The Efficacy of Providing Holistic Wellness Activities in Promoting Nursing Student Self-care

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Introduction
Self-care is defined as taking time to participate in activities that promote living well and improve the person's physical and mental well-being (National Institute, n.d.).Nursing students, in particular, may not take care of themselves well due to a variety of factors.The lack of self-care in nursing students may not be attributable to a lack of knowledge.Rather, the intensive nature of nursing school may be a factor in limiting nursing student self-care.Younas (2017) performed a review of literature and found that nursing students are often knowledgeable about practices that support physical, mental, and emotional health, yet frequently neglect to put this knowledge into practice in their personal lives.Chow and Kalischuck (2008) examined the self-care practices of 211 nursing students in Northern Canada.They found that the students' hectic schedules sometimes interfered with self-care activities, such as obtaining adequate sleep and participating in physical exercise on a routine basis.
Moving forward, there has been an effort to encourage the development of self-care in nursing students for their current wellness, and to encourage the continuation of self-care as licensed nurses.As an example, the American Association of Colleges of Nursing (AACN) recently updated its professional standards for nursing education to include developing nursing student self-care practices as part of this effort (AACN, 2021).Many international nursing organizations are promoting self-care for nurses to improve their personal well-being, as well as to increase the quality of the care that they provide.The International Council of Nursing (2021) includes self-care as a mandate for nurses in their code of ethics.The American Nursing Association states that self-care is a duty for nurses (American Nurses Association, 2023).Furthermore, the Nursing and Midwife Council (2018) in the United Kingdom has self-care included in their code of ethics.Since the onset of the COVID-19 pandemic and the subsequent increase in nursing stressors, self-care has moved to the forefront of initiatives for nursing practice, as well as those for nursing students preparing to enter the profession.

Materials Studied
Deficiencies in self-care practices among nursing students have been well documented.Armstrong et al. (2022) found entry level nursing students had lower levels of nutrition, physical activity and were deficient in accessing health information and avoiding exhaustion.The COVID-19 pandemic has contributed to additional stressors and challenges that have impacted self-care practices in nursing students.Spurr et al. (2021) examined wellness and resilience among 196 nursing students in Canada.The study used the Nursing Well-being and Resilience tool to examine health status, professional quality of life, well-being, and ego-resilience of the participants.Findings reveal that the nursing students reported to be in good health and had high levels of professional satisfaction.However, several students reported feeling stressed, overwhelmed, depressed, and anxious.Increased psychological stress in nursing students has been found to have a negative impact on physical activity and diet.Ramón-Arbué s et al. ( 2023) utilized the Hospital Anxiety and Depression Scale in 648 nursing students in Spain to measure anxiety, depression, and self-care activities.The study found a 24% prevalence of anxiety and 3% prevalence of depression among the participants.Additionally, the findings reveal that inadequate levels of physical activity and poor diet practices were associated with higher levels of anxiety and depression.Another study affirms the findings that there is a negative relationship of self-care practices to increased rates of psychological distress in nursing students.In particular, poor sleep quality was correlated to increased psychological distress (Brouwer, et al., 2021).With the increasing levels of stress, anxiety, and depression among nursing students, it is essential for nursing education to incorporate self-care into curricula.
The literature reveals that increased stress, anxiety, and depression among nursing students is associated with burnout.It is estimated that 46% of nursing students experience burnout with 22.5% of those experiencing severe burnout (Arian, et al., 2023).In a worldwide nursing shortage, it is imperative that nursing education implement solutions by addressing the burnout that students are experiencing.Literature identifies several programs that have incorporated interventions into nursing curricula to improve self-care practices and reduce burnout.Peterson et al. (2023) developed a program that included educational and support resources to assist nursing students with COVID-19 coping strategies.There were 360 nursing students participating in the program with 224 participants completing the pre/posttest surveys.The findings reveal positive course evaluations with an increase in knowledge, decrease in stress levels, and a reduction in burnout.Woods-Giscombe (2021) describes the LeVine Wellness Program that incorporates stress-management activities along with the promotion of wellness into a nursing program.This was offered to undergraduate and graduate students and nursing faculty and staff.A sample of the activities include chair massages, Tai Chi and yoga classes, and mindfulness training.The program results reveal positive post-event surveys among faculty, staff and students which demonstrates effective interventions within nursing curricula are important to improve self-care and reduce stress.
In an effort to contribute to the support of nursing students and self-care, a pilot project was started in fall 2022.This project provided the foundational data of nursing student's self-care practices and preferences of self-care activities.The findings from this project supported the need for implementing self-care practice interventions with nursing students (Armstrong et al., 2022).Bi-monthly self-care practice activities were provided by the faculty team members that included pet therapy, art, yoga, and beverage breaks.All activities promoted a sense of community and socialization among nursing students and faculty.The purpose of this article is to discuss the findings of the post-intervention implementation and recommendations for future improvement and evaluation.

Methods
The post intervention implementation (Phase 2) will be described in this section.Prior to the implementation of the intervention and surveys, IRB approval was obtained.Students were recruited via a convenience sample in their third semester of a baccalaureate nursing program.This sample was chosen as a cohort as this was the group that was originally surveyed in 2022.The original survey and focus group questions from 2022 were used for the phase 2 of this study for comparative analysis.Inclusion criteria include age of 18 years or older and English speaking.Students were invited to complete the anonymous online follow up survey via email and were informed that responses would be collected as aggregate data without identifying information.The potential participants were informed that this was voluntary and not connected to any course.The risks and benefits of the project were explained to the students.There were minimal risks associated with participation in the survey.
The team utilized The Health -Promoting Lifestyle Profile II survey that was used initially in 2022.This survey assesses self-reports of current self-care practices.This survey tool has been found psychometrically valid and reliable.Areas measured in this survey include; health responsibility, physical activity, nutrition, spiritual growth, interpersonal relations, and stress management.There were 52 Likert scale questions where each item was rated on a four-point scale, with responses ranging from 1=Never to 4=Routinely.Demographics collected included race, gender and age.A QR code was created and used for students to access the survey.Survey results were collected and analyzed using Qualtrics.
Additionally, qualitative data was collected through the use of focus groups.Prior to beginning the focus group, students were informed that participation was voluntary and that there would be no student identifiers used in the data analysis.Informed consent was obtained from all participants prior to beginning the focus groups.The following questions were asked to the participants: 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 focus group meetings, the team members compiled a list of the results onto one shared document and determined common themes.

Results
The follow up survey did not demonstrate statistically significant results however; the qualitative feedback was meaningful.There were 31 students that completed the online survey that was given in the spring 2023 semester.The response rate for this cohort was 93%.Demographics include 25 females, 1 male and 1 non-binary individual.There were 30 participants in the age range of 18-24 years, with one student falling into the 25-34 age range.Twenty-nine participants identified themselves as white, one as Asian and one as Latino.The current retention rate for this cohort was calculated at 76% and will be continuously monitored throughout the program.Focus group feedback was meaningful (n=31).Similar results related to self-care knowledge were consistent from 2022 and 2023 which demonstrated that students were able to define self-care.Students defined self-care as taking care of themselves physically, emotionally, and academically.For example, students stated that self-care involves, "Taking a break from school."From the discussion and responses, it appears that there is general knowledge regarding self-care practices.
In response to implications of self-care related to nursing practice common themes include; better outcomes for patients, improved quality of care and decreased burnout.From 2022 to 2023 this feedback was similar.However, upon reviewing literature there appears to be a gap that supports better patient outcomes in relation to self-care in nurses.This may be an opportunity for further exploration.Mealer et al. (2011) completed a national study with 1239 intensive care nurses that explored the relationship between resiliency, burnout syndrome, anxiety, depression and posttraumatic stress disorder.The findings were statistically significant and demonstrated that nurses that reported greater resiliency had less psychological reports such as burnout syndrome.The researchers also reported that only 22% of the participants scored highly resilient (Mealer et al., 2011).This information further supports the need for earlier guidance through nursing educational programs.
The students also provided feedback in regards to what types of mindfulness activities they would be interested in participating in and the responses were similar to previous discussions (i.e.pet therapy, movie nights, yoga, coffee breaks).Feedback also included the request for more frequent breaks during didactic courses throughout the day.
In relation to specific activity feedback students reported that they were thankful for the planned activities.One comment that was made during the end of the semester included: "I think it was awesome and gave everybody a boost to get through the end of the semester!Support goes a long way!"

Discussion
Although nursing students may be knowledgeable about healthcare information, many do not participate in self-care practices on a routine basis that would demonstrate overall behavioral change within a 12-month evaluation.The team discussed the idea that embedding self-care into nursing curricula may improve the overall health of students, build resilience which may increase retention in nursing programs and have a greater impact on the nursing profession overall.Consideration related to the type of survey was also reviewed as the students were not guided in relation to concepts that would improve diet or health seeking behavior, but rather mindfulness techniques and periods of rest.The activities were only offered twice a month which is arguably not adequate to promote a behavior change for self-care.The faculty working on the project found time as a barrier in the development and implementation of the self-care intervention activities, as this was outside their teaching and clinical workload.Literature finds that the lack of time is a barrier to wellness programming.Future planning may consider incorporating upper class nursing students that would aid in the delivery of activities as part of coursework duties.Woods-Giscombe (2021) identified that the lack of time or the perception of lack of time contributes to the inability of students to participate in self-care initiatives.The team is recommending and developing a course that can be offered to all nursing students in the program with objectives that would focus on overall wellness and self-care activities on a routine basis with individual student evaluations that could be tracked for effectiveness.Peterson et al. (2023) studied the implementation of an 8-hour stress awareness course that also implemented support groups for nursing students.The results demonstrated significant improvement in signs of stress and level of burnout.Sustainability for a similar program is well supported by leadership and establishing faculty support would be imperative for success.Incorporating graduate nursing students may also be a discussion to cast a wider net and lean in to the rich experiences those students would provide.
There were several other limitations to the project.One of the limitations of the project were variances in the sampling of students from one survey to the next.Some students from the cohort were not available for the post-intervention survey.The results were self-reported, which can result in inaccurate results due to the Hawthorne effect.The small sample size limits the generalization of the findings to a larger student nursing population.The small cohort size and the short period of time for evaluation may have also contributed to the overall results.The faculty are planning to develop a similar project that would be offered to all nursing students.Expanding the project and increasing the number of participants may provide a better understanding of the impact of the self-care interventions.
The thought continues that early implementation may increase future self-care practices and improve overall health and professional satisfaction.It may be important to offer and promote these activities to all nursing students, nursing faculty and staff.Healthcare professionals are at risk for burnout and hospital administration continues to struggle with retention (Haddad, Annamaraju, Butler, 2023).Laying the groundwork for good self-care practices continues to be important for our student population and our nursing profession.

Conclusions
Self-care is vital in order for nursing students to maintain physical, mental, and emotional well-being.However, it can be difficult for these students to overcome the inherent barriers to self-care, such as increased stress levels and taxing workloads.It is imperative that nursing programs work to foster self-care in their students, for their current well-being, as well as in preparation for their future careers.Utilizing modeling behavior among faculty is also imperative to create a culture of support, wellbeing and connectedness.By supporting course objectives that teach the concepts of self-care and overall wellness, we are modeling those practices.While the self-care activities provided by the team did not result in measurable improvements in the self-care practices of the students, the focus group findings supported international evidence for the duty to provide nursing students with opportunities to participate in mindfulness, stress reduction, and general health promotion activities.The project is significant in that it demonstrates the importance of providing such opportunities to nursing students.But, it also highlighted the need to do more so that all students are aware of the need for self-care, and be given an opportunity to truly develop the practice of self-care in their lives.This next step of self-reflection, education, and repetition outside of the instructional setting will be needed in order to observe change in the personal lives of the students.These activities in this project serve as a reminder of the need for the students to take time for themselves and their overall health.These interventions serve as a reminder of the need for the students to take time for themselves and their overall health.They also provide an opportunity for the nursing faculty and administration to emphasize that students are cared for and supported.
Table 1 below demonstrates the result of the survey utilizing Welch's t-test for analysis.
Note: M=Mean, SD=standard deviation, p=p value.Items were rated on a 1-4 scale.Pre-post comparisons are based on Welch's t-test.