Thriving psychological well-being in undergraduate nursing student: a grounded theory study with the life grid approach

The mental health of nursing students has attracted considerable international attention [1, 2]. Although mental health issues and well-being are likely to be at opposite extremes of a continuum [3], enhancing nursing students' well-being may also lessen their psychological distress [4]. In the past few decades, "positive psychology" has also increased the attention of psychologists and other scientists to the concept of "well-being", implying different philosophical views. Diener E(1985) measured subjective well-being by Satisfaction with Life and emotional experience, under hedonic philosophy [5]. According to eudaimonic, the six components of psychological well-being (PWB) identified by Ryff (1989) are autonomy, environmental mastery, positive connections with others, purpose in life, the realization of potential, and self-acceptance [6]. According to Keyes (2002), well-being is formed when individuals display high amounts of hedonic and eudaimonic symptoms [7]. Seligman (2012) and Kern (2016), like Keyes, rely on both hedonic and eudaemonic philosophical foundations and suggested two models of well-being: the PERMA model (i.e. Positive emotion, engagement, relationships, meaning, and accomplishment) [8] and EPOCH model (i.e. engagement, perseverance, optimism, connectedness, and happiness) [9], respectively. Moreover, Feeney and Collins (2016) mentioned that closer interactions also increase PWB [10]. Evidence shows that greater well-being may be fostered by multidimensional components [11].

Psychological well-being was defined as the existence of psychological adjustment indicators as well as a sense of progress and self-realization [12, 13]. Research showed that psychological well-being is essential in nursing students' mental health as well as a successful adaptation to college/university life [14, 15]. Nursing students are more vulnerable to psychological distress than other professions due to the challenges encountered [16]. In China, the prevalence of anxiety, depression, and anxiety and depression co-occurring was, respectively, 55.0%, 56.4%, and 31.6% [17]. Psychological well-being also affects nursing students' decisions to stay in the nursing profession [18]. Meanwhile, a workforce shortage of nurses has been a major global concern, particularly during COVID-19 [19]. Around half (49.1%) of Chinese nursing students planned to switch majors, and nearly as many (45.4%) said they had no interest in becoming nurses after graduation [20]. Considering that poor PWB is associated with an increased likelihood of maladaptation and workforce shortages, it is crucial to understand how PWB is promoted among nursing students. Therefore, the main aim of the study was to investigate qualitatively the perspectives of undergraduate nursing students regarding aspects that promoted PWB along their journey.

Although extensive research has been carried out on the well-being of nursing students, the systematic mechanism in helping to promote psychological well-being among nursing students remains unknown. A review of the literature reveals that the available evidence has tended to focus on factors that reduced PWB or investigated indicators of psychological distress (e.g. [21, 22]). For example, considerable research on stress [23]; anxiety [24]; burnout [25]; and depression [26] has been gathered among nursing students. Furthermore, much of the research up to now has been quantitative, focused on correlation studies or hedonic well-being (e.g., subjective/emotional well-being). Social support [27], resilience [28], self-esteem [29], self-efficacy [30], and mindfulness [31] have been identified as being positively associated with nursing students’ well-being. While the existing evidence can help understand the link between PWB and these factors, it is equally valuable to explore the thriving mechanisms of psychological well-being, what promotes higher PWB in the undergraduate nursing program, to develop more holistic evidence of PWB in nursing students.

The presence of a research gap in the field indicated the need for the generation of a more comprehensive theoretical model for promoting PWB. This model would allow for the consolidation of knowledge in the area. Grounded theory [32] can be used to address this issue. To enrich the form of the data and to reduce recall bias, the life grid approach [33] was also conducted to improve the reliability of the results. This study aimed to construct a substantive theory of nursing students' perceived experience, knowledge, and skills for enhancing PWB based on a positive psychology perspective and conceptualize thriving psychological well-being.

This constructivist GT provides a theoretical perspective on how Chinese undergraduate nursing students promote their psychological well-being to conceptualize the thriving PWB. This study qualitatively explored undergraduate nursing students' perspectives of PWB-enhancing elements. The insights concentrate on the positive aspects of nursing students' experiences and provide extensive descriptions of the elements that promote PWB by referencing positive psychology and collecting data using LGM and interviews. These holistic and multifaceted sets of promoting elements play a vital role in strategies for mental health among nursing students.

Consistent with conceptualizations of PWB [8, 9, 13], positive relationships within the academic and professional community appeared to be instrumental to nursing students’ PWB, especially positive feedback from supervisors, patients, and peers. As regards relationships with patients, encouragement is vital to developing confidence and self-identity. Educational interventions that optimize the capability of dealing with the relationships with patients could be valuable [43], which better enables nursing students to adapt to changes in the academic-clinical environment. Interventions that target to manipulate and enhance other social support are also necessary [15]. As regards support from supervisors, alongside constructive and professional feedback, almost participants emphasized the benefits of care, especially during the clinical placement. Hence, the emphasis should be placed on programs that promote the growth of positive supervisor-student interactions. Universities might, for example, provide clinical and academic supervisors with preparation on the qualities of a helpful supervisory relationship and make ensuring that supervisors have enough time and experience to engage nursing students [37].

Echoing previous theories suggesting that social support is also effective in facilitating nursing students to draw on the strengths of their supervisors and other relationships [10]. Receiving support could lead to immediate relational benefits including feeling valued and appreciated, being able to pursue aspirations on one's own, experiencing new things, and self-expanding with a close friend [44].

Interestingly, the findings show that social support not only influences relational attitudes but also promotes concentration and lifestyle. For example, participants reported that they were more able to stay focused and keep a healthy lifestyle with well-established social support. Social support promotes the individual's ability to self-regulate and focus on the present moment to effectively cope with stress and challenges (e.g. Reduced usage of alcohol, tobacco, or other addictive drugs to reduce anxiety; increased sleep quality; and better adherence to medical regimens) [45]. Given that maintaining a healthy lifestyle is regarded as the responsibility of both nursing students and their institutions [46], we suggest that the transition period at the clinical placement of nursing programs, as well as during the COVID-19 pandemic, could provide a prime opportunity for institutions to intervene and encourage the adoption of such self-care practices. Thus, this could be able to assist nursing students in preventing mental health problems before they arise.

Social support can be regarded as the threshold for all facilitators, in line with the theory proposed by Feeney and Collins [10], with relational attitudes as the foundation, alongside concentration and lifestyle, forming a supportive environment for thriving PWB. Supportive environments also indirectly enhance psychological well-being via the core category/thriving awareness.

The participants highlight the importance of adaptation, response, and outcome to events and situations due to the benefits of promoting their PWB. Indeed, accomplishments, resilience, intentional self-regulation, epiphany and inspiration, savoring, and self-efficacy share theoretical intersections with conceptualizations of PWB, according to previous models including dimensions such as achievement [8], environmental mastery [13], and meaning [47]. Compared to non-medical peers, nursing students may experience a greater range of life challenges, including but not limited to exposure to death [48], workplace violence, negative portrayal of the nursing profession, and apprehension towards the COVID-19 pandemic [20, 49]. A greater ability to focus on positive experiences is the key to overcoming obstacles and challenges and predicted greater psychological well-being [50]. Specifically, nursing students' ability to better endure negative events and savor positive ones can promote self-acceptance and self-development, exert greater effort in tasks, and achieve greater accomplishments to maintain better psychological well-being [51]. Meanwhile, intentional self-regulation, such as selection, optimization, and compensation, can be used to deal with goal conflict and reach goals [52]. Additionally, a supportive environment predicts increased self-efficacy and perceived control to the extent that it has equipped the nursing students with courage, knowledge, resources, or skills to overcome the adverse circumstance [40, 53], that is, the supportive environment promotes processing, feedback, and adaptation to events and situations by enhancing the self-efficacy of nursing students.

Finally, the results demonstrated that internal drive and self-representation helped promote their PWB. Previous theories have suggested that support can encourage individuals to grow in the face of adversity, motivating them to change their lives, and work to rebuild and persevere through difficult times [54]. Conversely, in good times, a supportive environment can also motivate individuals to stretch to new levels and not settle for good enough, leaving one's comfort zone to grow and reach one's potential [10]. We extended the findings to Chinese nursing students and found that nursing students' internal drive is more likely to increase self-efficacy and self-concept clarity to enhance nursing students' professional self-concept and professional identity, thereby improving self-acceptance and self-growth to promote psychological well-being [15]. As such, we call for nursing students to be aware of the importance of intrinsic motivation to enhance their self-efficacy, as well as a sense of faith and mission in the nursing profession. Meanwhile, institutions could develop initiatives to promote nursing students' motivation and ability to explore novel, challenging, and exciting activities [55], as well as confidence in the nursing profession and nursing culture [56].

However, another noteworthy issue is that most of the nursing students interviewed have a negative self-perceived social identification with the nursing profession, which to some extent also affects their self-representation and self-integrity [57]. This, in turn, was the main reason for the significant decline in nursing students' psychological well-being upon entering clinical placements, as well as the period just entering university time. Therefore, it is also particularly crucial to educate nursing students about the mission of the nursing profession and nursing image [58]. Although previous studies have suggested that self-compassion is associated with increased self-identity and professional identity, very few nursing students interviewed were able to use self-compassion to promote psychological well-being. More fully, there are important differences in the modal cultures that exist in nursing and medicine that might change the way self-compassion is viewed or experienced as well as whether it buffers stress’s effects [59]. Universities could set up positive education for undergraduate nursing students, such as compassion cultivation training (CCT) program [60], self-care education, and resilience intervention [61], promoting self-compassion through nurturing kindness, acceptance, or mindfulness and meditation skills toward the self can aid in the development of a positive view of the self to refer to during negative experiences [15, 62].

The constructivist grounded theory study offers to ingratiate the theoretical model to promote undergraduate nursing students' PWB. Participants generally have experienced both peaks and troughs in their PWB. The psychological counseling and support for nursing students during their clinical placement, the period just entered the university time as well as after the repeated COVID-19 outbreak need to be enhanced. These holistic and multifaceted sets of supportive elements based on a positive psychology perspective are essential to enhance the psychological well-being of nursing students. Nursing educators and administrators should develop appropriate educational programs and interventions based on the findings of the present study to cope with the demand.