Factors that Influence Health-Promoting Self-Care in Registered Nurses: Barriers and Facilitators

Problem Statement and Purpose

The prevalence of obesity in U.S. adults is 39.3%¹ and rates of non-communicable, life-style diseases such as cardiovascular disease and type 2 diabetes are epidemic². Despite nurses’ training and role on the front lines of treatment and management of lifestyle-related diseases, nurses in the U.S. experience prevalence rates of obesity that range from 23% to 61.4%³. This problem is not exclusively a US phenomenon, as the prevalence of obesity in British nurses is 25.1%, similar to the 27% found in the general population of England⁴. Nurses may not be participating in health-promoting activities such as exercising, eating a healthy diet, and practicing stress reduction activities⁵. In a review of 13 mostly large-scale studies that examined physical activity levels and diets of U.S. hospital nurses, the majority of nurses reported that their diets were of poor quality (53%−61%) and that they participate in inadequate levels of physical activity (60–74%)⁶. Because of their poor diets and low levels of exercise, nurses are at increased risk for chronic disease, which in turn can lead to higher levels of absenteeism and turnover⁷. Indeed, poor health is one of the primary reasons why nurses intend to leave the workplace⁸. Nurses’ health status and rates of participation in health behaviors may influence both the nature and quality of patient care⁹. For example, nurses who exercise regularly are more likely to encourage their patients to engage in physical activity¹⁰. Conversely, overweight healthcare professionals may be less likely to provide weight loss advice to overweight or obese patients than would their normal weight counterparts¹¹. Nurses who do not exercise are more likely to experience low back pain¹², and nurses with low back pain are more likely to provide compromised patient care including medical errors and increased rates of patient falls¹³.

A healthy nursing workforce is a public health priority. Numerous studies have described the high prevalence of overweight and obesity in nurses³, and others have focused on the quality of nurses’ diets and/or on their levels of physical activity⁶. However, less research has focused on why nurses might not be engaging in health-promoting self-care. In order to improve nurses’ health status, a more thorough understanding of the factors that influence nurses’ participation in health-promoting behaviors is warranted. The purpose of this study is to describe nurses’ perceptions regarding factors that influence their participation in health-promoting behaviors such as exercising, consuming a healthy diet, and participating in stress reduction activities.

Research Question(s)

What are the barriers to nurses’ participation in health-promoting behaviors?

How do individuals within the workplace influence nurses’ participation in health-promoting behaviors?

Theoretical Context

According to Pender’s model of health-promotion, individuals have personal factors (biological, psychological, and sociocultural) that directly influence participation in health-promoting behaviors¹⁴. The model also demonstrates that the impact of personal factors on health-promoting behavior is mediated by three factors: 1) perceived barriers and benefits associated with health-promoting behaviors, 2) interpersonal factors, such as norms and support provided by social relationships, and 3) situational or environmental factors, which in the case of nurses includes workplace factors such as the type of unit and shift worked. Competing preferences, defined as alternative behaviors in which the individual would like to participate, may override one’s desire to participate in health-promoting behaviors.

Background and Significance

Several researchers have examined the relationship between workplace factors and nurses’ participation in health-promoting activities. The type of unit on which a nurse works, as well as the type of job that a nurse holds may influence participation in health-promoting activities. For example, critical care nurses reported lower participation in health-promoting behaviors than do medical-surgical and telemetry nurses¹⁵. Polish nurses working shifts reported practicing fewer health-promoting behaviors than nurses who did not participate in shiftwork¹⁶. Korean nurses who worked rotating shifts were more likely to overeat when stressed than nurses who did not work rotating shifts¹⁷. How much a nurse enjoys his or her work may be health-protective, as nurses who reported higher levels of compassion satisfaction participated in more health-promoting behaviors than those who had lower compassion satisfaction scores^18,19.

Albert, Butler and Sorrell²⁰ used Pender’s theory to examine multiple factors related to diet and physical activity in hospital-based nurses; they found that nurses with higher self-efficacy, more perceived benefits and fewer perceived barriers were more likely to eat a healthy diet and to be physically active; perceived barriers was the most important factor related to not consuming a healthy diet. Interestingly, nurses who worked day shift had more perceived barriers to healthy eating and physical activity than nurses working other shifts.

In an integrative review of 26 research studies, researchers found that nurses experienced numerous situational barriers to healthy eating in the workplace including: organizational factors such as long work hours and shiftwork, environmental factors such as the lack of availability of fresh food and/or storage facilities, personal factors such as low levels of motivation and self-efficacy, and social factors such as the eating habits of colleagues²¹. The authors found few studies that focused on facilitators of healthy eating in the workplace.

Other researchers have examined barriers and/or benefits to physical activity and/or healthy behaviors in nurses. Perceptions of positive personal health¹⁰, belief in the benefits of exercise²² and the opportunity to recover from disrupted circadian rhythm between shifts²³ were cited as factors positively influencing participation in physical activity. Significant overlap exists between barriers to nurses’ participation in physical activity and barriers to eating a healthy diet. For example, nurses in several studies cited shift work, disrupted circadian rhythm, and/or lack of breaks as primary barriers to eating a healthy diet and to engaging in physical activity^16,23,24. Additionally, lack of time due to responsibilities at work and home, lack of accessible and affordable food/exercise space in the workplace, fatigue, and stress were identified as barriers to participating in both physical activity and eating a healthy diet^20,24,25.

Though minimal, existing evidence from these quantitative studies suggests that nurses, a vital component of our healthcare work force, experience significant barriers to participating in behaviors that could improve their health and keep them healthy. However there are gaps in the literature regarding this phenomenon, as the bulk of research in this area has focused on who is or is not participating in health-promoting behaviors, while very few studies have examined why nurses are or are not engaging in health-promoting self-care. Further, the majority of research in this area has focused almost exclusively on barriers to healthy eating, with considerably fewer studies focusing on barriers to physical activity and none focusing on barriers to other important healthy behaviors such as participation in stress reduction activities. This is an important omission, given the overwhelming evidence that nursing is a stressful profession and that stress is associated with negative health consequences. Nearly all of the studies in this area have used quantitative methodology to examine barriers to health-promoting behaviors as a small part of a larger descriptive study. Thus, the knowledge gained regarding barriers to healthy behaviors in these studies was limited by the quality and/or quantity of the multiple-choice questions that were asked. In order to obtain a richness of detail about the phenomenon, qualitative methodology is needed. Finally, very few studies have focused on interpersonal facilitators to health-promoting behaviors. In particular, no published studies to date have focused on how individuals at work might facilitate participation in health-promoting activities. Therefore, a more thorough examination of barriers and interpersonal factors that influence physical activity, healthy eating, and stress reduction activities in nurses is needed.

Study Design

The data in these analyses are part of a broader cross-sectional survey, “Nurses and Self-Care: Do we practice what we preach,” which was conducted during a three week period in November, 2016¹⁸. An anonymous cross-sectional survey design was used to collect information about factors that influence whether or not registered nurses (RNs) participate in health-promoting self-care behaviors. Three open-ended questions collected information regarding factors or individuals who influence nurses’ participation in health-promoting behaviors, and these are analyzed qualitatively in this manuscript. This study was approved by the Office of Human Subjects Research Protections at the National Institutes of Health Clinical Center (NIHCC) (OHSR#13263). Consent was implied if participants accessed the link and completed the survey.

Methods and Procedures

This study took place at the NIHCC, a facility devoted to clinical research, with 200 inpatient beds, 15 outpatient clinics and nearly 100 day hospital stations that support over 100,000 patient visits per year²⁶. The nursing department is comprised almost entirely of RNs, with the majority having a bachelor’s degree or higher. All RNs (n = 1363) at the NIH, both within the CC and within the other 26 institutes and centers, were eligible to participate. This included staff nurses and float RNs, research nurses and research nurse coordinators, advanced practice nurses, educators, and those in supervisory positions such as administration and management.

RNs were invited to participate via a series of three emails sent by the Principal Investigator (PI) that included a study description and a link to the online survey. Participants were allowed to opt out of any questions that they did not wish to complete. Three open-ended questions were included to assess RNs perceptions regarding barriers and facilitators to participation in health-promoting activities: “What barriers within your workplace interfere with or prevent your participation in health promotion activities such as eating a healthy diet, exercising, and participating in stress reduction activities?” and “What barriers outside of your workplace interfere with or prevent your participation in health promotion activities such as eating a healthy diet, exercising, and participating in stress reduction activities?” A final question asked, “Individuals with whom we work can influence our participation in healthy activities positively by being supportive and/or by being good role models, and they can influence our participation negatively by not being supportive or by encouraging unhealthy behaviors. Without providing specific names, how do individuals within your workplace influence your personal participation in health promotion activities such as eating a healthy diet, exercising, and participating in stress reduction activities, both positively and negatively?”

Analysis of Data

Researchers used conventional content analysis, sometimes referred to as inductive content analysis, to analyze subjects’ written responses to the open-ended questions²⁷. Inductive content analysis involves a qualitative analytical approach that is used to describe phenomena in text data by discovering patterns, categories, and themes in the data²⁸. Two researchers performed data analysis (AR, KTL). First, they immersed themselves in the data by reading the text repeatedly in order to obtain an overall sense of the data and a feel of the participants’ experiences. Then the researchers independently highlighted sections of the text that seemed to capture key concepts and/or thoughts, making notes regarding their impressions. Researchers independently assigned codes or labels that were reflective of the different key thoughts/concepts. These codes were phrases or words that described and summarized participants’ experiences, which were then placed into categories based upon how the codes were related/connected. Clusters, or subcategories of codes that were related to each other would emerge from the categories as themes.

After researchers independently coded the data and identified categories and themes, they met to review their findings. They abstracted similar categories and themes, although the number of and names of themes differed slightly. The researchers discussed their differences and reached consensus on two categories and seven themes. They then independently coded the data based on the agreed-upon themes. An expert in qualitative methodology (SG) validated the findings by auditing the categories, themes, and supporting quotes. NVivo (QSR International Pty Ltd Version 10.0, 2012) was used for qualitative data management and to establish inter-rater reliability; a kappa coefficient of .85 and percent agreement of 99.2% were calculated for this study. Descriptive statistics were calculated using IBM SPSS Statistics for Windows, Version 24.0.

Trustworthiness (reliability and validity) of the analysis was ensured through credibility, dependability, and transferability²⁹. Credibility was established by having two researchers independently perform the data analysis. An expert then validated the results and ensured that no relevant data was excluded. In addition, exemplar quotes that supported each theme were included in this manuscript to provide a link between the results and the data. Dependability of the findings was enhanced by strict adherence to the procedures for content analysis outlined by Hseih & Shannon (2005)²⁷, and by including statistics for inter-rater reliability and coefficients of agreement. Transferability of the findings was enhanced by providing a clear description of participants in this manuscript and in the primary publication¹⁸, as well as by including a diverse population of nurses in the study, including those in staff nursing, research, education, advanced practice, and supervision/management.

Findings

Of the 349 RNs who participated in the original study, 264 (75.6%) answered at least one of the open-ended questions and are included in this analysis (Table 1). Two hundred ten (60.2%) answered all three questions. Themes that emerged from the data were classified under two broad categories: barriers to health-promoting behaviors and individual influences of health-promoting behaviors. Barriers to health-promoting behaviors were defined as inanimate factors that served as obstacles or hindrances to nurses’ participation in health promoting behaviors such as exercising, consuming a healthy diet, and/or participating in stress-reduction activities. These factors could be both inside and outside of the workplace. Five themes related to barriers to participation were extracted including: no time or “overwork,” lack of adequate facilities/resources, fatigue and/or lack of sleep, outside commitments, lack of resources/facilities, and an unhealthy food culture.

Table 1.

Descriptive characteristics participants (N=264)

Characteristic	Mean (SD) Range
Age in Years (n = 251)	46.9 (10.7) 23–68
Years Nursing Practice (n = 262)	19.2 (11.3) 0–45
	n (%)
Gender (n = 256)
Female	232 (90.6)
Race (n=251)a
White	180 (71.7)
Black	30 (12.0)
Asian	22 (8.8)
Other	19 (7.6)
Ethnicity (n = 247)
Non-Hispanic	236 (95.5)
Marital Status (n = 255)
Married/partnered	185 (72.5)
Divorced/separated/never married/widowed	70 (27.5)
Provides care for a dependent child (n = 254)	132 (52.0)
Provides care for a sick/disabled family member (n = 256)	60 (23.4)
Doubleduty Caregiverb (n = 257)	38 (14.8)
Education (n=256)
Diploma/Associate’s Degree	17 (6.6)
Bachelor’s Degree	137 (53.5)
Master’s Degree	89 (34.8)
Doctoral Degree (PhD/DNP)	13 (5.1)
Employment Status (n = 264)
Full Time	229 (86.7)
Part time/PRN	35 (13.3)
Shifts worked (n = 261)
Days only	189 (72.4)
Evenings only	4 (1.5)
Nights only	12 (4.6)
Rotating/Variable	56 (21.5)
Length of shift worked (n = 263)
Less than 12 hours	208 (79.1)
12 hours or more	55 (20.9)
Primary Position (n = 264)
Staff Nurse	103 (39.0)
Research Nurse/Research Coordinator	82 (31.1)
Manager/Administrator, Scientist, Educator)	52 (19.7)
Advanced Practice (NP, CNS, CRNA, etc…)	27 (10.2)

PRN = Pro Re Nata/ As needed. NP = Nurse Practitioner. CNS = Clinical Nurse Specialist. CRNA = Certified Registered Nurse Anesthetist.

^aOther includes: “other” unspecified (n = 10), multiracial (n = 7), American Indian or Alaska native (n = 2).

^bDoubleduty Caregiver refers to those nurses who were taking care of a dependent child at home, as well as a sick or disabled family member.

The second category that emerged from the data was individuals who influence health- promoting behaviors. Two themes emerged from the data that pertained to how individuals influence participation in health-promoting behaviors: supportive versus unsupportive individuals and positive versus negative role-models. The two categories, seven themes with frequency data, and supporting quotes are detailed in Table 2.

Table 2.

Categories, themes and supporting quotes from content analysis (n = 264)

Category	Theme	n (%)	Supporting Quotes
1. Barriers to Health-Promoting Behaviors	1.1 No time/overworked	203 (76.5)	“…only allowed 30 minutes for lunch. Not enough time to take an exercise break or nice walk even. High level of deliverables requires constant work during day.”
			“…long commute, so no time to work out before/after work. On 12 hr shifts, only time to shower and then quickly eat before going to bed when I get home. Get home at 8:30 and need to be in bed by 9 in order to get 8 hrs of sleep before next shift. No time for any relaxation activities…”
			“The hours I work prevent me from exercising as much as I would like and my ability to prepare healthier meals as often as I would like. I also don't always have the time or resources to take a full break and eat the lunch I have prepared, but rather have to snack. Also, there is no time or ability to get outside during the day- even just for a 10/15 minute walk.
			“Schedule does not permit, our work does not allow for us to readily leave the floor.”
			“Office culture that you have to be working 100% of the time, even at lunch.”
	1.2 Lack of adequate facilities/resources	71 (26.9)	“Not enough affordable healthy choices in the cafeteria. Lack of employee gym…Lack of employee showers.”
			“Lack of healthy [food] choices on evenings, weekends and holidays”
			“Lack of quiet space to get away from others and decompress and rejuvenate for a few minutes.”
			“The price[s] of healthy food is always more than cheaper junk food. There is no gym or staff relaxation areas available.”
			“No healthy food available during the night shift. All choices high in salt, fat, cholesterol, sugar, etc….”
	1.3 Fatigue/lack of sleep	61 (23.1)	“Too tired to exercise.”
			“I am usually too tired and emotionally drained after work, so I usually just try to get some rest.”
			“Stress of job sometimes makes it too draining to go to the gym or for a long run after work.”
			“Often too tired to exercise or prepare food after work. I want something convenient.”
			“I find it hard, too, to pack healthy food or to eat healthfully when I get home after a twelve hour shift. Because I leave for work an hour before my shift starts and get home thirty minutes to an hour after I get off (which is not always on time), I have often spent 14 hours+ away from home. It takes all the energy I have just to walk and feed my dog. I don't want to cook a whole meal. Sometimes I just eat cereal for dinner, if I even eat dinner at all.”
	1.4 Outside commitments	117 (44.3)	“Completing chores that can't be completed during the week when busy at work takes up time for exercise.”
			“Family requiring ‘more time’ with me. I want some alone time. Space.”
			“3 kids playing different sports at different fields - always shuffling them around.”
			“Home life demands of caring for family, especially ill family members.”
			“I have a busy life with two kids. I tend to put their needs first, which leaves little time for my activities.”
			“Running errands and toting my kid around to her activities eats up most of my free time. I don't have much me-time left. When I finally get me time, I just want to read or internet surf or sleep.”
			“Too tired after work and busy with school to participate in activities.”
	1.5 An unhealthy food culture within the workplace	59 (22.3)	“Another co-worker has a candy jar on her desk, which promotes poor compliance with my sweet limitation on those low will-power days.”
			“We tend to have lots of parties, which ends up with everyone eating more sweets. It's great socially, but not good for the waist line.”
			“People in my workplace are always bringing junk food in to eat. I try not to eat any but sometimes I give in to temptation.”
			“Lots of fattening foods and people forcing foods on you.”
			“The carb fest that starts every Fall from Halloween candies to potlucks for the holidays. There is a lot of junk food.”
2. Individuals who Influence Health-Promoting Behaviors	2.1 Supportive versus unsupportive Individuals	135 (51.1)	“On our unit, we try to bring healthy snacks for everyone. We also started various workout challenges and text each other our progress.”
			“My unit tries to keep each other accountable for eating healthy. We try to pack and share healthy snacks and lunches. We put candy that others bring in the break room so it is not at the nurses station where it is easy to eat a lot.”
			“We try to support one another for breaks when possible and encourage once done to leave unit and get fresh air and or view of outside. Many of us attempt to find walking buddies.”
			“Certain members of [our department] have been doing Fitbit challenges. Its super fun and motivating me to get up and move. More groups like this would be amazing!”
			“My direct supervisor is open to employees arriving late/leaving early as long as we ensure the work needs are met. Some days, I am able to leave early and go exercise and then go home and finish up email and other projects…”
			“Health promotion and stress reduction are not priorities; hence when you go to take a walk outside, your colleagues give you an interrogation as to what you are doing…..”
			“I would love to go running at work during my break times, but then it is looked upon poorly as though you are not doing your job.”
			“All of these healthy activities or any activities outside your work are considered and looked upon negatively by supervising staff as though you are not doing your job or do not have enough workload if you can make time for exercising.”
	2.2 Positive versus negative role models	77 (29.2)	“Most of my coworkers are very health-conscious so it does encourage me to be and do better.”
			“My office mate is the healthiest eater ever, she motivates me to eat a healthier diet.”
			“[I] work with people who maintain a healthy lifestyle despite stressors of long work days. Hearing about how they manage this influences me to do a better job at it.”
			“One of my colleagues has completely changed her lifestyle habits and it has been inspiring to watch. I am so proud of her and she has motivated me to change my ways. She’s been an unofficial coach and walking partner.”
			“My supervisor provides me with information about cycling, running, and swimming events. I know my supervisor exercises which is motivating for me”.
			“My work friends also don’t have time to eat right and exercise so we indulge in negative behaviors together.”
			“Some regular meetings occur during lunch time…When colleagues respond to non-time sensitive issues during evening, weekends, or when I know they should be on leave, this increases my stress that I should be doing the same and decreases my enjoyment during off hours.”
			“Culture is one in which work/life balance is discussed yet not actively reinforced or modeled by leadership.”

Barriers to Health-Promoting Behaviors

Theme one: No time/overwork

The most frequently mentioned barrier to health-promoting behaviors, reported by more than three quarters of participants, was a lack of time and/or overwork. RNs commented that the work load and pace, long and often unpredictable hours, rotating/variable shifts, long commutes, and lack of coverage to take needed breaks and/or meals presented barriers to participation in health-promoting behaviors. Many participants spoke of commutes in excess of one hour that, coupled with shifts of 10+ hours, left precious little time for exercising or preparing healthy meals. One nurse stated that “long hours-early mornings, late nights make it difficult to participate in organized physical activities; lack of lunch break/eating on the go makes healthy eating challenging….” Irregular, rotating work schedules made taking regularly scheduled exercise or yoga classes difficult. One nurse explained that “[My] work schedule [is] not regular- sometimes days, sometimes evenings, sometimes weekends- varies week to week. Can’t participate in organized classes because don’t know if I’ll be able to attend.” Participants spoke about wanting to take a walk or to eat meals away from their units but felt too guilty asking their overworked peers to cover for their very sick patients. RNs outside of direct patient care in administration, education, and research also cited lack of time as a major barrier; these RNs reported that back-to-back meetings and deadlines forced many to eat meals on the run or at their desks, and last-minute emergencies forced them to stay late at work.

Theme two: Lack of adequate resources/facilities

Over a quarter of the nurses cited a lack of resources or facilities as another major barrier, including the lack of convenient access at work to a gym, exercise/yoga classes, showers/changing facilities, and/or refrigerators and microwave ovens for storing and reheating healthy food from home. “No gym… no relaxation classes or exercise classes that work with a nurses schedule,” explained one nurse. Many mentioned a lack of healthy, reasonably priced food options within the hospital. “There is not much in the way of healthy snack options at a reasonable price.” This was particularly problematic for nurses working nights and/or weekends, as food choices during off hours were limited to less healthy food or vending machine snacks. Many nurses working outside of direct patient care in administration, education, and /or research reported working long hours in front of a computer, often in cubicles with little or no privacy.

Theme three: fatigue/lack of sleep

A third barrier identified by nearly a quarter of the nurses was fatigue, which was pervasive and left them too drained, exhausted, and unmotivated to exercise, prepare healthy meals/snacks, and/or to reduce stress by attending yoga/meditation classes or socializing with family and friends. Getting adequate sleep when they had rapid turnarounds between shifts was challenging. “We are too weary for words anymore.”

Many nurses commented that they spent their days off trying to recuperate or catch up on sleep, as opposed to participating in health-promoting activities. Several mentioned that, not only did the fatigue interfere with their participation in health-promoting self-care, but that it often contributed to unhealthy activities and food choices. “Fatigue, feeling ““beat”“ makes me want to binge-watch TV rather than go to an exercise class… I often need to spend time on weekends napping or recovering from the work week, which cuts into time with friends/family and other stress reduction,” described one nurse. Another explained, “I’m so tired after work I do not want to do anything. Some days are 13–13.5 hours long and I don’t get home until 9 pm. Sometimes I am physically drained, sometimes emotionally. It makes it difficult to find the motivation to go to an exercise class or even make a healthy dinner.”

Theme four: Outside commitments

In addition to long work hours and fatigue/lack of sleep, nearly half of the nurses cited outside commitments and obligations that presented barriers to their participation in health-promoting behaviors. These competing outside demands included family/household responsibilities, school, and community activities. Many of the nurses were busy parents who, after working long shifts would return home to prepare meals, chauffeur children to sports and other activities, and help with homework. Some discussed caring for sick/elderly family members. Repeatedly, nurses wrote that they felt overextended and lacked any “down” time. “I started graduate school a year ago and have not been able to do what I used to do. I used to exercise at least 3 times a week, no more. I used to watch what I eat and eat healthy, no more.”

Theme Five: Unhealthy food culture

A final theme in this category was that an unhealthy food culture exists within the workplace that often presents a barrier to healthy behaviors. “People in our office bring in junk (doughnuts, cakes, etc...), and we celebrate everything with food - much of it unhealthy.” The nurses discussed the ample availability of unhealthy food within the workplace including candy, junk food, and baked goods such as cookies, cakes, and donuts. They reported frequent potlucks and the tendency to celebrate birthdays, promotions, and holidays with food that, while delicious and often home-cooked, was often high in sugar, fat and salt. Some commented that these temptations were frequent and hard to resist, making efforts at dieting difficult. “Work parties and celebrations often have unhealthy food. If I’m having a particularly hard day, I am more likely to eat unhealthy- thinking of it as a reward to myself for having a rough day. Like you deserve a doughnut today...”

Individuals who influence Health-Promoting Behaviors

Theme one: Supportive versus unsupportive individuals

Over half of the nurses commented that individuals with whom they work have some influence over their efforts at health-promoting self-care. A quarter of the nurses commented that some individuals at work contribute to an environment that discouraged or prevented engagement in healthy behaviors. Nurses mentioned wanting to leave the nursing unit for meals or exercise/stress breaks but feeling “judged” if they did so. Others commented that finding colleagues to “cover” their patients during such breaks was difficult and that feelings of guilt over leaving were overwhelming and often kept them on the unit. “Other nurses will stress me with their attitudes. It’s hard to leave the floor. I would like to walk the stairs or sit outside for lunch but feel guilty asking for that time.” Participants mentioned managers or supervisors that were inflexible regarding scheduling and coverage for meals and breaks. One nurse explained that “we do not participate in self-scheduling, therefore I have little control of my life. It is hard to take outside classes because my unit won’t commit/support that.”

Conversely, over a third mentioned that peers and managers/supervisors can be supportive and helpful regarding attempts to adopt a healthy lifestyle. “Co-workers and office mates discuss healthy recipes and positive eating habits. Very positive environment. We also discuss job frustrations and demands that cause poor eating habits and ‘comfort food’ binging.” Several mentioned going for walks with peers, sharing healthy snacks/recipes, and engaging in friendly competitions such as fit bit challenges or “biggest loser” weight loss contests. Others mentioned having managers/supervisors who supported leaving the unit for meals and breaks or allowing nurses to work flexible schedules that allowed them time to exercise.

Although not included in the total counts of this theme, it should be noted that 53 nurses (20.1%) mentioned themselves as the individual who had the largest impact on their participation in health-promoting behaviors, both positively and negatively. Some of these nurses stated that they provided their own motivation, but more than half cited their lack of will power and/or motivation as their biggest obstacle to healthy behaviors. “My problem of not doing exercise is that I am not motivating myself.” Another noted, “Craving cookies and sweets, I am weak in control.”

Theme two: Positive versus negative role models

Approximately a third of the nurses commented that individual at work can be role models for healthy and/or unhealthy lifestyles. The majority of the comments were favorable (n = 65; 24.6% of participants), with nurses mentioning that peers and managers/supervisors could inspire them by being role models for healthy living. Nurses reported that observing peers and nurses in leadership positions who exhibited healthy eating habits, exercised regularly, and demonstrated a healthy work-life balance motivated the nurses to follow their example. These role models would not only model healthy behaviors, but they would share exercise and nutrition information. “Everyone is talking about eating healthier, which is encouraging and makes you want to join in.”

Conversely, a small number of participants (n = 18, 6.8%) commented that peers and nurses in supervisory positions could be role models for unhealthy behaviors. Nurses mentioned finding it hard to resist sweets and fattening foods when everyone else is indulging. “If I see others eating unhealthy food, I feel less guilty about doing it myself.” The nurses mentioned administrators/supervisors who held regular “lunch meetings” where staff were expected to work while eating or who responded to emails during evenings, weekends, and nights, even when those emails were not time sensitive. They explained that role modeling these behaviors raised their stress levels and contributed to an environment where self-sacrifice was valued and considered the norm.

Conclusions

Many of the barriers identified in this study including a lack of time, work and family demands, and fatigue confirmed similar findings of past research²¹. Like past studies, barriers that were identified were institutional in nature, such as long work hours; environmental, such as a shortages of affordable, healthy food options and/or convenient access to exercise facilities; social, such as the eating habits of their nurse peers; and personal, such as a lack of motivation and/or energy to exercise and prepare healthy meals. Unlike past studies that found that nurses who worked certain shifts or on certain types of units experienced more perceived barriers^15,17, nurses in this study worked a broad diversity of jobs ranging from patient care, to management, to research, yet they reported similar barriers to participation in health-promoting behaviors.

Pender’s model emphasized the importance of interpersonal factors such as social norms in participation in health-promoting behaviors¹⁴. This aspect of the model was confirmed by the nurses’ responses that the norms and values of the work environment influenced their participation in health-promoting behaviors, both positively and negatively. Epidemiological data from the Framingham Heart Study has shown that obesity is contagious, with levels of obesity increasing if one’s family and, more importantly, one’s friends are obese³⁰. The relationship between one’s social network and obesity is believed to be due to shared norms regarding eating and weight, or possibly to shared environmental experiences such as close proximity to high caloric foods or lack of access to exercise facilities ³¹. The findings in this study lend confirmation to the theory that shared norms and a shared environment play a role in weight gain; an unhealthy hospital culture and norms, in addition to a lack of access to facilities/resources were among the barriers to health-promoting behaviors that were identified in this study. Nurses discussed the unhealthy norms surrounding food at the hospital that contributed to a near constant barrage of high-caloric foods as well as pressure to consume them. Others discussed the norm of self-sacrifice, whereby working to the point of exhaustion is respected and self-care is considered selfish.

However, the news was not entirely bleak. Administrators and peers could also be inspirational, providing support and/or serving as role models for healthy living. The identification of coworkers as potential facilitators of healthy behaviors is a novel finding and it represents an area of research that has received little emphasis in the past. Another finding that has received little research attention to date is the impact of outside demands on nurses’ participation in health-promoting behaviors. According to Pender’s model, despite the best intentions and support, immediate competing demands may derail one’s decision to participate in health-promoting self-care¹⁴. Over half of the participants were caring for dependent children in the home, and nearly a quarter were providing unpaid care for a sick or ill family member or friend. The nurses in this study clearly were exhausted, and their comments underscore the impact of family caregiving on their ability to participate in self-care. While rewarding, other outside responsibilities, such as attending school or participating in community or religious organizations, may represent one more stressor as well.

Implications for further research and nursing practice

The nurses in this study identified numerous barriers to health-promoting behaviors that have implications for nursing practice and management. Some of these barriers are changeable, while others, such as commute times and workplace demands, may be immutable. In order to adequately address the issue of barriers to nurses’ participation in health-promoting behaviors, change is needed on institutional, interpersonal, and intrapersonal levels. Institutional change is needed to address the lack of facilities and resources within an organization such as the availability of workout facilities, refrigerators, and affordable, convenient healthy food options. However, a healthy nursing workforce is critical for the operations of any hospital, and nurse administrators might utilize research regarding the cost of an unhealthy workforce in staff turnover and diminished patient care to justify needed expenditures on health-related facilities and resources.

While institutional change is difficult, changing the culture or interpersonal relationships within a nursing department may be more achievable. Such change likely must come from the top. By implementing leadership styles that allow nurses more control and autonomy, improve workplace communication, and support nurses’ efforts at self-care, nurse leaders can improve the work environment and increase the job satisfaction of staff nurses³². Nurses who are happy with their work tend to engage in healthier behaviors^18,19. Because their own actions contribute to the norms of the unit and hospital, nurse leaders at all levels need to be role models in civility, self-care, and work-life balance.

Nurses in this study cited their personal levels of fatigue and lack of motivation as primary barriers to health-promoting self-care. Thus, in addition to institutional and interpersonal change, nurses need to take personal responsibility for their own self-care. A personal change of mindset is needed to overcome the guilt associated with taking lunch or a brief meditation break away from the unit. Most nurses would freely reassure family caregivers of very sick patients that it is not only acceptable but imperative that family caregivers take a break away from the bedside in order to eat a healthy meal, visit the chapel, or take a walk outside. However, nurses are less likely to extend such kindness and permission to themselves.

While barriers to nurses’ participation in health-promoting self-care has received research attention, additional research regarding norms surrounding food and self-care in nurses is needed. Such research should focus on novel interventions that increase the positive impact of supervisors, peers, and the work environment rather than merely describing their negative impact on nurses’ self-care. Research is also needed that examines the impact of double-duty caregiving and the impact of non-work activities on self-care and other health outcomes in nurses.

This study had several limitations. As in any anonymous survey, there is the threat of response bias and deception. Because it was cross-sectional in nature, we were unable to validate the findings with the participating nurses. These findings were based on responses to three open-ended questions that focused on two specific issues related to participation in health-promoting behaviors: barriers and individuals who served as facilitators. Limiting the study strictly to those two topics might have introduced response bias. A greater depth of detail could be obtained from qualitative interviews, focus groups, and/or ethnographic studies that broadened the scope of focus beyond barriers and interpersonal facilitators.

Despite these limitations, this study had several strengths including the broad diversity of nursing positions and education backgrounds in the sample, nearly all of whom reported similar barriers to participation in health-promoting behaviors. This study confirmed Pender’s model and findings from past studies regarding the presence of situational/workplace and interpersonal barriers to self-care in nurses. It provided novel insights regarding how individuals at work could be facilitators by providing social support and serving as role models. This study identified an unhealthy food culture and norms that value self-sacrifice over self-care that exist within nursing. Further, the study underscored the influence of non-work activities and outside demands on nurses’ ability to participate in health-promoting self-care.