Investigating Self-Care Behaviors for Prelicensure Nursing Students: Baseline Findings

Abstract

Background

Prelicensure nursing students face multiple stressors specific to their nursing education. Due to the nursing shortage, identifying methods to mitigate stress in nursing students is a priority. Adding integrative health modalities to the prelicensure nursing curriculum may encourage student resiliency and well-being.

Method

A 3-year prospective repeated measures cohort trial for prelicensure nursing students entering one of three tracts was conducted at a southwestern United States university. Students were followed for four semesters of the nursing program and for 6 months after graduation. Valid and reliable measures were used to explore anxiety, depressive symptoms, stress, resilience, and self-care.

Results

Baseline findings showed a relationship between mental health and self-care.

Conclusion

The findings highlight several important points including the link between self-care and mental health. A significant positive correlation was observed between engaging in self-care activities and improved mental health indicators. [J Nurs Educ. 2025;64(7):440–444.]

Nursing is a demanding profession that requires advanced knowledge, specific skills, and caring. Nurses are involved regularly in intense, emotional, and sometimes life-threatening experiences with their clients. These experiences cause stress and have the potential to affect the psychological well-being of nurses. The World Health Organization defines stress as “a state of worry or mental tension caused by a difficult situation” (^{World Health Organization, 2023}). Research has consistently demonstrated that stress is a significant trigger for depressive symptoms (^{Fuchs & Flügge, 2004}) and is strongly correlated with anxiety (^{Daviu et al., 2019}). Furthermore, anxiety and depressive symptoms frequently co-occur, highlighting their high comorbidity (^{Kalin, 2020}).

Like their counterparts in practice, nursing students report high levels of stress. Stressors specific to nursing school include academic demands, client care responsibilities, and interactions with nursing staff and faculty (^{Labrague, 2024}). Stress levels are higher in nursing students than their counterpart non-nursing college students (^{Bartlett et al., 2016}). Li and colleagues (²⁰²⁰) found a statistically significant negative correlation between caring behavior and stress perception in a sample of 792 nursing students. In addition, nursing students also may have financial concerns, homelessness, relationship stressors, health conditions, and other social determinants of health that may hinder their ability to focus on learning.

Hospitals have been actively implementing strategies to retain nurses for decades. Schools of nursing also are exploring ways to decrease stress and improve success and retention. Onieva-Zafra et al. (²⁰²⁰) examined the coping strategies, perceived stress, and anxiety of nursing students and suggested that nursing faculty should develop programs designed to aid nursing students in coping with stressors. Schools of nursing have included self-care modalities such as yoga, progressive muscle relaxation exercise, transformative thinking, and reflection that have yielded positive results in regard to self-compassion, mindfulness, burnout, and resilience (^{Mathad et al., 2017}; ^{Pelit-Aksu et al., 2021}; ^{Rajamohan et al., 2023}).

Mandates for system-wide change in nursing retention strategies have emphasized the need for more holistically prepared and practice-ready nursing graduates (^{Drennan & Ross, 2019}). Combining the recognized nursing shortage nationwide with the desire to build a more holistic nursing program, a baccalaureate nursing (BSN) subplan was developed from a well-established traditional BSN sister program at the same university. In 2019, a Bachelor of Science in Nursing with an emphasis in integrative health was launched. The program was created by university faculty with the pedagogy of the six integrative nursing principles from the book, Integrative Nursing (^{Kreitzer & Koithan, 2018}).

Threaded throughout the curriculum is a purposeful focus on integrative health and wellness for both the nurse and client, which aligns closely with the updated American Association of Colleges of Nursing (²⁰²¹) Essentials of baccalaureate nursing competencies for entry-level professional nursing education to demonstrate a commitment to personal health and well-being. We have chosen to actualize health promotion and wellness as promoting self-care and resilience. Self-care involves activities that promote physical and mental health, while resilience refers to the ability to recover and maintain well-being in the face of adversity. Both self-care and resilience align with Domain 10 of The Essentials, which emphasizes personal, professional, and leadership development (^{American Association of Colleges of Nursing, 2021}).

Activities and modalities associated with these principles are threaded throughout the curriculum for both self-care and as a component of client care. As principle 6 focuses on caregiver well-being, regular self-care is encouraged and is a component of the clinical hour requirement in each level of the pathway. Faculty in each course, didactic and clinical, have autonomy in the design of educational activities and assignments to promote self-care and have included activities as diverse as mindfulness, cognitive behavioral skills building, journaling, nature walks, yoga, Tai Chi Easy, forest bathing, and meditation. Students also engage in self-reflections on their self-care practices throughout the curriculum, which fosters opportunities for personal growth and positive change, guided by the self-care knowledge integrated into the program.

Since no prior studies were found on implementing a prelicensure program with an integrative health focus, evaluating its effectiveness was considered essential. We chose to assess self-care utilization, resilience, anxiety and depressive symptomatology, and stress, as these factors frequently are highlighted in the literature regarding prelicensure nursing students. The purpose of this repeated measures longitudinal study was to follow nursing students throughout their training and 6 months after graduation to explore relationships among anxiety, depressive symptoms, stress, resilience, and self-care in baseline data.

Method

This study was a 3-year prospective cohort trial with repeated measures for prelicensure nursing students entering one of three pathways at a large university in the southwestern United States. All incoming students for three semesters were invited to participate, and eligibility was extended to all students who were admitted during this period with no exclusion criteria. Approval for the study was obtained from the university's institutional review board. Prior to completing the initial survey, students completed a consent form. All students were provided information regarding mental health resources through the university system. A research faculty member with no association with students sent survey links and managed the data. Faculty were blinded to which students participated in the study.

One week before starting their prelicensure program, students were invited by email to participate in the study. Emails were reviewed to identify any repeat students so that students were not invited twice to participate. Interested students who consented to participate completed questionnaires through Research Electronic Data Capture (REDCap^®), a secure web-based application for data collection. Data were collected at four time points: (1) baseline; (2) halfway through the four-semester program; (3) at the end of the program; and (4) approximately 6 months after employment as an RN. At each data point, students enrolled in the study received an email link to complete questionnaires. This report presents the baseline findings from this study.

Measures

Demographic information and valid and reliable measures were used to explore anxiety and depressive symptoms, stress, resilience, and self-care. Students had the option to skip any item they did not wish to answer. Depressive symptoms were measured with the Patient Health Questionnaire 2 (PHQ-2), a summed two-item instrument using a 4-point Likert scale ranging from 0 = not at all to 3 = nearly every day. Participants ranked their depressive symptoms for the previous 2 weeks with summative scores ranging from 0 to 6. The PHQ-2 has good sensitivity (.61) and specificity (.92) for detecting depression when using a cut-off score of 3 (^{Arroll et al., 2010}). The PHQ-2 also has construct and criterion validity (^{Kroenke et al, 2003}). Cronbach's alpha for this sample was 0.75.

Anxiety levels were assessed using the Generalized Anxiety Disorder 2 (GAD-2), a summed two-item instrument, with a 4-point Likert scale ranging from 0 = not at all to 3 = nearly every day. Participants ranked their anxiety levels for the previous 2 weeks on a scale of 0 to 3 with summative scores ranging from 0 to 6. The GAD-2 has good sensitivity (.76) and specificity (.81) for detecting generalized anxiety disorder using a cut-off score of 3 (^{Plummer et al., 2016}). Reliability and construct validity is supported in university samples (^{Byrd-Bredbenner et al, 2021}). Cronbach's alpha for this sample was 0.89.

Stress was measured with the Perceived Stress Scale 4 (PSS-4), a summed four-item instrument, with a 5-point Likert scale ranging from 0 = never to 4 = very often. Participants ranked their stress in the past month with higher scores indicating higher levels of stress. Adequate reliability and validity of a 4-item version of the PSS was found (^{Cohen et al., 1983}; ^{Lee, 2012}). Cronbach's alpha for this sample was 0.85.

Resiliency was measured with the 10-item Connor Davidson Resilience Scale (CD-RISC) using a 5-point Likert scale ranging from 0 = not true at all to 4 = true nearly all the time. The items are summed with higher scores indicating higher levels of resiliency. Internal consistency was good with a Cronbach's alpha of .85, and construct validity was supported (^{Campbell-Sills & Stein, 2007}). Cronbach's alpha for this sample was 0.90.

Self-care was measured with the Mindful Self-Care Scale (MSCS). This scale has six subscales of which four were used for this study. There are additional “Clinical” and “General” items that are not scored in a subscale. Items are scored on a 5-point Likert scale ranging from 1 = 0 days to 5 = 6 to 7 days. Subscales (physical care, supportive relationships, self-compassion and purpose, and supportive structure) are averaged for a subscale score. The physical care subscale includes items such as, “I practiced yoga or another mind/body practice (e.g., Tae Kwon Do, Tai Chi).” The supportive relationships subscale includes items such as, “I spent time with people who are good to me (e.g., support, encourage, and believe in me).” The self-compassion scale includes questions such as, “I kindly acknowledged my own challenges and difficulties.” The supportive structures subscale includes items such as, “I maintained a manageable schedule.” Cronbach's alpha for the entire scale was .89 and Cronbach' alpha for the subscales ranged from .69 and .92 (^{Cook-Cottone & Guyker, 2018}). Analysis during scale testing and development supported the construct and concurrent validity (^{Hotchkiss & Cook-Cottone, 2019}). For this sample, Cronbach's alpha for all items was .88 with subscale Cronbach's alphas of .65 for physical care, .77 for supportive relationships, .87 for self-compassion, and .82 for supportive structures.

Baseline data were assessed with descriptive statistics, and Spearman's rho correlations were analyzed for relationships among baseline data (^{Shaqiri et al., 2023}).

Results

Sixty-nine nursing students were recruited to participate in the study. Most of the sample were women (85.5%), White (60.9%), and Hispanic (26.1%) (Table A; available in the online version of this article). Fifty-five participants responded regarding current medical conditions in which 47% identified as having anxiety and 31% indicated having depression. A quarter of the sample indicated having both anxiety and depression.

Table A

Participant Demographics

	n	%
Gender
Men	10	14.5
Women	59	85.5
Total	69	100
Race and ethnicity	n	%
American Indian/Alaska Native	2	2.5
Asian American/Pacific Islander	3	3.8
White	42	53.2
Hispanic	18	22.8
Middle Eastern	1	1.3
Multiracial	3	4.3
Missing data	10	1.7
Total	69	100
Program type	n	M (SD)
BSN–traditional	10	21.1 (2.7)
BSN–integrative health	28	23.4 (5.4)
MEPN-Phoenix	7	28.0 (3.1)
MEPN-Tucson	18	31.5 (8.0)

Baseline scores indicated that the mean GAD-2 score was 2.8 with 3 being the recommended cut-off for additional testing (^{Kroenke et al., 2007}) (Table B; available in the online version of this article). The PHQ-2 mean score was 1.3 (SD = 1.9) with a score >3 being associated with major depression (^{Kroenke et al., 2003}). The mean PSS-4 score was 5.8 (SD = 3.3). Although there is no established cut-off to screen for adverse levels of stress, scores >6 are suggestive of high levels of stress (^{Malik et al., 2019}). The mean score for the CD-RISC was 28 (SD = 6.7). The population quartile scores are 25th percentile = 29; 50th percentile = 32; 75th percentile = 36. The mean participant level of resilience was in the lowest quartile (^{Connor-Davidson Resilience Scale, n.d.}). There currently are no standardized scores for the MSCS.

Table B

Pearson Correlations

	Anxiety	Stress	Depression	Resilience	Physical Care	Supportive Relationships	Self-Compassion	Supportive Structures
Anxiety	1	.753**	.519**	−.573**	−0.303*	−368**	−.298*	−.497**
		<.001	<.001	<.001	0.224	0.002	0.015	<.001
	66	66	66	65	64	66	66	65
Stress		1	.606**	−.661**	−.293*	−.324**	−.374**	−.593**
			<.001	<.001	0.163	0.008	0.002	<.001
		66	66	65	64	66	66	65
Depression			1	−.544**	−.373**	−.445**	−.290*	−.477**
				<.001	0.038	<.001	0.018	<.001
			66	65	64	66	66	65
Resilience				1	.378**	0.182	.451**	.528**
					0.037	0.146	<.001	<.001
				65	63	65	65	64
Physical care					1	0.145	0.168	0.208
						0.429	0.435	0.077
					67	66	64	63
Supportive relationships						1	0.073	.318**
							0.56	0.01
						68	66	65
Self-compassion							1	.475**
								<.001
							66	65
Supportive structures								1

Significant correlations were noted among baseline variables (Table C; available in the online version of this article). Anxiety was significantly positively correlated with stress and depression, and negatively correlated with resilience and the four MSCS subscales. Depression was significantly positively correlated with stress and anxiety, and negatively correlated with resilience and three of the four MSCS subscales. There was a significant positive correlation for resilience with all four of the mindful self-care sub-scales and negatively correlated with stress. Stress was significantly negatively correlated with all four of the MSCS subscales.

Table C

Spearman's rho Correlations

	Gad -2	Stress	PhQ-2	CDRS-10	MSCS PC	MSCS SR	MSCS SC&P	MSCS SS
GAD-2	1	.782**	.565**	−.561**	−.257*	−.373**	−.269*	−.518**
		<.001	<.001	<.001	0.04	0.002	0.029	<.001
Stress		1	.595**	−.663**	−.247*	−.404**	−.323**	−.564**
			<.001	<.001	0.049	<.001	0.008	<.001
PHQ-2			1	−.571**	−.366**	−.450**	−0.233	−.468**
				<.001	0.003	<.001	0.06	<.001
CDRS-10				1	.422**	.250*	.336**	.494**
					<.001	0.045	0.006	<.001
MSCS PC					1	0.1	0.077	0.19
						0.423	0.544	0.137
MSCS SR						1	0.174	.321**
							0.159	0.009
MSCS SC&P							1	.444**
								<.001
MSCS SS								1

Discussion

Although it is recognized that there are stressors common to all postsecondary education students, prelicensure nursing students experience added stressors related to overall program rigor, expectations of proficiency in clinical skill development, the newness and uncertainty of caring for ill clients and families in an unfamiliar health care environment, and the nature of working with peers and other members of the health care team (^{Jenkins et al., 2019}). Additional stressors may include student hypervigilance as students strive to learn and maintain the standards of safe nursing practice. Consistent with our findings, Shepherd and Newell (²⁰²⁰) identified that health care workers who engaged in more self-care behaviors had better mental health. Hricová (²⁰²⁰) analyzed the mediating role of self-care activities in helping professionals in the stress-burnout relationship and found that health self-care mediated the relationship between stress and emotional exhaustion and that psychological self-care mediated the relationship between stress and depersonalization. Keesler and Troxel (²⁰²⁰) investigated the relationship of self-care and resilience in direct support professional for people with intellectual and developmental disabilities. A positive significant correlation was found between self-care and resilience.

Faculty-led teaching of self-care strategies for prelicen-sure nursing students at the beginning and throughout their training may allow for the formation and utilization of coping and stress management skills resulting in improved mental health and potentially decreasing the likelihood of burn-out and medical errors. Jenkins and colleagues (²⁰¹⁹) noted that “learning and practicing self-care not only supports the management of current stressors, but also builds resilience for coping with future stressors” (p. 14). Citing increased levels of stress and childhood trauma in students enrolled in a Doctor of Nursing Practice program, Bouchard et al. (²⁰²⁴) noted that “building resilience is a recommended strategy for overcoming ACEs [Adverse Childhood Experiences] and reducing burnout” (p. 104). The ability of nurses to effectively manage stress is also important in terms of the systemic high turnover rate for new graduate nurses (^{Kelly et al., 2021}). Baseline data of this research clearly shows the expected inverse relationship between self-care behaviors and anxiety and depression.

Aloufi et al. (²⁰²¹) noted in a systematic review that common areas of nursing student stress were assignments, theory course workload, and clinical workload; they also noted one of the most common sources of stress was teachers. The promotion of self-care in a nursing program with teachers and faculty as the leaders of the self-care modalities may help bridge the connection between students and faculty, helping to reduce this type of stress. A significant decrease in stress was noted in several studies with the implementation of mind-body, stress management information, and coursework directed toward self-care (^{Aloufi et al., 2021}).

It is important to note some limitations of this study, which include a small sample size, a convenience sample allowing for the possibility of sampling and selection bias, and self-reported measures that may have recall bias. In addition, students reported fairly high levels of anxiety and depression, which may affect their use of self-care. Overall, the internal consistency of scales was >0.7, with the exception of the physical care subscale of the MSCS. This may be due to the wide variety of activities included in this subscale (i.e., water consumption, eating nutritious food, exercise, and mindful/body practice). Possible threats to internal consistency may include social desirability bias as participants were entering nursing school, misinterpretation of items, or an environmental factor of beginning a nursing program. The length of the survey also may have dissuaded participants from completing the surveys as three of the 69 participants only completed a small portion of the survey items. Outside of these three participants, there was minimal missing data; missing were not imputed.

Conclusion

The findings highlight several important points including the link between self-care and mental health. A significant positive correlation was observed between engaging in self-care activities and improved mental health indicators. This emphasizes the need to further explore this relationship and the importance of incorporating self-care strategies into prelicensure nursing curriculum. By promoting self-care, nursing educators can contribute to holistic well-being, addressing not only mental health but also physical, emotional, and social aspects of health. Although further research is needed, due to significant recognized stressors inherent in prelicensure nursing education as well as the national nursing shortage, inclusion of integrative health modalities and opportunities for self-care should be considered as a component of prelicensure nursing curriculum.

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