nurses Association

Call for Papers

Call for Editorial Board Members

The Journal of the New York State Nurses Association is currently seeking papers.

Help Promote Nursing Research

Authors are invited to submit scholarly papers, research studies, brief reports on clinical or educational innovations, and articles of opinion on subjects important to registered nurses. Of particular interest are papers addressing direct care issues. New authors and student authors are encouraged to submit manuscripts for publication.

Information for Authors For author’s guidelines and submission deadlines, go to the publications area of www.nysna.org or write to journal@nysna.org.

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The Journal of the New York State Nurses Association is currently seeking candidates interested in becoming members of the publication’s Editorial Board. Members of the Editorial Board are appointed by the NYSNA Board of Directors and serve one 6-year term. They are responsible for guiding the overall editorial direction of The Journal and assuring that the published manuscripts meet appropriate standards through blinded peer review. Prospective Editorial Board members should be previously published and hold an advanced nursing degree; candidates must also be current members of NYSNA. For more information or to request a nomination form, write to journal@nysna.org.

Journal of the New York State Nurses Association, Volume 48, Number 2


What’s New In Healthcare Literature

n

n WHAT’S NEW

IN HEALTHCARE LITERATURE n Colorectal Cancer Screening Clinical Practice Guidelines

(USPSTD, 2021)

n Medscape. (2021, June 4). https://reference.medscape.com/ viewarticle/952440 According to the American Cancer Society, colorectal cancer is the third leading cancer in the United States. Death from this cancer has steadily decreased among people over 65 years of age. However, between 2013 and 2017, it increased by 2% annually in people younger than 50 and 1% in people 50–64. Guidelines on screening for colorectal cancer have been updated and were published by the United States Preventive Services Task Force (USPSTF) in JAMA.

Principal recommendations include:  Screening for colorectal cancer in adults beginning at age 45 to 49 years  Screening for colorectal cancer in all adults aged 50 to 75  Clinicians should selectively offer screening for colorectal cancer in adults aged 76 to 85 years, based on consideration of the patient’s overall health, prior screening history, and preferences.

n Secondary Stroke Prevention Clinical Practice Guidelines (AHA/

ASA 2021) Update

n Medscape. (2021, June 1). https://reference.medscape.com/ viewarticle/952019 Stroke remains a leading cause of death and serious long-term disability in the United States. The American Heart Association/American Stroke Association now recommends diagnostic testing to determine the cause of a first stroke or TIA within 48 hours after symptomatic onset. Key Messages:  When possible, to define the ischemic stroke etiology, identify treatment targets in order to reduce the risk of recurrent ischemic stroke.  Multidisciplinary management of, and personalized treatment goals for vascular risk factors, particularly hypertension, diabetes, lipid levels, and smoking cessation can prevent secondary strokes.

 Lifestyle factors such as limiting salt intake and/or following a hearthealthy Mediterranean diet are also advised, as well as, when possible, engaging in at least moderate-intensity aerobic activity for at least 10 minutes four times a week or vigorous-intensity aerobic activity for at least 20 minutes twice a week.  Atrial fibrillation (AF) should be screened for. Anticoagulation, including antiplatelets or anticoagulants in the absence of contraindications should be prescribed to reduce recurrent stroke. If no other cause of stroke can be identified, heart rhythm monitoring for occult AF is frequently recommended.  No benefit has been found for empirical treatment with anticoagulants or ticagrelor in patients with embolic stroke of uncertain source.

n Lyme Disease Clinical Practice Guidelines (IDSA, AAN, ACR, 2021) n Medscape. (2021, April 2). https://reference.medscape.com/ viewarticle/948564

of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR) in Neurology.

According to the Centers for Disease Control, approximately 30,000 cases of Lyme disease are reported annually. The disease remains underreported; it has been estimated that approximately 476,000 people may be infected annually in the United States. Lyme disease is spread through the bite of a blacklegged tick (Ixodes scapularis or Ixodes pacificus) that is infected with Borrelia burgdorferi. Guidelines for preventing, diagnosing, and treating Lyme disease were published by the Infectious Diseases Society

Prevention  Individuals at risk of exposure to ticks should implement personal protective measures, including using N,N-diethyl-meta-toluamide (DEET), picaridin, ethyl-3-(N-n-Butyl)-N-acetylaminopropionate (IR3535), oil of lemon eucalyptus (OLE), p-menthane-3,8-diol (PMD), 2-undecanone, or permethrin as repellents.

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n

What’s New In The Healthcare Literature

Lyme Disease Clinical Practice Guidelines Continued  Ticks should be removed mechanically using a fine-tipped tweezer inserted between the tick body and the skin. Burning of attached ticks is not recommended. Diagnosis  The removed tick should be submitted for species identification.  Testing a removed Ixodes tick for Borrelia burgdorferi is not recommended.  Testing asymptomatic patients for exposure to B. burgdorferi following an Ixodes spp. tick bite is not recommended.

bites that are equivocal risk or low risk. Risk depends on species, regions where Lyme disease is highly endemic, and length of attachment time greater than 24 hours.  A single dose of oral doxycycline within 72 hours of tick removal should be administered for high-risk Ixodes spp. bites in all age groups.  Oral antibiotic therapy with doxycycline (10-day course), amoxicillin (14-day course), or cefuroxime axetil (14-day course) is recommended for patients with erythema migrans.

Treatment  Prophylactic antibiotic therapy should be given only to adults and children within 72 hours of removal of an identified high-risk tick bite, but not for

n Antibody Combo ‘Reduces Mortality in Most Vulnerable

COVID Patients’

n Russell, P. (2021, June 16). Medscape. https://www.medscape.com/ viewarticle/953179 An intravenously administered antibody combination has been found to reduce the risk of mortality by 20% when given to seronegative patients hospitalized with severe COVID-19. The results are reported from the

Randomized Evaluation of COVID-19 Therapy (RECOVERY) trial. Treatment involves a combination of two monoclonal antibodies, casirivimab and imdevimab (REGEN-COV, Regeneron Pharmaceuticals), that bind specifically to two different sites on the coronavirus spike protein, neutralizing the ability of the virus to infect cells.

n Most U.S. Adults Are Unfamiliar With Palliative Care n Rapaport, L. (2021, June 14). Medscape. https://www.medscape.com/ viewarticle/952993 Nine out of 10 U.S. adults may have little knowledge about palliative care, particularly if they’re infrequent users of health care, a new study suggests. Researchers examined data on responses from a total of 3,450 participants in the 2018 National Cancer Institute Health Information National Trends Survey (HINTS) to assess overall familiarity with palliative care as well as factors that influence knowledge of this care modality. Frequent health care utilization, defined as two or more visits annually, was associated with a greater likelihood that participants would have

knowledge of palliative care, as was having a regular source of care. Individuals with a college or more advanced degree were significantly more likely to be familiar with palliative care than people without a high school diploma. Women and married people were also more likely to be knowledgeable about palliative care, researchers report in Cancer Epidemiology, Biomarkers, & Prevention. It is important to frame palliative care as one which improves quality of life for anyone with a serious illness at any stage of their disease and not reserved for people at the end of life. As palliative care is normalized and incorporated into routine care, it will be better received by patients.

n Physical Activity Offsets Serious Health Risks of Poor Sleep n Yasgur, B. S. (2021, August 5). Medscape. https://www.medscape.com/ viewarticle/956083 A recent study of nearly 400,000 middle-aged adults over an 11-year period found that participants with poor sleep combined with low levels of physical activity (PA) had 57% greater risk for all-cause mortality, a 67% greater risk for death from cardiovascular disease (CVD), a 45% higher risk for death from any type of cancer, and a 91% greater risk for death from lung cancer when compared with participants with good sleep and high PA levels. Researchers noted that The World Health Organization recommends 150 minutes of moderate or 75 minutes of vigorous PA weekly. 44

Their research suggests that meeting or exceeding the weekly recommended amount of PA may offset serious health risks, including death associated with poor sleep quality. Lead researcher Stamatakis concluded, “by adding a physical activity prescription to a sleep disorder treatment plan, clinicians will assist patients to enjoy the multitude of direct health benefits of an active lifestyle, improve their sleep patterns and, as our new study shows, may even mitigate some of the health risks that come from poor sleep. Investing in physical activity is a win-win all around investment for clinicians and public alike.”

Journal of the New York State Nurses Association, Volume 48, Number 2


n CE Activity: Nursing Students’ Experiences on NCLEX-RN Preparation

Thank you for your participation in “Nursing Students’ Experiences on NCLEX-RN Preparation,” a new continuing education (CE) activity offered by NYSNA. NYSNA members and nonmembers are invited to take part in this activity; you do not need to be a resident of New York State.

LEARNING OUTCOME Participants will identify learning styles and approaches associated with successful first-time student pass rates on the NCLEX-RN. OBJECTIVES

INSTRUCTIONS In order to receive contact hours for this educational activity, participants are to read the article presented in this issue of The Journal, complete and return the post-test, evaluation form, and earn 80% or better on the post-test. This activity is free to NYSNA members and $10 for nonmembers. Participants can pay by check (made out to NYSNA;) or credit card. The completed answer sheet and evaluation form may be mailed or faxed back to NYSNA; see the evaluation form for more information. The New York State Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation. This program has been awarded 1.0 contact hour through the New York State Nurses Association Accredited Provider Unit. The New York State Nurses Association is accredited by the International Association for Continuing Education and Training (IACET) and is authorized to issue the IACET continuing education units (CEUs). The New York State Nurses Association is authorized by IACET to offer 0.1 CEUs for this program. In order to receive contact hours and CEUs, participants must read the entire article, fill out the evaluation form, and get 80% or higher on the post-test. Presenters disclose no conflict of interest. NYSNA wishes to disclose that no commercial support was received for this educational activity. All planners/authors involved with the development of this independent study have declared that they have no vested interest. NYSNA program planners and authors declare that they have no conflict of interest in this program.

By completion of the article, the reader will be able to: 1. Distinguish between learning styles and learning approaches. 2. Describe the elements of two learning approaches that help students prepare for the NCLEX-RN. 3. Identify nursing education strategies to support nursing students in preparing for the NCLEX-RN. Please answer either True or False to the questions below. Remember to complete the answer sheet by putting the letter of your corresponding answer next to the question number. Each question has only one correct answer. The 1.0 contact hours and 0.1 CEUs for this program will be offered until December 1, 2024. 1) Accreditation of academic nursing programs is contingent upon the average GPA of students and not on NCLEX-RN pass rate. a. True b. False 2) Using the in-depth learning approach, students relate concepts to each other to get the entire picture. a. True b. False 3) Kolb’s Learning Style Inventory is a self-scored tool that can help identify a student’s learning style. a. True b. False

INTRODUCTION The first-time NCLEX-RN pass rate is an important figure to many stakeholders. Primarily, student nurses invest their time, money, and professional prospects on an educational program designed to prepare them for successful entry into the nursing workforce. Academic programs require adequate NCLEX-RN pass rates in order to maintain accreditation. The ongoing nursing staff shortages demand that qualified individuals obtain licensure for practice. This article presents findings from a qualitative multiple case study exploring student experiences on NCLEX-RN preparation. Kolb’s Learning Style Inventory was used to explore students’ learning styles and thematic findings are discussed. The study provides recommendations for nursing educators and leaders that can be used to improve NCLEX-RN pass rates.

4) The author’s findings support Kolb’s Experiential Learning Theory model. a. True b. False 5) Having a study plan and remaining focused on academic goals helped students pass the NCLEX-RN on their first attempt. a. True b. False

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6) The study suggests that nursing educators should plan study strategy seminars for students in associate degree nursing programs. a. True b. False

9) The majority of study participants prepared an organized schedule for studying practice questions and materials and taking time for personal activities and breaks. a. True b. False

7) The study recommends that nursing programs identify students’ preferred learning styles as a strategy to ensure success on the NCLEX-RN. a. True b. False 8) The author suggests that incorporation of NCLEX-style questions into class exams would improve students’ confidence on the actual NCLEX-RN.

10) A learning style is how a student grasps and comprehends new information, whereas learning approaches are methods by which a student studies new concepts. a. True b. False

a. True b. False

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Journal of the New York State Nurses Association, Volume 48, Number 2


The Journal of the New York State Nurses Association, Vol. 48, No. 2

Answer Sheet Nursing Students’ Experiences on NCLEX-RN Preparation Note: The 1.0 contact hour and 0.1 CEU for this program will be offered until December 1, 2024.

Please print legibly and verify that all information is correct. First Name: MI: Last Name: Street Address: City: State: Zip Code: Daytime Phone Number (Include area code): Email: Profession: NYSNA Member # (if applicable):

Currently Licensed in NY State? Y / N (Circle one)

License #:

License State:

ACTIVITY FEE: Free for NYSNA members/$10 nonmembers PAYMENT METHOD Check—payable to New York State Nurses Association (please include “Journal CE”). Credit Card:

Mastercard

Visa

Discover

American Express

Card Number: Name:

Expiration Date:

Signature:

/

CVV# Date:

/

/

Please print your answers in the spaces provided below. There is only one answer for each question.

1._________ 2._________ 3._________ 4._________ 5. _________

6._________ 7._________ 8._________ 9._________ 10._________

Please complete the answer sheet above and course evaluation form on reverse. Submit both the answer sheet and course evaluation form along with the activity fee for processing. Mail to: NYSNA, attn. Nursing Education and Practice Dept. 131 West 33rd Street, 4th Floor, New York, NY 10001 Or email to: education@nysna.org or fax to: 212-785-0429

Journal of the New York State Nurses Association, Volume 48, Number 2

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The Journal of the New York State Nurses Association, Vol. 48, No. 2

Learning Activity Evaluation

Nursing Students’ Experiences on NCLEX-RN Preparation Please use the following scale to rate statements 1–7 below: Poor

Fair

Good

Very Good

1. The content fulfills the overall purpose of the CE Activity. 2. The content fulfills each of the CE Activity objectives. 3. The CE Activity subject matter is current and accurate. 4. The material presented is clear and understandable. 5. The teaching/learning method is effective. 6. The test is clear and the answers are appropriately covered in the CE Activity. 7. How would you rate this CE Activity overall? 8. Time to complete the entire CE Activity and the test?

____ Hours (enter 0–99) _____ Minutes (enter 0–59)

9. Was this course fair, balanced, and free of commercial bias?

Yes / No (Circle one)

10. Comments:

11. Do you have any suggestions about how we can improve this CE Activity?

48

Journal of the New York State Nurses Association, Volume 48, Number 2

Excellent


n CE Activity: Nurses Unions Can Help Reduce Stress, Burnout,

Depression, and Compassion Fatigue, Part 4: Promoting Quality Nursing Care Through Better Self-Care Pilot Study Results

Thank you for your participation in “Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion, Fatigue Part 4: Promoting Quality Nursing Care Through Better Self-Care Pilot Study Results,” a new continuing education (CE) activity offered by NYSNA. NYSNA members and nonmembers are invited to take part in this activity; you do not need to be a resident of New York State. INSTRUCTIONS In order to receive the 1.0 contact hour for this educational activity, participants are to read the article presented in this issue of The Journal, complete and return the post-test, evaluation form, and earn 80% or better on the post-test.

quality of care. The New York State Nurses Union (NYSNA) developed a pilot program to reduce workplace stress through the use of self-care exercises. This peer-led initiative was evaluated prior to, during, and upon completion using combined quantitative and qualitative methods. It examined the efficacy of several self-care exercises over the duration of the study, the experience of peer leaders, barriers to nurse participation, identified leading nurse stressors, and analyzed whether there was a change in symptoms attributed to work-related stress. The study explored the role of the union in facilitating workplace stress reduction so as to promote quality nursing care. Learning Outcome

This activity is free to NYSNA members and $10 for nonmembers. Participants can pay by check (made out to NYSNA) or credit card. The completed answer sheet and evaluation form may be mailed or faxed back to NYSNA; see the evaluation form for more information.

Participants will identify how the integration of daily self-care strategies through a peer-led stress-reduction program can mitigate the harmful consequences of workplace stress.

The New York State Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

OBJECTIVES

This program has been awarded 1.0 contact hour through the New York State Nurses Association Accredited Provider Unit. The New York State Nurses Association is accredited by the International Association for Continuing Education and Training (IACE) and is authorized to issue the IACET continuing education units (CEUs). The New York State Nurses Association is authorized by IACET to offer 0.1 CEUs for this program. In order to receive contact hours and CEUs, participants must read the entire article, fill out the evaluation, and get 80% or higher on the post-test. Presenters disclose no conflict of interest. NYSNA wishes to disclose that no commercial support was received for this educational activity. All planners/authors involved with the development of this independent study have declared that they have no vested interest. NYSNA program planners and authors declare that they have no conflict of interest in this program.

By completion of the article, the reader will be able to: 1. Identify environmental and workload stressors that nurses face daily. 2. Analyze stress-reduction strategies. 3. Identify the negative consequences of workplace stress on health and professional well-being. 4. Define the efficacy and barriers of a peer-led stress reduction program. Please answer either True or False to the questions below. Remember to complete the answer sheet by putting the letter of your corresponding answer next to the question number. Each question has only one correct answer. The 1.0 credit hour and 0.1 CEU for this program will be offered until December 1, 2024. 1) The literature suggests that a few simple factors contribute to workplace stress. a. True b. False

INTRODUCTION The reduction of workplace stress is a priority identified by the National Institute for Occupational Safety and Health for all industries. In health care, nurses report a disproportionate level of workplace stress with consequential adverse physical and mental health. A silent operator, workplace stress leads to burnout and turnover, cost to healthcare organizations, and reduced

2) Effects from workplace stress include headaches, impaired personal relationships, poorer work performance, and reduced patient safety. a. True b. False

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3) The majority of nurses who have access to a workplace stress-reduction program participate in it.

7) Deep breathing helped participants “slow things down,” which helped them focus more clearly on tasks at hand.

a. True

a. True

b. False

b. False

4) Participants identified improvements in their relationships with coworkers and a more positive work environment when engaging in peer-led stressreduction programs.

8) Some participants found that linking a self-care exercise with an activity, such as handwashing or an alarm on their phone, helped them overcome the challenge to remember to use the exercise.

a. True

a. True

b. False

b. False

5) A pilot study conducted by nurses demonstrated that mental health may have been improved through the use of self-care exercises for stressreduction. a. True

9) Integrating self-care into routine daily work life can effectively reduce work stress for individuals and peer groups. a. True b. False

b. False 10) Workplace stress can cause body aches, sleep disruption, and burnout. 6) The short-term length of the program was identified as a barrier to conducting a peer-led stress-reduction program. a. True

a. True b. False

b. False

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Journal of the New York State Nurses Association, Volume 48, Number 2


The Journal of the New York State Nurses Association, Vol. 48, No. 2

Answer Sheet Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue, Part 4: Promoting Quality Nursing Care Through Better Self-Care Pilot Study Results Note: The 1.0 contact hour and 0.1 CEU for this program will be offered until December 1, 2024. Please print legibly and verify that all information is correct. First Name: MI: Last Name: Street Address: City: State: Zip Code: Daytime Phone Number (Include area code): Email: Profession: NYSNA Member # (if applicable):

Currently Licensed in NY State? Y / N (Circle one)

License #:

License State:

ACTIVITY FEE: Free for NYSNA members/$10 nonmembers PAYMENT METHOD Check—payable to New York State Nurses Association (please include “Journal CE”). Credit Card:

Mastercard

Visa

Discover

American Express

Card Number: Name:

Expiration Date:

Signature:

/

CVV# Date:

/

/

Please print your answers in the spaces provided below. There is only one answer for each question.

1._________ 2._________ 3._________ 4._________ 5. _________

6._________ 7._________ 8._________ 9._________ 10._________

Please complete the answer sheet above and course evaluation form on reverse. Submit both the answer sheet and course evaluation form along with the activity fee for processing. Mail to: NYSNA, attn. Nursing Education and Practice Dept. 131 West 33rd Street, 4th Floor, New York, NY 10001 Or email to: education@nysna.org or fax to: 212-785-0429 Journal of the New York State Nurses Association, Volume 48, Number 2

51


The Journal of the New York State Nurses Association, Vol. 48, No. 2

Learning Activity Evaluation

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue, Part 4: Promoting Quality Nursing Care Through Better Self-Care Pilot Study Results Please use the following scale to rate statements 1–7 below: Poor

Fair

Good

Very Good

1. The content fulfills the overall purpose of the CE Activity. 2. The content fulfills each of the CE Activity objectives. 3. The CE Activity subject matter is current and accurate. 4. The material presented is clear and understandable. 5. The teaching/learning method is effective. 6. The test is clear and the answers are appropriately covered in the CE Activity. 7. How would you rate this CE Activity overall? 8. Time to complete the entire CE Activity and the test?

____ Hours (enter 0–99) _____ Minutes (enter 0–59)

9. Was this course fair, balanced, and free of commercial bias?

Yes / No (Circle one)

10. Comments:

11. Do you have any suggestions about how we can improve this CE Activity?

52

Journal of the New York State Nurses Association, Volume 48, Number 2

Excellent


n CE Activity: Adaptation to Motherhood for Rural Women With Newborn(s) in the Neonatal Intensive Care Unit

Thank you for your participation in “Adaptation to Motherhood for Rural Women With Newborn(s) in the Neonatal Intensive Care Unit,” a new continuing education (CE) activity offered by NYSNA. NYSNA members and nonmembers are invited to take part in this activity, and you do not need to be a resident of New York State.

neonate and the mother will influence maternal adaptation, and ultimately the short- and long-term maternal-child relationship. Knowing where patients come from can inform nurses considerations in supporting the new and/or growing rural family. This study utilized the Roy adaptation model (RAM) as a framework for structured inquiry into the phenomenon of rural maternal adaptation.

INSTRUCTIONS In order to receive 1.0 contact hour for this educational activity, participants are to read the article presented in this issue of The Journal, complete and return the post-test, evaluation form, and earn 80% or better on the post-test.

Learning Outcome

This activity is free to NYSNA members and $10 for nonmembers. Participants can pay by check (made out to NYSNA) or credit card. The completed answer sheet and evaluation form may be mailed or faxed back to NYSNA; see the evaluation form for more information.

OBJECTIVES

The New York State Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation. This program has been awarded 1.0 contact hour through the New York State Nurses Association Accredited Provider Unit. The New York State Nurses Association is accredited by the International Association for Continuing Education and Training (IACET) and is authorized to issue the IACET continuing education units (CEUs). The New York State Nurses Association is authorized by IACET to offer 0.1 CEU for this program. In order to receive credit hours and CEUs, participants must read the entire article, fill out the evaluation and get 80% or higher on the post-test. Presenters disclose no conflict of interest.

Participants will recognize that trust-building is crucial to rural mothers’ adaptation to motherhood when newborns are placed in the NICU.

By completion of the article, the reader will be able to: 1. Discuss the unique vulnerabilities of adapting to motherhood for rural women when they have a newborn in the neonatal intensive care unit (NICU) 2. Discuss how the Roy adaptation model is applicable to studying the experiences of rural-based mothers who have a newborn in the NICU. 3. Identify how trusting relationships facilitate maternal adaptation for the mother living in a rural community with a newborn admitted into a NICU. Please answer either True or False to the questions below. Remember to complete the answer sheet by putting the letter of your corresponding answer next to the question number. Each question has only one correct answer.

NYSNA wishes to disclose that no commercial support was received for this educational activity.

The 1.0 contact hour and 0.1 CEU for this program will be offered until December 1, 2024.

All planners/authors involved with the development of this independent study have declared that they have no vested interest.

1) The admission of a newborn to the NICU represents the same challenges for rural dwelling mothers as it does for urban mothers.

NYSNA program planners and authors declare that they have no conflict of interest in this program. INTRODUCTION Women living in rural communities face greater risk for severe complications during pregnancy and childbirth than urban dwelling women. Yet little is known about the experience of mothers’ adaptations to motherhood when their newborns require a stay in a neonatal intensive care unit (NICU). Positive role adaptation bolsters an individual’s confidence and well-being. This places them at lower risk for anxiety, depression, distress, which can otherwise interfere with maternal adaptation. The role of “mother” is critical to the immediate and long-term health of newborns, particularly in the rural setting. The therapeutic relationship nurses and other healthcare providers working in the NICU setting can offer to the

a. True b. False 2) One of the most important contextual stimuli identified in this study was first-time motherhood. a. True b. False 3) Identifying as a mother was different for mothers under age 21 than it was for those who were older. a. True b. False

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4) Rural dwellers are receptive to help from people outside of their community when children are in need.

8) Nurses can support and encourage mothers to provide care for their newborns as a way to enhance maternal adaptation to motherhood.

a. True

a. True

b. False

b. False

5) The feeling of guilt interferes with women’s adaptation to motherhood in the NICU setting.

9) The authors identify the nurses’ ability to build trusting relationships as an essential skill that may be incorporated into nursing education.

a. True

a. True

b. False

b. False

6) Trust was identified by the authors as a mediator of level of adaptation where it seemed to enhance maternal adaptation. It can also be considered for other patients in their adaptive experience. a. True

10) The greatest help described by mothers under the age of 21 was their own mother. a. True b. False

b. False 7) During patient recruitment, researchers realized that nurses did not know where the mothers of their patients lived. a. True b. False

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Journal of the New York State Nurses Association, Volume 48, Number 2


The Journal of the New York State Nurses Association, Vol. 48, No. 2

Answer Sheet Adaptation to Motherhood for Rural Women With Newborn(s) in the Neonatal Intensive Care Unit Note: The 1.0 contact hour and 0.1 CEU for this program will be offered until December 1, 2024. Please print legibly and verify that all information is correct. First Name: MI: Last Name: Street Address: City: State: Zip Code: Daytime Phone Number (Include area code): Email: Profession: NYSNA Member # (if applicable):

Currently Licensed in NY State? Y / N (Circle one)

License #:

License State:

ACTIVITY FEE: Free for NYSNA members/$10 nonmembers PAYMENT METHOD Check—payable to New York State Nurses Association (please include “Journal CE”). Credit Card:

Mastercard

Visa

Discover

American Express

Card Number: Name:

Expiration Date:

Signature:

/

CVV# Date:

/

/

Please print your answers in the spaces provided below. There is only one answer for each question.

1._________ 2._________ 3._________ 4._________ 5. _________

6._________ 7._________ 8._________ 9._________ 10._________

Please complete the answer sheet above and course evaluation form on reverse. Submit both the answer sheet and course evaluation form along with the activity fee for processing. Mail to: NYSNA, attn. Nursing Education and Practice Dept. 131 West 33rd Street, 4th Floor, New York, NY 10001 Or email to: education@nysna.org or fax to: 212-785-0429

Journal of the New York State Nurses Association, Volume 48, Number 2

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The Journal of the New York State Nurses Association, Vol. 48, No. 2

Learning Activity Evaluation

Adaptation to Motherhood for Rural Women With Newborn(s) in the Neonatal Intensive Care Unit Please use the following scale to rate statements 1–7 below: Poor

Fair

Good

Very Good

1. The content fulfills the overall purpose of the CE Activity. 2. The content fulfills each of the CE Activity objectives. 3. The CE Activity subject matter is current and accurate. 4. The material presented is clear and understandable. 5. The teaching/learning method is effective. 6. The test is clear and the answers are appropriately covered in the CE Activity. 7. How would you rate this CE Activity overall? 8. Time to complete the entire CE Activity and the test?

____ Hours (enter 0–99) _____ Minutes (enter 0–59)

9. Was this course fair, balanced, and free of commercial bias?

Yes / No (Circle one)

10. Comments:

11. Do you have any suggestions about how we can improve this CE Activity?

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Journal of the New York State Nurses Association, Volume 48, Number 2

Excellent



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