Use of a Mindfulness-Based Resiliency Intervention to Reduce Nurse Intention to Quit the Organization

Practice Problem: Nurse turnover is a rapidly growing problem that affects the healthcare industry worldwide. Nursing shortages created by increased turnover have a negative effect on patients and staff and create a financial strain on healthcare organizations. PICOT: For registered nurses within a select pilot group, does implementation of a mindfulnessbased resiliency (MBR) intervention, compared to no intervention, reduce nurse intent to quit over an eight-week period? Evidence: The positive impact of resiliency on turnover was best described in eight articles and two doctoral papers. Studies using MBR interventions have been shown to improve the coping skills of nurses, and to decrease stress and reduce intention to quit. Intervention: The implementation of a MBR intervention was the selected intervention completed over an eight-week period. Participants completed a Personal and Organizational Quality Assessment-(POQA-R4) designed to measure personal and job‐related constructs pre and post intervention. Outcome: “Intent to quit” did not show a statistically significant change post-implementation of the MBR intervention. The result of the two-tailed paired samples t-test” was not significant (p=.179, alpha=0.05). However, clinical significance was achieved with reduction of stress for the 10 project participants. Conclusion: Reducing the intention to quit achieved clinical significance by promoting nurse well-being. Consideration should be given for implementation of the MBR intervention with a larger group of nurses. REDUCING NURSE INTENTION TO QUIT 4 Use of Mindfulness-Based Resiliency Interventions to Reduce Nurse Intention to Quit Nurse turnover has become a rapidly growing work force issue that has a far-reaching effect within the healthcare industry. Turnover statistics for bedside registered nurses (RNs) in the United States in 2019 was 15.9% percent (NSI, 2020). The turnover rate for RNs in California as reported in 2018 was 10.4% (Chu & Spetz, 2020). The annual RN turnover rate at the project site in FY19 was 12.8%. The purpose of this evidence-based practice project was to reduce nurse turnover as measured by “intent to quit”, by providing a mindfulness-based resiliency (MBR) intervention. The scope of the project was to help determine if a work environment where employees use positive and effective coping skills would reverse the effects of perceived stress and reduce nurse intent to quit the organization. Significance of the Practice Problem The area of concern at the project site related to new nurse turnover. The turnover rate for 1st year RN employees in FY19 was 33%. This is consistent with findings from a study in 2020 that stated that novice nurses are at risk for dropout from the nursing profession. It was described as most noticeable when these nurses experience a period of stress and anxiety with the role adjustment and when faced with the reality of beginning practice as an RN (Kox et al., 2020) The average cost of turnover for an RN working within the Unites States ranges from $37,700 to $58,400 per nurse. Hospitals can lose $5.2 million to $8.1 million annually in onboarding and orientation costs (NSI Nursing Solutions, 2016). On the local level at the practice site, nurse turnover rates within the organization were estimated based on job vacancy rates to cost the organization approximately $3.5 million dollars annually for RN training and REDUCING NURSE INTENTION TO QUIT 5 replacement costs. Staffing shortages created by nurse turnover affect staff morale, diminish the ability of nurses to meet patient care needs, and can lead to negative patient outcomes (Mosadeghrad, 2013). In addition, RN turnover creates staffing problems such as the loss of experienced and competent nurses, RN schedule vacancies, and scheduling imbalances of new and experienced nurses (Dewanto & Wardhani, 2018). Intent to quit an organization appears to be associated with multiple steps and has been identified as a predictor of actual turnover behavior (Lu et al., 2017). According to one study, the majority of nurses leaving an organization began the cognitive process within the year preceding their final decision (Hasselhorn et al., 2015). Another study demonstrated that nurse’s intention to quit an organization had significantly predicted their actual decision to resign from the profession. The study also suggests that interventions should take place to reverse a nurse’s intent to leave an organization while in the formative phase prior to the last step in the turnover process, demonstrating the importance of implementing an intervention at the “intention” state. (Krausz et al., 1995).


Use of Mindfulness-Based Resiliency Interventions to Reduce Nurse Intention to Quit
Nurse turnover has become a rapidly growing work force issue that has a far-reaching effect within the healthcare industry. Turnover statistics for bedside registered nurses (RNs) in the United States in 2019 was 15.9% percent (NSI, 2020). The turnover rate for RNs in California as reported in 2018 was 10.4% (Chu & Spetz, 2020). The annual RN turnover rate at the project site in FY19 was 12.8%.
The purpose of this evidence-based practice project was to reduce nurse turnover as measured by "intent to quit", by providing a mindfulness-based resiliency (MBR) intervention.
The scope of the project was to help determine if a work environment where employees use positive and effective coping skills would reverse the effects of perceived stress and reduce nurse intent to quit the organization.

Significance of the Practice Problem
The area of concern at the project site related to new nurse turnover. The turnover rate for 1st year RN employees in FY19 was 33%. This is consistent with findings from a study in 2020 that stated that novice nurses are at risk for dropout from the nursing profession. It was described as most noticeable when these nurses experience a period of stress and anxiety with the role adjustment and when faced with the reality of beginning practice as an RN (Kox et al., 2020) The average cost of turnover for an RN working within the Unites States ranges from $37,700 to $58,400 per nurse. Hospitals can lose $5.2 million to $8.1 million annually in onboarding and orientation costs (NSI Nursing Solutions, 2016). On the local level at the practice site, nurse turnover rates within the organization were estimated based on job vacancy rates to cost the organization approximately $3.5 million dollars annually for RN training and replacement costs. Staffing shortages created by nurse turnover affect staff morale, diminish the ability of nurses to meet patient care needs, and can lead to negative patient outcomes (Mosadeghrad, 2013). In addition, RN turnover creates staffing problems such as the loss of experienced and competent nurses, RN schedule vacancies, and scheduling imbalances of new and experienced nurses (Dewanto & Wardhani, 2018).
Intent to quit an organization appears to be associated with multiple steps and has been identified as a predictor of actual turnover behavior (Lu et al., 2017). According to one study, the majority of nurses leaving an organization began the cognitive process within the year preceding their final decision (Hasselhorn et al., 2015). Another study demonstrated that nurse's intention to quit an organization had significantly predicted their actual decision to resign from the profession. The study also suggests that interventions should take place to reverse a nurse's intent to leave an organization while in the formative phase prior to the last step in the turnover process, demonstrating the importance of implementing an intervention at the "intention" state. (Krausz et al., 1995).

PICOT Question
For registered nurses within a select pilot group (P), does implementation of a mindfulness-based resiliency (MBR) intervention (I), compared to no intervention (C), reduce nurse intent to quit (O) over an eight-week period (T)?
The aim of this project intervention is to determine if evidenced-based practices (EBPs) as compared to standard practices can reduce nurse "intent to quit" the organization by reducing perceived stress through the use of a MBR intervention at a medical center in northern California. The PICOT for this EBP project provides interest for specific evidence-based interventions that are reproducible and effective for reducing nurse intent to leave the organization, decreasing perceived stress, and increasing nurse coping skills.

Evidence-Based Practice Framework & Change Theory
The EBP formal framework that was incorporated into this project is the Johns Hopkins nursing evidence-based practice (JHNEBP) model. It provides a comprehensive problem-solving guide to clinical decision-making and is tailored to the needs of nurses practicing in clinical settings. The model incorporates a three-step process called PET: practice question, evidence, and translation (Johns Hopkins Medicine, 2017).
The change theory used for this EBP project is the Kotter's change model. This model was selected for its basic step-by-step format that focuses on preparing and accepting change (Aziz, 2017). The phases of change are described as steps that must all be completed to ensure success (Kotter, 2007). There are a total of eight steps associated with Kotter's change model that blend with this EBP project.

Evidence Search Strategy
The three data bases utilized for the evidence search included PubMed, ProQuest and CINAHL. Key words for a combination of searches included "mindfulness", "turnover", "resiliency", "resiliency training", "nurses", "HeartMath™" and "perceived stress". The keyword search process was facilitated by using the mesh term AND between words or phrases.
In the ProQuest database, an initial search using the keywords "mindfulness", "resiliency training", "perceived stress" "nurse" and "turnover," as well as filters for English, and within the last five years, resulted in seven citations. By excluding the keyword word "resiliency" and adding "nursing" and filters for scholarly journal and peer reviewed, the search provided 422 citations. Adding the filter for studies and evidenced-based healthcare, provided a final list of 8 studies. A second ProQuest search with the keywords "HeartMath™" and "turnover" within the last five years in English and a scholarly journal and peer review filter resulted in a final seven citations. A third search in ProQuest with the keywords, "perceived stress", "mindfulness" "turnover", "nurses" and "resiliency training" and filters for English and last five years, resulted in 70 citations. A final review relevant to the PICOT question narrowed the list to 47 citations.
An initial search in PubMed and CINAHL with the keywords, "mindfulness", "resiliency", "nurses" and "turnover" and filters for academic journals, last five years and English resulted in 25 citations. An advanced search in PubMed with MeSH topics "HeartMath™" with filters for: the last 10 years, English, and journal articles, resulted 26 citations. A third search in CINAHL with keywords "HeartMath™" and "resiliency" provided three articles.
A final search was conducted through the HeartMath Institute Research Library through permission of the HeartMath Institute (HMI). The search included the keywords "nurses", "resiliency" and "turnover" and provided seven citations. A scarcity of available evidence specific to mindfulness, resiliency training and turnover for nurses led to the expansion of search criteria to include relevant studies involving physicians and other professionals and expansion of the time frames for studies to 2010-2020. In addition, reference lists from articles were reviewed for the inclusion of additional relevant studies and it was important to include grey literature from the data base searches and books pertaining to the PICOT.

Evidence Search Results
The search results described previously in four data bases, PubMed, ProQuest, CINAHL and the HeartMath Institute (HMI) research data base resulted in a total of 121 citations. In addition, reference lists from foundational articles including studies involving resiliency training were reviewed along with meta-analysis articles resulting in 15 additional records. The list of 136 records were narrowed to 110 based on duplicate titles. This list was further reduced to 35 based on exclusion criteria (Figure 1). Examples included studies focused on resiliency as a trait, and interventions designed to foster resilience. In addition, records were excluded where studies comparing resiliency with mental wellbeing, or correlated job retention with specific leadership traits and organizational culture. Articles and citations addressing burnout were included in the primary evidence list to demonstrate the association between burnout, resiliency, and nurse turnover.
The next step included reviewing records that included a project paper for a Doctorate of Nursing practice (DNP) and a Doctorate of Philosophy with the topic of "resiliency training", "HeartMath™" and "turnover intention". This provided studies conducted with physician and auditor participants that were included in the primary evidence table. This evidence table (Appendix A) lists a total of 10 articles and the doctoral papers that were considered relevant, peer reviewed studies representing experimental and evidence-based practice projects.
The primary research evidence citations were critically evaluated using the JHNEPB model (Johns Hopkins Medicine, 2017). Articles and grey literature were scored for quality by the JHNEPB rating scale for either A for high, B for good, or C for low. Qualitative studies were scored as A/B high quality/ good quality or C low quality (Appendix C). The level of evidence was scored ranging from level 1 as the highest level of evidence, experimental study/randomized controlled trial (RCT), to level V as the lowest level, based on non-research evidence (Appendix A). The final 10 articles and two papers listed in the Prisma (Figure 1) included one level IA, one level IB, one level IIB two level IIA/B, three level IIB, one level IIIA, two level IIIA/B and one level VA (Appendix D).
Two articles were included in summary of systematic reviews. The first article was an integrative review scored as a level V-A. It provided a comprehensive review of research conducted on nurses and resiliency. The second article, a meta-analysis was scored as level IIIA.
It included a matrix that outlined studies associated with resiliency interventions focused on nurses and assessed the rigor of each study (Appendix B).

Practice Recommendation Themes in the Literature
Various themes were located within the literature that relate to stress, nurse burnout, turnover, and MBR interventions. The themes throughout the literature included the mediating effects of resiliency on turnover, intent to leave, and the importance of resiliency in reducing turnover. MBR interventions have also been documented in the literature to improve the coping skills of nurses (Craigie et al., 2016) and have been shown to improve self-confidence, selfmindfulness, communication, and problem-solving skills (McDonald et al., 2012).
The positive impact of resiliency on turnover was described in five articles and two doctoral papers with various terms used for turnover that included intent to quit, intent to leave and intent to stay (Yu & Lee, 2018;Pipe et al., 2012;Larrabee et al.,2009;Smith et al.,2020;D'Alfonso, 2017;Hudgins, 2016;Lackey, 2014). The themes located in one Level IIA study, two Level IIB studies and one Level VA dissertation, employed survey techniques, and validated tools to measure resilience and intent to leave quit both pre and post mindfulness-based resiliency (MBR) interventions (Pipe et al., 2012;Buchanan & Reilly, 2019;D'Alfonso, 2017;Lackey, 2014). Each demonstrated that MBR workplace interventions, were effective in promoting positive strategies for coping and enhancing well-being, both personally and organizationally. This was evidenced in the studies through data demonstrating a decrease in "intent to quit".
A study by Smith et al (2020) was graded as a level IIB, which indicated that resilience exerts a positive effect on reducing turnover intentions This theme is repeated in four additional quantitative studies describing the effects of burnout, negative coping skills and stress on clinicians, and the role resiliency plays in reducing the effects of each emotional state (Yu & Lee, 2018;Larrabee et al., 2009;Hudgins, 2016, Gensimore et al., 2020.The role that resiliency plays in reducing stress, burnout, and turnover intention is evident. There are negative effects of stress and the potential for resiliency enhancement activities, and training for non-clinical professionals can be adapted to health care settings. Studies demonstrating the effects of MBR on populations were included in the literature review. Two studies graded as a level IA and level IB looked at MBI resiliency training interventions for radiologists and for the department of medicine faculty and reported the benefits of the intervention on stress reduction and improvements in resiliency (Sood et al., 2014;Sood et al., 2011). Abbreviated training sessions including a single session were shown to have a significant impact on participants well-being and improved resiliency (Sood et al., 2014) These studies along with a third by Magtibay et al. (2017) provide practice recommendations related to the benefit of the low intensity interventions with a shorter duration.
Interventions utilizing HeartMath™ provide a focus on the heart-brain connection, which can be measured by heart rate variability (HRV) as the beat-to-beat interval of the heart rhythm.
HeartMath™ self-regulation techniques generate self-induced positive emotions, which increase coherence and reduce the effects of stress (D'Alfonso, 2017). The HeartMath Institute (HMI) provides a description of a coherent state in several studies, as the association of positive emotions and heart coherence measured by HRV (McCraty, 2015). The emotional self-regulation strategies to achieve heart coherence are designed to enable individuals to intervene in the moment they start to experience stress to facilitate a shift in feelings and obtain physiological coherence as described in the MBR protocol intervention ( Figure 2).

Practice Recommendations
Recommendations from the literature review were incorporated into this EBP project including the use of an intervention that provides immediate positive outcomes and the use of EBPs that promote resilience and coherence. Program tools and modules were easily adaptable to health care settings as recommended in the literature. The project intervention also provided an evidence-based approach that adds credibility to the practice change to reduce nurse "intent to quit". Each of these recommendations correlates with the PICOT question along with the selection of an eight-week timeframe for the EBP project.

Project Setting
The project setting was a 355-bed acute care medical center located in central, California.
The organization reported 22,000 patient admissions in 2019 and employs 2,700 staff members.
The facility is one of the largest private employers in the county with over $370 million in salary and benefits for FY-2019. The medical center scored an 'A' for the Fall 2019 and Spring 2020 Leapfrog hospital safety grade report. It has an intense focus on patient safety as exemplified by their commitment to train all staff and physicians to use best practices, each and every time, to reduce the risk of harm and create a high reliability organization (HRO) and safe patient environment.

Organizational Structure
The facility is one of seven hospitals in the central California division of a larger entity that was involved in a merger with another healthcare system in 2019. This combined corporation became the second-largest nonprofit hospital chain in the United States, with more than 700 care sites and 142 hospitals in 21 states. The organizational structure includes a facility based executive team that reports to a division president. The nurse executive has accountabilities and oversight for all areas where nursing care takes place in the medical center.

Organizational Need
In discussion with the corporate director for clinical education and professional development, a gap was identified within the organization related to the lack of EBPs that support resiliency within the nursing teams. It was also determined that the COVID-19 pandemic had created a gap in nurses' self-care activities, and the timing was right for an EBP intervention that supports reducing turnover and enhancing the coping skills of nurses. New RNs at the facility listed as 1 st year employees had a turnover rate of >20% for the last two fiscal years. This generated additional support for the MBR project intervention from the chief nurse executive (CNE) who saw it as a potential method to reduce new nurse turnover at her medical center and improve the well-being of her staff.

Key Stakeholders
The primary stakeholders for this project include the nursing staff, and the patients, and the families they care for at the medical center. Additional stakeholders included the CNE, the nursing director for operations, the chief medical officer (CMO), the quality director, and a physician champion. It was also important to have an identified front line staff nurse champion stakeholder who served as an advisor and provided the staff nurse perspective for implementation of the MBR intervention.

The SWOT Analysis
The SWOT analysis presented challenges associated with facility level and system level change within the organization and barriers related to the COVID-19 pandemic. A major barrier included a surge in COVID cases at the facility, creating issues for the intervention team and participants due to scheduling conflicts. A blended virtual and live program for nurses participating in the intervention's skill-building activities was required as a back-up plan during the DNP project intervention phase. The weaknesses included limited administrative support and project funding. Both areas were addressed with the CNE project sponsor including opportunities for grant funding and administrative support from the facility education department (Appendix D). The SWOT analysis identified the interprofessional collaboration required for the success of the project. Support from both the CMO and the physician project champion were evident. This support also included a commitment from the current HeartMath™ certified trainers (HMCTs) at the facility to recruit project participants. (Appendix D).

Plan for Organizational Spread
When evaluating possibilities for an intervention's spread within an organization, it is imperative to define the opportunities at various sociological levels. These levels have been classified as micro, meso and macro levels (Cerderbom et al., 2020). An example of a micro, or facility level change included the plan for the use of the MBR intervention at unit huddles. A meso level change occurred at the organizational level, including the spread of the MBR protocol intervention for use at meetings throughout the division. The macro level change would be the organization's commitment to spread the MBR protocol intervention within a variety of sites and medical centers in multiple divisions.

Plans for Sustainability
The preceptor for the project is positioned within the parent corporation, to drive change at the macro level and expand the intervention system-wide for clinicians. The intervention also provides an opportunity beyond the DNP project for future use by clinicians with patients and by evaluating the EBP practice intervention measuring the Hospital Consumer Assessment of

Project Objectives
The project intervention included four mindfulness-based resiliency intervention sessions provided over an eight-week period. The intervention also included modules and tools focused on the domains of resilience and psychological coherence. The project included the implementation a MBR intervention with the objective of reducing nurses' "intent to the quit" scores by five percent. The MBR intervention was developed based on the HeartMath™ domains of resiliency which have been shown to successfully manage stress in high-pressure groups such as RNs.
A sample size of 27 participants was referenced in a foundational HeartMath™ study documenting a resiliency intervention for oncology nurses (Pipe et al., 2012). Another study provided results using the HeartMath™ POQA-R4 tool with 26 healthcare providers in a pretest/posttest model (Buchanan & Reilly, 2019). The intent was to recruit a total of 32 RNs for participation in the HeartMath resiliency intervention sessions. This would have allowed for attrition with a goal of maintaining a size of 30 participants in the EBP intervention.
Participants were provided a series of informational and skill building sessions focusing on a resiliency intervention based on tools from Heart Math's Resiliency Advantage™ program.
The MBR intervention was provided to nurses over an eight-week period. A resiliency tool utilizing HeartMath™ techniques for quick coherence was introduced at huddles by the nurse participants ( Figure 2).
Pre-intervention surveys with the pilot cohort of participants were completed along with a post-intervention survey. Intended outcomes and objectives included: improving nurse coping skills and reducing perceived stress to improve nurse well-being, and reduce intentions to quit the organization. The following outcome, process measures and objectives were evaluated throughout the project implementation phases and at the conclusion of the intervention. Specific details and times are listed for each item (Table 1).
1. "Intention to quit" high score on the POQA assessment tool will decrease by five percent in eight-weeks.
2. 80 Percent of the MBR intervention homework assignments will be completed by project participants by week four of the project, March 30, 2021.
3. The MBR protocol intervention will be initiated by intervention participants at four huddles a week over a four-week period ending April 24, 2021.

EBP and Change Model
The Johns Hopkins Nursing EBP model was adopted for the implementation of a practice change to support RN resiliency and reduce intent to quit among nursing staff. The evidence from the literature indicates that resiliency interventions such as those found in the HeartMath™ quick-coherence resiliency intervention tool can improve coping skills and promote self-care (Yilmaz, 2017). This translated into a practice change for nurse participants who were presented and informed on the implementation of this protocol intervention along with additional tools by HeartMath™ certified trainers (HMCTs) at each of the intervention skill building sessions.
The steps of Kotter's change model were incorporated into the project at various phases of the intervention. Kotter's first step is to create a sense of urgency as was demonstrated to the facility CNE with the data on the nurse turnover rate within her organization (Mindtools, nd).
The second step included building a powerful coalition with the nurse leaders for the implementation of a MBR intervention at the project site which occurred as they witnessed the stressful effects of the Covid-19 pandemic on their staff (Mindtools, nd).
The third step included creating a vision for change by implementing the MBR intervention with a pilot group who could then articulate the MBR practice change.
Step four included communicating the vision as was done through multiple emails and in-person stakeholder meetings conducted by the project coordinator (PC) (Mindtools, n.d.). Removing barriers as described in step five, was accomplished by the PC who continued to remove obstacles to the change process by securing funding for the project and addressing questions and concerns (Mindtools, n.d.).
Step six of Kotter's theory emphasizes short terms wins which was achieved by improving nurse coping skills within an 8 week-period (Mindtools, n.d.).
Step seven and eight builds on the change and anchors the change within the corporate culture (Mindtools, n.d.). The latter two steps were achieved by working with the preceptor who was a part of the national leadership team for the organization. Ultimately, this change project has the potential to spread through-out the organization, with a corporate leader who will advocate for the MBR intervention as a model for use at other facilities.

Interprofessional Collaboration for Implementation
The PC provided direct oversight for the implement of the MBR intervention and assisted with data collection for the outcome measures in the EBP project. The PC also oversaw the work of the project interventionist who informed the nursing staff about the MBR intervention. The EBP project team also included nurse leaders and a quality specialist. This provided an interprofessional perspective for the project and intervention. Additional team members included: a contracted statistician, a nursing director, a physician champion, a staff nurse champion, and an executive sponsor. The physician champion supported dissemination of the MBR intervention and project outcomes with the medical staff within the medical center.

Intervention Schedule of Activities and Timeline
Beginning on March 1, 2021, participants took part in initial 2-hour information and intervention review sessions. Additional one-hour skill building, and refresher sessions were timed at two-weeks, four-weeks, and eight-weeks. Participants were encouraged to complete MBR homework assignments between the sessions. This was designed as an outcome measure to determine if additional reinforcement of the intervention tools was required during the project implementation phase (Appendix E & F).

Resources and Budget
The MBR intervention budget had funding from a variety of sources, though primarily costs were funded by the practice site. The majority of expenses included in the budget were the labor costs for the nurse participants during the intervention component of the project. Grant funding and support for intervention materials from a partner facility supported the project cost structure (Appendix G).

Project Coordinator Role
The PC guided and monitored successful competition all of the activities described in the timeline (Appendix E) and project milestones (Appendix F). The PC demonstrated basic financial competencies in keeping the project on budget (Appendix G). Excellent time management skills were evident by completing the project within the stated eight-week implementation time frame. The PC first met with the project steering committee to communicate the project scope and project metrics. Weekly stakeholder meetings included key communication talking points, project progress, and additions or changes to the project plan. It was imperative that the PC lead by example in demonstrating resiliency when challenges or unexpected issues developed during the implementation phase, as well as to exhibit delegation skills for specific activities.

Evaluation Tool
The POQA-R4 known as the personal and organizational quality assessment scale is a validated assessment tool designed to provide an overview of personal and job-related constructs (Pipe et al., 2012). The POQA-R4 was developed by the HIM and has been used in a variety of health care settings to evaluate the impact of HeartMath™ interventions (D'Alfonso, 2017). As a set of validated scales, the POQA-R4 is used to assess factors at baseline (pre-intervention) and again after practicing coherence techniques for two to four weeks (Larkey & Hector, 2014).
Standardized scores enable comparisons of individual or aggregate scores with those of pertinent reference groups (Pipe et al., 2012).

Project Participants
Nurse participants were recruited for the project intervention and skill building sessions by members of the nursing leadership team from the project facility site. The PC met with interested participants and discussed the interventions, time frames and participant's commitment. Flyers and huddle messages were provided that described the project and were shared at huddles on nursing units. Nurses not in active employment status were excluded from the criteria for participants. The actual number of participants recruited for the project included 13 RNs due to multiple competing priorities with COVID-19 vaccination clinics and significant staffing shortages at the project site.
The PC provided a weekly communication email that was distributed to key stakeholders which included. reminders for the skill building and MBR intervention refresher sessions. A set agenda and objectives were provided at each session along with a knowledge assessment and evaluation (Appendix I) The baseline pre-intervention POQA R-4 was administered just prior to the start of the initial 2-hour skill building and MBR intervention review session, and was repeated after the last session (Appendix L)

Statistical Data Analysis
Data were analyzed using Intellectus software, and the Shapiro-Wilk test was not significant based on an alpha value of 0.05, W = 0.89, p = .179 (Razali & Wah, 2011). This result suggests the differences in "intention to quit" pre-intervention and "intention to quit" postintervention was produced by a normal distribution ( Figure 3). Therefore, a two-tailed paired samples t-test was conducted to examine whether the mean difference of "intention to quit" preintervention and "intention to quit" post-intervention were significantly different from zero. The result of the two-tailed paired samples t-test were not significant based on an alpha value of 0.05, p = .179, indicating the null hypothesis cannot be rejected.

Demographic Results
Socio-demographic information describes the participants characteristics: gender, age, marital status, employment status, level of education, hours worked per week, number of years in the organization, and number of years in the current job. The demographics results for the 10 matched pairs included seven (70%) who were married or partnered. The majority of participants were ages of 41 to 70 (70%), with a diverse distribution: 30% were 31 to 40, 10 were 41 to 50, 50% were 51 to 60, 10% were 61 to 70. The majority of participants 70% (n=7) had a bachelor's degree or higher; 50% (n=5) reporting a masters and 10% (n=1) a DNP as the highest degree (Appendix H).

Process Measures
Hours worked by participants ranged from 36 to 60 hours per work. Of note was the decrease in weekly hours worked between the pre-intervention and post intervention timeframe by 20% of participants (n=2) who went from between 51hr to >60 hours, down to at or below 50 hours a week. A possible explanation might be that these two participants found benefit in the MBR intervention which supports self-care by finding a balance between work and life activities.
Years working within the organization ranged from 1-20 years and time at current position from 1-10+ years. The employment status was split with 50% (n=5) of the participants working in management positions and 50% (n=5) listing their employment status as professional (Appendix H).
Cronbachs's coefficient alpha was used to determine internal consistency with all primary scales demonstrating reliability (> 0.75). Across the other eight subscales, the coefficient ranged from 0.76, for "health symptoms" to 0.90 for "emotional buoyancy" "intention to quit" and "anxiety/depression" thus measuring unidimensionality (Pipe et al., 2012) (Table 4). This indicates that the instrument is highly reliable in measuring the constructs of interest for this project.
The results of the POQA-R4 survey administered pre-intervention and repeated post intervention at eight-weeks are presented as mean raw scores for the four primary scales and the nine subscales. The scales and subscales have been grouped into positive and negative factors.
The direction of change is indicated by a positive or negative number, demonstrating if the scale score increased or decreased from the initial point of measurement. Interpretation of the scores includes noting the change in the direction after the intervention. An important example includes the positive directional movement downward for relational tension and stress. Conversely, an upward directional movement is noted for emotional buoyancy and emotional commitment.
Observed differences in mean scores that are statistically significant are flagged in the table by one or more asterisk, signaling the level of significance (Table 3).
The final 10 participants surveys were matched by a unique ID number and represent the subset of respondents who had usable data from both time points. Primary scales for these participants reported positive shifts in organizational stress (-15%) emotional vitality (+16%), emotional stress (-24%), and physical stress (-26%). Of significance is the POQA-R4 sub-scale for stress, demonstrating a significant reduction from pre-intervention of (-48%).

Process Measures
A data file was set up in a spread sheet to record the number of completed homework assignments. Descriptive analysis results showed that 70% (7) of the homework logs were received at week 2, 50% (5) of the logs at week 4 and 10% (1) log at week eight. More assignments were received in the beginning of the intervention contributing to a 60% completion rate by week four, 20% below the stated goal of 80%. Results from the huddle logs indicated that a total of eight huddles were conducted by project participants using the MBR intervention during the first four weeks of the project implementation, which exceeded the goal of four huddles by week four.
The written comments received from participants on the evaluations and knowledge assessments were all positive. Some of the statements included: "The tools and the knowledge shared is applicable to my job and my personal life", "Learning so many tools and techniques to help me bring a sense of peace and balance to my life and the lives of others", and "I am more capable of dealing with stressful moments".

Data Integrity
When the data analyses process was completed, the contracted statistician and project coordinator (PC) evaluated the degree of missing data. In consultation with the HeartMath Institute (HMI), specific instructions were provided that when the POQA-R4 questionnaires were evaluated pre and post intervention, only matched pairs were to be included for final analysis.
The homework and the MBR intervention logs were also evaluated for missing data. Participants were asked to evaluate accuracy and completeness by validating that correct data was entered into their logs prior to submission. There were no penalties for not completing logs or homework assignments, which was clearly conveyed by the HeartMath certified Trainers (HMCTs) to the nurse participants.

Protection of Human Rights and Confidentiality
The project was approved through the University of St. Augustine for Health Sciences (USAHS) Nursing Evidence-Based Practice Review Council (EPRC) ensuring the proposal met the elements of a DNP project including the identification of an organizational need for an EBP project (USAHS, 2020). The approval process required through the organization at the project site as a DNP sponsored translation project, required Institutional Review Board (IRB) approval at the facility level. This included a thorough review of the project plan and compliance with human-subject protection. It was an expedited review, as minimal risk had been identified for participants and the project did not include the use of protected health information (PHI).
The data was collected and stored in a lock location in the PC's office. The project data files stored on the PC's computer were password protected for security purposes. When surveys were collected at the completion of the intervention, they were immediately placed in an envelope, sealed, and taken to the HeartMath Institute (HMI) by the PC for evaluation and analysis. Pre-intervention scores were compared to norms from a large (HMI) convenience sample of 5,971 health care workers.

Clinical Significance
The clinical significance or usefulness of this project demonstrates that the intervention improves both the well-being of the nurse and the well-being of the organization. The "organizational stress" scale from the POQA-R4 measured the degree to which employees felt negatively pressured by stressors and conflicts at work and in their personal lives. It is comprised of three components including "pressures of life", "relational tension" and "stress" (Appendix J).
High scores on this scale corelates to the stressors and tensions employees feel. These stressors can interfere with work performance and also signal an intention to quit. The scores demonstrated a positive trend post-intervention with a percentage drop of -15% indicating scores moved in a positive downward trend on the Likert scale for this particular group of questions.
The average of the groups mean scores pre-and post-intervention were compared to derive the percentage change (Table 3). The POQA-R4 question regarding stress saw a significant reduction down to 10 at the end of the eight-week intervention from a pre-questionnaire average of 50 on a scale ranging 0-100. (Appendix K). This is clinically significant as poor scores on this stress subscale suggest that employees may be feeling overwhelmed by various sources of stress in their lives as a whole.
The built-in sustainability with this project is related to the spread of the mindfulnessbased resiliency (MBR) project to other organizations within the hospital system. The intent is that a cycle will occur in which nurse's experience reduced perceived stress and improve their coping skills that would be reflected in the project site's HCAHPS nurse communication scores.

Impact
The project's aim was to determine if implementation of a MBR intervention within a pilot group of nurses would decrease nurse's intent to quit the organization. An MBR intervention was implemented utilizing evidence-based emotional regulation tools to effectively manage perceived stress and reduce negative emotions as a means to reduce nurse turnover. The project change was impacted by the COVID-19 pandemic in terms of the need for a resilience program for nurses. Altered practices within the project site included implementation of MBR tools utilizing quick coherence techniques at huddles. It also included a forum for nurses to discuss the emotional tool created by the pandemic at both a personal and professional level and to learn new techniques for managing such stressful events. It provided an opportunity for selfcare that came at an important time for both the facility and the project participants.
The benefits of this eight-week intervention implementation program, that is both useful and cost effective, makes it appropriate for spread within the project facility site and within the larger healthcare organization. The MBR intervention could provide some cost savings associated with reduction in nurse turnover predicted to occur following the Covid-19 pandemic (Said & El-Shafei, 2020).
Of the 10 participants in the pilot group of nurses, five have committed to becoming HeartMath™ certified trainers (HMCTs). Continuation of the change will be managed by this group of HMCTs and will be expanded to include more nurses at the facility. The project preceptor as a national leader within the health care organization (HCO), has committed to sharing the effectiveness of the MBR intervention at the system level with the data that supports expansion of the pilot throughout the HCO. Improvements associated with the intervention implementation include developing additional staff nurse champions to support MBR intervention skill-building for all clinical nurses, as well as those in management positions.
Limitations of the intervention included the small number of the project participants, thus, limiting statistical significance. A larger sample size may have achieved statistical significance. Time was also a limiting factor as the project implementation coincided with the COVID-19 vaccine clinics that were staffed by some of the project participants.

Dissemination
Results from the EBP project were initially shared virtually as a slide presentation with the Chief Nurse Executive (CNE) and the physician champion. An emphasis was placed on the clinically significant results during discussions with the executive team on expanding implementation within the project site. The results were also shared as an interactive slide presentation to the project participants and recorded so participants could view at a later date if unable to attend the virtual presentation.
Results and project outcomes have been shared with the project preceptor who serves in the role as national director for clinical education and professional development. Results will also be shared with system level stakeholders within the organization. The audience will include representation from assorted healthcare disciplines dedicated to decreasing nurse turnover by promoting the MBR intervention.
The project will be archived at the University of Saint Augustine for Health Sciences Library, Scholarship and Open Access Repository (SOAR). This allows for access to scholarly projects throughout the academic and professional nursing community. The project will also be submitted to the HeartMath Institute for inclusion in their on-line research and dissertation database.
A goal will be to submit the DNP project manuscript for publishing considerations to the Journal of Nursing Administration (JONA) and as an abstract for a poster board presentation at the America Organization for Nursing Leadership™ (AONL) annual conference. JONA is committed to presenting practicable content informed by data (JONA, n.d.) and AONL is interested in projects that can be replicated and support the well-being of nurses. The DNP project manuscript will also be developed into a professional publication for submission to the Journal of Nursing Management (JONM) and the Journal for Nurses in Professional Development (JNPD). Both publications focus on promoting and reporting evidenced-based best practices in leadership and education. The project preceptor and academic colleagues will assist with the peer review process prior to submission. This will follow a thorough review and implementation of manuscript guidelines from each publication.

Conclusion
The intent of this project was to determine if the implementation of an MBR intervention would improve nurse coping skills and reduce nurse perceived stress and intention to quit the organization. Nurse participants were informed on the MBR intervention at four sessions over an eight-week period. Measurements included statistical outcomes from baseline and eight-week post-intervention implementation. The project was based on the Johns Hopkins Nursing EBP framework (JHNEBP) and the Kotter change model. The project participants and project team members were presented in the context of a willingness at the project site for a MBR intervention. The literature review provided practice recommendations that were incorporated into the project including data collection and intervention timelines. Clinical and statistical significance for all measures from the validated POQA-R4 tool were presented and included in a table and appendices format.
Though "intention to quit" did not show a statistically significant change after implementation of the MBR intervention, clinical significance was achieved with reduction of stress for the 10 project participants. In the future, using a larger group may provide statistical significance. The project helped determine that a work environment where employees use positive and effective coping skills can reverse the effects of perceived stress and reduce nurses' intention to quit the organization. Given the negative impact of stress and burnout in nurses, particularly during the COVID-19 pandemic and the cost of nurse turnover for an organization, it was important to provide evidence-based tools found in the MBR intervention that builds resilience.      Intervention -Mindfulness-Based Resiliency 1. Use of Quick Coherence Technique at department and unit huddles. Explain the evidence-based practice and mindfulness-based resiliency (MBR) intervention. Review the steps and provide a quick coherence card:

University of San
2. Review 2 key features at huddle: a. Use Quick Coherence especially when you begin feeling a draining emotion such as frustration, irritation, anxiety, or anger. b. Renewing emotions or regenerative feelings include: Appreciation, Kindness, Care, Love, Tolerance, Courage, Honor, Confidence, Enthusiasm, Joy 3. The first huddle session will be supported by a HeartMath™ Certified Trainer (HMCT) or HeartMath™ Interventionists. 4. Record the number of times quick coherence interventions competed at each huddle per week over 2 weeks. 5. Describe Heart Rate Variability (HRV) and Emotional Coherence at huddles in--week 3. 6. Script: This image is a picture of Heart Rate Variability (HRV), It measures the beat-to-beat variations and plots it on a graph. It is a great window in the Autonomic Nervous System (ANS) and shows how the sympathetic and parasympathetic branches are activating, and if they are in sync (coherence) or out of sync (in coherence). This is one data set for an individual who was asked to simply recall (experience the feeling) of something that was frustrating shown on the top graft that created a stress response, and the heart rhythms become very erratic. Any depleting emotion (such as anger, fear, frustration, etc.) will trigger this response. The second graph shows when we recall (and re-experience) renewing feelings, such as appreciation, care, love, kindness as the heart rhythms instantly shift into a coherent state (harmonious, effective use of energy) reflected in our HRV as the foundation of self-care, inner balance and efficient energy use which facilitates health, healing, and mental clarity. Evaluation of the correlations among the observed variables revealed that turnover intention was negatively correlated with the WES score (r = −0.26, P < 0.001), while it was positively correlated with emotional labor (r = 0.40, P < 0.001) and burnout (r = 0.61, P < 0.001), but it was negatively correlated with resilience (r = −0.27, P < 0.001) and job involvement (r = −0.48, P < 0.001).

Difference Between Intention to Quit Pre and Intention to Quit Post-Intervention
Resilience mediated the effect of emotional labor and burnout which directly affect turnover intention. Given the results of this review, which suggest that certain types of resilience training can modify predictor variables, it is reasonable to consider whether those entering careers such as medicine, nursing, policing, paramedicine or firefighting should be provided with resilience training. Legend: SMD: Standardized Mean difference