Health Promoting Behaviors among RN to BSN Students at Two Public Universities

Background:  Healthcare reform has refocused attention on health promotion.  Most research in this area has focused on clients.  Nurses and nursing students, who are responsible for client health promotion education, are important to the success of this paradigm shift from a disease model to health promotion.  With the pressure for RNs to complete the baccalaureate degree in nursing, more students are entering RN-BSN programs. Often, the majority of these RN-BSN students are nontraditional (e.g., older, working, have families) (Bryer, Cherkis, & Raman, 2013).  Health promotion has been associated with maintaining enrollment in nursing school (Al-Kandari, & Vidal, 2007), and educational interventions with nursing students have shown promise (Belguzar, 2015).   

The Health-Promoting Lifestyle Profile II (HPLP II) was used to assess health promotion in this study.  Internal consistency (Cronbach’s alpha) for the 52-item HPLP II is reported at .943 (Walker, Sechrist, & Pender, 1987).  Answers to questions are formatted on a 4-point Likert scale (never, sometimes, often, routinely), and it takes approximately 15-20 minutes to complete.  This tool is based on Nola Pender’s mid-range theory of health promotion (Pender, 1996; Sakraida, 2010).  Health promotion is different from simply prevention of disease, but is rather a proactive, goal-directed behavior that improves health and wellbeing.  Constructs include the value others place on the outcome and if the person feels a sense of self-efficacy.  The decision-making phase and the action phase are part of the conceptual framework of health promotion.  They include individual perceptions, and modifying factors, along with barriers and cues that can trigger the motivation to act (Duffy, 1988; Sakraida, 2010).  Health promoting actions can be influenced by: a) perceived barriers that can hinder commitment, b) environmental influences (peers, situations) that can either increase or decrease commitment, and c) competing and uncontrollable demands that may lead to loss of attention to commitment (McCullagh, 2004; Sakraida, 2010).  In addition to the use of the HPLP II, minimal demographic data was requested (e.g., age, ethnicity, gender, family/marital status, highest level of education, years in nursing, shifts worked).

Selected Literature Review:  The HPLP II has been used in numerous research studies with a variety of populations.  However, health promotion research with working nurses is sparse.  A study examining health-promoting behaviors in an acute care hospital, nurses revealed differences between nurses working on medical-surgical units and critical care units, with the former exhibiting greater overall scores (McElligott, Siemers, Thomas, & Kohn, 2009).  A more recent study found no significant differences between public health nurses and critical care nurses (Rector, & Gilchrist, 2014). 

Nursing students have more often been participants in health promotion studies.  College nursing students in the US and Kuwait had results on health promotion similar to an earlier study of nursing students in this country (Jackson, Tucker, & Herman, 2007; Al-Kandari, & Vidal, 2007; Stark, Manning-Walsh, & Vliem, 2005).  Canadian and Jordanian nursing students’ health-promoting behaviors were compared in a 2004 study, with Jordanian students scoring lower on the total HPLP II and on all subscales except Interpersonal Relations.  Cultural differences in the definition of health as “absence of disease,” among other things, were thought to be contributory to the differences in scores (Haddad, Kane, Rajacich, Cameron, & Al-Ma’aitah, p. 88).  Bryer, Cherkis, and Raman (2013) examined health-promoting behaviors of traditional with more nontraditional (e.g., older, ethnically diverse, previous education, employed, families) nursing students at a US associate degree program.  They noted significant differences on the total HPLP II scores and all subscales, with the exception of Nutrition.  A second tool, Barriers to Health Promoting Activities (BHPA), was administered and statistically overall higher scores were found.  There were noted differences with traditional students regarding lack of help, time, transportation, and support from family and friends.  This is important information, as more nontraditional students are entering nursing education, especially at the ADN and the RN-BSN levels.  In a correlational study of Kuwaiti nursing students, a significant relationship was found between those with higher body mass index (BMI) and the total HPLP II scores as well as the Nutrition subscale scores.  

A longitudinal study being conducted by Wills in England found that a good number of nursing students are overweight and 40% never engage in physical activity (Gillen, 2014).  Data gathering continues through 2016, but early evidence indicates that the health of individual nurses can affect their ability to promote health among their patients and ultimately provide better nursing care.  The researcher posits that obese nurses and nurses who smoke are more reluctant to broach these subjects with their patients.  A wellness website is being utilized for nursing students to track their progress with weight and exercise.  She advocates the need for health promotion at universities in order to achieve better health behaviors among students (Dooris, Wills, & Newton, 2014).  A three-year study of 108 female Turkish nursing students found that an educational intervention to promote health behaviors was effective (Kara, 2015).  At the end of each year, the HPLP II was administered and significant positive differences were noted on the total score and subscales of exercise, nutrition, stress management, health responsibility and self-actualization.

Design:  A descriptive, cross-sectional quantitative research methodology was used.  A non-randomized, convenience sample from two public universities’ RN-BSN programs was used.  Permission was received from both university IRBs to conduct the study.

Sample, Recruitment, & Consent:  Students in the first two semesters of a three semester online program at both universities were invited to participate through an email invitation from their respective faculty member.  A link to SurveyMonkey © was provided, and they could choose to participate or not.  Remainder emails were sent after several weeks.  The consent form was the first screen available to participants and students could print it for their records.  Further participation was deemed as consent, since they had to click on a button to begin the survey.  Anonymity was ensured, and participation was voluntary.

Results:  Forty RN-BSNs completed all or part of the survey.  The mean age (n=33) was 33.26 (s d=7.25; range=224 to 49).  The majority of respondents (n=40) were Hispanic/Latino (55%), with 20% Asian, 5% Black, and 12.5% White.  Over 92% were female, and 51.28% were married or in a domestic partnership with dependents.  Over 25% were single with no dependents.  The majority had an associate degree in nursing (92.31%), with 15.38% having a bachelor’s degree in another area, and 5.13% reporting a master’s degree in another area.  Participants reported a mean of 3.18 years working as an RN (n=39; s d=l3.31; range= <1 to 16 years).  The majority worked 12-hour shifts (70%), with 47.5% working during the day.  When asked how often they left the unit for meals, 32.5% reported “never” and 35% reported “sometimes.”  Out of 40 respondents, only two smoked cigarettes (1=10/month; 1=30/month).  Most characterized themselves as “overweight” (47.5%), with 32.5% reporting they were at a “normal weight.” The mean height was 64.34 inches (s d=2.69; range=60 to 71) and mean weight was 160.51 lbs. (s. d=40.08; range=105 to 280).

            Cronbach’s alpha for the total HPLP II was .916 for this sample (n=33 surveys with no missing responses).  The mean for the total HPLP II was 2.525 (s d=.35).  Subscale means were:  health responsibility 2.57 (s d .46); physical activity 2.07 (s d=.57); nutrition 2.57 (s d=.42); spiritual growth 3.08 (s d=.42); interpersonal relationships 2.895 (s d=.44); stress management 2.19 (s d=.39). 

Discussion & Implications:  No prior research on health promotion in RN-BSN students was found.  Sadly, these RN-BSNs are not following the health guidelines that they educate their patients on each and every day.  By not leaving their units for meals, RN-BSNs are impinging on their nutritional status and possibly affecting their cognitive ability to function as a nurse.  In comparing the total mean score to other research with nursing students, this result is only slightly higher than the 2.47 mean among nontraditional ADN students in the Byer et al. (2013) study.  The mean for traditional students in that study was 2.74.  For junior level college nursing students in the Midwest, an HPLP II total mean score of 2.84 was reported (Stark, Manning-Walsh, & Vliem, 2005).  This is somewhat higher than the present study.  A Kuwaiti study of second semester college nursing students by Al-Kandari, Vidal, and Thomas (2008) reported overall HPLP II means between 2.5 (17-20 age group) and 3.0 (31-35 age group), with means increasing for each successive age group.  Hensel (2012) reported a mean of 2.80 in a study of hospital nurses, and McElligott and colleagues (2009) in their study of hospital nurses reported a mean of 2.6. 

            Because the majority of RN-BSN students are employed RNs returning to college, they have stressors from both work and school, as their results indicate.  They often have family responsibilities and juggle multiple roles.  Would a stress management course help to increase their scores?  Understanding their health-promoting behaviors and providing interventions to promote healthy behaviors may foster their educational goals and improve their nursing practice.  More research is needed on methods that inspire RN-BSNs to be more health conscious and good role models for their patients.