Saturday September 23rd 2017

A study in de-stressing

Helping nursing students to better cope and manage their overall health

Nursing students repeatedly put aside their own health and wellness to get through the rigors of challenging courses and clinical rotations. But some students and practicing nurses are working to reverse that troublesome trend, because they know that good self-care strategies — such as effective stress management — form early and can last a lifetime.

“One of the many challenges that we as nursing students share with nursing professionals is the need to take better care of ourselves,” said Joseph Potts, immediate past-president of the National Student Nurses’ Association (NSNA).

It’s a challenge NSNA takes seriously. The NSNA board considers improving students’ health a priority and organized its April national convention around the topic of health, according to Potts. At that event, American Nurses Association (ANA) Chief Executive Officer Marla J. Weston, PhD, RN, FAAN, noted that nursing students face many challenges that undermine their health and well-being, including juggling school life and family life; performance anxiety; and fear of failure.

“Clinicals add a lot of stress,” said Glenda Christiaens, PhD, RN, AHN-BC, president of the American Holistic Nurses Association (AHNA), an organizational affiliate of ANA. “Unlike being a math major, for example, nursing students feel like they are always being watched and that any mistake will get them kicked out of nursing school. Many have never been in a caregiver role and don’t yet know what ‘thinking like a nurse’ really means. And nursing curricula do not focus enough on self-care and reflection.”

Students also don’t get enough sleep, she said. And when their stress levels rise, so does their cortisol, which can make them more susceptible to illness.

Then there is the long-held mantra that continues within the nursing profession.

“[Nursing students] are told to always put the patient first,” said Christiaens, a Utah Nurses Association member who also speaks at campuses nationwide to help nursing students manage stress. “That way of thinking sets up a pattern that follows them into their jobs. But self-care is a core value in holistic nursing and in all nursing. We need to care for ourselves and be healthy role models if we are going to take care of anyone and have them be willing to follow our guidance.”

Potts agrees about the importance of reducing stress and promoting self-care.

“For me personally, one of the most frustrating things to see is  fellow nursing students stressing out about making it though nursing school with the highest possible GPA he or she can achieve,” Potts said. “We need to not forget that the purpose of nursing school is to learn how to be the best possible nurse and patient advocate. To be exceptional, you must take care of yourself.”

Stress and unhealthy habits can affect students at all levels of education.

“Our training is very stressful,” said Janet Dewan, MS, CRNA, chair of the Health and Wellness Program at the American Association of Nurse Anesthetists (AANA), also an organizational affiliate of ANA. “As a nurse anesthetist, you’re responsible for every breath and heart beat. So students are very scared at the beginning of their program in particular, because they realize the impact they can have on their patients.”

Programs that benefit students

Capital University in Columbus, OH, teaches nursing students about the importance of self-care and managing stress beginning in their freshman year, according to David Shields, MS, RN, QTTT, an assistant professor in its department of nursing and an Ohio Nurses Association member. Students learn relaxation techniques, including mindfulness meditation and other stress-reducing activities.

Students in the traditional baccalaureate, RN-to-BSN and graduate programs are required to complete a holistic self-care assessment and then develop a plan of care to improve their own health and fitness. Shields said that some students have willingly shared with him the results of their self-assessment, as well as their surprise at how much they actually smoke or use alcohol.

The nursing program, which has earned the American Holistic Nurses Credentialing Center’s endorsement for its holistic-focused curriculum, introduces students to the “AHNA Core Values of Holistic Nursing” in their first nursing course. The faculty is committed to helping students integrate self-care and reflection into their lives and create diverse assignments and activities that support these practices, according to Shields. The school also offers an elective course that addresses holistic healing and integrative therapies, such as therapeutic touch and aromatherapy.

Additionally, Shields works individually with students early on in their programs at Capital and other schools to help them manage anxiety, in particular, around tests and the performance of clinical procedures, which often have many steps that can trip up stressed-out students.

“I was a horrible test-taker and had a lot of anxiety around exams,” Shields said. “So I know how important it is to help these students before their anxiety gets really bad.”

He teaches in-depth relaxation techniques to students, asking them to practice these strategies every day and perform them just before stepping into a patient room or taking a test. These strategies include mindful breathing and guided imagery, which invites students to visualize themselves relaxed and successfully performing a procedure.

Shields said that another important way students can alleviate stress involves open communication.

“A lot of students struggle and struggle because they are afraid to ask for help,” Shields said. “They can just talk with their professors and ask them to either show them a procedure again or ask them to watch them do it.”

Christiaens, who formerly worked at Brigham Young University’s nursing program, helped that school develop an eight-hour clinical day that focused on stress management and relaxation techniques for students. She also is the former dean of nursing at Fortis College, which requires all students to develop a mission statement with their cohorts that will guide and support them through completion of their program. That statement, which usually includes anti-bullying principles, also helps to strengthen peer support.

Ideally, Christiaens said stress management and student health promotion programs should be built into nursing program curriculums. However, educators can suggest and students can explore many activities that have been shown to reduce stress and promote health, such as music therapy, yoga and tai chi.

AHNA also has online, stress-management resources for students, nurses and other health care providers on its website ( One strategy is the “advanced stop technique,” which involves stopping negative self-talk, taking a deep breath, and then thinking about a useful or wise response to a situation.

A commitment from AANA

For the past 28 years AANA has offered a national 24/7 peer assistance helpline for certified registered nurse anesthetists (CRNAs) and student nurse anesthetists to get help or information on substance abuse issues. Every state association also has a state peer assistance adviser.

The need for AANA to expand the peer assistance efforts to a more comprehensive health and wellness program took hold after the death of the association’s past president, Janet R. Stewart, CRNA, ARNP, according to Dewan. Stewart died from an accidental self-administered overdose of an anesthetic in 2002.

“We work long hours, have to solve problems on our own, and can get called in the middle of the night for an emergency and have to fly into action,” Dewan said. “All of those factors are stressors on the job. And, we have access to potent substances.”

Student registered nurse anesthetists have reported experiencing symptoms weekly, such as agitation, cravings, decreased concentration and sleep disturbances in a 2008 survey conducted by Anthony Chipas, PhD, CRNA, and his colleague.

“We believe education is an important strategy for students so they do not get tempted by substances [and instead find healthy coping mechanisms],” Dewan said.

Beginning in 2004, AANA has offered the Jan Stewart Memorial Wellness Lecture Series annually, which covers a range of topics from the power to change to the emotional toll of an adverse event. The association continues to expand its health and wellness resources on its website, including resources on eating nutritious foods, healthy aging and taking care of one’s eyes, and topics specifically for students (  AANA also offers a six-module educational program on wellness and chemical dependency for student nurse anesthetists.

Additionally, AANA has student representation on its Health and Wellness Committee. Its current representative, Marci Papiernik, RN, is working on a student wellness connection project that focuses on building a network of at least one wellness liaison from each nurse anesthetist education program to share ideas and initiatives on health and wellness activities. Activities include strategies to foster group support to organizing free gym memberships, Dewan said.

Take ‘smart’ actions

Promoting nurses’ health, wellness and safety is a priority for ANA. And in talking with students at the NSNA convention, Weston conveyed the importance of pursuing or maintaining their own health. She encouraged students to try to focus on one action that can help them become a healthier nursing student and future nurse. The goal should be smart: specific, measurable, achievable, realistic and time-bound.

Some recommendations that can help students gain control of their health include taking one night a week off to read a novel, have a meal with friends or try a Zumba class; drinking one less cup of coffee a day; or finding a quiet spot to sit and meditate during the day.

Potts added that, when thinking about their own health and well-being, nursing students and new nurses should take a page from a flight attendant’s instructions for an emergency.

“As a passenger, you must place the oxygen mask on yourself before assisting others,” Potts said. “Nursing students and nurses must focus on their own health and stressors to be the best advocate for their patients.”

— Susan Trossman is the senior reporter for The American Nurse.


To see more resources, go to ANA’s HealthyNurse™ webpage at

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