Wellbeing interventions often focus on resolving problems, but a preventative strategy has been developed to help students and others cope more effectively
Pre-registration nursing programmes place many challenges on students and these can affect their health and wellbeing. The wellness recovery action plan (WRAP) is a strengths-focused technique to reduce stress and improve health and wellbeing that was initially used in mental health care. This article discusses the potential for using WRAPs to support student nurses, as well as those studying other health professions. They can be used to enhance students’ educational and clinical self-awareness, reduce anxiety and vulnerability, and enhance resilience, enabling them to cope more effectively with educational and personal challenges.
Citation: Hamilton S et al (2015) A strategy for maintaining student wellbeing. Nursing Times; 111: 7, 20-22.
Authors: Stephen Hamilton is nurse education consultant, Clinical Education Centre, Knockbracken Healthcare Park, Belfast; Karen Murray is lead midwife (education), Queen’s University Belfast; Shona Hamilton is consultant midwife at the Northern Health and Social Care Trust and Queen’s University Belfast; David Martin is senior nurse manager at the Belfast Health and Social Care Trust.
- This article has been double-blind peer reviewed
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Pre-registration nursing programmes are challenging; their mix of academic work and clinical practice places demands on students that are not experienced by most undergraduates.
As the next generation of nurses will form the backbone of the NHS, maximising their health and wellbeing should be a priority for education providers, practitioners and students themselves.
Universities in Northern Ireland offer excellent counselling facilities to their students, but this approach involves addressing something that has already gone wrong, rather than taking steps to prevent or minimise problems occurring.
Zubin and Spring (1977) first suggested that levels of resilience and/or vulnerability are significant protective/risk factors influencing individuals’ overall state of health and wellbeing. One possible strategy for maximising student resilience and minimising their vulnerability is through the use of Copeland’s (1997) wellness recovery action plan (WRAP).
Although this strengths-focused approach - which carries the tagline “it’s not what’s wrong, it’s what’s strong” - was first used in the context of mental health service provision, many other groups now use it. These include those experiencing diabetes, epilepsy, cardiac problems, retirement, addiction, stress and depression. As recovery and wellness is desirable for all, there is no reason why students and qualified health professionals should not use WRAP.
The five health and social care trusts in Northern Ireland use this recovery approach for both patients and service-users, and we hope universities in the province will also adopt WRAP to help students maintain overall physical and psychological wellbeing. However, their application outside of the mental health field with student cohorts has not previously been formally offered.
What is WRAP?
The WRAP approach is underpinned by five key concepts:
- Personal responsibility;
These concepts can be applied to a broad range of healthcare and educational contexts. For example, students who develop their own WRAP, facilitated by a personal tutor or mentor, may feel they have a greater sense of control, thereby reducing their feelings of anxiety. By thinking about potentially stressful events that may occur in the future, such as failing a placement or making a clinical error, and by imagining their responses to such events, students may be able to reduce the impact of such stressors if and when they occur. This is a type of stress inoculation therapy, as discussed by Meichenbaum (1993).
In practical terms, the WRAP has seven distinct dimensions (Box 1). Students should complete their WRAP when they are feeling well; a significant benefit of the approach is that students do not have to be ill to possess, implement and develop their own plan.
Box 1. Dimensions of Wellbeing Recovery Action Planning
- Wellness toolbox
- Daily maintenance plan
- Opportunities to identify triggers (with action plan)
- Opportunities to identify early warning signs (with action plan)
- Opportunities to identify when things are breaking down (with action plan)
- Crisis plan
- Post-crisis plan
The tools in the wellness toolbox, which are specific to the individual, have a dual function. They help to:
- Keep the student well;
- Make them feel better if their mental or physical health declines.
Anything that has a positive effect on the student can be a wellness tool, so activities that most people enjoy, or that make them feel connected, tend to be included in WRAP toolboxes.
For example, students may include talking to a mentor or personal tutor, visiting or speaking to friends and family, going to the library, socialising, being organised, turning up for class on time, eating well, attending counselling with student services, exercising, listening to music, being a member of a club or society, getting enough sleep, or studying for examinations. Fig 1 gives examples of commonly used wellness tools.
However, wellness toolboxes can also contain things for students to avoid to maintain their wellness, such as illicit drugs or too much alcohol.
Although the examples of wellness tools given in this article may seem rather obvious, this is one of the benefits of including them in a WRAP. At a time when students begin to feel their health or wellbeing declining, such straightforward, obvious, safe and non-surgical tactics are more likely to be used successfully than unfamiliar or complicated strategies.
It must be remembered that what might be a wellness tool for one person could have a negative effect on another, so it is essential that students fill their wellness toolboxes with things that are meaningful to them.
The toolbox (Fig 1) is a reference point for students to dip into, and out of, as and when they feel the need.
Daily maintenance plan
The daily maintenance plan is slightly different to the wellness toolbox, as it refers to things that students need to do every day to maximise their wellness.
Triggers, in the context of a WRAP, refer to people, events and/or circumstances that have a negative effect on the student; they are usually external and may be things over which the student has little or no control, but which may contribute to them feeling or becoming unwell.
Conversely, early warning signs are internal; these are often subtle indications that the student might need to take more assertive action to restore physical and/or psychological balance or wellbeing.
If early warning signs are not addressed, the student may be at risk of a crisis; if they are addressed at an early stage, however, the student can retain control, while attempting to prevent a crisis.
Each student should write their crisis plan when they are well; they can do so with support from someone else, such as a personal tutor. The plan will instruct others as to how to care for them if they become unwell, thereby enabling them to maintain control, even in difficult times. The crisis plan is the only part of their WRAP that the individual student needs to share with others if the need arises; it includes:
- Details of what they are like when well;
- Indicators that will show that others need to “take over”;
- Details of who should do this;
- Specific information, for example, on healthcare contacts, current medications, acceptable and unacceptable treatment options, respite plans, and acceptable and unacceptable hospital facilities.
Finally, the crisis plan details:
- Things others can do that will help the student;
- What could make the situation worse;
- A list of tasks for others;
- Indicators that the crisis plan can be deactivated.
A WRAP involves an eclectic approach, so users do not need to use all its dimensions, but can cherry-pick those that are meaningful and useful to them.
Evidence in support of WRAPs
There is a growing evidence base on the benefits of using WRAPs in mental health care, and its use in other contexts is also rapidly developing. A mounting body of empirical evidence suggests that when people develop their own ideas about where, when and how to make positive behavioural changes in their lives, they are much more likely to do it and, more importantly, sustain it (Tierney et al, 2011).
Developing a WRAP can help an individual get to know themself better; it can perhaps be likened to having a courageous and honest conversation with yourself - with that honesty and openness fuelling a lasting, sustained wellbeing.
Hamilton and Hoyle (2013) highlight that using the term “recovery” in reference to a WRAP should not be confused with “cure”, but rather perceived and interpreted through the mnemonic in Box 2.
Box 2. How WRAP facilitates recovery
R = Release your potential
E = Engage with relevant services if necessary
C = Communicate and express yourself
O = Take ownership of your health
V = Avoid vagueness and be specific
E = Evaluate your strategies
R = Remember your strengths
Y = Remember, it’s your journey, your health, your future
The potential benefits of having a WRAP are highlighted by recent research evidence that revealed 12% of university students in the UK reported having engaged in self-injurious behaviour, with cutting being the most common form of self-harm (University of Manchester, 2012). Given the secretive nature of self-harming behaviour, it is likely that this percentage is an underestimate.
Benefits of WRAPs
The potentially stressful nature of nurse education was highlighted by Tully (2004) in a qualitative examination of the experiences of mental health nursing students. Participants reported significant levels of anxiety and distress, and possessed limited coping strategies; levels of stress and anxiety grew substantially as they progressed through their three-year undergraduate programme.
It would, therefore, be reasonable to suggest that giving various students the chance to develop their own WRAP, not only during their pre-registration period but also throughout their post-qualification perceptorship period, would be a proactive attempt to maximise resilience and reduce vulnerability.
WRAPs could also help to reduce attrition rates in nurse training. The approach provides a flexible structure that each student can use to facilitate courageous and honest conversations with themself to maximise their physical and psychological wellness over time.
It gives each student the opportunity to gain valuable self-insight and could help them prepare for professional life through interaction and the sharing of ideas.
Each student can use a WRAP in the way that best suits them. Some will embrace it wholeheartedly, use all its elements and find it changes their lives for the better, while others may adopt some elements that suit them.
Some students will not wish to use a WRAP at all. But if universities adopt WRAPs, it is important that all students are aware of their existence and can make an informed decision about whether they are suitable for them.
Developing a WRAP is inexpensive/cost neutral, non-invasive, unlikely to be psychologically damaging and can be done by anyone. Whatever their circumstances, if a person fails to care for themself, they will be less effective in their various roles. This is particularly pertinent to student nurses - and those studying other health professions - who, on qualification, will be responsible for caring for people at their most vulnerable; they would therefore need to be as psychologically and physically robust as possible.
The concept of lifelong learning is accepted as the norm these days, particularly for health professionals. Given the pressures associated with healthcare provision, helping students to develop increased resilience through a person-centred process like the WRAP approach is increasingly important.
We intend to design, implement and evaluate a pilot WRAP project in Northern Ireland geared specifically towards facilitating the wellness of students.
Universities would provide an excellent forum through which undergraduate and postgraduate students alike could engage with the process, share their experiences and support each other.
The fact that the WRAP approach encourages users to focus more on staying well, maintaining optimum function and using their strengths - rather than emphasising illness - surely makes the process highly relevant for students, and particularly those studying to enter into healthcare professions.
The WRAP approach is not a replacement for existing university pastoral care practices; it is a potential adjunct to the many other wellbeing interventions that universities offer.
It is helpful for individuals, whether students or otherwise, to check in with themselves every now and then and ask “what stands between me and feeling well - or, at least, feeling a little better?”
- Health professionals and students of health professions face many challenges
- Health workers need to have robust physical and psychological health to do their jobs well
- Universities should consider the wellbeing of their students to be a priority
- Individuals should be helped to understand themselves and their wellbeing
- Having a wellness recovery action plan in place can help individuals avert crises or deal with them when they occur
Copeland ME (1997) Wellness recovery action plan. Brattleboro, VT: Peach Press.
Hamilton SJ, Hoyle H (2013) Someone has to take the WRAP: the origins of recovery. Skills for Nurses; 32: 6-8.
Meichenbaum D (1993). Stress inoculation training: a twenty year update. In: Woolfolk RL, Lehrer PM (eds) Principles and Practices of Stress Management. New York, NY: Guilford Press.
Tierney P et al (2011) Promoting health behaviour change in the cardiac patient. British Journal of Cardiac Nursing; 6: 3, 126-130.
Tully A (2004) Stress, sources of stress and ways of coping among psychiatric nursing students. Journal of Psychiatric and Mental Health Nursing; 11: 1, 43-47.
University of Manchester (2012) STORM (Skills-Based Training on Risk Management) Facilitators Handbook. University of Manchester.
Zubin J, Spring B (1977) Vulnerability: a new view on schizophrenia. Journal of Abnormal Psychology; 86, 103-126.