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. Author manuscript; available in PMC: 2023 Mar 1.
Published in final edited form as: J Radiol Nurs. 2021 Dec 31;41(1):22–27. doi: 10.1016/j.jradnu.2021.11.001

Self-Care in Nurses

Susan G Williams a,*, Sharon Fruh a, Jennifer L Barinas b, Rebecca J Graves a
PMCID: PMC9007545  NIHMSID: NIHMS1766405  PMID: 35431686

Abstract

The health of nurses impacts the care of patients in healthcare settings today both inside and outside of hospitals. Many papers are written about nurses’ burnout, depression, poor physical and mental health, weight gain, unhealthy eating patterns, back injury, moral negativity, and lack of job satisfaction. However, little attention has been paid to self-care in nurses. The goal of this paper is to discuss the importance of nurses caring for themselves as they work under stressful conditions regularly. Job satisfaction is necessary for nurses to have a healthy work-life balance and a desire to go to work. There are evidence-based interventions that can make a difference in a nurse’s quality of life that can be implemented independently or within the work setting. Suggestions made by researchers include working less than 40 hr/week in a clinical setting, working a consistent time of day without rotations, expressing emotions, taking time to exercise, participating in a support group, and incorporating a place designated as a sanctuary in the clinical setting. Personal ways to improve health include preparing healthy meals before working a shift, getting proper sleep, utilizing cognitive behavioral therapy, participating in mindfulness training, and practicing stress reduction techniques.

Keywords: Self-care, Nurses, Wellbeing, Work environment, Job satisfaction

Nurses are one of the world’s most valuable resources. The World Health Organization (2020) reports that there are over 20.7 million nurses and midwives across the world. They care for patients in hospitals, clinics, home health agencies, rehabilitation centers, nursing homes, schools, and countless other settings (Robert Wood Johnson Foundation, 2021). It is clear that nurses play a crucial role in providing healthcare services for others, but less attention has been paid to health promotion among nurses. Marking the 200th anniversary of Florence Nightingale’s birth and the Year of the Nurse, it is important to recognize the need to promote health and wellbeing among our nursing professionals (American Nurses Association, 2021). One way to do so is by encouraging the use of evidence-based self-care practices to help nurses manage their health over the course of their careers (Healthy Nurse – Healthy Nation, 2017).

Most nurses view serving patients as their duty and give of themselves endlessly despite how they feel on any given day. All over the world, nurses are prepared to care for patients in clinical environments that are often fast-paced and demanding. The nature of this work puts nurses at risk for physical and mental health problems associated with stress and burnout (Maharaj, Lees, & Lal, 2019; Melnyk, 2020). Miller (2011) discusses that burnout in nursing occurs when there is a decrease in job satisfaction and a sense of moral negativity. Burnout may also be associated with negative patient outcomes (Dall’Ora, Ball, Reinius, & Griffiths, 2020). Prior research has described various stressors experienced by nurses including high patient caseloads; workplace incivility; sexual harassment; and exposure to infectious diseases, crises, and death (Bautista et al., 2020; Kahsay, Negarandeh, Dehghan Nayeri, & Hasanpour, 2020). One study found that 44% of nurses experienced verbal abuse by colleagues, and an even greater number (62%) reported abuse by patients (Tucker et al., 2016; Tucker, Harris, Pipe, & Stevens, 2010).

These stressors have several consequences for the wellbeing of nurses as well as the patients for whom they provide care. A recent systematic review of 22 studies found that occupational fatigue among nurses was consistently associated with mental health concerns, work absences, and worsening work performance (Cho & Steege, 2021). Moreover, in a study involving 3,132 nurses, Tucker, Harris, Pipe, and Stevens (2010) found that stress was a reliable predictor of poorer ratings of personal health and work environment. In this study, over half of the participants had a body mass index in the overweight range, and only half reported engaging in regular physical activity. In a similar study in South Africa, Phiri, Draper, Lambert, and Kolbe-Alexander (2014) found that nurses experienced weight gain, hypertension, and barriers to health-promoting activities. Nurses in this study reported that a stressful working environment and long shifts led to extreme fatigue and that limited time and energy were barriers to preparing healthy meals. The hospital environment was also found to offer primarily unhealthy foods with few healthier alternatives (Phiri, Draper, Lambert, & Kolbe-Alexander, 2014). Vending machines are often the only convenient choice for a nurse who is working the night shift at a hospital, and they are known to offer options that are less nutritious. One recent study showed that at hospitals, half of beverages offered in vending machines contained greater than 55g of sugar per serving. Moreover, approximately one-third of foods in these vending machines consisted of candy, while the rest were chips and other sweets (Champ, Iarrobino, & Haskins, 2019).

It is no secret that these problems exist and yet, teaching, encouraging, and normalizing self-care practices among nurses has remained uncommon (Phiri, Draper, Lambert, & Kolbe-Alexander, 2014). Despite these challenges, many nurses aspire to be healthy role models for their patients, families, and communities. Self-care practices, which consist of behaviors that promote and maintain physical and psychological wellbeing, may be key to helping nurses develop self-efficacy and manage their health despite the stressors and obstacles they face (Melnyk, 2020). The purpose of this paper is to discuss how nurses can be empowered to create their own self-care path and encourage other nurses to follow while continuing to work in the challenging yet rewarding field of nursing. Practical and realistic ideas and strategies will be provided as to how to engage in routine healthy self-care behaviors.

Work environment

Researchers recognize that the daily activities of a nurse and the work environment can have an impact on job satisfaction and turnover. Creating a workplace that is supportive to front-line workers and adequate managerial support may be key to promoting job satisfaction as well as quality patient care (O’Brien-Pallas, Murphy, Shamian, Li, & Hayes, 2010). A study of 778 nurses from seven different hospitals in Beijing, China examined work environment, job characteristics, work engagement, and turnover. Results indicated that working in a positive environment was associated with decreased turnover and increased work engagement (Wan, Li, Zhou, & Shang, 2018). Similarly, Lake et al. (2021) reviewed survey data related to safety in 177 hospitals in the United States. These researchers examined safety in pediatric care in general hospitals as well as hospitals that only care for children and not adults; more than half of the pediatric nurse participants (N = 1,875) rated patient safety as less than excellent. Furthermore, 46% of participants felt that mistakes were held against them by administration, and many did not feel safe asking questions related to safety issues. This again emphasizes that hospitals with a safe clinical environment foster satisfaction in nurses (Lake et al., 2021).

Emotional stability is another factor that influences resilience versus burnout. Emotional labor is the act of regulating feelings and expressions while working (Grandey, 2003). In a South Korean study, researchers surveyed 303 nurses from 27 different hospitals. They examined surface acting (regulating and suppressing emotions), deep acting (changing internal feelings to comply with organizational expectations), and expressing naturally felt emotions (genuine emotional expression). These researchers found that nurses who express naturally felt emotions experience lower levels of burnout. Encouraging nurses to express emotions when they are experienced may ultimately improve turnover rate and decrease stress for nurses (Kim, 2020).

Workplace wellness has recently emerged as a focus in nursing research (Lowensteyn et al., 2019; Melnyk, 2020; Melnyk et al., 2018). One such Canadian study included a web-based wellness intervention for 775 employees of a pharmaceutical company to improve/increase exercise, mental health, nutrition, and weight using gamification methods (Lowensteyn et al., 2019). The first goal was to insure employee participation, and the second goal was to sustain physical and mental health improvement. Two years after beginning of the study, participants demonstrated decreased blood pressure, total cholesterol, insomnia, fatigue, glycated hemoglobin, cardiovascular problems, and perception of stress and increased physical activity. Additionally, employees who had higher health risks received the highest benefits from this program (Lowensteyn et al., 2019).

When trying to promote a positive workplace, Miller (2011) suggested mentoring and team building programs as well as reflection on shared values to positively impact nursing job satisfaction and retention. This can occur via a support group in the hospital providing a forum for nurses and other healthcare professionals to discuss challenges and positive situations they experience at work. A free tool kit called The GoodWork Toolkit (https://pz.harvard.edu/resources/the-good-work-toolkit) (was designed by Harvard University and provides discussion questions and scenarios to facilitate discussion about difficult ethical and moral situations (Garner et al., 2001). This may be a place to begin work-related discussions in nursing.

Physical health

Many nurses may suffer poor physical health while caring for their patients, which may be influenced by the activities completed in a typical workday. For instance, a study of 224 nurses from 9 different departments in a hospital found that nurses who worked in areas where manual lifting was involved had a 53% higher prevalence of reporting lower back pain. Nurses who worked in surgery also had a higher prevalence of low back pain (Almaghrabi & Alsharif, 2021). Although it is important to recognize that nurses are needed around the clock, researchers found that working rotating shifts may cause problems with job satisfaction. Ferri et al. (2016) found that nurses working rotating shifts (N = 213) had the lowest scores for quality and quantity of sleep, chronic fatigue, and cardiovascular symptoms compared to nurses who worked only during day shift (Ferri et al., 2016). Finding ways to improve the quality of life and minimizing the rotation of shifts may be an additional way to help increase positive work-life balance of valuable nurses (Chang & Peng, 2021; Lee & Jang, 2020).

Mental health

In almost any clinical setting, nurses will experience stress. Many nurses report personal distress, which, unfortunately, tends to be the responsibility of the nurse to manage without employer support. Providing focused interventions related to decreasing stress while in the work setting may be another key to keeping nurses on the job (Cottrell, 2001). In a study of nurses working in five different hospitals in Tehran, researchers found that spreading a culture of humor may provide positivity to the lives of health professionals. Spreading humor can be taught and could possibly improve the workplace atmosphere (Ghaffari, Dehghan-Nayeri, & Shali, 2015). Another area that has had a positive impact on nurses’ stress is a concept called the Lavender Lounge or “Code Lavender,” which first appeared at the Cleveland Clinic Hospital in Cleveland, Ohio in 2018. A Lavender Lounge was designed as a place for respite during an unusually difficult time when a healthcare provider feels overwhelmed with a situation, such as a death of a patient, to recoup for a short period of time before returning to their stressful environment or situation. This lounge may include a comfortable chair or recliner, electronics’ charging stations, a massage chair, relaxing music, a beanbag chair, coloring books, and even sports equipment such as an indoor basketball hoop. The room is often painted a lavender color and frequently has scented oils (e.g., lavender) to promote relaxation (Gregory, 2021; Johnson, 2014 – Cleveland Clinic; Stone, 2018; You Tube, 2021).

Nurses also have spiritual and emotional ties that often provide them with a feeling of purpose in life and a foundation to cope during challenging situations. In addition, nurses need to feel that their co-workers accept them and that they are understood (Crane & Ward, 2016; Kim & Shin, 2020). In a study related to nurses’ attitudes about death and how it affects spirituality and spiritual care, Ausar, Lekhak, and Candela (2021) conducted a scoping review of 10 studies related to nursing and self-care. Findings indicated that there was very little information about spiritual care in nurses and how they use spirituality to improve their quality of life. Many of the articles were about spiritual care for patients. The spiritual self-care definitions focused on a nurse’s relationship with self and having a transcendent connection with issues beyond self. Furthermore, the review suggested that nurses picture themselves as spiritual individuals and reflect on their continuous journey to increase their spiritual awareness and ability to care for others.

Work-life balance

In nursing, finding the most effective work-life balance is a difficult task. Unsurprisingly, nurses who work full-time (30–40 hr/week) or part-time (≤34 hr/week) in a clinical setting experience more job satisfaction than those who work overtime (Dall’Ora, Ball, Reinius, & Griffiths, 2020). Realistically, however, in hospital settings, many nurses work voluntary or mandated overtime to help meet staffing and patient care needs (Stimpfel, Fletcher, & Kovner, 2019). These challenges have been further exacerbated by the COVID-19 pandemic (Arnetz, Goetz, Arnetz, & Arble, 2020). During this time of unprecedented staffing issues, personal responsibilities, such as children, elderly parents, and household chores, are also important to consider in relation to work-life balance (Chunta, 2020). After accounting for work and personal demands, very little time is left for self-care practices, such as exercising, meditation, or even obtaining a full-nights rest, which in turn can lead to significant impairments (Tierney, 2021).

Varma, Kelling, and Goswami (2016) recognized that nurses are a critical component of healthcare. These researchers developed an instrument, the Work-Life Scale, to assess work-life balance across four domains. The first scale focuses on job-related stressors including patient care, workload, equipment, safety, job security, and the perceived value of the employee in their clinical setting. The second domain focuses on the organizational culture, and assesses level of autonomy, the regularity of scheduling patterns, and whether there is required overtime. Support structure was the third component and assesses support from family, coworkers, and the supervisor of the employee. Finally, the fourth domain assesses training such as stress reduction, coping skills, work environment training, and professional growth. Utilizing the Work-Life Scale may help nurses to identify areas of strength and areas to improve regarding work-life balance to facilitate their functioning both personally and as a practicing professional nurse (Varma, Kelling, & Goswami, 2016).

Radiological nurses

Nurses who work in the radiology department have some of the same stressors as nurses working in the intensive care unit, operating room, or on a medical-surgical floor in the hospital setting. However, there are unique stressors and concerns that radiological nurses may face. Laukhuf and Laukhuf (2016) identified stressors unique to radiological nurses including increased exposure to radiation and risk of back injuries from frequently moving of patients. They also found that radiological nurses report stress related to needing to continually monitor patients and maintain accuracy during procedures, while complying with strict regulations and managing difficult interactions with family members, coworkers, or other hospital professionals. Radiological nurses often must work mandatory overtime due to the specialty nature of their qualifications and the need for emergency interventions. As a result, nurses in this specialty may be more likely to have irregular work schedules and have difficulty with work-life balance (Laukhuf & Laukhuf, 2016).

Waddil-Goad (2019) discusses the importance of radiologic nurses prioritizing self-care, particularly as mid-life approaches. Maintaining a balance of work, family, self, and enjoyment in life must occur to combat stress, fatigue, and burnout. Speaking up for your needs and continuing to maintain your ability to work in a safe, healthy environment are paramount for radiology nurses in our healthcare systems (Waddill-Goad, 2019). Other suggestions for preventing burnout and increasing self-care during this unprecedented time of COVID-19 are provided by Janeway et al., (2020) including a consultation with a psychiatry liaison who can provide a stress management program, a mindfulness stress reduction technique, and meditation app recommendations.

Promoting self-care among nurses

Practicing self-care as a nurse is not a new concept, but this behavior is often overlooked by nurses in a busy day working in a fast-paced environment. Blum (2014) discusses the importance of self-care with reminders that we must compensate with personal, social, physical, psychological, and mental care either before or after working. If we neglect this crucial advice, we may also become a patient in need of specialized care (Blum, 2014).

Mindfulness Strategies

Mindfulness is one of the most well-researched self-care strategies used to promote the wellbeing of nurses (Melnyk, 2020). Mindfulness refers to a set of practices that increase awareness by intentionally attending to and nonjudgmentally observing the present moment (Kabat-Zinn, 2003). Among nurses, mindfulness has been shown to significantly improve regulation of emotions in stressful situations; reduce anxiety and depression; improve communication; and increase empathy (Guillaumie, Boiral, & Champagne, 2016). Thus, mindfulness-based approaches have the potential to improve the wellbeing and work performance of nurses. Most of the mindfulness programs designed for nurses have used Mindfulness-Based Stress Reduction (Kabat-Zinn, 2003), but others have focused on individual mindfulness exercises introduced via workshops (Guillaumie, Boiral, & Champagne, 2016). Examples of mindfulness exercises include formal exercises such as deep breathing, body scans, guided imagery, or meditations and informal exercises such as mindful walks/meditation or yoga (Bernstein, 2019). Mindfulness can be a practical approach for nurses, given that many of these exercises can take as little as 5 min and can be practiced virtually anywhere, especially with the use of mindfulness books (e.g., The Mindful Nurse: Using the Power of Mindfulness and Compassion to Help You Thrive in Your Work by [Sheridan, 2016]; A Mindfulness-Based Stress Reduction Workbook by [Stahl & Goldstein, 2019]), phone applications (e.g., Headspace, Breathe2Relax), and online resources (http://depts.washington.edu/bmindful/meditations/).

Cognitive-Behavioral Strategies

Cognitive-behavioral strategies are also strongly supported by prior research and have often been coupled with mindfulness approaches (Guillaumie, Boiral, & Champagne, 2016; Lan et al., 2014). They have been shown to be effective in improving various conditions including depression, anxiety, stress, insomnia, and health-related behaviors including physical activity, diet, and smoking, while increasing resilience (Luberto, Magidson, & Blashill, 2017; Spears et al., 2017; Yüksel & Yılmaz, 2020). Among nurses, cognitive-behavioral interventions have been shown to effectively reduce stress and anxiety, while improving self-efficacy, healthy lifestyle behaviors, and job satisfaction (Sampson, Melnyk, & Hoying, 2020; Terp, Bisholt, & Hjärthag, 2019; Orly, Rivka, Rivka, & Dorit, 2012; Weiner et al., 2020).

Cognitive behavioral therapy centers on the idea that thoughts, behaviors, and emotions are interrelated; therefore, by changing your behavior or how you approach your thoughts, you can improve how you feel (Leddy, Anderson, & Schulkin, 2013). These skills include identifying unhelpful thoughts such as negative forecasting about the future and behaviors such as avoidance and isolation while learning to develop more adaptive ways of thinking and behaving (Yovel, Mor, & Shakarov, 2014). This may include reflecting on thoughts by checking for assumptions, taking an alternate perspective, and recognizing the positives. Behavioral strategies can include goal setting, problem-solving, and behavioral activation (increasing enjoyable, valued, and goal-oriented activities) (Hughes et al., 2020; Huguet et al., 2018). For nurses, this may look like setting realistic, attainable goals for physical activity; addressing work-related stressors; and improving work-life balance by protecting time with family and friends. Cognitive behavioral interventions for nurses are often delivered via in-person workshops, and studies support that this often improves understanding and engagement (Strauss et al., 2021). Still, there are several accessible and practical resources for learning these self-care strategies independently, including books or work-books—Inner Spark: Finding Calm in a Stressful World (Vikjord, 2020), The Art of Mindfulness (Farrarons, 2018), Ten to zen: Ten minutes a day to a calmer, happier you (O’Kane, 2018), Stress less-accomplish more (Fletcher, 2019: Audio book), What happened to you? Conversations on trauma, resilience, and healing (Perry & Winfrey, 2021: Audio book)—phone applications (e.g., Thought Challenger), and online programs (MoodGYM, StressGYM) (Pospos et al., 2018).

Physical Activity and Nutrition Strategies

Nurses frequently struggle with getting appropriate nutrition and exercise when working 12-hr shifts in most hospital settings. In a qualitative study with 24 new registered nurses, Brogan, Rossiter, Duffield, and Denny-Wilson (2021) examined healthy eating and physical activity, identifying four barriers: time, shift work, work environment, and work culture. Although participants had high interest in a healthy work environment, these nurses discussed that unhealthy snacking related to lack of time to eat healthy food, lack of energy, and reduced motivation played a big role in these poor habits. Suggestions for better nutrition included being aware of the amount of sugar, fat, and carbohydrates in food consumed in a typical day at work (Crane & Ward, 2016). Often nurses who take the time to “meal prep” their breakfast, lunch, and dinner on days that they are off so that they will have healthy food on the days that they are working consumed much healthier nutrition that can be heated or refrigerated easily at the workplace compared to getting “fast food” in the typical hospital cafeteria (Nicholls, Perry, Duffield, Gallagher, & Pierce, 2017).

Sleep Hygiene

Regularly sleeping an average of 6 to 8 hr per night (or day, depending on the nurse’s work schedule) benefits overall well-being, cognitive function, control of hormones, appetite, memory, the immune system, short- and long-term memory, as well as stress reduction (Perkins, 2021). Eanes (2015) defined insufficient sleep and sleep debt as occurring when a person sleeps less than 7 to 8 hr over multiple days. This sleep loss may not only impair memory, learning ability, performance, and judgment, but it has also been linked to motor vehicular injuries, weight gain and obesity, and musculoskeletal injuries. Furthermore, Eanes (2015) suggests only scheduling nurses for a maximum of three consecutive workdays consisting of 12-hr shifts, and if possible, encouraging nurses to take a short break or nap away from the work area during a shift to refresh.

At home, standard sleep hygiene is recommended, including maintaining a regular sleep schedule (as much as possible) and sleeping in a dark, quiet, and cool space. An important aspect of sleep hygiene is practicing stimulus control and reducing sleep-interfering arousal. For instance, it is best to avoid eating heavily before bedtime, using a cell phone or computer close to bedtime, and sleeping with the television on. In addition, avoiding caffeine, nicotine, alcohol, and other stimulating activities before going to bed can lead to better sleep patterns (Eanes et al., 2020). Perkins (2021) reminds us that spending time in the sun and keeping naps to a maximum of 20 to 30 min can help maintain a regular circadian rhythm. For nurses experiencing difficulties falling asleep, practicing relaxation techniques, such as deep breathing, meditation, or progressive relaxation, may be beneficial. If insomnia is a persistent concern or if additional support is needed, it may be helpful to consider seeking cognitive behavioral therapy for insomnia (CBT-I) (Sleep Foundation.org).

COVID-19 and self-care

Since the coronavirus disease 2019 (COVID-19) was identified in December 2019, there have been over 241,411,380 million cases worldwide, with over 4,912,111 million deaths as of October 15, 2021 (World Health Organization [WHO], 2021). In the United States, there have been 44,771,558 million cases of COVID-19 and 722,690 million deaths as of October 15, 2021 (World Health Organization, 2021). Although these statistics are alarming, nurses working on the front line in hospitals, urgent care centers, ambulatory care settings, outpatient surgery centers, and many other public settings must continue to work (Foli, Forster, Cheng, Zhang, & Chiu, 2021). Labrague and de los Santos (2020) examined the fear of COVID-19 by nurses and how this affects psychological distress, satisfaction with work, and the intent to leave the work-place. These researchers found that in 261 nurses working on the front lines of health care, the fear of COVID-19 was related to more psychological distress, decreased job satisfaction, and increased turnover (Labrague & de los Santos, 2020).

In 2020, nurses had to care for patients in the hospital without family members by their sides, and often the patients died alone. Other issues in the current COVID-19 pandemic have been a lack of personal protection supplies, short staffing, and frequent changes in protocols. A nurse caring for a patient and facing this psychological distress, time restraints, and limited equipment and support during a crisis frequently experiences ethical conflict and moral injury (Foli et al., 2021; Hossain & Clatty, 2021).

Employing tools to decrease stress may be vital for coping during this crucial time in our history. Monteverde (2014) discusses that individuals with moral resilience are empowered to address complex, distressing, and uncomfortable situations. It is essential to recognize that some situations are beyond a nurse’s control, and the inability to improve that situation is not a personal weakness (Cacchione, 2021). Further suggested by Cacchione (2021) is for nurses to remember that they must first take care of themselves to care for others and be present to those they love. It is essential to know your limits and to reach out for help when needed. Trying to do something that brings you joy at least once per day and practicing 5 min of meditation can also ease some of the hour-by-hour stress nurses are facing daily. Self-care can lead to a better understanding of yourself, a better quality of life, and a chance to grow in personal enhancement (Nelson, Hall, Anderson, Birtles, & Hemming, 2018). Self-care goes hand in hand with self-compassion, which can be implemented by being kind to ourselves and treating ourselves as we would treat a friend by providing comfort and resisting harshness. It is wise to acknowledge that we are hurting without judging ourselves. It is self-affirming to recognize that we are human and make mistakes (Nelson, Hall, Anderson, Birtles, & Hemming, 2018).

Conclusion

Radiology nurses are facing difficulties maintaining a balance in self-care along with most nurses especially during this unprecedented time of stress in hospital inpatient, outpatient surgery clinics, physician offices, and urgent care settings. The information presented reviews how self-care practices can help promote the health and wellbeing of nurses. It highlights various sources of stress and the importance of addressing multiple aspects of functioning, including the work environment, physical health, mental health, work-life balance, and spiritual wellbeing. The techniques presented are evidence-based and emphasize practical strategies to help nurses incorporate self-care into their lives. It is important that fellow nurses, managers, hospital administrators, and others empower nurses to invest in their self-care just as much as they invest in taking care of their patients. Suggestions provided included developing workplace interventions such as cognitive behavioral and mindfulness workshops, promoting self-care mobile phone apps, as well as creating a safe space for respite (a Lavender Lounge) specifically for departments that tend to experience more potentially emotionally taxing or stressful situations (e.g., the intensive care unit, COVID-19 floors, etc.). When nurses practice self-care and have sufficient personal and systemic support, the results are healthier, happier, and longer lasting futures in the field of nursing.

Funding:

University of Alabama at Birmingham Center for Clinical and Translational Science - UL1TR003096.

Footnotes

CRediT authorship contribution statement

Susan G. Williams: Conceptualization, Writing – original draft, Visualization, Investigation, Writing – review & editing. Sharon Fruh: Conceptualization, Writing – original draft, Visualization, Investigation, Writing – review & editing, Funding acquisition, Supervision. Jennifer L. Barinas: Writing – original draft, Investigation, Writing – review & editing. Rebecca J. Graves: Writing – original draft, Investigation, Writing – review & editing.

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