Investigating Self-Care Practices in Nursing Students From a Holistic Nursing Perspective: A Cross-Sectional Study

Abstract

Purpose: Using the holistic nursing perspective as a guide, this study aimed to explore nursing students’ self-care practices in Indonesian nursing educational institutions. Design: A cross-sectional study. Methods: Nursing students enrolled in undergraduate programs across 13 institutions in Indonesia were recruited using proportionate stratified random sampling. A total of 1,071 students participated in an online survey. Data were analyzed using univariate, bivariate, and multivariate statistics. Findings: Overall, students took care of themselves. Self-care scores were highest in the emotional and spiritual dimensions, while physical self-care was lowest. Students’ self-care practices differed significantly based on their age, self-care education, self-care perception and health status. Educational background, self-care education, self-care perception and health status were all significant predictors of students’ self-care practices. Conclusion: Indonesian nursing students demonstrated satisfactory scores in the total Integrated Health and Wellness Assessment, but strategies to support students’ positive self-care practices beyond their nursing education should be established, alongside a focus on self-care dimensions that scored low. Centrally regulating nurse self-care education could ensure uniformity in curriculum integration and maximize long-term benefits for nursing students, the profession and the healthcare system in general.

Keywords

holistic Indonesia nursing education nursing students self-care

Introduction

Nurses are the biggest group of health professional worldwide, with about 28 million nurses, making up 59% of the global healthcare workforce (Hall, 2021; Lal, 2023). Research has consistently demonstrated the vulnerability of nurses to the harmful effects of stressors inherent to their profession (Badu et al., 2020; Groves et al., 2023). Promoting nurse self-care is a key strategy to help nurses manage their stressors, meet self-care needs, and support both their personal and professional growth (American Nurses Association, 2017; Nursing and Midwifery Board of Australia, 2016; Royal College of Nursing, 2018; Slemon et al., 2021). The International Council of Nursing's (ICN's) competency standards for general registered nurses (ICN, 2009) and code of ethics (ICN, 2021) draw attention to nurse self-care by emphasizing the need to build the self-nurturing capacity of prelicensure nursing students. However, corresponding nursing education standards in individual countries do not necessarily align with those of the ICN.

In Indonesia, nurse self-care pro-policies are still developing. The national core nursing curriculum for entry-level nurses has not yet incorporated nurse self-care, although there may be some variations in individual institutional curriculum content (Association of Indonesian Nurse Education Center (AINEC), 2024). According to the latest available data, over 850 nursing institutions are currently operating in Indonesia, with more expected (Association of Indonesian Nurse Education Center (AINEC), 2025; Indonesian Accreditation Agency for Higher Education in Health (IAAHEH), 2025). Additionally, Indonesian nurses continue to experience health-related issues and burnout, with rates exceeding 50% (Juanamasta et al., 2024), far above the global burnout rate of 30% for the nursing workforce (Ge et al., 2023). Exploring the current self-care engagement of Indonesian nursing students is a valuable initial step to ensuring that students are adequately equipped with skills necessary to become a reflective, healthy, more productive and resilient future nursing workforce.

Background

Research, conducted predominantly in developed countries, concluded that health profiles and behaviors among nursing students were relatively poor, and consistent with research related to professional nurses (Mulyadi et al., 2021; Turner & McCarthy, 2017). Physical and mental health problems, such as fear, stress, anxiety, depression, post-traumatic stress disorder, sleep disturbance, burnout, and somatic symptoms (Mulyadi et al., 2021), may arise for nursing students who can neither effectively manage stressors, nor replenish their self-care needs (Brouwer et al., 2021; Jenkins et al., 2019). Insufficient self-care practices in nursing students have also been associated with adverse outcomes, such as lower levels of emotional intelligence (Goudarzian et al., 2019), resilience (Martin et al., 2022), well-being (Brouwer et al., 2021), and quality of life (Labrague et al., 2017). These issues may negatively affect their productivity, performance, and job satisfaction, leading to professional impairments that impede to the provision of quality nursing care to clients (Jun et al., 2021). It may also impact their decision to continue nursing and imperil the nursing profession's longevity (Mills et al., 2021).

Research on nurse self-care has increased in recent years; however, the available evidence still shows a marked variation in how self-care for nursing students is conceptualized. Slemon et al. (2021) concluded that there are currently three realms of self-care for nursing students: (1) self-care as viewed from a holistic nursing perspective, (2) from a health-promoting lifestyles stance, and (3) self-care linked to stress management and coping strategies. The holistic self-care perspective in particular has garnered widespread acclaim because of its strong alignment with nursing values (Patestos et al., 2019; Slemon et al., 2021). As a whole-person approach, holistic self-care places a greater focus on the broader determinants of health (Schoon & Krumwiede, 2022).

A definition provided by Shields and Stout-Shaffer (2022) is among the few references that offer a specific conceptualization of self-care for nurses, grounded in both holistic nursing and an integrative perspective, and its implications for caregiving practice. These authors contend that the currently available self-care definition is insufficient to portray the complexity of the phenomenon in the nursing profession. They propose the terms “self-development” or “holistic self-care” (Shields & Stout-Shaffer, 2022, p. 179) to depict a more comprehensive understanding of self-care. To care for others effectively, nurses need to be able to self-assess and reflect as a means to develop a deeper state of consciousness, or healing consciousness (Shields & Stout-Shaffer, 2022).

Dossey (2022) extends the concept of holistic self-care in nursing students by emphasizing the need to be reflective learners who can discover their innate healing potential, to navigate stressors or sufferings they encountered during their education and career journeys. The holistic self-care will ultimately assist students in becoming effective role models and healing instruments for their clients (Dossey, 2022). Nursing education can benefit from the holistic concept of self-care by teaching students how to care for themselves while learning how to care for others. In the initial stages of self-development, students should be provided with opportunities to reflect and assess themselves (McElligott & Turnier, 2020). Self-assessment will enhance insight or awareness into their self-care practices, including their strengths and vulnerabilities. Growing awareness of self-care practices encourages students to reflect on their self-care needs, establish goals and gather resources, and be proactive in exploring and implementing holistic self-care strategies (Dossey, 2015a).

In the literature, assessment of nursing students’ self-care practices has largely been conducted under the health-promoting lifestyle perspective (Abdou & Helal, 2018; Diana et al., 2023; Gurusamy et al., 2022). The current study aimed to explore Indonesian nursing students’ self-care practices from a holistic nursing perspective. This was considered the first fundamental step in nurturing students’ self-development or holistic self-care practice, which will lay a solid foundation for students’ future nursing practices.

Methods

Design

This article discusses a specific component of a larger ongoing study using a variety of research methods to explore the nurse self-care phenomenon in Indonesia from the perspectives of differing target groups. The current quantitative study employed a cross-sectional design. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBES) guidelines (Vandenbroucke et al., 2007) were followed in the preparation of this article.

Theoretical Framework

The study was underpinned by Dossey's Theory of Integral Nursing (TIN) (2022). The most significant aspect of TIN related to this study was its integral worldview and process, which maintains that while learning to care for clients, students should be encouraged and facilitated to reflect on their own (Dossey, 2022). In addition to TIN, the current study was also guided by Dossey's Theory of Integrative Nurse Coaching (TINC). Self-development was deemed the most useful TINC component for the current study. It was used to understand how nursing students nurture self-care needs by engaging in a series of self-reflection, self-assessment, self-evaluation and self-care processes (Dossey, 2015a). McElligott et al. (2018) also used Dossey's TINC to develop the Integrated Health and Wellness Assessment (IHWA) tool for evaluating individual self-development or holistic self-care. As such, IHWA served as an initial stage in supporting nursing students’ self-development by encouraging them to reflect on and examine their current self-care practices.

Participants and Settings

The current study was conducted at 13 tertiary nursing education institutions in Indonesia, offering entry-to-practice programs for professional nurses, or the Bachelor of Nursing (BSN) leading to the Professional Nursing (PN) qualification for high school graduates. The average duration of this program is five years, comprising four years of academic study and one year of clinical placement (AINEC, 2024). The sample included full-time nursing students enrolled in any year level, aged 18 years or older. Proportionate stratified random sampling was utilized. The sample size was determined using the Yamane formula (Yamane, 1973), with a 3% margin of error and a 95% confidence interval. The result was then adjusted to account for a possible non-response rate of 10%. This sample size was a basis for calculating the sample to be drawn randomly from each institution, proportional to the number of students across different study years (strata). The within-stratum selection was conducted using an online random generator, based on anonymous student attendance lists from each institution.

Ethical Considerations

Ethics approval for the study was obtained from the Monash University Human Research Ethics Committee (approval: 40946) and the Universitas Udayana Institutional Review Board (approval: 2602/UN14.2.2.VII.14/LT/2023). Research permits were also secured from the local authorities and all participating institutions. Informed consent was obtained from prospective participants who were advised of their voluntary and anonymous participation and the right to withdraw.

Data Collection

The data were collected using two-part online questionnaires via Qualtrics Plus software (Qualtrics, Provo, UT). The first part focused on assessing nursing students’ demographic characteristics. The second part consisted of a 36-item-questionnaire using a 5-point Likert scale of the IHWA (McElligott et al., 2018). The IHWA measures an individual's health and wellness level by identifying their health and personal habits, behaviors and attitudes. It consists of eight subscales, including (1) life satisfaction and balance (two items), (2) relationships (four items), (3) spiritual (three items), (4) mental (four items), (5) emotional (three items), (6) physical (eight items), (7) environmental (three items), and (8) health responsibility (nine items). The sum of each dimension needs to be added up to score an individual's level of wellness. The scores on the IHWA tool can range from 36 to 180, with higher scores indicating greater health and wellness (McElligott et al., 2018). In this study, the Likert scales were treated as interval measurements, as Harpe (2015) and Mircioiu and Atkinson (2017) suggested, with evenly spaced numbers and anchors for each response providing the scales with an absolute reference point. The instrument's internal consistency was 0.88 as assessed by the Cronbach alpha (McElligott et al., 2018). Permission to access and use the IHWA short form was granted by the copyright holders. Before being used in this study, the original (English version) IHWA underwent a cross-cultural adaptation following Beaton's et al. (2000) guidelines. From January to May 2024, a survey link was distributed to potential respondents by the research liaisons at each institution.

Data Analysis

The survey data were analyzed using the IBM Statistical Package for Social Science (SPSS) Statistics program version 29 for Windows. The descriptive statistics were used to generate the respondents’ profiles, the IHWA scores and assess the data's normality. The independent-samples t-test and F-test (one-way analysis of variance/ANOVA) were employed in this study to explore differences in Indonesian nursing students’ self-care patterns based on their demographic characteristics. A three-stage hierarchical multiple regression analysis was further performed using the IHWA total score as the dependent variable for determining the factors that contributed to students’ self-care practices, as measured by IHWA. Two-sided p-values of less than .05 were considered statistically significant.

Results

From a total of 1,094 targeted responses, 1,071 filled out the survey, giving a 97.90% response rate. In Indonesian nursing research surveys, the response rate is often high (Damayanti et al., 2022; Mustikasari et al., 2022). The final analysis, however, used only data gathered from 1,043 respondents after removing 28 responses due to complete missing values (n = 9), unengaged responses (n = 16) and outliers (n = 3) in the IHWA variable. Figure 1 presents a flow diagram, which illustrates the process of refining the data for the analysis in this study strand.

Figure 1.

Flowchart of respondents.

Baseline Characteristics

The respondents were dominated by female (76%, n = 814) and unmarried nursing students (98.7%, n = 1057). A mean age of 20.56 (SD = 1.73) years was observed, with ages ranging from 18 to 27. The proportion of the students based on their year of study represented their actual distribution in their population, with first-year (27.0%, n = 289) and second-year (26.1%, n = 280) students the most prevalent. Most respondents were general high school (GHS) graduates (72.8%, n = 780). A significant number of students were financially dependent (93.8%, n = 1,005), and lived with their family (60.7%, n = 650). More than 90% of the respondents declared that they had been taught about nurse self-care (96.1%, n = 1,029) and rated learning it as very (48.1%, n = 515) and extremely (37.4%, n = 401) important. Students rated their health status as excellent and good, 46.1% (n = 494) and 43.7% (n = 468), respectively (Table 1).

Table 1.

Characteristics of Respondents (n = 1,071)

Characteristics	Frequency (n)	Percentage (%)	Mean (SD)
Gender
Female	814	76.0
Male	257	24.0
Age			20.56 (1.73)
≤18 years	116	10.8
≥19 years	955	89.2
Marital status
Unmarried	1,057	98.7
Married	14	1.3
Living arrangement
With family	650	60.7
Living alone	421	39.3
Source of living cost
Dependent	1,005	93.8
Independent	66	6.2
Educational background
General high school (GHS)	780	72.8
Vocational high school (VHS)	291	27.2
Year of study
One	289	27.0
Two	280	26.1
Three	222	20.7
Four	146	13.6
Five	134	12.5
Taught about self-care
Yes	1029	96.1
No	42	3.9
Learning self-care perception
Extremely important	401	37.4
Very important	515	48.1
Moderately important	83	7.7
Not at all important	72	6.7
General health status
Excellent	494	46.1
Good	468	43.7
Fair	109	10.2

Table 2 illustrates the respondents’ self-care practices as assessed by the IHWA. The mean total of IHWA was 131.06 ± 20.029. While the instrument developers suggest calculating the sum of the scores across the 36 items and each dimension of the IHWA (McElligott et al., 2018), this study also calculated means for total and dimension responses to make meaningful comparisons across self-care dimensions. Based on the calculations, the mean for the mean scores of the total IHWA was 3.64 ± 0.56. From the highest to lowest, the IHWA dimensions had mean scores of 4.16 ± 0.72 (emotional), 4.02 ± 0.84 (spiritual), 3.91 ± 0.94 (environment), 3.73 ± 0.76 (relationships), 3.70 ± 0.74 (health responsibility), 3.64 ± 0.77 (mental), 3.46 ± 0.89 (life satisfaction), and 3.14 ± 0.70 (physical). The sum scores were used consistently for the subsequent data analysis.

Table 2.

Mean Total IHWA and Dimensions Scores (n = 1,043)

IHWA dimensions	Mean of the sum scores ± SD	Min–Max	Possible obtainable scores	Mean of the mean scores
Total score IHWA (36 items)	131.06 ± 20.029	78–179	36–180	3.64 ± .56
Life satisfaction (2 items)	6.91 ± 1.787	2–10	2–10	3.46 ± .89
Relationships (4 items)	14.92 ± 3.046	5–20	4–20	3.73 ± .76
Spiritual (3 items)	12.05 ± 2.524	5–15	3–15	4.02 ± .84
Mental (4 items)	14.54 ± 3.080	6–20	4–20	3.64 ± .77
Emotional (3 items)	12.47 ± 2.161	6–15	3–15	4.16 ± .72
Physical (8 items)	25.11 ± 5.597	11–40	8–40	3.14 ± .70
Environment (3 items)	11.74 ± 2.826	3–15	3–15	3.91 ± .94
Health responsibility (9 items)	33.31 ± 6.616	13–45	9–45	3.70 ± .74

Group Differences in Self-Care

Group comparison analysis revealed significant findings in total IHWA but not in all characteristic subgroups (see Table 3). Significant differences were observed (p < .05) in the total IHWA based on students’ age (t (1,041) = 2.67, p = .01), self-care education exposure (t (1,041) = 3.83, p < .001), self-care perception (F (3, 1,039) = 24.43, p < .001) and perceived general health status (F (2, 1,040) = 36.97, p < .001). It should be noted that despite these significant findings, the magnitude of the mean differences in the total IHWA based on students’ age and lessons in self-care was dominated by small effect sizes (Cohen's d < .5). The observed power for these two factors was 75% and 96%, respectively. Meanwhile, health status and self-care perceptions had medium effect sizes in total IHWA (η2 ≥ .06), as calculated by eta squared. The observed power for these two factors was 100%. A Tukey HSD post-hoc test showed a significant difference (p < .05) between the mean scores of students who rated learning self-care as extremely important (M = 135.93, SD = 18.93) from those in very (M = 128.84, SD = 19.75) and moderately (M = 117.70, SD = 20.31) important groups. Self-care was not significantly different (p > .05) between the groups considering it to be extremely important and those not considering it at all (M = 135.55, SD = 18.05). Tukey HSD analysis of perceived health status revealed significant mean differences across all groups being compared (p < .001). Conversely, gender, marital status, year of study, educational background, living arrangement and source of living cost were statistically non-significant (p > .05).

Table 3.

IHWA Mean Scores of Respondents According to Their Characteristics (n = 1,043)

	Mean ± SD	t or F (p-value)	d or η2	95% CI
	Mean ± SD	t or F (p-value)	d or η2	LL	UL
Gender		1.47 (.14)	.11	−.04	.25
Female (n = 797)	131.56 ± 19.72
Male (n = 246)	129.42 ± 20.94
Age		−2.67 (.01)*	−.26	−.46	−.07
≤18 years (n = 115)	126.37 ± 20.21
≥19 years (n = 928)	131.64 ± 19.94
Marital status		−0.14 (.89)	−.37	−.56	.49
Unmarried (n = 1,029)	131.05 ± 19.99
Married (n = 14)	131.79 ± 23.66
Living arrangement		−1.36 (.18)	−.09	−.21	.04
With family (n = 627)	130.37 ± 20.34
Alone (n = 416)	132.09 ± 19.53
Source of living cost		1.68 (.09)	.22	−.04	.48
Dependent (n = 981)	131.32 ± 20.01
Independent (n = 62)	126.92 + 20.09
Educational background		1.90 (.06)	.13	−.00	.27
General high school (n = 757)	131.78 ± 20.06
Vocational high school (n = 286)	129.14 ± 19.84
Year of study		2.07 (.08)	.01	.00	.02
One (n = 284)	129.87 ± 20.45
Two (n = 272)	129.65 ± 21.24
Three (n = 211)	131.46 ± 19.25
Four (n = 145)	131.63 ± 19.51
Five (n = 131)	135.24 ± 17.86
Taught about self-care		3.83 (< .001)*	.45	.14	.76
Yes (n = 1,001)	131.42 ± 20.15
No (n = 42)	122.45 ± 14.60
Learning self-care perception		24.43 (< .001)*	.07	.04	.10
Extremely important (n = 390)	135.93 ± 18.93
Very important (n = 505)	128.84 ± 19.75
Moderately important (n = 81)	117.70 ± 20.31
Not at all important (n = 67)	135.55 ± 18.05
General health status		36.97 (< .001)*	.07	.04	.10
Excellent (n = 479)	135.97 ± 19.36
Good (n = 456)	128.52 ± 19.32
Fair (n = 108)	119.99 ± 19.65

*Significant at 0.05 level.

d: .2 = small effect; .5 = medium effect; .8 = large effect.

η2: .01 = small effect; .06 = moderate effect; .14 = large effect.

Predictors of Self-Care

Preliminary analyses ensured that multiple regression assumptions, including normality, linearity, multicollinearity, and homoscedasticity were met. Nevertheless, Casewise diagnostics detected one studentized deleted residual greater than ±3 standard deviations (−3.06), which was discarded from the analysis, leaving 1,042 datasets. Table 4 displays the three-stage hierarchical multiple regression analysis results in this study.

Table 4.

Hierarchical Multiple Regression Predicting IHWA (n = 1,042)

Variable	IHWA
	Model 1		Model 2		Model 3
	β	t	β	t	β	t
Constant		8.45		9.53		9.96
Gender (Female: 0; Male: 1)	−.05	−1.53	−.03	−.84	−.04	−1.18
Age	.09	1.79	.07	1.42	.07	1.38
Marital status (Single: 0; Married: 1)	−.01	−.35	−.01	−.28	−.01	−.37
Living arrangement (With family: 0; Alone: 1)	.03	1.08	.03	1.14	.04	1.47
Source of living cost (Dependent: 0; Independent: 1)	−.05	−1.74	−.04	−1.39	−.04	−1.46
Educational background (GHS: 0; VHS: 1)	−.07*	−2.13	−.06	−1.90	−.06*	−2.04
Year of study
One	−.03	−.41	−.07	−1.03	−.06	−.94
Two	−.06	−.99	−.08	−1.44	−.06	−1.07
Three	−.04	−.71	−.04	−.84	−.03	−.62
Four	−.04	−.95	−.05	−1.11	−.03	−.79
Five	Reference
Taught about self-care (Yes: 0; No: 1)			−.08*	−2.73	−.08*	−2.74
Learning self-care perception
Not at all important			−.01	−.24	−.01	−.40
Moderately important			−.24**	−7.62	−.19**	−5.87
Very important			−.18**	−5.55	−.16**	−5.01
Extremely important	Reference
General health status
Fair					−.20**	−6.32
Good					−.15**	−4.77
Excellent	Reference
R²	.021		.092		.133
Adjusted R²	.011		.080		.120
df	(10, 1032)		(14, 1028)		(16, 1026)
F	2.21*		7.45**		9.86**
ΔR²	.021		.071		.041
Δdf	(10, 1032)		(4, 1028)		(2, 1026)
ΔF	2.21*		20.15**		24.36**

Note. * p < .05, ** p < .001.

According to Model 1 in Table 4, socio-demographic characteristics could significantly clarify students’ self-care practices as reflected in the IHWA scores with 2.1% variability (F (10, 1.032) = 2.21, p = .015). However, educational background was the only predictor that reached significance (β = −.07, t = −2.13, p = .03). This β value indicates that the IHWA scores were lower for students with vocational high school (VHS) backgrounds than those graduated from GHS. After adjusting for the socio-demographic characteristics and adding self-care education exposure and students’ perception about it into the next equation, Model 2 could explain 9.2% variances in IHWA scores (F (14, 1.028) = 7.45, p < .001). The two added predictors could account for an additional 7.1% in the variance of IHWA or an increase of .071 in R² (F (4, 1,028) = 20.15, p < .001). Specifically, the beta value for self-care education exposure was −08 (t = –2.73, p = .006), suggesting that prior self-care education participation was associated with higher self-care practices. As for the importance of learning self-care, the beta values were −24 (t = –7.62, p < .001) and −.18 (t = –5.55, p < .001) for moderate and very important groups, respectively. Accordingly, IHWA scores were higher among those who rated learning self-care more positively (extremely important). In this second model, the educational background no longer had a significant impact on IHWA scores. The full model for predicting IHWA scores (Model 3) showed statistical significance and had a variability of 13.3% (F (16, 1.026) = 9.86, p < .001). More precisely, the inclusion of general health status into the equation increased explanatory variance (R²) by 4.1% (F (2, 1,026) = 20.15, p < 0.001). These were statistically significant for students with fair (β = –20, t = –6.32, p < .001) and good (β = –18, t = –4.77, p < .001) health status, implying that rating health status as fair or good was notably associated with lower IHWA scores compared with those with excellent health status. With the addition of general health status in this model, educational background and self-care education exposure remained significant predictors of IHWA. Finally, Model 3 indicates that general health status (fair) emerged as the strongest predictor of the IHWA scores, followed by learning self-care perception (moderately and very important), general health status (good) and educational background.

Discussion

The significance of nurse self-care has attracted global focus in recent years, mainly because of its substantial benefits for individual nurses, their patients, organizations, and healthcare system at large. A growing body of evidence also supports the need for nursing students to be educated as professional nurses who can address patients’ health-related needs while also attending to their own. Despite its importance, this phenomenon has been insufficiently explored in Indonesia, providing rationale for conducting this study.

Although the overall mean for the total IHWA scored above the midpoint, the range of scores indicated that some students scored below it. Future research will be necessary to explore the barriers perceived by these students and identify strategies to support them. The IHWA is a relatively new tool, and it has not been widely used, so direct comparisons between our findings and those found in previously published studies should be undertaken with discretion. Earlier studies reported that nursing students’ self-care practices ranged from low and fair to high levels (Abdou & Helal, 2018; Blake et al., 2017; Diana et al., 2023). Most of these studies were underpinned by the Health Promotion Model by Pender et al. (2015), utilizing the Health-Promoting Lifestyle Profile HPLP-II instrument (Walker et al., 1987), rather than holistic perspectives adopted in this study (Slemon et al., 2021). Apart from different theoretical frameworks and assessment tools, variations in the level of self-care practices among nursing students across the studies reviewed may have been due to differences in contextual-related aspects, such as the geographical location, socio-cultural backgrounds and sample characteristics.

The IHWA descriptive analysis, by its dimensions, revealed that Indonesian nursing students were more inclined to engage in self-care practices that nurture their emotional health. It implies that students can recognize, express and constructively respond to a wide range of feelings about themselves and others (McElligott & Turnier, 2020). Better emotional health can protect students from impact of stressors and the potential emotional costs associated with caring for others, which is inherent in the helping professions (Dwyer & Hunter Revell, 2015). Our results, however, differ from those of the Younas (2017) literature review, which concluded that nursing students often neglect their emotional self-care. This conflict might be explained by Younas’ (2017) broader definition of emotional self-care, which incorporates interpersonal relationships, spiritual growth, stress management, and complementary therapies. We also caution against comparing our findings with prior studies based on the HPLP-II instrument because this instrument does not include emotional self-care as a dimension (Walker et al., 1987). Another interesting point is that previous literature has shown Indonesians are generally less emotionally expressive (Gupta & Sukamto, 2020), which makes our result intriguing and worth further exploration.

Aside from the emotional dimension, our study also revealed that spirituality and relationships were dominant in shaping how Indonesian nursing students cared for themselves. These findings are consistent with those of previous studies that utilized HPLP-II, conducted in Egypt (Abdou & Helal, 2018), Columbia (Bermeo et al., 2023a), Iran (Farokhzadian et al., 2020), Turkey (Polat et al., 2016) and Malaysia (Soh et al., 2018). While spirituality does not necessarily imply religion (Dossey, 2015a), it is apparent that spirituality has generally been rated among the highest dimensions across countries with high levels of religious observance and influence (Abdou & Helal, 2018; Bermeo et al., 2023a; Soh et al., 2018). Our findings could also be explained by the fact that Indonesian educational institutions are mandated to teach religious education to all students at every level. Within the relationship dimension, students were encouraged to reflect on how meaningful their relationships were and how effective their communication was (McElligott & Turnier, 2020). The nursing curriculum in Indonesia includes communication and interpersonal skill content from the first year and carries through all subsequent years (AINEC, 2024). Furthermore, Indonesian society is a strong collectivist culture, in which interpersonal relationships are central in defining one's identity and are defined by the connection between self and others (Gupta & Sukamto, 2020). It may be for these reasons that the relationship dimension scored among the highest dimensions in this study.

By contrast, physical self-care in this study scored the lowest out of all dimensions, indicating the need for this area to be prioritized (Dossey, 2015a). In studies that utilized HPLP-II, physical activity was consistently cited as the least practiced self-care dimension by nursing students (Diana et al., 2023; Farokhzadian et al., 2020; Gurusamy et al., 2022; Hwang & Oh, 2020). However, interpretation should consider that the physical dimension in the current study covered not only areas of physical activity, but also students’ perceptions of their nutrition and weight management practices (McElligott & Turnier, 2020). Our study's findings are comparable with those of Gurusamy et al. (2022), conducted among Indian nursing students across different study years, which concluded that physical activity and nutrition were the two aspects students practiced least. Chust Hernández et al. (2022) explained that nursing students are susceptible to adopting unhealthy physical behaviors due to intense study loads and clinical placement-related stressors. Mak et al. (2018), however, asserted that low physical activity in nursing students simply reflects a worldwide phenomenon whereby young people, or students, not prioritizing physical activity. From a sociocultural perspective, exercising regularly may not yet be considered a basic need, but rather a leisure activity in Indonesia. As for the diet, we found that Indonesian nursing students did not consume enough healthy foods. This phenomenon may reflect a general transition in dietary consumption among Indonesians to more energy-dense nutrition, including sweet, salty, fatty and processed/pre-packaged meals (Rachmi et al., 2021). From an economic standpoint, inadequate access to affordable healthy foods and exercise facilities may also be responsible for unhealthy dietary practices and lack of physical activities in our study population. Furthermore, while healthy diets and physical activity are also topics covered in many nursing courses in Indonesia that are geared toward patient care, our findings suggest that students find it difficult to apply the knowledge and skills they gain during their education to meet their own physical needs.

Our study also reveals observable disparities among the groups being compared, based on student characteristics. However, significant values were only found in four out of ten characteristics being explored. Older students who received self-care education, valued self-care and positively perceived their health status engaged in self-care practices more than their counterparts. A significant difference in self-care practices according to students’ age was also found in previous studies (Bermeo et al., 2023a; Damayanti et al., 2022). In terms of self-care education exposure, our study revealed significant differences in self-care practices, which was consistent with previous research (Fairchild & Tully, 2024; Gipson et al., 2024). Despite the majority of participants claiming to have been taught about self-care, the information should be interpreted carefully, because the nurse self-care topic has yet to be covered in the latest national nursing curriculum. Students were therefore more likely to misinterpret between self-care for students and self-care for patients.

Based on hierarchical multiple regression analyses, it was revealed that students’ educational backgrounds, self-care education exposure, self-care perception and health status significantly predicted self-care practices. Students with a high school education and previous self-care education exposure, as well as those who valued self-care and positively perceived their health status, were more likely to engage in self-care practices. Based on the final model, the four significant predictors should be the primary targets for modifying Indonesian nursing students’ self-care practices. However, it is important to note that only 13.1% of the variance in nursing students’ self-care practices, as measured by IHWA, can be explained by the final model. There may have been other variables, not measured in the current study, that could explain the higher variance of students’ self-care practices. These variables may include but are not limited to self-efficacy (Farokhzadian et al., 2020), self-esteem (Bermeo et al., 2023b), self-care agency (Ister, 2020), medical conditions, stress (Hensel & Laux, 2014), anxiety, depression (Kwon & Oh, 2023), personality (Lim et al., 2016), quality of life (Mak et al., 2018), and health literacy (Rababah & Al-Hammouri, 2022).

Among the significant determinants, health status and self-care perceptions emerged as the strongest predictors. As in previous studies, we found that healthier people and those who valued self-care take better care of themselves (Abdou & Helal, 2018; Bermeo et al., 2023b; Hwang & Oh, 2020; Kwon & Oh, 2023; Martin et al., 2022). It is consistent with TINC's holistic self-care or self-development principles that individuals must have a positive attitude toward self-care and a positive outlook upon themselves in order to achieve a sense of balance and well-being in their lives (Dossey, 2015b). Another interesting predictor of self-care engagement was students’ educational background, with GHS students performing better than those with VHS graduates. As per the curriculum, VHSs are more practical and skills-oriented than GHSs, combining classroom instruction with more practicums and internships (Suharno et al., 2020). Accordingly, these students might lack sufficient time for self-care, and the tendency to engage in inadequate self-care routines could persist into their current lives. However, more research is required to fully comprehend this finding.

In contrast to previous studies, our study was unable to confirm any significant correlations between age (Bermeo et al., 2023a), gender (Hwang & Oh, 2020), marital status, living arrangement, source of living cost (Diana et al., 2023), and year of study (Gurusamy et al., 2022) to students’ self-care. These variations may be attributable to differences in study contexts/settings, which are reflected in participant characteristics in different studies. Studies may also have reached different conclusions due to differences in the number of respondents across categories of student characteristics. Based on these findings, the influence of students’ sociodemographic characteristics on their self-care practices cannot be conclusively established. The non-significant variables, in particular, need to be investigated in more detail in subsequent studies.

Limitations

The study we conducted has limitations. First, in a cross-sectional study, causal relationships between variables cannot be examined. Second, the use of survey designs is inclined to yield superficial rather than detailed information. Third, employing self-administered instruments can lead to social-desirability and self-reporting bias. Fourth, generalizability might be limited beyond the study's geographical scope. However, this article presents data from a large-scale, multicentered study, conducted in 13 nursing institutions scattered across Indonesia. The study had a very high response rate and balanced proportions of respondents representing both their institutions and year levels. By incorporating TIN, TINC and IHWA into this study, it is among the few studies to capture the nurse self-care phenomenon from a holistic nursing perspective and validate a newly developed instrument.

Implications

Several implications can be drawn from the results of this study, particularly regarding low-scoring group of students and self-care dimensions least practiced. As previously discussed, younger students and those with a VHS background were less likely to practice self-care. Observable lower IHWA scores were also evident among those at lower study levels, especially first-year students, despite not being statistically significant. These findings, for instance, may inform future recruitment and retention strategies that support the most vulnerable student groups. Furthermore, providing students with tailored physical self-care programs and increasing access to physical self-care facilities and services should be a priority.

Our study population demonstrated satisfactory IHWA scores despite the lack of standardized guidance on integrating nurse self-care into Indonesian nursing education. Its long-term benefits, however, remain to be seen. Students’ health and well-being should be continuously monitored through periodic self-reflection and self-assessment. Ultimately, this could encourage students to practice self-care regularly throughout their nursing careers. Indonesia has a large number of nursing educational institutions, so centrally regulating nurse self-care may also be necessary to ensure uniformity. In particular, AINEC should incorporate nurse self-care into the core curriculum to guide and support nursing institutions and educators in its implementation. Finally, nurse self-care should also be extended into workplace contexts to maximize its impact on practicing nurses.

As for theoretical implications, our study demonstrates the practical usefulness of TIN (Dossey, 2022) and TINC (Dossey, 2015b) as theoretical frameworks for exploring nursing students’ self-care engagement from a holistic nursing perspective. The IHWA was shown to be a reliable and effective tool for assessing nursing students’ self-care practices. Based on our study findings and limitations, further research is needed. For example, studies employing a longitudinal design or those with a fuller exploration of the wider determinants of nurse self-care would be useful. Gathering information on how nurse self-care is currently taught in the Indonesian nursing education context also merits further scrutiny.

Conclusions

Providing quality, compassionate, safe, and responsible nursing care to clients is reliant on nurses’ health and well-being, which can be improved by nurses practicing self-care. Underpinned by the holistic nursing theories, this study assessed nurse self-care among Indonesian nursing students, by providing students with an opportunity to reflect on and thoroughly evaluate their current self-care engagement. This acted as a crucial step in students’ self-development or holistic self-care, fostering their self-consciousness and capacity to become reflective learners. These strategies can lay a firm foundation for their future professional practices, assisting students to become nurses who are empathetic, compassionate, holistic, and person-centered in their care. Our study population demonstrated satisfactory scores in the total IHWA, despite nurse self-care has not yet been centrally regulated in Indonesian nursing education. Nonetheless, those dimensions and students who scored lower on self-care should receive additional attention, along with efforts to ensure students maintain favorable nurse self-care practices throughout their educational and careers.

Footnotes

Data Availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Ethical Approval and Informed Consent Statement

The Monash University Human Research Ethics Committee approved the survey (approval: 40946) on November 24, 2023. Domestic ethic approval for the study was also granted by Universitas Udayana Institutional Review Boards (approval: 2602/UN14.2.2.VII.14/LT/2023) on December 06, 2023. Research permits were also secured from the local authorities and all participating institutions in Indonesia. The prospective participants were given an explanatory statement and informed consent before participating in the survey. Informed consent was obtained from prospective participants who were fully informed about their voluntary participation and right to withdraw. Individuals had to select ‘the next/the survey link’ on the explanatory statement page to indicate their willingness to be respondents and proceed to the main questionnaire (implied consent). The questionnaire was anonymous. Participants were also guaranteed anonymity in presenting study findings and any potential publications resulting from the study.

Author Contributions

Made Rini Damayanti: conceptualization, methodology, formal analysis, investigation, data curation, writing—original draft, writing—review and editing, visualization, project administration, funding acquisition. Kaori Shimoinaba: conceptualization, methodology, formal analysis, writing—review and editing, supervision. Katrina Recoche: conceptualization, methodology, formal analysis, writing—review and editing, supervision.

ORCID iDs

Made Rini Damayanti

Kaori Shimoinaba

Katrina Recoche

Made Rini Damayanti, RN, MNS, is a PhD candidate at the School of Nursing and Midwifery at Monash University in Australia and serves as an assistant professor within the Department of Nursing at Universitas Udayana, Indonesia. Her research focuses on self-care and health promotion in educational settings, with a particular emphasis on holistic nursing perspectives.

Kaori Shimoinaba, RN, PhD, MN, MCounselling, is a senior lecturer in the School of Nursing and Midwifery at Monash University in Australia. Her areas of research are palliative and end-of-life care, aged care, grief support and resilience for health care professionals, death education, cultural competency, and cross-cultural nursing and education.

Katrina Recoche, RN, PhD, MN, is a senior lecturer at the School of Nursing and Midwifery at Monash University in Australia. Her research areas include palliative care, interprofessional education, continuing professional education, cultural empathy, and learning and teaching interventions in health professional education.

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