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Teaching and Learning Forum 2010 [ Refereed papers ]
Sustainability of future professionals

Selma Alliex
University of Notre Dame Australia

As educators it is our responsibility that we not only teach our students sustainability strategies but also practices to sustain them in a world that is ever changing. This study addresses the theme of this conference because it deals with teaching students strategies to equip themselves with practices that will impact on their role as professionals. This pilot study aimed to assess effectiveness of a 3 week self-care intervention program from the perspective of 3rd year nursing students at the University of Notre Dame Australia. The methodological approach underpinning the study was descriptive and the students were engaged as active participants in the study with the aim of having a positive impact on the lives of the participants. The study sought student nurse participants who would be involved in 3, 1 hour instructional sessions. All students were given the opportunity to participate in the research. Students who consented to participate were given a pre-questionnaire followed by three 1 hour instruction on self-care. On completion of the third session, students were asked to complete the post-questionnaire and were invited to participate in a focus group interview. This paper will present the findings from this innovative pilot project. Recommendations from this study were included as part of the University's strategy to promote and facilitate students' self-care abilities.


Introduction

Nursing education has not traditionally espoused a self-care philosophy (Crout, Chang & Cioffi, 2005). A small number of pilot programs have been conducted within nursing schools to encourage self-care. However, this is in contrast to the wealth of programs offered to medical students, particularly in the USA. Such programs are finding their way into Australian Medical Schools, with Monash University in Victoria (Hassed, 2002) leading the way with a mandatory self-care course for all first-year medical students. Such Medical School offerings range from semester-length courses, including the Mind/Body Medicine Skills Program offered at Georgetown Medical School (Harazduk, 2003) and the University of Arizona (Gilbert, 2004) to wellness programs and initiatives of various kinds. Some of these initiatives are student-directed and sustained, demonstrating the degree to which self-care has found its place in Medical School education.

Discussions with Nurses-Academics indicate that one reason for the lack of self-care programs in nursing education is that the curriculum is more than full. Another factor is that students, as a rule, feel concerned about their academic and clinical requirements and so do not want to take time away from these. Therefore, any self-care intervention needs to work within the constraints of the curriculum and students perceptions of their priorities.

Literature review

Self-care is defined as caring for oneself physically, mentally, emotionally and spiritually in order to gain personal insight and in so doing "increase potential, self-esteem and self-efficacy" (Ellis, 2000, p. 47). It is accepted that the practice of self-care is a powerful antidote to the effects of stress in an individual's life.

A review of the literature indicates that there is ample evidence of stress and its consequences in the nursing profession. It is known that stress can influence job-satisfaction, psychological well-being and physical health. In a study exploring the relationship between stressors, coping methods, demographic characteristics and health in Australian nurses, significant correlations between stressors and both physical and mental health were found (Chang, Daly, Hancock, Bidewell, Johnson, Lambert, Lambert, 2006).

Jones and Johnson (1997) reiterate this finding when they state that nursing students face not only the demands of their profession but also the range of stressors that a Bachelor program entails. These stressors include fear of failure, long hours of study and lack of free time. The study also found that the level of stress among nursing students exceeded the stress level in senior medical students and in the general population (Jones, Johnson, 1997). Beck and Srivastava (cited in Kanji, 2006, p.730) delineated these stressors further citing the intense emotional challenges associated with nursing work and also the challenge of assimilating difficult and tentative information caused stress in nursing students. Additionally, there is evidence to suggest that the perceived level of stress by student nurses does not vary significantly across the branches of child, adult and mental health nursing (Por, 2005).

There exists a range of modalities, which can be drawn from to prevent stress and so to develop 'resilience' in nursing students and nurses. Likewise, the literature highlights several interventions offered to nurses and nursing students. One intervention focused on the effects of Mindfulness Meditation on student nurses' stress levels. Following the 8-week intervention, which included use of guided meditations at home, participating nurses reported significantly reduced anxiety. Favourable trends were observed in a number of stress dimensions, including attitude, time pressure and total stress levels (Beddoe & Murphy, 2004).

Another intervention using a controlled group design was a creative arts exercise for nursing students. Significant differences existed between the two groups with the experimental group reporting less stress, decreased anxiety and more positive emotions (Walsh, Chang, Schmidt & Yoepp, 2004). A third controlled prospective crossover study examined the impact of a 6-session Recreational Music-Making protocol on burnout and mood dimensions in first year associate nursing students. Statistically significant reductions in multiple burnout and mood dimensions were noted (Bittman, Snyder, Bruhn, Liebfreid, Stevens, Westengard & Umbach, 2004).

At the Griffith University Research Centre for Clinical Practice Innovation in Queensland, a study was conducted to determine the benefits of a 15 minute weekly massage in reducing physical and psychological stress in nurses. Sixty nurses participated in the study, and though the intervention may appear modest, the results were definitive. Differences in State and Trait Anxiety levels, measured over the five weeks, were statistically significant (Bost & Wallis, 2006).

A randomized controlled trial, focused on the intervention of Autogenic Training to reduce anxiety in nursing students. The intervention consisted of eight weekly sessions of Autogenic Training, a form of guided relaxation/imagery. Results demonstrated a significantly greater reduction of anxiety in the experimental group (Kanji, White and Ernst, 2006).

In the literature, the term hardiness and resilience appears to have been used interchangeably. However, "hardiness" is defined by Maddi and Khoshaba (2004, p 265) as "psychological vitality and enhanced performance" whilst "resilience" is defined by Vaishnavi, Connor and Davidson (2007, p293) as "personal qualities that enable one to thrive in the face of adversity". The relationship between hardiness, or resilience, stress and health-promoting behaviours was explored in a study of 250 female nursing students from 39 nursing schools in the USA. The findings indicate a significant positive relationship between hardiness and health-promoting behaviours and a significant negative relationship between stress and health-promoting behaviours. Interestingly, the participants in this study indicated that their nursing faculty members were good exemplars of health-promoting behaviours (Nikou, 1998, Ph.D. thesis).

A final consideration is raised by a nursing student herself. In her student paper, Caring for Self: A Pre-requisite of Caring For Others, Canadian nursing student, Jaime Mantesso, considers nursing theorist Dr. Gwen Sherwood's Theory of Caring. She draws the conclusion, based in part on her own life experience that it is only by "being in tune to self-care that a nurse can more fully address the needs of others through a caring mode of being." (Mantesso, 2005, p.75)

This pilot project was undertaken to evaluate the benefits of a self-care intervention within a sample group of 3rd year nursing students at University of Notre Dame Australia. Nursing students, it is recognized, carry the stressors associated with their profession but also the full range of stresses faced by mainstream academic students, including long hours of study, fear of failure and lack of free time (Kanji, 2006). In a literature review of workplace stress in nursing (cited in Kanji, 2006, p. 730), McVicar concluded that stress intervention measures should be introduced that focus on stress prevention for individuals. This pilot project is a response to this call for prevention. Third year nursing students were offered the opportunity to learn and practice Guided Imagery, within a 3-week pilot program.

It is well recognised that demands on students nurses and nurses in practice are not lessening; that nurses need to be able to cope with the demands, or even better to have developed a certain resilience in the face of these demands. These issues have provided an impetus for this project. This study has a number of implications that translate to a national as well as a local (Western Australian) level. This pilot project was considered to be an early intervention and therefore has the promise of fostering an individual's commitment to self-care early in professional life. This pilot project carries with it the possibility of becoming a template for self-care interventions in nursing schools around Australia.

Aims

The aim of the study was to assess the effectiveness of a 3-week self-care intervention from the perspective of 3rd year nursing students.

Objectives

The objectives of the study were:
  1. To assess 3rd year nursing students perceptions of self-care strategies.
  2. To introduce a self-care practice to nursing students.
  3. To evaluate the effectiveness of the self-care practices from the perspective of participating students.
  4. To initiate dialogue about the feasibility of incorporating self-care education into an established undergraduate nursing education curriculum.

Methodology

Design

This project was planned as a pilot project to ascertain the feasibility of introducing guided imagery for students that wanted this experience. As such the methodological approach underpinning this research project was Triangulation (Taylor, Kermode and Roberts, 2007). As the aims of the research were to focus on the immediate real world problems faced by student nurses, engage the participants as active participants rather than passive 'subjects' in the research and to attempt to initiate a positive change in the lives of the participants descriptive research methods were used in this study (Polit, Beck & Hungler, 2001). It was felt that this methodology suited the study the most because the intent of the pilot study was to describe the impact of the intervention but not to predict relationships between the variables or the direction of the relationship. In this study, data was collected in the form of pre and post-test surveys.

Triangulation was also used in this research because according to Halcomb and Andrew (2005), the use of multiple data sources and methods to validate findings increase the depth and quality of the results. Morse (1989) cited in Minichiello, et al. (1999) believes that triangulation is a means by which the researcher is able to capture a comprehensive picture of the phenomenon. In this study triangulation was used to collect data from focus group interviews about the perception of students in relation to the effectiveness of the intervention on their personal lives.

The methods employed were the interventional sessions and techniques used to support positive self-care activity throughout the 3, 1 hour sessions and an evaluation of these sessions. A pre and post intervention survey (questionnaire) and a focus group interview, were conducted after the conclusion of the interventional sessions with those participants who undertook the interventional program.

The research process is as explained below:

  1. Ethical approval for the study was sought from the UNDA, Human Research Ethics Committee.
  2. Appropriate dates / times for the self care intervention pilot project were negotiated with the Dean of School of Nursing. A guided imagery expert was employed to deliver the sessions to the students.
  3. 20-25 nursing students were recruited for the purpose of engaging them in 3, 1 hour interventional sessions.
  4. Prior to the commencement of the sessions all consenting students in the 3rd year student cohort were given an opportunity to complete a pre intervention survey. Each of the participants were provided with an information sheet and invited to attend 3, 1 hour sessions over three weeks
  5. At the end of the interventional program participants were asked to complete a post intervention evaluation form.
  6. Participants were then requested to attend a follow up focus group to further evaluate the interventional activity.

Sample

The population employed in the self-care intervention pilot project were 3rd year undergraduate nursing students at University of Notre Dame Australia, in Perth. There were 105 students in this cohort. To recruit participants to the study, the whole student body was addressed at the beginning of an educational session (15 Minutes), early in their semester. At this time the self-care intervention pilot project was outlined and students called up on to register their interest as potential participants. The recruitment of students was done by the expert and not by any contracted staff employed in the School of Nursing. Students who expressed an interest were given the information sheet and consent form to complete. The proposal was presented to the School of Nursing Research Committee and the University's Human Research Ethics Committee for approval. 24 students participated in the Pre-test and 19 in the post-test.

Data collection

Data was recorded in a number of ways.
  1. Pre intervention surveys for participating students: The survey was distributed to students a week prior to the relaxation session. The survey had seven statements and was based on a 7 point Likert scale that ranged from Very Strongly Disagree (1) to Very Strongly Agree (7). The survey was sent to three nurse leaders and a guided imagery expert. No changes were recommended. Completed surveys were collected on the day of the session prior to its commencement.
  2. Post intervention surveys were conducted for all students involved in the intervention after all the relaxation sessions had been completed.
  3. Focus group discussions took place following the third guided imagery session.

Analysis and findings

Quantitative data was analysed using descriptive statistics of frequencies and percentages. There was no attempt to use any other statistical measures in this pilot project. Focus group interview data was analysed using content analysis with major themes identified and described. 24 students participated in the pre-test and 19 completed the post-test.

Effectiveness of the self-care practices according to students

It can be seen in the Table 1 below that in the pre-test students answered mainly from Very Strongly Disagree to Very Strongly Agree but mainly neither agreed nor disagreed.

Table 1: Pre-test results (n=24)


1234567
I feel relaxed4.17%8.33%25%8.33%45.8%4.17%4.17%
I feel confident0025%16.7%50%8.3%0
Learning to relax is important to me000016.7%25%58.33%
Self Care is important to me04.17%04.17%16.7%20.83%54.17%
Self care is important to my performance as a nurse0008.33%12.5%29.17%12%
Guided imagery can improve my effectiveness as a nurse00054.1%20.8%16.7%8.33%
Guided imagery can improve my effectiveness in other areas of my life00054 1%16.7%12.5%16.7%

Students were requested to write comments on the survey if they chose. Some of the comments, highlighted below, indicated a degree of anticipation and the willingness of students to apply new strategies to dealing with their personal issues. These were:

I am looking forward to discovering more about myself and hoping these skills will give me the opportunity to expand and grow as an individual.

A lot happened to me in the past couple of years from family issues to being diagnosed with Coeliac's disease. I am interested in learning about self-care because my lack of self-care ended up leaving me in ________ emergency department... despite many attempts I have not learnt to put me first.

The post-test results are presented in Table 2 below.

Table 2: Post-test results (n=19)


1234567
I feel relaxed000021.05%36.84%42.10%
I feel confident000036.8%31.57%31.6%
Learning to relax is important to me0000010.52%89.47%
Self Care is important to me00004.17%4.17%89.5%
Self care is important to my performance as a nurse000004.17%94.73%
Guided imagery can improve my effectiveness as a nurse000010.5%15.78%73.68%
Guided imagery can improve my effectiveness in other areas of my life000010.5%10.5%78.945

The important thing of note between the pre and post-test was that no students answered below an "agree" and a significant number very strongly agreed with the survey questions.

Some students chose to respond to the comments section in the post intervention survey. The overwhelming response was positive as indicated below.

In a short space of time, I have learnt valuable tools that I can take into my professional and personal life.

Brilliant life-long skill to master and use often

This relaxation is fantastic. I have been using it during the past couple of weeks during particular times in my life. It is great thanks.

It is important to point to another finding from this pilot study in relation to the statement "Self care is important to my performance as a nurse". The blue column in Figure 1 below indicates the pre-test and the pink the post. In the post-intervention survey 18 out of 19 students very strongly agreed with this statement.

Figure 1

Figure 1: Self-care is important to my performance as a nurse

Findings from focus group sessions

This was the third aspect of the data collection. The one hour follow up session was devoted to students. Eight students attended the focus group interview. Students were encouraged to:

Students' perceptions of self-care strategies

Following analysis of data using Content Analysis, the researcher identified three common themes. These were:

Power of guided imagery
Those who spoke at the meeting confirmed what they had written in the comments section of the post-test - that they found Guided Imagery a powerful tool, one in which they would like to develop more proficiency.

Processing emotions through guided imagery
A common question that arose was about how to process fear, sorrow or anger during a Guided Imagery exercise. Some students talked about a specific emotion that they had trouble releasing. Given that the question had a real relevance and applicability, the expert focused on demonstrating to students how to release the emotion. They participated fully and one of them commented at the end of the exercise that she had "never felt so open."

Future of GI in nursing practice
Several students talked about their wanting to work at hospitals that subscribe to a holistic vision of nursing. They pointed out that their education at Notre Dame had always ("from day one," in one student's words) subscribed to this vision. Two specifically asked about working at a particular hospital that included GI in the care of their employees as they would like to be involved in the Relaxation and Guided Imagery project.

Discussion of findings

The overwhelming results from the survey indicated that nursing students found the Guided Imagery sessions valuable from their individual perspectives. It could be argued that as students self-selected to participate in the pilot that this would be an expected outcome. However, some students did find the first week difficult and had to confront many of their emotions and had to work through these during the remaining sessions. Students, who commenced with an ambivalent attitude, changed their minds following the three sessions of Guided Imagery.

As is indicated the majority of students could see the benefit of implementing this strategy in their future professional lives. Some of them sought employment where the opportunity to undertake self-care activities were promoted by the employers.

During the focus group sessions, students identified areas within the curriculum where this education could be incorporated and made suggestions for further development of this intervention.

Anecdotal information from the practitioner indicated that many of the students who participated in the pilot project continued their sessions with her individually.

Conclusion

This pilot project has identified some areas within the nursing curriculum where this strategy could be provided through means of an elective unit. Following suggestions from the School of Nursing, the University has employed the GI expert in the Student Life Office. Students across the University can now access this service free of charge especially during exams. This strategy could present a good opportunity to conduct further research in the area using a larger sample.

The self-care intervention offered in this pilot project contained identified limitations. The program was voluntary and consisted simply of three one hour sessions. The intention was to help students discover that self-care practice can be manageable time-wise and can yield significant benefits that justify the time spent.

One challenge clearly emerged from the depiction of a profession characterized by intensely stressful demands. The challenge, described by Hodges, is that nursing educators must consider how to more adequately prepare nursing students for sustained pressure, given the many indeterminable forces inherent in contemporary nursing (Hodges, Keeley & Grier, 2004, p.548). How can they face their demons head on? In the words of one of my students, "Since taking part in these sessions I've started gaining more confidence and have learnt how important self-care is. If I can't look after myself and my own problems I cannot look after others. As a nurse you need to be very well centred, grounded, focused and self-caring. I've found these sessions incredibly helpful and hope the University incorporates more of this in the nursing course".

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Author: Professor Selma Alliex, University of Notre Dame Australia. Email: salliex@nd.edu.au

Please cite as: Alliex, S. (2010). Sustainability of future professionals. In Educating for sustainability. Proceedings of the 19th Annual Teaching Learning Forum, 28-29 January 2010. Perth: Edith Cowan University. http://otl.curtin.edu.au/tlf/tlf2010/refereed/alliex.html

Copyright 2010 Selma Alliex. The author assigns to the TL Forum and not for profit educational institutions a non-exclusive licence to reproduce this article for personal use or for institutional teaching and learning purposes, in any format, provided that the article is used and cited in accordance with the usual academic conventions.


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