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Letter to the Editor

Factors Related to Healthy Diet and Physical Activity in Hospital-Based Clinical Nurses

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Nancy M. Albert, PhD, CCNS, CHFN, CCRN, NE-BC, FAHA, FCCM
Robert Butler, MS
Jeanne Sorrell, PhD, RN

Abstract

Hospitals often promote healthy lifestyles, but little is known about nurses’ actual diet and physical activity. Greater understanding about these lifestyle choices for clinical nurses may improve existing hospital-based programs and/or create desirable services. This article discusses a study that considered diet and physical activity of clinical nurses, using elements of Pender’s self-care theory as a conceptual framework. Study methods included a cross-sectional, correlational design and a convenience sample of 278 nurses who worked on units with 24 hours/day and seven days-per-week responsibilities. Participants completed diet and exercise questionnaires about perceptions of attitudes and opinions, barriers, diet benefits/exercise motivators, self-efficacy, and locus of control, and personal and work characteristics. Diet and activity categories were created. Study results demonstrated that over 50% of nurses had moderately healthy diets but were insufficiently active. Healthy diet and physical activity levels were associated with higher self-efficacy, more diet benefits and physical activity motivators, fewer perceived barriers, and confidence in body image. The article discussion and conclusion sections note areas for future research and suggest that focused interventions that address benefits, motivators, and self-efficacy may increase participation in hospital-based programs and enhance healthy lifestyle for hospital-based clinical nurses.

Citation: Albert, N. M., Butler, R., Sorrell, J., (September 30, 2014) "Factors Related to Healthy Diet and Physical Activity in Hospital-Based Clinical Nurses" OJIN: The Online Journal of Issues in Nursing Vol. 19, No. 3, Manuscript 5.

DOI: 10.3912/OJIN.Vol19No03Man05

Key words: body image, physical activity, exercise, diet, smoking, locus of control, attitudes, motivators of physical activity, benefits of healthy diet, self-efficacy, shift work, Pender health promotion model, wellness program

...knowledge about [healthy behaviors] does not necessarily transfer to nurses’ own lifestyle behaviors. Nurses serve an important role in promoting healthy lifestyle behaviors for their patients. Researchers have demonstrated, however, that knowledge about this area does not necessarily transfer to nurses’ own lifestyle behaviors (Malik, Blake, & Batt, 2011). Healthy lifestyle behaviors can encompass many factors that promote wellness. For the purpose of this article, healthy lifestyle is operationalized as behaviors reflecting a healthy diet and engagement in physical activity and exercise.

In a study of 194 nurses from six hospitals, the majority of nurses were overweight and self-reported health, diet, and physical activity (PA) behaviors were low (Zapka, Lemon, Magner, & Hale, 2009). Various stressors, such as long working hours, shift work, responsibilities for difficult patients, and a continually changing work environment may affect nurses’ adoption of healthy lifestyle behaviors and put them at risk for obesity (Han, Tinkoff, Storr, & Geiger-Brown, 2011). However, investigation of factors associated with healthy lifestyles in this population is limited. In a systematic review of interventions focused on healthy lifestyle promotion for nurses, Chan and Perry (2012) found only three intervention studies. Authors pointed out that since nurses working full time spend almost one quarter of their lives in the workplace, it is important to identify factors in the work environment that affect healthy lifestyle behaviors.

...since nurses working full time spend almost one quarter of their lives in the workplace, it is important to identify factors in the work environment that affect healthy lifestyle behaviors. The Surgeon General made a recommendation for Creating Healthy Worksites and called for establishment of work environments that facilitate and encourage employee participation in healthy eating choices and exercise (Surgeon General, n.d; Fitness Works, 2011). In spite of an increasing numbers of employer-sponsored healthy lifestyle programs, including multiple healthy lifestyle programs in our own workplace, the Cleveland Clinic, little is known about the impact of such programs for nurses. Greater understanding of diet and activity behaviors among clinical nurses, who work irregular shifts and long workdays, will aid in determining best practices related to healthy lifestyle programming for these individuals.

This article discusses a cross-sectional, correlational study that considered diet and physical activity in a convenience sample of clinical nurses, using elements of Pender’s self-care theory as a conceptual framework. Study results demonstrated that over 50% of nurses had moderately healthy diets but were insufficiently active. The article discusses areas for future research and suggests that focused interventions that address benefits, motivators, and self-efficacy may increase participation in hospital-based programs and enhance healthy lifestyle for hospital-based clinical nurses.

Study Conceptual Framework

Elements of Pender’s holistic predictive model of health-promoting behavior on wellness were used as a framework for this study (Pender, Murdaugh, & Parsons, 2011). Health promotion by Pender was defined as behavior motivated by the desire to increase well-being and actualize human health potential. Pender’s model integrates research findings from nursing, psychology and public health and includes key concepts related to the person, environment, nursing, health and illness.

Health promoting behavior is based on individual characteristics and experiences and behavior-specific cognitions and affect. Health promoting behavior is based on individual characteristics and experiences and behavior-specific cognitions and affect. Specific components from Pender’s model used in this research to determine their influence on healthy diet and physical activity behavioral outcomes were both individual characteristics (current dietary and activity behaviors and personal factors), and four of eight behavior-specific cognition factors (perceived benefits of action; perceived barriers to action; perceived self-efficacy; and interpersonal influences including family, work colleagues, work leadership, and others). Aspects of Pender’s model that were not a focus for the purposes of this study were activity-related affect prior to behavior, situational influences, commitment to a plan of action (intentions to carry out healthy lifestyle behaviors) and preferences or alternate behaviors that include immediate competing demands with healthy lifestyle behaviors.

The Pender model of health promotion is helpful for conceptualizing the complex relationships between variables that determine nurses’ commitment to a healthy lifestyle. Identification of healthy diet and physical activity attitudes and opinions, benefits (healthy diet), motivators (exercise), barriers, and self-efficacy within Pender’s model of health promotion can help enhance understanding of the multifaceted nature of healthy lifestyle among medical-surgical hospital nurses.

Review of Literature

Healthy Dietary Habits

Although nurses comprise a large part of the adult workforce, little research is available on dietary patterns or obesity prevalence in this population (Zapka et al., 2009). In the United Kingdom, 1,452 hospital employees in the National Health Service, including many nurses, completed surveys to assess health and wellbeing before development of a workplace wellness intervention. In total, 43% of participants were classified as overweight (Blake, Mo, Lee, & Batt, 2012). No nursing studies were identified that focused specifically on understanding the current diet and factors associated with a healthy diet. In the United Kingdom, a majority of hospital employees believed they had a healthy diet, yet over half of the participants stated they did not eat the recommended daily intake of fruit or vegetables and over one third admitted to eating foods high in fat and sugar (Blake et al., 2012). Physicians in the United Kingdom identified the most frequent barriers to healthy eating as cafeteria opening times, lack of selection of healthy food items, and lack of breaks (Winston, Johnson, & Wilson, 2008).

Physical Activity

In general, adults lack healthy physical activity behaviors. In general, adults lack healthy physical activity behaviors. In the United Kingdom, 45% did not meet physical activity guidelines of 30 minutes per day of moderate activity (Blake et al., 2012). Common barriers to engaging in physical activity were lack of time, feeling tired, and lack of motivation (Blake et al., 2012; Malik et al., 2011). When barriers and facilitators to physical activity in the workplace were studied, time was a universal concern, and specific issues were shift work, scheduling and work conflicts (Blake et al., 2012; Fletcher, Behrens, & Domina, 2008; Stutts, 2002). Facilitators of physical activity were self-efficacy for physical activity (Stutts, 2002) and health; however, white-collar workers were more concerned with appearances and were motivated by quick weight loss through exercise (Fletcher et al., 2008).

Healthy Lifestyle Programs in the Workplace

Reports in the literature that assessed healthcare worker healthy lifestyle did not discuss the availability of healthy lifestyle programming in the workplace. At our worksite, many healthy lifestyle programs were in place at study initiation and healthy lifestyle behaviors were promoted by the hospital’s chief executive officer, both internally at town hall meetings and externally in the press. Healthy lifestyle programs included four themes; physical activity (including access to a fitness center with strength and cardio equipment, pool access, and group activities, such as wellness walks); an online healthy eating and weight program (including encouragement for employees to work in teams to eat better, become more active, and lose or maintain weight through use of a social networking platform); stress management (including yoga classes and a cell phone app that promoted daily meditation); and tobacco cessation (providing one-on-one support and resources to increase understanding of treatment options and develop a customized plan to lead a tobacco-free life). Other features in our workplace that promoted healthy lifestyles were the ability to purchase only non-sugary soda beverages from the cafeteria and vending machines; use of signs with calories and nutrition facts by each cafeteria food item; increased visibility of healthier snacks and removal of many unhealthy snacks (e.g., baked chips and fresh fruit rather than chocolate, sugary candies, and baked goods); and signage with distance walked on long skyways. Availability of both dietary and physical activity healthy lifestyle programs in the workplace could be considered a situational factor that promotes healthy lifestyle behaviors among nurses.

The purpose of this study was to determine if selected individual and behavior factors identified in Pender’s model of health-promoting behavior were associated with healthy diet and physical activity level among clinical nurses who were exposed to healthy lifestyle workplace programs. Specific research questions were:

  1. What is the current level of healthy diet and physical activity behaviors?
  2. What individual and behavior-specific cognition factors are associated with healthy diet?
  3. What individual and behavior-specific cognition factors are associated with physical activity and exercise?

Methods

This research study used a cross-sectional, correlational design and survey methods to address the research questions. The hospital Institutional Review Board approved the research protocol prior to study initiation and participants reviewed a research information sheet that described confidentiality of data and anonymity.

Setting and Sample

Exposure to the hospital-based healthy lifestyle dietary and physical activity and exercise programs was available through newsletters, electronic mail, and website stories. Hospital-based, clinically-active registered nurses on the main campus of Cleveland Clinic, a quaternary care medical center in Northeast Ohio, were invited to participate. Exposure to the hospital-based healthy lifestyle dietary and physical activity and exercise programs was available through newsletters, electronic mail, and website stories. Nurses were enrolled in the study using convenience sampling. Since our goal was to have diversity in work shifts and job duties, nurses were included if they worked on a hospital nursing unit (medical, surgical, specialty care or critical care) that had 24 hours/day and seven days-per-week responsibilities. Nurses were excluded if they had work roles that were primarily office or desk jobs or worked daytime business hours, such as educators, clinical nurse specialists, administrators, directors, and case managers.

Outcomes and Outcome Measurement

Current level of healthy diet. Current level of healthy diet was measured using five of nine dietary items from the Survey of Dietary and Exercise Habits (Silliman, Rodas-Fortier, & Neyman, 2004). The nine-item survey of dietary habits used multiple choice response sets that allowed choice of all-that-apply. Of the nine items, four dietary habit items were used as background information since they focused on snack, beverage, and alcohol consumption. The five items used to determine the level of healthy diet included the frequency of consuming milk or yogurt, lean meat, non-lean meats, vegetables, and fruit. Multiple choice responses available to determine healthy diet varied in wording and in the number of options, based on the food item. Generally, options ranged from never or do not consume the item to consuming the item multiple times per week. Scores were summed and subjects were categorized as having unhealthy, moderately healthy, or mostly healthy dietary habits.

Current level of physical activity. Current level of physical activity was measured using two of three activity items from the Survey of Dietary and Exercise Habits (Silliman et al., 2004). All activity items used multiple choice responses. Exercise was defined as 20 to 30 minutes of activity that increased heart rate, increased respiratory (listed in tables as resp) effort and caused perspiration or sweating. One of the two items used to determine physical activity and exercise habits assessed the amount of time spent in exercise in the last 30 days. The four-option response set ranged from zero-to-two times per week to five or more times per week. The second item asked participants to report the level of intensity of their usual exercise based on three response options, light, moderate, or heavy. Response options were combined and categories of not active, insufficiently active, and active were created. The third item, not used in determining the level of physical activity, asked nurses to select the types of activities they usually completed. There were five specific options (e.g., cross training and competitive sports) and one option was other.

Attitudes/opinions; benefits (diet); motivators (physical activity); self-efficacy; and barriers. Attitudes and opinions; self-efficacy (self-confidence); benefits of healthy diet and motivators of physical activity; and barriers of healthy diets and physical activity/exercise were derived from the Obstacles to Action questionnaire (Hutton et al., 2010) that was based on the North American Healthstyles questionnaire (Maibach, Maxfield, Ladin, & Slater, 1996). The questionnaire was developed using five steps that included cognitive testing, and assessment of internal reliability. Cronbach’s alpha for all but one factor of self-efficacy was at or above 0.879 (Pawlik & Colby, 2009). Psychometric properties of the Healthstyles questionnaire were previously reported. Each factor had good reliability, discriminative and construct validity, and predictive validity (Hutton et al., 2010). All factors used Likert scale response sets. Table 1 provides additional information about each scale.

Table 1. Description of Factors Assessed for relationships to Healthy Lifestyle Behaviors

Healthy Lifestyle Factor

Description of Statements Used

Number
Items

Response Options

Cronbach’s Alpha*

Diet

   Attitudes and   

    Opinions

… about the healthfulness of whole wheat bread; whole wheat cereal; oatmeal; flaxseed; unsalted nuts; fruits; orange vegetables; green vegetables; beans; red meat; processed meat

11

6-options; 0= I do not know, 1= very unhealthy to 5= very healthy

0.72

   Barriers

… too expensive; do not taste good; takes too long to prepare; not sweet enough; not salty enough; too low in fat; do not satisfy cravings; unsure how to find healthy foods in grocery store; do not know how to prepare; children do not like healthy foods; friends do not like healthy foods; spouse does not like healthy foods

12

7-point scale; 1= doesn’t influence me at all to 7= influences me a lot

0.87

   Benefits

… feel better; take care of body; lose weight; more nutrients; healthier; energy; look young; cleanse body; advice from doctor/nurse; biblical diet; avoid constipation

11

7-point scale; 1= doesn’t influence me at all to 7= influences me a lot

0.88

   Self Efficacy

(self-confidence)

…when bored, frustrated, stressed, lonely, angry, depressed, anxious, happy, feeling good, at restaurants, when only unhealthy foods available; have to prepare healthy meals; healthy meals are too much trouble; need to cook it; substituting healthy for unhealthy food is a pain; eating unhealthy is more convenient 

16

10-point scale; 1= not at all confident to 10= extremely confident

0.93

   Locus of control

(LOC)

6 items on internal LOC, for example: I am directly responsible for my diet getting better or worse; 6 items on external LOC, for example: … it is up to other people to see that the right things happen; and 6 items on influences from chance, for example, … what will be will be.

18

6- point scale; 1= strongly disagree to 6 = strongly agree.

NA; multiple factors

Physical Activity (PA)/Exercise (E)

   Attitudes and

   Opinions

…get enough PA to keep healthy; more PA than people my age; being PA is a priority; regular PA helps in leading a healthy life; I am ready to become PA and am inactive due to permanent illness 

6

6-point scale; 1= strongly disagree to 6= strongly agree

0.69

   Barriers

… is uncomfortable; takes too much effort; too out of shape; arthritis or health problems; too old; do not like others seeing me E; too overweight; do not know how to E; other things I’d rather do; too tired; get bored quickly; no one to do PA with; facilities too hard to get to; costs too much; others discourage PA; worry about safety; lack time; too many household chores; too much work; need to watch children.

20

7-point scale; 1= doesn’t influence me at all to 7= influences me a lot

0.91

   Motivators

… enjoy; an important choice; care about keeping in shape; consistent with life goals; need to for health; good role model; feel guilty if do not E; want others to see; dog needs E; feel pressure from others; take responsibility for health; good for health; want approval from others; family likes it; others would be upset if not E.

15

7-point scale; 1= doesn’t influence me at all to 7= influences me a lot

0.82

   Self-Efficacy

(self-confidence)

…in being PA five days a week; try a new PA this month

2

10-point scale; 1= not at all confident to 10= extremely confident

0.67

   Locus of control

6 items on internal LOC, for example: I am directly responsible for PA and E getting better or worse; 6 items on external LOC, for example: … it is up to other people to see that the right things happen; and 6 items on influences from chance, for example, … what will be will be.

18

6- point scale; 1= strongly disagree to 6 = strongly agree.

NA; multiple factors

* Among this study sample; E, exercise or exercising; NA, not applicable; PA, physical activity or physically active

Health locus of control. Health locus of control questionnaires for healthy diet and physical activity were adapted from the Multidimensional Health Locus of Control Form C (Wallston, 1992; Wallston, Stein, & Smith, 1994) that was originally developed to measure disease level. The two forms used for diet pattern and activity and exercise level contained the same 18 items used in the original form, with original wording, except the areas where the items had a medical condition or disease of interest listed were reworded to ‘diet pattern’ or ‘activity/exercise level,’ where applicable. Table 1 contains questionnaire details. In previous research, people who believed that control over health was influenced by someone or something else, such as powerful others, had an external locus of control and individuals who believed they could influence their own health had an internal locus of control (Wallston, 1992; Wallston et al., 1994). When assessed, health locus of control influenced weight reduction (Adolfsson, Andersson, Elofsson, Rössner, & Undén, 2005) and self-care with medical conditions, such as asthma (Burkhart, Rayens, Oakley, Abshire, & Zhang, 2007).

Nurse and work characteristics. Nurse and work characteristics included gender, age, ethnicity, marital status/living with, highest level of post-high school education, unit type and typical shifts, current body weight and height (to obtain body mass index), activity at work and away from work, and smoking status. Responses included multiple choice, checkbox or fill-in-the-blank. Shift options were reclassified into three categories; mostly day shift, mostly off shift and rotating shifts.

Level of confidence in body image was measured with one three-option multiple choice item (confident, somewhat confident or don’t feel confident). This item was created after personal communication with Michael F Roizen, MD, about body image when looking in the mirror, as discussed in the book, YOU. Being Beautiful (Roizen & Oz, 2009). This item was intended to provide a general expression of feelings of inner and outer beauty to learn if feeling confident or satisfied with body image was associated with healthy lifestyle.

Data Collection

Anonymous paper questionnaire packets with all surveys stapled together and a research information sheet clipped to the front of packets were distributed to nurses working in hospital nursing units. To maintain confidentiality of potential subjects, study recruiters were research nurses who did not work on selected units, and students who were completing a clinical research practicum as part of a master’s degree program. Surveys were placed in unit mail boxes, or on unit lounge tables when mailboxes were unavailable. Study announcements were posted on unit bulletin boards. Each survey packet contained a self-addressed, pre-labeled, self-sealing envelope for returning surveys to the principal investigator through the hospital’s inter-office mail. The data collection period was 10 months, without incentives.

Data Analysis

Responses to factors potentially associated with healthy diet and physical activity, and nurse and work characteristics, were assessed using either chi-square analysis of N x M tables of association (categorical, nominal measures) or Cochran–Mantel–Haenszel analysis (ordinal ranking). Summed responses of Likert scale questions were analyzed using methods of one-way ANOVA with pairwise comparisons of means. Tukey-Kramer adjustments were applied to correct for multiple comparisons. A p-value < 0.05 was considered statistically significant. All analyses were performed using SAS version 9.2 (Cary, North Carolina) software.

Results

Characteristics of Nurse Participants

Of 278 nurse participants, median (minimum, maximum) age was 31.5 (22, 65) years, 91% were women, 91.2% were Caucasian, and median (minimum, maximum) body mass index was 25.5 (18.4, 57.8) kg/m2. When asked about confidence in how their body looked (confidence in body image), 36.1% of nurses were non-confident, 43% were somewhat confident and 20.9% were confident. Roundtrip drive time to work was 60 minutes, most were full time employees, and 38% worked in a critical care environment. Table 2 provides additional participant personal and work characteristics.

Table 2. Characteristics of Nurse Participants; N = 278

 

Personal Characteristics

 

Total N

N (%)

Median (Min, Max)

Age, years

256

31.5 (22.0,65.0)

Gender, Female

268

244 (91.0)

Body Mass Index, kg/m2

261

25.5 (18.4, 57.8)

Ethnicity

274

   White

250 (91.2)

   Black

9 (3.3)

   Other

15 (5.5)

Living With 

276

   Partner or spouse

182 (65.9)

   Self

51 (18.5)

   Children

15 (5.4)

   Parents

15 (5.4)

   Roommate

13 (4.7)

Smoking status

268

   Current

8 (3.1)

   Previous

60 (22.4)

Highest Nursing Education

278

   Diploma or Associate

65 (23.4)

   Bachelor

180 (64.7)

   Graduate (Masters or Doctorate)

33 (11.92)

Chronic Medical Condition;* yes

265

64 (24.2)

Body Image, Confidence

277

   Not confident

100 (36.1)

   Somewhat confident

119 (43.0)

   Confident

58 (20.9)

Confidence: [Scale 1, no confidence; 10, extremely confident]

   Eating 5 Servings of Fruits / Vegetables/Day

277

7.0 (1.00,10.0)

   Maintaining a healthy Weight or Losing weight

277

7.0 (1.00,10.0)

 

Work Characteristics

 

Total N

N (%)

Median (Min, Max)

Drive time to work, minutes

251

30.0 (5.0,120.0)

Work Area Type

276

   Intensive care unit

105 (38.0)

   Telemetry /other traditional non-intensive care unit

133 (48.2)

   Other

38 (13.8)

Work Area Patient Population

248

   Medical

93 (37.5)

   Surgical

65 (26.2)

   Mixed medical and surgical unit

89 (35.9)

Employment Status

277

   Full time

233 (84.1)

   Part time

25 (9.0)

   As needed.

19 (6.9)

Usual Work Shift

277

   Weekday, Day Shift

111 (40.1)

   Evening or Night Shift

42 (15.2)

   Days with Rotation to Evening/Nights

97 (35.0)

   Weekend – any Shift

27 (9.7)

 * chronic medical condition, defined as a condition that requires ongoing and consistent evaluation or management by a healthcare provider

Healthy Diet

...savory type snacks were consumed most often, especially when bored. Of dietary habits, 66.3% of nurses had a moderately healthy diet, 16.7% had a mostly healthy diet and 17% had an unhealthy diet. During snacking episodes, savory type snacks were consumed most often, especially when bored. Non-alcoholic beverages containing sugar were consumed by more than 60% of participants, but intake was not frequent (see Table 3).

Table 3. Healthy Lifestyle Habits of Nurse Participants; N = 278

 

Eating Habits

Total N

N (%)

Median (Min, Max)

Eat Whole or Canned Fruit

277

   1 time/week or less

20 (7.2)

   2-6 times/week

69 (24.9)

   1 time/day

59 (21.3)

   2-3 times/day

110 (39.7)

   >4 times/day

19 (6.9)

Eat Vegetables

277

   1 time/week or less

7 (2.5)

   2-6 times/week

62 (22.4)

   1 time/day

68 (24.5)

   2-3 times/day

114 (41.2)

   >4 times/day

26 (9.4)

Eat Lean Meats

278

   Never

16 (5.8)

   Once/week or less

24 (8.6)

   2- 4 times/week

147 (52.9)

   >4 times/week

91 (32.7)

Eat Processed or High Fat Meats (bologna, bacon, etc.)

   Never

57 (20.7)

   Once/week or less

162 (58.7)

   2- 4 times/week

50 (18.1)

   >4 times/week

7 (2.5)

Type of Milk / Yogurt Consumed:

278

   No cow’s milk products

25 (9.0)

   Only skim or 1% milk fat products

147 (52.9)

   Skim or 1% milk fat products and others

50 (18.0)

   2 or 3% milk fat products

56 (20.1)

Snacks, Favored Foods:

278

   Chips, crackers, or nuts (savory)

189 (68.0)

   Ice cream, cookies, candy (sweet)

138 (49.6)

   Fast foods (e.g. pizza, fries)

85 (30.6)

   Other

54 (19.4)

Snacking; Most likely when:

278

   Studying

139 (50.0)

   Partying

156 (56.1)

   Bored

214 (77.0)

   Emotional

152 (54.7)

   Other

37 (13.3)

Regular Soda / Sugared Beverages; Frequency

278

   Never

108 (38.8)

   Occasionally

110 (39.6)

   Few times/Week

33 (11.9)

   1-2 times/Day

15 (5.4)

   3-4 times/Day

10 (3.6)

   >4 times/Day

2 (0.72)

Alcoholic Beverages Consumed/Week; Number

277

   0-7

246 (88.8)

   8-14

21 (7.6)

   >14

10 (3.6)

 

Physical Activity Habits

Total N

N (%)

Median (Min, Max)

Patterns of Activity at Work, Previous Week; yes response

   Brisk*

259

201 (77.6)

   Moderate**

243

132 (52.2)

   Vigorous***

245

18 (7.3)

Patterns of Activities Away From Work, Previous Week; yes response

   Brisk*

245

189 (77.1)

   Moderate**

256

210 (82.0)

   Vigorous***

260

142 (54.6)

Frequency of Exercise in the Last 30 Days

278

0-2  Times/week

118 (42.4)

3-4  times/week

135 (48.6)

   >4 times/week

25 (9.0)

Exercise Intensity

277

   Light (no/slight increase in HR and resp;  no  sweating)

51 (18.4)

   Moderate (noticeable increase in HR and resp; some sweating)

142 (51.3)

   Heavy (fast HR, labored resp; obvious sweating)

84 (30.3)

Exercise Type

277

   Cross-training

51 (18.3)

   Aerobic (walking/running, bicycling, swimming etc.)

226 (81.3)

   Strength-training

129 (46.4)

   Competitive sports

26 (9.4)

   Combination

51 (18.3)

* Brisk (walking), pace is faster than your usual walking pace and lasts at least 10 minutes at a time;
** Moderate (activities) makes you work as hard as brisk walking and lasts at least 10 minutes at a time;
*** Vigorous (activities) makes you work as hard as jogging and lasts 20 minutes at a time HR; heart rate; resp, respirations

Generally, nurses had an internal locus of control regarding their current dietary habits, reflecting that they felt responsible for diet choices. Factors related to healthy diet: Attitudes, barriers, benefits, self-efficacy, and locus of control. In general, nurses had somewhat healthy attitudes about different types of foods that constitute a healthy diet; a low level of barriers to eating healthy foods; and believed eating healthy foods was moderately important to help them achieve positive benefits, such as losing weight, being healthier, having more energy, feeling better, and helping them look young. Nurses were neither confident nor non-confident about being able to eat healthy in different situations, for example, when bored, frustrated, stressed, lonely, angry, or depressed. Generally, nurses had an internal locus of control regarding their current dietary habits, reflecting that they felt responsible for diet choices. Table 4 provides scores from questionnaires.

Table 4. Attitudes and Opinions, Barriers, Benefits (Diet)/Motivators (Activity), Self-Efficacy, and Locus of Control Related to Nurses’ Dietary Habits and Activity

 

Factor, Score Ranges

Median (Minimum - Maximum)*

Healthy Diet

Physical Activity

Attitudes, Diet;*  0-55

Opinions, Activity;* 6-36

48.5 (14-55)

28.1 (14-36)

Barriers,  Diet;*  12-84

Barriers, Activity;* 20-140

34.1 (12-73)

54.2 (20-114)

Benefits, Diet;* 11-77

Motivators, Activity;* 15-105

67.7 (15-105)

55.5 (11-77)

Self-Efficacy, Diet;* 16-160

Self-Efficacy, Activity;*

93.8 (20-160)

12.0 (2-20)

Locus of Control; ** 6-36

   Internal

   External, including doctors/powerful others

   Chance

29.8 (15-36)

14.8 (6-36)

13.1 (6-36)

31.1 (12-36)

14.5 (6-30)

11.0 (6-30)

* items were summed; higher score, higher amount of each factor
** higher score, dominant locus of control

Based on the three categories of dietary habits created, eating a healthy diet was not associated with the accuracy of nurses’ opinions about what constitutes a healthy diet (p =0.32). Nurses who were more likely to have a healthy diet had fewer barriers of a healthy diet (p <0.0001); believed a healthy diet led to more benefits (p =0.019); and had higher self-efficacy for eating healthy foods in various situations, eating 5 servings of fruits/vegetables (both p <0.0001), and maintaining a healthy weight (p =0.003). Neither an internal or external locus of control were associated with eating a healthy diet (p= 0.88 and 0.31, respectively); however, nurses whose locus of control was driven by chance were more likely to have an unhealthy diet, p= 0.011.

Nurse diet and work characteristics. Nurses had a healthier diet when they walked at a brisk pace away from work (p=0.001) for at least 10 minutes at a time, carried out moderate (p=0.024) and vigorous (p<0.0001) activities away from work, were non-smokers (p=0.044) and felt more confidence about how their body looked (p=0.0006). Nurses working mostly day shift had more barriers to healthy diet (p=0.045) and exercise (p=0.005) and were more likely to have a locus of control for healthy diet based on chance (p=0.047). Nurses’ age, gender, ethnicity, marital status, number of chronic medical conditions, highest nursing degree, employment status (full versus part time), work area, and patient population served were not related to healthy diet.

Physical Activity and Exercise

Of three physical activity levels, 54% of nurses were active but at an insufficient level, 30% were active and 16% were inactive. At work, brisk walking was common and away from work, nurses carried out brisk walking and also moderate and vigorous activities. Aerobic exercises were the most common form of exercise. Table 3 provides physical activity responses.

Nurses had weak self-efficacy that they could be physically active five days per week and try a new physical activity. Factors related to physical activity and exercise: Attitudes, barriers, motivators, self-efficacy, and locus of control. Nurses’ attitudes and opinions were slightly above midrange that physical activity would keep them healthy and was a priority in their lives. Nurses had very few barriers to being active; their median score was in the second lowest of seven categories (i.e., does not influence me most of the time); but motivation scores were mid-range, reflecting that factors such as enjoyment, good health, and keeping in shape, were not a great influence on engaging in physical activity. Nurses had weak self-efficacy that they could be physically active five days per week and try a new physical activity. Overall, nurses had an internal locus of control regarding activity and exercise, reflecting that they were responsible for their current level of activity and exercise completed (see Table 4).

Based on the three categories of physical activity and exercise created, nurses who were more likely to be active had more positive attitudes and opinions about physical activity and exercise (p <0.0001), higher motivators scores (p =0.003), higher self-efficacy for physical activity (p <0.0001), and fewer barriers (p <0.0001). Neither an internal or external locus of control was associated with activity and exercise levels (p =0.10 and 0.15, respectively); however, nurses whose locus of control was driven by chance were more likely to be inactive, p=0.005.

Nurse activity and work characteristics. Nurses were more physically active when they walked at a brisk pace at work (p=0.007) and away from work (p=0.0003) for at least 10 minutes at a time, had a lower body mass index (p=0.0003), were non-smokers (p=0.005) and felt more confident about how their body looked (p=0.014).Nurses’ age, gender, ethnicity, marital status, number of chronic medical conditions, highest nursing degree, employment status (full vs. part time), work area, and patient population served were not related to an active physical activity level.

Discussion

All nurses in this study were employed by a workplace that provides healthy lifestyle programs, as described above. Those with healthier diets were more likely to be physically active and exercise away from work. Further, nurses who were in the active category of physical activity and exercise were more likely to be physically active at work and away from work. Components of the Pender health promotion model served as a useful framework for this study, as barriers; benefits (of a healthy diet) and motivators (of physical activity); self-efficacy; and current activity level outside of work were related to commitment to action for health promoting diet and a high level of physical activity.

Factors Related to a Healthy Diet

Most nurses in this study stated that they had moderately healthy diets. Our results could have been influenced by a hospital environment that supported a healthy diet in relation to purchased food options. Multisite research that includes hospitals with different levels of healthy workplace programs is needed to provide new knowledge about the overall influence of the environment. Further, it is unknown if self-assessments were indicative of actual dietary behaviors. Blake, Malik, Mo, and Pisano (2011) found that overall perceptions of healthy eating may not have been reflective of actual behavior.

It is essential to develop hospital programs that reduce barriers to eating healthy at work... Of factors associated with a healthy diet, perceptions of fewer barriers was the most important. It is essential to develop hospital programs that reduce barriers to eating healthy at work, especially when work interruptions prevent leaving the floor to buy healthy foods or the cost of eating healthy foods is prohibitive. New work habits could translate to habits on non-work days. Results of the study regarding unhealthy diet habits and a locus of control driven by chance suggest a potential benefit of programs designed to increase personal responsibility for dietary habits. In a study of health promoting lifestyles in nurses, although chance locus of control was negatively correlated with health-promoting behavior, internal locus of control was positively correlated (Carson, 1994).

Factors Related to Physical Activity

Results of this study provide new evidence that hospital nurses working on units that require much movement during a typical work day may be insufficiently active... Results of this study provide new evidence that hospital nurses working on units that require much movement during a typical work day may be insufficiently active, even though the work environment supported healthy activity behaviors. Programs that would increase nurses’ self-efficacy for activity and exercise might promote healthy exercise patterns, since nurses in this study only had mid-range scores for motivators of exercise and weak self-efficacy that they could be physically active five days per week. Hensel (2011) found that nurses who integrated core health practices into their lives had a stronger sense of professional adequacy, with more self-efficacy that they could engage in care relationships with their patients, share information with colleagues, and direct the health care team. Thus, helping employees attain higher self-efficacy in integrating physical activity into their lives may have workplace and patient effects that could benefit from further study.

Nurse and Work Characteristics and Levels of Healthy Diet and Physical Activity

Hospital-based programs may not need to have complex features based on age or other factors. The lack of relationships between healthy diet and physical activity behaviors and most nurse and work characteristics provides new evidence that diet habits and activity behaviors could be improved universally. Hospital-based programs may not need to have complex features based on age or other factors. Since smoking status was associated with less healthy diets and less physical activity, smoke-free hospital workplaces and incentives to participate in smoking cessation programs may improve diet and activity behaviors.

In the literature, researchers reported that hospital-based night shift nurses had unhealthy diet behaviors compared to non-night shift hospital nurses (Wong, Wong, Wong, & Lee, 2010), but no research reports discussed shift work among nurses and physical activity. Thus, this study provides new knowledge about shift work and diet and physical activity that has not been previously reported.

It was surprising to find that nurses who worked day shift had more barriers to healthy diet and exercise. Perhaps nurses who worked day shift had more interruptions in work flow and unexpected events that prohibited regular meal breaks and opportunities to get physical activity off the floor. Alternately, more barriers to eating healthy on day shift could be due to eating in groups rather than alone, buying fast foods rather than bringing healthy foods to work, eating two meals rather than one or failure to resist unhealthy snacks or desserts from colleagues and patient families.

It was surprising to find that nurses who worked day shift had more barriers to healthy diet and exercise. Barriers to more physical activity on day shift could be related to having more personnel available to assist with care, decreasing the need to walk from room to room. Finally, a locus of control driven by chance may have been a mediating factor between shift work and healthy diet. More research is needed to determine factors occurring on day shift that can be altered to improve healthy lifestyles, especially since, in non-nurse shift workers, quality of appetite and perceptions of healthy eating habits were also poorer in first shift workers and some first shift workers never engaged in exercise (Love, 2012).

Confidence in body image was associated with greater likelihood of a healthy diet and physical activity. Hensel (2011) found important connections between health, lifestyle, and self-concept and recommended that programs focusing on self-care for nurses are needed since nurses do not consistently learn about healthy lifestyle behaviors on their own. Finally, since nurses in this study with healthier diets and higher levels of activity were also more likely to walk at a brisk pace outside of work, more research is needed to learn if a brisk-paced walking program could promote healthier lifestyles and have short and long term health benefits. Walking at a brisk pace is a simple intervention that does not require props, equipment or extra time and was associated with reduced mortality among nearly 39,000 recreational adult walkers who participated in the National Walkers’ Study (Williams & Thompson, 2013).

Limitations

This research had some limitations. It was a single center study with a convenience sample of nurse participants from a large hospital. Due to the hospital size, nurses were used to walking to meet work demands. The hospital’s work environment provided many opportunities for healthy diet and active physical activity and exercise that may have created a social desirability bias in participants’ responses. Lack of identifiers on questionnaires was used to maintain anonymity of participants, preventing an assessment of characteristics among nurses who chose to participate and not participate. A count of nurses who were approached to participate was not maintained, since some unit managers requested that questionnaire packets be placed in the unit lounge; and it was impossible to know if nurses started completing paperwork but abandoned it. The long questionnaire packet could have minimized responses; although among nurses who submitted completed packets, the response rate to most questions was very high.

Ultimately, results may not be generalizable to nurses working in smaller hospitals or those without healthy lifestyle programs. Results could also differ by characteristics of nurses that differed from our sample; especially in age, obesity and smoking rate; and by nurses whose lifestyle many be dictated by differing employee policies and insurance programs. Self-assessment of healthy diet and physical activity may not match actual behaviors. Further, quantitative self-assessment of attitudes and opinions, benefits/motivators, barriers and self-efficacy may not match objective assessments of the same factors, since content of questionnaires may not have encompassed all possible responses.

Conclusion

Although workplace programs are convenient, targeted interventions... might increase nurses’ participation in in available programs and ultimately, improve general health.  Among nurses whose workplace provided healthy lifestyle programs, over 50% in the study had moderately (rather than mostly) healthy diet habits and were insufficiently active, reflecting room for improvement. Higher levels of healthy diet and physical activity were associated with greater perceived benefits from healthy diet and more motivators for physical activity, fewer perceived barriers, and higher self-efficacy for each behavior.

Confidence in body image was associated with both a healthier diet and higher physical activity level. Conversely, current smoker status and higher body mass index were associated with less physical activity and current smoker status was associated with a less healthy diet. When locus of control was based on chance, nurses had less healthy diets and were less active.

Most other nurse and work characteristics were not associated with diet behaviors and activity and exercise pattern. Although workplace programs are convenient, targeted interventions that include factors associated with benefits of healthy diet, motivators of physical activity and self-efficacy of both healthy lifestyle behaviors might increase nurses’ participation in in available programs and ultimately, improve general health.

Authors

Nancy M. Albert, PhD, CCNS, CHFN, CCRN, NE-BC, FAHA, FCCM
Email: albertn@ccf.org

Nancy M. Albert, PhD, CCNS, CHFN, CCRN, NE-BC, FAHA, FCCM, is Associate Chief Nursing Officer in the Office of Nursing Research and Innovation at Cleveland Clinic Health System.

Robert Butler, MS
Email: butlers@ccf.org

Robert Butler, MS, is a biostatistician in Quantitative Health Sciences at Cleveland Clinic in Cleveland Ohio.

Jeanne Sorrell, PhD, RN
Email: jsorrell@gmu.eduJeanne Sorrell PhD, RN, is Senior Nurse Scientist in the Nursing Institute, Office of Nursing Research and Innovation at Cleveland Clinic Health System.

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© 2014 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2014


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