For centuries, nurses have put the needs of their patients ahead of their own and have often been trained to do so (Davidson et al., 2020). Years of nursing research on work overload, stress, and compassion fatigue have demonstrated strong links between these phenomena and increased risk for nurse burnout, nurse turnover, and poor patient outcomes (Babenko-Mould & Laschinger, 2014; Docherty-Skippen et al., 2019; Hensel & Laux, 2014). In fact, 60% of nurses surveyed by the American Nurses Association (ANA; 2019) identified workplace stress as the most common safety risk in their jobs. As a result, nurses are at a higher risk for suicide than the general population (Davidson et al., 2020).
Rates of these adverse outcomes are even higher for nursing students and new graduate nurses because they are also grappling with rigorous academic workloads, challenging class and nurse residency schedules, negativity and bullying from their peers and supervisors, as well as the added stress of trying to develop their clinical proficiency (Boamah et al., 2017; Hensel & Laux, 2014). Personal psychosocial factors, such as financial strain and conflicts in personal relationships, also contribute to overall stress. Alarmingly, nurses younger than age 25 have higher rates of burnout, nonproductive coping, depression, and anxiety than their older colleagues (Boamah et al., 2017). Fortunately, research has demonstrated that knowledge and use of positive coping strategies are linked with lower levels of perceived stress in nursing students and new nurse graduates (Enns et al., 2018; Reyes et al., 2015). In the current study, self-care skills were taught to undergraduate nursing students using a brief, experiential approach in each class period to increase the knowledge and use of positive coping strategies. The purpose of this qualitative thematic analysis was to examine the effects of introducing positive coping skills and self-care strategies to undergraduate nursing students in the classroom setting.
A thematic analysis of qualitative data was conducted using Braun and Clarke's (2006) six-step framework for thematic analysis. Braun and Clarke's (2006) framework was selected due to its flexibility and applicability to a variety of teaching and learning experiences. Thematic analysis goes beyond summarizing data to analyzing and interpreting findings to make them applicable to real world situations. The six steps include: (1) become familiar with the data, (2) generate initial codes, (3) search for themes, (4) review themes, (5) define themes, and (6) write findings (Braun & Clarke, 2006). In addition, Braun and Clarke (2006) describe two types of themes. Semantic themes focus on what is being said at a superficial level, whereas latent themes examine deeper meanings and assumptions in the data. Analysis of data in the current study aimed to illuminate latent themes and provide a richer illustration of undergraduate nursing student experiences with self-care.
Sample and Setting
The current study was conducted at a midsize, teaching-intensive university in the Mid-Atlantic region of the United States after obtaining institutional review board approval. The sample included 149 undergraduate nursing students enrolled in a face-to-face psychiatric–mental health nursing course in the second semester of a traditional, four-semester baccalaureate nursing program. The average number of students enrolled in the course each semester was approximately 37, and data were collected over four semesters. Each semester, the psychiatric–mental health nursing course met once per week for 14 weeks in a 3-hour time block. The last 5 to 10 minutes of each class period were used to introduce students to a new self-care activity or positive coping skill (Table 1). Examples of activities included guided meditation, progressive muscle relaxation, coloring pages, creative journaling prompts, gratitude lists, positive affirmations, and breathing exercises. Most activities included an experiential component that was facilitated by the instructor (e.g., guided meditation), and students received handouts or related web links for each activity at the end of the class. The instructor presented each self-care activity as something students could use for themselves, as well as something they could teach patients and families under their care.
Descriptions of Select Self-Care Activities
Qualitative data were collected from standard university student course evaluation surveys that are electronically distributed to all students in the final week of the semester. Seventy-nine of 149 psychiatric–mental health nursing students completed the survey (Table 2). This response rate of 53% is consistent with those for courses in a variety of disciplines across campus. The survey included three optional, free-text response questions: (1) What did you like about this course?; (2) What could be improved about this course?; and (3) Would you recommend this course to others? Explain.
Psychiatric–Mental Health Nursing Students Who Completed the End-of-Course Evaluation
Anonymous survey results were released to faculty after final course grades were submitted to minimize faculty bias when assigning grades. Although data are reported anonymously, survey results are not distributed to faculty if less than 30% of students complete the survey to minimize the risk that faculty would be able to identify a student based on their responses. Survey results from four academic semesters were analyzed.
Table 3 shows the number of comments related to the in-class self-care activities out of the total number of comments per question over the course of four semesters. Because responses to the survey questions were not mandatory, some students left these responses blank, whereas others included multiple comments per question.
Comments About Self-Care Activities of Total Number of Comments
Following Braun and Clarke's (2006) framework, qualitative data were thoroughly reviewed and initial notes were made in the margins of the survey report. By examining comments made specifically about the self-care strategies and color-coding them by hand, open codes were developed. These codes were modified and refined by reviewing data and revisiting previous notes. Eventually, similar codes were grouped to form preliminary themes. Initially, some codes fit under multiple themes, so these were reevaluated. For example, feeling anxious and overwhelmed was related to the preliminary theme of using coping skills, but it was determined that the volume of comments about high stress levels necessitated its own distinct theme, separate from how students coped with these high stress levels. Themes were reviewed to verify that each was distinct and supported by relevant data.
Finalized themes were defined and examined for semantic and latent themes within each. For example, some students explicitly stated that they used the coping skills on their own outside of class, whereas others implied that they were using the skills on their own based on their comments about being able to manage stress in other classes or in their personal lives. Finally, exemplar quotes were chosen to illustrate each theme in preparation for the final write-up stage (Braun & Clarke, 2006).
Overall, students expressed positive perceptions of the in-class self-care strategies and indicated that they were a valuable addition to the course. Notably, there were no critical or constructive comments made by students on the second free-text survey question (What could be improved about this course?) that indicated dissatisfaction or discomfort with the incorporation of in-class self-care activities (Table 3). Several student comments indicated that the incorporation of self-care activities was a positive factor in their decision to recommend the course to other students. After thematic analysis of the qualitative data, four major themes emerged: (a) Stress Levels, (b) Use of Self-Care Strategies and Coping Skills, (c) Self-Reflection, and (d) Perception of Instructor.
Student comments reinforced what is already well-documented in the nursing literature: they are under an intense amount of personal, academic, and professional stress. Many students referenced the “stressful semester,” “overwhelming curriculum,” and “very busy schedule.” Most comments focused on the intense academic workload and long clinical days, and some alluded to personal and psychosocial stressors. Some comments referred to the stress of trying to maintain a job or internship/externship while in a rigorous nursing program. A few students described the experience of “living and breathing nursing school,” without time to “eat or sleep properly or workout.” Some students discussed feeling as though they never had a “break,” and one student described their experience as follows: “At the beginning of the semester, I was scared, tired, and extremely stressed… constant exams and scrutiny.” Students provided comments on their stress levels as context for the next theme, Use of Self-Care Strategies and Coping Skills.
Use of Self-Care Strategies and Coping Skills
Students indicated that they found value in the self-care strategies incorporated into each class, and they appreciated the experiential component of these techniques, which “definitely helped in reducing stress.” One student referred to the self-care strategies as “the amazing details that made the difference” in their ability to mitigate stress and “control my anxiety.” Another stated that the self-care strategies “made nursing school seem like an achievable journey.” Others mentioned how they likely would not have tried some of the coping strategies on their own, so they were grateful for the opportunity to learn about them and participate in them in class. By using class time to incorporate these self-care strategies, students perceived them as valued by the instructor, and thus, a valuable addition to their nursing knowledge.
In addition to adding value to the course itself, many students commented that they regularly used these strategies outside of the psychiatric–mental health nursing course. One student remarked that the self-care techniques “took stress off of my other courses and helped me realize the importance of self-care.” Another stated, “The self-care activities are much appreciated, and I utilize them outside of class all the time.” One student discussed meditation specifically, stating “we did it [meditation] right before I had a big test in another class, and it helped me calm down so much.” Other students discussed that they “loved the coping skills” because they “offered peace” at a time in their lives that was extremely stressful and overwhelming and “helped us see the good, no matter how small.”
By learning about and practicing the self-care strategies and coping skills, students discussed an increase in self-awareness and self-reflection. By engaging in self-reflection, many students reported that they were able to identify when they were extremely stressed and struggling, and they were able to recognize the positive effects that the self-care strategies had on their mental, emotional, and physical state. One student reported, “The self-care activities helped me out A LOT. I became a better student, nurse, and overall person. I saw the human side of nursing every Friday at 8am [the time the class was scheduled].” Others remarked that the self-care strategies “helped me learn about myself as a person” and “made me reflect on my own mental health.” Many students mentioned that they were not fully aware of how stressed they were and how poorly they were coping until they began practicing the self-care activities in class.
Perception of Instructor
Implementation of self-care strategies in each class resulted in many positive comments related to students' perception of the instructor. Although students' perception of the instructor is undoubtedly influenced by additional factors, many students consistently commented that the incorporation of self-care activities demonstrated that the instructor cared for students' well-being and success. For example, students reported that by sharing self-care techniques, they perceived that the instructor “cares about her students on more than just a grade level.” Another student stated, “you can tell [the instructor] wants us to succeed.” Another commented that they believed the instructor was “always open if we ever need [them]” and that they felt “totally supported.” One student remarked that “the ‘de-stress’ activities show that [the instructor] truly cares about us as individuals and wants us to do well in all aspects of our lives.” In addition, a student shared that the instructor “understands what is valuable in learning and creates a safe environment to practice positive coping skills.” Students' comments indicated that this feeling of being cared for and supported was a key factor in their ability to manage their workload and remain enrolled in the nursing program. As one student stated, “[the instructor is] super caring and the reason I learned how to manage my anxiety and a big part of why I stayed in school.”
Discussion and Implications
The current study findings have important implications for nursing education and nursing practice. Often, educators have no way of really knowing the intensity and frequency of personal, academic, and professional stressors affecting their students (Boamah et al., 2017). Incorporating these in-class self-care activities has potential to improve student self-reflection, reduce student burnout, and prevent students from dropping out of or failing a rigorous nursing program by teaching healthy coping and stress management skills. Similarly, when students then carry these strategies with them into the practice setting as new graduate nurses, they again have potential to reduce nurse burnout and increase nurse retention when faced with the demands of the nursing profession (Enns et al., 2018). Therefore, institutions and facilities benefit as well.
Benefits are not limited to nurses and institutions alone. The literature consistently demonstrates that healthier nurses provide higher quality care that results in better patient outcomes, including decreased nursing errors and decreased patient morbidity and mortality (ANA, 2019). Nurses of any level can teach and practice these self-care strategies with patients and their loved ones to provide holistic care, promote autonomy, and assist with the development of lifelong strategies for self-care and stress management. Unlike other more radical or invasive interventions, using self-care strategies, such as those described in the current study, are unlikely to cause any harm to individuals.
The self-care interventions used in this study were low-cost or free and simple to implement in a short time span with little or no equipment needed, making them low-barrier options with significant benefits for nurse educators and nurses. Due to their relative simplicity, the self-care activities are feasible for use in a variety of populations, settings, and situations. The efficacy of many of the self-care strategies used in the course is strongly supported by the literature, which dovetails with the evidence-based mindset of nursing education and nursing practice (Davidson et al., 2020; Davis et al., 2008; Thornton, 2013).
Despite the many positives, barriers to the incorporation of self-care activities may exist. For example, nurse educators and nurses may not feel comfortable introducing some or all of these strategies into their classroom and/or clinical, simulation, or practice settings due to their own lack of knowledge or experience with them. For these same reasons, nursing students may also be hesitant to engage with self-care strategies. Time constraints may limit the willingness or ability of nurses and nurse educators to learn about and use these strategies, as they continue to be faced with greater demands on their time and attention. In addition, it may take time to develop institution and facility buy-in regarding incorporation of self-care strategies, if such a culture does not already exist. Future research on this topic with different populations of nursing students and nurse educators in a variety of programs (e.g., undergraduate, graduate, master's, doctoral) may help illuminate further benefits and challenges to the implementation and practice of self-care strategies in a more diverse array of situations.
A prominent limiting factor of the current study was the general format of the standard university student course evaluations. Due to the broad, nonspecific nature of the optional questions, it is feasible that students did not provide positive or negative feedback about the self-care activities because they were not asked directly about them. In the future, using a more specific survey tool with required answer fields would likely capture more robust data. In addition, including questions about which self-care activities the students found most helpful would assist educators and administrators in focusing their efforts on providing access to self-care activities with the greatest impact and benefit. The small sample size was another limiting factor. Future research should include a larger number of nursing students from a variety of courses and in various stages of the undergraduate program. All self-report data involve a degree of bias, and although anonymously reported, it is possible that students included favorable feedback about the self-care activities for the instructor's benefit.
Stress and burnout continue to be major concerns for nursing students and nurses. In addition to the myriad personal ramifications, these phenomena affect patients and organizations by resulting in poor outcomes and high turnover rates. Nursing students begin to experience stress and burnout early in their educational programs and careers as new graduate nurses. Nurse educators have the opportunity to interrupt progression toward burnout by teaching nursing students strategies to self-reflect and manage stress effectively early in their academic careers. By promoting self-care and creating a culture of self-preservation, nurse educators can have a meaningful impact on the health, success, and career longevity of nursing students and new graduate nurses.
- American Nurses Association. (2019). Healthy nurse, healthy nation. https://www.nursingworld.org/practice-policy/work-environment/health-safety/healthy-nurse-healthy-nation/
- Babenko-Mould, Y. & Laschinger, H. K. S. (2014). Effects of incivility in clinical practice settings on nursing student burnout. International Journal of Nursing Education Scholarship, 11(1). doi:10.1515/ijnes-2014-0023 [CrossRef] PMID:25367690
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- Davis, M., Eshelman, E. R. & McKay, M. (2008). The relaxation and stress reduction workbook. New Harbinger.
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- Thornton, L. (2013). Whole person caring: An interprofessional model for healing and wellness. Sigma Theta Tau International.
Descriptions of Select Self-Care Activities
|Self-Care Activity||Description||Resources to Share with Students|
|Guided meditation||Dim the lights, and invite students to close their eyes if they are comfortable.
Play relaxing music in the background.
Read a guided meditation script or play a pre-recorded guided meditation for approximately 5 minutes. Encourage students to use guided meditation websites or free smartphone applications (apps) on their own outsideof class.||https://www.tarabrach.com/guided-meditations/https://www.headspace.comhttps://insighttimer.com|
|Breathing exercises||Lead students through a 2- to 3-minute breath practice, such as any kind of yoga breathing. This can be an energizing breath practice (Lion's Breath) or calming breath practice (Centering Breath).
Encourage students to practice on their own outside of class.||https://wanderlust.com/journal/prana-power-simha-pranayama-lions-breathhttps://www.yogajournal.com/meditation/movement-meditation-centering-breath|
|Gratitude list||Have students take out a piece of paper or use a smartphone app. Have students write down at least four things for which they are thankful. Tell them these can be big or small, and concrete or abstract (e.g., a safe place to live, a partner who loves me, my favorite team won the championship). Encourage students to make a gratitude list each day before bed or when they wake up in the morning.||https://www.wikihow.com/Make-a-Gratitude-List|
|Creative journaling prompts||Print a brief journaling prompt on the top of a sheet of paper. Print enough for each student to have one. Give students different prompts or give them all the same. Have them write quietly for 5 minutes on their own prompt. Encourage students to use creative journaling as a mental break in their daily routine.||712 More Things to Write About by San Francisco Writers' Grotto (2014)|
Psychiatric–Mental Health Nursing Students Who Completed the End-of-Course Evaluation
|Semester||Students Enrolled in the Course (N = 149)||Students Who Completed the Evaluation (n = 79)|
Comments About Self-Care Activities of Total Number of Comments
|Free-Text Evaluation Question||n/N (%)|
|Fall 2017||Spring 2018||Fall 2018||Spring 2019|
|What did you like about this course?||7/23 (30.4)||4/18 (22.2)||9/30 (30.0)||8/45 (17.8)|
|What could be improved about this course?||0/37 (0)||0/31 (0)||0/38 (0)||0/36 (0)|
|Would you recommend this course to others? Explain.||1/13 (7.7)||2/15 (13.3)||3/27 (11.1)||1/34 (2.9)|