This article discusses the importance of self-care for nurses and is the third in a series on professionalism in nursing
Nursing is a rewarding career but it is also demanding physically, emotionally and psychologically. This article is the third in a series on professionalism, and discusses the need for undergraduate nurses to look after their own wellbeing by adopting and embedding self-care practices. It is important that nursing students can recognise the signs of stress, both in themselves and their colleagues. Breathwork, meditation, movement, sleep hygiene and nutrition are some of the self-care strategies that can be explored.
Citation: Smart A, Creighton L (2022) Professionalism in nursing 3: the value of self-care for students. Nursing Times [online]; 118: 6
Authors: Alison Smart and Laura Creighton are lecturers in education, Queen’s University Belfast.
A popular saying among those who promote self-care is: “You can’t pour from an empty cup”. The proverb – which means you must take care of yourself before you can take care of others – is important for nurses to remember as their professional and personal lives become increasingly busy.
Nurses must strive for positive wellbeing so they can meet the standards of patient care and work as set out in the code of conduct published by the Nursing and Midwifery Council (NMC) in 2018. Nursing can come at a significant cost to mental, emotional and physical wellbeing and, in addition to their professional workload, nurses are often also supporting family and friends; over time, this can take a toll on both mental and physical wellbeing.
It is important to develop and embed coping strategies as a student nurse to ensure you recognise when you are feeling stressed and understand how to deal with negative stress. Self-care is mandated by the NMC’s (2018) Code and, each year, student nurses are asked to complete a declaration of good character and health before they continue with the next stage of their course.
What is self-care?
Self-care is self-initiated behaviour that people incorporate to be proactive in promoting good health and general wellbeing (Sherman, 2004). It relates to activities that are done with the aim of:
- Enhancing energy;
- Restoring health;
- Reducing stress.
This can help people gain a greater capacity to manage stress, increase resilience and reduce symptoms of mental health problems (Jiang et al, 2021). It is important that student nurses take the time to identify self-care practices that enhance their wellbeing.
Student nurses and stress
High stress and anxiety in nursing students affects learning and raises attrition levels (Turner and McCarthy, 2017), and student nurses have been shown to have higher stress and anxiety compared with those on other professional undergraduate courses (Crary, 2013). Many factors can contribute to this, not least the fact that they are required to complete 2,300 hours of clinical placement to be eligible to join the NMC register. This means working shift patterns that can result in a lack of routine and structure.
Other common triggers of stress are around:
- A fear of the unknown;
- Working with unfamiliar equipment or practices at different trusts;
- Worries about a gap between theory and practice and the possibility of making a mistake;
- Issues around communication with staff, students and peers (Nelwati et al, 2013; Pulido-Martos et al, 2012).
Stress can lead to disease, deterioration in health, poor academic performance and, in some cases, students withdrawing from their course. Many sources of stress are unavoidable and need to be proactively managed. However, if nurses take care of themselves, they will be more effective in their capacity to care for others (Royal College of Nursing (RCN), 2015).
Recognise the signs of stress
It is important to be self-aware and recognise signs of stress. The body has a physiological response to acute stress, triggered by the ‘fight-or-flight’ response of the sympathetic nervous system, which is often experienced by health professionals on a daily basis. Prolonged or chronic stress can be harmful to health and wellbeing and left unmanaged, can impact a person’s capacity to care as a professional nurse.
Chronic stress can present itself in many ways, including physical manifestations as well as thoughts, behaviours and feelings (RCN, 2015). Each person will react differently to stress but symptoms may include:
- Pounding heart;
- Sweaty palms;
- The mind racing or going blank;
- Plummeting self-esteem and confidence (RCN, 2015).
An activity that can be done to help a person recognise how stress manifests in themselves is outlined in Box 1.
Box 1. Stress recognition activity
- Draw a person on a page
- Think of a time when you felt stressed, perhaps at university or on clinical placement
- Look at the body image on the page and identify the different ways in which your body responded to stress
Student nurses should take responsibility for their own wellbeing to ensure continued safe practice. Practising self-care is a great first step. Nurses must give themselves permission to care for themselves as well as others, and to create time for that (Andrews et al, 2020).
Mindfulness is the art of letting your mind be still in the present moment; Box 2 details an exercise aimed at helping you to be in the present.
Box 2. Mindfulness activity
Close your eyes, breath in deeply for a count of five and breathe out for five. Repeat three times. Open your eyes and identify the following:
- Five things you can see
- Four things you can reach out to and touch
- Three sounds you can hear
- Two things you can smell
- One thing you can taste
Van der Reit et al (2018) found that mindfulness meditation can improve nurses’ and student nurses’ wellbeing. Positive effects include a restructuring of the brain; Hölzel et al (2011) found that mindfulness is associated with changes in grey matter concentration in brain regions involving “learning and memory processes, emotion, regulation, self-referential processing and perspective taking”. In addition, Chiesa et al (2011) demonstrated that the constant practice of meditation demonstrates neuroplasticity and improves cognitive functions. Further positive effects include helping the processing of emotions and decreasing blood-pressure and stress hormones, such as cortisol (Green and Kinchen, 2021).
Certain apps, for example Headspace and Calm, can help with a daily meditation practice. The RCN’s website also includes details of mindfulness activities.
Intentional, or diaphragmatic, breathing is an efficient tool for body/mind training. Xiao et al (2017) described diaphragmatic breathing as involving the:
- Contraction of the diaphragm;
- Expansion of the belly;
- A deep inhale and exhale.
Compared with the normal breathing processes, this technique can have a noticeable impact on calming the autonomic nervous system (Zaccaro et al, 2018). By taking time to focus on breathing, it is possible to reset the fight-or-flight response when experiencing stress.
The US Navy’s Sea, Air and Land teams – commonly known as Navy SEALs – implement intentional breathwork as a tool to help with stressful situations (Nazish, 2019). This takes the form of ‘box breathing’, a multistaged breathing exercise in which a person visualises travelling around the sides of a box (Box 3). This exercise can be done anywhere at any time; it is taught to student nurses at Queen’s University Belfast and informal feedback from those who have used the technique during their placement suggests that they find it helpful in dealing with stressful situations during a shift.
Box 3. Box-breathing exercise
The idea of this multistage breathing exercise is to imagine breathing while travelling around the sides of a box:
- Close your eyes and visualise one surface of a square box, then:
- Inhale slowly to a count of four as you visualise travelling up one side of the box
- When you reach the top, hold your breath to a count of four as you imagine traveling across the top of the box
- Exhale slowly to a count of four as you visualise moving down the other side of the box
- Hold your breath for a count of four as you imagine travelling along the bottom of the box.
The World Health Organization (WHO) (2020) defines physical activity as any bodily movement produced by skeletal muscles that requires energy expenditure. Most of us are aware that physical activity is good for us and improves physical and mental health; obvious examples of such activities are walking, running, cycling, yoga and Pilates, team sports and other exercise regimes of varying intensity. In a study of student nurses, Hawker (2012) found a correlation with physical activity and mental wellbeing through improved mood, reduced anxiety and depression, and increased self-esteem and life satisfaction.
For those who find it hard to stay active, big changes start with small steps; something as simple as a walking challenge – perhaps done with family, friends or colleagues – can be a good place to start (Smart and O’Neill, 2021).
Sleep problems are common among health professionals because of shift patterns; Stimpfel et al (2020) found that nurses’ short sleep duration was associated with poorer quality of care and reduced patient safety. Those who want to improve their sleep can do a sleep assessment to help identify what strategies may be effective; a sleep assessment tool is available on the NHS website.
Walker (2018) offered these tips to help improve sleep quality:
- Find a bedtime routine: as an example, drinking a cup of herbal tea, reading a book, taking a warm bath (the dip in your core body temperature afterwards signals to your body that it is time to sleep) will help to programme your body to understand that it is bedtime;
- Avoid screen time an hour before bed: the blue light emitted from the screens of digital devices such as computers and smartphones reduces sleep time, quality and depth by fooling your brain into thinking it is still daytime;
- Ensure your bedroom is cool (around 18°C), so your body experiences the drop in core temperature to initiate sleep;
- Restrict caffeine and nicotine: avoid both in the four to five hours before bed.
Hydration and nutrition
Dehydration in nurses is common and is not helped by a culture of it being hard to take drinks breaks; a report on safe and effective staffing found that 59% of nurses had not managed to take enough breaks during their previous shift (RCN, 2017). Dehydration alone can reduce concentration and cognitive function, and lead to fatigue (RCN, 2018). Nurses should always:
- Hydrate before starting a shift;
- Keep a water bottle with them and make sure to top it up when on a break;
- Look out for signs of dehydration, such as a sore head, feeling tired/lethargic and having difficulty concentrating.
Good nutrition is vital, but long shifts, working nights and starting early mean this can get lost. Emotional eating as a form of comfort is not sustainable, and leads to overeating and unhealthy food choices, which can store up future health problems (Liu et al, 2017).
Tips to maintain good hydration and nutrition are outlined in Box 4.
Box 4. Tips for good hydration and nutrition
- Be equipped for a shift with water and nutritious snacks; try not to rely on vending and coffee machines
- Opt for high-protein meals and snacks
- Try not to give in to cravings for sugary snacks while at work
- Prepare nutritious meals in batches at home if doing a few shifts in a row
Find what works
Student nurses can adopt various other activities that can help with self-care. Examples include:
- Connecting with others;
- Gratitude (Sansone and Sansone, 2010).
For the more adventurous, evidence suggests that open-water swimming or cold-water therapy has mental and physical health benefits by stimulating endorphins to improve mood (Oliver, 2021). It is important to find what works for you and make it part of your life.
Student nurses can experience high levels of stress; this can lead to increased levels of anxiety and depression, reduce the quality of patient care they can provide, and compromise patient safety. Stress can present itself in physical, psychological and emotional ways. Student nurses should embed self-care into daily routines and recognise stress in themselves and in others. Various effective strategies – including movement, meditation, breathwork, positive sleep hygiene, and ensuring optimum nutrition and hydration – can be used to boost mental and physical wellbeing.
Those working in nursing education should direct students to wellbeing activities when discussing professionalism and the NMC Code. It is important to embed, early in a nurse’s career, an awareness of wellbeing and supportive strategies that can be adopted.
- The Nursing and Midwifery Council’s code of conduct places an emphasis on nurses prioritising their own wellbeing
- People who work in positions of care tend to provide care for everyone but themselves
- Student nurses experience high levels of stress because of the nature of their course
- Proactive approaches to self-care should be adopted early on in a nursing career
- It is important to find the strategies that work for individual people
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