Healthy Lifestyle Behaviors and Health Promotion Attitudes in Preregistered Nurses: A Questionnaire Study.

TL;DR: In this paper, the authors investigate attitudes towards being role models for healthy eating, and examine predictors of health promotion attitudes in pre-registered nurses as health professionals of the future.

Abstract: Background: Nurses report inadequacies in health promotion practices and recognise their own lifestyle choices influence their willingness to give health promotion advice. The aim of this study was to investigate attitudes towards being role models for healthy eating, and examine predictors of health promotion attitudes in pre-registered nurses as health professionals of the future. Method: Questionnaire survey with 493 pre-registered nurses. Measures included health promotion attitudes, healthy lifestyle index (combining diet and physical activity habits), self-esteem and body satisfaction. Results: Pre-registered nurses (89.5%) felt that nurses should be role models for health; at the same time 37% had rather negative health promotion attitude. Those who disagreed were more likely to be dissatisfied with their body and lead less healthy lifestyles. Most pre-registered nurses (96%) felt that delivering health promotion would be a key element of their job and held positive health promotion attitudes. Healthy lifestyle was the most consistent significant predictor of health promotion attitude. Conclusion: Pre-registered nurses with unhealthy lifestyle, lower self-esteem (and body dissatisfaction among overweight/obese student nurses) held more negative health promotion attitude. Intervention is needed to support pre-registered nurses in making healthy lifestyle choices, improving self-perception and health promotion attitude.

Summary

IN PRE-REGISTERED NURSES

• An early meta-analysis showed that self-esteem was lower in individuals with higher BMI than in those with a healthy weight (Miller & Downey, 1999) .
• The aims of the study were: [1] to investigate pre-registered nurses' opinions of being role models for healthy eating and their attitudes, and confidence towards giving health promotion advice; [2] to investigate the relationship between BMI, self-esteem, selfperception, healthy lifestyle and attitudes towards health promotion.

Methods

• Ethical approval was granted by the local institutional review board in March 2014.
• The completion of the study was voluntary and anonymous.
• Informed consent was assumed from return of the questionnaire.

Measures

• Five constructs were measured in this study: (a) demographics, (b), self-reported healthy lifestyle index combining diet and physical activity habits, (c) health promotion attitude (including Likert scale and three binary questions), (d) self-esteem, and (e) body satisfaction.
• Healthy lifestyle was reported by each participant through their responses to questions created by the authors, starting with how healthy they considered their own diet to be.
• For the purpose of this study, it was considered that the higher the score on this index, the healthier was the reported lifestyle.
• The scale has high test-retest reliability and low social desirability (e.g., McMullen & Resnick, 2013) .
• The level of reliability of this scale was satisfactory, with Cronbach's α=.86.

Results

• This section provides information regarding sample demographics (Table 2 ), together with results demonstrating variables affecting pre-registered nurses' attitude toward health promotion (Tables 3, 4 and 5 ).
• Of the 868 pre-registered nurses invited to participate, 535 responded (67%), but 42 (8%) did not provide height and weight and were not included in analysis.

Sample Characteristics

• Respondents were 493 pre-registered nurses (62% response rate; 90% female) from all four years of a degree programme.
• Age and gender were controlled for in the analyses of group differences (see Table 2 ).
• 43% (n=230) of student nurses viewed their diet as rather healthy (equal or higher than seven on the 10-point healthy diet scale).
• Body dissatisfaction was prevalent with 78% (n=414) of the preregistered nurses expressing dissatisfaction.
• On average the attitudes towards health promotion (HPA) of pre-registered nurses were more likely to be negative or neutral rather than positive (M=2.22, SD=.52; range 1 -4; where 1 = strongly negative, and 4 = strongly positive), as over one-third (n=175, 37%) of the pre-registered nurses scored ≤ 2, where 2 represented a rather negative attitude.

Relationships Between Variables

• This suggests that pre-registered nurses with a healthier lifestyle and those with higher self-esteem are more likely to hold positive attitudes towards health promotion.
• Similarly, there was a significant relationship between HPA and body dissatisfaction (r = -.11, p = .02).
• These partial correlations (controlling for age and gender) are shown in Table 3 .

Multivariate Regressions

• Age, gender, BMI, healthy lifestyle, body dissatisfaction, self-esteem and year of study were entered into a multiple linear regression model predicting the HPA of pre-registered nurses (see Table 4 , left panel).
• Where possible (given adequate sample sizes) the binary logistic regression models were conducted, if else, percentage comparison and qualitative results are reported.
• There were 113 (23%) pre-registered nurses who reported that they would not feel competent giving health advice.
• Delivering healthy eating advice as a nurse.
• The analysis of the open-ended responses indicated that the majority of participants held a belief that nurses would not be good health models if they lead an unhealthy lifestyle, for example, if they smoke, eat unhealthily, do not exercise, or are overweight.

Discussion

• This study investigated pre-registered nurses' opinions of being role models for healthy eating and their attitudes, and confidence towards giving health promotion advice.
• This is based on self-reports that are more likely to over-estimate healthy eating and physical activity behaviours, and underestimate weight, than the reverse (especially among obese participants: e.g., Lichtman, Pisarska, Raynes-Berman, Pestone, Dowling, Offenbacher, Weisel, Heshka, Matthews, & Heymsfield, 1992).
• This study showed that pre-registered nurses with a healthier lifestyle felt more competent to deliver health promotion.
• The majority of the pre-registered nurses in this study thought that nurses should be role models for health, which is consistent with previous findings (e.g., Blake et al., 2011; ) .
• Some early efforts were made to address this need, through electronic learning tools offered in some institutions to promote health amongst student and registered nurses, for example, in Taiwan (Hsiao, Chen, Gau, Hung, Chang, & Tsai, 2005; Yu & Yang, 2006) .

Limitations

• The findings reported here are based on self-reported cross-sectional data from a sample of pre-registered nurses at a single institution, although participants were based on multiple hospital sites, and the demographics and health lifestyle profile of the sample were broadly comparable with samples of pre-registered nurses in previous studies (e.g., Malik et al., 2011) .
• The healthy lifestyle index was a simple measure targeted only to diet and physical activity behaviour and does not include other aspects of healthy living.

Conclusion

• Pre-registered nurses' health promotion attitudes depended on their own health-related dietary and physical activity practices and self-perception.
• Pre-registered nurses should be equipped with early training around core concepts of healthy lifestyle, including diet, physical activity and weight management.
• Educational institutions should seek to generate a health-promoting culture and facilitate healthy lifestyle choices amongst preregistered nurses as their next generation of nurses, nurse educators and placement mentors.
• Items creating Health Promotion Attitude (HPA) scale, with scale's description.

Figures

Table 5. Binary regression coefficients for models predicting feeling competent in delivering health advice (n=457).

Full text

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Citation for published item:
Blake, H. and Stanulewicz, N. and Griths, K. (2017) 'Healthy lifestyle behaviors predict health promotion
attitudes in pre-registered nurses: a questionnaire study.', Journal of nursing education., 56 (2). pp. 94-103.
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Blake, Holly and Stanulewicz, Natalia and Griffiths,
Katherine (2016) Healthy lifestyle behaviours predict
health promotion attitudes in pre-registered nurses.
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1
HEALTHY LIFESTYLE BEHAVIOURS PREDICT HEALTH PROMOTION
1
ATTITUDES IN PRE-REGISTERED NURSES: A QUESTIONNAIRE STUDY
2
Holly Blake
1
, Natalia Stanulewicz
2
, Katherine Griffiths
3
3
4
1
School of Health Sciences, University of Nottingham, UK.
5
2
School of Psychology, University of Nottingham, UK.
6
3
Nottingham University Hospitals NHS Trust, Nottingham, UK.
7
8
Holly Blake PhD CPsychol
9
Associate Professor of Behavioural Science, School of Health Sciences, University
10
of Nottingham, Queen's Medical Centre, Nottingham, Nottinghamshire.
11
12
Natalia Stanulewicz MA (corresponding author)
13
Doctoral student, School of Psychology, University of Nottingham, Nottingham,
14
Nottinghamshire.
15
address: Natalia Stanulewicz
16
School of Psychology, East Drive, University Park Campus, University of
17
Nottingham, Nottingham, Nottinghamshire, NG7 2RD, United Kingdom
18
e: lpxnkk@nottingham.ac.uk
19
20
Katherine Griffiths MNursSci
21
Staff Nurse, Queen's Medical Centre, Nottingham University Hospitals NHS Trust,
22
Nottingham, Nottinghamshire.
23
24
25

2
HEALTHY LIFESTYLE BEHAVIOURS PREDICT HEALTH PROMOTION ATTITUDES
26
IN PRE-REGISTERED NURSES
27
Abstract
28
Background: Nurses report inadequacies in health promotion practices and recognise their
29
own lifestyle choices influence their willingness to give health promotion advice. The aim of
30
this study was to investigate attitudes towards being role models for healthy eating, and
31
examine predictors of health promotion attitudes in pre-registered nurses as health
32
professionals of the future.
33
Method: Questionnaire survey with 493 pre-registered nurses. Measures included health
34
promotion attitudes, healthy lifestyle index (combining diet and physical activity habits), self-
35
esteem and body satisfaction.
36
Results: Pre-registered nurses (89.5%) felt that nurses should be role models for health; at the
37
same time 37% had rather negative health promotion attitude. Those who disagreed were
38
more likely to be dissatisfied with their body and lead less healthy lifestyles. Most pre-
39
registered nurses (96%) felt that delivering health promotion would be a key element of their
40
job and held positive health promotion attitudes. Healthy lifestyle was the most consistent
41
significant predictor of health promotion attitude.
42
Conclusion: Pre-registered nurses with unhealthy lifestyle, lower self-esteem (and body
43
dissatisfaction among overweight/obese student nurses) held more negative health promotion
44
attitude. Intervention is needed to support pre-registered nurses in making healthy lifestyle
45
choices, improving self-perception and health promotion attitude.
46
47
Key words: Health promotion, healthy lifestyle, nurses, obesity, self-perception.
48

3
HEALTHY LIFESTYLE BEHAVIOURS PREDICT HEALTH PROMOTION ATTITUDES
49
IN PRE-REGISTERED NURSES
50
Excess weight and obesity are a major population health issue in the United Kingdom
51
(NOF, 2014) and worldwide (James, 2004), with devastating effects for individual health,
52
healthcare services and the economy. As the advocates for health, nurses play an important
53
role in health promotion and the reduction of population obesity (Prime Minister’s
54
Commission, 2010). As such, patients view nurses as role models for health (Blake, 2013).
55
Nurses generally agree with this view, and recognise that their lifestyle choices can influence
56
those of their patients (e.g., poor diet and smoking: Blake & Harrison, 2013). However,
57
nurses often do not lead healthy lifestyles themselves (McElligott, Siemers, Thomas, &
58
Kohn, 2009), which can negatively impact on care quality (Hebert, Caughy, & Shuval, 2012;
59
Lobelo, Duperly, & Frank, 2009) and their credibility (Blake & Harrison, 2013), as healthcare
60
professionals who lead healthy lifestyle are more likely to deliver health promotion to
61
patients than those who do not (Hebert et al., 2012, Lobelo et al., 2009). Nurses have reported
62
previously that being overweight or engaging in unhealthy behaviours would reduce their
63
willingness to promote health promotion to their patients (Blake & Patterson, 2015).
64
Even though nurses largely agree that it is important for them to make healthy lifestyle
65
choices, this view does not necessarily translate into a healthier nursing workforce. In the
66
UK, the Department of Health (DH, 2009) reported that 58% of nurses working for the
67
National Health Service (NHS) were overweight; with 25% being obese. This is close to the
68
amount of people with BMI > 25 in the general UK population – 61.7% (PHE, 2015), which
69
is concerning taking into account the health-related education and training that nurses
70
receive. Still, overweight and obesity remain prevalent amongst pre-registered (student) and
71
registered (qualified) nurses (e.g., DoH, 2009; Blake, Mo, Lee, & Batt, 2012). Dietary habits
72
are less than exemplar among nurses (especially among pre-registered nurses), as many of
73

Frequently asked questions

Q1. What are the contributions in this paper?

The aim of 30 this study was to investigate attitudes towards being role models for healthy eating, and 31 examine predictors of health promotion attitudes in pre-registered nurses as health 32 professionals of the future. 

Q2. What were the measures of health promotion attitudes among pre-registered nurses?

Measures included health 34 promotion attitudes, healthy lifestyle index (combining diet and physical activity habits), self-35 esteem and body satisfaction. 

Q3. What is the main reason why pre-registered nurses are not able to make healthy?

Supporting pre-registered nurses in making 338 healthy diet and exercise lifestyle choices may help to enhance body satisfaction, particularly 339 in those who are dissatisfied with their body or have negative self-perception; in their study 340 these individuals tended to be those who were overweight or obese. 

Q4. What county did the pre-registered nurses hold positive health promotion attitudes?

Most pre-39 registered nurses (96%) felt that delivering health promotion would be a key element of their 40 job and held positive health promotion attitudes. 

Q5. How many NHS trusts have invested in health promotion initiatives?

423 Following the NHS Five Year Forward View (2014), £5million has recently been invested in 424 exemplar NHS trusts for enhancing their workplace initiatives to support and improve 425 physical and mental health in hospital employees. 

Q6. What was the average self-esteem score of the pre-registered nurses?

Of the 868 pre-registered nurses invited to participate, 535 167 responded (67%), but 42 (8%) did not provide height and weight and were not included in 168 analysis. 

Q7. How many pre-registered nurses did not meet the 185 government guidelines for physical activity?

184Almost one third (32%, n=160) of the pre-registered nurses did not meet the 185 government guidelines for physical activity (i.e., a minimum of 30 minutes of moderate 186 physical activity on at least five days per week: DoH, 2011), and these were mostly the 187 overweight/obese nurses (Χ 2 = 7.16, p = .007). 

Q8. What was the only significant predictor for the feelings of competence?

The only significant predictor for the feelings of competence was healthy lifestyle 244 (B = -.12, p = .003; Wald = 8.80; odds = .89) (see Table 5). 

Q9. What percentage of the pre-registered nurses did not meet the government recommendations for healthy eating?

An exceptionally high proportion of the sample 274 (83%) did not meet generic government recommendations for healthy diet (‘5-a-day’) even 275 though just under half the sample believed that they consumed a healthy diet.