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Letter to the Editor

Practicing Self-Care for Nurses: A Nursing Program Initiative

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Cynthia A. Blum PhD, RN, CNE

Abstract

Self-care is imperative to personal health, sustenance to continue to care for others, and professional growth. This article briefly reviews stressors common to students and nurses and the importance of practicing self-care to combat stress and promote health in practice. Florida Atlantic University offers a course for all levels of undergraduate nursing students called Caring for Self. The course, supported by principles of Adult Learning Theory, focuses on guiding the nurse to practice and model self-care. The author describes the evolution of this self-care initiative by discussing the needs assessment, course description and strategies, examples of course activities, and an exemplar of student impact. The conclusion offers discussion of challenges and lessons noted by faculty and students.

Citation: Blum, C., (September 30, 2014) "Practicing Self-Care for Nurses: A Nursing Program Initiative" OJIN: The Online Journal of Issues in Nursing Vol. 19, No. 3, Manuscript 3.

DOI: 10.3912/OJIN.Vol19No03Man03

Key words: Self-care, nursing education, stressors, personal health, lifestyle, life goals, elective courses, Adult Learning Theory, nursing, journaling, creative self

“You cannot keep giving to others if you do not give to yourself, first. It is like pouring water from a vessel: you cannot pour and pour without ever refilling it - eventually it will run dry." Leslie K. Lobell (2001, para. 7)

...nurses often express reluctance to take the time required to care for themselves... Nurses are taught to care for others; it is ingrained in their life purpose. However, in my experience, nurses often express reluctance to take the time required to care for themselves or they have difficulty finding self-care activities that match their interests and that are easily assimilated into their lives. Yet self-care can help one cope with stressors inherent to both practicing nurses and nursing students that can lead to exhaustion, tension, and fatigue (sometimes known as burnout), such as clinical decision-making and staffing concerns (Awa, Plaumann, & Walter, 2010). While short term stress reduction programs (Kravits, McAllister-Black, Grant, & Kirk, 2008) and techniques (Mackenzie, Poulin, & Seidman-Carlson, 2006) are reported in the literature, an academic course focused on self-care has not been described.

This article briefly reviews stressors common to students and nurses and the importance of practicing self-care to combat stress and promote health in practice. At Florida Atlantic University (FAU), we offer a course for all levels of undergraduate nursing students called Caring for Self. The course, supported by principles of Adult Learning Theory (Knowles, 1990), focuses on guiding the nurse to practice and model self-care. I will describe the evolution of this course by discussing the needs assessment, course description and activities, and an exemplar of student impact. The article conclusion offers discussion of lessons learned and challenges encountered by faculty and students.

Brief Overview of Stressors in Nursing

Stressors for Nursing Students

Jimenez, Navia-Osorio, and Diaz (2009) reported on types of nursing student stress. They identified stressors primarily related to clinical practice that often result in psychological symptoms. Using the Perceived Stress Scale, the researchers identified “Seeing the pain and suffering of patients and relatives (item 23), Being unable to provide appropriate responses to doctors’, teachers’, and patients’ questions (item 19), [and] Not knowing how to help patients with biopsychosocial problems (item 7)” as the most stressful aspects of clinical practice (Jimenez et al., 2009, p. 446). Academic and external stressors also existed, but were perceived as less stressful than those encountered in clinical practice. The authors suggested “informing students about possible stressors associated with their profession, and introducing interventions to support development of professionalism, social skills, and coping capacity for clinical practice” (Jimenez et al., 2009, p. 442).

...it may be helpful for nursing faculty to examine program curricula and implement self-care strategies in coursework... In a systematic review of the literature, the most common sources of nursing student stress related to academics were reported as reviews, workload, and problems associated with studying (Pulido-Martos, Augusto-Landa, & Lope-Zafra, 2012). In a study of Japanese students, Yamashita, Saito, and Takao (2012) found that the most commonly reported source of stress was taking examinations, followed by relationships with friends, engaging in clinical practice, and presenting reports. The stressors described above have been reported informally by nursing students for many years. To address them, it may be helpful for nursing faculty to examine program curricula and implement self-care strategies in coursework if possible. Such strategies could guide nursing students to develop self-care activities and habitual practices aimed at decreasing stress at an early point in their careers.

Stressors for Practicing Nurses

For practicing nurses, occupational stressors noted in the literature included protecting patients’ rights; autonomy and informed consent to treatment; staffing patterns; advanced care planning; surrogate decision-making (Ulrich et al., 2010); greater patient acuity; unpredictable and challenging workspaces; violence; increased paperwork; reduced managerial support (Ward, 2011); and role-based factors such as lack of power, role ambiguity, and role conflict (Moustaka & Constantinidis, 2010). Threats to career development and achievement, including threat of redundancy, being undervalued, and unclear promotion prospects were also reported as stressful (Moustaka & Constantinidis, 2010).  Ulrich et al. (2010) found that younger nurses and those with less experience were more prone to experience job related stress. 

...person directed interventions reduced burnout in the short-term, the programs with both intervention types created longer lasting positive effects. Workplace models of self-care designed to decrease stress and incorporate self-care have been implemented and evaluated (Kravits et al., 2008; Mackenzie et al., 2006). Kravits et al. (2008) described the use of relaxation techniques and art as stress reducing interventions. After discussing the impact of stress on health, program participants developed a personalized wellness plan to incorporate these modalities into their lives. While immediate effects were found, the authors suggest that longitudinal studies are needed to determine if the interventions produced long term stress reduction.  In a pilot study, Mackenzie et al. (2006) implemented a mindfulness-based stress reduction program noting significant improvement in burnout symptoms, relaxation, and life satisfaction. A recent review of 25 person- and/or organization-directed programs provided a summary of interventions aimed to prevent burnout which may result from persistent stress (Awa et al., 2010). The authors found that 80 percent of the programs they reviewed led to a reduction in burnout with 68 percent of these programs being person-directed, 8 percent being organization-directed, and 24 percent being a combination of both intervention types. While person directed interventions reduced burnout in the short-term, the programs with both intervention types created longer lasting positive effects.

Finally, it is well documented in the literature that stress contributes to disease. When the hormones cortisol and adrenalin remained too long in the blood stream, the results can be hyperglycemia, hyperinsulinemia, arteriosclerosis, hypertension, and a decrease in the function of the immune system. In addition, stress can prematurely age us and leave us chronically fatigued or depressed (Cohen, Janicki-Deverts, & Miller, 2007; Wilson, Begeny, Boyle, Schneider, & Bennett, 2011). Nursing students and practicing nurses alike frequently deal with many of the stressors discussed above. It is hoped that by developing and practicing self-care habits, nurses may be able to decrease some of the stressors and improve their health. The next section will briefly describe some benefits of self-care and one way to incorporate this concept into a nursing program.

A Self-Care Initiative for Nursing Students

Needs Assessment

Common themes of self-care... included proper diet, exercise, and stress-reduction techniques. While provision of holistic care is a hallmark of competent nursing practice, holistic activities centered on self are less prevalent for nurses (McElligott, Siemers, Thomas, & Kohn, 2009). However, the importance of caring for self is reflected in the positive energy and vitality that can be brought to the workplace (Richards, 2013). Researchers have described self-care practices of older aging female nurses (Gabrielle, Jackson, & Mannix, 2008), nurses practicing in end-of-life settings (Malloy, Thrane, Winston, Virani, & Kelly, 2013), and students (Chow & Kalischuk, 2008). Common themes of self-care for each of these groups included proper diet, exercise, and stress-reduction techniques.

The lesser prevalence of self-care activities noted in nurses (McElligott et al., 2009) combined with the clear benefits of self-care practices (Richards, 2013) prompted the nursing faculty at Florida Atlantic University to explore the option of including these types of activities in the nursing program coursework. The faculty moved forward with this initiative under the premise that teaching about the concept of self-care should be linked to the recipients in a manner in which they best learn, and guided by the principles of adult learning theory (Knowles, 1990).

Adult Learning Theory

Knowles (1990) proposed andragogy as the art and science of teaching adults. Andragogy is a theory of adult learning that shifts the power relationship to learner-centered as opposed to teacher-centered. When designing courses centered on these principles, learners are independent and self-directed using previous experience as a resource upon which they can draw (Knowles, Holton, & Swanson, 1998). Applying adult learning theory, the teacher recognizes that adult learners use problem centered approaches in which immediate application can be made. Attention to the learner’s personal goals and providing instruction and assignments that are practical and useful in their work or personal life makes the course relevant and meaningful to the adult learner. Using these principles, we developed the course so that the students would self-identify stressors and potential self-care practices to address them.

Course Description and Strategies

In the nursing program at Florida Atlantic University, we focus on all aspects of caring and recognize that to care for others, it is equally important to care for oneself. As such, we offer a three credit elective course, primarily attended by registered nurses (RNs) returning for a baccalaureate degree, called Caring for Self. The course description reads; “Experiential course through which students and faculty work together to address the nature of personal mind/body/spirit connectedness as integral to healing and health. Students are assisted in making this experiential knowledge relevant to others” (Florida Atlantic University, 2014).

Teaching and learning strategies employed in this course are lecture, small group work, focused discussions, exploration of various self-care modalities, journaling, and evaluation of mind/body/spirit approaches to health. Consistent with the nursing metaparadigm for professional identity development in undergraduate nursing education, course objectives include examination of the images of nurses and the discipline of nursing from multiple perspectives and exploration of the holistic perspective of caring in the framework of nurse, environment, person, and health (Lee & Fawcett, 2013).

Participants use reflective journaling to self-examine stressors. As the course progresses, guest speakers present content along with experiential opportunities that include steps to incorporate selected self-care activities (e.g., Feng Shui, labyrinth walks, pet therapy, nutritional changes) into one’s life. Participants use reflective journaling to self-examine stressors. Students then address these concerns by creating a personal treasure map with an unfolding plan to achieve a self-selected life goal. Finally, students complete the course with an activity where they introduce fellow nurses to another modality of self-care and a written assignment to reflect upon their experiences with incorporating self-care activities into their lives. Table 1 describes the coursework which supports achievement of the course objectives and the weight given to each assignment toward the overall course grade. To incorporate principles of Adult Learning Theory (Knowles, 1990), students actively participate in amending and revising assignments to reflect their understanding of the course content.

 

Table 1. Examples of Caring for Self Course Assignments

Assignment

Percent of Grade

Brief description

Active participation and attendance

10%

Students participate actively in this experiential course. Thoughtful and respectful comments and critiques are encouraged. Attendance is taken at each class.

7 hour personal care day

10%

Students are responsible for planning a personal self-care day to share with the class on the online discussion board. Active participation with peers about this day is required.

Reflective Journal

15%

Students write reflections in journals on a weekly basis. Reflections include entries about ongoing personal growth and insight as a result of this course. Journal entries should include information gained from class presentations and evaluation of other mind/body/spirit modalities.

Treasure maps

15%

Each student identifies a single goal or objective he or she wishes to achieve and illustrates it on a poster board or diorama with steps to take to reach the intended goal. The student should include a (self) picture along with positive affirmations and encouragement demonstrating success. The treasure map is shared with the class at midterm. It is expected that peers support each other in attaining the personal goal.

Group oral presentation

20%

Students work in small groups. Groups select a health promoting complementary or alternative therapy of interest. The topic to promote personal health through self-care must be approved by faculty. The group prepares a 30 minute, interactive class presentation that includes: topic definition, scientific review of the literature, strengths and weaknesses of therapy, and a current reference list.

Self-care paper

30%

Each student writes a 5 to 7 page, double-spaced professional paper utilizing APA format. Students are required to include at least 3 scholarly references external to course content to support the paper narrative. The paper summarizes what he/she has learned during the course and the subsequent influence on the writer’s self-care. Examples of areas that students may consider in this paper are: Which topic or topics have had the most impact? Which topics may create suspicion and why? Have lifestyle changes resulted from content in this course and if so, descriptions of the changes and/or outcomes. Students are also encouraged to share expectations for the course and offer suggestions for improvement.

Clear guidelines can provide direction for students as they progress through a course and thus help to set the stage for self-transformation to occur. Table 2 describes the course philosophy used as a framework in the Caring for Self course to remind participants of our purpose. These assertions were originally developed by a faculty member (Schuster, 1997) and have since expanded as other faculty teach the course and incorporate work from the course text, The Artist’s Way (Cameron, 1992).

Table 2. Caring for Self Course Philosophy

Guiding Assertions

  1. Course work is based on the assumption that our lives are grounded in our creative selves.
  2. Our creative selves need consistent honest acknowledgement, respect, and nurturing.
  3. When we relinquish attention to our creative foundation, unbalance occurs and we are unhappy at our deepest levels which can create “dis-ease”.
  4. ANY choice we make either supports or diminishes our creative selves.
  5. The creative self is always there: we cannot lose it but we can ignore or abandon it. This is to our peril as whole persons.
  6. There are no short cuts.
  7. There are no “excused absences,” we either do the work or not. We have a choice.
  8. Paradoxically, our creative selves respond only to light, playful, loving attention and not to a task master “have to” approach. It is our inner child (but far from childish)…honest, spontaneous, energetic, playful, funny, loving, appealing, entirely present, empathetic, available, noisy, curious, risk-taking, intuitive, loyal, beautiful…that directs our work.
  9. When we are life artists, we bring that artistry to all of our roles and we create new roles to accommodate our artistry.
  10. The life artist blends and balances the role of teacher, healer, leader, and visionary.
  11. Our technologies, which we respect, come from without- “how to do” and our artist comes from within-“how to be.”
  12. Our lifeline is in paying attention to our doing and our being; the artistry is in maintaining the balance.

 

Examples of Course Activities

The Caring for Self course meets weekly. For each class, a speaker or activity introduces potential self-care practice activities so that students have many opportunities to find at least one modality to incorporate into their lives. Topics vary each semester, based on available experts, and have included: Feng Shui, music therapy, massage, Tai Chi, Reiki, a labyrinth walk, Mantra, drum circles, traditional yoga, tea, herbal therapy, healing touch, and mindfulness meditation. Table 3 briefly describes some of these self-care practices.

A student favorite is chair yoga taught by Vera Paley, a 93 year old chair yoga instructor (Picture 1) who leaves the students feeling challenged to keep up and inspired to become more active. Picture 2 shows a student excited by breaking a board in her first attempt at marital arts. Each modality listed above includes student participation to help students learn the activity and encourage them to incorporate it into their daily lives.

Picture 1. Chair Yoga Instructor (used with permission)

Picture 2. Nursing Student Excited about Breaking a Board when Participating in Martial Arts (used with permission)

In addition to the planned presentation for a class, we discuss readings focused on coming to know one’s self using the course text, The Artist’s Way (Cameron, 1992) as a guide. Within the class, self is referred to as one’s creative self, inner child, and life artist (Cameron, 1992).

At the end of the semester, a weekend intensive is held where students present additional self-care activities and health promotion topics important to them. Past groups have shared interactive experiences including pet therapy, art therapy, guided imagery, Chakra mediation, aromatherapy, and various forms of marital arts. Writing the final course paper helps the student to “pull it all together” and identify course content that was meaningful to them and self-care activities that they intend to incorporate into their lives.

Table 3. Brief Descriptions of Self-Care Practice Activities

Activity

Brief Description

Feng Shui

Feng Shui is an environmental science, conceptualized to create harmony and balance through the of use energy in the most positive way (Boykin & Raines, 2006; Eitel, 2003).

Music/art/pet therapy

Therapies centered on music, art, or pets (Lamont, Bruneo, & Sutton, 2009; Rao et al., 2009; Smith & Waugh, 2009; Coakly & Mahoney, 2009).

Massage

A method of relaxation, often using oils to stimulate and manipulate large muscle groups in various parts of the body (Bost & Wallis, 2006).

Tai Chi (one form of martial arts)

A martial art with the “requisite capacity for sustained concentration, precision, mechanical exactness, and slow execution of movements” (Wall, 2005, p. 230).

Reiki/healing touch

Reiki practice is an ancient form of Japanese healing, administered through a gentle laying on of hands, or in absentia based on the assumption that the Reiki practitioner maintains a meditative presence and allows the Reiki energy to flow to where the patient needs it, in a nondirected and nondiagnostic manner (VanderVaart, Gijsen, De Wildt, & Koren, 2009, pp. 1157-8).

Labyrinth walk

“The labyrinth is a real path for meditation and a metaphorical pathway for changing directions as we release and let go of the past, receive gifts that education brings, and return as transformed individuals practicing nursing” (Diaconis, 2010, p.43). 

Mantra

An “ancient practice of silently repeating a mantram or mantra—a word or phrase with spiritual meaning… as an innovative form of stress management that is portable, immediate, inexpensive, invisible, and nontoxic” (Bormann, 2005, p. 163).

Drum circle

A drum circle is a gathering of people sitting in a circle, all drumming or playing some kind of percussion instrument while building community (Clare, 2008).

Hypnotherapy

A therapeutic procedure in which a health professional makes suggestions to help a person experience post-hypnotic alterations in perception, sensation, emotion, thought, and/or behavior (Horowitz, 2006).

Traditional yoga

Yoga means the union of individual consciousness with the supreme consciousness leading to self-realization; a holistic way of life leading to a state of complete physical, social, mental, and spiritual well-being and harmony with nature (Taneja, 2014, p. 68).

Tea and/or herbal/aroma therapy

Aromatic herbs and flowers were planted primarily to provide a spiritual sanctuary. Persians were taught from an early age that it was the duty of each individual to conserve and honor nature as part of the divine creation, and these sacred gardens were looked upon as a means of recreating and experiencing heaven on the earth (Ross, 2011).

Mindfulness/guided/Chakra meditation

“Mindfulness-based Stress Reduction (MBSR) is based on the central concept of mindfulness, defined as being fully present to one's experience without judgment or resistance” (Cohen-Katz, Wiley, Capuano, Baker, & Shapiro, 2005, p. 26)

Guided imagery

“The use of relaxation and mental visualization to improve mood and/or physical well-being” (Ford-Martin, 2009, p. 971). A range of techniques from simple visualization and direct imagery-based suggestion through metaphor and storytelling (Utay & Miller, 2006).

 

Students have indicated that they enjoyed learning about the various self-care practice activities. The next section will describe an exemplar of a specific student (name changed) enrolled in the Caring for Self course, taken from classroom discussion and her personal reflection assignment.

Exemplar

Within class discussion, Jamie (name changed) described herself as a hard working nurse who prided herself on excellent patient care and administrative abilities on a special procedures unit. She said that she was frequently recognized by patients with letters of praise and through her employer’s recognition program. Yet, she found that although she gave her heart and soul to her patients, she often left work feeling dissatisfied and feeling that she was not where she belonged. From the first day of class in our weekly discussions, Jamie shared her distress and her desire to abandon her situation. She said that she feared not knowing what was next or how she would pay her bills should she leave her long term position. In the following weeks of the course, Jamie said that she found the class to be place where she could express herself openly and her peers were very supportive. Each week, Jamie would share that her reflective journaling continued to focus on her job-related frustrations.

One day, I noticed that Jamie entered the class with a beaming look on her face. She shared that a few days before she had left her distressing work situation and felt lighter, and in control. As a result of her class discussions and reflective journaling, she had decided to focus on herself, her education, and being happy with her life choices. Soon after, Jamie took a homecare position working with an elderly gentleman whose family was out of state. Eighteen months later she is completing her baccalaureate degree in nursing and has decided to enter a nurse practitioner program this fall, where she will specialize in gerontology.  Making a deliberate choice to care for herself has changed Jamie’s outlook and helped her to find contentment in her current work environment which she will now pursue in an advanced practice role.

Conclusion

Challenges and Lessons

The realization that all undergraduate students... need content focused on self-care practices has led to incorporation of self-care activities within several required courses... Recently our college underwent a curriculum re-evaluation to assure that we were meeting a) accreditation standards as defined by the American Association of Colleges of Nursing (2008) using Essentials of Baccalaureate Education for Professional Nursing Practice and b) state mandated criteria for nursing programs. As faculty came together to identify the presence of consistent curricular objectives within required nursing courses, the need to assure that we were teaching self-care practices became evident. However, we were challenged by state limits on the maximum number of credit hours that our program could require in the baccalaureate nursing degree program. The realization that all undergraduate students (and not just BSN completion students) need content focused on self-care practices has led to incorporation of self-care activities within several required courses for pre-licensure programs and the RN-BSN programs. The Caring for Self course remains available to all undergraduate nursing students as an elective.

A challenge in teaching the elective course is student perception that the course will result in an easy “A” grade. Students quickly learn that the academic work is intermingled with challenging activities; some of which their belief systems may not support. A course goal is to find one or more self-care activities that are meaningful to each student; in this quest they hopefully learn to appreciate the uniqueness of both the activities and of each other.

Final Reflections from the Author

...self-care not only has personal benefits but also may help nurses to role model desirable self-care behaviors to others. One only needs to look at our 93 year old chair yoga instructor to be reminded that caring for oneself has lasting effects. Ms. Paley shares how her work at the FAU College of Nursing Memory and Wellness Center keeps seniors active despite any physical limitations they may have. The life lessons and implications for one’s health and well-being demonstrated by this instructor’s presentation and work remind my students that self-care not only has personal benefits but also may help nurses to role model desirable self-care behaviors to others.

In light of the benefits I have seen in the development of this academic course and the successes of my students, I challenge you to consider what you currently do to practice self-care behaviors. Are you satisfied with the results? Are you successfully coping with your stressors, such as work, school, home, and life balance as they may apply to you? Do you need to change your routine and invigorate your lifestyle? Consider trying something new today as you care for yourself! Although my work is with nursing students, the literature supports both the presence of stressors (Moustaka & Constantinidis, 2010; Ulrich et al., 2010; Ward, 2011), and the benefit of healthy behaviors for practicing nurses (Gabrielle et al., 2008; Malloy et al., 2013; Richards, 2013), and all of society.

It is my hope that by describing the basis of this nursing program initiative to promote self-care, our work at FAU may provide the impetus for other nursing programs to discuss how to potentially include this type of content for nursing students, whether it be in a standalone course or incorporated throughout the curricula. I hope that employers consider sessions for nurses that address stressors and self-care behaviors, and that practicing nurses, even without employer support, would choose to explore one or more of the activities I have described in this article. I close with a final quote that I feel accentuates the absolute necessity of practicing self-care: “I have come to believe that caring for myself is not self-indulgent.  Caring for myself is an act of survival." Audre Lorde (Stanny, 2012) .

Author

Cynthia A. Blum PhD, RN, CNE
Email: cblum@fau.edu

Cynthia A. Blum is an Associate Professor at the Christine E. Lynn College of Nursing at Florida Atlantic University (FAU) in Boca Raton, Florida. Dr. Blum is a Certified Nurse Educator since 2007. She obtained her PhD from Florida Atlantic University, where caring is studied as integral to knowing self and other. This work emphasizes the importance of self-care as a basic premise to honoring self. Dr. Blum teaches an elective course, Caring for Self, for undergraduate students at FAU.

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© 2014 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2014


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