Running head: IMPORTANCE

The Importance of Implementing Self-Care in Nursing Curriculum

Kami Alexander, Michelle Carrillo, and Lilia Murashov
Western Washington University

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The Importance of Implementing Self-Care in Nursing Curriculum

Introduction
When I was in nursing school, we had a group meeting in the staff lunchroom at the end
of every clinical day. When one of my fellow students complained that she did not have time to
use a bathroom, one of the nurses from that floor shared a joke with us. Did you hear about the
body found alongside the road? They dont know her name, but they know she is a nurse because
her back is broken, her nerves are frayed, her ankles are swollen, and her bladder is full.
Although we all laughed, the sad reality is that many nurses care for others at the expense of
their own health. The population focused on in this paper are students currently in the nursing
program at Bellingham Technical College (BTC), as well as new nurses in the residency program
at PeaceHealth St. Joseph Medical Center (PHSJMC). The American Nurses Association (ANA)
defines a healthy nurse as one who actively focuses on creating and maintaining a balance and
synergy of physical, intellectual, emotional, spiritual, personal and professional wellbeing
(ANA, 2016, p. 1).
Although self-care is important in nursing education, these skills are often neglected and
the curriculum is usually focused toward care for others. How can we change the culture around
poor self-care in nursing? It is often forgotten that healthcare providers must be healthy
themselves to provide safe and effective care to others. During nursing school students appear to
experience an increased level of stress. Ashcraft and Gatto (2015) found that students slowly stop
practicing self-care as the intensity increases.
When nursing school curriculum incorporates the importance of self-care, students can
see the value in it instead of as just another cumbersome requirement. Nurse educators are in a

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perfect position to assist their students in developing a foundational understanding of self-care.

Implementing self-care curriculums into nursing programs will provide several benefits. First,
students will improve their own health and will know how to deal with stress at an earlier point
in their career (Blum, 2014). Second, caring for oneself will prepare students to be better nurseeducators for their patients because nurses who practice positive self-care behaviors become
better role models, educators, and patient advocates (ANA, 2016, p. 1).
Review of Literature
We will discuss components of self-care often missed in nursing curriculum including
emotional, physical, social, spiritual, nutritional and occupational well-being as it pertains to the
healthcare profession. Introducing these topics early in nursing education will tremendously help
student nurses to develop and build on skills that can be utilized throughout their careers. These
components were selected through a review of the evidence based literature and will be
implemented in the nursing curriculum.
Emotional Self-Care
Emotional self-care is one of the most neglected topics in nursing that encompasses many
areas. Here the focus is on stress management and resilience as they apply to nursing. In schools
of nursing in particular, several classic studies have demonstrated that nursing students have high
levels of stress and could benefit from learning to manage stress during their academic journey
(Clark & Pelicci, 2011). Exploring skills for managing stress is crucial early on in nursing
education. As the expectations and difficulty of a nursing curriculum increase, stress
management skills can be utilized to maintain a healthy life balance. Nursing students often
spend an increased amount of time balancing many obligations. Nursing programs usually

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require additional time in class, in the laboratory, and in the clinical setting. In addition to the
obligations specific to nursing programs, these students face unique stresses, including a fear of
failure, lack of free time, and long study hours (Bryer, Cherkis, & Raman, 2013). Developing
techniques for managing stress are beneficial throughout nursing education and into professional
careers.
Resilience can be defined as a state of recovery, or a return to a previous state after a
time of stressful transition or an adverse event (Stephens, 2013, p. 125). A review of the
literature suggests that nursing students develop resilience and are more successful in the
workplace when they are exposed to potentially difficult situations, and are taught techniques for
coping successfully in nursing curriculum. This concept can also be applied to the increasing
challenges and difficulty of nursing education.
Physical Self-Care
Das and Evans (2014) found that students believe that poor health choices will
detrimentally impact their physical and mental health which would then impact not only their
academic lives, but their social lives as well (p. 490). This study found that at least 33 percent of
college students are considered overweight, obese, or morbidly obese. There is an overwhelming
amount of research supporting the benefits of exercise; however, with the demand of managing
many obligations it can be difficult for nursing students to find time or energy to exercise.
Unfortunately, when nursing students develop poor self-care techniques they often carry them on
to their practice. Esposito and Fitzpatrick (2011) found that when nurses do not practice a
particular aspect of self-care they are less likely to participate in patient-teaching regarding that
topic. If faculty promotes student engagement in exercise, it will strengthen students self-care

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outlook and self-efficacy in mastering the connectedness of theory and practice, and improve
their confidence when engaging in patient teaching (Singleton, Bienemy, Hutchinson, Dellinger,
& Rami, 2011).
Social Component
The social component of self-care is crucial in nursing education. Our ability to maintain
positive relationships with family, friends and co-workers affects our wellness. Studies show that
our need to connect with other people is more fundamental than our need for food and shelter
(Lieberman, 2013). Liebermans (2013) research illustrates that our brain responds to social pain
and pleasure just as powerfully as it does to physical pain. Lieberman (2013) explains that it is
well proven that money does not bring people happiness, but social aspects of our lives do:
social factors had a more positive impact on well-being than income (p. 247). Lieberman
(2013) and his colleagues at the University of California Los Angeles learned that positive
communication is associated with improved thinking and decision making. The data collected
from our surveys closely matches Liebermans findings. Therefore, it is essential for nursing
students to learn how to maintain positive relationships with not just their friends and families,
but also with their classmates and co-workers.
Spiritual Care
The effect of spirituality on health has been studied for years. The ANA incorporates
spiritual care in the Scope and Standards of Nursing Practice, and the American Association of
Colleges of Nursing has integrated spiritual care in the Essentials of Baccalaureate Education
(AACN, 2016; ANA, 2010). Even though many organizations address the importance of
providing spiritual care, nursing textbooks cover very little about this subject and not every nurse

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feels comfortable to start a conversation about spirituality. As patients and their families deal
with illnesses, stress, suffering and loss, they often turn to a nurse for support or advice.
Research suggests that integrating spiritual care into nursing curricula will not only increase
students ability in providing spiritual care, but will help students to use reflective practices to
help support them during stressful times (Burghart & Schmidt, 2012).
Nutrition
Buxton and Davies (2012) suggest that nurses are better prepared to provide nutritional
education to their patients when nutrition is emphasized in the nursing curriculum. Roux (2014)
agrees that nurses serve as positive role models to their patients by modeling a healthy diet and
lifestyle. By teaching nursing students healthy lifestyle behaviors in the curriculum, they are
better equipped to educate patients about health promotion and disease prevention. Nursing
curriculum is often lacking nutritional content and as a result, student nurses have a knowledge
deficit (Roux et al., 2014). By incorporating nutritional self-care into the nursing curriculum,
student nurses can adopt and implement healthy lifestyle behaviors that they can carry with them
in the healthcare profession.
Occupational well-being
There is a well-known saying that Nurses eat their young and there is a lot of truth to
this. Becher and Visovsky (2012) define lateral and horizontal violence as hostility within the
workplace or any unwanted abuse. Many new nurses, as well as student nurses, encounter
bullying and belittling while practicing the art of nursing. A lot of this comes from seasoned
nurses who potentially perceive new or less experienced nurses to be a threat. Nationally, there is
a nursing shortage which Becher and Visovsky (2012) feel is related to horizontal violence. By

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including occupational well-being as a component of nursing curriculum, student nurses can be

better prepared to handle these situations in a professional manner.
Results
Two surveys were conducted to gather qualitative data about current engagement in selfcare practices. One survey with five open-ended questions was distributed to 18 registered nurses
(RN) in the residency program at PHSJMC in Bellingham, Washington. There was a return rate
of 50 percent and the results indicated that self-care wasnt taught or emphasized enough in their
nursing programs. Since they recognize the importance of self-care, they are likely to engage in
healthy behaviors that have a positive effect on well-being (please refer to Appendix A for the
survey questions).
The second survey was distributed to student nurses at BTC. The survey from BTC was
sent to 110 students and had a total of 52 participants, yielding a 47 percent return rate. The
survey contained nine questions including five open-ended and four with a Likert scale. The
survey results from BTC indicated that student nurses didnt feel that self-care topics were
relevant to nursing practice. Nursing students not recognizing the importance of self-care puts
them at greater risk as they enter the healthcare profession. Therefore, emphasizing self-care in
the curriculum is essential (please refer to Appendix B for the survey questions).
Recommended Interventions
Of the six evidence based practice (EBP) assignments that BTC currently has, only two
focus on self-care topics including physical exercise and nutrition. BTC expressed interest in
additional self-care components for each quarters EBP assignment including spiritual and
emotional care as well as social and occupational well-being. After thoroughly analyzing our

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survey data, there are three possible interventions to incorporate an improved self-care
curriculum in the nursing program at BTC.
Individual Level Intervention
The first recommendation is to implement the best-self curriculum that focuses at the
individual level as a primary level prevention. There are six categories in the best-self curriculum
including wisdom and knowledge, courage, transcendence, temperance, justice and humility.
There are several qualities in each category. Participants can assess which qualities are strengths
and which are weaknesses and chose a focus based on this assessment. The curriculum focuses
on setting individual goals to continuously work on being ones best possible self. The thought
process in the best-self can be applied to any goal. The next step is choosing a classmate to be
accountability partners. Ideally a best-self partner would have similar goals. As part of class
each day, a short period of time is dedicated to checking in with each persons selected partner to
discuss progress and barriers. Classmates are able to enlighten and support one another in
meeting their goals. Implementing the best-self curriculum allows students to encourage each
other to practice self-care.
Community Level Intervention
Our next intervention focuses at the community level and could be considered primary,
secondary or tertiary prevention. This plan incorporates self-care workshops focusing on specific
self-care practices related to nursing, such as caregiver burnout, resilience and compassion
fatigue. Ideally these workshops would be open to nursing students and residents and would take
place at least once a month, allowing students to choose a topic of interest and a time that is
convenient. The workshops could take place at BTC and PHSJMC, however, limited space may

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be a barrier. We thought this would be a widely accepted plan because it allows students to
choose a workshop that would benefit their personal goals. Some barriers to this intervention are
limited financial resources and faculty to lead the workshops, as well as limited free time in the
nursing program schedule.
System Level Intervention
The final intervention that we recommend for BTC, based on our review of the evidence,
focuses at the systems level by incorporating self-care practices into the nursing curriculum.
BTCs faculty expressed interest in changing the EBP assignments to incorporate different selfcare aspects in each quarter. There are six broad self-care topics chosen based on the current
curriculum. Creating broad topics allows students flexibility to choose a topic of interest that
falls under the specific category. For instance, in the first quarter, the topic is emotional self-care.
A student could choose a number of different topics including, burn-out or therapeutic
communication. This intervention is considered primary prevention with the goal that
researching specific self-care topics related to nursing, will allow students to incorporate selfcare throughout their career. We chose this intervention over the others discussed because BTC
expressed interest in changing the current EBP curriculum to incorporate self-care topics.
Conclusion
Nursing students need to know that although the nursing profession involves plenty of
responsibilities and hard work, this career is also interesting, exciting and highly respected. Good
health, however, is mandatory for nurses to handle the demands of their profession. Taking care
of themselves will build nurses resilience and allow them to provide the best possible care.
Gaining knowledge about the six main elements of self-care as weve outlined in this paper, will

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benefit not only personal health and wellbeing, but will prepare future nurses to be positive role
models for patients.

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References

American Association of Colleges of Nursing. (2016). The essentials of baccalaureate education

for professional nursing practice. Retrieved from http://www.aacn.nche.edu/educationresources/baccessentials08.pdf
American Nurses Association. (2016). Healthy nurse. Retrieved from
http://www.nursingworld.org/healthynurse
Ashcraft, P. F., & Gatto, S. L. (2015). Care-of-self in undergraduate nursing students: a pilot
study. Nursing Education Perspectives, 36(4), 255256. http://doi.org/10.5480/13-1241
Becher, J., & Visovsky, C. (2012). Horizontal violence in nursing. MEDSURG Nursing, 21(4),
210-214.
Blum, C. (2014). Practicing self-care for nurses: a nursing program initiative. The online Journal
of Issues in Nursing, 19(3), doi: 10.3912/OJIN.Vol19No03Man03
Bryer, J., Cherkis, F., & Raman, J. (2013). Health-promotion behaviors of undergraduate nursing
students: a survey analysis. Nursing Education Perspectives, 34(6), 410415.
http://doi.org/10.5480/11-614
Burkhart L., & Schmidt, W. (2012). Measuring effectiveness of a spiritual care pedagogy in
nursing education. Journal Of Professional Nursing, 28(5), 315-321.
doi:10.1016/j.profnurs.2012.03.003
Buxton, C., & Davies, A. (2013). Nutritional knowledge levels of nursing students in a tertiary
institution: lessons for curriculum planning. Nurse Education in Practice, 13(5), 355-360.
doi:10.1016/j.nepr.2012.09.014

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Clark, C.S., & Pelicci, G. (2011). An integral nursing education: a stress management and life
balance course. International Journal for Human Caring, 15(1), 1322.
Das, B. M., & Evans, E. M. (2014). Understanding weight management perceptions in first-year
college students using the health belief model. Journal of American College Health,
62(7), 488497. http://doi.org/10.1080/07448481.2014.923429
Esposito, E. M., & Fitzpatrick, J. J. (2011). Registered nurses beliefs of the benefits of exercise,
their exercise behaviour and their patient teaching regarding exercise. International
Journal of Nursing Practice, 17(4), 351356.
Lieberman, M. D. (2013). Social: why our brains are wired to connect. New York, NY: Crown
Publishing Group.
Roux, G., DiMarco, N., Gu, Y., Ballard, E., Scott, S., Ellison, A., & Efesoa, M. A. (2014). Eating,
activity, and supportive environment (EASE) for nursing students. Nursing Forum, 49(1),
49-58. doi:10.1111/nuf.12047\
Singleton, E. K., Bienemy, C., Hutchinson, S. W., Dellinger, A., & Rami, J. S. (2011). A pilot
study: a descriptive correlational study of factors associated with weight in college
nursing students. ABNF Journal, 22(4), 8995.
Stephens, T. M. (2013). Nursing student resilience: a concept clarification. Nursing Forum,
48(2), 125133. http://doi.org/10.1111/nuf.12015

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Appendix A
PHSJMC survey

1. Looking back on your nursing school experience, what suggestions do you have to improve
the self-care curriculum?
2. What were the most helpful stress reduction techniques you used while you were in the
nursing program?
3. What helps you now while in the residency?
4. Do you have any recommendations on how to reduce compassion fatigue?
5. What suggestions do you have for nursing programs to incorporate self-care techniques?

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Appendix B
BTC survey

1. What do you do to care for yourself?

2. How do you reduce stress?
3. How often do you take time for yourself each week?
Daily
Weekly
Monthly
Rarely
4. How much physical exercise do you get each week?
None
At least 60 minutes
90 minutes
More than 90 minutes
5. What is the best way to incorporate spiritual care (meditation, prayer etc.) into your self-care
routine?
6. How often do you spend time with family and friends that doesnt involve school?
None
At least 30 minutes per week
60 minutes per week
More than 90 minutes per week

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7. How important is spending time with family and friends to your self-care routine?
A little important
Very important
Important
Not important
8. What changes would you like to see to the EBP projects each quarter?
9. What topics would you be interested in researching for an EBP project?

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