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Health promotion in nurses: Is there a healthy nurse in the house?
Applied Nursing Research 22 (2009) 211 – 215 www.elsevier.com/locate/apnr
Research Briefs
Health promotion in nurses: Is there a healthy nurse in the house? Deborah McElligott, RN, ANP, HNP, AHN-BC a,⁎, Sarah Siemers, RN, MSN, ANP a,1 , Lily Thomas, PhD, RN b,2 , Nina Kohn, MA b,c,3 a North Shore University Hospital, Manhasset, NY 11030, USA North Shore Long Island Jewish Health System, New Hyde Park, NY 11042, USA c Biostatistics Unit, the Feinstein Institute for Medical Research, Manhasset, NY 11030, USA Received 6 June 2007; received in revised form 10 July 2007; accepted 23 July 2007 b
Abstract
The purpose of this pilot study was to examine the health-promoting lifestyle behaviors of acutecare nurses using the Health Promotion Model. Statistical analysis of 149 returned HealthPromoting Lifestyle Profile II surveys indicates areas of weakness in stress management and physical activity. No significant difference is found between unit, demographic factors, and subscale scores at the p b .01 level, but medical–surgical nurses consistently scored better than the criticalcare nurses in health promotion. Findings support the need for the development of holistic nursing interventions to promote self-care in the identified areas. Strategies include educational/experiential classes in holistic nursing; individualized unit-based activities fostering stress management, such as massage, reflexology, and imagery; and development of an employee wellness program. © 2009 Elsevier Inc. All rights reserved.
1. Background As nurses focus on the health of their patients, families, and communities, are they practicing health-promoting behaviors for themselves? Is there a healthy nurse in the house? Competent self-care, a major component of holistic nursing since Nightingale's (1859, 1992) Notes on Nursing, is receiving increased attention in this era of an aging nursing population and an increasing nursing shortage (American Association of Colleges of Nursing, 2007; Health Resources and Services Administration [HRSA], U.S. Department of Health and Human Services, 2004). The Standards of
⁎ Corresponding author. Tel.: +1 516 562 4007 (work), +1 516 208 7222 (home). E-mail addresses: [email protected] (D. McElligott), [email protected] (S. Siemers), [email protected] (L. Thomas), [email protected] (N. Kohn). 1 Present address: 31 James Lane, Levittown, NY 11756, USA. Tel.: +1 516 562 4100 (work). 2 Present address: 400 Lakeville Road, New Hyde Park, NY 11042. Tel.: +1 718 470 4512 (work). 3 Tel.: +1 516 240 8300. 0897-1897/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.apnr.2007.07.005
Practice of the American Holistic Nurses Association (AHNA) identify the need for self-care, self-responsibility, spirituality, and reflection to be integrated into nurses' lives (AHNA, 2007, p2.). Therefore, the purpose of this pilot study was to assess nurses' health-promoting lifestyle behaviors using the midrange theory of health promotion (Pender, 1987, 1996) and the Health-Promoting Lifestyle Profile II (HPLP II) questionnaire (Walker, Sechrist, & Pender, 1997). The Health Promotion Model (HPM; Pender, 1996; Peterson & Bredow, 2004) offers a framework to integrate nursing and perspectives from behavioral sciences into factors that may influence health behaviors. Health promotion is defined as a behavior that is “motivated by the desire to increase well-being and actualize human health potential” (Pender, Murdaugh, & Parsons, 2006, p. 7). This actualization is possible through competent selfcare, goal-directed behavior, and harmony with the environment, including interpersonal relationships. Health promotion is differentiated from disease prevention due to its motivational dynamics. Whereas prevention is disease or injury specific in its approach, health promotion seeks to expand the potential for health. The foundation of the model is formed by the theories of reasoned action,
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planned behavior, and social cognitive theory (Pender et al., 2006). These theories propose that people will more likely adapt a behavior if they believe that it will have a desired outcome, if others value the outcome, if they feel that they have control over the situation, or if there is a direct relationship between self-efficacy and engagement in the behaviors. The model has two dynamic and reciprocal phases. The decision-making phase includes the individual perceptions and modifying factors. The action phase includes the barriers and cues that trigger activity (Duffy, 1988). This conceptual framework targets characteristics for assessment and suggests interventions to alter perceptions and improve healthpromoting behaviors. Nursing self-care may easily be impacted by several of the model's propositions: (a) Perceived barriers can hinder commitment to action; (b) peers and situational influences in the environment can increase or decrease commitment to participation in health promotion behavior; and (c) commitment is less likely to occur when uncontrollable competing demands require attention (McCullagh, 2004). Although the HPM has been used in many studies, applications are limited to clients with cognitive function and areas where health is not primarily motivated by threat (Pender et al., 2006). The HPLP II is the most widely used tool to test the HPM (Walker et al., 1997). A literature review for the HPM and for the use of the HPLP II assessment tool was conducted using PubMed and the Cumulative Index to Nursing and Allied Health Literature and is limited to the adult population and to those conducted in English, with the last 10 years being the inclusive period. Research supporting the theory has included populations in schools, workplaces, rehabilitation centers, ambulatory settings, and prisons (McCullagh, 2004). Studies have also included individuals with varying health problems (Stuifbergen & Becker, 1994), people from various cultures (Kerr & Richey, 1990; Weitzel & Waller, 1990), and women (Adams, Bowden, Humphrey, & McAdams, 2000). Self-actualization, interpersonal support, and social support have been directly related to health promotion (Adams et al., 2000; Duffy, Rossow, & Hernandez, 1996; Kerr & Richey, 1990). The HPLP II has been used with populations of nursing students in various countries including the United States, Japan, Canada, and Jordan (Haddad, Kane, Rajacich, Cameron, & Al-Ma'aitah, 2004; Hui, 2002; Nikou, 1998). Results found hardiness being inversely related to stress, stress being negatively related to health promotion behaviors, and poor scores in physical activity, with significant differences in stress management and spiritual growth among college students, senior students reporting the worst scores, and cultural differences in scores. Another study on nursing students suggests increased self-care when education (content and time) was integrated into a nursing course (Stark, ManningWalsh, & Vliem, 2005).
Whereas the effects of nurses' health promotion on quality care have not been examined, the lack of self-care resulting in fatigue, stress, and burnout has been examined and linked to poor-quality outcomes. Fatigue has been linked to errors of omission, slowed reaction time, attention lapse, poor problem solving, and reduced motivation (Institute of Medicine, 2004). Stress has been linked to increased health care costs, turnover, obesity, and illness as well as to decreased satisfaction and quantity and quality of care (AbuAlRub, 2004; Jackson, Smith, Adams, Frank, & Mateo, 1999). There is limited evidence for interventions that effectively reduce stress levels in health care settings according to a Cochrane review of 19 studies (Marine, Ruotsalainen, Serra, & Verbeek, 2007). Lower staffing levels, whether due to illness, turnover, or injury, result in less time with patients and decrease in quality (Agency for Healthcare Research and Quality, 2004). In one survey, more than 70% of nurses believed that the nursing shortage negatively affects the quality of work life, patient care, and the time nurses can spend with patients (Buerhaus, Donelan, Ulrich, Norman, & Dittus, 2006). Finally, research on employee health and productivity has linked poor health status with higher direct health care costs of institutions, higher rates of disability, absenteeism, injury, workers' compensation, and lower work output (Partnership for Prevention, 2005).
2. Method The goal of this descriptive pilot study was to assess the health-promoting lifestyles of a select group of nurses. Approval was granted from the institution's review board. This study used an anonymous, convenience sample of registered nurses (RNs) working in a tertiary hospital. The sample included the nursing staff working in the cardiac and neuroscience services in medical, telemetry, and critical-care units. Permission to use the HPLP II was obtained from the authors. This is a self-administered questionnaire with 52 questions covering different aspects of wellness: nutrition, stress, spirituality, health responsibility, interpersonal relations, and physical activity. The HPLP II asks respondents to select one of four answer choices. The answer choices are rated from 1 to 4 (1 = never, 2 = sometimes, 3 = often, 4 = routinely). The scores are then totaled in each of the six subscales and results are tabulated. The subscales with the lowest scores indicate areas of weakness. Walker, Sechrist, and Pender (1997) reported findings supporting the validity and reliability of the tool. Surveys were available to 500 RNs working on the cardiac and neuroscience services. An envelope containing the surveys and a cover letter explaining the purpose were left in the nurses' lounge on each of the participating units. A separate envelope was provided for completed surveys. Announcements were made at staff meetings and unit service meetings to encourage participation, which was anonymous.
D. McElligott et al. / Applied Nursing Research 22 (2009) 211–215
A 30% return rate resulted in the completion of 149 surveys over the course of 1 month. Associations between demographic factors and scores (overall score and subscores) were examined using the Mann–Whitney U test or Kruskal–Wallis test as appropriate. A Bonferroni-type adjustment was used, such that associations were considered significant for p b .01. The reason for applying this adjustment was based on the number of statistical tests. It is more likely to find a significant difference at the nominal 5% level when one does not actually exist. 3. Results No significant associations between (the demographic factors) age, race, unit, years in nursing, and level of education and scores on the HPLP II were found. Therefore, summary statistics (mean and standard deviation as well as median and interquartile range) for the overall score as well as for each subscore for the entire cohort (N = 149) are reported (Table 1). In this study sample, 45% of respondents were more than 40 years of age, 69% were White, 36% worked in critical care, 31% worked on medical–surgical floors, 33% failed to identify the unit, 50% had greater than 10 years of nursing experience, and 60% had at least a bachelor of science in nursing (BSN) degree (Table 2). The outcome variables of the HPLP II are the overall score and the subscale scores. The overall mean, median, and mode scores (Table 1) were 2.6, 2.5, and 2.8, respectively, with a mean range from 1.8 to 3.5. In this sample of nurses, when the subscales (ranging from 1 [never] to 4 [routinely]) were examined, the mean outcomes for stress management (2.2), physical activity (2.38), and health responsibility (2.44) scored lowest. Nutrition (2.6), spirituality (2.87), and interpersonal relationships (3.01) scored highest. Although no significant differences were noted at the b.01 levels, overall scores on the HPLP II were consistently higher (better) in one group when the demographics of the unit is examined. The nurses on the medical–surgical/telemetry floors scored consistently higher (better) on the overall score
Table 1 HPLP II results (1 = never, 2 = sometimes, 3 = often, 4 = routinely) Results (N = 149) Overall scores Subscale category Interpersonal relations Spirituality Nutrition Health responsibility Physical activity Stress management IQR = interquartile range.
M (SD) 2.6 (0.41) 3.01 (0.46) 2.87 (0.54) 2.60 (0.51) 2.44 (0.50) 2.39 (0.74) 2.25 (0.53)
Range
Mode
Median (IQR)
1.8–3.5
2.8
2.56 (0.62)
1.6–3.8 1.6–3.7 1.2–3.7 1.1–3.6 1.0–3.8 1.2–3.8
2.8 2.4 2.6 2.5 2.0 2.2
3.00 (0.56) 2.89 (0.78) 2.56 (0.67) 2.44 (0.67) 2.25 (1.13) 2.25 (0.75)
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Table 2 Demographics Demographics
n (%)
Age (years) 20–30 31–40 41–50 51–60 N60 Missing Race Asian Black Hispanic Native American Other White Missing Unit Critical care Floor Missing Years in nursing 0–5 6–10 11–20 21–25 26–30 31–35 Highest level of education Associate in applied science BSN Diploma Master's Post-master's Missing
35 (23.81) 46 (31.30) 47 (31.98) 18 (12.24) 1 (0.68) 2 (1.36) 18 (12.08) 10 (6.71) 6 (4.03) 1 (0.67) 3 (2.01) 104 (69.80) 7 (4.70) 54 (36.24) 46 (30.87) 49 (32.89) 39 (26.71) 32 (21.92) 43 (29.45) 17 (11.64) 12 (8.22) 3 (2.05) 39 (26.17) 69 (46.31) 17 (11.41) 21 (14.10) 1 (.67) 2 (1.34)
and each of the subscale scores than the nurses on the critical-care areas (Table 3). 4. Discussion The demographics of this pilot study reported that 45% of the nurses are more than 40 years old, with at least 10 years experience, and 60% obtained at least a BSN degree. Our nursing population mirrors the national trend in an aging nursing workforce, where the average age of RNs in 2004
Table 3 Comparison of critical-care nurses (n = 54) and floor nurses (n = 46) HPLP II scores
Critical care, M (SD)
Floor, M (SD)
Overall score Subscale category Interpersonal relations Spiritual growth Nutrition Health responsibility Physical activity Stress management
2.52 (0.35)
2.69 (0.46)
2.98 (0.46) 2.76 (0.52) 2.52 (0.43) 2.36 (0.45) 2.32 (0.73) 2.14 (0.49)
3.05 (0.48) 2.95 (0.51) 2.73 (0.55) 2.53 (0.56) 2.46 (0.80) 2.35 (0.53)
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Table 4 Poststudy identified barriers to stress management Lack of time Inability to choose method Competing demands Environmental factors Lack of support
was 46.8 years (HRSA, U.S. Department of Health and Human Services, 2004) and continues to increase. Overall low scores demonstrate the need to address the healthpromoting lifestyle behaviors of our nurses, especially the weaker areas of stress management and physical activity. The link between stress management and health promotion is consistent with the literature review. The difference in scores in the medical–surgical and critical-care areas may deserve further investigation and require different interventions. The general overall higher scores in spirituality and interpersonal relationship may facilitate a holistic approach using group work and spiritually based interventions in addressing nurses' health promotion. Previous studies identifying the interrelation of the areas of wellness (Kerr & Richey, 1990; Adams et al., 2000) further support a holistic approach. Health promotion behaviors encompass the individual perceptions, modifying factors, barriers, and triggers (Duffy, 1988). This pilot study identifies target health promotion areas needed in nurses. Interventions need to support health promotion and changes in health perception and behaviors. As health is multifaceted, health promotion interventions for nurses should be comprehensive, incorporating a holistic wellness approach, and fostered in the workplace. Barriers need to be identified and modified, whereas peer support and education need to be fostered. This study prompted discussion topics with the staff of each of the involved units and supported the initial efforts to focus on self-care at our institution. Using the HPM framework during the unit discussions, the staff identified barriers to stress management as lack of time, inability to choose a method, competing demands, environmental factors, and lack of support (Table 4). 5. Implications for practice Holistic nursing, recently recognized by the American Nurses Association as a specialty, describes the theory and practice of self-care through numerous resources including books, journals, conferences, and a national certification program (AHNA, 2006). In addition to a holistic emphasis, programs focusing on nursing wellness must be comprehensive, affordable, educational, and experiential. Translating the pilot study findings into our practice setting resulted in the development of educational classes, staff massage, and renewed interest in an employee wellness program. Two-day educational and experiential classes are
offered to introduce holistic nursing and incorporate the modalities of reflexology techniques and integrative imagery. It is hoped that this will encourage the use of these interventions for self-care. Massage, reflexology, or both are offered on the unit for staff when there is an identified need, at a convenient time, with peers providing relief. Examples of a “need” included unit leadership transition, difficult patient situations, or personal issues. While there is limited evidence of effective interventions reducing stress in health care workers (Marine et al., 2007), a 2002 study in our institution using massage on nurses revealed decreased anxiety and increased awareness of the need for self-care (McElligott et al., 2003). The final initiative is greater emphasis and support for the development of an employee wellness program and focus on the removal of environmental barriers (e.g., creation of a “relaxation room” and onsite exercise program). 6. Conclusion Holistic caring and nurturing of self support a healthy balance and increase productivity and a fuller participation in the life experience (Eliopoulous, 2004). Support of this paradigm shift to an emphasis on self-care provides the energy for nurses to enhance their care of patients, families, and communities. The use of the midrange theory allows practitioners to translate theory into practice. The HPM, which guides the assessment of the nursing staff, is an important first step of this process. As staff wellness needs are identified, institutions can develop ongoing programs to assist in meeting these needs and decrease the indirect costs of poor employee health. Benefits such as discounted gym membership may have new meaning for nurses as they identify the role of exercise in their own stress reduction and overall wellness. Future studies may examine the impact of the above-identified holistic wellness programs, demographics, and the interrelation of the various subscales of the HPLP II, as well as the relationship between nurses' health promotion behaviors (scores on HPLP II) and patient outcomes. The nurses who can assess and address their wellness from a physical, emotional, and spiritual level can more easily model this behavior for their patients, families, peers, and communities. As a result of this pilot study, we know that health promotion is an area of concern in this sample population. Our interventions are just beginning. Awareness of the issue has been raised. Health promotion, which is a vital component of nursing, needs to be ingrained in the lifestyle of each nurse and supported in the research arena.
Acknowledgment We wish to thank the cardiac and neuroscience nurses of North Shore University Hospital for their participation.
D. McElligott et al. / Applied Nursing Research 22 (2009) 211–215
References American Association of Colleges of Nursing. (2007). Fact sheet. Nursing shortage. Retrieved May 23, 2007, from: http://www.aacn.nche.edu/ Media/FactSheets/NursingShortage.htm. AbuAlRub, R. (2004). Job stress, job performance, and social support among hospital nurses. Journal of Nursing Scholarship 36(1), 73–78. American Holistic Nurses Association. (2006). Mariano, C. Holistic nursing achieves specialty status. Retrieved May 23, 2007, from: http://www. ahna.org/new/specialty.html. American Holistic Nurses Association. (2007). Holistic Nursing Scope and Standards of Practice. Silver Springs, MD: ANA. Agency for Healthcare Research and Quality. (2004). Research in action: Hospital nurse staffing and availability of care. Adams, M. H., Bowden, A. G., Humphrey, D. S., & McAdams, L. B. (2000). Social support and health promotion lifestyles of rural women. Online Journal of Rural Nursing and Health Care 1(1). Buerhaus, P., Donelan, K., Ulrich, B., Norman, L., & Dittus, R. (2006). State of registered nurse workforce in the United States. Nursing economics online. Retrieved June 27, 2007, from: http://www.medscape.com/ viewarticle/525650. Duffy, H., Rossow, R., & Hernandez, M. (1996). Correlates of healthpromotion activities in employed Mexican American women. Nursing Research 45, 18–24. Duffy, M. E. (1988). Determinants of health promotion in midlife women. Nursing Research 37(6), 358–362. Eliopoulos, C. (2004). Invitation to holistic health. Toronto: Jones & Bartlett Inc. Haddad, L., Kane, D., Rajacich, D., Cameron, S., & Al-Ma'aitah, R. (2004). A comparison of health practices of Canadian and Jordanian nursing students. Public Health Nursing 21(1), 85–90. Health Resources and Services Administration, U.S. Department of Health & Human Services. (2004). Preliminary findings: 2004 National Sample Survey of Registered Nurses. Retrieved May 23, 2007, from: http://bhpr.hrsa.gov/healthworkforce/reports/rnpopulation/ preliminaryfindings.htm. Hui, W. C. (2002). The health-promoting lifestyles of undergraduate nurses in Hong Kong. Journal of Professional Nursing 18(2), 101–111. Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: The National Academic Press.
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Jackson, B., Smith, S., Adams, R., Frank, B., & Mateo, M. (1999). Healthy life styles are a challenge for nurses. Journal of Nursing Scholarship 31(2), 196. Kerr, M., & Richey, D. (1990). Health promoting lifestyles of Englishspeaking and Spanish-speaking Mexican American migrant farm workers. Public Health Nursing 7, 80–87. Marine, A., Ruotsalainen, J., Serra, C., & Verbeek, J. (2007). Preventing occupational stress in healthcare workers (review). The Cochrane Collaboration. Wiley & Sons Ltd. McCullagh, M. (2004). Health promotion. In: Peterson S, Bredow T (Eds.), Middle range theories, application to nursing research. (pp. 288Q301). Lippincott Williams & Wilkins. McElligott, D., Holz, M., Carollo, L., Somerville, S., Baggett, M., & Kuzniewski, S., et al. (2003). A pilot feasibility study on the effects of a touch therapy on nurses. The Journal of the NY State Nurses Association 34(1), 16–24. Nightingale, F. (1859, 1992). Notes on nursing (commemorative ed.). Philadelphia: Lippincott. Nikou, V. R. (1998). The relationship among hardiness, stress and health promoting behaviors in undergraduate nursing students. Unpublished doctoral dissertation, New York University. Partnership for Prevention. (2005). Leading by example. Washington, DC: The WorkCare Group Inc. Pender, N. (1996). Health promotion in nursing practice. (3rd ed.). Stamford, CT: Appleton & Lange; 1996. Pender, N., Murdaugh, C., & Parsons, M. (2006). Health promotion in nursing practice. (5th ed.). Upper Saddle River: Pearson Prentice Hall. Pender, N. J. (1987). Health promotion in nursing practice. Appleton, NY: Century Crofts. Peterson, S., & T.Bredow, T. (2004). Middle range theories. Application to nursing research. Philadelphia: Lippincott Williams & Wilkins; 2004. Stark, M. A., Manning-Walsh, J., & Vliem, S. (2005). Caring for self while learning to care for others: A challenge for nursing students. Journal of Nursing Education 44(6), 266–270. Stuifbergen, A. K., & Becker, H. A. (1994). Predictors of health-promoting lifestyles in persons with disabilities. Research in Nursing and Health 17, 3–13. Walker, S., Sechrist, K., & Pender, N. (1997). The health promoting lifestyle profile: Development and psychometric characteristics. Nursing Research 39(5), 268–273. Weitzel, M., & Waller, P. (1990). Predictive factors for health-promotive behaviors in White, Hispanic and Black blue-collar workers. Family and Community Health 13, 23–34.
Research Briefs
Health promotion in nurses: Is there a healthy nurse in the house? Deborah McElligott, RN, ANP, HNP, AHN-BC a,⁎, Sarah Siemers, RN, MSN, ANP a,1 , Lily Thomas, PhD, RN b,2 , Nina Kohn, MA b,c,3 a North Shore University Hospital, Manhasset, NY 11030, USA North Shore Long Island Jewish Health System, New Hyde Park, NY 11042, USA c Biostatistics Unit, the Feinstein Institute for Medical Research, Manhasset, NY 11030, USA Received 6 June 2007; received in revised form 10 July 2007; accepted 23 July 2007 b
Abstract
The purpose of this pilot study was to examine the health-promoting lifestyle behaviors of acutecare nurses using the Health Promotion Model. Statistical analysis of 149 returned HealthPromoting Lifestyle Profile II surveys indicates areas of weakness in stress management and physical activity. No significant difference is found between unit, demographic factors, and subscale scores at the p b .01 level, but medical–surgical nurses consistently scored better than the criticalcare nurses in health promotion. Findings support the need for the development of holistic nursing interventions to promote self-care in the identified areas. Strategies include educational/experiential classes in holistic nursing; individualized unit-based activities fostering stress management, such as massage, reflexology, and imagery; and development of an employee wellness program. © 2009 Elsevier Inc. All rights reserved.
1. Background As nurses focus on the health of their patients, families, and communities, are they practicing health-promoting behaviors for themselves? Is there a healthy nurse in the house? Competent self-care, a major component of holistic nursing since Nightingale's (1859, 1992) Notes on Nursing, is receiving increased attention in this era of an aging nursing population and an increasing nursing shortage (American Association of Colleges of Nursing, 2007; Health Resources and Services Administration [HRSA], U.S. Department of Health and Human Services, 2004). The Standards of
⁎ Corresponding author. Tel.: +1 516 562 4007 (work), +1 516 208 7222 (home). E-mail addresses: [email protected] (D. McElligott), [email protected] (S. Siemers), [email protected] (L. Thomas), [email protected] (N. Kohn). 1 Present address: 31 James Lane, Levittown, NY 11756, USA. Tel.: +1 516 562 4100 (work). 2 Present address: 400 Lakeville Road, New Hyde Park, NY 11042. Tel.: +1 718 470 4512 (work). 3 Tel.: +1 516 240 8300. 0897-1897/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.apnr.2007.07.005
Practice of the American Holistic Nurses Association (AHNA) identify the need for self-care, self-responsibility, spirituality, and reflection to be integrated into nurses' lives (AHNA, 2007, p2.). Therefore, the purpose of this pilot study was to assess nurses' health-promoting lifestyle behaviors using the midrange theory of health promotion (Pender, 1987, 1996) and the Health-Promoting Lifestyle Profile II (HPLP II) questionnaire (Walker, Sechrist, & Pender, 1997). The Health Promotion Model (HPM; Pender, 1996; Peterson & Bredow, 2004) offers a framework to integrate nursing and perspectives from behavioral sciences into factors that may influence health behaviors. Health promotion is defined as a behavior that is “motivated by the desire to increase well-being and actualize human health potential” (Pender, Murdaugh, & Parsons, 2006, p. 7). This actualization is possible through competent selfcare, goal-directed behavior, and harmony with the environment, including interpersonal relationships. Health promotion is differentiated from disease prevention due to its motivational dynamics. Whereas prevention is disease or injury specific in its approach, health promotion seeks to expand the potential for health. The foundation of the model is formed by the theories of reasoned action,
212
D. McElligott et al. / Applied Nursing Research 22 (2009) 211–215
planned behavior, and social cognitive theory (Pender et al., 2006). These theories propose that people will more likely adapt a behavior if they believe that it will have a desired outcome, if others value the outcome, if they feel that they have control over the situation, or if there is a direct relationship between self-efficacy and engagement in the behaviors. The model has two dynamic and reciprocal phases. The decision-making phase includes the individual perceptions and modifying factors. The action phase includes the barriers and cues that trigger activity (Duffy, 1988). This conceptual framework targets characteristics for assessment and suggests interventions to alter perceptions and improve healthpromoting behaviors. Nursing self-care may easily be impacted by several of the model's propositions: (a) Perceived barriers can hinder commitment to action; (b) peers and situational influences in the environment can increase or decrease commitment to participation in health promotion behavior; and (c) commitment is less likely to occur when uncontrollable competing demands require attention (McCullagh, 2004). Although the HPM has been used in many studies, applications are limited to clients with cognitive function and areas where health is not primarily motivated by threat (Pender et al., 2006). The HPLP II is the most widely used tool to test the HPM (Walker et al., 1997). A literature review for the HPM and for the use of the HPLP II assessment tool was conducted using PubMed and the Cumulative Index to Nursing and Allied Health Literature and is limited to the adult population and to those conducted in English, with the last 10 years being the inclusive period. Research supporting the theory has included populations in schools, workplaces, rehabilitation centers, ambulatory settings, and prisons (McCullagh, 2004). Studies have also included individuals with varying health problems (Stuifbergen & Becker, 1994), people from various cultures (Kerr & Richey, 1990; Weitzel & Waller, 1990), and women (Adams, Bowden, Humphrey, & McAdams, 2000). Self-actualization, interpersonal support, and social support have been directly related to health promotion (Adams et al., 2000; Duffy, Rossow, & Hernandez, 1996; Kerr & Richey, 1990). The HPLP II has been used with populations of nursing students in various countries including the United States, Japan, Canada, and Jordan (Haddad, Kane, Rajacich, Cameron, & Al-Ma'aitah, 2004; Hui, 2002; Nikou, 1998). Results found hardiness being inversely related to stress, stress being negatively related to health promotion behaviors, and poor scores in physical activity, with significant differences in stress management and spiritual growth among college students, senior students reporting the worst scores, and cultural differences in scores. Another study on nursing students suggests increased self-care when education (content and time) was integrated into a nursing course (Stark, ManningWalsh, & Vliem, 2005).
Whereas the effects of nurses' health promotion on quality care have not been examined, the lack of self-care resulting in fatigue, stress, and burnout has been examined and linked to poor-quality outcomes. Fatigue has been linked to errors of omission, slowed reaction time, attention lapse, poor problem solving, and reduced motivation (Institute of Medicine, 2004). Stress has been linked to increased health care costs, turnover, obesity, and illness as well as to decreased satisfaction and quantity and quality of care (AbuAlRub, 2004; Jackson, Smith, Adams, Frank, & Mateo, 1999). There is limited evidence for interventions that effectively reduce stress levels in health care settings according to a Cochrane review of 19 studies (Marine, Ruotsalainen, Serra, & Verbeek, 2007). Lower staffing levels, whether due to illness, turnover, or injury, result in less time with patients and decrease in quality (Agency for Healthcare Research and Quality, 2004). In one survey, more than 70% of nurses believed that the nursing shortage negatively affects the quality of work life, patient care, and the time nurses can spend with patients (Buerhaus, Donelan, Ulrich, Norman, & Dittus, 2006). Finally, research on employee health and productivity has linked poor health status with higher direct health care costs of institutions, higher rates of disability, absenteeism, injury, workers' compensation, and lower work output (Partnership for Prevention, 2005).
2. Method The goal of this descriptive pilot study was to assess the health-promoting lifestyles of a select group of nurses. Approval was granted from the institution's review board. This study used an anonymous, convenience sample of registered nurses (RNs) working in a tertiary hospital. The sample included the nursing staff working in the cardiac and neuroscience services in medical, telemetry, and critical-care units. Permission to use the HPLP II was obtained from the authors. This is a self-administered questionnaire with 52 questions covering different aspects of wellness: nutrition, stress, spirituality, health responsibility, interpersonal relations, and physical activity. The HPLP II asks respondents to select one of four answer choices. The answer choices are rated from 1 to 4 (1 = never, 2 = sometimes, 3 = often, 4 = routinely). The scores are then totaled in each of the six subscales and results are tabulated. The subscales with the lowest scores indicate areas of weakness. Walker, Sechrist, and Pender (1997) reported findings supporting the validity and reliability of the tool. Surveys were available to 500 RNs working on the cardiac and neuroscience services. An envelope containing the surveys and a cover letter explaining the purpose were left in the nurses' lounge on each of the participating units. A separate envelope was provided for completed surveys. Announcements were made at staff meetings and unit service meetings to encourage participation, which was anonymous.
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A 30% return rate resulted in the completion of 149 surveys over the course of 1 month. Associations between demographic factors and scores (overall score and subscores) were examined using the Mann–Whitney U test or Kruskal–Wallis test as appropriate. A Bonferroni-type adjustment was used, such that associations were considered significant for p b .01. The reason for applying this adjustment was based on the number of statistical tests. It is more likely to find a significant difference at the nominal 5% level when one does not actually exist. 3. Results No significant associations between (the demographic factors) age, race, unit, years in nursing, and level of education and scores on the HPLP II were found. Therefore, summary statistics (mean and standard deviation as well as median and interquartile range) for the overall score as well as for each subscore for the entire cohort (N = 149) are reported (Table 1). In this study sample, 45% of respondents were more than 40 years of age, 69% were White, 36% worked in critical care, 31% worked on medical–surgical floors, 33% failed to identify the unit, 50% had greater than 10 years of nursing experience, and 60% had at least a bachelor of science in nursing (BSN) degree (Table 2). The outcome variables of the HPLP II are the overall score and the subscale scores. The overall mean, median, and mode scores (Table 1) were 2.6, 2.5, and 2.8, respectively, with a mean range from 1.8 to 3.5. In this sample of nurses, when the subscales (ranging from 1 [never] to 4 [routinely]) were examined, the mean outcomes for stress management (2.2), physical activity (2.38), and health responsibility (2.44) scored lowest. Nutrition (2.6), spirituality (2.87), and interpersonal relationships (3.01) scored highest. Although no significant differences were noted at the b.01 levels, overall scores on the HPLP II were consistently higher (better) in one group when the demographics of the unit is examined. The nurses on the medical–surgical/telemetry floors scored consistently higher (better) on the overall score
Table 1 HPLP II results (1 = never, 2 = sometimes, 3 = often, 4 = routinely) Results (N = 149) Overall scores Subscale category Interpersonal relations Spirituality Nutrition Health responsibility Physical activity Stress management IQR = interquartile range.
M (SD) 2.6 (0.41) 3.01 (0.46) 2.87 (0.54) 2.60 (0.51) 2.44 (0.50) 2.39 (0.74) 2.25 (0.53)
Range
Mode
Median (IQR)
1.8–3.5
2.8
2.56 (0.62)
1.6–3.8 1.6–3.7 1.2–3.7 1.1–3.6 1.0–3.8 1.2–3.8
2.8 2.4 2.6 2.5 2.0 2.2
3.00 (0.56) 2.89 (0.78) 2.56 (0.67) 2.44 (0.67) 2.25 (1.13) 2.25 (0.75)
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Table 2 Demographics Demographics
n (%)
Age (years) 20–30 31–40 41–50 51–60 N60 Missing Race Asian Black Hispanic Native American Other White Missing Unit Critical care Floor Missing Years in nursing 0–5 6–10 11–20 21–25 26–30 31–35 Highest level of education Associate in applied science BSN Diploma Master's Post-master's Missing
35 (23.81) 46 (31.30) 47 (31.98) 18 (12.24) 1 (0.68) 2 (1.36) 18 (12.08) 10 (6.71) 6 (4.03) 1 (0.67) 3 (2.01) 104 (69.80) 7 (4.70) 54 (36.24) 46 (30.87) 49 (32.89) 39 (26.71) 32 (21.92) 43 (29.45) 17 (11.64) 12 (8.22) 3 (2.05) 39 (26.17) 69 (46.31) 17 (11.41) 21 (14.10) 1 (.67) 2 (1.34)
and each of the subscale scores than the nurses on the critical-care areas (Table 3). 4. Discussion The demographics of this pilot study reported that 45% of the nurses are more than 40 years old, with at least 10 years experience, and 60% obtained at least a BSN degree. Our nursing population mirrors the national trend in an aging nursing workforce, where the average age of RNs in 2004
Table 3 Comparison of critical-care nurses (n = 54) and floor nurses (n = 46) HPLP II scores
Critical care, M (SD)
Floor, M (SD)
Overall score Subscale category Interpersonal relations Spiritual growth Nutrition Health responsibility Physical activity Stress management
2.52 (0.35)
2.69 (0.46)
2.98 (0.46) 2.76 (0.52) 2.52 (0.43) 2.36 (0.45) 2.32 (0.73) 2.14 (0.49)
3.05 (0.48) 2.95 (0.51) 2.73 (0.55) 2.53 (0.56) 2.46 (0.80) 2.35 (0.53)
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Table 4 Poststudy identified barriers to stress management Lack of time Inability to choose method Competing demands Environmental factors Lack of support
was 46.8 years (HRSA, U.S. Department of Health and Human Services, 2004) and continues to increase. Overall low scores demonstrate the need to address the healthpromoting lifestyle behaviors of our nurses, especially the weaker areas of stress management and physical activity. The link between stress management and health promotion is consistent with the literature review. The difference in scores in the medical–surgical and critical-care areas may deserve further investigation and require different interventions. The general overall higher scores in spirituality and interpersonal relationship may facilitate a holistic approach using group work and spiritually based interventions in addressing nurses' health promotion. Previous studies identifying the interrelation of the areas of wellness (Kerr & Richey, 1990; Adams et al., 2000) further support a holistic approach. Health promotion behaviors encompass the individual perceptions, modifying factors, barriers, and triggers (Duffy, 1988). This pilot study identifies target health promotion areas needed in nurses. Interventions need to support health promotion and changes in health perception and behaviors. As health is multifaceted, health promotion interventions for nurses should be comprehensive, incorporating a holistic wellness approach, and fostered in the workplace. Barriers need to be identified and modified, whereas peer support and education need to be fostered. This study prompted discussion topics with the staff of each of the involved units and supported the initial efforts to focus on self-care at our institution. Using the HPM framework during the unit discussions, the staff identified barriers to stress management as lack of time, inability to choose a method, competing demands, environmental factors, and lack of support (Table 4). 5. Implications for practice Holistic nursing, recently recognized by the American Nurses Association as a specialty, describes the theory and practice of self-care through numerous resources including books, journals, conferences, and a national certification program (AHNA, 2006). In addition to a holistic emphasis, programs focusing on nursing wellness must be comprehensive, affordable, educational, and experiential. Translating the pilot study findings into our practice setting resulted in the development of educational classes, staff massage, and renewed interest in an employee wellness program. Two-day educational and experiential classes are
offered to introduce holistic nursing and incorporate the modalities of reflexology techniques and integrative imagery. It is hoped that this will encourage the use of these interventions for self-care. Massage, reflexology, or both are offered on the unit for staff when there is an identified need, at a convenient time, with peers providing relief. Examples of a “need” included unit leadership transition, difficult patient situations, or personal issues. While there is limited evidence of effective interventions reducing stress in health care workers (Marine et al., 2007), a 2002 study in our institution using massage on nurses revealed decreased anxiety and increased awareness of the need for self-care (McElligott et al., 2003). The final initiative is greater emphasis and support for the development of an employee wellness program and focus on the removal of environmental barriers (e.g., creation of a “relaxation room” and onsite exercise program). 6. Conclusion Holistic caring and nurturing of self support a healthy balance and increase productivity and a fuller participation in the life experience (Eliopoulous, 2004). Support of this paradigm shift to an emphasis on self-care provides the energy for nurses to enhance their care of patients, families, and communities. The use of the midrange theory allows practitioners to translate theory into practice. The HPM, which guides the assessment of the nursing staff, is an important first step of this process. As staff wellness needs are identified, institutions can develop ongoing programs to assist in meeting these needs and decrease the indirect costs of poor employee health. Benefits such as discounted gym membership may have new meaning for nurses as they identify the role of exercise in their own stress reduction and overall wellness. Future studies may examine the impact of the above-identified holistic wellness programs, demographics, and the interrelation of the various subscales of the HPLP II, as well as the relationship between nurses' health promotion behaviors (scores on HPLP II) and patient outcomes. The nurses who can assess and address their wellness from a physical, emotional, and spiritual level can more easily model this behavior for their patients, families, peers, and communities. As a result of this pilot study, we know that health promotion is an area of concern in this sample population. Our interventions are just beginning. Awareness of the issue has been raised. Health promotion, which is a vital component of nursing, needs to be ingrained in the lifestyle of each nurse and supported in the research arena.
Acknowledgment We wish to thank the cardiac and neuroscience nurses of North Shore University Hospital for their participation.
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