Exploring the Self-care Practices and Needs of Entry-Level Nursing Students: A Pilot Project

Self-care is often lacking in nursing students worldwide. The objectives for this study were to discover the current self-care practices of one group of entry level undergraduate nursing students, the students’ understanding of self-care, and the students’ preferences for self-care interventions aimed at improving self-care. Quantitative and quantitative measures were used to measure the students’ current self-care practices, needs, and recommendations for interventions to be used in future semesters to improve nursing student self-care. The students were found to generally be deficient in areas related to nutrition, obtaining healthcare information or guidance, pacing themselves to avoid exhaustion, and performing relaxation exercises. They scored well on areas related to psychosocial self-care, such as believing their life has meaning or having meaningful relationships. Several suggestions were made by the students for encouraging nursing student self-care. Nursing students are often lacking in self-care. It is important for nursing programs worldwide to develop and encourage student self-care.


Introduction
One of the foundational attributes of nursing practice is caring for the wellbeing of others. However, self-care is not always a priority for nurses. Despite being generally well-versed in health promotion strategies, nurses may not apply those strategies to their own lives. This lack of self-care often extends to nursing students, as well. Assisting nursing students in developing self-care skills has become an area of focus for nursing programs around the world. For example, the American Association of Colleges of Nursing (AACN) has added a recommendation for incorporating self-care and self-reflection as part of their recently-updated professional standards for nursing education (AACN, 2021). As nursing programs worldwide begin to focus on student self-care, it is hoped that these students will continue the practice into their careers as nurses, providing a healthier workforce and, hopefully, improved patient care.

Materials Studied
Nursing students worldwide have been found to be deficient in self-care. Macedo et al. (2020) analyzed the lifestyle behaviors of 353 undergraduate nursing students in Brazil. They found that around 80% did not consume the daily recommended number of fruits and vegetables. A small percentage of the students smoked, while 23.1% consumed more than four alcoholic beverages at a time. Eighty-five percent of the students led a sedentary lifestyle. Similarly, Khorshtd, Ergin, and Zaybak (2020) surveyed 720 nursing students in Turkey. They discovered that the students generally had a good understanding of the benefits of routine exercise. Despite being knowledgeable, 53.2% did not exercise on a regular basis. Some possible reasons for the nursing students' lack of self-care include personal and academic workloads, and stress levels. Senturk, and Dogan (2018) surveyed 318 nursing students in Turkey about their stress levels. They concluded that the nursing students were experiencing stress levels that were slightly higher than moderate. Charlton and Wofford (2022) completed an integrative review focused on the coping abilities of undergraduate nursing students. They discovered a high level of maladaptive coping responses in the students, most commonly anxiety, depression, and insomnia. Persistently elevated anxiety levels can interfere with activities of daily level and result in avoidance behaviors (Mayo Clinic, 2022). This maladaptive coping can result in a lack of self-care in nursing students.
Uzziel Perez-Gress, Maya-Sanchez, Lopez-Nolasco, & Cano-Estrada (2021) studied the stress levels of prelicensure nursing students in Mexico. They found that the major factors that influenced the students' stress levels were anxiety and somatization, followed by workload. It is well-documented that nursing students have a comparatively heavy workload, in contrast to many other fields of study. Heavy student workload and the pressure of providing patient care were found to be the major contributors to nursing student stress (Labrague, McEnroe, De Los Santos, & Edet, 2018). Due to the potential for elevated stress levels and heavy workloads in nursing students, effective coping strategies are needed to encourage students to take care of themselves, as they learn to take care of others.
An interesting subtext found in the research was personal factors that contributed to an increased risk of anxiety and stress, potentially reducing the students' ability to provide self-care. Female nursing students reported significantly higher anxiety responses than males, but some psychosocial strengths were also primarily found in female nursing students (McDermott, Fruh, Williams, Hauff, Sittig, Wright, …Hall, 2019). Uzziel Perez-Gress, Maya-Sanchez, Lopez-Nolasco, and Cano-Estrada, (2021) found statistically significant differences between male nursing students and female nursing students in the areas of somatization and anxiety levels in stress management, with female nursing students at a greater risk for a negative stress response. They also found significant differences in the stress responses of students who worked while in nursing school and those who did not. Recognizing that female students and students with outside work responsibilities may be at greater risk for a negative stress response, can help self-care facilitators gear interventions that might appeal to, and be timed most advantageously to accommodate, these students. The literature review reveals common self-care issues in nursing students. However, in order to intervene with a particular student group, an individualized assessment needs to be conducted. As well, the literature focused on individual self-care issues in isolation, such as only focusing on sleep deprivation or student workload issues. The researchers aimed to look at the holistically at all areas of self-care issues related to one group of nursing students. The researchers found a lack of qualitative evidence focusing on nursing student perceptions of self-care and suggestions on how nursing programs can promote self-care in students. This study incorporates a qualitative piece that provides rich data on the student self-care perspective and provides a venue to begin the conversation regarding the importance of self-care in nursing students.
The evidence supports the need to assist nursing students worldwide in focusing on their own physical, mental, and emotional wellbeing through self-care. There were three objectives for this study. The first objective was to use quantitative and qualitative methods to discover the current self-care practices of one group of entry level undergraduate nursing students. The second objective was to discover the students' understanding of self-care and its potential impact on nursing practice. The final objective was to discover the students' preferences for self-care interventions to potentially be used in future semesters in promotion of student self-care.

Methods
Before the study was implemented, IRB approval was obtained. Recruitment for the quantitative research focused on a convenience sample of 37 students in their first semester of nursing coursework at a baccalaureate nursing program at a regional university in the Midwest in the United States. This sample was chosen, because the researchers plan to use the data to create interventions specifically geared to this group of nursing students in future semesters, based on the study results. The requirements for inclusion were that nursing students be English-speaking and at least 18 years of age. A short email was sent to the students, informing them about the nature and purpose of the study and the criteria for participation. The researchers met with the students at a prearranged time in March 2022 to begin the quantitative phase of the research, meeting with the students at the end of a scheduled meeting time for one of their nursing courses.
The students were assured of the confidentiality of the survey, that no participant identifiers would be collected and that the results would only be available to the researchers in the aggregate. The risks, which were minimal, and benefits of the project were shared with the students. The potential participants were assured that participation in the study was optional and voluntary, and not connected with their course in any way, including the assignment of grades. There was one ethical issue that the researchers considered prior to implementation of the study. The participants would potentially be future students of the researchers. However, several students decided not to participate in the project, leading the researchers to believe that they adequately conveyed the optional nature of study participation. Consent was implied by completion of the survey.
The Health-Promoting Lifestyle Profile II survey was selected to evaluate the student's current self-care practices. Permission to use the survey was obtained. This survey has been used in multiple studies and has been found to be psychometrically sound. Based on the original psychometric evaluation, the survey tool was found to have an overall alpha coefficient of internal consistency of 0.943 (Walker & Hill-Polerecky, 1996). The survey consists of 52 Likert-type questions measuring the frequency of self-reported health promotion behaviors in the areas of health responsibility, physical activity, nutrition, spiritual growth, interpersonal relations, and stress management. The scale responses ranged from 1 to 4, with 1 scored as "Never" and 4 scored as "Routinely" for how often the participant takes part in a health promotion practice. The survey also included three demographic data items. The students were asked to select their age from an age range, gender, and race from a list of possible responses at the beginning of the survey. The researchers created a QR code for the students to scan with their smartphones or devices as they were ready to complete the survey. Upon completion, the results of the survey automatically were sent to the surveying program Qualtrex for data analysis, which included the mean and maximum score for each item on the survey in the aggregate. The students were informed that the researchers would return in two weeks to for small group discussions about nursing student self-care.
Two weeks following the quantitative portion of the study. The researchers returned to meet with the same group of students to complete the qualitative portion of the study. The researchers again shared with the students the nature and purpose of the study, and that the data collected would be reported without any student identifiers. The students were informed that participation in the research would not influence course grades and that participation was voluntary and optional. Informed consent was obtained from all participants in the qualitative portion of the study.
By dividing the students into three groups, the researchers were able to compare data across groups to help strengthen the dependability and credibility of the results. They also followed a script, in which the researchers asked the questions without variance and did not make suggestions or attempt to sway the participants. The instructors practiced the questions with each other to ensure as much uniformity as possible in the delivery of the questions. Because this research did not involve high-risk questions, no questions about personal behaviors or needs, a casual small group discussion methodology was used.
The researchers allowed the students to divide themselves into groups, as they were comfortable, making three small groups that moved to separate classrooms to complete the discussions in a quiet, private setting. The three researchers acted as group facilitators and took notes on the student responses. The students were asked their response to three questions: 1. How would you define self-care? 2. How does self-care impact nursing practice? 3. If we were able to provide support for self-care activities, what suggestions do you have At the conclusion of the small group meetings, the researchers compiled a list of their results onto one shared document.

Results
Twenty-seven students participated in the quantitative portion of the study. The demographic data was fairly uniform among the participants. The age range of 18-24 included 26 participants, with one student falling into the 25-34 range. All twenty-seven participants identified as white. Twenty-three students identified as female, while four students identified as male.
The responses to the health promotion survey were recorded using Likert-type items, with the following scoring, 1 = never, 2 = sometimes, 3 = often, and 4 = routinely in response to how often the students participated in a particular health promotion activity. There were two survey questions in which the maximum score for any student was two, both relating to seeking health information through various formats. There were four areas in which the students' maximum response was three: seeking additional information from healthcare providers, eating daily recommended fruit servings, seeking a second opinion about healthcare as needed, and maintaining work-life balance.
There were a few notable low scoring areas on the survey, correlating with a decreased frequency in participating in health promoting behaviors. Some of the lowest mean scores involved questions related to maintaining a healthy diet. This included questions about how often the students ate foods low in fat (M = 2.04) and limiting dietary sugar (M = 2.07). They also often scored low in areas focused their frequency on obtaining healthcare information or care. Those areas included seeking healthcare information through various formats (M = 1.38, M = 1.63), getting a second opinion in healthcare as needed (M = 1.93), and seeking counseling or guidance as needed (M = 1.96). The students also scored lower on some questions about health maintenance practices. That included questions about inspecting their body routinely for changes (M = 1.96), practicing daily meditation or relaxation (M =1.77), and pacing themselves to avoid fatigue (M =2.15).
The students had a mean score of greater than three in some areas of the survey, correlating with an increased frequency of practicing health promotion activities. Many of these areas focused on psychosocial self-care. Specifically, the students scored in the aggregate above three on items such as praising others for their successes For the qualitative data, the students appeared to be familiar with the definition of self-care, when they were asked to define the term. Common themes for the participants' responses included: maintaining balance in life, being social, getting rest, not "stressing" over things, and maintaining mental health along with physical health. A shared quote for the three groups was "taking care of yourself." As well, the students seemed to have a good understanding of how self-care impacted nursing practice in all groups. The students reported that a lack of self-care could cause the nurses to "stress out" the patients. The students felt that the quality of patient care would be improved if the nurses took care of themselves. The student shared that the nurses would be healthier and would be mental clearer, calmer if they practiced self-care. They also felt that self-care would reduce nursing burnout. The students shared that they felt that self-care was particularly hard for nursing students. A common quote for all groups was a variation of, "You cannot take care of others, unless you take care of yourself first." The final question focused on self-care activities that the students would suggest being implemented in the following semester for this group of students to promote nursing student self-care. There were some suggestions shared by all groups. These activities included pet therapy, painting/coloring, and providing snacks or food at various times during the semester. Repeated items in two of the groups included having movie nights and sports or recreational activities. Other suggestions that occurred in one group involved planting flowers/gardening, journaling, having a quiet/meditation room, having class outdoors sometimes, nap times, massage therapy, and holiday parties. Another recurring theme during the self-care discussions was a focus on improving the students' classroom success. There were suggestions such as having open study periods with instructors available, exam review sessions, gaming/fun learning activities, and tutoring sessions with instructors and former students.
Finally, the researchers asked the students for feedback about how best to promote these activities to encourage participation in future semesters. The students recommended frequent reminders via email and flyers. They also thought it would be helpful to poll the students for dates and times that best work with their schedules, focused on students who would truly plan on attending the events, and to give plenty of notice prior to an activity date. They also suggested a class visit by the researchers to promote the activities. The students encouraged the researchers to make events free of cost to encourage participation.

Discussion
The available evidence reveals that nursing students are often under stress and have heavy course workloads that sometimes make it difficult to maintain focus on their own health. This has been found to be a consistent problem globally. A focus on educational success can make self-care difficult for nursing students. The students in this study seemed to struggle with maintaining a proper diet at times. This was found to be an issue internationally in the literature, as well. One of the frequent responses in the small group discussions about promoting self-care involved providing snacks at various times during the semester. It is not uncommon for college students to be in locations where vending machines are the closest source of readily available food. Sankavaram, Goldschmidt, Mehta, and Sahyoun (2021) studied food sources on one campus in the United States and found that most students were one half of a mile away from a quality food source. This is a possible area for intervention.
Another area that seemed to be problematic for the students was seeking health information routinely. It is possible the students are already somewhat well-informed about general health needs and interventions, due to taking coursework focused on future careers in a healthcare field. Also, it is likely that many of the students are generally in good health, due to their age, and may not have the need to seek a second opinion or a need to elicit more http: //ijsn.julypress.com International Journal of Studies in Nursing Vol. 7, No. 3;2022 information from a healthcare provider due to an uncomplicated health history. However, this is an area in which intervention might be needed, especially in maintaining body self-inspection, an area of weakness on the survey, so that it becomes routine self-care practice.
The students had low participation frequency in some health promotion practices on the survey. Being able to pace themselves to avoid fatigue was an area of weakness. It is not surprising that this was a problematic issue, due to the aforementioned stress and workload issues for nursing students. The students also had low frequency scores on meditation and relaxation. This also coincides with students' requests for a quiet room and pet therapy. The need to find times of rest and relaxation are areas where intervention may be needed.
Nursing students need to allow for rest and relaxation to balance their workloads. In the small groups, the students requested a variety of relaxation and recreational activities to help them rejuvenate, such as painting or coloring. Phillips and Becker (2019) performed a systematic review on the use of expressive arts to reduce psychosocial stress in healthcare workers and found evidence that this type of intervention is helpful in stress reduction. Pet therapy has also been found to be helpful in reducing nursing student anxiety (Hall, 2018). Art and recreational activities may help nursing students provide some balance in their hectic lives. As well, relaxation exercises have been shown to reduce stress and anxiety in nursing students (Pelit, Özkan, Yaman, & Şentürk, 2021).
While not definitely related to self-care, the students discussed promoting classroom success, to allow them to focus on self-care. Even though these are not self-care or health promotion activities, helping students succeed in the classroom can help them to reduce anxiety and stress. This could be an area of focus for nursing students as an indirect way of assisting students in focusing on taking care of themselves.
It is important that nursing faculty recognize the self-care deficits that are common nursing students worldwide. It is common for nursing students to be strained by the burdens of personal and educational workloads. They also are often experiencing stress and anxiety, due to the demands of learning to patient care, preparing for class assessment, and the pressure to perform well. These issues can lead to a lack of self-care, including sleep deprivation, poor diet, and the use of maladaptive coping methods. It is important for educators working with nursing students to encourage the students to take the time to provide for their physical, emotional, and mental well-being on a routine basis. Scheduling interventions that allow for rest and relaxation are an important component of all aspects of health.
There were some limitations to the study. A convenience sample of students was used from one nursing program with fewer than 30 participants. While this will assist the researchers in planning student group-specific interventions in the future, it makes the results less generalizable to a greater nursing student population. The student responses were self-reported, which could result in the Hawthorne effect. As well, the students might not be able to honestly judge their own behaviors, due to self-deception.
As a result of the quantitative and qualitative data collected, there are several recommendations that could be made to promote self-care in student nurses. It might be worthwhile for nursing programs to consider providing healthy snacks at various times throughout a semester at no or low cost to students, to promote physical well-being. A variety of relaxing activities and recreational activities could be offered throughout each semester to allow for nursing students to promote work-life balance. Even though these students may be knowledgeable about healthcare information, it is still important that they be encouraged to self-reflect on their own health practices to ensure that they are learning to fully incorporate physical and mental wellness care into their lives. This self-reflection and self-care focus could be a part of at least one class for each semester in nursing programs.
The researchers plan to take the recommendations of the nursing students in this study and plan a monthly self-care activity aimed at the study participants in the upcoming semester. The students will be solicited to share the times that they are available at the beginning of the semester. The researchers will promote these activities per the students' recommendations with frequent and early reminders of upcoming activities. Current plans involve activities such as pet therapy, pumpkin carving, movie nights, and yoga. It is hoped that these activities reduce student stress and promote self-care, to help the students in their current life, as well as in their future careers in nursing.

Conclusions
Nursing students worldwide are prone to elevated stress levels and heavy coursework loads which are factors that can contribute to a lack of self-care. It is important for nursing programs across the globe to recognize the need to promote nursing student self-care through a holistic lens, with an emphasis on promoting physical, emotional, and psychosocial well-being. Incorporating self-care activities within the curriculum has the potential to enhance the self-care practices of nursing students. Implementing these practices early may increase the likelihood of the students maintaining self-care into their future as licensed nurses, which can improve professional practice. This could result in an improvement in their lives and in the lives of the patients they will care for in the future.