Self-Care Concept

* Indicates cost associated with resource.

1. Self-Care for New and Student Nurses*
Fontaine, D.K., Cunningham, T., & May, N. (2021). Sigma Theta Tau International Honor Society of Nursing. Indianapolis, IN.

The authors provide a 360-degree view on self-care for student nurses while remaining relevant and engaging for nursing faculty and clinical preceptors. It serves as a go-to guide for continuous insights and inspiration.

Faculty Suggestions for Use: 

• Recommended as an easily accessible and valuable resource for curriculum integration.
• Provides a comprehensive guide for student self-care that can be incorporated at multiple levels of the curriculum, with accompanying workbook and faculty guide.
• Serves as an introduction to self-care practices, benefiting both student nurses and faculty.
• Utilized in precepted acute care clinical courses, prompting students to journal and reflect on their clinical experiences.
• Multiple workbook exercises used to prompt self-care, wellness, and resilience activities.
• Incorporated into a senior leadership course with a precepted clinical experience, where students completed a discussion board post at the beginning of the term asking to rank their priorities for selecting their first workplace. Then students were asked to complete the discussion board assignment again after reading the assigned chapter on Health Work Environments and compare/contrast their responses.
• Utilized on a learning management system discussion board for asynchronous online classes.
• Used to introduce journaling.

2. Integrating Wellness into Curricula Using the Ten Dimensions of Wellness as a Framework 
Gawlik, K., Teall A., Zeno, R. et al. (2024). Integrating wellness into curricula using the ten dimensions of wellness as a framework. Journal of Professional Nursing 50 (6), 73-82. DOI:10.1016/j.profnurs.2023.11.006

To inspire and support nurse faculty, this article outlines strategies within each dimension of wellness that can be adapted across educational settings, student cohort sizes, course delivery modes, and organizational cultures. These strategies are intended to provide the rationale and tools for nurse educators to optimize learning environments, foster student well-being, prevent or reduce burnout, and provide educational experiences that promote a positive entry into the nursing profession. 

Key Points:

• Strategies offer rationale and tools for nurse educators that can be used to encourage students to self-assess their level of wellness in each dimension, and to subsequently establish self-care goals.
   
• This article encourages integrating self-reflection practices and goal setting that empower students to value their own well-being. 
   
• The learning strategies presented are examples of activities and assignments that faculty can consider implementing into their curriculum, depending on the institution’s curriculum and learning environment.

3. National Academy of Medicine. Clinical Well-Being and Resilience Initiative

In 2017, the National Academy of Medicine launched the Action Collaborative on Clinician Well-Being and Resilience, a network of more than 200 organizations committed to reversing trends in clinician burnout. In 2022, the NAM Clinician Well-Being Collaborative released the National Plan for the health workforce well-being to address the following objectives:

• Raise the visibility of clinician anxiety, burnout, depression, stress, and suicide

• Improve baseline understanding of challenges to clinician well-being 

• Advance evidence-based, multidisciplinary solutions to improve patient care by caring for the caregiver. 

Faculty Suggestion for Use:

• Recognized as a significant, no-cost resource, beneficial for systems and organizational leaders.
   
• Offers valuable background information and insights explaining external factors influencing individuals' system wellness and addresses policy-related issues.
   
• Particularly useful for faculty and graduate students seeking to deepen their understanding of clinician well-being and resilience.

Integration with Syllabus and Role Modeling:

• Syllabus Integration: The syllabus is the gold standard that students are expected to follow. Embedding self-care strategies as part of the program of study emphasizes their importance to students.
• Role Modeling: Faculty can demonstrate self-care practices, such as starting the day with a moment of pause or integrating deep breathing exercises into class activities or course work.

Assessing Student Engagement:

• Observational Assessment: Faculty can observe student behavior, such as phone usage or chatting, as indicators of engagement and address it through conversations on being fully present, as well as what it means particularly for novice learners.
• Self-Reflection and Self-Evaluation: Implement exercises where students assess their own mindfulness or engagement level using scales like the MAAS scale or self-reflection exercises. You may ask students on a scale from1-10 how much their mind wanders. This engages the students in their own self-assessment.
• Resources for Assessment: 
  • Mindfulness scales can be accessed from sources like Positive Psychology or the Harvard Center Repository of Positive Psychological Well-Being Scales.

Consider caution when using individual mindfulness assessments, as some students may find the results distressing if they haven't integrated awareness practices into their wellness strategies. Tools are still being developed for measuring individual self-care capacity; consider the scoping review by El-Osta et al, 2023, or Questionnaire Center | Authentic Happiness listed in the Additional Resource list below. 

Foundational Self-Care Practices:

Fontaine and colleagues¹ believe the four practices described below are foundational for whatever strategies are used for building a self-care tool kit:  

• Drink water: Review physiological importance of hydration and the restorative properties of water; identify work and learning environment hydration systems; role model keeping bottle full of cool water. (This strategy may not be doable by students working in clinical settings that restrict having water bottles or other possible sources of infection.) 
• Unclench: Review body scan techniques to identify muscles that are clenched and how to relax and be okay with being present with self-acknowledging the tension and working to relax. 
• Take a deep, restorative breath: Review physiological importance of using diaphragmatic breathing for stress reduction; demonstrate Box Breathing technique: keep lungs empty for four counts, inhale through nose for four counts, hold air in lungs for four counts-not getting tense, release then exhale smoothly through nose for four counts and repeat five times.
• Be present: Review evidence that supports living in the moment fosters happiness and well-being ² and adopting appreciative inquiry and mindfulness practices ³ can help develop full presence to recognize what is happening in the moment and how to shape feelings and behaviors to respond. 

The behaviors described above we want to see in students, but do not want to make it difficult or more stressful. One suggestion would be to have students reflect and do a self-assessment on their “mindfulness.”  Integrating the behaviors into a virtual or in-person class provides evidence that they are important and easy to do during other activities. For example, a faculty member could stop in the middle of a 75-minute class and do deep breathing exercises with the students or play a dance video where they get up and dance and move.  

It is hard to assess outcomes or move the needle on some of these desired behaviors in respect to well-being because it is made up of so many things and is complex.  However, engaging in these behaviors regularly and reinforcing their importance are process outcomes rather than actual learner outcomes that demonstrate we have really changed their behavior.

Self-Care Assessment: There is little in the literature that addresses assessing self-care behaviors in others. The important skill is the ability to assess oneself and to understand the importance of engaging in self-care behaviors. Numerous studies suggest that stress related to work is the primary fuel of burnout and job dissatisfaction in healthcare providers. Vlachou, et al. reported a positive relationship between emotional intelligence and burnout syndrome, suggesting that emotional intelligence acts protectively against burnout syndrome and even reduces it. Numerous studies have shown a relationship between stress and emotional intelligence. Assessment tools are available from the work on self-awareness and emotional intelligence. To know oneself is the first step to understand what works well for self but may not work for someone else.  O’Connor, Hill, Kaya, and Martin provide an overview and recommendations on the measurement of emotional intelligence which can be accessed here.

Studies on Self-Care Practices: Cunningham and colleagues (2017) reported pilot data that addressed the use and frequency of nurses applying practices of self-care, resilience, and compassion. They hypothesized that nurses with frequent self-care practice (a dose effect) would score lower on scales that represented perceived stress; however, the opposite was reported. The nurses surveyed reported a variety of forms of self-care beyond traditional practices covered in the survey, such as exercise, meditation, reflective journaling, deep breathing, etc. The authors had not included self-care practices such as reading, knitting, napping, gardening, and spending time with family which called to question “do we need a traditional self-care definition if we run the risk of excluding people from practicing it” (Fontaine, 2021, page 239). Their study also concluded that self-care is ongoing and not a one and done event. One recommendation is to first have students assess “what you know about self” using a variety of validated assessment tools for Emotional Intelligence and/or Self Awareness, recording/reporting/tracking the types of personal activities conducted similar to APPS tracking “steps/day” and intentionally building in time for “self-care” daily.

Resources for Mindfulness Assessment: Also, as described above, there are many mindfulness scales that are available for individuals to assess their own mindfulness. The one most frequently used by the Advisory Work Group members is the MAAS. Access the MAAS and other mindfulness scales here.

American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements, 2015. 

Docherty-Skippen, S.M., Hansen, A., & Engel, J. (2019). Teaching and assessment strategies for nursing self-care competencies in Ontario's nursing education programs, Nurse Education in Practice, Volume 36, 2019, Pages 108-113, ISSN 1471 5953, https://doi.org/10.1016/j.nepr.2019.03.011. 

El-Osta, A., Sasco, E.R., Barbanti, E. et al. (2023). Tools for measuring individual self-care capability: a scoping review. BMC Public Health, 23, 1312 (2023). https://doi.org/10.1186/s12889-023-16194- 

Institute for Organizational Mindfulness

Koprowski, K., D. Meyer, D., Stanfill, T., & Tivis, L. J. (2021). "Cultivating joy: Improving nurse resilience through use of a practice playbook." Applied Nursing Research, 62, 151484. 

Maslach, C., Jackson, S.E., & Leiter, M.P. (1996). Maslach Burnout Inventory Manual. 3 ed. Palo Alto, CA: Consult Psychol Press; 1996. 

Miller, J., Grise-Owens, E., Addison, D., Marshall, M., Trabue, D., & Escobar-Ratliff, E. (2016). Planning an organizational wellness initiative at a multi-state social service agency. Evaluation and Planning: The International Journal, 15, 1–10. 

Grise-Owens, E., Miller, J., & Eaves, M. (2016). A to Z Self-Care Handbook for Social Workers and Other Health Professionals. Harrisburg, PA: New Social Worker Press.

National Academy of Medicine. Clinical Well-Being and Resilience Initiative.  

National Institute of Mental Health: Digital Shareables on Suicide Prevention 

Sitzman, K., & Watson, J. (2018). Caring science, mindful practice : implementing Watson's human caring theory (Second edition. ed.). New York, NY: Springer Publishing Company, LLC. 

The Ohio State University MINDSTRONG / MINDBODYSTRONG. [Includes reference list of studies to support integration of the program into health sciences curricula]. 

University of Pennsylvania: Questionnaire Center | Authentic Happiness 

Vlachou, E.M., Damigos, D., Lyrakos, G., Chanopoulos, K., Kosmidis, G., & Karavis, M.Y. (2016). The Relationship between Burnout Syndrome and Emotional Intelligence in Healthcare Professionals. Health science journal, 10.  

World Health Organization: Mental Health