FINDING MEANING AND JOY IN WORK 1 Transformational Leadership’s Impact on Finding Meaning and Joy in Work Melisa P. Salmon Edson College of Nursing and Health Innovation, Arizona State University Author Note Melisa P. Salmon is a registered nurse at Banner Casa Grande Medical Center in the critical care nursing department. She has no known conflict of interest to disclose. Correspondence regarding this paper should be addressed to Melisa P. Salmon, Edson College of Nursing and Health Innovation, Arizona State University, Downtown Campus, 550 N. 3rd Street, Phoenix, AZ 85004. Email: Mpsalmo1@asu.edu FINDING MEANING AND JOY IN WORK 2 Acknowledgement I would like to thank God for giving me strength and sanity to endure the many challenges experienced on my Doctor of Nursing Practice journey. Thanks to my faculty mentor, Dr. Kara Mangold, who guided me through the project phases, gave me meaningful feedback, and kept me inspired. Thanks to Dr. Jacqueline Medland, faculty, who gave me new insights on leadership and inspired me to take risks and develop my creative skills. Thanks to my DNP Innovation Leadership cohort, Natalie Heywood and Mary Hodges, I have learned so much from you ladies and appreciate the diverse perspectives you brought to our conversations. My sincere gratitude to my direct work supervisors who allowed me to have a set schedule which made working, being a new mom, and pursuing a doctoral degree possible. Thanks to the project site’s executive and unit leaders, mentor - Taylor Nelson, DNP project team, intensive care unit, emergency department, and care unit RNs who participated in my project – without you this could not have been possible – thanks for supporting my academic journey and success. To my dear friends (work and personal) and family, thank you for praying for me and believing in me. Thanks to my parents for unceasingly praying for me and for caring for my daughter during my absences. Finally, thanks to my little girl, Gabriella, for understanding the reason mommy was not able to spend quantity time with you. I promise I will make it up to you and my hope is that my dedication to advancing my education will inspire you to always seek opportunities to expand your knowledge and skills. Thank you all for helping me to find and sustain meaning and joy in my personal and professional lives. FINDING MEANING AND JOY IN WORK 3 Abstract Aim: To evaluate the impact transformational leadership (TFL) behaviors and What Matters to You conversations have on RNs finding meaning and joy in work (MJW) and turnover. Background: The nursing profession is plagued by burnout - a precursor to loss of MJW. Loss of MJW was exhibited as low morale and increased turnover among acute care RNs at a small hospital in Southwest Arizona. Addressing loss of MJW aligns with caring for the caregiver, the fourth aim of the quadruple aim initiative. Methods: This was a quasi‐experimental mixed methodology evidence-based project. The target populations were core RNs and leaders working in the intensive care unit, care unit, and emergency department. Intervention was multimodal – survey using Meaning and Joy in Work Questionnaire, TFL education, and steps one and two of the IHI four steps for leaders model. Results: Final sample was 18 RNs. Statistical analyses did not reveal significant impact; preand post-survey MJWQ scores remained above four. Themes from the What Matters to You conversations included making a difference, coworkers/connections, staffing, and negativity. Turnover trended positively in two of the three units. Conclusion: This project heightened awareness about MJW and illuminated the impact TFL behaviors can have on RNs finding MJW and turnover. The coronavirus pandemic and acute nursing shortage were significant limitations of the project. Implications: Healthcare organizations are encouraged to view MJW as a system asset, embed it in their cultures, invest in innovative solutions, and continually evaluate outcome measures of MJW. Key Words/Phrases: burnout, meaning and joy in work, acute care, RNs, leadership, transformational leadership, turnover FINDING MEANING AND JOY IN WORK 4 Transformational Leadership’s Impact on Finding Meaning and Joy in Work Acute care registered nurses (RNs) worldwide are experiencing increased stress in the workplace secondary to increasing complexities of patients’ conditions, demanding volatile work environments, limited resources, and the mental turmoil associated with being on the frontline of the coronavirus disease (COVID-19) pandemic. Ongoing exposure to work-related stressors results in burnout syndrome. One ramification of burnout syndrome is a loss of meaning and joy in work (MJW) which precipitates turnover and RNs leaving the profession. Finding ways to support MJW is imperative because when organizations support and engage RNs - the largest portion of the healthcare workforce - they are more likely to achieve goals related to providing safe, high-quality care to the communities served. Plus, RNs who engage in behaviors to create and sustain their MJW build resilience, preventing burnout. Finding MJW is the shared responsibility of organizational leaders and employees. Background and Significance Problem Description Acute healthcare settings are inevitably stressful (Tully & Tao, 2019; Woo, et al., 2020). Burnout is a psychological phenomenon resulting from prolonged exposure to stress at work manifested as emotional exhaustion, depersonalization or cynicism, and feelings of low personal accomplishment (Garcia, et al., 2019; Gomez-Urquiza, et al., 2017; Press Ganey, 2018; Tully & Tao, 2019; Woo, et al., 2020). Burnout affects healthcare workers worldwide and is contagious (Berlanda, et al., 2020; Press Ganey, 2018). Burnout precedes the loss of MJW (Perlo, et al., 2017). Meaning refers to the sense or importance of an action, and joy is a positive emotion that implies perceived success, fulfillment, and happiness at work (Emmons, 2020; Galuska et al., 2018; Lucian Leape Institute, 2013; Rutledge, et al., 2018). Joy does not mean burnout is non- FINDING MEANING AND JOY IN WORK 5 existent; it goes beyond; it is about connections to one's purpose (Deetz, et al., 2020; Muisal, et al., 2019; Perlo, et al., 2017). Lack of MJW negatively impacts patient safety, quality of care, employee well-being, and organizational well-being (Berlanda, et al., 2020; Davis & Batcheller, 2020; Deetz, et al., 2020; Dempsey & Assi, 2018; Perlo, et al., 2017; Perlo & Feeley, 2018; Press Ganey, 2018; Wei, et al., 2020). An RN who has little or no joy or purpose can experience mental and physical ailments, negatively impacting interpersonal and interprofessional relationships. Patients who are acutely ill trust acute care RNs to provide compassionate, patient-centered care; when RNs lack MJW, patient outcomes can be devastating (Perlo, et al., 2017). The lack of MJW in acute care RNs places healthcare organizations at risk for decreased reimbursement, decreased public ratings, and litigation from dissatisfied patients who are victims of errors, safety events, and poor-quality care (Berlanda, et al., 2020; Carter & Hawkins, 2021; Dempsey & Assi, 2018; Perlo, et al., 2017; Perlo, et al., 2018). In 2007, the Institute for Healthcare Improvement (IHI) developed the triple aim initiative to increase patients' experiences, reduce healthcare costs, and improve population health (Perlo, et al., 2017). The initiative's success was impossible because healthcare workers were burnt out and lacked MJW (Fitzpatrick, et al., 2019; Hahn, et al., 2021; Perlo, et al., 2017). In 2014, caring for the caregiver was added as a fourth aim to facilitate the initiative's success, and the initiative was called the quadruple aim (Hahn, et al., 2021; Perlo, et al., 2017). The IHI challenges healthcare organizations to go beyond focusing on burnout by focusing on restoring MJW, a shared responsibility of organizational leaders and employees (Perlo, et al., 2017; Perlo & Feeley, 2018; Wu, et al., 2020). Purpose and Rationale FINDING MEANING AND JOY IN WORK 6 This paper aims to emphasize the significance of acute care RNs finding and sustaining MJW, which is a fundamental right (Balik, 2018; Musial, et al., 2019; Perlo, et al., 2017). When RNs are joyful and find value in their work, there is a positive ripple effect at all healthcare levels. The prevalence of loss of MJW is increasing, which negatively impacts patient safety, quality of care, RNs' well-being, and the nursing profession's stability (Davis & Batcheller, 2020; Perlo & Feeley, 2018). The COVID-19 pandemic has precipitated work stress and is associated with acute care RNs experiencing increased death, dying, and prolonged suffering of patients daily (Hansen & Tuttas, 2022; Krystal & McNeil, 2020; Ruiz & Gibson, 2020; Rutledge, et al., 2021; Shah, et al., 2021). Plus, RNs sometimes work in unpleasant volatile environments, have limited resources, are expected to learn new technology and therapies in a short space of time, work long hours, and have little or no work-life balance (Gomez-Urquiza, et al., 2017; Tully & Tao, 2019). The ever-growing stress associated with the COVID-19 pandemic could destabilize the nurse workforce for years, further increasing the global nursing shortage, escalating burnout, and loss of MJW (Davis & Batcheller, 2020). Epidemiologic Data Acute Care Nurses Nurses make up the largest portion of the healthcare workforce and play a critical role in enhancing patient outcomes (Berlanda, et al., 2020; Dempsey & Assi, 2018; Shah, et al., 2021). Compared with other healthcare professionals, RNs report the highest stress levels at work, primarily acute-care RNs working in acute care settings (Gomez-Urquiza, et al., 2017; Shah, et al., 2021; Tully & Tao, 2019; Woo, et al., 2020). A meta-analysis conducted by Gomez-Urquiza, et al. (2017) revealed the estimated prevalence of burnout symptoms in emergency department RNs was between 20% to 44% for emotional exhaustion, between 23% to 51% for FINDING MEANING AND JOY IN WORK 7 depersonalization, and between 15% to 41% for low personal accomplishment. Of note, the same meta-analysis revealed intensive care unit (ICU) RNs in the United States reported higher levels of burnout symptoms – emotional exhaustion 61% to 67%, depersonalization 44% to 49%, and low personal accomplishment 50% to 62% (Gomez-Urquiza, et al., 2017). When RNs experience a loss of MJW, absenteeism increases, job satisfaction is low, retention is low, turnover is high, patient outcomes suffer, and organizational costs increase (Carter & Hawkins, 2021; Perlo, et al., 2017; Woo, et al., 2020). The turnover rate in nursing is significant (NSI Nursing Solutions Inc., 2021; Shah, et al., 2021; Sherman & Blum, 2018). In 2020, the turnover rate for United States hospital staff RNs increased by 2.8% (NSI Nursing Solutions Inc., 2021). The current turnover rate for acute care RNs in the United States is as follows: ICU RNs 18.7%, ED RNs 20%, and telemetry RNs 19.3% (NSI Nursing Solutions Inc., 2021). Turnover is highest among new RNs in the first three years of practice (NSI Nursing Solutions Inc., 2021; Sherman & Blum, 2019). Lack of MJW is a system-level problem that requires an ongoing combined effort from leaders and employees (Davis & Batcheller, 2020; Deetz, et al., 2020; Galuska, 2018; Johnson Foundation’s Wingspread Center, 2017; Musial, et al., 2019; Perlo, et al., 2017). Finding MJW is viewed as an asset-based solution to stress and burnout, which is sometimes called a “hidden crisis” or a “dangerous public health epidemic” (Perlo, et al., 2017; Press Ganey, 2018). A common theme in the literature is that leadership behaviors directly impact MJW (Balik, 2018; Choi, et al., 2016; Cummings, et al., 2018; Deetz, et al., 2020; Dempsey & Assi, 2018; Fitzpatrick, et al., 2019; Galuska, et al., 2018; Mehrad, et al., 2020; Perlo, et al., 2017; Perlo & Feeley, 2018; Wu, et al., 2020). Transformational Leadership Behaviors FINDING MEANING AND JOY IN WORK 8 Leaders can positively influence organizational culture and help restore and sustain MJW by consistently practicing authentic and transformational behaviors (Balik, 2018; Choi, et al., 2016; Cummings, et al., 2018; Mehrad, et al., 2020; Morsiani, et al., 2017; Wei, et al., 2018; Wu, et al., 2020). These behaviors include forming meaningful relationships, being transparent, being visible, being consistent, promoting shared decision making, promoting teamwork, engaging in positive recognition, and leading by example (Choi, et al., 2016; Cummings, et al., 2018; Galuska, et al., 2018; Frantz, et al., 2017; Mehrad, et al., 2020; Wu, et al., 2020). Transactional Leadership Styles Current practices in acute care settings surround transactional leadership behaviors, not enough transformational and authentic leadership (Choi, et al., 2016; Cummings, et al., 2018; Mehrad, et al., 2020; Morsiani, et al., 2017; Wei, et al., 2018). Leaders pressure RNs to work harder and faster to meet productivity targets while ignoring their physical and mental wellbeing, leading to increased errors and feelings of low personal accomplishment (Choi, et al., 2016; Morsiani, et al., 2017). Organizations have reported success in applying the four leader steps outlined in the IHI Framework for Improving Joy in Work to combat burnout and restore MJW (Balik, 2018; Bernard, 2019; Perlo, et al., 2017; Perlo & Feeley, 2018). Other promising interventions in the literature include creating a positive organizational culture (Carter & Hawkins, 2021; Tully & Tao, 2019; Wei, et al., 2020; Wu, et al., 2020) and implementing resiliency bundles (Bernard, 2019; Carter & Hawkins, 2021; Davis & Batcheller, 2020). Resiliency bundles consist of strategies to combat burnout and other mental issues in healthcare workers. Bundles include transformational and authentic leadership behaviors, robust recognition programs, shareddecision making, competency-building opportunities, peer support programs, debriefings after FINDING MEANING AND JOY IN WORK 9 events such as codes, and training geared toward developing positive thinking and coping skills (Bernard, 2019; Carter & Hawkins, 2021; Davis & Batcheller, 2020; Joint Commission, 2018). Outcomes of Finding and Sustaining Joy in Work The desired outcomes of finding MJW include decreased burnout, decreased turnover, increased retention, and fostering positive work environments where acute care RNs are empowered to consistently provide high quality and safe care (Berlanda, et al., 2020; Dempsey & Assi, 2018; Perlo, et al., 2017). Restoring MJW positively impacts organizational performance and financial well-being (Deetz, et al., 2020; Dempsey & Assi, 2018; Galuska, 2018; Press Ganey, 2018; Rutledge, et al., 2018). Improper management of MJW will result in failure to meet the quadruple aim goals (Perlo, et al., 2017), and burnout will become rampant (Shah, et al., 2021; Sherman & Blum, 2019). Internal Evidence Loss of MJW is a problem at an acute care hospital in Southwest Arizona. Soft data revealed low morale, inactive engagement, and poor interprofessional relationships (B. Kellar, personal communication, September 30, 2020). Hard data revealed increased absenteeism (paid time off sick and Arizona sick time) in the Care Unit and ICU from 9,259 hours in 2019 to 13,658 hours in 2020). Turnover rate, January 2019 to January 2021, increased significantly and ranged 14% to 64% (ICU), 0% to 54% (Care Unit), and ED 0% to 62%). Loss of MJW negatively impacts employee well-being, hospital ratings, system processes, and the financial well-being of the organization because of increased use of premium labor, increased cost to orient and onboard new hires, and decreased reimbursement secondary to low patient satisfaction scores (E. Leuthold, personal communication, September 30, 2020). FINDING MEANING AND JOY IN WORK 10 Poor documentation of care, lack of ownership and accountability, and low patient satisfaction scores are some of the negative impacts on patient care delivery (T. Nelson, personal communication, September 30, 2020). Community members and partners have little trust in the organization because of past negative experiences (B. Kellar, personal communication, September 30, 2020). PICOT Question Preliminary interest in this problem led to an inquiry into current evidence to determine the best interventions for finding MJW. This literature review has led to the clinically relevant PICO question, “In acute care nurses (P), how does transformational leadership behaviors (I) compared to transactional leadership behaviors (C) impact finding meaning and joy in work (O)?” Evidence Synthesis Search Strategy An exhaustive literature search was done using the Cumulative Index of Nursing and Allied Health (CINAHL), PubMed, PsychInfo, Academic Search Premier, AB/Inform, and TRIP databases to answer the PICO question. These databases are credible platforms that are sources of scholarly and peer-reviewed information related to healthcare. Databases were searched using Medical Subject Heading (MeSH) terms, Boolean operators “AND” and “OR” to accommodate different terminology related to the PICO question, and key words/phrases nurs*, acute care nurses, hospital nurses, critical care nurses, emergency room nurses, ER nurses, ED nurses, and ICU nurses, leader, leadership, leadership skills, leadership behaviors, leadership role, leadership styles, transformational leadership, authentic leadership, transactional leadership, managerial leadership, innovation leadership, and complexity leadership, joy, happiness, joy in FINDING MEANING AND JOY IN WORK 11 work, joy at work, meaning in work, and finding joy in work. The reference lists of relevant studies were manually screened to identify additional undetected, relevant studies. CINAHL The initial search in CINAHL using all keywords and phrases yielded 142 results. Filters were then applied, narrowing the search to include only articles from scholarly journals published between 2016 and 2021 and omitting any articles published in a language other than English. The final search yielded 64 results. PubMed The initial search of PubMed utilized the exact keywords and phrases as CINAHL. This initial search yielded 73 results. After filtering the results to include only articles published between 2016 and 2021, the final search yielded 35 articles. PsychInfo The initial search launched in the PsychInfo using all keywords and phrases yielded 62 results. Limits were applied to refine results to peer-reviewed articles published in scholarly journals in the English language between the years 2016 and 2021. This yielded seven results, of which one was relevant to the PICO question. Academic Search Premier The initial search of Academic Search Premier utilized all keywords and phrases. This initial search yielded 96 results. After filtering the results to include only peer-reviewed articles published in scholarly journals between 2016 and 2021, the final search yielded 32 articles. AB/Inform The initial search in AB/Inform yielded 25,744 results. The application of numerous filters resulted in yields above 1000. To reduce the results to a manageable number with relevant FINDING MEANING AND JOY IN WORK 12 articles, the search strategy was changed to only include key phrases acute care nurses AND joy at work. This search yielded 3148 results. Refinement was accomplished by selecting peerreviewed articles published from 2016 to 2021 plus limiting the subject to studies; qualitative research; research; nurses; work environment; job satisfaction; nursing; burnout; hospitals; leadership; research methodology; and systematic review. The final yield was 32 articles, which were saved for critical review and analysis. TRIP Database The TRIP database was included because it is a clinical search engine that focuses on high-quality research evidence and consists of some potential grey literature. This database was searched using the exact phrases from the PICO question and yielded five studies, one of which was published within the required data range. Inclusion Criteria The final yield from the databases included quantitative, qualitative, and mixed methods studies. Each article’s abstract and introduction from final yields (total 171) were read to ensure they aligned with the PICO question. All studies were evaluated for validity, reliability, and relevance to clinical practice. Articles were included whether the intervention yielded positive or negative results to avoid personal bias in presenting data. Because the proposed evidence-based project focuses on acute care RNs in an adult hospital setting, any study featuring non-acute care settings and pediatric RNs were excluded. Studies not specific to MJW but focused instead on outcomes of MJW in work and the impact of leadership behaviors on those outcomes were also included. After exclusions were made, the remaining 18 articles underwent critical appraisal. Critical Appraisal and Synthesis of Evidence FINDING MEANING AND JOY IN WORK 13 Rapid critical appraisal tools to determine the quality and level of evidence for each study were adopted from Melnyk and Fineout-Overholt (2019). Ten studies, of which nine were level VI, and one was level I were retained. This level of evidence is appropriate for behavior-based research. The studies were conducted internationally and included one systematic review, two descriptive correlational, four cross-sectional surveys, one narrative analysis, one exploratory descriptive, and one mixed-method research (see Appendix A, Table A3). The qualitative studies were retained as it is deemed essential to understanding acute care RNs' subjective experience in finding MJW (see Appendix A, Table A2). All research settings included acute care hospitals and involved acute care bedside RNs, except Deetz, et al., (2020), who studied the impact of nurse managers’ MJW on previous employee engagement scores to validate the Meaning in Joy and Work Questionnaire (MJWQ). Biases associated with the studies related to the selected research designs and sampling techniques (see Appendix A, Tables A1 and A2). Also, it was noted that samples comprised females predominantly, except for the systematic review, which did not mention demographics related to gender (see Appendix A, Tables A1 and A2). This finding aligns with the fact that nursing is a feminized profession, and as stated in The Lancet (2020, para. 4), “Globally, 90% of the nursing and midwifery workforce are women.” Measurement tools were mainly heterogeneous; the Multifactorial Leadership Questionnaire™ (MLQ) was used as the primary measurement tool in four studies. Theoretical frameworks were diverse; 90% of the studies stated the theoretical framework used, which strengthens the validity of study findings and enriches the confidence to act on the evidence reported. Three studies focused specifically on MJW, and all 10 studies included one or more outcome variables associated with finding MJW. Seven studies looked at the impact of TFL FINDING MEANING AND JOY IN WORK 14 behaviors on the outcome measures of MJW. The results reveal that TFL positively correlates with job satisfaction (seven studies) and employee engagement (four studies) (see Appendix A, Table A3). All three qualitative studies revealed that TFL behaviors had a positive impact on finding meaning and purpose in work. Positive work environment was mentioned in 50% of the studies as having a positive influence on job satisfaction, employee engagement, burnout, and intention to leave. Other variables found to positively impact MJW were expressing positivity when stressed and having a positive perception of one’s leader. Conclusion of Evidence Synthesis Burnout which leads to loss of MJW is a significant problem in healthcare settings globally. This synthesis concludes that TFL behaviors positively correlate with MJW, employee engagement, job satisfaction, and decreasing burnout among acute care RNs globally. TFL behaviors need to be supported and encouraged by individuals and organizations. The evidence shows creating and sustaining MJW is a shared responsibility. While the studies did not highlight specific interventions, they highlighted the impact of leadership styles and practice environments on MJW. Research evidence concludes that project interventions must include a leadership and bedside nurse component to be successful and sustainable. Theoretical and Implementation Frameworks Full Range Leadership Model The first conceptual framework selected to guide this project is the full-range leadership model (FRLM), which posits that leadership styles vary from transformational to passiveavoidant (Kanste, et al., 2009). Nine factors are divided among these leadership styles (see Appendix B, Figure B1). The five TFL factors are idealized influence behaviors, idealized FINDING MEANING AND JOY IN WORK 15 influence attributes, inspirational motivation, intellectual stimulation, and individual consideration (Kantse, et al., 2009; Manning, 2016; Morsiani, et al., 2017). The three transactional factors are contingent reward (recognition), active management by exception (monitors mistakes), and passive management by exception (fights fires) (Kantse, et al., 2009; Manning, 2016). Management by exception fosters reactive punitive work environments and can contribute to a lack of MJW. The final style is passive-avoidant leadership (laissez-faire), classified as ineffective, meaning the leader takes a hands-off approach to situations and delays decisions (Kantse, et al., 2009; Manning, 2016). The rationale for selecting the FRLM is that while finding MJW is a shared responsibility; leaders play a significant role in helping employees find and sustain MJW and create positive work environments (Perlo, et al., 2017). TFL, which is relational, can profoundly affect others (Manning, 2016; Mehrad, et al., 2020; Morsiani, et al., 2017) and will be critical when integrating the IHI four steps for leaders model (See Appendix B, Figure B2). Education on TFL factors will be provided to acute care leaders to facilitate the successful integration of the model. Leaders will be educated on the benefits of building trust, acting with integrity, inspiring others, fostering innovative thinking, and providing individual and team support. IHI Four Steps for Leaders Model The second conceptual framework is the IHI’s four steps for leaders (see Appendix B, Figure B2). This model is unique because it tells organizations how to achieve joy. The rationale for selection is that organizations internationally have successfully used this framework to help healthcare workers find MJW (Perlo, et al., 2017). The IHI posits that MJW is a system asset that leaders strongly influence (Perlo, et al., 2017). Of note, step one requires that leaders ask employees what matters to them (what gives them MJW) (Perlo, et al., 2017). This first step is a FINDING MEANING AND JOY IN WORK 16 way for leaders to establish meaningful connections, allow employees to reflect on what gives them MJW, and promote positivity (Perlo, et al, 2017). Rosswurm and Larrabee Evidence-based Practice Model The Rosswurm and Larrabee model, a six-step model, was selected to guide this evidence-based project because of its systematic and dynamic approach to integrating evidence into practice (see Appendix B, Figure B3). This can be beneficial when working on complex topics such as finding MJW. The model has been used in nursing practice within acute care settings (Rosswurm & Larrabee, 1999), aligning with this project's population and setting. The steps in the process include 1) assessing the need for change, 2) locating the best evidence, 3) critically appraising the evidence, 4) designing practice change, 5) implementing and evaluating change in practice, and 6) integrating and maintaining the change in practice. Change and Innovation Theoretical Application In alignment with Kotter’s theory of change (Dawson & Andriopoulos, 2017), the need and urgency for change related to reclaiming MJW were recognized, and stakeholder buy-in and commitment were established. Leaders understood the rationale for changing their current leadership practices, and acute care RNs understood the rationale for reclaiming their MJW (Dawson & Andriopoulos, 2017). Change in behavior required participants to engage in reflective activities to identify current predominant leadership practices and levels of MJW. The Doctor of Nursing Practice (DNP) project team was multidisciplinary and included bedside RNs. When point of service employees are actively engaged in change processes, outcomes can be profound (Porter-O’Grady & Malloch, 2018). The changes that result will add value to acute care RNs and leaders. Thus, principles of innovation were used to guide this project. Open innovation concepts focus on efficiently FINDING MEANING AND JOY IN WORK 17 communicating, collaborating, and coordinating efforts with all stakeholders (Dawson & Andriopoulos, 2017). Networking was critical to success because the collective intelligence of stakeholders resulted in richly connected interactions and allowed for diversity which contributed to the innovativeness of the project (Uhl-Bien & Arena, 2017). Setting The DNP project site was a non-profit acute care hospital that serves communities in and around Southwest Arizona. This hospital is part of a large health system and is the only hospital in the city. The hospital has 177 private rooms and, at the time of the project planning and design, employed 214 registered RNs. The project was implemented in the ICU, ED, and Care Units. Stakeholders Critical stakeholders were the project site’s acute care RNs and their leaders because they were the selected target population. The faculty and site mentors guided, mentored, and provided psychological support to the DNP student through all project phases. The project site’s leadership team (executive and unit level) created a sense of urgency for the change and were champions of the project. The site’s chief financial officer provided guidance on the project’s budget; an information technology representative and an administrative assistant helped with setting up an email distribution list and data collection, storage, and security; and the project leader and team were champions who actively engaged in all phases of the project using the Rosswurm and Larrabee model as a guide (see Appendix A, Figure A3). Patients are also stakeholders because they stand to benefit from the RNs finding MJW. The approval entities were stakeholders because, without their approvals, the project could not have been implemented. FINDING MEANING AND JOY IN WORK 18 Methods Approvals and Protection of Participants Approvals to conduct this project were obtained from the project site’s Research/Evidence-Based Practice Council, the project site’s parent company’s Research Determination Committee, and the affiliated university’s Internal Review Board. Project participation was voluntary, and the completion of electronic surveys was considered consent to participate. The minimum necessary data to accomplish the project's intended purpose was collected. Participants’ privacy, anonymity, and confidentiality were protected by implementing deidentification coding strategies for survey responses. Participants created their code using their mothers’ initials, birth month, and date. For example, if the mother’s name is Jane Doe and her birthday is May 14th, the participant’s code would be JD0514. All data were stored on Microsoft Teams which was password protected. The project leader was the only one with access to the data collected, which was securely destroyed after data collection and analysis were completed. Evaluation Question and Project Description The evaluation question was, for acute care RNs, does MJW improve after providing education about TFL to their leaders and implementing the IHI’s four steps for leaders model? This project started in the Fall of 2020 with a needs assessment. The project leader conducted site visits and had group and one-on-one conversations with senior leaders, unit leaders, and bedside RNs to ascertain current problems, issues, and gaps being experienced. Common themes were low morale, increased turnover, loss of MJW, and increased burnout. Approvals were obtained to conduct a doctoral-level project to help RNs restore MJW. In the Spring of 2021, an exhaustive literature search was conducted to find the best evidence to support the PICO question. Current literature was critically appraised, conceptual FINDING MEANING AND JOY IN WORK 19 and implementation frameworks identified, and findings shared with stakeholders. A multidisciplinary project team was formed, and monthly meetings were held to discuss the project details and provide updates. The project team consisted of the DNP student, site mentor, faculty mentor, ED director, chief nursing officer, ICU RN onboarding specialist, human resource personnel, and a bedside nurse from each participating unit. In the Summer of 2021, discussions continued with critical stakeholders, and the project design process began. The DNP project was evidence-based and used a quantitative (survey) and qualitative (interviews/conversations) methodology. The design was quasi‐experimental, including pre and post-test approaches. Permission to use a validated survey, frameworks, and IHI content was sought and received. Project approvals were obtained in July 2021, and implementation began the last week of August and ran through the second week of December. The electronic survey and demographic data forms were entered in the Microsoft Forms software. An email distribution list was created, and a voluntary participation statement was emailed to participants on August 29th. A link and QR code to the anonymous pre-survey were included in the voluntary participation statement, and the pre-survey was completed by September 11th. Taking the survey implied consent. The project leader tracked survey responses daily via Microsoft Forms. Responses were exported from Microsoft Forms and stored on a Microsoft Excel spreadsheet housed in a Microsoft Teams folder owned solely by the project leader. This folder was accessed via the project leader’s work email address and unique password, which was not shared with anyone. Reminders to voluntarily participate in the anonymous survey were done via email on day 10, during staff meetings and pre-shift huddles. The project leader hosted an in-person interactive TFL workshop on September 8th at the project site. The project leader educated leaders about the five factors of TFL (see Appendix B, FINDING MEANING AND JOY IN WORK 20 Figure B1). During the workshop, the IHI four steps for the leaders model were introduced (see Appendix B, Figure B2), and printed copies of the IHI conversational guide were distributed to leaders. The project lead met with each acute care leaders on September 9th and 10th and twice monthly to find out progress, answer questions, and provide additional resources and education as needed. After the workshop, leaders were asked to watch IHI joy in work videos, reviewed the conversation guide, and engaged in What Matters to You conversations with direct reports (RNs) after September 12th. Each leader was sent an invitation with a unique link and QR code to the What Matters to You Microsoft Teams folder to log nursing unit, conversation month, and themes using short phrases on a Microsoft Excel spreadsheet within that folder. The project leader attended the project site’s nursing leadership meetings in October to provide additional TFL education and answer questions. RNs were asked to do a post-survey (MJWQ) from November 28th through December 12th. Access to, monitoring and security, and voluntary participation reminders were the same as for the pre-survey. In the Spring of 2022, data collected were analyzed using descriptive statistics and thematic analysis. Evaluation and dissemination of project findings took various formats, including but not limited to a presentation to the site’s research/evidence-based practice committee and leadership team and the university’s DNP students and faculty. Participants and Recruitment The participants for this project were acute care RNs and their leaders. All full-time and part-time RNs working in the ICU, ED, and Care Units – a total of 144; and their eight leaders (directors and associate directors) were eligible to participate. Travel, registry, and staffing services RNs were not invited to participate because they were temporary workers who did not FINDING MEANING AND JOY IN WORK 21 consistently work at the project site. Eligible participants were recruited via pre-shift huddles, staff meetings, work emails, fliers posted in acute care units and common areas within the project site, and physical work mailboxes. Data Collection Meaning and Joy in Work Questionnaire and Demographic Data Meaning and Joy in Work is a complex phenomenon and has proven challenging to measure using one tool. The MJWQ is newly developed and validated to measure MJW in acute care RNs (see Appendix C, Figure C2). Validity and reliability were tested using a sample of employed acute care RNs. The MJWQ has three subscales with a total of 17 Likert-style questions. The subscales are meaningful work (10 questions), values/connections (five questions), and caring (two questions). The total Cronbach’s alpha coefficient for the MJWQ was alpha 0.94, supporting the tool’s internal consistency (Rutledge, et al., 2018; Rutledge, et al., 2021). The Cronbach’s alpha coefficient for the three subscales is as follows: value/connections 0.78, meaning 0.93, and caring 0.68 (Rutledge, et al., 2018; Rutledge, et al., 2021). See Appendix C, Figure C1 for survey questions under each subscale and scoring guidelines. Demographic data questions were placed at the end of the electronic MJWQ (see Appendix C, Figure C1). Outcomes to be Measured This project's primary intended outcome is that acute care RNs will find MJW; this will be measured using the newly validated MJWQ (Appendix C, Figure C1). Individual units and aggregate changes will be measured. Second, each unit’s voluntary turnover rate will be measured, including reasons for leaving (aggregate). Data will be obtained from the site’s human resource department. Third, the integration of steps one and two of the IHI’s four steps for FINDING MEANING AND JOY IN WORK 22 leaders model will be measured in the form of the number of What Matters to You conversations and common themes derived from the conversations had with direct reports (RNs) from September to November. Data Analysis Plan Quantitative Data MJWQ and demographic data collected will be organized into two sets: (a) preintervention survey responses (two weeks before implementation of the TFL education and IHI model), and (b) post-intervention survey responses (11 weeks after implementation of the TFL education and the IHI model). The Intellectus Statistical Software will be used to analyze quantitative survey responses. Descriptive statistical analysis in frequencies, mean, median, percentages, and standard deviations will be calculated and reported using tables. Paired t-test will be used to calculate the difference between the means of the pre and post MJWQ survey scores and then split by unit (Fain, 2021). Wilcoxon signed-rank test, a non-parametric test, will be used if basic assumptions of the paired t-test are not met to determine changes in pre-survey median and post-survey median and split by unit (Fain, 2021). Voluntary turnover data will be reported as the number of RNs from participating units who left the organization from August 2021 to December 2021, compared to the same time in 2020. Qualitative Data Reasons for leaving the organization will be summarized and written in narrative format. Themes logged by leaders from the What Matters to You conversations will be examined to identify common themes – topics, ideas, and patterns of meaning that come up repeatedly. Budget Direct and Indirect Costs FINDING MEANING AND JOY IN WORK 23 Direct costs for this DNP project include paying two non-exempt registered RNs for attending project team meetings. The average salary for each RN was $40 per hour, and the meetings were held monthly for 30 minutes. If the RNs were already working on meeting days, this did not incur an additional cost. However, taking time away from patient care to attend meetings could have resulted in RNs leaving work late, thereby incurring indirect costs associated with lost productivity and working minutes over a scheduled shift. Exempt members of the project team were not calculated in the direct cost because meetings are held within business hours, and attending meetings was part of their daily routine. The project lead facilitated the education sessions, and which did not incur a cost. Copies of the educational materials were emailed to leaders to eliminate printing costs. There was no cost associated with using Microsoft Office applications because the project lead is an employee of the project site. All employees are given free access to the Microsoft Office application. Indirect costs associated with advertising included designing, printing, and distributing project flyers and purchasing t-shirts with the phrase “Today I Choose Joy” written on the front. These t-shirts were worn by all site leaders and project team members to advertise, promote, and stimulate conversations about the project. There were no tax or shipping fees for the t-shirts. The indirect costs of meeting and education rooms were zero dollars because all were hosted at the project site or via Microsoft Teams. The indirect costs of traveling to and from the site were minimal because the project lead lives eight miles from the site. Travel expenses for participants and leaders were not accounted for because interventions took place on their scheduled shifts. The Intellectus Statistics software used in the data analysis portion of the project was of no direct cost because the university paid for the license which was covered in the project lead’s school fees. FINDING MEANING AND JOY IN WORK 24 Funding The proposed project budget (see Appendix D, Table D1) was discussed with the project site’s chief finance officer, finance analyst, and chief nursing officer. All three deemed the project a “low budget” project and stated the site would fund the overall project costs as operational expenses. The Arizona State University - College of Nursing and Health Innovation grant of $1125 awarded to the project lead for the Fall of 2021 was the second funding source if unforeseen events resulted in exceeding the planned budget. Cost Versus Savings Costs associated with each RN turnover range between $28,400 to $51,700 (NSI Nursing Solutions, 2021). Replacement costs include advertising, recruitment services, hourly wages, benefits, orientation, training, sign-on bonuses ($10,000 currently offered by project site), and relocation bonuses. In addition, using premium labor RNs to fill gaps until replacements are hired and trained is expensive. The benefit-cost ratio of preventing one RN from leaving (value of benefit minus cost of intervention) is positive (see Appendix D, Table D2). This means the project site stands to save thousands of dollars if the project outcomes are achieved. Reducing turnover by even 1% will be cost-effective because “…each percent change in RN turnover will cost/save the average hospital $270,800 per year” (NSI Nursing Solutions, 2021, p. 6). The site could see an annual savings of $269,432 ($270,800 minus the cost of the project) if turnover reduces by 1%. Having had RN turnover greater than 60% in some nursing units in 2020, the organization will experience substantial financial savings from a decrease in turnover. In addition, if RNs experience increased MJW, the quality of care and patient satisfaction may improve, which will result in increased reimbursement from payers. Results FINDING MEANING AND JOY IN WORK 25 Quantitative and qualitative data were collected between August and December 2021 from full-time and part-time RNs working in the ICU, Care Unit, and ED of a hospital in Southwest Arizona. The Intellectus Statistical software was used to analyze the quantitative data. Seventy-four RNs participated in the pre-survey using the MJWQ, and 72 RNs participated in the post-survey using the MJWQ. Eighteen RNs who completed the pre-survey also completed the post-survey, representing 24.32% of the pre-survey sample. The quantitative analysis is based on the final survey sample of 18 RNs. Descriptive Data Demographics by Unit Frequencies and percentages were initially calculated for demographic data and split by unit (see Appendix E, Table E1). The ICU and the ED had the largest number of participants (n = 7). Most (85.71%) of the ED and ICU participants had been RNs for greater than four years. The number of years as an RN was equally divided within the Care Unit, with one (25%) falling into each category. Three (75%) Care Unit RNs and six (85.71%) ED RNs had worked at the project site for less than three years. The number of years worked at the project site among ICU participants was equally divided between three categories except in the 0-3years category (n=1, 14.29%). The most frequently observed category related to the number of years working in the unit was 0-3 years (Care Unit n=7, 100%; ED n=6, 85.17%; ICU n=4, 57.14%). The highest degree held by the ED and ICU participants was a bachelors (n = 5, 71.43%; n = 4, 57.14% respectively) and in the Care Unit was an associate’s (n = 2, 50.00%). The most frequent age group within the ICU and Care Unit was 36-50 years (n = 4, 57.14%; n = 2, 50.00%) and within the ED was 20-35 years (n = 3, 42.86%). Majority of the participants did not have a national certification (ICU n = 6, 85.71%; Care Unit n = 3, 75.00%; ED n = 4, 57.14%). FINDING MEANING AND JOY IN WORK 26 Demographics of Total Sample Seven (38.8%) of the 18 RNs had been RNs for 14 or more years. Ten (56%) RNs worked at the project site for less than three years, and three (16%) for 14 to 19 years. Fourteen (77.78%) of the 18 RNs worked on their assigned units for less than three years. The age range of the RNs varied. Ten (56%) RNs had a bachelor's degree, five (27%) had a master’s degree, and three (17%) had an associate degree. Five (28%) RNs held a national certification. The final survey sample's demographic frequencies and percentages can be found in Appendix E, Table E2. MJWQ Each question in the MJWQ was rated on a Likert scale (1 = strongly disagree; 2 = disagree; 3 = neither agree nor disagree; 4 = agree; 5 = strongly agree). The MJWQ (see Appendix C, Figure C1). The MJWQ subscales scores were calculated using the sum of the ratings in each subscale divided by the number of statements in the subscale. The MJWQ total score was calculated using the sum of ratings for all statements divided by the number of statements in the questionnaire (n = 17). The higher the score, the more MJW (Rutledge, et al., 2021). The observations for the final sample pre-survey MJWQ total scale had a mean of 4.20 (SD = 0.56, Min = 3.00, Max = 5.00), and post-survey MJWQ total scale had a mean of 4.05 (SD = 0.74, Min = 1.94, Max = 5.00). See Appendix E, Table E3 for standard deviations and ranges. This analysis was further broken down by unit as shown in Appendix, Table E4. A two-tailed paired samples t-test was conducted to examine whether the mean difference of the pre-MJWQ total scale and post-MJWQ total scale for the final sample was significantly different from zero (Fain, 2021). The result of the two-tailed paired samples t-test was not FINDING MEANING AND JOY IN WORK 27 significant based on an alpha value of .05, t(17) = 0.91, p = .373 as seen in Appendix E, Table E4. Wilcoxon signed-rank test, a non-parametric test, was conducted to test for differences without concern for distribution assumptions (Fain, 2021). Results revealed no significant differences between the pre and post MJWQ total scale for the 18RNs using an alpha value of .05, where V = 5.00, z = -1.07, p = .285. The pre-survey MJWQ total scale had a median of 4.47, and the post-survey MJWQ total scale had a median of 4.03. Wilcoxon was done for each unit, and the results were not statistically significant. All results were based on an alpha value of .05. For the ICU V = 8.00, z = -1.01, p = .310, pre-survey MJWQ median was 3.88 and post-survey MJWQ median was 4.06. The results for the Care Units showed V = 5.00, z = -1.07, p = .285, pre-survey MJWQ median was 4.47 and post-survey MJWQ median was 4.03. The results for the ED showed V = 13.00, z = -0.52, p = .600, pre-survey MJWQ median was 4.65 and postsurvey MJWQ median was 4.71. What Matters to You Conversations Ninety RNs participated in the What Matters to You Conversations (ICU n = 21, ED n = 35, Care Units n = 34). A thematic analysis was conducted. The project lead and an independent reviewer reviewed the data and extracted common themes. The top five themes were extracted from each unit. Results are displayed in Appendix F, Table F1. Making a difference/having a sense of purpose, coworkers/connections, and teamwork were the top three factors that brought RNs MJW. Poor staffing/increased workload, negative attitudes, and unrealistic expectations/lack of time were the three top factors that prevented RNs from finding MJW. Turnover FINDING MEANING AND JOY IN WORK 28 Turnover data were received from the project site’s senior human resource consultant. The number of RNs from participating units who voluntarily left the project site and an aggregate of reasons for leaving from August to December 2020 (total of 24 RNs) and August to December 2021(total of 28 RNs) were received. The Care Units saw a 55.56% increase in voluntary RN turnover (2020 n = 9; 2021 n = 14). The ED saw a 12.5% decrease in turnover (2020 n = 8; 2021 n = 7). The ICU turnover for the review periods did not change (2020 n = 7, 2021 n = 7). The top three aggregate reasons for leaving in 2020 were personal (n = 13), career advancement (n = 4), and moved/military spouse (n = 3). The top three reasons for leaving in 2021 were personal (n = 12), unavailable to work, pay and benefits, workload (n = 4), and career advancement (n = 2). Results Discussion MJWQ and Voluntary Turnover A multimodal approach was used to measure outcomes of MJW, which aligns with the current literature. The MJWQ is the only validated tool available to measure MJW; higher scores indicate more MJW (Rutledge, et al., 2021). Results from the MJWQ survey indicate RNs who participated in the survey had a high sense of MJW. There was a slight decrease in the average MJWQ total scores, but the average scores were high and aligned with results reported in studies done by Deetz, et al. (2020), Rutledge, et al. (2018), and Rutledge, et al. (2021). When analyzed by unit, the Care Unit ‘s median scores decreased post-survey, though not statistically significant (see Appendix E, Table E4). One contributing factor could have been the project implementation occurring during a COVID-19 surge which precipitated burnout and compounded staffing shortages. Such as the changes to the ICU staffing ratios by the Arizona Governor who issued an executive order stipulating safer staffing ratios in the project site’s ICU FINDING MEANING AND JOY IN WORK 29 (E. Smith, personal communication, September 24, 2021). As a result, the staffing ratios and workload on the Care Units increased because Care Unit RNs were floated to the ICU to facilitate 3:1 team assignment. On the Care Unit RNs were left in 6:1 or higher ratios (the normal ratios were 4:1 or 5:1). This could also explain why the Care Unit experienced the most significant turnover during the project implementation (a 55.5% increase compared to the same period in 2020). The ICU did not experience an increase in turnover compared to the same period in 2020. With that said, the impact of project interventions on turnover was hard to decipher because nursing has become more fluid and financially lucrative since the start of the COVID-19 pandemic and has resulted in increased voluntary RN turnover across the United States (Hansen & Tuttas, 2022). Therefore, it is hard to determine if RNs left the project site because they lost MJW or wanted to capitalize on the financial benefits of travel nursing. Using the site’s turnover classification terminologies, two of the top aggregate reasons RNs left the project site from August to December 2021 were “pay and benefits” and “personal,” the latter being open to multiple interpretations. The ED participants’ MJW median scores improved, and they experienced a 12.5% reduction in turnover. This success could be related to the department’s retention committee chair and the director of nursing being members of the DNP project team and MJW champions. Highly engaged champions can positively impact change endeavors (Porter-O’Grady & Malloch, 2018). The ICU participants’ MJW median scores improved, and the turnover rate did not change. This could be related to the project lead being a member of the ICU team, thereby having increased opportunities to engage in conversations about MJW and providing opportunities during pre-shift huddles for RNs to positively reflect and share joyful moments (Carter & Hawkins, 2021). Another contributing factor could be the changes in the staffing ratios FINDING MEANING AND JOY IN WORK 30 in September, which meant ICU RNs were no longer placed in 3:1 ratio, decreasing their workload. Even though 77.78% of the final sample worked on their assigned units for less than three years, 71.53% of the ICU and 57.14% of ED participants had been RNs for greater than nine years. They thus may have had more positive nursing experiences to reflect on and higher levels of resiliency than the Care Unit RNs (Carter & Hawkins, 2021; Davis & Batcheller, 2020). What Matters to You Conversations: Impediments to Joy It was not a surprise that staffing and increased workload were among the top pebbles preventing RNs from having increased MJW (Perlo, et al., 2017). Those two factors are known stressors that increase RN burnout (Tully & Tao, 2019). The COVID-19 pandemic intensified these stressors because RNs across the nation left core positions to do travel nursing to take advantage of historically lucrative nursing compensation packages (Hansen & Tuttas, 2022). Some RNs left the acute care setting to work in less stressful settings, and some left the nursing profession (Hansen & Tuttas, 2022). Another pebble was the negative attitudes displayed by RNs, physicians, and patients. Burnout, which is highly contagious, contributes to negativity in the work environment and vice versa (Berlanda, et al., 2020; Perlo, et al., 2017; Press Ganey, 2018). Negative attitudes can damage interprofessional relationships, diminish trust, and create a work environment that is void of joy (Carter & Hawkins, 2021). What Matters to You Conversations: Bright Spots Leaders engaging in MJW conversations with staff during the peak of a COVID-19 surge could have contributed to the overall average MJWQ scores not significantly decreasing (Carter & Hawkins, 2021; Cummings, et al., 2018; -Perlo, et al., 2017; Perlo & Feeley, 2018). These conversations exemplify TFL behaviors because leaders were intentional in interacting with and listening to RNs to find out what mattered to them, thereby facilitating the establishment of FINDING MEANING AND JOY IN WORK 31 trusting relationships (Cummings, et al., 2018; Galuska, et al., 2018; Perlo, et al., 2017; Perlo & Feeley, 2018). Teamwork, making a difference, and connections were top themes identified when RNs shared what gave them MJW. These top themes are like themes found in the literature (Galuska, et al., 2018; Hakan, et al., 2020; Manion, 2003; Morsiani, et al., 2017; Perlo, et al., 2017; Perlo & Feeley, 2018) and can foster joyful resilient work environments (Carter & Hawkins, 2021; Davis & Batcheller, 2020). A qualitative study conducted by Manion (2003) revealed four factors that contribute to joy at work – connections, love of the work, achievement, and recognition – all of which were stated by RNs of the participating unit as factors that brought them MJW (see Appendix F, Table F1). A study conducted by Tully and Tao (2019) unexpectedly found that when acute care RNs experience increased work-related stressors, it positively correlated with an increase in positive thinking. Acute care leaders engaging RNs in positive reflection could have inspired RNs to stay with their teams and become more resilient during those unprecedented times (Carter & Hawkins, 2021; Galuska, et al., 2018; Hakan, et al., 2020; Perlo, et al., 2017; Perlo & Feeley, 2018; Tully & Tao, 2019). Leaders who foster positive and supportive practice environments foster a culture that enriches employee success, wellbeing, and MJW (Carter & Hawkins, 2021; Hakan, et al., 2020; Pericak, et al., 2020; Tully, et al., 2019). Process Outcomes As a result of this project, joy is now a buzzword used during meetings, pre-shift huddles, and random conversations. Leaders are more intentional in starting meetings by asking attendees to engage in positive reflection and sharing joyful experiences with others. This type of appreciative inquiry fosters positivity which can improve interprofessional relationships, creativity, innovation, and sustain MJW (Carter & Hawkins, 2021; Emmons, et al., 2020; FINDING MEANING AND JOY IN WORK 32 Galuska, et al., 2018; Mehrad, et al., 2020; Musial, et al., 2019; Perlo, et al., 2017; Perlo, et al., 2018; Tully, et al., 2019). To help weave MJW into the site’s culture, the DNP project leader was asked to be a champion of a long-term strategic initiative called Wellness in Nursing, which aligns with the project’s goal of increasing MJW through TFL behaviors. Clinical Significance Culture creation and meaningful change take time and require the free flow of information between leaders and employees to foster shared learning and shared experiences (Schein & Schein, 2016). This project facilitated the free flow of information between leaders and RNs using various modalities to heighten awareness related to the positive impact finding and sustaining MJW can have on RNs’ overall well-being and engagement, leadership effectiveness, patient outcomes, and organizational performance. The pre- and post-survey total MJWQ mean and median scores did not significantly change; they held steady with scores above four (see Appendix E, Table E1). This result implies that participating RNs experienced a high sense of purpose and joy during one of the most challenging times of this era, the peak of a pandemic. This outcome was clinically significant and has implications for critical stakeholders. The positive turnover trends in the ED and ICU have the potential for significant cost savings for the organization (NSI Nursing Solutions Inc., 2021). Example of potential saving can be seen in Appendix D, Table D2. The increasing turnover trend in the Care Unit is concerning and can result in significant financial losses for the department and the organization (NSI, Nursing Solutions Inc., 2021). This finding should inspire leaders to collaborate with RNs to develop and implement innovative retention strategies as well as consistently practice TFL behaviors which have proven to increase job satisfaction and engagement and reduce intention to FINDING MEANING AND JOY IN WORK 33 leave - outcome measures of MJW (Choi, et al., 2016; Cummings, et al., 2018; Mehrad, et al., 2020; Rutledge, et al., 2018; Rutledge, et al., 2021; Yasin, et al., 2020). Experiencing MJW is contagious, and it behooves organizational leaders to take actions to build practice environments where MJW can flourish (Bernard, 2019; Galuska, et al., 2018; Perlo, et al., 2017). For example, top themes derived from the What Matters to You conversations can be used by unit leaders to implement steps three and four of the IHI Four steps for leaders model (see Appendix B, Figure B2) which involves committing to improving MJW and using principles of improvement science to collaboratively test different strategies (Perlo, et al., 2017, Perlo & Feeley, 2018). Top bright spots (having a sense of purpose, teamwork, and connections) can be leveraged to create innovative campaigns to attract new hires and retain existing RNs. “Human connection and relationships enable nurses to provide care that makes a difference, is meaningful, and makes them feel joyful about their impact” (Galuska, et al., 2018, p. 157). As it relates to impediments to MJW, addressing the nursing shortage will require establishing internal and external partnerships, which may take time (Hansen & Tuttas, 2022). However, being transparent about efforts to improve staffing and involving RNs in those efforts can intellectually stimulate and inspire RNs to be innovative – attributes of TFL (Cummings, et al., 2018; Manning, 2018; Morsiani, et al., 2017; Sherman & Blum, 2019; Yasin, et al., 2020). Leaders influence culture (Schein & Schein, 2016) and have an obligation to foster positive work environments where employees can thrive and be their best selves (Galuska, et al., 2018; Hakan, et al., 2020; Mehrad, et al., 202; Pericak, 2020; Yasin, et al., 2020). Thus, it is imperative that leaders urgently collaborate with staff to develop strategies to decrease negativity in the practice environment. Sustainability FINDING MEANING AND JOY IN WORK 34 This project was designed using evidence-based practice principles, had a solid theoretical basis, used a multimodal approach, and was deemed low-budget by the project site’s executive leadership team. These factors enhance the project's sustainability and increase the potential for replicability (Whelan, et al., 2014, Zullig & Bosworth, 2015). In addition, the What Matters to You Conversations can seamlessly be added to the quarterly one-on-one Aspirations, Results, and Challenge to Grow (ARC) conversations leaders are already required to have with RNs. Through these ongoing meaningful dialogs with RNs, leaders can delve deeper into identified themes, highlight, and celebrate bright spots, and take active collaborative measures to eliminate pebbles. Conclusion of Results Participants were acute care RNs and their leaders working in three different acute care units at a hospital in Southwest Arizona. Most of the final survey sample had worked on their current units for less than three years. The MJWQ pre- and post-intervention scores did not exhibit statistically significant results. Turnover data showed a positive trend for the ICU and the ED, and the top aggregate reason for leaving was classified as “personal.” The themes derived from the What Matters to You conversations highlighted bright spots (making a difference and teamwork) and pebbles (poor staffing and negative attitudes) which aligns with findings in the literature. The results of this project were clinically significant and highlighted the need for consistent TFL practices at the project site. Limitations and Barriers Outcome measures for MJW are multiple and are not standardized (Deetz, et al., 2020, Perlo, et al., 2017; Rutledge, et al., 2018), which makes it challenging to measure the true impact of this evidence-based project and may limit the validity and generalizability of project findings. FINDING MEANING AND JOY IN WORK 35 Implementing the project during a COVID-19 surge was a significant barrier to participation and outcomes of this project. There were numerous competing priorities, increased stressors, and cancellation of meetings that were to be used to promote the project and educate leaders on TFL practices. The canceled meetings did limit the amount and the quality of TFL education and follow-up meetings with acute care leaders. An alternative used was to send educational materials via email and Microsoft Teams; however, leaders expressed they did not have the time to review the materials because of time constraints and competing priorities. The short timeframe to implement and evaluate the project was another limitation; plus, the project site’s launching its annual VOICE survey in week two of the pre-MJW survey may have resulted in survey fatigue and a shift in survey focus by leaders. Turnover was a limitation and a challenge. Deciding on the “right” timeframe and how to measure turnover was challenging because there were many compounding factors. Turnover decreased the final sample size, limiting data analysis options and the generalizability of findings. Another barrier was a significant mismatch in the pre- and post-participant IDs. This could have resulted from the QR code being publicly posted on participating units resulting in a new set of RNs participating in the post-survey and the lack of clarity related to instructions to participants for creating their unique IDs. Recommendations Future Projects One recommendation is to use the already available validated and reliable tools used by the project site to gather and analyze data surrounding MJW. For example, the Maslach Burnout Inventory measures burn-out; the National Database of Nursing Quality Indicators survey asks about job enjoyment; and the VOICE survey measures turnover intentions, engagement, and FINDING MEANING AND JOY IN WORK 36 leadership effectiveness. The timing of all the surveys could be aligned so that more RNs can participate, and a more robust data analysis, including correlations, can be done. Of note, these specific tools were not used for this project because of the misalignment in timing regarding this project’s evaluation phase and distribution of the surveys. Another recommendation is that the project lead could partner with the newly launched Wellness in Nursing Program leads to refine and re-implement this project when the pandemic has settled and when RN staffing conditions have improved. Expanding the implementation timeframe could also allow for more creative and robust TFL education and development programs, thus improving leadership participation and opportunities to practice what is learned. Leadership practices are developed when applied consistently (Cummings, et al., 2018). Having a clear turnover analysis plan; for example, analyzing turnover before and after project implementation could be more meaningful. To increase participation IDs matching and final sample size, two recommendations are to review the literature for best practices related to unique participant ID creation processes which maintains anonymity, and include a sample of potential participants when developing instructions for creating unique IDs to increase comprehension of the instructions. Leaders One recommendation for executive leaders is to view and treat MJW as a system asset by investing resources into developing, implementing, and evaluating innovative solutions or programs (Perlo, et al., 2017). A second recommendation for all leaders is that they continue to refine their TFL skills which can be achieved through ongoing leadership development training, self-assessment, reflection, and mentorship. These skill-building activities can positively impact FINDING MEANING AND JOY IN WORK 37 organizational outcomes, such as RNs not only finding MJW but sustaining MJW and decreasing voluntary turnover (Choi, et al., 2016; Wu, et al., 2020). Conclusion The increasing burnout and loss of MJW experienced by RNs threaten the well-being of the profession, individual RNs, healthcare organizations, communities, and the nation. Loss of MJW manifested as low morale and increased turnover among acute care RNs at a small hospital in Southwest Arizona. A literature review revealed that relational leadership practices, such as TFL, can help RNs find MJW. Thus, the goal of this DNP project was to evaluate the impact TFL behaviors and actively engaging in What Matters to You conversations could have on RNs finding MJW. Providing education about TFL to acute care leaders and implementing the IHI’s four steps for leaders model did not result in increased MJW as measured by the MJWQ. However, there is a heightened awareness of the value of finding MJW. Other project outcomes – turnover trends and themes from What Matters to You conversations - have practical clinical implications for major stakeholders. The COVID-19 pandemic was a significant limitation of this project. Healthcare organizations must view finding MJW as a system asset and invest in implementing innovative, evidence-based solutions to improve the holistic well-being and level of MJW experienced by RNs to achieve the quadruple aim goals. FINDING MEANING AND JOY IN WORK 38 References Balik, B. (2018). Joy in work: The vital role of nursing leadership. Nurse Leader, 16(4), 220– 223. https://doi.org/10.1016/j.mnl.2018.05.006 Berlanda, S., de Cordova, F., Fraizzoli, M., & Pedrazza, M. (2020). Risk and protective factors of well-being among healthcare staff. A thematic analysis. International Journal of Environmental Research and Public Health, 17(18), 6651. https://doi.org/10.3390/ijerph17186651 Bernard, N. (2019). Resilience and professional joy: A toolkit for nurse leaders. Nurse Leader, 17(1), 43-48. https://doi.org/10.1016/j.mnl.2018.09.007 Carter, & Hawkins, A. (2021). Joy at work: Creating a culture of resilience. The Journal of Nursing Administration, 51(11), S48–S55. https://doi.org/10.1097/NNA.0000000000001072 Choi, S., Goh, C., Adam, M., & Tan, O. (2016). Transformational leadership, empowerment, and job satisfaction: The mediating role of employee empowerment. Human Resources for Health, 14(1), 73–73. https://doi.org/10.1186/s12960-016-0171-2 Cummings, G., Tate, K., Lee, S., Wong, C., Paananen, T., Micaroni, S., & Chatterjee, G. (2018). Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review. International Journal of Nursing Studies, 85, 19–60. https://doi.org/10.1016/j.ijnurstu.2018.04.016 Davis, M., & Batcheller, J. (2020). Managing moral distress in the workplace: Creating a resiliency bundle. Nurse Leader, 18(6), 604–608. https://doi.org/10.1016/j.mnl.2020.06.007 FINDING MEANING AND JOY IN WORK 39 Dawson, P. & Andriopoulos, C. (2017). Managing change, creativity, and innovation (3rd ed.). Sage. Deetz, J., Davidson, J., Daugherty, J., Graham, P., & Carroll, D. (2020). Exploring correlation of nurse manager meaning and joy in work with employee engagement. Applied Nursing Research, 55, 151297–151297. https://doi.org/10.1016/j.apnr.2020.151297 Dempsey, C. & Assi, M. J. (2018). The impact of nurse engagement on quality, safety, and the experience of care: What nurse leaders should know. Nursing Administration Quarterly, 42(3), 278–283. https://doi.org/10.1097/NAQ.0000000000000305\ Emmons, R. (2020). Joy: An introduction to this special issue. The Journal of Positive Psychology, 15(1), 1–4. https://doi.org/10.1080/17439760.2019.1685580 Fain, J. A. (2021). Reading, understanding, and applying nursing research (6th ed.). F. A. Davis. Fitzpatrick, B., Bloore, K., & Blake, N. (2019). Joy in work and reducing nurse burnout: From triple aim to quadruple aim. AACN Advanced Critical Care, 30 (2), 185–188. https://doi.org/10.4037/aacnacc2019833 Galuska, L., Hahn, J., Polifroni, E. C., & Crow, G. (2018). A narrative analysis of nurses’ experiences with meaning and joy in nursing practice. Nursing Administration Quarterly, 42(2), 154–163. https://doi.org/10.1097/NAQ.0000000000000280 Garcia, C. L., Abreu, L. C., Ramos, J., Castro, C., Smiderle, F., Santos, J., & Bezerra, I. (2019). Influence of burnout on patient safety: Systematic review and meta-analysis. Medicina (Kaunas, Lithuania), 55(9), 553. https://doi.org/10.3390/medicina55090553 Gómez-Urquiza, J., De la Fuente-Solana, E., Albendín-García, L., Vargas-Pecino, C., OrtegaCampos, E., & Cañadas-De la Fuente, G. (2017). Prevalence of burnout syndrome in FINDING MEANING AND JOY IN WORK 40 emergency nurses: A meta-analysis. Critical Care Nurse, 37(5), e1–e9. https://doi.org/10.4037/ccn2017508 Hahn, J., Galuska, L., Polifroni, E. C., & Dunnack, H. (2021). Joy and meaning in nurse manager practice: A narrative analysis. The Journal of Nursing Administration, 51(1), 38–42. https://doi.org/10.1097/NNA.0000000000000964 Johnson Foundation’s Wingspread Center. (2017). A gold bond to restore joy in nursing: A collaborative exchange of ideas to address burnout [White paper]. https://ajnoffthecharts.com/wpcontent/uploads/2017/04/NursesReport_Burnout_Final.pdf Hakan, N., Monica, E., Ayman, O., Lisbeth, H., Anh, T., & Sandra, P. (2020). Salutary factors and hospital work environments: A qualitative descriptive study of nurses in Sweden. BMC Nursing, 19(1), 125–125. https://doi.org/10.1186/s12912-020-00521-y Hansen, A. & Tuttas, C. (2022). Professional choice 2020-2021: Travel nursing turns the tide. Nurse Leader, 20(2), 145–151. https://doi.org/10.1016/j.mnl.2021.12.018 Kanste, O., Kääriäinen, M., & Kyngäs, H. (2009). Statistical testing of the full‐range leadership theory in nursing. Scandinavian Journal of Caring Sciences, 23(4), 775–782. https://doi.org/10.1111/j.1471-6712.2008.00663.x Krystal, J. H. & McNeil, R. L. (2020). Responding to the hidden pandemic for healthcare workers: Stress. Nature Medicine, 26(5), 639–639. https://doi.org/10.1038/s41591-0200878-4 Manion, J. (2003). Joy at work! Creating a positive workplace. The Journal of Nursing Administration, 33(12), 652–659. https://doi.org/10.1097/00005110-200312000-00008 FINDING MEANING AND JOY IN WORK 41 Manning, J. (2016). The influence of nurse manager leadership style on staff nurse work engagement. The Journal of Nursing Administration, 46(9), 438–443. https://doi.org/10.1097/NNA.0000000000000372 Mehrad, A., Fernández-Castro, J., & González Gómez de Olmedo, M. P. (2020). A systematic review of leadership styles, work engagement and organizational support. International Journal of Research in Business and Social Science, 9(4), 66–77. https://doi.org/10.20525/ijrbs.v9i4.735 Melnyk, B. M. & Fineout-Overholt, E. (2019). Evidence-based practice in nursing and healthcare: A guide to best practice (4th ed.). Wolters Kluwer. Morsiani, G., Bagnasco, A., & Sasso, L. (2017). How staff nurses perceive the impact of nurse managers’ leadership style in terms of job satisfaction: A mixed method study. Journal of Nursing Management, 25(2), 119–128. https://doi.org/10.1111/jonm.12448 Musial, A., Clemens, N., Meier, K. A., Olbrecht, V. A., Gerrein, B. T., Ungard, W., Schweer, M., Statile, A. M., & White, C. M. (2019). Joy in work: A systems-based approach. Curr Treat Options Peds, 5, 26–36. https://doi.org/10.1007/s40746-019-00148-5 NSI Nursing Solutions Inc. (2021). 2021 NSI national health care retention & RN staffing report. https://www.nsinursingsolutions.com/Documents/Library/NSI_National_Health_Care_R etention_Report.pdf Pericak, A., Hogg, C., Skalsky, K., & Bourdeanu, L. (2020). What influences work engagement among registered nurses: Implications for evidence‐based action. Worldviews on Evidence-Based Nursing, 17(5), 356–365. https://doi.org/10.1111/wvn.12469 FINDING MEANING AND JOY IN WORK 42 Perlo, J., Balik, B., Swensen, S., Kabcenell, A., Landsman, J., & Feeley, D. (2017). IHI framework for improving joy in work [White paper]. http://www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Improving-Joy-inWork.aspx Perlo, J., & Feeley, D. (2018). Why focusing on professional burnout is not enough. Journal of Healthcare Management, 63(2), 85–89. https://doi.org/10.1097/JHM-D-1800003 Porter-O’Grady, T., & Malloch, K. (2018). Quantum leadership: Creating sustainable value in health care (5th ed.). Jones and Bartlett Press Ganey. (2018). Burnout and resilience: A framework for data analysis [White Paper]. http://www.pressganey.com/resources/white-papers/burnout-and-resilience-a-frameworkfordata-analysis. Ruiz, M. A., & Gibson, C. M. (2020). Emotional impact of the COVID-19 pandemic on U. S. health care workers: A gathering storm. Psychological Trauma: Theory, Research, Practice, and Policy, 12, S153-S155. https://doi.org/10.1037/tra0000851 Rosswurm, M. A., & Larrabee, J. H. (1999). A model for change to evidence-based practice. The Journal of Nursing Scholarship, 31(4), 317–322. https://nursingfy.com/wpcontent/uploads/2018/09/RosswurmLarrabee.A_model_for_change_to_evidence.pdf Schein, E. H., & Schein, P. A. (2016). Organizational culture and leadership (5th ed.). John Wiley and Sons Incorporated. Shah, M., Gandrakota, N., Cimiotti, J., Ghose, N., Moore, M., & Ali, M. (2021). Prevalence of and factors associated with nurse burnout in the U. S. JAMA Network Open, 4(2), e2036469–e2036469. https://doi.org/10.1001/jamanetworkopen.2020.36469 FINDING MEANING AND JOY IN WORK 43 Sherman, R. O. & Blum, C. (2019). Finding joy in the workplace. American Journal of Nursing, 119(4), 66–69. https://doi:10.1097/01.NAJ.0000554557.54393.5f. The Lancet. (2020). The status of nursing and midwifery in the world. The Lancet (British Edition), 395(10231), 1167–1167. https://doi.org/10.1016/S0140-6736(20)30821-7 Tully, S., & Tao, H. (2019). Work-related stress and positive thinking among acute care nurses: A cross-sectional survey. The American Journal of Nursing, 119(5), 24–31. https://doi.org/10.1097/01.NAJ.0000557886.73585.d2 Uhl-Bien, M., & Arena, M. (2017). Complexity leadership: Enabling people and organizations for adaptability. Organizational Dynamics, 46(1), 9-20. https://doi.org/10.1016/j.orgdyn.2016.12.001 Wei, H., Kifner, H., Dawes, M. E., Wei, T. L., & Boyd, J. M. (2020). Self-care strategies to combat burnout among pediatric critical care nurses and physicians. Critical Care Nurse, 40(2), 44–53. https://doi.org/10.4037/ccn2020621 Wei, H., Sewell, K., Woody, G., & Rose, M. (2018). The state of the science of nurse work environments in the United States: A systematic review. International Journal of Nursing Sciences, 5(3), 287–300. https://doi.org/10.1016/j.ijnss.2018.04.010 Whelan, J., Love, P., Pettman, T., Doyle, J., Booth, S., Smith, E., & Waters, E. (2014). Cochrane update: Predicting sustainability of intervention effects in public health evidence: Identifying key elements to provide guidance. Journal of Public Health (Oxford, England), 36(2), 347–351. https://doi.org/10.1093/pubmed/fdu027 Woo, T., Ho, R., Tang, A., & Tam, W. (2020). Global prevalence of burnout symptoms among nurses: A systematic review and meta-analysis. Journal of Psychiatric Research, 123, 9– 20. https://doi.org/10.1016/j.jpsychires.2019.12.015 FINDING MEANING AND JOY IN WORK 44 Wu, X., Hayter, M., Lee, A. J., Yuan, Y., Li, S., Bi, Y., Zhang, L., Cao, C., Gong, W., & Zhang, Y. (2020). Positive spiritual climate supports transformational leadership as means to reduce nursing burnout and intent to leave. Journal of Nursing Management, 28(4), 804– 813. https://doi.org/10.1111/jonm.12994 Yasin, Y., Kerr, M., Wong, C., & Bélanger, C. (2020). Factors affecting job satisfaction among acute care nurses working in rural and urban settings. Journal of Advanced Nursing, 76(9), 2359–2368. https://doi.org/10.1111/jan.14449 Zullig, L. L., & Bosworth, H. B. (2015). Selecting, adapting, and sustaining programs in health care systems. Journal of Multidisciplinary Healthcare, 8(1), 199–203. https://doi.org/10.2147/JMDH.S80037 THE IMPACT OF TRANSFORMATIONAL 45 Appendix A Evaluation and Synthesis Tables Table A1 Quantitative Evaluation Table Citation Theoretical/ Conceptual Framework TFL and TAL; Leadership Practices; Situational Leadership Model; Magnet Hospital Model; Path Goal Theory; Consideratio n and Initiation; Kanter’s Organizatio nal Empowerme nt Theory Design/ Purpose Sample/ Setting Variables Measurement/ Instrument Data Analysis Results/ Findings Level of Evidence/ Application to practice Cummings, SR N = 129 quantitative Leadership SR: QAVTCS Content Outcomes – total 121 LOE: I et al., (2018). studies Styles Validity and Analysis (6 categories DV1 to Strengths: Large Leadership Purpose: To Databases IV1: reliability not DV6) sample size with styles and systematically Searched: Relational established. IV1 = positive well-established outcome review the CINAHL, Medline, IV2: Taskoutcomes (DV1 to theoretical patterns for literature PsychInfo, ABI, focused Articles: DV6) frameworks, clear the nursing examining the ERIC, Sociological Outcomes (commonly patterns of workforce relationships Abstracts, Embase DV1: Staff used) IV2 (TAL) = negative relationships of DVs and work between Cochrane, Health, satisfaction MLQ (39) DV3 with IVs. Study environment: leadership Star Academic, and with job high degree of designs appropriate A systematic styles and Search Premier factors validity and Most significant for subject. review. outcomes for DV2: Staff reliability findings: Weaknesses: the NWF and Demographics: relationships α = 0.76 to 0.89 IV1 = increased DV1 Variability in Country: NWE. Countries of Study: with work IV2 = decreased DV1 conceptualizations Canada USA – 53, Canada – DV3: Staff Leadership and measurement of 29, Europe – 24, Asia health and Practices leadership may limit Funding: – 11, Middle East – wellbeing Inventory (11) the validity and Not reported 8, Australasia – 4, DV4: – validity generalizability of for this Africa – 2, Canada Relations established; findings. Potential updated SR and USA – 1, Canada among staff reliability α = publication bias. and Australia – 1, and DV5: 0.81–0.91 Common weakness no stated country – 6. Organization of studies related to Key: AC – acute care; CCS - Coping with Organizational Change Scale; CLQ - Chinese Leadership Questionnaire; CR - contingent reward; CSE - Core Self-Evaluation Scale; DV- dependent variable; ENSS - Expanded Nursing Stress Scale; ICAWS - Interpersonal Conflict at Work Scale; IIA - Idealized influence attributes; IIB - idealized influence behaviors; IM - inspirational motivation; InCon - individual consideration; IS - intellectual stimulation; IV- independent variable; LF- laissez-faire; LOE – level of evidence; M – mean; MA – mean age; MBEA - management by exception active; MBEP - management by exception passive; MBI - Maslach Burnout Inventory-General Survey; MEES Maslach's Emotional Exhaustion Scale; MJW – meaning and joy in work; MJWQ – Meaning and Joy in Work Questionnaire; MLQ - Multifactor Leadership Questionnaire; NM – nurse manager; NSS - Nurses Stress Scale; NWE – nursing work environment; NWF – nursing workforce; NYNE – number of years nursing experience; NYNME – number of years nurse manager experience; N - number of participants/articles; OCS - Organizational Constraints Scale; PGEES – Press Ganey Employee Engagement Survey; Pr – predictor; PSI - Physical Symptoms Inventory; PTSS - Positive Thinking Skills Scale; QAVTCS - Quality Assessment and Validity Tool for Correlational Studies; QWI Quantitative Workload Inventory; SAQ – Safety Assessment Questionnaire; SCS - Spiritual Climate Scale; SD – standard deviation; SG – study group; SN – staff nurses; SPSS – statistical package for the social sciences; SR – systematic review; t – t test; TIS - Turnover Intention Scale; TFL – transformational leadership; TAL – transactional leadership; UWES - Utrecht Work Engagement Scale. THE IMPACT OF TRANSFORMATIONAL Citation Theoretical/ Conceptual Framework Design/ Purpose Bias: Potential publication bias. Deetz, et al., (2020). Exploring correlation of nurse Duffy’s Quality Caring Model Design: Descriptive Correlational 46 Sample/ Setting Variables Measurement/ Instrument Sample Designs and Ratings: Correlational, nonexperimental, and cross-sectional moderate or high quality. al environment factors DV6: Productivity and effectiveness Leader Behavior Descriptive Questionnaire (8) – validity established; reliability α = 0.75–0.87 Inclusion: Peerreviewed research published in English between 1985 and 2017; measured leadership by nurses; measured 1 or > outcomes of nursing leadership; and examined relationship between leadership and outcomes for the NWF or NWE. Exclusion: Qualitative and grey literature. Attrition: N/A N=32 NM Sampling: Convenience Demographics: MA: 44.16 Definitions: TFL (relational) Data Analysis Results/ Findings Level of Evidence/ Application to practice sampling and design. Feasibility: Overwhelming evidence to support PICO intervention to restore joy in work. Frequencies IV and DV1: r =.216 IV and DV2: r = .227 DV1 and DV2: r=.774. p = <.001 LOE: VI Strengths: Strong statistical analysis; low attrition rate; MJWQ validation – TAL (taskfocused) IV: NM MJW MJWQ Validity: α =0.94 Reliability: α = 0.46 – 0.79 Measures of central tendency Key: AC – acute care; CCS - Coping with Organizational Change Scale; CLQ - Chinese Leadership Questionnaire; CR - contingent reward; CSE - Core Self-Evaluation Scale; DV- dependent variable; ENSS - Expanded Nursing Stress Scale; ICAWS - Interpersonal Conflict at Work Scale; IIA - Idealized influence attributes; IIB - idealized influence behaviors; IM - inspirational motivation; InCon - individual consideration; IS - intellectual stimulation; IV- independent variable; LF- laissez-faire; LOE – level of evidence; M – mean; MA – mean age; MBEA - management by exception active; MBEP - management by exception passive; MBI - Maslach Burnout Inventory-General Survey; MEES Maslach's Emotional Exhaustion Scale; MJW – meaning and joy in work; MJWQ – Meaning and Joy in Work Questionnaire; MLQ - Multifactor Leadership Questionnaire; NM – nurse manager; NSS - Nurses Stress Scale; NWE – nursing work environment; NWF – nursing workforce; NYNE – number of years nursing experience; NYNME – number of years nurse manager experience; N - number of participants/articles; OCS - Organizational Constraints Scale; PGEES – Press Ganey Employee Engagement Survey; Pr – predictor; PSI - Physical Symptoms Inventory; PTSS - Positive Thinking Skills Scale; QAVTCS - Quality Assessment and Validity Tool for Correlational Studies; QWI Quantitative Workload Inventory; SAQ – Safety Assessment Questionnaire; SCS - Spiritual Climate Scale; SD – standard deviation; SG – study group; SN – staff nurses; SPSS – statistical package for the social sciences; SR – systematic review; t – t test; TIS - Turnover Intention Scale; TFL – transformational leadership; TAL – transactional leadership; UWES - Utrecht Work Engagement Scale. THE IMPACT OF TRANSFORMATIONAL Citation Theoretical/ Conceptual Framework manager meaning and joy in work with employee engagement. Country: USA 47 Design/ Purpose Sample/ Setting Variables Measurement/ Instrument Data Analysis Results/ Findings Purpose: To pilot the use of the MJWQ to examine the relationship of manager joy and meaning in the workplace to employee engagement. M NYNE: 17.42 (7-40) M NYNME: 5.91 (0.5-15) DV1: Employee engagement DV2: Employee perception of their NM PGEES (2018 results): Validity established internationally. Reliability: α = 0.895-0.958 Pearson correlation (anecdotal finding) MJWQ Subscales: Value/Connections: α = 0.736 Meaningful Work: α = 0.933 Caring: α = 0.817 MJWQ Total score: α = 0.923 UWES - high degree of validity and reliability α = .71 to .84. Descriptive Statistics M (SD) Highest IV3 2.69 (1.01) DV2 4.49 (0.95) Lowest IV9 1.43 (0.98) DV3 3.65 (0.82) Regression Analysis IV1 to IV9 impact on DV1 ns Funding: Unfunded Setting: AC and ambulatory care within metropolitan hospital system Inclusion: NM Spearman rho Cronbach’s alpha Definitions: Engagement MJWQ Exclusion: Non-NM Bias: None stated. Manning (2016). The influence of nurse manager leadership style on staff nurse work engagement. Attrition: 9% (did not complete survey) Full Range Leadership Model Work Engagement Conceptual Framework Descriptive Correlational N = 630 n = 441 Purpose: To investigate the influence of NM leadership style on SN work engagement. Sampling: Convenience Demographics: Settings: Three ACH southeastern USA. IV1: IIA IV2: IIB IV3: IM IV4: IS IV5: InCon IV6: CR IV7: MBEA IV8: MBEP IV9: LF DV1: vigor MLQ - high degree of validity and reliability α = .76 to .89 Level of Evidence/ Application to practice moderate to strong IC. Weaknesses: Underpowered, small sample size, PGEES RR below national average, and poor work conditions during survey period – union strikes. Feasibility: Recommended for use in practice due to study replicability, and validation of MJWQ use in NM population. MJWQ can be used to measure project outcomes. LOE: VI Strengths: Solid conceptual frameworks, reliable and validated instruments, and strong statistical analysis. Findings are consistent with previous research on the same topic. Key: AC – acute care; CCS - Coping with Organizational Change Scale; CLQ - Chinese Leadership Questionnaire; CR - contingent reward; CSE - Core Self-Evaluation Scale; DV- dependent variable; ENSS - Expanded Nursing Stress Scale; ICAWS - Interpersonal Conflict at Work Scale; IIA - Idealized influence attributes; IIB - idealized influence behaviors; IM - inspirational motivation; InCon - individual consideration; IS - intellectual stimulation; IV- independent variable; LF- laissez-faire; LOE – level of evidence; M – mean; MA – mean age; MBEA - management by exception active; MBEP - management by exception passive; MBI - Maslach Burnout Inventory-General Survey; MEES Maslach's Emotional Exhaustion Scale; MJW – meaning and joy in work; MJWQ – Meaning and Joy in Work Questionnaire; MLQ - Multifactor Leadership Questionnaire; NM – nurse manager; NSS - Nurses Stress Scale; NWE – nursing work environment; NWF – nursing workforce; NYNE – number of years nursing experience; NYNME – number of years nurse manager experience; N - number of participants/articles; OCS - Organizational Constraints Scale; PGEES – Press Ganey Employee Engagement Survey; Pr – predictor; PSI - Physical Symptoms Inventory; PTSS - Positive Thinking Skills Scale; QAVTCS - Quality Assessment and Validity Tool for Correlational Studies; QWI Quantitative Workload Inventory; SAQ – Safety Assessment Questionnaire; SCS - Spiritual Climate Scale; SD – standard deviation; SG – study group; SN – staff nurses; SPSS – statistical package for the social sciences; SR – systematic review; t – t test; TIS - Turnover Intention Scale; TFL – transformational leadership; TAL – transactional leadership; UWES - Utrecht Work Engagement Scale. THE IMPACT OF TRANSFORMATIONAL Citation Theoretical/ Conceptual Framework Design/ Purpose Country: USA Funding: New Orleans Chapter of American Organization of Nurse Executives. Variables Inclusion: Consented, completion of entire survey, working as a SN, and not in orientation. DV2 dedication DV3 absorption Attrition: 70% met inclusion criteria for analysis Bias: None noted. Morsiani, et al., (2017). How staff nurses perceive the impact of nurse managers’ leadership style in terms of job satisfaction: A mixed method study. Full Range Leadership Developmen t Theory Mixed Method Phase 1 – Correlational Purpose: To identify which leadership style was mostly associated with SN’s job satisfaction. Phase 2 48 Sample/ Setting Phase 1 N = 87 SN N = 29 NM Sampling: Convenience Setting: 3 AC hospitals northern Italy Inclusion: SN whose NM worked >1year in the same ward staffed by 10 or >10 SN Measurement/ Instrument Data Analysis IV1 to IV9 influences DV2 p <0.001 IV1 to IV7 positive significant impact on work engagement p <0.001 Definitions: TFL (IV1 to IV5) IV8 and IV9 negative significant impact on work engagement p = 0.001 TAL (IV6 to IV9) Work Engagement (DV1 to DV3) Phase 1 IV1: TFL IV2: TAL IV3: IIA IV4: IIB IV5: IM IV6: IS IV7: InCon IV8: CR IV9: MBEA IV10: MBEP IV11: LF Results/ Findings Phase 1 MLQ Validated and used internationally Reliability: α > 0.80 Phase 2 3 Focus Groups Quiet environment. Phase 1 M and SD Kruskal– Wallis test Spearman’s coefficient Phase 2 Thematic analysis related to DV - IV7 and IV9 negative significant influence on DV3 p <0.05 IV1: M = 2.89 SD = 0.72 IV2: M = 2.42 SD = 0.72 IV1 and DV: r = 0.71; p < 0.01) all positive correlations IV2 and DV: r = 0.55; p < 0.01 positive correlations (except IV11 and IV9 negative correlations) IV3 and DV: Level of Evidence/ Application to practice Weaknesses: Convenience sample limits generalizability and one time survey which reports SN perceptions may not present facts. Feasibility: Supports all elements of PICO question. Highlights the value of leadership development to engage and retain AC RNs. LOE: VI Strengths: Strong theoretical framework, data collection methods, and statistical analysis. Categorization process adds to the reliability and validity or qualitative results. Weaknesses: Small sample size and restriction to three Key: AC – acute care; CCS - Coping with Organizational Change Scale; CLQ - Chinese Leadership Questionnaire; CR - contingent reward; CSE - Core Self-Evaluation Scale; DV- dependent variable; ENSS - Expanded Nursing Stress Scale; ICAWS - Interpersonal Conflict at Work Scale; IIA - Idealized influence attributes; IIB - idealized influence behaviors; IM - inspirational motivation; InCon - individual consideration; IS - intellectual stimulation; IV- independent variable; LF- laissez-faire; LOE – level of evidence; M – mean; MA – mean age; MBEA - management by exception active; MBEP - management by exception passive; MBI - Maslach Burnout Inventory-General Survey; MEES Maslach's Emotional Exhaustion Scale; MJW – meaning and joy in work; MJWQ – Meaning and Joy in Work Questionnaire; MLQ - Multifactor Leadership Questionnaire; NM – nurse manager; NSS - Nurses Stress Scale; NWE – nursing work environment; NWF – nursing workforce; NYNE – number of years nursing experience; NYNME – number of years nurse manager experience; N - number of participants/articles; OCS - Organizational Constraints Scale; PGEES – Press Ganey Employee Engagement Survey; Pr – predictor; PSI - Physical Symptoms Inventory; PTSS - Positive Thinking Skills Scale; QAVTCS - Quality Assessment and Validity Tool for Correlational Studies; QWI Quantitative Workload Inventory; SAQ – Safety Assessment Questionnaire; SCS - Spiritual Climate Scale; SD – standard deviation; SG – study group; SN – staff nurses; SPSS – statistical package for the social sciences; SR – systematic review; t – t test; TIS - Turnover Intention Scale; TFL – transformational leadership; TAL – transactional leadership; UWES - Utrecht Work Engagement Scale. THE IMPACT OF TRANSFORMATIONAL Citation Country: Italy Funding: No source of funding Bias: None noted. Theoretical/ Conceptual Framework 49 Design/ Purpose Sample/ Setting Variables Measurement/ Instrument Data Analysis Results/ Findings Three Focus Groups - 80 minutes each. Nine to 10 participants each. Exclusion: SN whose NM worked in education, administration, outpatients’ clinics, in the community and in wards with < 10 SN. Response Rate: 94% DV: SN satisfaction Audiotape Verbatim transcription Independent extraction of meanings and coding by two researchers. Categorizati ons crossreferenced for final categories. Final categories checked by six SN who participated in focus groups. Spearman rho 0.71 (highest strongest correlation) Purpose: To describe which behaviors NM should adopt to increase SN satisfaction. Phase 2 N = 27 SN Sampling: Random number selector Setting: 1 AC hospital northern Italy Demographics: Female - 26 Male - 1 MA – 40 M NYNE –13 Inclusion: SNs internal medical wards; completed phase 1; did not complete phase 1 Data saturation Definitions: TFL (IV3 to IV7) TAL (IV8 to IV11) Phase 2 (based on IV3) Q1: What is your idea of leadership and what comes to your mind when we talk about leadership? Q2: What should a good leader do to influence job satisfaction? Q3: Which of the leader’s IV9 and DV: Spearman rho 0.22 (weak correlation). IV4, IV6, and IV9 most displayed. IV3 and IV5 most effective and satisfying. Phase 2 Theme 1 - Respect (professional recognition, fairness, and consistency) Level of Evidence/ Application to practice ACHs limits generalizability of results. Feasibility: Applicable to all elements of PICO question. Highlights leadership styles have a direct impact on finding RN job satisfaction which in turn impacts intention to leave, turnover rates, the quality of care and patient outcomes – outcome measures of joy in work. Theme 2 - Feeling cared for (advocacy, support, and listening) Theme 3 – Being valued (personal and team development) Summary of Phase 2: Respect was most Key: AC – acute care; CCS - Coping with Organizational Change Scale; CLQ - Chinese Leadership Questionnaire; CR - contingent reward; CSE - Core Self-Evaluation Scale; DV- dependent variable; ENSS - Expanded Nursing Stress Scale; ICAWS - Interpersonal Conflict at Work Scale; IIA - Idealized influence attributes; IIB - idealized influence behaviors; IM - inspirational motivation; InCon - individual consideration; IS - intellectual stimulation; IV- independent variable; LF- laissez-faire; LOE – level of evidence; M – mean; MA – mean age; MBEA - management by exception active; MBEP - management by exception passive; MBI - Maslach Burnout Inventory-General Survey; MEES Maslach's Emotional Exhaustion Scale; MJW – meaning and joy in work; MJWQ – Meaning and Joy in Work Questionnaire; MLQ - Multifactor Leadership Questionnaire; NM – nurse manager; NSS - Nurses Stress Scale; NWE – nursing work environment; NWF – nursing workforce; NYNE – number of years nursing experience; NYNME – number of years nurse manager experience; N - number of participants/articles; OCS - Organizational Constraints Scale; PGEES – Press Ganey Employee Engagement Survey; Pr – predictor; PSI - Physical Symptoms Inventory; PTSS - Positive Thinking Skills Scale; QAVTCS - Quality Assessment and Validity Tool for Correlational Studies; QWI Quantitative Workload Inventory; SAQ – Safety Assessment Questionnaire; SCS - Spiritual Climate Scale; SD – standard deviation; SG – study group; SN – staff nurses; SPSS – statistical package for the social sciences; SR – systematic review; t – t test; TIS - Turnover Intention Scale; TFL – transformational leadership; TAL – transactional leadership; UWES - Utrecht Work Engagement Scale. THE IMPACT OF TRANSFORMATIONAL Citation Theoretical/ Conceptual Framework Design/ Purpose Variables Exclusion: SNs not working internal medicine ward behaviors arouse your pride? Q4: Which are the leader’s behaviors that subordinate his/her own interests to those of the group? Q5: What does the leader have to do to win your respect? Q6: When does the leader show a sense of power and selfconfidence? DV: UWES Attrition rate: 0% Pericak, et al., (2020). What influences work engagement Kahn’s Theory of Employee Engagement Observational Cross-sectional N = 201 AC RNs Sampling: Snowball Purpose: To investigate the relationship 50 Sample/ Setting Demographics: Female - 186 Work-related Pr1: ICAWS Pr2: OCS Measurement/ Instrument Data Analysis Results/ Findings Level of Evidence/ Application to practice important to increase DV. UWES Reliability: α = > 0.70 ICAWS Reliability: α = 0.74 Structural Equation Model Contribution to the variance in DV: Pr5 (β = .31, p = .001), Pr4 (β = .30, p < .001), Pr9 (β = 0 .22, p=.002) LOE: VI Strengths: Strong theoretical framework; robust data analysis. Key: AC – acute care; CCS - Coping with Organizational Change Scale; CLQ - Chinese Leadership Questionnaire; CR - contingent reward; CSE - Core Self-Evaluation Scale; DV- dependent variable; ENSS - Expanded Nursing Stress Scale; ICAWS - Interpersonal Conflict at Work Scale; IIA - Idealized influence attributes; IIB - idealized influence behaviors; IM - inspirational motivation; InCon - individual consideration; IS - intellectual stimulation; IV- independent variable; LF- laissez-faire; LOE – level of evidence; M – mean; MA – mean age; MBEA - management by exception active; MBEP - management by exception passive; MBI - Maslach Burnout Inventory-General Survey; MEES Maslach's Emotional Exhaustion Scale; MJW – meaning and joy in work; MJWQ – Meaning and Joy in Work Questionnaire; MLQ - Multifactor Leadership Questionnaire; NM – nurse manager; NSS - Nurses Stress Scale; NWE – nursing work environment; NWF – nursing workforce; NYNE – number of years nursing experience; NYNME – number of years nurse manager experience; N - number of participants/articles; OCS - Organizational Constraints Scale; PGEES – Press Ganey Employee Engagement Survey; Pr – predictor; PSI - Physical Symptoms Inventory; PTSS - Positive Thinking Skills Scale; QAVTCS - Quality Assessment and Validity Tool for Correlational Studies; QWI Quantitative Workload Inventory; SAQ – Safety Assessment Questionnaire; SCS - Spiritual Climate Scale; SD – standard deviation; SG – study group; SN – staff nurses; SPSS – statistical package for the social sciences; SR – systematic review; t – t test; TIS - Turnover Intention Scale; TFL – transformational leadership; TAL – transactional leadership; UWES - Utrecht Work Engagement Scale. THE IMPACT OF TRANSFORMATIONAL Citation among registered nurses: implications for evidencebased action. Country: USA Funding: Not mentioned Bias: Potential sampling bias. Theoretical/ Conceptual Framework Job DemandsResources Theory 51 Design/ Purpose Sample/ Setting Variables Measurement/ Instrument between nurserelated and work-related variables associated with work engagement and provide a model that explains work engagement. Male – 15 Age 20-29 (58) 30-39 (49) 40-49 (26) >50 (68) YNE <5 = 86 6-10 =37 11-20 = 22 >20 = 56 Current job <5y 63.5% Worked overtime >84.5% Absent due to health in past year = 47.8% (avg days missed 12) Married = 68% Pr3: NSS Pr4: QWI QWI Reliability: α = 0.82 NSS Reliability: α = 0.89 CSE Reliability: α = 0.75 CCS Reliability: α = 0.77 MBI Reliability: α = 0.76 to 0.89 Setting: AC hospitals across USA Inclusion: RN license, work in AC. Attrition: 0% Nurse-related Pr5: Age Pr6: MBI Pr7: PSI Pr8: CCS Pr9: CSE Definition: Engagement Validation established for all tools except OCS and PSI causal indicator scales α coefficient irrelevant. Data Analysis Results/ Findings Pr8 (β = .20, p = .001) Pr6 (β = −.17, p = .03). Work engagement model fit (GFI = .996; χ2 (2, N = 201) = 4.02, p = .135; RMSEA = .07; CFI = .983; NFI = .976) Nurse-related factors significant effect on DV: p <0.05. Pr5 (b = .105), Pr6 (b = −.207), Pr8 (b = .4790), and Pr9 (b = .372) Work-related factors: Pr4 only factor directly significantly affected DV (b = .254). Level of Evidence/ Application to practice Weaknesses: Snowball sampling, potential sampling bias, decreased ability to generalize findings. Feasibility: Study relates to all elements of the PICO question. Results will aid in developing appropriate interventions aimed at increasing the work engagement and joy in nurses working in an acute care setting. Supports the thought that finding joy in work is a shared responsibility. Level of work engagement is more frequently predicted by nurse-related factors (16.7%) rather than work-related factors (9.2%). Key: AC – acute care; CCS - Coping with Organizational Change Scale; CLQ - Chinese Leadership Questionnaire; CR - contingent reward; CSE - Core Self-Evaluation Scale; DV- dependent variable; ENSS - Expanded Nursing Stress Scale; ICAWS - Interpersonal Conflict at Work Scale; IIA - Idealized influence attributes; IIB - idealized influence behaviors; IM - inspirational motivation; InCon - individual consideration; IS - intellectual stimulation; IV- independent variable; LF- laissez-faire; LOE – level of evidence; M – mean; MA – mean age; MBEA - management by exception active; MBEP - management by exception passive; MBI - Maslach Burnout Inventory-General Survey; MEES Maslach's Emotional Exhaustion Scale; MJW – meaning and joy in work; MJWQ – Meaning and Joy in Work Questionnaire; MLQ - Multifactor Leadership Questionnaire; NM – nurse manager; NSS - Nurses Stress Scale; NWE – nursing work environment; NWF – nursing workforce; NYNE – number of years nursing experience; NYNME – number of years nurse manager experience; N - number of participants/articles; OCS - Organizational Constraints Scale; PGEES – Press Ganey Employee Engagement Survey; Pr – predictor; PSI - Physical Symptoms Inventory; PTSS - Positive Thinking Skills Scale; QAVTCS - Quality Assessment and Validity Tool for Correlational Studies; QWI Quantitative Workload Inventory; SAQ – Safety Assessment Questionnaire; SCS - Spiritual Climate Scale; SD – standard deviation; SG – study group; SN – staff nurses; SPSS – statistical package for the social sciences; SR – systematic review; t – t test; TIS - Turnover Intention Scale; TFL – transformational leadership; TAL – transactional leadership; UWES - Utrecht Work Engagement Scale. THE IMPACT OF TRANSFORMATIONAL Citation Tully, et al., (2019). Work-related stress and positive thinking among acute care nurses: A crosssectional survey Country: USA Funding: Not mentioned Bias: To control the influence of organizationa l environment on the results, two groups of RNs were recruited into the study. Theoretical/ Conceptual Framework Transaction Model of Stress and Coping 52 Design/ Purpose Sample/ Setting Variables Measurement/ Instrument Data Analysis Results/ Findings Design: Crosssectional Survey N = 298 RNs n = EG 160 n = IG 138 Convenience sampling Setting: 8 campuses AC hospital system in the Central Florida region Demographics: Females EG - 141 IG - 127 Males EG - 17 IG - 11 Education Associates - EG - 31 IG - 46 Bachelors - EG - 100 IG – 83 Doctorate - EG - 28 IG - 6 White EG 112 IG80 African American EG 12 IG 22 Asian EG 20 IG 9 NYNE <3 EG 17 IG 23 >3 EG 142 IG 115 IVI: Positivity IV2: EG IV3: IG IV4: ethnicity IV5: SG DV: Perceived work-related stress Definitions: Coping Positive thinking Demographic questionnaire Pearson Correlation ENSS t = 3.09 PTSS t = 2.38 ENSS Validity: Established good Reliability: amongst nurses established. Multiple linear regression analysis ENSS p = 0.002 PTSS p = 0.018 IV1 and DV ENSS – IV3 = increase DV (mean score 135.90 in IV3 versus 122.92 in IV2). Purpose: To assess the relationship between perceptions of work-related stress and the use of positive thinking among acute care nurses. Inclusion Criteria: RN PTSS Validity: Established – good Reliability: α = 0.89 IVI and DV PTSS – IV3 = higher DV (M 15.40 in IV3 versus 14.14 in IV2). DV and IV1 Higher level of DV was associated with greater use of IV1. Pearson r = 0.194 (p = 0.001) IV5 – increase DV predicts increased use of IV1. IV4 Asian – predicts increased use of IV1. Level of Evidence/ Application to practice LOE: VI Strengths: Strong statistical analysis, use of reliable and validated tools to collect data. Weaknesses: convenience sampling, which limits generalizability of findings, crosssectional design reflects only a single point in time, and limited sample diversity. Feasibility: Applicable to population and project outcome. Implications for job satisfaction and retention which are outcome measures of finding joy in work. Highlights what organizations (offer training and education) and employees (positive Key: AC – acute care; CCS - Coping with Organizational Change Scale; CLQ - Chinese Leadership Questionnaire; CR - contingent reward; CSE - Core Self-Evaluation Scale; DV- dependent variable; ENSS - Expanded Nursing Stress Scale; ICAWS - Interpersonal Conflict at Work Scale; IIA - Idealized influence attributes; IIB - idealized influence behaviors; IM - inspirational motivation; InCon - individual consideration; IS - intellectual stimulation; IV- independent variable; LF- laissez-faire; LOE – level of evidence; M – mean; MA – mean age; MBEA - management by exception active; MBEP - management by exception passive; MBI - Maslach Burnout Inventory-General Survey; MEES Maslach's Emotional Exhaustion Scale; MJW – meaning and joy in work; MJWQ – Meaning and Joy in Work Questionnaire; MLQ - Multifactor Leadership Questionnaire; NM – nurse manager; NSS - Nurses Stress Scale; NWE – nursing work environment; NWF – nursing workforce; NYNE – number of years nursing experience; NYNME – number of years nurse manager experience; N - number of participants/articles; OCS - Organizational Constraints Scale; PGEES – Press Ganey Employee Engagement Survey; Pr – predictor; PSI - Physical Symptoms Inventory; PTSS - Positive Thinking Skills Scale; QAVTCS - Quality Assessment and Validity Tool for Correlational Studies; QWI Quantitative Workload Inventory; SAQ – Safety Assessment Questionnaire; SCS - Spiritual Climate Scale; SD – standard deviation; SG – study group; SN – staff nurses; SPSS – statistical package for the social sciences; SR – systematic review; t – t test; TIS - Turnover Intention Scale; TFL – transformational leadership; TAL – transactional leadership; UWES - Utrecht Work Engagement Scale. THE IMPACT OF TRANSFORMATIONAL Citation Theoretical/ Conceptual Framework Design/ Purpose Sample/ Setting 53 Variables Measurement/ Instrument Data Analysis Results/ Findings Level of Evidence/ Application to practice thinking) can do to find joy in work. IV emotional exhaustion DV1 – TL DV2 – spiritual climate DV3 – Turnover intention Definitions: spiritual climate Transformati onal leadership SCS MLQ (CLQ) MEES TIS Descriptive statistics, using SPSS Clinical sites positive DV2 (mean 65.20–SD 19) Validity: Established for all. Reliability: SCS α = .938 MLQ (CLQ) α = .880 MEES α = .94 TIS α = .859 Pearson's product correlation Mediation analysis LOE: VI Strengths: Sample size enhances validity of study results. Strong statistical analysis, use of reliable and validated tools to collect data. Weaknesses: Results was aggregated (did not specify area of practice). Study only done in hospitals affiliated with the university that funded study. Feasibility: Applicable to population and intervention. Shows TFL in the workplace can reduce RNs’ burnout with a positive spiritual >3m AC experience =50%/>50% direct patient care Response Rate: EG - 29.4% IG - 41.9% Wu, et al., (2020). Positive spiritual climate supports transformatio nal leadership as means to reduce nursing burnout and intent to leave. Country: China Funding: Postgraduate Research & Practice Innovation Program of Spirituality Theory Design: Crosssectional survey N = 400 RNs n = 391 RNs Purpose: To evaluate whether there is a link between perceived positive spiritual climate and TFL and whether this impact nurse burnout and intention to leave the profession. Sampling: Cluster random sampling Setting: Two hospitals within the Jiangsu Province of China Demographics: Age <30 – 223 30-50 – 164 >50 – 4 Unit Worked Medicine 117 Surgery 125 ICU 57 Emergency 25 Experience at the hospital <3 years – 90 >3 years - 301 DV2 - significant negative with IV and DV3 (r = −.455, p < .01; r = −.323, p < .01 DV4 – mild correlation with DV2 and DV1 (r = .100, p < .05; r = .181, p < .01) DV1 and DV2 a = 0.198, p < .01 DV1 and IV c = −0.115, p < .05 DV2 and IV b = −0.499, p < .01 Key: AC – acute care; CCS - Coping with Organizational Change Scale; CLQ - Chinese Leadership Questionnaire; CR - contingent reward; CSE - Core Self-Evaluation Scale; DV- dependent variable; ENSS - Expanded Nursing Stress Scale; ICAWS - Interpersonal Conflict at Work Scale; IIA - Idealized influence attributes; IIB - idealized influence behaviors; IM - inspirational motivation; InCon - individual consideration; IS - intellectual stimulation; IV- independent variable; LF- laissez-faire; LOE – level of evidence; M – mean; MA – mean age; MBEA - management by exception active; MBEP - management by exception passive; MBI - Maslach Burnout Inventory-General Survey; MEES Maslach's Emotional Exhaustion Scale; MJW – meaning and joy in work; MJWQ – Meaning and Joy in Work Questionnaire; MLQ - Multifactor Leadership Questionnaire; NM – nurse manager; NSS - Nurses Stress Scale; NWE – nursing work environment; NWF – nursing workforce; NYNE – number of years nursing experience; NYNME – number of years nurse manager experience; N - number of participants/articles; OCS - Organizational Constraints Scale; PGEES – Press Ganey Employee Engagement Survey; Pr – predictor; PSI - Physical Symptoms Inventory; PTSS - Positive Thinking Skills Scale; QAVTCS - Quality Assessment and Validity Tool for Correlational Studies; QWI Quantitative Workload Inventory; SAQ – Safety Assessment Questionnaire; SCS - Spiritual Climate Scale; SD – standard deviation; SG – study group; SN – staff nurses; SPSS – statistical package for the social sciences; SR – systematic review; t – t test; TIS - Turnover Intention Scale; TFL – transformational leadership; TAL – transactional leadership; UWES - Utrecht Work Engagement Scale. THE IMPACT OF TRANSFORMATIONAL Citation Theoretical/ Conceptual Framework Design/ Purpose Jiangsu Province China, and Program of International Academic Exchange for Postgraduate Students of Yangzhou University, China. Bias: None noted. Yasin, et al., (2020). Factors affecting job satisfaction among acute care nurses working in rural and urban settings. Country: Canada Sample/ Setting 54 Variables Measurement/ Instrument Data Analysis Inclusion criteria: RN with >1 NYNE Exclusion criteria: RN with <1 NYNE Response Rate: 97.75% Herzberg's Two-Factor Theory Cross-sectional Correlational (paper and online survey) Purpose: To explore the similarities and differences between job satisfaction as expressed by rural and urban nurses in Canada and to N = 349 AC RNs n = 167 (rural) n = 177 (urban) Sampling: Disproportional stratified random Demographics: MA – 42.7 Female – 96.3% Male – 3.7% M NYNE – 18.1 Critical care – 51.6% Bachelor – 51% Diploma – 47% Graduate – 2% Results/ Findings DV2 with DV1 and IV −0.089 with estimate for ab = −0.089, p < .01 IV1: Intention to leave IV2: Job satisfaction DV1: Intrinsic factors DV2: Extrinsic factors Definitions: Acute Care Nurses’ Job Satisfaction Scale Validity: Established Reliability: α = 0.71–0.92 Anticipated Turnover Scale Validity: α = 0.84 Binary logistic regression Simple linear regression Regression analysis IV2 median overall score 7/10; IR 2 DV1 and DV2 significant predictors of IV2 (χ2 = 193.01, df = 22, p < .0001) DV1 strongest association with IV2 (Wald = 22.8, df = 1, p < .001) Quality supervision 2nd strongest association with IV2 Wald = 5.91, df = 1, p < .05 Level of Evidence/ Application to practice climate that increases meaningfulness in their work. Shows TFL can increase retention of RNs. LOE: VI Strengths: Robust data analysis and sampling technique improved data quality and internal validity. Weaknesses: Crosssectional design reduces external validity of findings and limits the inference of causality. Underpowered final sample size. Key: AC – acute care; CCS - Coping with Organizational Change Scale; CLQ - Chinese Leadership Questionnaire; CR - contingent reward; CSE - Core Self-Evaluation Scale; DV- dependent variable; ENSS - Expanded Nursing Stress Scale; ICAWS - Interpersonal Conflict at Work Scale; IIA - Idealized influence attributes; IIB - idealized influence behaviors; IM - inspirational motivation; InCon - individual consideration; IS - intellectual stimulation; IV- independent variable; LF- laissez-faire; LOE – level of evidence; M – mean; MA – mean age; MBEA - management by exception active; MBEP - management by exception passive; MBI - Maslach Burnout Inventory-General Survey; MEES Maslach's Emotional Exhaustion Scale; MJW – meaning and joy in work; MJWQ – Meaning and Joy in Work Questionnaire; MLQ - Multifactor Leadership Questionnaire; NM – nurse manager; NSS - Nurses Stress Scale; NWE – nursing work environment; NWF – nursing workforce; NYNE – number of years nursing experience; NYNME – number of years nurse manager experience; N - number of participants/articles; OCS - Organizational Constraints Scale; PGEES – Press Ganey Employee Engagement Survey; Pr – predictor; PSI - Physical Symptoms Inventory; PTSS - Positive Thinking Skills Scale; QAVTCS - Quality Assessment and Validity Tool for Correlational Studies; QWI Quantitative Workload Inventory; SAQ – Safety Assessment Questionnaire; SCS - Spiritual Climate Scale; SD – standard deviation; SG – study group; SN – staff nurses; SPSS – statistical package for the social sciences; SR – systematic review; t – t test; TIS - Turnover Intention Scale; TFL – transformational leadership; TAL – transactional leadership; UWES - Utrecht Work Engagement Scale. THE IMPACT OF TRANSFORMATIONAL Citation Funding: Qatar National Library Bias: None noted Theoretical/ Conceptual Framework 55 Design/ Purpose Sample/ Setting Variables Measurement/ Instrument examine the intrinsic and extrinsic factors affecting overall job satisfaction and turnover intentions. Setting: Rural and urban southern Ontario, Canada Intrinsic factors – achievement, job interest, and responsibility Extrinsic factors - peer support, work conditions, and quality of supervision. Reliability: α = 0.89 Inclusion: AC RN, working rural and urban southern Ontario, fulltime, part-time, read and understand English. Exclusion: Not involved in direct patient care and temporary position. Attrition: Response rate 36% Data Analysis Results/ Findings IV2 negatively correlated with IV1(r = −.55, p < .01) IV2 significant predictor of IV1 (β = −0.548, p < .001) IV2 = 30% of the variance in IV1 (F (1,340) = 145.71, p < .001). Level of Evidence/ Application to practice Feasibility: Useful findings to support PICO population and outcome. Knowledge of intrinsic and extrinsic factors that influence job satisfaction and intention to leave can be used to streamline project intervention(s). Key: AC – acute care; CCS - Coping with Organizational Change Scale; CLQ - Chinese Leadership Questionnaire; CR - contingent reward; CSE - Core Self-Evaluation Scale; DV- dependent variable; ENSS - Expanded Nursing Stress Scale; ICAWS - Interpersonal Conflict at Work Scale; IIA - Idealized influence attributes; IIB - idealized influence behaviors; IM - inspirational motivation; InCon - individual consideration; IS - intellectual stimulation; IV- independent variable; LF- laissez-faire; LOE – level of evidence; M – mean; MA – mean age; MBEA - management by exception active; MBEP - management by exception passive; MBI - Maslach Burnout Inventory-General Survey; MEES Maslach's Emotional Exhaustion Scale; MJW – meaning and joy in work; MJWQ – Meaning and Joy in Work Questionnaire; MLQ - Multifactor Leadership Questionnaire; NM – nurse manager; NSS - Nurses Stress Scale; NWE – nursing work environment; NWF – nursing workforce; NYNE – number of years nursing experience; NYNME – number of years nurse manager experience; N - number of participants/articles; OCS - Organizational Constraints Scale; PGEES – Press Ganey Employee Engagement Survey; Pr – predictor; PSI - Physical Symptoms Inventory; PTSS - Positive Thinking Skills Scale; QAVTCS - Quality Assessment and Validity Tool for Correlational Studies; QWI Quantitative Workload Inventory; SAQ – Safety Assessment Questionnaire; SCS - Spiritual Climate Scale; SD – standard deviation; SG – study group; SN – staff nurses; SPSS – statistical package for the social sciences; SR – systematic review; t – t test; TIS - Turnover Intention Scale; TFL – transformational leadership; TAL – transactional leadership; UWES - Utrecht Work Engagement Scale. THE IMPACT OF TRANSFORMATIONAL 56 Appendix A Evaluation and Synthesis Tables Table A2 Qualitative Evaluation Table Citation Theoretical/ Conceptual Framework Design/ Method Sample/Setting Galuska, et al., (2018). A narrative analysis of nurses’ experiences with meaning and joy in nursing practice. Authentic Happiness Theory (inferred) Narrative Inquiry (lens of appreciation) N = 27 AC RNs Sampling: Snowball Country: USA Funding: None mentioned Bias: None noted Purpose: To elicit and interpret nurses’ stories of their experiences with joy and meaning in work. To explore factors contributing to nurses’ experiences of meaning and joy. Demographics: Female - 20 Male – 7 Age – 31 to 60 NYNE – 2 to 40 Setting: Diverse, including acute care hospitals across the USA. Inclusion: >1 NYNE in USA Exclusion: <1 NYNE in USA Attrition – Not mentioned Definitions: Joy Meaning Major Variables/ Research Questions Q1 Why did you become a nurse? Measurement/ Instrumentation Data Analysis Findings/ Themes Demographic data collection form Thematic analysis Theme 1 Fulfilling purpose (“I am a nurse”) Interview Q2 Can you share your experience with meaning and joy in your practice? (include examples, details, and context) Recorder - Smart phone App: StoryCorps Data transcribed, deidentified, and shared within the research team through a secure, shared data repository. Independent reading of narrative, extraction of meanings, and formulation of preliminary themes by researchers then reviewed by team. Categorization, definition, and review of final themes. Theme 2 Meaningful connection Theme 3 Impact—the wow factor Theme 4 Practice environment: -Teamwork - Leaders model the way. - Opportunities to learn and grow. LOE; Application to practice/ Generalization LOE: VI Strengths: Use of lens of appreciation to elicit and interpret nurses’ stories. Transparent data collection method - StoryCorps. Diversity of participants and areas of practice. Thorough thematic analysis process. List of recommendations for nurse leaders based on the four themes. Weaknesses: No mention of study limitations. Snowball sampling = potential sampling bias and decreased Key: AC – acute care; COREQ - Consolidated Criteria for Reporting Qualitative Research Checklist; JoS – job satisfaction; M – mean; MA – mean age; MMF – most meaningful factor; NYNE – number of years nursing experience; PR – professional role; Q – question; SL – supportive leadership. THE IMPACT OF TRANSFORMATIONAL Citation Hakan, et al., (2020). Salutary factors and hospital work environments: A qualitative descriptive study of nurses in Sweden. Country: Sweden Theoretical/ Conceptual Framework Salutogenic Theory Design/ Method Phenomenology: Exploratory Descriptive Purpose: To understand the factors that can increase both the professional longevity of nurses working in hospitals and nurses’ willingness to remain in work and the Sample/Setting N = 12 RNs Sampling: Purposive Demographics: Female – 12 MA – 48 M YNE - 16 Married/cohabitation - 12 Setting: AC hospital in western Sweden Inclusion: Understand and speak Swedish. 57 Major Variables/ Research Questions JoS Q1: What does JoS mean for you? Q2: What makes you feel good at work? Can you give some examples? PR Q3: Are you proud to be a Measurement/ Instrumentation In-depth face-toface interviews (M 80mins) Semi-structured questions Open-ended questions Notes Verbatim transcription COREQ Data Analysis Qualitative Content Analysis (deductive and inducive) Independent reading of text several times; joint reduction into meaning units, coding, themes, and subthemes. Excerpts from interviews Findings/ Themes Data saturation Theme 1 Meaningfulness - JoS – MMF for staying - Fun at work - Acknowledgement - Productivity - Togetherness - Team security Theme 2 Manageability - Manageable workload LOE; Application to practice/ Generalization ability to generalize findings. Feasibility: Study aligns with the population, intervention, and outcome of the PICO question, and the foundation of the project – accomplishing fourth goal of the Quadruple Aim initiative. Findings suggest the IHI framework can be applied in nursing and can be used to inform nursing leadership practices. LOE: VI Strengths: Focused on nurses’ perspectives, excerpts from interviews provided, strong theoretical framework, and data saturation. Weaknesses: All female nurses, analysis (risk of Key: AC – acute care; COREQ - Consolidated Criteria for Reporting Qualitative Research Checklist; JoS – job satisfaction; M – mean; MA – mean age; MMF – most meaningful factor; NYNE – number of years nursing experience; PR – professional role; Q – question; SL – supportive leadership. THE IMPACT OF TRANSFORMATIONAL Citation Funding: Department of Health Sciences at University West Bias: None note Theoretical/ Conceptual Framework Design/ Method Sample/Setting profession. = or > 5 NYNE Attrition: 0% Definitions: Salutogenesis Sense of coherence 58 Major Variables/ Research Questions nurse? Describe. Job Engagement Q4: What motivates you to go to work? Explain. Q5: What drives you to do a good job? Explain. Working Conditions and Remaining in Profession: Q6: What factors have made you want to start working as a nurse? Describe. Measurement/ Instrumentation Data Analysis Findings/ Themes Widely used; validity and reliability not established. provided. CCRQRC used to fulfil the standards of high-quality research. - Collaboration and SL Theme 3 Comprehensibility - Valued role - Commitment - Involvement - Pride in professional role LOE; Application to practice/ Generalization misinterpretation), and purposive sampling technique. Feasibility: Applicable especially to outcome of PICO question. Useable findings - describe major factors which impact joy and meaning in work – consistent with other studies on the topic. Provides good evidence that creating work environments where nurses feel pride in their professional roles in an organization that supports collaboration and togetherness with colleagues and leaders can bring joy. Key: AC – acute care; COREQ - Consolidated Criteria for Reporting Qualitative Research Checklist; JoS – job satisfaction; M – mean; MA – mean age; MMF – most meaningful factor; NYNE – number of years nursing experience; PR – professional role; Q – question; SL – supportive leadership. THE IMPACT OF TRANSFORMATIONAL 59 Appendix A Evaluation and Synthesis Tables Table A3 Synthesis Table Author Year Design/LOE Sample and Setting Size Bedside Nurses Nurse Managers Acute Care Hospital Country Theoretical Framework Measurement Tools Conditions Present TFL Behaviors Perception of Leader (+ve) Work Environment (+ve) Positive Thinking Outcomes Reported Meaning and Joy in Work Engagement Job Satisfaction Intent to Stay Burnout Employee Well-being Themes Identified Purpose and meaning Meaningful Connections Impact (Wow factor) Cummings 2018 SR/I Deetz 2020 DC/VI Galuska 2018 NI/VI Hakan 2020 ED/VI Manning 2016 DC/VI Morsiani 2017 DC FG/VI Pericak 2020 OCS/VI Tully 2019 CSS/VI Wu 2020 CSS/VI Yasin 2020 CSCS/VI 129 (studies) ✓ 32 27 12 630 201 298 400 349 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ USA AHT Interview ✓ Sweden Salutogenic Interview ✓ USA FRLM MLQ 116 (Quan) 27 (Qual) ✓ ✓ ✓ Italy FRLM MLQ, FG ✓ USA KTEE MBI ✓ USA TMSC PTSS ✓ China Spirituality MLQ ✓ Canada HTFT ATS ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓       ✓ ✓ ✓ ✓ ✓ ✓ Canada FRLM MLQ ✓ ✓ USA DQCM MJWQ ✓ ✓       ✓ ✓ ✓ ✓               ✓ Key: ✓- yes;  - increase/improve/positive correlation;  - decrease/ negative correlation; AHT – Authentic Happiness Theory; ATS – Anticipated Turnover Scale; CSC – crosssectional correlational; CSS – cross-sectional survey; DC – descriptive correlational; DQCM – Duffy Quality Caring Model; ED – exploratory descriptive; FG – focus group; HTFT - Herzberg's Two-Factor Theory; LOE – level of evidence; FRLM - Full Range Leadership Model; KTEE - Kahn’s Theory of Employee Engagement; MBI - Maslach Burnout Inventory-General Survey; MJWQ – Meaning and Joy in Work Questionnaire; MLQ - Multifactor Leadership Questionnaire; NI – narrative inquiry; OCS – observational cross-sectional; PTSS - Positive Thinking Skills Scale; Qual – qualitative; Quan – quantitative; SR – systematic review; TFL – transformational leadership; TMSC - Transaction Model of Stress and Coping. THE IMPACT OF TRANSFORMATIONAL Appendix B Models and Frameworks Figure B1 Bass and Avolio’s The Full Range Leadership Model 60 THE IMPACT OF TRANSFORMATIONAL 61 Appendix B Models and Frameworks Figure B2 IHI Four Steps for Leaders Perlo, et al., (2017) THE IMPACT OF TRANSFORMATIONAL 62 Appendix B Models and Frameworks Figure B3 Rosswurm and Larrabee’s Model for Evidence-based Practice Change Rosswurm & Larrabee (1999) THE IMPACT OF TRANSFORMATIONAL 63 Appendix C Data Collection Figure C1 Meaning and Joy in Work Questionnaire Rutledge, et al. (2018). THE IMPACT OF TRANSFORMATIONAL 64 Appendix C Data Collection Figure C2 Demographic Data Age range in years:  20-35  36-50  51-65  >66 Number of years as a RN:  0-3  4-8  9-13  14-19  >20 Length of time employed at the facility:  0-3  4-8  9-13  14-19  >20 Length of time on the current unit in years:  0-3  4-8  9-13  14-19 Nursing department:  Care Unit  ED  >20  ICU Employment status:  Full-time  Part-time Highest degree obtained:  Associates  Bachelors National certification: Yes No  Masters  Doctorate THE IMPACT OF TRANSFORMATIONAL 65 Appendix D Budget Table D1 DNP Project Proposed Budget Phase Activities Preparation Salaries for non-exempt RNs. 30-minute monthly project team meetings January to July 2021. Design, print, and distribute recruitment fliers Create electronic versions of data collection tools using Microsoft Forms Delivery Evaluation Type of Cost Direct Unit of Cost Cost 2RNs @$20/meeting x 7 meetings Direct Direct 180 single pages @$0.10 each (print) $0 (internal software) Salaries for bedside RNs. 30-minute monthly project team meetings August to November 2021. Education facilitator and educational materials Snacks and drinks for education sessions. Direct 2RNs @$20/meeting x 4 meetings $160 Direct Direct @$0 (internal) 15 leaders @$10 each $0 $150 Space for meetings and education sessions. Indirect @$0 (internal) $0 Today I Choose Joy t-shirts. Indirect 30 @$14 each $420 Cakes for participating units - dayshift and night shift. Thank you cards for each participating unit. Indirect $160 Indirect 4 units x 2 cakes each = 8 cakes @$20 each 4 cards @$5 each Intellectus Statistical Software subscription for data analysis. Salaries for bedside RNs. 30-minute monthly project team meetings January to April 2022. Direct @$0/month (internal) Direct 2RNs @$20/meeting x 4 meetings Subtotal Total $280 $18 $0 $20 $298 $910 $0 $160 $160 $1368 THE IMPACT OF TRANSFORMATIONAL 66 Appendix D Budget Table D2 Potential Cost Versus Savings DNP Project Budgeted Cost Average Cost of Each RN Turnover Potential Savings from Preventing 1 Voluntary RN Turnover $1368 $40,038 $40,038 - $1368 = $38,670 THE IMPACT OF TRANSFORMATIONAL 67 Appendix E Quantitative Results Table E1 Frequency Table Showing Demographic Variables by Unit Variable Number of Years as RN 0-3 years 4-8 years 9-13 years 14 -19 years More than 20 years Total Number of Years at Facility 0-3 years 4-8 years 9-13 years 14 -19 years Total Number of Years on Unit 0-3 years 4-8 years 9-13 years Total Age Group 20-35 years 36-50 years 51-65 years Total Highest Degree Associates Bachelors Masters Total National Certification Yes No Total ICU Care Unit ED 1 (14.29%) 1 (14.29%) 1 (14.29%) 2 (28.57%) 2 (28.57%) 7 (100.00%) 1 (25.00%) 1 (25.00%) 1 (25.00%) 0 (0.00%) 1 (25.00%) 4 (100.00%) 1 (14.29%) 2 (28.57%) 2 (28.57%) 0 (0.00%) 2 (28.57%) 7 (100.00%) 1 (14.29%) 2 (28.57%) 2 (28.57%) 2 (28.57%) 7 (100.00%) 3 (75.00%) 0 (0.00%) 0 (0.00%) 1 (25.00%) 4 (100.00%) 6 (85.71%) 1 (14.29%) 0 (0.00%) 0 (0.00%) 7 (100.00%) 4 (57.14%) 2 (28.57%) 1 (14.29%) 7 (100.00%) 4 (100.00%) 0 (0.00%) 0 (0.00%) 4 (100.00%) 6 (85.71%) 1 (14.29%) 0 (0.00%) 7 (100.00%) 2 (28.57%) 4 (57.14%) 1 (14.29%) 7 (100.00%) 1 (25.00%) 2 (50.00%) 1 (25.00%) 4 (100.00%) 3 (42.86%) 2 (28.57%) 2 (28.57%) 7 (100.00%) 1 (14.29%) 4 (57.14%) 2 (28.57%) 7 (100.00%) 2 (50.00%) 1 (25.00%) 1 (25.00%) 4 (100.00%) 0 (0.00%) 5 (71.43%) 2 (28.57%) 7 (100.00%) 1 (14.29%) 6 (85.71%) 7 (100.00%) 1 (25.00%) 3 (75.00%) 4 (100.00%) 3 (42.86%) 4 (57.14%) 7 (100.00%) THE IMPACT OF TRANSFORMATIONAL 68 Appendix E Quantitative Results Table E2 Frequency Table Showing Demographic Variables of Final Sample (n = 18 RNs) Variable n Number of Years as RN 0-3 years 3 4-8 years 4 9-13 years 4 14 -19 years 2 More than 20 years 5 Number of Years at Facility 0-3 years 10 4-8 years 3 9-13 years 2 14 -19 years 3 Unit 7 Intensive Care Unit 4 Care Unit 7 Emergency Department Number of Years on Unit 0-3 years 14 4-8 years 3 9-13 years 1 Age Group 20-35 years 6 36-50 years 8 51-65 years 4 Highest Degree Associates 3 Bachelors 10 Masters 5 National Certification Yes 5 No 13 Note. Due to rounding errors, percentages may not equal 100%. % 16.67 22.22 22.22 11.11 27.78 55.56 16.67 11.11 16.67 38.89 22.22 38.89 77.78 16.67 5.56 33.33 44.44 22.22 16.67 55.56 27.78 27.78 72.22 THE IMPACT OF TRANSFORMATIONAL 69 Appendix E Quantitative Results Table E3 Summary Statistics of Pre and Post MJWQ Scores Divided by Subscales and Total – Final Sample Variable n M 18 18 4.21 4.03 Mdn SD Min Max t p d Meaningful Work Subscale Pre Post 4.20 0.62 3.00 5.00 4.10 0.89 1.40 5.00 Two-tailed paired sample t0.99 .338 test Values/Connections Subscale Pre 18 4.14 4.20 0.64 2.80 5.00 4.02 4.00 0.66 2.40 5.00 Post 18 Two-tailed paired sample t0.74 .469 test Caring Subscale Pre 18 4.28 4.25 0.60 3.00 5.00 4.22 4.00 0.67 3.00 5.00 Post 18 Two-tailed paired sample t0.32 .756 test Total MJWQ Scale Pre 18 4.20 4.12 0.56 3.00 5.00 4.05 4.09 0.74 1.94 5.00 Post 18 Two-tailed paired sample t0.9 .373 test Note. n = 18. Alpha = 0.05. Degrees of Freedom for the t-statistic = 17. d represents Cohen's d. 0.23 0.17 0.07 0.22 THE IMPACT OF TRANSFORMATIONAL 70 Appendix E Quantitative Results Table E4 Summary Statistics Table for Pre and Post MJWQ Scores by Unit Variable Meaningful Work Subscale Intensive Care Unit Pre Post Care Unit Pre Post Emergency Department Pre Post Values/Connections Subscale Intensive Care Unit Pre Post Care Unit Pre Post Emergency Department Pre Post Caring Subscale Intensive Care Unit Pre Post Care Unit Pre Post Emergency Department Pre Post MJWQ Total Scale Intensive Care Unit Pre Post Care Unit Pre Post Emergency Department Pre Post n M Mdn SD Min Max 7 7 3.91 4.20  4.01 4.00 0.49 0.48 3.00 3.40 4.40 4.70 4 4 4.42 4.45 4.08 4.05 0.67 0.17 3.80 3.90 5.00 4.30 7 7 4.37 4.50 4.03 4.90 0.68 1.42 3.30 1.40 5.00 5.00 7 7 3.77 3.80 4.03 4.00 0.66 0.47 2.80 3.40 4.60 4.60 4.35 3.90 4.40 4.00 0.44 3.80 4.80 0.50 3.20 4.40 4.20 4.00 0.59 3.60 5.00 7 4.40 4.09 0.94 2.40 5.00 7 7 4.00 4.21 4.00 4.00 0.65 0.64 3.00 3.50 5.00 5.00 4.62 3.88 4.75 4.00 0.48 4.00 5.00 4 0.25 3.50 4.00 7 7 4.36 4.50 4.43 5.00 0.56 0.84 3.50 3.00 5.00 5.00 7 7 3.88 3.88 4.04 4.06 0.44 0.39 3.00 3.53 4.29 4.71 4 4 4.43 4.00 4.47 4.03 0.53 0.21 3.88 3.76 4.88 4.18 7 7 4.38 4.09 4.65 4.71 0.60 1.16 3.47 1.94 5.00 5.00 4 4 7 4 THE IMPACT OF TRANSFORMATIONAL 71 Appendix F Qualitative Results Table F1 Top Themes from What Matters to You Conversations by Unit and Overall What Brings MJW (Bright Spots) Impediments to MJW (Pebbles) Intensive Care Unit (n=21) Co-workers/interacting - 12 Making a difference/patients care - 9 Adequate staffing - 2 Teamwork - 2 Appreciation – 2 Intensive Care Unit (n=21) Poor staffing - 11 Floating - 3 Negativity - 2 Lack of teamwork - 2 Care Unit (n=34) Sense of purpose - 13 Teamwork - 12 Co-workers - 7 Adequate staffing - 5 Appreciation - 5 Care Unit (n=34) Poor staffing/High workload - 17 Negative attitudes - 12 Lack of teamwork - 4 Poor communication - 4 Unrealistic expectations – 4 Emergency Department (n=35) Making a difference - 12 Connections/relationships/co-workers - 10 Appreciation/respect - 6 Learning - 3 Adequate staffing - 2 Emergency Department (n=35) Poor staffing/High workload - 19 Negative attitudes of RNs/physicians - 9 Abuse from patients - 5 Lack of time/unrealistic expectations - 5 Lack of supplies – 4 Overall (n=90) Sense of purpose/making a difference - 34 Coworkers/Connections - 29 Teamwork - 14 Appreciation/respect - 13 Adequate staffing - 9 Overall (n=90) Poor staffing/High workload - 47 Negative Attitudes - 23 Unrealistic expectations/lack of time - 9 Lack of teamwork - 6 Abuse from patients – 5 Note: Some RNs stated more than one factor which brought them MJW and impediments to finding MJW.