The COVID-19 pandemic created unique demands, uncertainty, and emotional strain among healthcare workers, especially nurses. This demanding work environment and accumulating professional/personal stressors affected the resiliency and overall well-being of even the most experienced nurse [1]. Before the pandemic, nurses identified stress and burnout as significant occupational concerns [2]. A recent meta-analysis of 93 studies that included 93,112 nurses demonstrated that nurses working during the COVID-19 pandemic suffered mental health symptoms, including stress (43%), depression (35%), anxiety (37%), and sleep disturbances (43%) [3]. In an additional study, over 50% of registered nurses (n = 1800) reported poorer physical and mental health [4].

The post-pandemic era has amplified burnout rates across all healthcare professions [5]. In a recent study of 50,273 nurses, 31.5% reported leaving their jobs due to burnout secondary to a stressful work environment and inadequate staffing [6]. Since the COVID-19 pandemic, nurses’ burnout rate has increased, ranging from 35% to 54%, with an associated cost of $4.6 billion to taxpayers of the United States (U.S.) [7]. In 2022, 52% of nurses surveyed reported that they were considering leaving their positions due to insufficient staffing, adversely affecting their health and well-being [8]. Among acute care nurses (e.g., hospital inpatient), 60% reported burnout, and 75% reported high stress and exhaustion [8]. Further, burnout is associated with increased medical errors, the third highest cause of death in the U.S [9].

Like our national counterparts, our midwestern region also saw mounting frustrations among the healthcare workforce. One registered nurse stated in an organizational survey, “At this point, I'd rather work in a grocery store than put my critical care skills as a nurse to work anymore.” [10] The large percentage of self-reported weary and burned-out nurses, coupled with projections that approximately 20–30 percent of the aging nursing workforce will retire in 10–15 years, has created a nursing workforce crisis [11,12].

Currently, most nursing workforce burnout literature describes the problem; however, fewer articles discuss potential interventions to reduce nursing workforce burnout and turnover. Understanding work-life quality among nurses has important implications for understanding the COVID-19 pandemic's long-lasting effects on the nursing workforce. The unprecedented emotional stressors and demands faced by today's nursing workforce deserve leadership and researchers' attention.

Because nurses comprise a large portion of the U.S. workforce, the long-term health outcomes of nurses working under conditions that influence chronic stress are equally concerning for downstream health risks, including heart disease and breast cancer [13]. Chronic stress has shown an association with adverse outcomes in individuals with cancer, including immune dysregulation leading to mortality [14]. Relationships between chronic stress and disease risk are consistent with psychoneuroimmunological theory, which posits relationships between perceived stress, psychosocial variables (e.g., coping skills), neuroendocrine-immune responses, and the manifestation of wellness versus disease [15,16]. According to psychoneuroimmunological theory, nurses experiencing chronic high stress are at risk for neuroimmune dysregulation and adverse long-term health outcomes.

Researchers have been interested in complementary health approaches to promote well-being in clinicians, including nurses [17,18]. Well ahead of the COVID-19 pandemic, existing evidence supported the use of massage therapy for reducing occupational and workplace-related stress in nurses [19]. Less attention has focused on integrating complementary therapies within healthcare organization settings to promote the well-being of individuals and address the organization's needs to reduce burnout and improve the retention of an experienced clinical workforce.

With more than a third of nurses planning to leave the workforce due to retirement or burnout, workforce solutions are urgently needed. It is generally agreed that multilevel interventions are required to mitigate clinician burnout and turnover; however, research is lacking regarding what interventions are meaningful to nurses that reduce burnout, promote well-being, and reduce intentions to leave the workforce [20]. Another challenging aspect of considering interventions to address nursing burnout is the fatigue that arises from nurturing patients. For many nurses, nurturing those unable to care for themselves attracts many people to nursing. However, sustained nurturing or caregiving requires significant mental and physical energy that the healthcare system has slowly acknowledged as an occupational hazard. Thus, our team is interested in understanding the role of complementary therapies like massage as potential interventions that restore nurses’ energy (i.e., nurture the nurses) as they expend energy actively caring for others.

With the looming national shortage of nurses in mind and severe nursing staffing shortages occurring in our academic health science center during the COVID-19 pandemic, our team formed a joint academic-clinical partnership to engage hospital-based registered nurses in assessing the feasibility of interventions to reduce stress and promote well-being in nurses within their organization. During study design deliberations, the study team gathered information through informal conversations with the organization to assess interest in supporting a stress-reduction intervention to promote the well-being of nurses. The study team offered organizational stakeholders a variety of interventions for consideration, including mantram repetition, affirmations, listening to music, guided visualization, massage therapy, and virtual-reality experiences. Consensus from the organization indicated that massage therapy was the preferred intervention.

A brief literature review shows several massage therapy reports before the COVID-19 pandemic. Among these studies were reports of massage therapy sessions lasting 10 minutes [21], 15 minutes [[22], [23], [24]], and 25 minutes [19]. Some study durations consisted of a one-time massage [21]; however, most durations were longer, including five weeks [22], eight weeks [24], and 10 weeks [23]. One team delivered twice-weekly massages for four weeks [19]. Among these studies were several randomized controlled designs [19,21,22,24] and one single-group feasibility design [23]. Findings from these studies supported the feasibility of providing massage therapy in nursing work settings. Further, studies showed that massage therapy is associated with favorable outcomes in nurses, including reductions in pain [23,24], anxiety [22], perceived stress [21], occupational stress [19], and improvements in mood, sleep, and relaxation [21,24]. Noted limitations from these studies included the challenges of using measures in healthy populations in which normal baseline measures preclude the ability to detect post-intervention changes (e.g., blood pressure) [22]. Recommendations from previous studies suggest examining the longitudinal impact of massage therapy on nurses’ well-being and on organizational outcomes, including absenteeism, time lost to injury, and retention [21,23].

It is worth mentioning that some healthcare organizations have explored using mechanical massage chairs to reduce stress in nurses. In a quality improvement project, Hand et al. [25] found that 51% of nurses (n = 100) on an ambulatory oncology unit used a massage chair an average of four times in six months, and usage of the massage chair was associated with a 43.5% reduction in perceived stress, blood pressure, and heart rate. In another quality improvement project, In one of the few massage studies to occur during the COVID-19 pandemic, Pagador et al. [26] found that nurses (n = 67) in 10 nursing units used a massage chair. Those using the chair for at least 10–20 minutes (or longer) reported significant decreases in anxiety. Although not statistically significant, patterns in the data indicated decreases in burnout, stress, and emotional exhaustion [26]. Pagador et al. [26] noted the importance of system-level wellness initiatives that provide adequate resources and supportive policies to create a healthy work environment.

In summary, evidence suggests that both manual massage and mechanical chair massage therapies offer well-being benefits to nurses and may benefit organizational outcomes. Although it is beyond the scope of this paper, these therapies are arguably different in potential therapeutic effects because manual massage involves human interaction and touch (kneading). In contrast, mechanical chairs deliver the massage using vibration, and the human interaction element is missing. Regardless, organizations’ ability to offer manual massages versus mechanical chair massages depends on the resources devoted to implementation and long-term sustainability.

In response to our organization's preference for manual massage therapy, we designed a Phase IIA proof-of-concept study based on the Obesity-Related Behavioral Intervention Trials (ORBIT) model. Given the considerable resources required to conduct behavioral interventions and the scarcity of current research funding, the ORBIT model encourages a practical approach to obtaining the necessary information to design, refine, and implement a fixed protocol with a small sample before proceeding to the resource-intensive costs of a full-scale study [27]. Our team discussed with the organization which unit would be ideal for conducting a small study and the eligibility criteria for nurses. Staffing situations in units with higher acuity patients, including those with COVID-19, posed suboptimal conditions for conducting a pilot study. Importantly, we chose a hospital-based ambulatory services unit that was less likely to incur additional stress in accommodating the study and had the necessary physical accommodations.

This paper reports findings from our ORBIT Model phase IIA proof-of-concept study. The primary objective was to assess the feasibility and acceptability of a 15-minute massage intervention for hospital-based ambulatory infusion nurses during their regularly scheduled shifts during the COVID-19 pandemic.