Stress Intervention for Healthcare Workers in a Youth Residential Treatment Center: An Evidence-Based Project

Background: Healthcare workers in residential treatment centers experience high stress, which contributes to burnout, staff turnover, and poor patient outcomes. Stress management interventions for healthcare workers have been shown to improve well-being, decrease turnover, and improve patient outcomes. Healthcare professionals working in this residential treatment center for at-risk youth encounter a challenging work environment marked by significant stress. This stress arises from several factors, including frequent interruptions in their work, interactions with emotionally dysregulated youth, difficulties in collaborating with parents, and frequent staff turnover rates. Staff have been required to manage their work-related stress independently and separate from their work hours. This quality improvement project was conducted in four phases: assessment, development, implementation, and evaluation. The assessment phase included conducting preintervention surveys to evaluate healthcare workers' experiences with work-related stress and the Perceived Stress Scale. The development phase included identifying a stress intervention, the Stress First Aid Model, and adapting it for use with healthcare workers at a residential treatment center. The implementation phase included staff training, recruiting stress-intervention champions, and activating peer-to-peer support interventions to manage workday stress. The evaluation phase included post-intervention surveys to re-evaluate experiences of work-related stress and scores on the Perceived Stress Scale, as well as the feasibility, usability, and satisfaction of the interventions among healthcare workers. Interventions: Interventions to address workday stress were tailored to the specific needs of individual healthcare workers and implemented utilizing tools from the Stress First Aid Model. The effectiveness of the interventions was evaluated using the Stress Continuum. This model enabled staff to employ customized strategies, including mindfulness, humor, uninterrupted breaks, and supervisory support in high-stress situations. The Plan-Do-Study-Act (PDSA) cycle was employed to facilitate iterative enhancements of the interventions throughout the project implementation period. Results: Pre-implementation work stress levels (0-100 sliding scale) during the most recent shift ranged from 8 to 75 (M = 53.1 ± 20.7); work stress levels in the past month ranged from 5 to 80 (M = 59.4 ± 24.0); anticipated work stress in the upcoming week ranged from 6 to 70 (M = 44.0 ± 22.5). Post-implementation survey results revealed that work stress levels during the most recent shift ranged from 9 to 50 (M = 27.2 ± 16.8); work stress levels in the past month ranged from 50 to 61 (M = 54.4 ± 6.0); anticipated work stress in the upcoming week ranged from 25 to 72 (M = 49.4 ± 16.6). In the post-intervention Perceived Stress Scale, three respondents had low stress, and three had moderate stress. Healthcare workers were likely to continue using the stress continuum and interventions at work. They found using the stress continuum for peer check-ins easy. They noted improved communication and connection among coworkers. Implementing the Stress First Aid Model with healthcare workers in a residential treatment center provided a framework for stress management and benefited most healthcare workers. The reported stress management benefits include increased communication and connection among coworkers, improved healthcare worker well-being, and improved communication among staff. Continued stakeholder engagement is essential for the sustainability and successful implementation of this quality improvement project.

1 Stress Intervention for Healthcare Workers in a Youth Residential Treatment Center: An Evidence-Based Project Clint W Peterson, Sara E. Hart College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III April 20, 2025 2 Abstract Background: Healthcare workers in residential treatment centers experience high stress, which contributes to burnout, staff turnover, and poor patient outcomes. Stress management interventions for healthcare workers have been shown to improve well-being, decrease turnover, and improve patient outcomes. Local Problem: Healthcare professionals working in this residential treatment center for at-risk youth encounter a challenging work environment marked by significant stress. This stress arises from several factors, including frequent interruptions in their work, interactions with emotionally dysregulated youth, difficulties in collaborating with parents, and frequent staff turnover rates. Staff have been required to manage their work-related stress independently and separate from their work hours. Methods: This quality improvement project was conducted in four phases: assessment, development, implementation, and evaluation. The assessment phase included conducting preintervention surveys to evaluate healthcare workers’ experiences with work-related stress and the Perceived Stress Scale. The development phase included identifying a stress intervention, the Stress First Aid Model, and adapting it for use with healthcare workers at a residential treatment center. The implementation phase included staff training, recruiting stress-intervention champions, and activating peer-to-peer support interventions to manage workday stress. The evaluation phase included post-intervention surveys to re-evaluate experiences of work-related stress and scores on the Perceived Stress Scale, as well as the feasibility, usability, and satisfaction of the interventions among healthcare workers. 3 Interventions: Interventions to address workday stress were tailored to the specific needs of individual healthcare workers and implemented utilizing tools from the Stress First Aid Model. The effectiveness of the interventions was evaluated using the Stress Continuum. This model enabled staff to employ customized strategies, including mindfulness, humor, uninterrupted breaks, and supervisory support in high-stress situations. The Plan-Do-Study-Act (PDSA) cycle was employed to facilitate iterative enhancements of the interventions throughout the project implementation period. Results: Pre-implementation work stress levels (0-100 sliding scale) during the most recent shift ranged from 8 to 75 (M = 53.1 ± 20.7); work stress levels in the past month ranged from 5 to 80 (M = 59.4 ± 24.0); anticipated work stress in the upcoming week ranged from 6 to 70 (M = 44.0 ± 22.5). Post-implementation survey results revealed that work stress levels during the most recent shift ranged from 9 to 50 (M = 27.2 ± 16.8); work stress levels in the past month ranged from 50 to 61 (M = 54.4 ± 6.0); anticipated work stress in the upcoming week ranged from 25 to 72 (M = 49.4 ± 16.6). In the post-intervention Perceived Stress Scale, three respondents had low stress, and three had moderate stress. Healthcare workers were likely to continue using the stress continuum and interventions at work. They found using the stress continuum for peer check-ins easy. They noted improved communication and connection among coworkers. Conclusion: Implementing the Stress First Aid Model with healthcare workers in a residential treatment center provided a framework for stress management and benefited most healthcare workers. The reported stress management benefits include increased communication and connection among coworkers, improved healthcare worker well-being, and improved communication among staff. Continued stakeholder engagement is essential for the sustainability and successful implementation of this quality improvement project. 4 Keywords: Stress First Aid, residential treatment center, caregiver, healthcare worker, burnout, perceived stress scale 5 Stress Intervention for Healthcare Workers in a Youth Residential Treatment Center: An Evidence-Based Project Problem Description Healthcare workers in residential treatment centers face many challenges that contribute to stress and burnout (Chang & Shin, 2021; Hage et al., 2009). Adolescents in youth residential treatment centers experience severe emotional dysregulation, which triggers a sympathetic nervous system response of fight, flight, freeze, or fawn (Guy-Evans, 2023). Healthcare workers treating adolescents in this dysregulated state must be attuned to the adolescent and aware of transference and counter-transference anxiety and stress responses. Stress among healthcare workers is common. Excessive and persistent work-related stress can lead to compassion fatigue, staff turnover, and poor health for healthcare workers (Chang & Shin, 2021; Sullivan et al., 2022). When compassion fatigue affects the caregiver’s ability to provide empathetic care, the adolescents in residential treatment feel the impact (Hallam et al., 2021). Adolescents receiving care from unempathetic healthcare workers may be further triggered due to a prior history of neglect or abuse, compromising trust in the adolescentcaregiver relationship (Quick & Halasz, 2025). Treatment progress is threatened when there is no mutually respectful relationship with appropriate boundaries between healthcare workers and adolescents, resulting in increased frustration for both adolescents and staff (Maddox & Barreto, 2022). Healthcare workers who experience this frustration may feel devalued in their work and are more likely to change jobs, further contributing to worker turnover. Frequent staff turnover leads to undertrained or less-experienced employees and places additional pressure on veteran 6 staff to ensure patient safety and optimal care outcomes (Aiken et al., 2023; Boston-Leary et al., 2019). Available Knowledge Healthcare occupations are frequently ranked among the most stressful (Adam et al., 2024; Chernikoff & Alund, 2023; Indeed, 2024). Excessive stress can lead to burnout and further contribute to mental health issues. There is a strong correlation between burnout and depression in nurses (Chen & Meier, 2021). The risk for suicidal ideation also increases significantly with burnout (Kelsey et al., 2021). Suicide rates for registered nurses and healthcare workers are significantly higher than those of the general population (Olfson et al., 2023). According to a PRN National Nursing Engagement Report (King & Bradley, 2019), 15.6% of nurses experience burnout and have difficulty caring for themselves and their patients. Burnout contributes to poor mental and physical health (Sullivan et al., 2022). When working with adolescents, healthcare workers can be exposed to violence and aggression (Hage et al., 2009). Nurses experiencing aggression at work are likely to exhibit symptoms of burnout (Chang & Shin, 2021). The COVID-19 pandemic increased burnout among healthcare workers (Holliday et al., 2024). This heightened burnout among nurses resulted in over 200,000 nurses leaving the profession (American Organization of Nurse Leaders [AONL], n.d.). In addition to the nursing shortage being exacerbated by burnout, over one million nurses are expected to retire by 2030 (American Association of Colleges of Nursing [AACN], 2024). Implementing organizational interventions to reduce work-related stress can enhance healthcare workers’ well-being, decrease nursing turnover, and improve patient outcomes (Adams et al., 2019; Montgomery et al., 2022; Rickard et al., 2012). Much of the current 7 research on organizational interventions consists of cross-sectional studies that cannot demonstrate causality. This research has limitations, including self-report bias, small sample sizes, lack of control groups, and short-term follow-up. Additionally, there is a high heterogeneity of interventions used, ranging from person-directed techniques such as mindfulness and yoga to organizational interventions like implementing a Cultural Change Toolkit (Adams et al., 2019; Green & Kinchen, 2021; Hilcove et al., 2021). Many organizations offer Employee Assistance Programs (EAPs) to help promote employee wellness. Stress First Aid (SFA) for healthcare workers is an evidence-based model that encourages the identification and utilization of available resources, such as EAPs, provides a common language for staff to identify and communicate stress injury, and can decrease the stigma associated with seeking mental health services (Bellehsen et al., 2024; Convoy et al., 2024; Hilcove et al., 2021; McLean et al., 2023) The SFA model can be implemented as an occupational workday intervention that promotes improved communication about wellness among workers. In the youth residential treatment setting, emotionally dysregulated adolescents can lash out aggressively at healthcare workers (Hage et al., 2009). When adolescents respond by fighting, healthcare workers may need to restrain them to help regulate their behavior safely. Similarly, when adolescents exhibit a flight reaction, they may elope from campus, causing distress as healthcare workers must ensure the safety of both the adolescent and the local community (Milette-Winfree et al., 2017). The freeze reaction can be particularly challenging, as adolescents may stonewall or avoid caregiver redirection (Rusnak, 2023). The fawning response displayed by some adolescents may trigger a psychological urge in healthcare workers to rescue them from the situation, leading to feelings of conflict regarding their duty to maintain 8 appropriate boundaries (Walker, n.d.). All these challenges can increase stress for healthcare workers. Healthcare workers are responsible for the physical and mental well-being of adolescents in the residential treatment center. After any incident that results in a safety hold, physical violence, or elopement, healthcare workers must assess the adolescent involved. They provide physical first aid to adolescents and assist other caregivers in processing safety incidents. Reporting the outcomes of an incident to the adolescent’s parents can present additional challenges, depending on how the parents react to the news that their child was involved. Additional sources of stress for healthcare workers include medication errors, numerous urgent job tasks, limited resources, and the pressures associated with their responsibility for adolescents in the residential treatment center. Rationale The Johns Hopkins Evidence-Based Practice (JHEBP) Model guided this evidence-based project by following the Practice Question, Evidence, and Translation (PET) process (Dang et al., 2021). The JHEBP model has three essential components: inquiry, practice, and learning. This model guides the quality improvement process by developing a practice question, evaluating the evidence, and then translating the evidence into a quality improvement project. The practice question was formed using a PICO format (population, intervention, comparison, outcome): For nurses/HCWs at an at-risk youth residential treatment facility (P), what is the effect of an organizational workday intervention (I) for stress (O) compared with the current practice of leaving staff to deal with stress on their own time (C)? A literature search was performed through PubMed, the University of Utah’s Library Database, and CINAHL. Articles 9 related to nursing, occupational stress, and interventions to improve healthcare worker wellness were evaluated using the Johns Hopkins tools for appraising and synthesizing evidence. Through the PET process, the SFA model for healthcare workers was identified as a peer support model that can be adapted and integrated as a workday intervention to address stress for healthcare workers. Once a clinical question is formed, evidence is gathered, applied to practice, and reevaluated through the Plan-Do-Study-Act (PDSA) cycle (Katowa-Mukwato et al., 2021). The PDSA cycle is essential for implementing quality improvement projects. During the planning phase, evidence was collected, stakeholders were identified, and the implementation date was established. The implementation (do phase) included training healthcare workers about the project, coordinating staff buy-in and resources for the change, and rolling out the project. As healthcare workers utilized the SFA model and interventions, feedback was gathered and implemented as needed (study and act phases). Specific Aims This Doctor of Nursing Practice (DNP) initiative aims to use an occupational workday intervention to decrease stress levels for healthcare workers at a residential treatment facility for at-risk youth. Healthcare workers in this setting experience a stressful work environment, yet they are left to manage their stress independently, limiting their ability to manage stress at work. Incorporating an occupational workday intervention can improve staff empathy toward adolescents, alleviate compassion fatigue, decrease turnover, and improve patient outcomes (Lombardo & Eyre, 2011). A secondary aim is to enhance connectedness and support through increased check-ins among healthcare workers. 10 The project's aims were met by assessing healthcare workers’ stress levels, developing and implementing occupational stress management interventions based on the SFA model, reassessing healthcare workers’ stress levels, and evaluating the feasibility, usability, and satisfaction of the intervention among healthcare workers. Methods Context This project was implemented for healthcare workers at a residential treatment center for at-risk youth in an urban Utah city. The project intervention was available for healthcare workers in the nursing unit but excluded other residential treatment center staff such as coaches, teachers, and administrators. Healthcare workers included 11 medical assistants, five registered nurses (RNs), and three psychiatric mental health nurse practitioners (PMHNPs). Social determinants of health (SDoH), health equity, and health disparities affect all populations, including healthcare workers (Skillman et al., 2022). Among the healthcare staff in this unit, there is cultural, gender, educational, and socioeconomic diversity. Culture and background may affect how individuals react to stressors, including aggression and secondary trauma. Gender, education level, income disparities, and access to resources may also influence perceptions of stress and burnout. This project is based at a residential treatment center for at-risk youth. Within the community of patients, there are also multiple social determinants of health (SDoH) factors to consider. Adolescents are a vulnerable population, particularly youth with mental health diagnoses. Many of the youth are adopted, come from broken homes, and have significant neglect or trauma histories. A large population of the youth is neurodiverse and has developmental disorders. Some of the youth are part of the LGBTQ+ community, and some have 11 experienced racial disparities. Others have been marginalized due to religious beliefs. The youth come from all parts of the country, from urban, suburban, and rural communities. Many have little or no access to mental healthcare in their home communities. Most of the youth have struggled in school, sometimes due to learning disabilities, and are behind on their education. Many have been bullied in school and have few healthy peer support systems at home. Intervention Assessment An assessment of key stakeholders, including the site sponsor, unit manager, human resources, and unit staff, revealed the need for stress reduction among healthcare workers. Informal discussions with the stakeholders uncovered multiple causes of work-related stress (Appendix A). Interactions with the site sponsor and healthcare workers highlighted various stressors, including workflow interruptions. Interruptions during crucial times, such as packing or administering medications, may lead to medication errors (McLeod et al., 2015). Patient safety was a concern, associated both with potential medication errors and occasionally disrespectful, aggressive patient behaviors. The high volume of documentation and charting required throughout the shift was recognized as a burden, along with the pressure of having too much work to complete. When technology challenges arise, this adds another layer of stress, complicating the charting process. Additionally, less frequently reported sources of stress were considered, including insufficient coworker support, management support, bullying or aggression from coworkers, and concerns regarding work schedules. Intervention Development 12 The literature identified potential stress reduction interventions. The SFA model, which could be tailored to the needs of the nursing unit, was proposed as the implementation tool, and buy-in was achieved by unit and organizational leadership. The site coordinator and human resources were consulted and briefed using the SFA Implementation Workbook (New Jersey Nursing Emotional Well-Being, 2024). SFA is a peer-to-peer program designed to identify and address early signs of stress reactions and aims to “enhance individual and unit resilience” (New Jersey Nursing Emotional Well-Being, 2024). SFA has been identified as an intervention model that can be adapted to various healthcare settings (Bellehsen et al., 2024; Convoy et al., 2024; McLean et al., 2023). The adaptation and implementation of SFA provide a framework for translating evidence into practice. The SFA model includes tools for implementation, including The Stress Continuum and The Seven C’s of Stress First Aid (Appendices B & C). These tools are designed to improve peer support, enhance team culture and the work environment, and increase healthcare workers’ resilience to stress (New Jersey Nursing Emotional Well-Being, 2024). Implementation The SFA model was presented to healthcare workers for implementation during a staff meeting (Appendix D). Expectations for peer-to-peer support and interventions to address workday stress were discussed. Feedback was gathered during the meeting, and healthcare workers were encouraged to follow up with additional questions or input throughout the implementation process. Processes and expectations for peer check-ins were established with the staff, who demonstrated appropriate knowledge of the Stress Continuum. Healthcare workers were encouraged to use clinical judgment, discuss peer support options, refer to supervisors, and 13 access employee assistance plan (EAP) resources to manage workday stress. Two staff members volunteered as stress-intervention champions during the meeting to assist with peer check-ins and interventions. These champions helped with the implementation and data tracking (Appendix E). Following staff education and identification of stress-intervention champions, intervention tracking was conducted by asking staff to identify their “color” on the Stress Continuum and log the following information in a spreadsheet: date, time, staff position, preintervention color zone, intervention implemented, post-intervention color zone, and additional notes. After assessment of the current stress level, staff were encouraged to participate in stress management interventions such as coordinating coverage for uninterrupted breaks, participating in mindfulness, coordinating help with work tasks, connecting with coworkers, using humor interventions, or offering additional work training. Staff were encouraged to utilize EAP resources, and additional resources would be provided as appropriate. Throughout the implementation phase, the Plan-Do-Study-Act (PDSA) cycle was used to assess the effectiveness of the interventions and adjust as needed. Stress-intervention champions coordinated with the leadership of healthcare workers and the site sponsor to follow up on feedback received during peer check-ins. When healthcare workers remained under moderate or high stress, stress-intervention champions coordinated additional follow-ups to check on and assist the workers throughout their shifts. Evaluation The final phase involved gathering and evaluating data to assess the effectiveness of the intervention. Additionally, healthcare workers were asked to complete a follow-up survey to 14 reassess stress using the Perceived Stress Scale (PSS) (Simon, 2021). Results were linked through confidential identifiers to the previously completed pre-intervention surveys. Outcomes were evaluated and compared to pre-intervention data. Furthermore, satisfaction, feasibility, and usability were assessed to ensure sustainability post-implementation. Study of the Intervention(s) The effectiveness of the project was assessed through pre- and post-intervention surveys of the healthcare workers. The pre-intervention surveys included work-related stress questions, Perceived Stress Scale (PSS), and demographics (Appendices G-I). The post-intervention surveys included a re-evaluation of the work-related stress questions and PSS. Additionally, the effectiveness of each implemented intervention was documented at the time of intervention by comparing pre-and post-intervention stress levels using the Stress Continuum. Feedback and responses to interventions were incorporated and adjusted by using the PDSA cycle. Measures This DNP project utilized REDCap surveys to evaluate healthcare workers’ stress. The surveys included Work-Related Stress questions, the Perceived Stress Scale, Demographics, and a survey for Feasibility, Usability, and Satisfaction (Appendices G-J). Work-Related Stress To evaluate stress related to work, separate from outside factors, staff were asked three questions to evaluate their most recent shift, their work over the last month, and their anticipated stress for the upcoming work week. Response options ranged from “0” (low) to “100” (high). Respondents were next asked to rate the severity of identified potential work-related stressors on 15 a Likert Scale, which included “No stress,” “Low stress,” “Moderate stress,” “Moderate-high stress,” “High stress,” or “Not applicable.” The potential work-related stressors included: “Charting/documentation,” “Too much work to complete,” “Unable to take uninterrupted breaks,” “Lack of coworker support,” “Lack of management support,” “IT concerns,” “Student behaviors such as aggression or disrespect,” “Too many interruptions,” “Bullying or aggression from coworkers,” and “Work schedule.” An open response prompt was included to identify additional stressors: "Please note if any issues cause stress at work that have not been included.” To assess staff preference for potential workday stress interventions, respondents were asked to rank the following interventions from highest (most desirable to implement) to lowest (least desirable to implement): “Coworker check-ins and assistance,” “Mindfulness breaks,” “Desk yoga,” and “Uninterrupted breaks.” An additional open response prompt was included: “Are there other interventions that you would like to consider implementing at work?” (Appendix G). Perceived Stress Scale The PSS is a validated 10-item scale designed to measure stress perception (Simon, 2021). It utilizes Likert scale ratings of “Never,” “Almost Never,” “Sometimes,” “Fairly Often,” and “Very Often.” The questions prompt respondents to consider how often, in the past month, they have reacted to stress in various ways. “How often have you been upset because of something that happened unexpectedly?” “How often have you felt that you were on top of things?” “How often have you felt that you were unable to control the important things in your life?” “How often have you felt nervous and ‘stressed’?” “How often have you found that you could not cope with all the things you had to do?” “How often have you been angered because of things that happened that were outside of your control?” “How often have you felt difficulties were piling up so high that you could not overcome them?” “How often have you felt confident 16 about your ability to handle your personal problems?” “How often have you felt that things were going your way?” “How often have you been able to control irritations in your life?” (Appendix H). Demographics Demographic information was collected, including gender, race/ethnicity, highest level of education, and employment status. Each demographic question provided a “Prefer not to answer” option. (Appendix I). Feasibility, Usability, and Satisfaction Feasibility, usability, and satisfaction were assessed in the post-survey. Respondents were prompted, “How challenging was understanding the Stress Continuum (green, yellow, orange, red)?” Answers ranged from “very difficult, difficult, neither difficult nor easy, easy, or very easy.” Respondents were asked, “In the past month, how often did you check in with SFA? (0 times, 1-2 times, 3-4 times, or 5 or more).” The next question, “What are some barriers for SFA implementation?” included responses of “Insufficient training, Too time consuming, Hard to remember to use, Takes too much time, Not interested in using this tool, What is SFA? and Other.” Respondents were prompted, “If you marked ‘other’ please explain.” Then respondents were asked, “How challenging was implementing interventions related to the ‘7 C’s’ (check, cover, calm, connect, competence, and confidence)?” Answers ranged from “very difficult, difficult, neither difficult nor easy, easy, very easy, or N/A.” Open-ended feedback was requested with the question, “What were some of the challenges that you faced when trying to implement interventions to decrease stress?” The next question was, “Yes or no, Did you find the peer check-ins using the Stress Continuum to be beneficial for managing stress at work?” (Yes or 17 No). Followed by, “What did you find beneficial, or why did you find it not beneficial?” The next question, “What impact did this project have on your workday? (select all that apply)” had possible responses, including “Interfered with work, Increased work stress, No impact, Helped with coworker connection, Helped manage stress at work, and Other.” The final question, “How likely are you to continue to use the SFA Continuum and interventions?” had Likert responses of “Not at all Likely, Somewhat Likely, Likely, Very Likely.” (Appendix J). Analysis This project utilized a combination of quantitative and qualitative measures. Descriptive statistics were employed to detail the data and demographics. A content analysis was conducted to assess qualitative data from the open-ended questions in the pre- and post-implementation surveys. Content analysis was also performed to evaluate participants’ responses regarding their satisfaction with the intervention, including its usability and feasibility. Ethical Considerations The University of Utah IRB determined this project to be a quality improvement project and not subject to oversight by the Institutional Review Board. There were no conflicts of interest involved in this project. Participation was voluntary and did not affect employment for healthcare workers. Healthcare workers were sent email invitations with unique identifiers, allowing anonymous pre- and post-implementation survey comparison. The REDCap data set was exported to provide a copy of the data if needed for future reference. The participant list was also exported, and all participants were removed from the list to eliminate re-identification and maintain the anonymity of participants. 18 Results At the beginning of the project, 19 healthcare workers were eligible to participate. The eligible participants included three psychiatric mental health nurse practitioners (PMHNPs), five registered nurses (RNs), and eleven medical assistants (MAs). Of the 19, nine completed the preintervention survey (47.4%). Pre-intervention Survey Demographics Respondents included five females (55.6%) and four males (44.4%). They were primarily White (88.9%). One respondent was a high school graduate/GED (11.1%), three had some college (33.3%), two had bachelor’s degrees (22.2%), and three had graduate degrees (33.3%). Three worked part-time (33.3%), five worked full-time (55.6%), and one reported working both full-time and part-time (11.1%). (Table 1) Pre-intervention Work-Related Stress Survey and Perceived Stress Scale Respondents reported work stress levels on a 0-100 sliding scale. Responses for stress during their most recent shift ranged from 8 to 75, with a standard deviation of 20.7 and a mean of 53.1. Stress levels in the past month also ranged widely from 5 to 80, with a standard deviation of 24.0 and a mean of 59.4. Anticipated stress in the upcoming week ranged from 6 to 70, with a standard deviation of 22.5 and a mean of 44.0 (Table 2). Box plot analysis indicates that apart from a few outliers with low stress, most respondents rate their stress levels moderately high (Figure 1). Stress levels were assessed in various categories of work-related stress factors. Respondents ranked “too many interruptions” as the highest contributor to work stress and “lack 19 of management support” as the lowest source of work stress (Figure 2). There were two responses to the open-ended prompt to “Please note if any issues cause stress at work that have not been included”: “Working with parents,” and “Sometimes I worry for student's safety from SI/SH and behaviors that lead to more problems for them.” (Note SI/SH is the abbreviation for suicidal ideation/self-harm). Respondents were also asked to rank the desirability of five interventions: meme/comedy breaks were the most desirable, followed by coworker check-ins and assistance, mindfulness breaks, uninterrupted breaks, and desk yoga (Figure 3). One respondent added that they would like to consider work interventions that include fidgets, a coping skills list, and a sensory center. In the PSS pre-intervention survey, two respondents had scores indicating low stress, six indicating moderate stress, and one indicating high stress (N=9). Evaluation of the Intervention Between 10/24/24 and 12/11/24, stress-intervention champions documented 21 peer check-ins using the Stress Continuum. Among those check-ins, the stress level in the green zone was reported twice, green/yellow twice, yellow six times, yellow/orange twice, orange three times, and orange/red once. For 12 of the 21 check-ins, there was no change following the intervention. In eight instances, stress levels improved after the intervention. In one case, a healthcare worker’s stress level increased because that staff member reported feeling more anxious about “thinking of next week.” Post-intervention Survey Work-Related Stress Respondents used the same 0-100 sliding scale to report stress levels at work postintervention. Responses for stress during their most recent shift ranged from 9 to 50, with a 20 standard deviation of 16.8 and a mean of 27.2. Stress levels in the past month ranged from 50 to 61, with a standard deviation of 6.0 and a mean of 54.4. Anticipated stress in the upcoming week ranged from 25 to 72, with a standard deviation of 16.6 and a mean of 49.4 (Table 3). While not statistically significant, stress levels did decrease for stress experienced on the most recent shift (Figure 4). When work-related stress factors were reassessed post-intervention (Figure 5), “too much work to complete” ranked highest, while “lack of coworker support” was the lowest-ranked factor. Notably, “bullying or aggression from coworkers” increased from an average stress score of 1.8 to 2.7, and “IT concerns” rose from 1.9 to 2.7. Conversely, stress related to “Student Behaviors (Aggression/Disrespect)” decreased from 3.1 to 2.3. Post-Intervention Perceived Stress Scale In the PSS post-intervention survey, three respondents reported low stress scores, and three had moderate stress scores (n=6). Two participants experienced an improvement in their stress levels: one decreased 10 points from moderate to low stress, while the other declined by 4 points, moving from high to moderate stress. The remaining four participants maintained their stress levels, with two at moderate stress and two at low stress (Table 4). Feasibility, Usability, and Satisfaction A separate survey was sent to all respondents who had completed the pre-survey to assess the intervention's feasibility, usability, and satisfaction. Four of the nine responded (44.4%). All four responded that understanding the Stress Continuum was “very easy” (100%). One respondent reported not checking in with Stress First Aid (SFA) during the past month (25%), two respondents reported checking in 1-2 times (50%), and one respondent reported checking in 21 3-4 times (25%). Barriers to implementation included “Just remembering to check in with peers using this tool” and “Time. Prioritization.” Respondents rated implementing interventions related to the “7 C’s” as “very easy” (25%) or “easy” (50%), but one respondent did not answer this question (25%). Challenges faced when trying to implement the interventions to decrease stress included, “At times, it was difficult to know what options would be the most helpful in the moment,” “I was not involved in the implementation,” “Having time,” and “none.” Three respondents (75%) found peer check-ins using the Stress Continuum beneficial for managing stress at work, but one respondent (25%) did not answer. Benefits reported included, “It increased communication and attunement with coworkers,” “I did not check in but observed others doing it, which seemed to be helpful for the others to be more mindful of how they felt and take action to manage challenges,” “It was good to connect with others more,” and “It gave me a chance to release frustrations that I was feeling in the moment with someone.” When asked to explain the impact on their workday, respondents replied, “Possibly a little more direction in what we can do to help each other,” “I would engage,” “none,” and “Make it once a week thing.” Three respondents (75%) reported that they were “likely,” and one responded that they were “very likely” (25%) to continue using the SFA continuum and interventions at work. Discussion Summary Utilizing workday interventions for healthcare workers’ stress management is an important endeavor. Healthcare workers who participated in the interventions perceived them as beneficial for managing stress and improving communication and connection with coworkers. 22 Healthcare workers found it easy to understand and use the SFA model as a tool when checking in with one another. Causes of stress are multifactorial and often cannot be resolved immediately through interventions, but healthcare workers expressed appreciation when peers were willing to offer extra support. They found that having a straightforward way to express their stress levels using the SFA Continuum provided a quick method to acknowledge stress levels and offer support. Interpretation Implementing interventions based on the SFA model can be beneficial in managing the stress of healthcare staff. During the intervention, healthcare workers utilized the SFA model to complete peer check-ins using the Stress Continuum. Findings from the initial peer check-ins indicated that one-third of the time (7 out of 21), healthcare workers’ perception of stress was not a concern as they rated in the green Stress Continuum zone; 8 out of 21 (38% of the time), workers reported being in the green/yellow or yellow zone; 5 out of 21 (24% of the time) workers reported being yellow/orange or orange; and 1 out of 21 (5%) worker reported being in orange/red zone. Following interventions, these numbers either stayed the same (57%) or improved (38%) in all instances (95%) except for one (5%) when a healthcare worker reported going from the green zone to the yellow zone. In the one instance where the healthcare worker’s stress level increased, they reported feeling increased anxiety after a meeting and when thinking about the following week. The worker denied further intervention to help manage stress at the time. Response to the pre-intervention survey was low at 47.4%. This low response rate may have been due to healthcare workers being reluctant to participate, the timing of the survey being 23 inconvenient during work hours, some healthcare workers having low utilization of work emails, or other possible factors such as technological issues. The response rate for the post-intervention survey, which was offered only to respondents of the pre-intervention survey, was 66%. However, based on the number of healthcare workers initially eligible to participate, only 31% participated in the post-intervention survey. The results may not reflect the views of most healthcare workers and must be interpreted cautiously. Among those who responded, the perception was largely favorable toward implementing workday interventions for stress management. Respondents found the Stress Continuum color zones for stress easy to understand and use, observed improved communication among healthcare workers, and noted an improvement in the PSS for some individuals. Due to the diversity of stress perception, causes of stress, and resilience among workers, it is uncertain whether a workday intervention for stress contributed to the noted improvement. Challenges to the usability of a workday intervention for stress included difficulty remembering to use the SFA model for peer check-ins. Additional signage in the unit and teaching may help improve overall utilization. Healthcare workers also expressed barriers of not having adequate time during the workday for peer check-ins and difficulty knowing what interventions would be helpful. With continued utilization, workers would feel more confident in identifying helpful interventions based on the SFA model and recognize opportunities to assist coworkers with tasks during the workday, thus decreasing time burden and managing stress at work more effectively. Healthcare workers reported that they were likely to continue using the SFA model for peer check-ins and interventions. Following the intervention implementation phase, continued tracking was not available. However, during a post-intervention healthcare worker staff meeting, 24 the unit manager encouraged staff to check in using the Stress Continuum. The workers present at the meeting demonstrated understanding and used the color zones to check in. During the meeting, staff also commented on the improved communication among coworkers, while some reported feeling more connected and supported in their roles at work. Outside of the healthcare worker staff meeting, one worker reported utilizing the EAP benefit to meet with a therapist to help manage the anxiety and stress that they have been experiencing. Limitations Numerous limitations have been identified regarding the implementation of workday interventions for stress. Healthcare workers completed this quality improvement project at a residential treatment center for at-risk youth. The sample size of participants was small, and few engaged in both the pre-intervention and post-intervention surveys. Results from this project may not be generalized to other populations or settings due to various potential confounding factors and biases. Stress is a multifactorial and highly individualized experience. Workday interventions to address stress among healthcare workers must be tailored based on time, individual needs, and circumstances. This workday stress intervention employs a Stress First Aid Model that can be universally applied and personalized to the setting, but the implemented interventions may differ in other environments. While workday interventions to reduce stress can be beneficial, they should be combined with other known established treatments, such as mindfulness and therapy. In some cases, experiencing a severe stress injury necessitates additional assessment and professional help. Workplaces implementing similar interventions should inform staff of available resources, such as EAPs. 25 Despite the diversity among healthcare workers, those who responded to the surveys were primarily White. As part of a quality improvement project, there were inherent biases, including selection bias limited to healthcare staff, potential self-report response bias, and nonresponder biases. The follow-up for this quality improvement project was short-term. Workplace stress needs further study and understanding to help identify interventions for managing healthcare worker stress. Conclusions Utilizing an SFA model for implementing stress interventions among healthcare workers in a residential treatment center for at-risk youth was well received by stakeholders and healthcare workers. The model was easy to understand and cost-effective to implement. During the implementation, healthcare workers conducted peer-to-peer check-ins, generally initiated by the volunteer stress-intervention champions. Following the implementation period, workers utilized the model less frequently. Workers used the Stress Continuum check-in model during a work meeting two months after implementation, demonstrating positive sustainability. Human resources and the site sponsor also encouraged the continuation of the model and potential distribution among all staff at the residential treatment facility based on executive summary recommendations (Appendix K). Finding ways to address healthcare workers’ stress is worthwhile, particularly as the nursing shortage increases. Organizations should research and implement strategies to help workers manage stress throughout the workday rather than assuming that coping skills will develop outside of work. Resources such as Employee Assistance Programs (EAPs) may be underutilized if the work culture does not actively encourage stress reduction strategies. 26 Organizations should prioritize implementing workday interventions to manage stress that support and complement current organizational benefits, such as EAPs, for improved utilization of resources. 27 Acknowledgments My gratitude goes out to everyone who supported me during this project. I want to acknowledge my site sponsor, Dr. Jamis Leeper, content expert, Dr. Perry Gee, project chair, Dr. Sara Hart, and specialty track director, Dr. Teresa Garrett. These professionals have provided encouragement, expertise, and guidance throughout this project. I want to thank all my coworkers who participated in this project. I also want to express my love and gratitude for my incredible wife, Dr. Kristen Brown. Only with your support has this been possible. 28 References American Association of Colleges of Nursing (AACN). (2024). 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Pete Walker. 34 Table 1 Demographics of Healthcare Staff Participants Pre-intervention Survey (N=9) Characteristic Gender Female Male N % 5 4 55.6% 44.4% Race/Ethnicity White 8 88.9% Education High school graduate/GED Some college Bachelor’s degree Graduate degree 1 3 2 3 11.1% 33.3% 22.2% 33.3% Employment status Part-time Full-time Full-time/Part-time 3 5 1 33.3% 55.6% 11.1% 35 Table 2 Pre-Intervention Survey Work Stress Mean Std Dev Min 25th Percentile Median Max Most Recent Shift Stress 53.1 20.7 8 50 50 75 Stress in the Past Month 59.4 24 5 49 70 80 Upcoming Week Stress 44 22.5 6 40 50 70 36 Table 3 Post-Intervention Survey Work Stress Mean Std Dev Min 25th Percentile Median Max Most Recent Shift Stress 27.2 16.8 9 12.5 27 50 Stress in the Past Month 54.4 6 50 50 50 61 Upcoming Week Stress 49.4 16.6 25 50 50 72 37 Table 4 Perceived Stress Scale (PSS) Participant Pre-score Pre-interpretation Post-score Post-interpretation Change 1 22 Moderate Stress 12 Low Stress -10 2 18 Moderate Stress 3 9 Low Stress 12 Low Stress +3 4 29 High Stress 25 Moderate Stress -4 5 17 Moderate Stress 6 22 Moderate Stress 25 Moderate Stress +4 7 22 Moderate Stress 8 10 Low Stress 11 Low Stress +1 9 20 Moderate Stress 18 Moderate Stress -2 38 Figure 1 Pre-Intervention Survey Distribution of Work Stress 39 Figure 2 Pre-Intervention Survey Work Stress Factors 40 Figure 3 Ranked Desirability of Workplace Interventions 41 Figure 4 Post-Intervention Survey Distribution of Work Stress 42 Figure 5 Ranked Post-Intervention Survey Work Stress Factors 43 Appendix A The site sponsor and healthcare worker staff were informally asked about the causes of workrelated stress. The following causes of stress were identified: Burden of charting (charting/documentation) Too many interruptions. Student safety (including medication administration and aggression or disrespectful behaviors). Too much work to complete. Challenges with e-prescribing software/other IT concerns. Additional potential work-related stressors were also considered: Lack of coworker support Lack of management support Bullying or aggression from coworkers Work schedule 44 Appendix B Stress First Aid: Stress Continuum (NJ-NEW Stress Continuum) 45 Appendix C Stress First Aid: Seven Cs of Stress First Aid 46 Appendix D 47 48 49 50 51 52 53 54 Appendix E Data Tracking 55 Appendix F Notes taken during a staff meeting on November 22, 2024, healthcare workers reported the following feedback regarding the feasibility, usability, and satisfaction of my DNP project. Feasibility was demonstrated when the healthcare worker staff meeting started with the unit manager asking everyone to rate their stress level using the Stress First Aid Stress Continuum and express if they have noticed any improvements over the last month or needed additional support. Usability was demonstrated when each healthcare worker rated their stress level using the Stress First Aid Stress Continuum. One worker was in the orange zone, while all other staff were reportedly green or yellow. Satisfaction was reported by staff who had noticed improvements over the last month: Four staff members reported that communication has improved. Staff reported, “We have each other’s backs.” Two staff commented that they have a more “positive attitude.” Three staff members reported that they are “not afraid of making mistakes.” In addition, staff reported that when mistakes are made, they can learn from them without feeling judgmental. Staff reported stress of the job included nuances of learning the job and working with the students. Three staff reported that other staff have been “stepping up despite being short-staffed.” In addition, they have more flexibility and take on more roles at work. “We all really care that things run well.” “Helping things go right by being attuned to the needs of others.” Healthcare worker staff reported needing additional support with: “Work tasks” “Needs more awareness [from coworkers].” This staff recommends making work task checklists and an off-hours communication plan.” “Ensuring charting is up-to-date.” “Clarification of roles.” “Need compassion towards each other.” 56 Appendix G 57 58 Appendix H 59 60 Appendix I 61 Appendix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ppendix K Executive Summary: Workday Interventions for Employee Stress Summary Youth in residential treatment centers experience high stress due to many factors. Similarly, healthcare workers and caregivers experience high stress in their roles. Implementing stress management interventions for the staff is beneficial for the workers caring for the youth. Background Healthcare workers and caregivers experiencing moderate to high work-related stress can lead to burnout, mental health concerns for staff, staff turnover, and poor student outcomes. Employee Assistance Programs (EAPs) help promote employee wellness, yet this benefit is under-utilized. Workers are expected to manage stress but need resources to manage stress during their workday. In a pre-intervention survey, seven out of nine healthcare workers reported having moderate to high stress. Healthcare workers identified multiple causes of stress, including “too many interruptions,” “working with parents,” and worrying about student safety. Healthcare workers are exposed to aggression and sometimes violence from residents. Intervention The Stress First Aid (SFA) model was used to provide workday interventions for healthcare workers. SFA is a peer-support model that uses a simple, color-based Stress Continuum to rate stress quickly. Using the colors green, yellow, orange, and red, healthcare workers could rate their stress levels and provide support as needed. Interventions to help manage stress can be addressed at the moment, during the workday, and can be tailored to the immediate needs of the caregiver. Results Between 10/24/24 and 12/11/24, healthcare workers documented 21 peer check-ins using the SFA model. Six of those check-ins indicated that the employee was in moderate to high stress, requiring additional intervention to help manage the stress. In five of the six instances, stress levels decreased following an intervention. When the stress level remained moderately high, the employee was able to express the capability and confidence to manage the stress. Following the implementation period, two healthcare workers reported improved stress levels using the Perceived Stress Scale (PSS); two others experienced low stress and remained stable, while two employees continued to experience moderate stress. Using a peer-support model, such as SFA, to address stress during the workday improved communication and attunement with coworkers, which was found to be easy to implement and perceived as beneficial. There is no charge for using the SFA model; thus, costs are solely associated with employee training. Recommendation Work values employee wellness and education. I propose teaching all caregivers how to implement peer support using the SFA model at an upcoming quarterly caregiver education training.