Registered Nurse Stress: Implementing Relaxation Response Technique

This evidence-based project focuses on the impact of occupational stress on registered nurses and how relaxation response technique can help manage stress levels. The project proposes implementing a breathing technique to minimize stress levels and increase coping mechanisms among RNs working in high stress areas. The project recommends implementing the technique via education programs or rescheduling shift hours.

Running head: REGISTERED NURSE STRESS
Registered nurse stress
Name of the Student
Name of the University
Author Note

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Abstract
Nursing profession involves high workplace pressure and demand, and it increases stress.
Stress due to work in high stress areas like oncology, intensive care unit, and increases
psychological and physiological demand. This is considered problem for nurses as it impacts the
work performance and eventually the patient care. The evidence based project or EBP focuses on
stress among registered nurses. The problem is considered significant as the nurses free from
stress or with coping ability to stress are able to deliver high quality nursing care. The findings
from literature review showed that stress reduction methods like tai chi, yoga, music therapy has
been effective in reducing stress among nurses and better addressing patient needs. The EBP
project is an effort to help improve the efficiency of registered nurses or RNs working in
hospitals in high stress areas. The purpose of the project is to implement a relaxation technique
that is breathing technique for nurses to minimize the stress levels by increasing the coping
mechanism. The hospital mangers can implement the stress management technique among the
RNs, working on the medical surgical unit of an acute inpatient medical facility, via education
program or rescheduling the nurse’s shit hours so that nurses can take out time for their preferred
relaxation technique.
Keywords: registered nurse, stress, relaxation response technique

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Table of Contents
Chapter I-.............................................................................................................................4
Problem statement...........................................................................................................4
Problem background........................................................................................................5
Significance of the problem.............................................................................................8
Problem statement.........................................................................................................11
Clinical Question...........................................................................................................12
Operational Definitions of Concepts.............................................................................12
Chapter II- Literature Review............................................................................................14
Introduction....................................................................................................................14
Search Strategy with Inclusion and Exclusion Criteria.................................................14
Literature Review Relevant to PICOT & Critical Appraisal of Evidence.....................15
Recommendation...........................................................................................................22
Chapter III- Proposed implementation..............................................................................24
Introduction....................................................................................................................24
Methodology..................................................................................................................24
Setting where EBP will be implemented.......................................................................27
Facilitating Factors for Implementation........................................................................27
Barriers Factors for Implementation..............................................................................27
Summary........................................................................................................................28

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Reference...........................................................................................................................29
Appendix A: Synthesis Table............................................................................................36
Appendix B: Melnyk Level of Evidence...........................................................................41
Appendix C: Model...........................................................................................................41
Appendix D: Health Promoting Lifestyle Profile II questionnaire....................................42
Appendix E: Cohen’s Perceived Stress Scale....................................................................44

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Chapter I-
Problem statement
Nursing profession is very demanding in the dynamic health care sector. Stress has
increased among nurses with increasing progress and demand in the nursing profession. The field
of nursing is broad including various specialties such as aged care, dialysis, emergency trauma
units and others. In different specialties there is different level of stress. Stress occurs when the
demand placed on an individual outweighs the resources. Nurses are experiencing stress due to
psychological and physiological demand (Brborovic et al., 2016). Nursing professionals undergo
huge stress that impacts the work performance and eventually the patient care. Stress causes
emotional exhaustion among nurses. Additional factors of stress lead to chronic stress such as
home stress, and occupational stress. Occupational stress factors include poor supervision or
poor working relationships, home-work imbalances, demanding communication, and
understaffing. Stress is considered problem for nurses as it drives turnover and mobility
(Gulavani & Shinde, 2014). The EBP project is focused on the nursing professional related
occupational stress.
As explained above, occupational stress brings about major hazardous impacts on health
of the nurses and greatly affects their coping abilities with stress and job demands. There is an
established physiological assessment that supports the relationship between identified
occupational stress and illness (Sharma et al., 2014). In fact, work stress is cited as a severe
health problem among nurses as their role is based on human suffering, physical labour, and
staffing, work hours and interpersonal relationships. They are unable to deal with the stressors
effectively with lessening of impact and recurrence of stress among nurses. Occupational stress

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has significant effect on the physical and mental well-being of nurses as they show lack of
concentration, insomnia, become irritable, decreased performance and results in absenteeism and
burnout (Mosadeghrad, 2013). The high levels of distress may result in suicidal thoughts and
symptoms of depression.
Nurses need to learn to cope up with stress as it is a useful skill for nursing profession
and a life ahead. The term coping is used to describe the behavioural and cognitive efforts that an
individual employ for stress management categorized as problem and emotional focused coping.
Coping with stress is a dynamic process that is aimed at growth, survival and maintenance of
individual integrity (Folkman, 2013). Although, there are no standard guidelines for coping
strategies, yet healthy coping techniques are beneficial in managing stress among nurses. Various
coping strategies are used by nurses to manage stress like diversion, ventilation, self-reliance,
ventilation, avoidance, social peer group and support. For implementing one of the healthy
coping strategies that can help nursing workforce is relaxation response technique in managing
stress and eliminates stress factors. This technique encompasses meditation, deep breathing, yoga
and rhythmic exercise that is helpful in turning off flight or fight response that brings the body
back to the pre-stress levels (Patterson, 2016). Therefore, relaxation response technique can be
helpful for RNs in managing stress by activating the natural relaxation response of the body.
Problem background
In the performance of the health care workers stress has been recognized as the flash
point. It needs to be managed for effective health care delivery. When a person is exposed to
stress a set of physical reactions occur. In the holistic view of the patient, the concept of stress
can be seen as active. Stress according to World Health Organization, is the response of the
employees towards the pressure and demand of workplace that does not match with their ability

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and knowledge, challenging their ability to manage stress (Iyi, 2015). Stress also arises when
individual cannot cope with the workplace demands and threats to workplace. Godwin et al.
(2016) define stress as the “emotional and physical reactions” emerging from the workplace
demands and pressures that outweigh the capabilities and resources to manage the demands.
The response to stress can be of emotional, physical, psychological, or spiritual nature.
Stress is triggered by many internal and external factors. A moderate level of stress can be
motivating factor and is necessary at a normal level. It is known as Eustress and the same may be
considered as Distress or negative phenomena when stress continues for prolonger period
(Woodruff, 2018). Physical stressors affect body, feelings, thoughts and behaviour in many
ways. The physical and emotional ways in which body responds to pressure may cause physical
and mental problems. Stress may cause headache, fatigue, muscle tension, sleep problems and
changes in normal functioning of the body. Mood is also affected due to stress as it causes
restlessness, anxiety, lack of motivation to work, anger, depression or sadness. Unhealthy coping
behaviour can also developed due to stress like angry outbursts, alcohol or drug abuse, tobacco
consumption and social withdrawal (Drury et al., 2014).
Cognitive-emotional stress arises with response to the environmental changes (Khamisa
et al., 2015). There are various factors of stress among nurses including role ambiguity,
workload, and decreased job autonomy, less opportunities to learn on the job, insufficient
support from the supervisor and inadequate feedback from the supervisors/patients. A study
conducted by Yoder (2010) highlighted the fact that triggering situations and compassion fatigue
is witnessed in nurses who work for long shift hours like eight to twelve hour shifts. Moreover,
working unit and time of shift also triggers compassionate fatigue among nurses that demands
personal and work-related coping strategies. A study by Wilson & Nutt (2013) highlighted how

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working long hours shift, especially consecutive 12 hours shift in a row contributed to sleep
deprivation that eventually affect the nurse quality of life.
There are serious consequences of stress in nursing that can lead to emotional
disturbances and mental disorders as it is extremely debilitating. The negative impact of stress is
severe and can cause destructive psychological and physical effects along with direct
psychological consequences like exhaustion and illness. This reduces their work efficiency, low
job satisfaction and negative working attitudes that degrade their overall quality of life and
quality of healthcare that they offer. The quality of healthcare that is delivered is also hampered
as it is inextricably linked to occupational health and safety of nurses and cannot be considered
in isolation (Dyrbye et al., 2017). If nurses face occupational stress, it deteriorates the quality and
quantity of patient care compromising patient safety and health outcomes. High levels of
sustained stress can cause distress that ultimately results in decreased performance and
productivity. This is due to the fact that compassion fatigue and moral distress have severe
effects in terms of feelings of powerlessness, dissatisfaction and poor mental and physical health
outcomes.
Occupational stress among nurses triggers a reaction known as flight or fight response
that prepares body in surviving perceived external threat associated with psychological changes
produced by adrenal-cortisol and sympathetic nervous systems. In turn, activation of these
systems releases hormones that cause increase in heart rate, blood-glucose levels, blood pressure
and constriction of blood vessels in the body causing changes in the body. The long-term
consequences of stress can exacerbate or cause serious health problems like anxiety, depression,
and cardiovascular diseases including high blood pressure, heart disease, abnormal heart
rhythms, stroke and heart attacks. If these stressors are short-lived or infrequent, then the body is

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at low risk. However, repeated activation of these systems due to chronic or frequent episodes of
stress can give rise to many symptoms that affect health, mood and behaviour and may
contribute to development of health conditions either acute or chronic (Farquharson et al., 2013).
In order for the nurses to meet the World Health Organization’s standard, that is state of
the “complete physical, mental and social well being and not just the absence of disease”, care
provision must be effective (Iyi, 2015). Nursing stress is an important health issue as it affects
the quality of care provided by them. High levels of stress among them contribute to increased
percentage of safety breaches, sub-optimal patient care and frequent medical errors. According to
Chou, L. P., Li & Hu, (2014) personal factors like stress and tiredness are one of the factors that
cause medication errors as nurses lose the compassion to work for the patients and result in
unfavourable quality of health delivered. Wrong medication doses, wrong patient and other
nursing errors contribute to poor patient care. Therefore effective coping strategies are demanded
for nurses in reducing stress and in delivering quality patient care, thus ensuring patient safety
and integrity.
The nursing stress encountered by nurses varies based on the specialty. The kind of
occupational stress encountered by a home-care nurse or long-term facility/rehabilitation center
is different from stressor’s nurses who work in an acute inpatient facility. Stressors as recognized
by nurses in a descriptive qualitative study, through a semi-structured interview were categorized
into four groups which include work demands, emotional pressure, professional recognition and
interpersonal relations (Souza et al, 2017).
Significance of the problem
Nursing profession demands empathetic, delivery of humane, moral and proficient care,
culturally sensitive working environments with increasing responsibilities and limited resources.

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If there is any sort of imbalances witnessed in these factors, it can result in stressful working
conditions leading to unhealthy coping behaviour and burnout among nurses. Work-related stress
can contribute to job dissatisfaction and poor mental and physical health. Stressors also
contribute to work-related stress experiences including patients and peer conflict, poor
supervision, overtime and high demand in jobs (Khamisa et al., 2015). In addition, prolonged
exposure to occupational stress among nurses can result in lack of personal accomplishment,
depersonalization and emotional exhaustion. Stress theory by Cannon explains that prolonged
stressors exposure with imbalance in homeostasis can result in biological system breakdown
preventing anticipatory and compensatory changes that affects coping abilities of the nurses
(Palkovits, 2014). Healthy coping ability and strategies are required for the nurses as they play
the central role in healthcare and at the forefront of patient health and safety. These abilities can
reduce stress and influence nurses’ health and performance. Various stress coping strategies for
nurses can facilitate adoption, sustenance and maintenance of healthy behaviours among nurses
that can promote both their health and well-being. Nurses are healthy working in safe
environments; it can contribute to a well-functioning nursing workforce with improved job
satisfaction, retention, quality of care and thereby ensuring patient safety and satisfaction
(Happell et al., 2013).
Health issues among nurses due to occupation stress includes lower back pain, headache,
insomnia, despair, mood swings, fatigue, and certain diseases like stroke, myocardial infarction,
caused by persistent stress. The physical and emotional health effects may result in
psychosomatic disorders in the long run. The loss to organization due to nurses’ stress includes
economic loss, and ethical and legal issues. It may be caused by the lack of attention of nurses,
wrong decision, medical errors, or misdiagnosis, poor judgment, which are all the cause of

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chronic stress among nurses. Poor correlation has been obtained between the nursing
performance and the organizational commitment (Khamisa, Oldenburg, Peltzer & Ilic, 2015).
Untreated stress results in the nurse turnover. According to the 2018 “National Health Care
Retention & RN Staffing Report”, the cost of turnover for a bedside RN on an average remained
consistent at $49,500. It ranges from $38,000 to $61,100 which results in average hospital losing
$5.7M. Also, one must consider the cost of training a new nurse to integrate into the facility
(Khamisa, Oldenburg, Peltzer & Ilic, 2015).
Nurses free from job burnout can deliver high quality nursing care. They will work with
ultimate aim of the patient satisfaction. Nurses directly can influence the patients who perceive
the quality of care based on the involvement and the interaction with the nurses (Khamisa et al.,
2015). A positive correlation has been found between the nurse’s job satisfaction and the fall rate
of the patients.
There are many traditional means of managing the daily stress. It may include the
psychological therapies, or physical exercises, or any other mindfulness practice. The choice of
the technique depends on the nature of the stress. Learning healthy coping strategy is the best
management practice. In nursing profession, organized individual working practice and
organized management structure has been recognized as effective in coping with stress. Other
measures that will help nurses to cope up with stress include decreasing the working hours,
increasing the nurse is to patient ratio, and availability of social support and stress reducing
training program (Iyi, 2015). Godwin et al. (2016) conducted a descriptive study on this issue, he
recommends the need to manage the wok environment and have a means to access the stress
management measures.

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Holistic approach in coping with stress was recommended in a study conducted, to
demonstrate the effect of relaxation response, which is a diaphragmatic breathing for a specific
time period. This method was derived from a book written by a psychologist, Dr. Benson, in
order to help cope with stress, for instance, alleviate occupational stress (Calder Calisi, 2017).
Similar studies on stress response mechanism emphasize on the breathing technique, mindfulness
based exercises, yoga, meditations, guided imagery, progressive muscle relaxation techniques
(Kwekkeboom & Bratzke, 2016). Nurses can cope with stress through self care through
relaxation centre, or receive reiki, or light massage, in a quiet and comfortable setting
(Braunschneider, 2013). Ghafari et al. (2009) conducted a research on the muscle relaxation
technique to improve the quality of the life of patients with multiple sclerosis. The results
showed increase in quality of life of patients. According to Patel (2014), progressive muscle
relaxation technique is effective for the registered nurses to reduce the stress level.
In conclusion the problem of nurse stress is significant and calls for need of coping
mechanism of stress. It implies need of collective action at the organizational level that will
promote nurses' abilities to cope up with stress.
Problem statement
In nursing profession, they confront wide range of occupational health and safety (OHS)
risks while performing their roles of providing care to the people under their provision. The
sources of occupational stress include patient care, taking responsibility, decision-making and
change. Although, there is increased awareness about the problem of stress in nursing, however,
nurses experience high levels of stress in meeting their professional standards. According to
American Nursing Association (ANA) nurses at workplaces experience higher levels of stress as
compared to other professions including stressors like physical demands, lack of resources,

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management issues and imbalances in work and home responsibilities (Rushton et al., 2015).
Therefore, the purpose of the EBP project is to reduce stress levels through the utilization of
stress management techniques among RNs. The rationale for utilizing this technique is to
enhance coping mechanism in individual nurses through the implementation of evidence-based
stress reduction techniques. The technique of relaxation response would help in reducing stress
levels in RNs while they care for patients in acute inpatient facilities.
Clinical Question
A PICO question is designed for this EBP project-
“Will implementation of stress management techniques like yoga, tai chi,
meditation, on a daily basis minimizes the stress level in RNs caring for patients by
working on a high stress areas of an acute inpatient medical facility?”
Population: RNs working full time or long shift hours in high stress areas.
Comparison: RN that utilizes stress reduction technique versus those without.
Outcome: Decreased stress level in RNs via Perceived Stress Scale (PSS)
Scores
Time: 3 months
Operational Definitions of Concepts
Stress management technique- A technique encompassing breathing or meditation, yoga,
tai chi, prayer, visualization, that increases the body’s ability to release brain signals/chemicals
that increase blood flow to the brain and slows down the muscles/organs relieving from stress
and opposing the fight or flight response.
Registered nurses- qualified with basic B.Sc. Nursing and working with a designation of
Staff Nurse or oncology nurse or any other specialized domain

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Stress- is the physical or emotional disturbance of the employees towards the pressure
and demand of workplace that does not match with their ability and knowledge, challenging their
ability to manage pressure.

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Chapter II- Literature Review
Introduction
This section focuses on the extensive literature search that will be conducted to extract
available studies from the vast pool of literature on relaxation response techniques for RNs. This
technique is considered a self-care strategy where nurses learn to become confident and adopt
healthy coping ability that in turn helps in reducing their workplace stress and anxiety. This
technique is beneficial in reducing their occupational stress as the nurses get engaged in stress
reduction technique of response relaxation. The implementation of relaxation response technique
would help in reducing stress levels among nurses through production of natural relaxation
response of body that is characterized by lower blood pressure, slower breathing and increased
health and well-being (Smith, 2014). In addition to the relaxation response technique, the scope
of literature search also includes effectiveness of the relaxation response technique on stress
reduction among registered nurses.
Search Strategy with Inclusion and Exclusion Criteria
Search for articles was conducted using the Fairleigh Dickinson University's (FDU)
online library and CINAHL (Cumulative Index to Nursing and Allied Health Literature) plus
with full text database. The keyword used for searching the databases are- Registered Nurses,
stress, high stress areas, medical surgical unit, job burn-out, long shift hours, fatigue, tai chi,
yoga, meditation, and coping stress. The databases were searched using different combinations
of keywords. Initially the search yielded 6,399 articles. To narrow down the search it was limited
to full text articles published only in English language, published between 2007-2018 and peer
reviewed articles. This search limitation ensured validity of the study.

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The inclusion criteria for the selection of article and data extraction was studies dealing
with RNs, working on a medical-surgical unit, working full time on a day shift, or either twelve
or eight hours shift period. The articles that matched with the PICO question was considered for
data extraction. The inclusion criteria include studies dealing with RNs working in high stress
areas such as medical surgical unit, oncology setting and others. Another inclusion criteria is
RNs with 1 or more years of experience and working for long shift hours. The exclusion criteria
for the selection of article includes nurses stressed with illness and stress among enrolled nurses,
student nurses and midwifes. In case of review papers studies dealing with stress reduction
among student nurses are also considered. The exclusion criteria for article search are patents
with stress due to illness. Articles that were non-peer reviewed and beyond 8 years old were
excluded.
The inclusion and exclusion criteria helped narrowed down the articles to 10 articles hat
address the stress and fatigue of the nurses using the relaxation and stress minimizing methods. It
included studies conducted both in Unite States and outside. The studies included in the search
are randomized control trials, systematic review, experimental studies, and qualitative studies are
also included in the study.
Literature Review Relevant to PICOT & Critical Appraisal of Evidence
The level of evidence or LOE rating system as per Melnyk (2015) was used. According
to this system there are five RCT (LOE 1), two experimental study (LOE 1), one literature
review (LOE 5), two systematic review (LOE1) and one qualitative study (LOE 3) (See
Appendix B).
At level 1, the pretest and posttest randomized control study conducted by Najafi et al.
(2015) evaluated the effectiveness of Benson relaxation on fatigue of registered nurses working.

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The sample population includes nurses working in intensive care units. This experimental study
was conducted in Iran involving 63 nurses as participants. They were randomly allocated to the
control and intervention groups. For nurses in the intervention group the Benson’s relaxation
technique was implemented twice a day for 20 minutes. Two sessions were conducted in the
interval of 6 hours. These two weeks relaxation therapy was then evaluated using the fatigue
questionnaires followed by the statistical analysis using Chi-square test, independent t-test,
Fisher exact test and lastly the analysis of variance using SPSS version 21. As per the findings
the intervention group between the week 1 and 2 after intervention and before the intervention
showed mean SD of fatigue score are 4.58(0.94), 4.38(0.85), and 4.73(0.97), respectively. Over
time the mean fatigue score of the control group increased at (P=0.002) and there was significant
difference in terms of fatigue between both groups. This contributes to the strength of the study.
It can be concluded from the study that the Benson relaxation technique is useful to decreases the
fatigue and stress among nurses. It can be used for stress reduction plan. There is a probability
that the nurses missed the relaxation method as per false report. There is also chance of
contamination of the control group information. There was also no study blinding because of
self report data. The random group was preferred over the control group to miss the data
transmission.
Raingruber, & Robinson (2007) conducted study using the qualitative phenomenological
approach, (level 3) to evaluate the self care program designed for registered nurses. The program
consist of Yoga, Tai chi, meditation, Reiki healing sessions where the nurses taking the
intervention will have self report the experiences of 3 months course. The researcher explored
the shared experiences of the nurses and collected their reflective understandings. The
intervention required compulsory weekly attendance and at the end of the interventions

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submitted the self-care journals. The outcomes include sensations of warmth described by nurses
and feeling of warmth. They also described enhanced ability to solve patient’s needs. It means
the hospitals investing in the self care options for nurses can assume the work related benefits
and patient outcomes. However, these results are applicable only other similar setting in hospital
with similar population. It may be generalisable only if the similar philosophy of care is used in
other hospitals as well as nurse-patient ratio. Moreover, there is only 35 out of 49 nurses who
returned the self-care journals. The strength of the study includes nurses attending the classes on
a consistent basis in a 3 months course never missing more than one session.
In similar other pretest and post test study design by Patel (2014)) at level 1, tested the
effectiveness of the “Progressive Muscles Relaxation Therapy” to manage stress among the
registered nurses. The pretest and postest stress score when measured by Stress Assessment
Rating Scale. A total of 30 registered were recruited in the study for Progressive Muscles
Relaxation Therapy, in selected hospitals of the Vadodara city. The mean post-test stress score
was 36.67, and it is lower than the mean stress core of pretest 64.17. As per the results the 53.3
% nurses in the pre test had moderate stress, while mild stress was observed in the 40.0% of
nurses and severe stress was observed in the 6.7% nurses. After intervention, mild stress was
noted in 73.3 % of nurses and rest was found with no stress. There was significant reduction in
the stress after relaxation technique.
Guillaumie, Boiral & Champagne (2017) conducted a mixed method systematic review
of to assess the effectiveness of the mindfulness based programs such as meditation tai chi,
breathing technique on nurses in the adult hospital setting. This study of level 1, involves both
the qualitative and quantitative data. The data analysis was conducted based on the Thomas and
Harden framework. A total of 32 studies were included and as per metaanalysis, mindfulness‐

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based interventions may be effective in reducing workplace stress and related anxiety. Such
intervention as found from the review showed increases in calmness, awareness and enthusiasm
in work. It also improved the workplace performance and higher sensitivity towards patient’s
needs. The mindfulness intervention has been found to improve the mental health of nurse.
However, there is need to assess the long term impact of this intervention.
In the randomized control trial by Hersch et al. (2016), at level 1, the effectiveness of the
web based breathe program was evaluated. The BREATHE program was aimed for reducing
stress among nurses. In this program the nurses were taught different stress management
strategies, avoidance of negative coping such as use of alcohol, and other methods such as
assessment of triggers of stress. A total of 104 nurses were recruited including the registered
nurses. The primary outcome of the study was perceived stress related to the workplace and the
secondary outcomes includes job satisfaction, coping work limitations, and understanding
anxiety and stress. The participants in the interventions group showed significant reduction in the
stress in comparison to the control group.
The quantitative study involving hypothesis testing at level 1 by Villani et al. (2013)
evaluated the short term effects of the self-help stress management training for registered nurses
working in oncology department. Oncology is considered to be one of the most stressful
specialty areas in nursing. The study included sample size of 30 female oncology nurses working
as permanent employee in Italy. The intervention involves use of mobile phone for relaxation
and coping with stress. Participants in the experimental study undergoing SIT or stress
inoculation training through mobile phones were compared with the control group who were
allowed to use only mobile phones and neutral videos. The findings showed improvement in the
psychological improvement with acquisition of stress coping skills as well as reduction in

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anxiety and there was no change in control group. However, the study is limited due to small
sample size. Moreover, only self reporting questionnaires were used to measure the emotional
and affective states. However, the strength of the paper includes possibility of development of
the controllable self-help stress management-mediated experiences for registered nurses.
Another randomized crossover control trial by Lai & Li (2011) at level 1 examined the
efficacy of the music therapy on stress among the registered nurses. The study involves 54
registered nurses randomly assigned to the music and “chair rest sequence or the chair rest and
music sequence”. The intervention lasts for 30 minutes. Participants in the music intervention
group listened to x soothing music for 30 minutes. On the other hand the participants in the chair
rest group were allowed for sitting quietly for 30 minutes. Both the group outcomes were
measured using the parameters such as mean arterial pressure, mean arterial pressure, finger
temperature and blood pressure. The outcome of both the groups was compared. The participants
in the music therapy group showed less perceived stress level as well as heart rate, finger
temperature, heart rate, cortisol, mean arterial pressure at (P < 0·05). The perceived stress level
was lower when compared to the chair rest group. There was significant difference between the
two groups in regards to the post-test heart rate, finger temperature, cortisol levels. The mean
music preference score was 8·81 (sd = 1·05) and significant association was found with the
cortisol levels, self-perceived stress, finger temperature and mean arterial pressure. The strength
of the study is the crossover randomized controlled trial. It will help to avoid type II statistical
errors caused by insufficient sample size.
The critical literature review by Smith (2014) at level 5 determined the benefits of
mindfulness-based stress reduction method of coping with stress for nurses. The findings are
extracted from the databases like PubMed, EBSCOhost, ProQuest, Online Journal of Issues in

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Nursing and others. It includes 2 qualitative studies and 11 quantitative studies. As per the
findings from the empirical studies there are various benefits of mindfulness-based stress
reduction method for managing stress. It helps reduce anxiety, increase focus, decrease stress and
burnout. Therefore, this technique appears useful in increasing the nurse’s ability to cope up with
stress. There is need of further investigation to validate the benefits of interventions. The study
may be limited due to sample size characteristics. Most of the studies extracted has been found
with the limited sample size and sample demographics. Some of the studies also consider the
registered nurses. Some studies considered the nurses without specific age and ethnicity.
Evaluation of the data was conducted by matrix method, where each article is evaluated in
systematic manner such as “author, year, purpose, sample, N, design, interventions, and others”.
This thorough analysis gives broad picture of the collected evidence regarding the mindfulness-
based stress reduction method.
The before after experimental study by Cuneo et al. (2011) at level 1 assessed the
impact of the relaxing response technique known as Reiki when implemented for the registered
nurses working in high stress specialties like postanesthesia care unit, intensive care unit, and
others. The study involves 26 nurses and the intervention was given by Reiki Master Teachers.
The participants were assigned to complete the demographic data questionnaire and ‘Cohen’s
Perceived Stress Scale (PSS)”. 11-item demographic form and the 10-item PSS forms are used
for data collection. The psychological instrument determines the perception of stress. The
participants recruited are registered nurses experiencing the workplace stress. Reiki is the
oriental energy and healing practice. In these interventions relaxing music was used and no
words were spoken. The masters touched the head of the participants to administer the
attunement. The practice rebalances the biofield and allows the body to heal and increase the

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systemic resistance to stress. As per the self-Reiki diary comments delivered by the nurses there
was 5.9 point decrease in PSS scores. It includes good sleep, felt relaxed, and peaceful. The PSS
score from baseline to follow-up (p = .0063) is 17.9 and 12.0, respectively. The study is limited
due to small sample size and lack of control for the pilot study. The positive effects may not be
just because of the Reiki. Also the study was conducted in single stetting and hence it may not be
generalisable to other setting. However, the strength of the study is the decreases in work related
stress due to Reiki practice. The results were statistically significant (Cuneo et al. 2011).
The pilot level randomized control trial by Alexander et al. (2015) at level1 assessed the
effectiveness of yoga to improve self-care and reduce burnout among nurses. Twenty
participants were present in each group control and intervention. Yoga is the mind body practice
and the participants were given the self-care tools to increases the self-awareness and reduce
stress. Participants were trained on being conscious about their breathing. The results showed
less emotional exhaustion due to Yoga, on completion of the 8 weeks programs. Throughout the
study there was no change among the control group participants. There was significant
improvement in the intervention group. From pre test to post test intervention for mindfulness (p
= .028), self-care (p < .001), depersonalization (p = .007), and emotional exhaustion (p = .008),
there were significant improvement. It was measured using the demographic questionnaire, the
Health Promoting Lifestyle Profile II containing 52 items. The results were validated using the
ANOVA test. The study is limited due to reliance on self-report measures and lack of control
group.
Another randomized crossover control trial by Lai & Li (2011) at level 1 examined the
efficacy of the music therapy on stress among the registered nurses. The study involves 54
registered nurses randomly assigned to the music and chair rest sequence or the chair rest and

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music sequence. The intervention lasts for 30 minutes. Participants in the music intervention
group listened to self-selected soothing music using headphones for 30 minutes. On the other
hand the participants in the chair rest group were allowed for sitting quietly for 30 minutes. Both
the group outcomes were measured using the parameters such as mean arterial pressure, mean
arterial pressure, finger temperature and blood pressure. The outcome of both the groups was
compared. The participants in the music therapy group showed less perceived stress level as well
as heart rate, finger temperature, heart rate, cortisol, mean arterial pressure at (P < 0·05). The
perceived stress level was lower when compared to the chair rest group. There was significant
difference between the two groups in regards to the post-test heart rate, finger temperature,
cortisol levels. The mean music preference score was 8·81 (sd = 1·05) and significant association
was found with the cortisol levels, self-perceived stress, finger temperature and mean arterial
pressure. The strength of the study is the crossover randomized controlled trial to avoid type II
statistical errors caused by insufficient sample size.
Recommendation
Similar study can be conducted to get more reliable results using studies with large
sample size and different types of methodologies. Based on the findings it is recommended that
the hospital mangers and the health institutions should uptake stress evaluation models for the
registered nurses. They must adopt a stress reduction method or relaxation technique or a coping
model specific for their workplace to help nurses cope with stress. It will assist in assessing the
stress of the nurses at the workplace. An education program must be developed to create
awareness among registered nurses about stress management using relaxing techniques. The
assessment will help determine the most effective way of managing the stress that is most
effective relaxation method for creating the healthy environment (Lim et al., 2016). It is

23REGISTERED NURSE STRESS
recommended that the nurses should develop their personal strategies to identify their specific
nature of stress through research and constant education. To implement an effective stress
management technique there is need of collaboration between the hospital staff and mangers
(Seaward, 2017). There must be adequate awareness among the nurse mangers and nurse leaders
to support the effective communication of registered nurses (Iyi, 2015). There is further research
recommended for identification of the specific stressors and underlying pathogenesis. It will help
develop specific stressor management technique or any other possible stress treatment. There is
also need of longitudinal study design and is suggested to assess the effectiveness of
interventions like Yoga among register nurses and its long term benefits (Alexander et al., 2015).
In case of studies focusing on the self care descriptions and reports or feedback of interventions
given, there is need of “physiological or standardized stress measures” or Likert scale
evaluations. To ensure reliability, there is a need of rigorous documentation on improvement of
patient documentation. It is recommended to hospitals to invest in the self care options for nurses
as per their preferences. It will help anticipate the patient outcome and workplace benefits
Raingruber, & Robinson (2007).
.

24REGISTERED NURSE STRESS
Chapter III- Proposed implementation
Introduction
The purpose of the project is to reduce stress levels among RNs through the
implementation of evidence based practice, relaxation response technique. This breathing
technique is beneficial in minimizing the stress levels among nurses by enhancing their coping
mechanism.
Methodology
The model chosen for this EBP project is Johns Hopkins Nursing EBP model- PET
(Practice question, evidence and translation of evidence) process by Dearholt & Dang (2012).
The model consists of 3 steps for the effective implementation of the relaxation response
technique for the nurses.
Practice question
To effectively use this model Dearholt & Dang, states to “develop practice question”.
This can be achieved through understanding and inquiring the level of awareness about the
significant problem of stress among RNs (target population). The hospital managers or the nurse
leaders can work together in assembling the “evidence”, which is the step two of the model
(Dearholt & Dang, 2012). For the practice question the managers of the hospitals can assign
roles to a team for developing EBP question. Every team member should be assigned with
individual team roles taking the responsibility of developing the EBP question. Through,
frequent team meetings, the merits and demerits of the practice question can be discussed. The
identified problem is registered nurse related stress and decrease in high quality care given to the
patients. The practice question in this regards for EBP implementation may be determining the

25REGISTERED NURSE STRESS
effectiveness of the relaxation response technique (tai chi, yoga or mediation) when implemented
for registered nurses twice in day.
Data or evidence collection
To collect the evidence, the team of graduate nurses in the desired hospital will use the
online databases like Medline, CINAHL, and Cochrane to extract reliable and peer-reviewed
studies. This will be conducted by entering appropriate keywords or search terms on search bar
of electronic databases for filtering and retrieving articles in regards to relaxation response
technique and its impact on stress reduction. Furthermore, the graduate nurses will undertake an
extensive reading of abstracts of the articles for the synthesis of the body of evidence (Dearholt
& Dang, 2012). They will note down the merits and demerits of relaxation response technique
that would be helpful in understanding its effectiveness.
As a nurse practitioner my role would be to collect, compile and appraise the findings in
details and compare with the external data. I will also have the responsibility of convincing the
stakeholders on the implementation process by making poster presentation or writing blogs about
the purpose and benefit of proposed intervention. If the short term goal of reduction in stress
levels among nurses, following implementation of the intervention is achieved (as perceived
through the PSS scores and reflective diary) I would disseminate the results to a wider audience.
I would also determine the outcome and cost-effectiveness of the intervention, followed by
recommending it to different agencies for its implementation on a broader scale.
Translation of evidence
The third step deals with translation of the evidence (Dearholt & Dang, 2012). In this
process the nurse and the physician’s teams may determine the feasibility of the evidence and its
appropriateness in the hospital setting. In this step the EBP project implementation team will

26REGISTERED NURSE STRESS
create an action plan for the registered nurses working on high stress areas for long shift hours.
This may be followed by design of an action plan for short period of time. The intervention will
be implemented after taking consent from the hospital managers and senior level supervisors.
The team will have an open floor discussion on the relaxation response technique to be
implemented in the hospital for registered nurses.
The action plan would involve distribution of three sets of PSS scales in sealed envelopes
to the RNs before implementation of the relaxation response technique. They will be asked to
give responses for the ten questions present in the scale according to the scores provided against
each response. They will be asked to respond in a similar manner to the remaining two sets of
PSS during the intervention and after a three-month follow-up period respectively.
Evaluation of outcomes
The final PSS scores for the three time intervals will be calculated and analyzed to get an
overview of effectiveness of the intervention in reducing stress among RNs. The RNs will also
be asked to maintain reflective diaries on a regular basis, which will also provide an idea of their
perceptions and feelings towards stress. Final analysis of stress levels among nurses will be
followed by dissemination of findings. It must be ensured prior to the implementation that the
nurses are aware of these tools. It will also allow determining the barriers in implementing the
problem and factors facilitating the implementation. Considering the barriers the future
relaxation response intervention may be implemented tailored to specific needs of the registered
nurses. Meetings will be held where the nurses will report their PSS scores during the research
period.

27REGISTERED NURSE STRESS
Setting where EBP will be implemented
The EBP model will be implemented in the hospital setting. The schedule of the
registered nurses will be designed in a manner to allow them attend 20 minutes of relaxation
technique twice in a day. It includes diaphragmatic breathing.
Facilitating Factors for Implementation
There is a need of strong awareness among the hospital mangers and leaders as well as
physicians to understand the gravity of the stress issue and its impact on the patient outcomes.
There is need of more education and better collaboration among nurse educator, nurse manger,
and nurse leader to implement the relaxation technique for registered nurses. It is with their
support and encouragement that the practice change can be achieved.
Barriers Factors for Implementation
The low nurse to patient ratio that may hinder them in attending the relaxation response
session, lack of resources and space or unit designing, hectic and tiring shift hours and minimal
organizational support are the barriers to implementation. Relaxation technique may be
implemented as part of the EBP project. It can become the natural part of the holistic nursing
care. However, not determining this clinical issue of interest and understanding the validity and
reliability of the relaxation technique is added barrier. The lack of knowledge of effectively
applying the technique during hectic shift hours or failure in time management is other barriers
in its implementation. The barriers will be eliminated if the hospital staff shows willingness in
participating in relaxation technique.

28REGISTERED NURSE STRESS
Summary
It can be concluded that EBP project is essential in implementing the practice change that
can improve the quality of patient care. It is useful tool to address the issues of the health care
professionals by developing question and collecting the recent evidence. It is the conscientious
use of best available evidence that is helpful in making effective decisions about patient care
ensuring safety. EBP project allows increasing the research skills, reasoning and judgment skills
of nurses. Highlighting the issues of stress among the nursing professionals and helping them
understand the successful relaxation response techniques; will play an important role in, delivery
high quality care as well address patient needs. EBP project is aimed at providing the best
effective care to patients available to them beneficial for improving patient care as they expect to
receive the most effective care that is based on best available evidence. The main goal of EBP
project is to integrate the expert opinion or clinical expertise, scientific evidence, patient values
in providing high quality care services that reflects values, interests, choices and needs of the
individuals they serve. It will help nurses increase their problem solving capability. It will assist
nurses to increase their work efficiency and manage the hectic schedules or shifts. Thus, this
implementation process will have significant impact on the nurses as well as patients. The
nurses will have job satisfaction and the patients may have good outcomes. Although there is
need of further studies to evaluate the findings of the relaxation techniques like Reiki and Tai
Chi, it is amazing to the see the health befits it will have on registered nurses and the care
quality. There are several facilitations to implement such interventions in the workplace setting.
All that is required is to create awareness among the hospital staff on how relaxation response
technique may improve the workplace and patient benefits. It will positively impact the life of
the nurses.

29REGISTERED NURSE STRESS
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Appendix A: Synthesis Table
Author/Date Study
Design/LOE
Purpose Sample
Size/Setting
Outcome
Najafi et al.
(2015)
Randomized
control study
I
To evaluate the
effectiveness of
Benson relaxation
on fatigue of
registered nurses
working in
intensive care
units.
63 nurses
Stratified
sampling,
Shahid Rajai
Cardiovascular,
Medical and
Research Center
in Tehran, Iran
Intervention
group showed
significant
difference in
terms of
reduction of
fatigue when
compared to
control group in
two weeks
relaxation
therapy. The
findings were
statistically
significant
Raingruber,
& Robinson
(2007)
Qualitative
phenomenological
approach
III
To examine the
effectiveness of the
Yoga, Tai Chi,
Meditation classes,
and Reiki healing
Thirty-five
nurses
Hospital
Outcomes of the
relaxation
response
technique
includes

37REGISTERED NURSE STRESS
sessions on stress
among registered
nurses and explore
their experiences
enhanced
problem solving
ability with
decreased stress
and increase in
awareness of
the patient
needs
Patel (2014) Randomized
control study
I
To evaluate the
effectiveness of the
progressive
relaxation
technique on stress
among registered
nurses
30 registered
nurses, non
probability
convenient
sampling
technique,
physical
location and
condition is the
setting, in
selected
Hospitals at
Vadodara city.
The registered
nurses had high
stress level
before the
progressive
relaxation
theory and low
stress level after
the intervention
indicating the
effectiveness of
the technique.
Guillaumie,
Boiral &
Systematic review
with meta-analysis
To identify the
effectiveness of
Total 32 studies
involving
Mindfulness
appeared to

38REGISTERED NURSE STRESS
Champagne
(2017).
I mindfulness based
programs on
registered nurses to
reduce stress
controlled
designs and pre
controlled
designs as well
as qualitative
designs
improve nurses’
well being and
reduce stress
Villani et al.
(2013)
Experimental study
I
To evaluate the
short term effects
of self-help stress
management
training for
registered nurses
working in
oncology
department.
30 registered
nurses of
oncology
specialty
In oncology
ward in Italy
Psychological
improvement in
the experiment
group in terms
of acquiring
skills to cope
with stress
Hersch et al.
(2016)
Randomized
control trial
I
To evaluate the
effectiveness of the
web based
BREATHE
program on stress
reduction in nurses
04 nurses
In five hospitals
in Virginia
and one in
New York.
Nurses were
able to address
stress using the
program
Smith (2014) Literature review To explore the Sample Significant

39REGISTERED NURSE STRESS
V efficacy of the
mindfulness-based
stress reduction
technique for
registered nurses
consisted of 11
quantitative
studies and 2
qualitative
studies.
decrease in
stress reported
by nurses
undertaking
mindfulness
based stress
reduction
method as
coping
mechanism
Cuneo et al.
(2011)
Experimental study
I
To evaluate the
effect of the Reiki
intervention on the
work related stress
in Registered
nurses
26 nurse
participants
urban medical
center
The data
supports that the
Reiki practice
decreases the
stress levels
among the
Alexander et
al. (2015)
Randomized
control Study
I
To evaluate the
effectiveness of
yoga to improve
self-care and
reduce burnout
among nurses.
40 participants
8 weeks in
intervention
Random
sampling
urban 560-bed
teaching
Yoga reduces
the burn out and
stress among
nurses

40REGISTERED NURSE STRESS
hospital was
Lai & Li
(2011)
Randomized
control Study
I
To investigate the
effect of the music
on stress among
registered nurses
54 nurses
Purposive
sampling
Music therapy
relieves stress
and improves
heart rate,
arterial
pressure, and
Cortisol levels
in the
intervention
group when
compared to the
control group

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Appendix B: Melnyk Level of Evidence
(Melnyk & Fineout-Overholt, 2011).
Appendix C: Model
(Source: Newhouse et al. 2007)

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Appendix D: Health Promoting Lifestyle Profile II questionnaire
(Source: Walker, Sechrist & Pender, 1995)

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Appendix E: Health promoting lifestyle profile total and subscale mean scores (SAMPLE
PROFILE)
(Source: Shaheen et al., 2015)

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Appendix E: Cohen’s Perceived Stress Scale
(Source: Cuneo et al. 2011)