NURSE SELF CARE:

A BEST PRACTICE APPROACH

By
KAITLYN COURTNEY PARKS

____________________

A Thesis Submitted to The Honors College

In Partial Fulfillment of the Bachelors degree
With Honors in
Nursing
THE UNIVERSITY OF ARIZONA
DECEMBER2015

Approved by:
_____________________________
Dr. Melissa Goldsmith, PhD, RNC
Department of Nursing

Abstract
The purpose of this thesis was to develop a best practice recommendation for health
promoting interventions for nurses. A total of 26 studies were systematically included, and
identified a nurse self-care deficit, its correlation with adverse patient events, followed by an
array of health promoting interventions for nurses. An extensive review of this literature
supported the implementation of exercise, Reiki, mindfulness meditation, psycho-educational
programs, musical therapy, and auricular acupuncture as health promoting interventions for
nurses. Inclusion of the findings into a CBT module for nurses at various facilities could increase
awareness for the deficit and compliance for according health promoting interventions.
Increasing the awareness for, and availability of, health-promoting interventions could result in
an increase in nurse wellbeing could improve patient care, safety, and health as a whole.

CHAPTER 1
Introduction
Statement of Purpose
The purpose of this thesis was to develop best practice recommendations for health
promotion interventions for nurses. Recommendations derive from studies demonstrating
effective interventions by providing for improved health when performed by nurses. The author
will evaluate the current deficits in nurses health maintenance behaviors, address the correlation
between insufficient nurse health maintenance and poor patient results, and analyze recent
interventions to improve nurses health and patient outcomes. Following the evaluation of each
of these factors, best practice recommendations will be proposed as a means for improving the
health of the nurse population, subsequently improving patient outcomes.
Background on Nursing and the Necessity for Self-Care
The World Health Organization defines self-care as activities that individuals undergo
with the intentions of enhancing and renewing health, limiting illness, and preventing disease (as
cited in American Holistic Nursing Association [AHNA], 2014). Both professional and lay
experiences derive these activities, and are taken on the individuals own behalf, either
independently or in collaboration with other professionals (as cited in AHNA, 2014). In order to
provide adequate and holistic patient care, nurses must integrate self-assessment, self-care
behaviors, and opportunities for personal development into their daily life (AHNA, 2014).
Nurses must additionally identify themselves as instruments for healing (AHNA, 2014). Holistic
nursing requires the individual to value oneself, and pursue the necessary resources for self-care
(AHNA, 2014).

The American Holistic Nursing Association (2014) identified three primary components
to self-care: body, mind, and spirit. Bodily self-care includes practices such as grooming,
exercise, massages, breathing, yoga, and nutrition (AHNA, 2014). Mindful self-care practices
include contemplation, meditation, focus, healing music, and laugher (AHNA, 2014). Finally,
spiritual practices of self-care include prayer, reading spiritual literature, positivity, and random
acts of kindness (AHNA, 2014). According to Chen, Lin, Wang, and Hou (2009), nurses who are
able to address their wellness from an emotional, spiritual, and physical standpoint are more
capable of modeling this behavior for their patients and community. Given that health promotion
is a crucial component to the nursing profession, it is essential that it become embedded in the
lifestyle of each individual nurse (Chen et al., 2009)
The Standards of Practice of the American Holistic Nurses Association (AHNA) propose
the necessity for nurses to integrate self-care, spirituality, self-responsibility, and reflection into
their daily lives (as cited in McElligott, Siemers, Thomas, & Kohn, 2009). It is therefore
necessary to consider the current conditions among the nurse workforce and propose
interventions to improve the health of the profession. Given that nursing is a profession with
significant physical and emotional strains, it is essential for nurses to make self-care a priority
(Richards, 2014). Adequate self-care involves the performance of behaviors to counter these
stressors through various and personalized self-centered activities (Richards, 2014). Such
practices are crucial to the nurses well being and their ability to effectively distribute
compassionate and healing patient care (Richards, 2014).
Significance of Problem
In this era of an evolving nursing profession, there is a growing concern for the health
and wellbeing of nurses (McElligott et al., 2009). Among the evolving factors includes an aging

nursing population, increasing nursing shortage, and augmented prevalence of compassion

fatigue. While the average age of registered nurses in 1980 was 36 years, this statistic increased
to nearly 47 years in the year 2008 (The Department for Professional Employees [DPE], 2012).
Additionally, nearly one-third of the workforce is over the age of 50, and over half of registered
nurses express the desire to retire in the next ten years (DPE, 2012). It is estimated that 500,000
registered nurses in the United States are no longer in practice due to the difficult and stressful
working conditions at hand (DPE, 2012). Nurses frequently work overtime, which leads to poor
sleep quality, physical and mental fatigue, and nurse-related errors that place patients at greater
risk (McElligott et al., 2009). As a result there is a significant decrease in current nurses
satisfaction, and a high degree of turnover. These high levels of attrition lessen the nurse work
force; subsequently causing individual nurses to suffer a greater workload that decreases the
quality of patient care (McElligott et al., 2009).
In the year 2010, the rate of occupational injuries or illnesses increased to 6% for
healthcare providers in the United States (DPE, 2012). This factor averaged to 283 days away
from work per 10,000 full-time healthcare employees (DPE, 2012). Consistently, registered
nurses are among the top ten occupations with the most injuries, 5% of which are attributed to
on-the-job assault (DPE, 2012). While physical trauma is a significant concern for nurses, moral
suffering additionally poses a significant strain on their health. A total of 15% of nurses report
leaving their workplace as a result of moral and ethical distress (DPE, 2012). A significant
percent of these turnovers are attributed to the life and a death decisions that nurses are forced to
regularly make (DPE, 2012).
Following the 1990s restructuring of the healthcare industry, hospitals curtailed staffing
levels, causing nurses to care for an increased number of patients, and subsequent workload

(DPE, 2012). This workload, accompanied by the 12+ hour shifts many hospital units require,
has led to 39% of registered nurse (RN) injuries resulting from overexertion (DPE, 2012). These
changes have consistently taken a toll on patients safety and wellbeing. In response to the poor
patient outcomes, RNs from the Worcester campuses of University of Massachusetts Memorial
Medical Center (UMMMC) scheduled a strike on May 23, 2013, as a means for demanding
change (Massachusetts Nursing Association [MNA], 2013). Participating nurses sought to
express their disgust with inadequate staffing that had led to poor patient outcomes,
unmanageable patient loads, and inadequate resources (MNA, 2013). Consistent with the views
of nurses all around the United States, it was deemed that patients are considered the most
important aspect of the profession, and it is RNs personal duty to perform acts necessary to
protect their health (MNA, 2013).
Summary
The purpose of this thesis is to create best practice recommendations for various effective
interventions to reduce stress and improve nurses health. The quality of care that nurses
distribute to patients is dependent on their own ability to reflect on and care for themselves.
Nurses ability to serve as models for adequate self-care and health increases the likelihood that
patients will value and perform similar health promoting behaviors. Given that nursing is a
physically and emotionally demanding profession, the health of the overall nursing population is
at stake. In order to improve the health of the profession, evidence-based effective healthpromoting interventions can benefit the profession when implemented in various health care
facilities.

CHAPTER 2
Review of Literature
Chapter two includes the review of literature regarding nurses self care practices. The
author has conducted a literature review on various evidenced based relaxation and health
promoting modalities. The purpose of this review was to gather the evidence required in order to
propose best practice recommendations. The search included information from peer-reviewed
nursing journals in addition to several studies conducted by other professionals in the medical
field. Multiple data bases were used including CINAHL, Google Scholar, and PubMed using
keywords nurse self-care, nurse stress, nurse stress interventions, nurse stress and patient
outcomes, nurse self-care remedies, and nurse self-care interventions. Each of the sources were
categorized by a) health status of current nurses b) nurse working conditions and patient
outcomes, and c) outcomes associated with health promoting interventions. All constituent
studies were organized in chronological order, dating from most recent to least recent date of
publication. A total of 26 articles ranging from the years 2006-2014 were included in this review.
Health Status of Current Nurses
In order to identify health-promoting interventions for nurses, the first step is to evaluate
the current conditions and self-care deficits present among nurses. Samples include nurses
working in a wide range of locations, organizations, and patient specialty areas. This section
includes nine evidence-based research studies that identify various stressors and impeding
factors on nurses health.
A cross-sectional study design by Lin, Liao, Chen, and Fan (2014) evaluated the current
working conditions in Taiwan, and how they affect nurses stress, sleep quality, and selfperceived health status. To do so, 266 nurses from Taiwanese hospitals were included (Lin et al.,

2014). Data was collected using demographics, work schedule forms, a stress checklist, a sleepquality measure, and a health-status measure (Lin et al., 2014). Data was analyzed using an
independent t-test, one-way ANOVA, Pearsons r, and hierarchical regression (Lin et al., 2014).
The results demonstrated that, regardless of the amount of shift work, nurses reported moderate
job stress, poor sleep quality, and moderate self-perceived health (Lin et al., 2014). Job stress
was found to be inversely related to sleep quality, and sleep quality directly related to selfperceived health status (Lin et al., 2014). It is this concluded that sleep quality has a significant
impact on nurses wellbeing, but is lacking among the nursing profession.
Salehi, Javanbakht, and Ezzatababdi (2014) sought to identify the most significant
stressors present amongst Iranian nurses. To do so, they performed a quantitative cross-sectional
study assessing 225 nurses employed at six hospitals in Iran (Salehi et al., 2014). Data was
collected through a self-completed 44-item questionnaire, and was analyzed using Statistical
Package for the Social Sciences (SPSS) software which allowed for accurate statistical analysis
(Salehi et al., 2014). The findings demonstrated that nearly 75% of nurses suffered severe stress
in the past two years, concerning most heavily with stressors related to their occupation (Salehi
et al., 2014). Among these stressors included heavy workload, insufficient salary, high
expectations, discrimination, extensive patient responsibility, and occupational atmosphere
(Salehi et al., 2014). Gender, the type of ward, employment, and work experience demonstrated a
significant trend among the results, as well (Salehi et al., 2014). It is therefore concluded that
there is need for stress reduction mechanisms for nurses, or factors to help reduce stressors
relative to the nursing profession (Salehi et al., 2014).
Happell, Dwyer, Reid-Searl, Burke, Caperchione, and Gaskin (2013) explored nurses
perspective on occupational stressors and ways that they could be reduced. To do so, 38 nurses

including nurse directors, registered nurses, and nurse unit managers from various departments in
Queensland were evaluated using a qualitative exploratory approach (Happell et al., 2013). Two
open-ended interview questions were asked to participants including what occupational stressors
they experienced, and what interventions could be held to reduce this stressor (Happell et al.,
2013). Nurses reported occupational stressors to include high workloads, unavailability of
doctors, unsupportive management, human resource issues, interpersonal issues, patients
relatives, shift work, car parking, handover procedures, no common area for nurses, not
progressing at work, and patients mental health (Happell et al., 2013). The overall conclusion is
that nurses undergo a significant degree of stress in their daily life (Happell et al., 2013). The
importance of identifying interventions to reduce such stress is emphasized in this study.
In efforts to examine job stress levels and stressors among nurses, Yau, Xiao, King,
Tsang, Wong, and Wong (2012) perform a cross sectional descriptive survey design study. To do
so, a convenience sample of 93 nurses working in a Zhuhai hospital in china was recruited (Yau
et al., 2012). Subjects included registered nurses, nurse midwifes, nursing officers, and ward
managers (Yau et al., 2012). Data was collected using a Nurse Stress Inventory which was a 5point Likert-type questionnaire with 35 questions (Yau et al., 2012). Nurses reported an average
perceived stress index of 7.4/10, demonstrating significant overall stress. In decreasing order, the
most stressful aspects of nursing were workload and time, working environment and resources,
nursing profession and clinical duty, patient care, and management of interpersonal relationships
(Yau et al., 2012). There was additionally a significant difference among scores for working
environment and resources between nurses on different units, however no statistically significant
difference in stress levels were identified between nurses of different age groups (Yau et al.,
2012).

A survey study design by Han, Trinkoff, Storr, and Geiger-Brown (2011) aimed to
examine the relationship between job stress/work schedules and obesity among nurses. To do so,
body mass index (BMI) values were collected from 2,103 female nurses, and binomial logistic
regression models were adjusted for demographics, nurse position, mental/emotional distress,
health behaviors, and family related covariates (Han et al., 2011). The results demonstrated that
roughly 55% of the sample population was overweight or obese (Han et al., 2011). Nurses of
these categories described their job as requiring less physical movement, and being more
physically limiting when compared to nurses who were underweight or normal (Han et al.,
2011). Long work hours demonstrated a significant association with being overweight and obese
(Han et al., 2011). It is thus concluded that interventions to investigate long work hours and
nursing jobs with limited physical movement should be assessed.
A cross-sectional survey design by Hsu, Chen, Yu, and Lou (2010) evaluated job stress,
achievement motivation, and occupational burnout among male nurses and accordingly identify
the predictors of burnout. To do so, 121 male nurses in Taiwan were included in this study (Hsu
et al., 2010). Data was collected by questionnaires which were mailed to participants and
analyzed using descriptive statistics and stepwise multiple regression (Hsu et al., 2010). The
results demonstrated that job stress was a significant contributor to occupational burnout in male
nurses (Hsu et al., 2010). It is presumed that quality of care administered to patients may be
influenced by occupational burnout (Hsu et al., 2010). It is therefore concluded that job stress is
a significant negative factors among nurses today, demonstrating affects on both male nurses and
patients (Hsu et al., 2010).
Aycock and Boyle (2009) evaluated interventions to manage stressors of compassion
fatigue and burnout in oncology nurses. Variables included the availability of onsite professional

resources, education regarding workplace-related coping, and off-site retreat to promote renewal
(Aycock & Boyle, 2009). A sample of 103 US oncology nurses responded to a survey addressing
the interventions they found personally available. Resultantly, onsite professional counseling was
typically limited to three free yearly sessions (Aycock and Boyle, 2009). A total of 45 percent of
nurses described receiving no opportunity for knowledge and skill development in coping,
adaption, and emotional self-care (Aycock and Boyle, 2009). Retreats to address the
psychological toll of nursing were rarely described as a coping resource, and interventions are
currently only available to a small subset of oncology nurses. The overall conclusion is thus that
there are inadequate health promotion interventions for oncology nurses, leading to persistent
stress and potential burnout among nurses in this unit (Aycock and Boyle, 2009).
In a cross sectional study conducted by Chen, Lin, Wang, and Hou (2009), the stressors,
stress coping strategies, and job satisfaction of operating room (OR) nurses were evaluated. To
do so, 121 nurses with more than six months of job experience at seven difference Taiwanese
hospitals were included (Chen et al., 2009). Data was collected using a four-part questionnaire
addressing demographic and occupational information, job stress, stress coping strategies, and
job satisfaction (Chen et al., 2009). The results demonstrated that perception of self-esteem and
job satisfaction was positively correlated to constructive stress coping strategies (Chen et al.,
2009). Barriers to effective stress management included lack of time, the inability to choose a
method, competing demands, environmental factors, and a lack of support (Chen et al., 2009).
When asked to rate how often various health promotion practices were performed, the majority
of nurses reported participating in activities sometimes. It is therefore concluded that health
promotion is a major concern in this sample population.

Gabrielle, Jackson, and Mannix (2008) address the health and aging concerns of self-care
strategies of older female registered nurses currently working in direct caregiving roles in
hospitals and community facilities. The study explored the needs and health concerns are for
older adult nurses (Gabrielle et al., 2008). The sample included 121 employed female registered
nurses between 40-60 years of age in Australia using a feminist qualitative perspective study.
Participant narratives were audiotaped, transcribed, and thematically analyzed (Gabrielle et al.,
2008). Resultantly, the theme aches and pains of aging had four subthemes neglecting self,
physical changes, living with pain, and tiredness (Gabrielle et al., 2008). The theme evolving
lifestyles: working in progress had three subthemes the power of exercise, healthy eating, and
adapting to aging (Gabrielle et al., 2008). The results provide insights to the health concerns and
practices among older women nurses. Further research should address the specific health
concerns of older female nurses, and accordingly propose interventions to improve their health.
Nurse Working Conditions and Patient Outcomes
As a means for recognizing the significance of the nurse health and self-care deficit, it is
important to evaluate patient outcomes as they relate to nurses health. This section includes six
articles evaluating the correlation between nurses wellbeing and patient outcomes.
As part of a comprehensive assessment of stress, Allan, Farquharson, Johnston, Jones,
Choudhary, and Johnston (2014) aim to evaluate the performance effects of high stress levels
among telephone helpline nurses. To do so, 152 nurse advisors working for National Health
Service (NHS) across Scotland completed two normal shifts where pre- and post-shift choice
reaction time measures were assessed (Allan et al., 2014). Participants additionally completed a
12-item General Health Questionnaire, perceived stress of shifts questionnaire, Work-Specific
Cognitive Failures Questionnaire, Social Desirability Scale, Positive and Negative Affect

Schedule, and were evaluated for key performance indicators such as call time, wrap time, no
partner action, and ambulance call out (Allan et al., 2014). The results demonstrated that both
higher levels of stress and general occupational stress were associated with more failed attention,
concentration, and memory in nurses (Allan et al., 2014). Nurses who experienced more
cognitive failures on the job were more likely to refer patients to other health professionals and
abide by more conservative decisions (Allan et al., 2014). It is thus concluded that there is high
levels of stress among telephone nurses, affecting the care administered to patient callers.
A mixed method study by Maiden, Georges, and Connelly (2010) aimed to evaluate the
relationships between moral distress, compassion fatigue, and perceptions about medication
errors. To do so, 205 certified critical care nurses were included in a mail-based survey
addressing the nurses characteristics, Moral Distress Scale, Professional Quality of Life Scale,
and the Medication Administration Error Survey (Maiden et al., 2010). The results demonstrated
statistically significant correlations between moral distress, compassion fatigue, intent to resign,
and the perception of inadequate nurse staffing and the occurrence medication errors among
nurses (Maiden et al., 2010). Moral distress and compassion fatigue were positively correlated
with the belief that transcription related problems are a reason for the occurrence of medication
errors (Maiden et al., 2010). The author concluded that distress and compassion fatigue
contribute to medication errors, thus putting patients at increased risk.
Berland, Natvig, and Gunderson (2008) conducted a qualitative research study in order to
examine the effects of nurses occupational stress on patients safety. To do so, 23 nurses with
advanced training in anesthesiology, intensive care, and operating-room nursing were included
and divided into four focus groups (Berland et al., 2008). Interviews were conducted with nurses
who work with acute, critically ill patients in two selected hospitals (Berland et al., 2008). The

results demonstrated that a demanding occupational environment accompanied by minimal

control and social support from colleagues results in increased stress for nurses. This unfavorable
work environment accordingly affects patient safety, as nurses undergo an interrupted train of
thought causing them to make more errors. It was therefore concluded that a stressful atmosphere
is a strong contributor to nursing errors.
Buerhaus, Donelan, Ulrich, DesRoches, and Dittus (2007) conducted a survey-based
study to evaluate the impact of the nursing shortage on patient care. To do so, surveys were
completed nationally by 400 physicians, 1,697 registered nurses, and 142 hospital CEOs and
CNOs (Buerhaus et al., 2007). Questions assessed many aspects of the nursing shortage
including perceptions on its extent and severity (Buerhaus et al., 2007). The findings
demonstrated that 81% of physicians, 82% of registered nurses, 74% of CNOs, and 68% of
CEOs perceived a serious shortage of nurses (Buerhaus et al., 2007). The majority of all
participants reported the shortage to have a significant impact on the care delivery process, and a
lesser impact on the hospital capacity (Buerhaus et al., 2007). Registered nurses were
significantly more likely to report a larger affect on the capacity and care delivery process than
other professionals (Buerhaus et al., 2007). All respondents were in agreement that there is a) the
need for other staff to provide some nursing care b) the likelihood nurses will quit their job, and
c) the likelihood that the nurse shortage will decrease the quality of patient care. (Buerhaus et al.,
2007).
An observational study conducted by Stone, Mooney-Kane, Larson, Horan, Glance,
Zwanziger, and Dick (2007) examined the effects of nursing work conditions on elderly patients
outcomes and safety in intensive care units. To do 1,095 nurses from 31 hospitals were surveyed
in regards to 15,846 elderly ICU patients outcomes (Stone et al., 2007). Data was collected

using the National Nosocomial Infection Surveillance system protocols and Medicare files
(Stone et al., 2007). Outcome measures included Central Line Associated Blood Stream
Infections (CLBSI), ventilator-associated pneumonia, catheter associated urinary tract infections,
decubiti, and 30-day mortality (Stone et al., 2007). The results demonstrated that units with
higher staffing had a lower occurrence of all measures except catheter associated urinary tract
infections (Stone et al., 2007). The overall conclusion was thus that nurses working conditions
demonstrate an association with patient outcomes. As nurse-patient staffing ratios decreased,
patient wellbeing increased accordingly (Stone et al., 2007).
A cross-sectional questionnaire based study by Spence-Laschinger and Leiter (2006)
sought to test a theoretical model of nurse work environments as they relate to burnout and
patient safety and outcomes. To do so, 17,965 nurses working in 292 acute-care Canadian
hospitals were anonymously surveyed and included in the study (Spence-Laschinger & Leiter,
2006). The results demonstrated that adverse patient events were most strongly correlated with
staffing, emotional exhaustion, and depersonalization (Spence-Laschinger & Leiter, 2006).
Nurses reported the highest occurrence of adverse events to include patient complaints, followed
by nosocomial infections, patient falls, and medication errors. The authors concluded that the
results show that patient outcomes are associated with quality of nurses work environment, and
that burnout plays a significant mediating role in adverse patient outcomes (Spence-Laschinger
& Leiter, 2006).
Outcomes Associated with Health Promotion Interventions
Practices for health promotion and self-care improvement are the main focus of this
thesis. This section includes the review and evaluation of eleven studies, which evaluate the
efficacy of varying health promotion interventions.

Hensel and Laux (2014) conducted a research study in order to describe the effects of
professional identity acquisition on self-care and stress levels among nursing students. The
objective was to identify whether professional identity, as an independent factor, impacted the
students perception of stress during their pre-licensure education (Hensel & Laux, 2014).
Moreover, 45 BSN students were included in this longitudinal study that focused on a serial
survey design (Hensel & Laux, 2014). The findings demonstrated that all aspects of nurses self
care habits increased as the students acquired their professional identity to a further extent,
except for sense of fit (Hensel & Laux, 2014). This factor remained stable throughout the study,
and students reported this to be the strongest aspect of their identity, that could only improve
after employment (Hensel & Laux, 2014). It is therefore concluded that professional identity
acquisition can serve as a stress reduction intervention among nursing students, subsequently
improving their overall health.
Reilly, Buchanan, Vafides, Breakey, and Dykes (2014) evaluated the impact on caring as
it relates to psychosocial, physical, and emotional factors in healthcare providers lives. As one
of these factors is out of balance, the extent and quality of care administered to patient is
variable. Given such, the objective of this study was to evaluate whether auricular acupuncture is
an effective tool for reducing the stress that healthcare providers experience (Reilly et al., 2014).
To do so, 37 pre and post-intervention surveys were evaluated to identify if acupuncture was
associated with anxiety, qualify of life, or caring abilities (Reilly et al., 2014). The results
demonstrated that, compared with baseline, participants had significantly reduced anxiety,
burnout, and secondary traumatic stress scores (Reilly et al, 2014). Patience and courage were
accordingly increased in healthcare providers post-intervention (Reilly et al., 2014). Evaluating
this evidence, the overall conclusion is that there is evidence for the efficacy of auricular

acupuncture as a means for reducing provider stress and increasing the quality and extent of
patient care provided.
Using a pilot intervention study with a one sample pre- and post-intervention design,
Cuneo, Cooper, Drew, Naoum-Heffernan, Sherman, and Waltz (2011) explore the effects of
Reiki on occupational stress among registered nurses. Reiki is an ancient form of energy work
that has been believed to contribute to stress reduction (Cuneo et al., 2011). With exclusion of
any subjects suffering severe personal and external factors in their life, 17 RNs enrolled in Reiki
1 class at a large metropolitan hospital learned how to complete and perform Reiki (Cuneo et al.,
2011). The Perceived Stress Scale (PSS) tool was administered to subjects prior to completing
the class, and three weeks following (Cuneo et al., 2011). The findings demonstrated a 5.9 mean
decrease in PSS scores post-Reiki completion, demonstrating statistically significant stress
reduction following the class (Cuneo et al., 2011). Though a small sample size, this study
supports the benefits of Reiki on nurses wellbeing (Cuneo et al., 2011).
A quasi-experimental study by Moeini, Hazavehei, Hosseini, Aghamolaei, and
Moghimbeigi (2011) sought to assess the impact of a cognitive-behavioral stress management
training program on job stress among Iranian hospital nurses. To do so, 58 nurses from a single
hospital were equally split into intervention and control groups (Moeini et al., 2011). The
intervention group completed a five-session training program over three weeks in which problem
solving and relaxation was taught, while the control group received no intervention (Moeini et
al., 2011). Data was collected through a self-administered questionnaire that included
demographics and a nursing stress scale (NSS) (Moeini et al., 2011). The results demonstrated
that post-intervention stress results significantly decreased in the experimental group, while
remaining stable in the control group (Moeini et al., 2011). Stress management behaviors were

also noted to be more successful post-intervention (Moeini et al., 2011). It is thus concluded that
training programs may be effective on decreasing nurses job stress.
Lai and Li (2011) examined the effects of music on biochemical markers and stress
among nurses in this crossover-controlled trial. The objective was to examine the effects of
music and music preference on stress (Lai & Li, 2011). A total of 54 nurses were randomly
assigned to a music/chair rest sequence for the trial in this study (Lai & Li, 2011). After
listening to their personal choice of self-soothing music and sitting quietly for 30 minutes,
participants had a lower perceived stress level, cortisol, heart rate, mean arterial pressure, and
higher finger temperature while listening to music (Lai & Li, 2011). Music preference was as
well identified as significantly associated with mean arterial pressure, cortisol levels, selfperceived stress and finger temperature (Lai & Li, 2011). There is therefore conclusive evidence
that soothing music reduces nurses stress (Lai & Li, 2011).
Kravits, McAllister-Black, Grant, and Kirk (2010) evaluated the efficacy of a psychoeducational program on nurses stress and self-care levels. The overall objective was to develop
an effective program that can reduce the stress levels nurses experience, and improve their selfcare and health (Kravits et al., 2010). A second objective was to compare the emotional
exhaustion levels of newly hired and established oncology nurses (Kravits et al., 2010).
Moreover, 248 newly hired cancer center graduates and various community health nurses were
recruited from a local area (Kravits et al., 2010). Stress and burnout measures were conducted
pre- and post-course using the Maslach Burnout Inventory, Draw-a-Person-in-the-Rain Art
Assessment, and wellness plans (Kravits et al., 2010). The results demonstrated that postintervention emotional exhaustion subscales, burnout subscales, and feelings of
depersonalization all decreased (Kravits et al., 2010). It is concluded that psycho-educational

interventions such as practicing relaxation techniques, discussing risk factors, and exploring
coping patterns are promising methods to promote positive self-care strategies in nurses.
As a means for correlating role stressors to job satisfaction, and identifying the potential
for intervention methods, Ho, Chang, Shih, and Liang (2009) utilize a questionnaire in two large
hospitals. The overall objective was to identify whether the job rotation system might increase
their overall satisfaction (Ho et al., 2009). A second goal was to specifically integrate the
relational model of job rotation, role stress, job satisfaction, and organizational commitment
among nurses (Ho et al., 2009). Questionnaires were thus administered and returned from 532
nurses who had previous job rotation, or the acquisition of diverse skills through previous
experience in various departments and units (Ho et al., 2009). Statistical software packages were
used for data analysis and processing (Ho et al., 2009) Nurses consequentially reported that job
rotation could have a positive effect on their job satisfaction and organizational commitment (Ho
et al., 2009). Oppositely, they reported that role stress could have a negative effect on their job
satisfaction and organizational commitment (Ho et al., 2009). The overall conclusion is that
hospitals could promote the benefit of job rotation to both individuals and the hospital, and
implement it more frequently.
In efforts to examine nurses health and wellbeing, and to identify health promoting
activities currently used, McElligott, Siemers, Thomas, and Kohn (2009) conducted a pilot study
that examined the health-promoting lifestyle behaviors that acute care nurses currently abide by
(McElligott et al., 2009). To do so, 149 nurses completed surveys addressing their demographics
and current lifestyle habits (McElligott et al., 2009). The questionnaire contained 52 questions
addressing nutrition spirituality, health responsibility, interpersonal relations, stress, and physical
activity (McElligott et al., 2009). The results demonstrated that there were no significant

differences in demographics or in education levels between participants (McElligott et al., 2009).

In evaluating coping mechanisms for stress, health responsibility and physical activity scored
lowest (McElligott et al., 2009). Spirituality, nutrition, and interpersonal relationships scored
highest (McElligott et al., 2009). Barriers to stress management included lack of time, inability to
choose a method, competing demands, environmental factors, and lack of support (McElligott et
al., 2009). The overall conclusion is that each of these factors should be taken into consideration
when developing a best practice model for stress reduction and health promotion, and that time
constraints and workload are a significant impeding factor on nurses health.
A randomized-controlled trial by Pipe, Bortz, Dueck, Pendergast, Buchda, and Summers
(2009) sought to evaluate a mindfulness meditation program for nurse leaders. To do so, 33
nurse leaders were randomly assigned to a mindfulness meditation course (MMC) or leadership
course, at which point stress measures were gathered at baseline and one-week post course (Pipe
et al., 2009). Stress data was gathered using self-report measures (Pipe et al., 2009). The results
demonstrated that nurses undergoing the MMC intervention had significant improvement in their
Positive Symptom Distress Index, Global Severity Index, and Positive Symptom Total when
compared with the control group (Pipe et al., 2009). One important finding in this study was that
the prevalence and severity of stress experienced among nurses was significantly higher than
anticipated (Pipe et al., 2009). Thus, it is concluded that nurses undergo a significantly high
intensity of stress, but that a mindfulness meditation course may be beneficial to their health.
A qualitative phenomenological approach by Raingruber and Robinson (2007) aimed to
evaluate the efficacy of Tai Chi, yoga, Reiki, and meditation healing sessions on registered
nurses health and problem solving abilities. Nurses at a single hospital were invited to attend
classes, but were asked to attend just one of the four sessions and to complete a journal reflecting

weekly on their health and practice (Raingruber & Robinson, 2007). Following the completion of
their sessions, 35 nurses returned their journals and noted significant health benefits to result
(Raingruber & Robinson, 2007). Outcomes noted included nurses describing a sense of warmth,
tingling, and pulsating which were relaxing, becoming aware of enhanced problem solving
abilities, and an increased ability to focus on patients needs (Raingruber & Robinson, 2007).
The authors concluded that Reiki, Tai Chi, meditation, and yoga might have positive benefits on
not only nurses, but also the quality of care.
Mackenzie, Poulin, and Seidman-Carlson (2006) conducted a study in order to identify
the efficacy of mindfulness training on nurses health and stress. The objective was to address
the relative dearth of research on mindfulness training with nurses, and to evaluate the
Mindfulness-Based Stress Reduction (MSBR) program (Mackenzie et al., 2006). To do so, 14
nurses were recruited from continuing care units and used in the study (Mackenzie et al., 2006).
Nurses were randomly assigned to the intervention group, consisting of four MBSR training
classes, or the control group whom received no intervention (Mackenzie et al., 2006). Each nurse
completed the program and provided and pre- and post-intervention ratings (Mackenzie et al.,
2006). The results demonstrated that those who underwent mindfulness based training program
presented with less exhaustion, high levels of personal accomplishment, and increased relaxation
ratings (Mackenzie et al., 2006). The overall conclusion is therefore that the feasibility of four
mindfulness-training program consisting of 30-minute classes is supported.
Conclusion
The articles reviewed in this chapter provide evidence to support self-care deficits among
the current nursing population, its correlation to patient care and outcomes, and varying effective
interventions to promote health and reduce stress. Evidence supports intervention measures that

have proven to reduce stress and/or improve nurses health. Among these modalities include
psycho-educational training, professional identity acquisition, Reiki, job rotation, mindfulness
meditation, Tai Chi, yoga, musical therapy, job rotation, auricular acupuncture, and positive
coping strategies such as nutritive care, exercise, spirituality, and interpersonal relationships.
Further research needs to address several of these interventions in greater quantity and detail.
Barrier to nurse self-care practices include concerns for time, environmental restraints, and
personal demands. In conclusion, it is clear that nurses face significant challenges in this work
environment and professional roles, leading to stress, burnout, and self-care deficits. Moreover,
while the feasibility of self-care interventions may need further research, the efficacy of positive
self-care modalities in reducing stress and improving health is clear.

CHAPTER 3
Best Practice Recommendation: Implementation of Self-Care Interventions for Nurses
The purpose of this thesis was to create evidence based best practice recommendations
for health care facilities implementation of various health-promoting interventions for nurses.
This chapter will detail the proposed best practice recommendations to reduce nurses overall
stress and improve their health and wellbeing.
The literature reviewed in the previous chapter provides evidence for deficits in working
nurses health and self-care practices, while also demonstrating its association with adverse
patient outcomes. Among the primary factors contributing to the current self-care deficit among
nurses includes poor sleep quality and job stress, which are directly correlated with how nurses
perceive their own health (Lin et al., 2014). Additionally, heavy workloads, extensive
responsibility, and high expectations contribute to the excessive nurse stress (Salehi, et al.,
2014). High levels of job stress are correlated with poor attention, concentration, and memory in
working nurses (Allan et al., 2014). Heavy workloads as well are correlated to an interrupted
train of thought among nurses throughout their shift (Berland et al., 2008). The primary
obligations of registered nurses include patient health-promotion education, information
depiction, and critical decision-making in addition to an array of critical skills such as
medication administration (American Nurses Association, 2015). Minor errors in any of these
responsibilities have the potential to impose significant harm onto patients, therefore providing
evidence for the necessity to intervene on nurses health promotion opportunities.
As shown in Table I, 11 studies reviewed in the previous chapter provide evidence for
interventions to improve nurses health and wellbeing. The interventions described in Table I
will thus be included in an educational module for R.N.s to promote evidence based self-care

behaviors. It is essential to consider not only the efficacy of each intervention, but the feasibility
for nurses in consideration of their regular responsibilities and identified barriers to self-care. It
is moreover crucial to consider the necessity for a vast range of health-promoting opportunities
in order to increase nurse compliance with a health-promoting intervention.

Table I.
Best Practice Recommendation for Improving Nurses Awareness
for Self Care Deficits and Available Interventions
Content of Training
Module

Topics

References

Level of Evidence

Hsu, H. Y., Chen, S. H.,

Yu, H. Y., & Lou, J. H.
(2010). Job stress,
achievement motivation
and occupational burnout
among male nurses.
Journal of Advanced
Nursing, 66(7), 13652648. doi: 10.1111/j.13652648.2010.05323.x

Nurses are
subjected to job
stressors that
adversely affect
their health and
wellbeing

- Current issues include:

Long shifts, lack of
time, high expectations,
frequent overtime, and
heavy patient loads
- Adverse results for
nurses include:
Poor satisfaction, poor
sleep quality, increased
prevalence of nurse
related errors, increased
burnout and turnover,
and physical and mental
fatigue

Lin, S. H., Liao, W. C.,

Chen, M. Y., & Fan, J. Y.
(2014). The impact of shift
work on nurses
job stress, sleep quality
and self-perceived health
status. Journal of Nursing
Management, 22(5), 604612. doi:
10.1111/jonm.12020.
Salehi, A., Javanbakht, M.,
& Ezzatababdi, M. R.
(2014). Stress and its
determinants in a sample
of Iranian nurses. Holistic
Nursing Practice, 28(5),
323-328. doi:
10.1097/HNP.0000000000
000043
Stone, P. W., MooneyKane, C., Larson, E. L.,
Horan, T., Glance, L. G.,
Zwanziger, J., & Dick, A.
W. (2007). Nurse working
conditions and patient

Level III

safety outcomes. Medical

Care, 45(6), 571-578.
Yau, S. Y., Xiao, X. Y.,
Lee, L. Y. K., Tsang, A.
Y. K., Wong, S. L., &
Wong, K. F. (2011). Job
stress among nurses in
China. Applied Nursing
Research, 25(1), 60-64.
doi:
10.1016/j.apnr.2011.07.00
1

High stress levels

and poor nurse
self-care is directly
correlated with
patient outcomes

- Adverse patient events

are strongly correlated
with staffing, emotional
exhaustion, and
depersonalization
- High levels of stress
lead to impaired
attention, concentration,
and memory

Allan, J. L., Farquharson,

B., Johnston, D. W., Jones,
M. C., Choudhary, C. J., &
Johnston, M. (2014).
Stress in telephone
helpline nurses is
associated with failures of
concentration, attention
and memory, and with
more conservative referral
decisions. British Journal
of Pyschology, 105(2),
200-213. doi:
10.1111/bjop.12030
Berland, A., Natvig, G. K.,
& Gunderson, D. (2008).
Patient safety and jobrelated stress: A focus
group study. Intensive and
Critical Care Nursing,
24(2), 90-97.
Maiden, J., Georges, J. M.,
& Connelly, C. D. (2011).
Moral distress,
compassion fatigue, and
perceptions about
medication errors in
certified critical care
nurses. Dimensions of

Level II

Critical Care Nursing,

30(6), 339-345. doi:
10.1097/DCC.0b013e3182
2fab2a
Spence Laschinger, H. K.
& Leither, M. P. (2006).
The impact of nursing
work environments on
patient safety outcomes:
The mediating role of
burnout/engagement.
Journal of Nursing
Administration, 36(5),
259-267.
Stone, P. W., MooneyKane, C., Larson, E. L.,
Horan, T., Glance, L. G.,
Zwanziger, J., & Dick,
A. W. (2007). Nurse
working conditions and
patient safety outcomes.
Medical Care, 45(6), 571578.

Reiki, meditation,
and exercise are
effective and
feasible
interventions to
improve nurses
health and
wellbeing

- Tai Chi, yoga, Reiki,

and meditation sessions
were each proved
effective in reducing
nurse stress
- Reports among nurses
completing exercise
sessions included:
- Relaxing sensations
- Increased awareness
for enhanced problem
solving abilities
- Increased ability to
focus on patient needs

Cuneo, C. L., Curtis

Cooper, M. R., Drew, C.
S., Naoum-Heffernan, C.,
Sherman, T., Waiz, K.,
Weinberg, J. (2011). The
effect of Reiki on workrelated stress of the
registered nurse. Journal
of Holistic Nursing, 29(1),
33-43. doi:
10.1177/08980101103772
94.
Raingruber, B. &
Robinson, C. (2007). The
effectiveness of Tai Chi,
yoga, meditation, and
Reiki healing sessions in
promoting health and

Level IV

enhancing problem solving

abilities of registered
nurses. Issues in Mental
Health Nursing, 28(10),
1141-1155

Mindfulness
meditation is an
independent and
anytime
intervention to
improve awareness
and relieve stress

Psycho-educational
programs are an
effective way of
learning to cope
with the everyday
stressors of nursing
as a profession

- Intended to deepen the

capacity for attention
and strengthen present
moment attention
- Produced positive
results in improving
immune function,
strengthening coping
skills, and decreasing
potentially disabling
symptoms of stress

- Intended to empower
individuals to cope with
stressors through
education
- Reduces feelings of
emotional exhaustion,
depersonalization, and
burnout

Mackenzie, C. S., Poulin,

P. A., & Seidman-Carlson,
R. (2005). A brief
mindfulness-based stress
reduction intervention for
nurses and nurse aides.
Applied Nursing Research,
19, 105-109.
doi:10.1016/j.apnr.2005.08
.002
Pipe, T. B., Bortz, J. J.,
Dueck, A., Pendergast, D.,
Buchda, V., & Summers,
J. (2009). Nurse leader
mindfulness meditation
program for stress
management: A
randomized controlled
trial. Journal of Nurse
Administration, 39(3),
130-137. doi:
10.1097/NNA.0b013e3181
9894a0
Kravits, K., McAllisterBlack, R., Grant, M., &
Kirk, C. (2010). Self-care
strategies for nurses: A
psycho-educational
intervention for stress
reduction and the
prevention of burnout.
Applied Nursing Research,
23(1), 130-138.
doi:10.1016/j.apnr.2008.08
.002

Level II

Level II

Moeini, B., Hazavehei, S.

M., Hosseini, Z.,
Aghamolaei, T., &
Moghimbeigi, A. (2011).
The impact of cognitivebehavioral stress
management training
program on job stress in
hospial nurses: Applying
PRECEDE model. Journal
of Research in Health
Sciences, 11(2), 114-120.

Music therapy
improves both
psychological and
physiological
wellbeing when
utilized by nurses

Auricular
acupuncture is
effective at
improving both
nurse and patient
wellbeing and
outcomes

- Personal preference in
musical selection
promoted
- Positive results were
achieved in reducing
personal perceived
stress levels, cortisol,
heart rate, and mean
arterial pressure

- Aims at reducing
provider stress as a
means of increasing the
quality of patient care
- Reduces feelings of
anxiety, stress, and
burnout among nurses

Lai, H. L. & Li, Y. M.

(2011). The effect of
music on biochemical
markers and self-perceived
stress among first-line
nurses: A randomized
controlled crossover trial.
Journal of Advanced
Nursing, 67(11), 24142424. doi: 10.1111/j.13652648.2011.05670.x

Level VI

Reilly, P. M., Buchanan,

T. M., Vafides, C.,
Breakey, S., & Dykes, P.
(2014). Auricular
acupuncture to relieve
health care workers stress
and anxiety: Impact on
caring. Dimensions of
Critical Care Nursing,
33(3), 151-159. doi:
10.1097/DCC.0000000000
000039

Level VI

Summary of Proposed Education Module

The evidence-based proposed online educational module will include the most pertinent
data regarding nurses self care deficits, its relationship to adverse patient outcomes, and
effective and feasible interventions to reduce stress and improve overall health and well being.
The educational module will include information to promote nurses awareness of both the issues
and interventions that have been demonstrated to benefit other individuals in the nursing
profession. The main objective of this educational module is to bring awareness to the current
self-care deficit among nurses as a means of encouraging participation in strategies to improve
nurse self care, and patient outcomes. This educational module will target the nursing profession,
however may be utilized by other health care professionals, as well.

CHAPTER 4
Implementation and Evaluation
This chapter will concentrate on implementing a self-care module as part of a computer
based training (CBT) program for newly hired and currently employed nurses. This module will
be included among various other facility-based modules in an educational CBT program. Current
practice among numerous healthcare facilities requires new employees to complete a CBT
program prior to practicing in the healthcare facility. Furthermore, nurses are commonly required
to perform annual CBT in order to remain current with various hospital protocols. By
implementing a self-care module as part of regular nurse CBT, registered nurses will remain
properly informed on available options to care for themselves and improve overall health and
wellbeing.
Computer based training programs have become one of the most common and efficient
ways to deliver information to a group of individuals at different time periods. Among the most
common ways to deliver CBT programs include via an installed software program, a corporatebased intranet, or through the Internet as an entirely web-based training (Texas Tech University,
2015). CBTs are highly beneficial due to their ability to provide the same information to all
individuals, allow for hands-on interaction, and allow individuals to perform the program at their
own pace. CBTs additionally allow for pre- and post-test assessments to evaluate the efficiency
of a program and an individuals involvement (Texas Tech University, 2015).
In order to implement this educational CBT module, research will be performed on
various CBT software programs as a means for identifying the availability and usage of differing
programs. The Consolidated Framework for Implementing Research (CFIR) model will be used
in order to outline the implementation process through the structure of 1) Plan, 2) Do, 3) Study,

and 4) Act (Consolidated Framework for Implementing Research [CFIR], 2014). The CFIR
model provides a structured guideline for evaluating healthcare issues, collecting evidence, and
disseminating research to healthcare communities (CFIR, 2014). This model will provide a
framework for implementing the provided research into a self-care module in CBT programs
throughout various healthcare facilities.
Implementation
The CFIR model includes four different characteristics as a means for identifying,
collecting, analyzing, and implementing research into practice. The fourth characteristic is
entitled process and focuses on the final features of implementation (CFIR, 2014). The process
characteristic is concluded through evaluation of the progress and quality of the implementation
progress as a whole (CFIR, 2014).
Planning
Planning is the first stage of the CFIR process and will assist in identifying the
appropriate information to include in the CBT module (CFIR, 2014). One essential goal is to
include the information in an appealing manner. In order to effectively engage nurses on the best
practice recommendation, strategic measures will be taken on the presentation of the material.
Further planning will include inquiry on the availability and feasibility of local resources for
health promoting interventions. Matters of interest will include the cost, duration, and hours of
availability for a single session of an intervention at a local facility. A final plan will include the
need to inquire on information regarding the feasibility of implementing one of the evidencebased interventions into a health care setting. An example may include the availability of a large
on-site room in a hospital where a mindfulness meditation instructor may hold a weekly session
for employees.

Engaging
Engaging is the second stage of the CFIR process and will address the means for
presenting the research to nurses via a CBT module (CFIR, 2014). The primary goal of
engagement is to present the relevant research in an effectual and relatable manner for nurses.
The CBT module may thereby include questions such as, Do you commonly suffer from
physical and mental fatigue? and, Do you feel as though you are just too busy to exercise?
Many nurses may relate to these feelings, thereby increasing attention for the information
presented in the module. Research that is further presented in the module will include a variety
of colors and relevant pictures to increase attentiveness as nurses follow along. Specific to the
healthcare facility, local resources for each of the recommended interventions will be included in
the module for easy employee access. Upon completion of the module, nurses will then be
required to complete a five-question quiz reviewing the information presented to assess their
retention.
Executing
Execution is the third stage of the CFIR process and will focus on the mechanism for
decreasing the self-care deficit present among working nurses (CFIR, 2014). While the CBT
module will encourage nurse engagement and understanding of the self-care deficit, the goal of
this step is to implement an array of evidence based interventions for nurses. This strategy will
begin by reaching out to local MBSR instructors, auricular acupuncture facilities, and psychoeducational specialists. Efforts will aim at creating alliances with such specialists in hopes of
hosting an on-site class for working nurses, or organizing off-site classes for a group of
employed nurses. Nurses differing schedules will be taken into consideration, and classes will
be subsequently offered at various times throughout the day. Further efforts will evaluate

implementation of a policy on music therapy, such as allowing music to be played in the breakroom of various hospital units. A final goal will include implementation of educational posters in
break-rooms emphasizing the importance of optimal nutrition and regular exercise. Each of these
measures will serve to create the greatest availability of resources for health-promoting measures
for nurses.
Evaluation
Reflecting and Evaluating
The final stage of the CFIR process is reflection and evaluation, which will serve to
examine the efficacy of the CBT self-care module (CFIR, 2014). This will be completed at onemonth, three-months, six-months, and one-year post implementation of the self-care module and
interventions. The first step of the evaluation process will include examination of patient results
through comparison of pre- and post-intervention patient outcomes. Measures will include the
numerical occurrence of nurse-initiated medication errors and hospital-acquired infections, in
order to evaluate whether a decrease in such resulted following implementation of the self-care
module. The second measure will include the statistical evaluation on the occurrence of illnesses
and injury, absenteeism, and attrition rates among registered nurses. The final measure will
include the evaluation of pre- and post-CBT module survey to evaluate nurses individual reports
on the utilization of self-care interventions, in addition to their self perceived health and
wellbeing. This will allow for evaluation of nurses overall participation in self-care intervention
programs, as well their feelings of post-intervention wellbeing. Each of these measures will serve
to evaluate the efficacy of the self-care interventions and allow for accumulation of statistics in
order to encourage all nurses to participate.

Strengths/Limitations and Recommendations for Future Research

The strength of this best practice recommendation was the accumulation of numerous,
current research studies that supported the provided interventions. Nine studies were included in
the evaluation of the self-care deficit of nurses, each of which demonstrated significant findings
for the presence of stress, and the negative correlations it holds to poor job performance and
satisfaction. Six studies further identified statistically significant positive correlations with poor
nurse-reported workforce conditions and adverse patient events and outcomes. The final measure
included eleven articles that addressed a wide range of effective self-care interventions, thereby
allowing for the inclusion of several different recommendations for nurses. By addressing
numerous health-promoting options, a full evaluation of current research was included to allow
nurses to choose which intervention is most appropriate for their personal needs, subsequently
increasing compliance.
The limitation of this best practice recommendation is the lack of accumulated research
for each specific intervention for nurses. Given that studies included numerous effective
interventions, some recommendations are based off of a single study that demonstrated
significant positive results. It is therefore concluded that recommendations could be stronger
through identification of numerous studies supporting each health-promoting intervention,
though numerous studies for each recommendation have yet to be conducted.
Recommendations for future studies include the need to conduct further studies similar to
those included in this review. While positive results were identified from Lai and Li (2011), this
evaluation of music therapy is very unique in its kind. Further studies should attempt to repeat a
study similar to this in order to obtain similar findings in numerous studies and ensure that error
was not present. Reilly et al. (2014) proposed a similar situation in which positive results were

achieved from nurses who underwent auricular acupuncture, however further trials are needed to
obtain certainty in the findings.
Further recommendations include expanding research on other health-promoting
interventions for nurses. While many studies support interventions such as exercise, nutrition,
and mindfulness meditation, many of the interventions in this review have not been widely
studied. In conclusion, expanding focus on health promoting interventions for nurses may
significantly improve nurse wellbeing and patient care as a whole.
Summary
The purpose of this thesis was to develop a best practice recommendation for health
promotion interventions for nurses. A total of 26 studies were included and identified a nurse
self-care deficit, its correlation with adverse patient events, followed by an array of health
promoting interventions for nurses. An extensive review of literature supported the
implementation of exercise, Reiki, mindfulness meditation, psycho-educational programs,
musical therapy, and auricular acupuncture as health promoting interventions for nurses.
Inclusion of the findings into a CBT module for nurses at various facilities could increase
awareness for the deficit and compliance for according health promoting interventions. By
increasing awareness and availability for such interventions, a resultant increase in nurse
wellbeing could improve patient care, safety, and health as a whole.

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