An Online Module to Promote Self-Care and Resiliency in Nursing Students

Abstract

Because the demands of nursing education can impact the physical and mental health of nursing students, the American Association of Colleges of Nursing’s revised Essentials require inclusion of self-care and resilience education in nursing curricula. This article describes the development, implementation, and evaluation of a self-care module in a new online undergraduate course. Using the REST mnemonic (relationships, exercise, soul, and transformative thinking), students developed personalized self-care plans for the semester. End-of-course evaluations revealed an increase in self-care activities. The most used activities were exercise, humor, intentional rest, and healthy eating.

There is an urgency to improve the health and well-being of nursing students. Suicide rates among nurses are now higher than the general population, with suicide the second leading cause of death among college students (^{American Association of Colleges of Nursing [AACN], 2020}). The ^{AACN (2020)} issued a call to action for academic nursing programs to address the health needs of students and to implement strategies to improve health, well-being, and resilience. This call is supported by the inclusion of self-care in the revised ^{AACN (2021)} Essentials.

The AACN’s Essentials address self-care in Domain 10: Personal, Professional, and Leadership Development, described as “participation in activities and self-reflection that foster personal health, resilience, and well-being” (^{AACN, 2021}, p. 53). For entry-level nursing education, the expected outcome is demonstration of health promoting and resilience-building activities. To encourage healthy practices for our undergraduate nursing students, we created a self-care module for an online undergraduate course. This article describes the development, implementation, and evaluation of the self-care module.

SELF-CARE AND RESILIENCE

There is a lack of clarity on the definition of self-care for nursing students. In a scoping review of self-care in nursing education, ^{Slemon et al. (2021)} did not find a consistent definition of self-care. However, they identified three primary themes: holistic nursing, health promotion behaviors, and activities used for coping with stress.

Resilience is the quality of bouncing back or growing through adversity, and it is interwoven with self-care. ^{Cooper et al.’s (2020)} concept analysis of nurse resilience found key attributes of social support, self-efficacy, work-life balance/self-care, humor, optimism, and being realistic. Nurse educators can facilitate students’ participation in resilience and self-care practices through education about resilience, provision of social support, creation of individualized self-care plans, and opportunities for reflection (^{Slemon et al., 2021}; ^{Thomas & Asselin, 2018}).

SELF-CARE MODULE

To encourage students’ engagement in self-care practices, we created a self-care module for an undergraduate online primary care course that taught about self-care and resilience-building strategies. The module taught students about the importance of exercise/intentional activity, nutrition, rest, and regular medical and dental care for improving overall health. Additional educational content included resilience-building practices such as humor, mindfulness, gratitude, time management strategies, changing perspectives, and supportive relationships (^{Tabibnia & Radecki, 2018}).

^{Rajamohan et al. (2020)} recommend the REST acronym as an easy-to-follow guide to strengthen resilience. It stands for relationships-exercise-soul-transformative thinking. Relationships include relationships with self and with others. Exercise involves activities for healthier body, mind, and spirit. Soul represents self-compassion and self-kindness. Transformative thinking involves viewing experiences through a broader lens; it is learning and growing from experiences.

Assignments

There were three assignments for self-care. Students were asked to: 1) create a self-care plan at the beginning of the semester, 2) complete a reflection assignment at the end of the semester, and 3) submit a photo reflecting a self-care practice. After reviewing assigned readings, students outlined their plan for self-care for the semester. They were encouraged to use the REST mnemonic and personal interests to guide their plans for improving health, increasing resilience, and managing stress. In their two-page reflection, students summarized their initial plans, accomplishments, barriers they encountered, changes in their plans, and plans to integrate self-care in the future. Students submitted a photo depicting what self-care meant to them during the semester. A video was made of the photos to showcase the class’s journey.

Evaluation

We used a pretest-posttest anonymous online questionnaire to evaluate the module and assignments. Surveys were analyzed as aggregate data, and the reflection assignment and photo submissions were analyzed for common themes. The evaluation was approved as exempt by the institutional review board of the authors’ university.

Fifty-two students were enrolled in the class. To assess knowledge of self-care strategies, students were asked to rate their knowledge on a scale of 0 to 10, with 0 being not knowledgeable at all and 10 representing very knowledgeable. Students’ reported knowledge of self-care strategies had a statistically significant increase from a mean of 6.4 (SD = 1.81) to a mean of 9.2 (SD = 1.24), t = −8.871, p < .001.

To assess frequency of self-care practices, students were asked how often they engaged in wellness/self-care activities; options included never, once a month, several times a month, once a week, several times a week, and every day. The percentage of students who participated in activities daily or several days per week increased from 52.7 percent to 62.3 percent at the end of the semester. Using the McNemar test, this was not statistically significant (p = .188). Finally, students were asked to rank their top three most frequently used self-care/resilience-building practices; options were exercise, healthy eating, meditation, prayer, spiritual practices/mindfulness, journaling, practicing gratitude, humor/laughter, participation in hobbies, transforming your thoughts/perspective, and intentional rest/sleep. The most frequently endorsed activities at the beginning and end of the semester were exercise, humor/laughter, healthy eating, and intentional rest.

The photographs that students submitted were included as evaluation data to help faculty better understand the students’ ideas of self-care. Visual data, as captured in the photo submissions, add depth and richness to traditional data and may better capture subtle concepts that are difficult to fully describe in words (^{Glaw et al., 2017}). The photographs were reviewed for similar concepts and then categorized into conceptual themes. In the 51 photos that were submitted, themes that emerged included both physical and emotional self-care practices, such as exercise; rest and relaxation/pampering; journaling/meditation; reading and crafting; and time with family, friends, and pets. Forty-one percent of the photos showed some sort of exercise, and 22 percent had rest and relaxation activities, such as sleeping and lounging, enjoying sunset views, watching movies, and pampering activities such as getting a manicure or pedicure. As depicted in 11 photos (22%), students viewed time with family and friends as part of self-care. They also valued time with their pets, shown in 20 percent of the photos. Nine photo submissions (18%) included journaling/meditation, reading, and crafting. Almost half (41%) depicted self-care practices taking place in outdoor settings.

Feedback on the self-care module was overwhelmingly positive. In the final reflection paper, student comments highlighted an appreciation of the inclusion of self-care in the course and learning the importance of caring for themselves. The REST acronym was used by most students to guide their self-care plans, encouraging them to consider self-care practices beyond the usual activities of exercise, nutrition, and sleep. Several students focused on improving relationships and extending compassion and kindness to themselves, with one commenting that this was the first time they had ever thought about their own health. Some students noted improvements in health, weight loss, and ability to manage stress. Several identified the need to continue to prioritize their self-care.

DISCUSSION AND CONCLUSION

Improving self-care of BSN students is important for managing stress experienced during nursing education and can establish a foundation of healthy habits for professional practice. In alignment with the AACN Essentials, assignments in this module allowed students to select their own self-care activities and reflect on their experiences. Using REST as a guide encouraged them to consider an individualized, holistic approach to health. The assignments can be used in online and on-campus programs as well as in graduate nursing education. We recommend introducing self-care in the first semester, reinforcing it throughout the curriculum, and evaluating it during and at the end of the program. Heightened personal awareness of stress levels coupled with self-care activities leads to increased stress reduction abilities as a student and as a new graduate nurse. Most of our students were in their last semester; it is unknown if they continued their self-care activities after graduation. However, we believe that changes in health behaviors establish a foundation for self-care in professional practice. Prioritization of students’ self-care can result in healthier students and a healthier nursing workforce.