Abstract
Objective:
This study compared self-reported nutrition, physical activity, and body mass index (BMI) in undergraduate versus graduate nursing students.
Participants:
Respondents included 233 undergraduate and 230 graduate nursing students in a Southeastern public university.
Methods:
The study was an exploratory, descriptive, cross-sectional comparison administered via online questionnaire including self-reported demographics, nutritional intake, physical activity, and BMI.
Results:
Undergraduates reported exercising more than graduate students. Graduate students reported consuming significantly more vegetables than undergraduates; however, more graduate students self-reported BMIs in overweight and obese categories than undergraduates.
Conclusions:
Findings provide a foundational understanding that interventions or educational programs to improve self-care behaviors of nursing students should be tailored depending on the educational level of the students. Educators must establish self-care skills within nursing students at all levels to help them preserve their health in the fast-paced, strenuous, and stressful work of all echelons of nursing upon completion of the educational program.
Keywords: Graduate student health, nursing student self-care, self-care behaviors, undergraduate student health
Individuals often pursue a career in nursing because they enjoy caring for others or feel called to this challenging but rewarding work. Most nursing students and nurses also have empathy and altruism, which help carry them through many years of service to those in poor health.1–3 What is often unknown by students planning to enroll in nursing school are the challenges they may face during their educational process. Concerns such as how to maintain a healthy diet, incorporate regular physical activity, and maintain a healthy BMI while in school are not always considered.4–6
Practicing nurses and students must focus on patients, be open-minded and adaptable, and practice compassion and understanding. Ideally, they are in optimal physical condition and possess critical knowledge and clinical skills. These qualities are important for nurses to provide safe care for patients in hospitals and other settings.7 Also, nurses often face distressing moral, ethical, and emotional dilemmas. Cumulatively, these issues may lead some nurses to consider leaving the profession.8 Unfortunately, there is a nursing shortage. The United States (U.S.) needs 15% (438,100) more nurses by 2026.9 Thus, it is important to prepare the next generation of undergraduate and graduate nurses for these challenges that threaten their personal physical and mental health.
Although researchers have reported on undergraduate and graduate nursing students’ health behaviors separately, researchers in the U.S. have not compared behaviors of the two student populations in the same study. The purpose of this study was to determine differences in self-reported nutritional intake, physical activity, and BMI among undergraduate versus graduate nursing students. Understanding differences may assist nurse educators in designing targeted interventions or educational programs promoting healthy habits, serving students during their education and their future professions.
Methods
Procedure and participants
The study was approved by the university’s Institutional Review Board (IRB). Participants were provided IRB-approved study information at the beginning of the survey, with consent indicated by the participant’s elective completion and submission of the survey. An online, anonymous survey link was sent to 4,222 students enrolled in under-graduate and graduate nursing programs at a university in the Southeastern U.S., and 496 responded (11.7%). After removing participants with 100% missing data on variables of interest, the final sample consisted of 463 participants, representing three distinct nursing programs within the college of nursing: Bachelor of Science in Nursing (43%), Master of Science in Nursing (32%), and Doctor of Nursing Practice (18%); 8% of the sample did not report a specific program. Researchers divided respondents dichotomously into undergraduate and graduate groups for analysis.
Sample characteristics
Two hundrend thirty-three participants were undergraduate students (self-reported Freshmen, Sophomores, Juniors, or Seniors), and the remaining 230 participants self-reported as graduate students. In both groups, female students were overrepresented: 92% in the undergraduate sample and 91% in the graduate sample. This is consistent with nursing student demographics at this university as well as those of practicing nurses nationwide in 2017.10 Mean ages were 20.37 years (SD = 5.17) for undergraduates and 36.10 years (SD=8.45) for graduate students. Both groups mostly identified as White/Caucasian (undergraduate 71%; graduate 74%), followed by Black/African American (24% and 15% respectively). Employment rates at the time of the study were 37% in undergraduates and 89% in graduate students.
Measures
The BUCS: Live Well Survey was used for collecting the nutrition and physical activity data.11 This survey was created in 2013 for East Tennessee University (Buccaneer) students as part of a Master’s thesis study “Assessment of Dietary Behaviours of College Students Participating in Health Promotion Programs.” Reliability and validity of this survey were not accessible for the original data.
Nutritional intake
Nutritional intake was assessed using the following four items: 1) “How important is it to you to eat healthy each day?” with a Likert-type score ranging from 0 (Extremely Unimportant) to 5 (Extremely Important); 2) “On average, you eat how many daily servings of fruit (1 serving = 1 whole fresh fruit, ½ cup canned fruit, or ½ cup 100% fruit juice)?”; 3) “On average, you eat how many daily servings of vegetables (1 serving = 1/2 cup cooked or 1 cup raw)?”; and 4) “How often do you consume the following 18 commonly consumed foods and beverages?” with the following response options: Daily, 4–6 per week, 1–3 per week, Once per month, Never, or Not sure. Recommended daily intake was defined as three or more servings of fruit12 and two or more servings of vegetables.13 Cronbach’s alpha was .72 for a previous study using the nutritional questions of the BUCS survey.14 For the present study, Cronbach’s alpha was .65 for these items.
Physical activity
Three questions were used to assess physical activity: 1) “How important is it to you to be physically active each day?” with response options ranging from 0 (Extremely Unimportant) to 5 (Extremely Important); 2) “How many days per week do you exercise on average?”; and 3) “How many minutes do you exercise per day on average?” (e.g., none, 1–15, 16–30, 31–45, 46–60, over 60). Cronbach’s alpha was .73 for the physical activity items.
Body mass index
Researchers calculated BMI from self-reported height in inches and weight in pounds.15 For select analyses, clinically defined categories of BMI were used: underweight: <18.5; normal or healthy weight: 18.5–24.9; overweight: 25–29.9; and obese: ≥30.16
Analysis
Researchers examined the data using SPSS version 25 for missing values and univariate outliers. Thirty-three participants were removed from the sample due to missing 100% of data on the variables of interest, resulting in a final sample size of 463 (233 undergraduates and 230 graduate students). Two extreme outliers for height data were removed due to the improbability of their values. Each variable had less than 5% of missing data. Little’s Missing Completely at Random test (MCAR) was significant (χ2 (1260) = 1389.29, p =.006).17 Based on patterns of missing values, it was determined data were missing at random (MAR). Multiple imputation using the Markov Chain Monte Carlo (MCMC) method was used to replace missing values.18,19 Primary analyses consisted of descriptive statistics to provide basic information on the sample. Researchers conducted independent-samples t-tests and Chi-square tests for association with column comparisons (Bonferroni method) for potential differences in nutritional intake and physical activity between undergraduate and graduate nursing students.
Results
Nutritional intake
When asked to rate how important healthy eating was to them, graduate students (n=230) reported significantly higher ratings (M=4.12, SD=0.87) than undergraduate students (n=233; M=3.90, SD=0.89), t(461) = −2.71, p < .01. Nineteen percent of undergraduates and 21% of graduate students reported consuming the recommended daily intake of fruit; however, no significant difference in selfreported fruit intake by academic level was found, χ2 (1, N=463) = 0.29, p = .59. By contrast, the percentage of students who reported consuming the recommended daily servings of vegetables was significantly different by academic level, χ2 (1, N=463) = 20.13, p < .001 (Cramer’s V = .21), with more graduate students (72%) than undergraduates (52%) reporting meeting the daily recommendation. Please see Table 1 for additional descriptive data on the dietary patterns for both groups of nursing students.
Table 1.
Results from BUCS Live Well Survey.
| Question | Responses | Undergraduate | Graduate |
|---|---|---|---|
| On average, you eat how many daily servings of: | |||
| fruit (1 serving = 1 whole fresh fruit, ½ cup canned fruit, or ½ cup 100% fruit juice)? | Zero | 15.5% | 13.5% |
| One | 37.8% | 37.4% | |
| Two | 27.9% | 28.3% | |
| Three | 12.9% | 13.9% | |
| Four | 3.9% | 6.1% | |
| Five | 0.4% | 0.9% | |
| ≥ Six | 1.7% | 0% | |
| vegetables (1 serving = 1/2 cup cooked or 1 cup raw)? | Zero | 9.6%* | 4.3%* |
| One | 38.5%* | 23.5%* | |
| Two | 24.5%* | 33.0%* | |
| Three | 20.6% | 17.8% | |
| Four | 4.7%* | 12.2%* | |
| Five | 0.9%* | 6.1%* | |
| ≥ Six | 1.3% | 3% | |
| Thinking about your usual eating habits over the past 30 days, how often have you consumed each of the following foods or beverages? | |||
| Regular soda | Daily | 13% | 7% |
| 4–6 times/week | 9.9% | 1.8% | |
| 1–3 times/week | 30% | 13.5% | |
| Once/month | 23.9% | 20.2% | |
| Never | 23.3% | 57.6% | |
| Diet soda | Daily | 2.1% | 9.1% |
| 4–6 times/week | 2.7% | 6.3% | |
| 1–3 times/week | 7.1% | 14.1% | |
| Once/month | 10.6% | 8.8% | |
| Never | 77.3% | 61.7% | |
| Sweet tea | Daily | 8.2% | 3.9% |
| 4–6 times/week | 11.3% | 4.4% | |
| 1–3 times/week | 28.2% | 14.2% | |
| Once/month | 15.7% | 18.7% | |
| Never | 36.6% | 58.8% | |
| Unsweet tea | Daily | 0% | 4.8% |
| 4–6 times/week | 4% | 5.3% | |
| 1–3 times/week | 7% | 16.2% | |
| Once/month | 8.6% | 14.8% | |
| Never | 80.4% | 59% | |
| Energy drinks | Daily | 7% | 4.3% |
| 4–6 times/week | 5.3% | 5% | |
| 1–3 times/week | 17% | 11.8% | |
| Once/month | 16.5% | 11.8% | |
| Never | 54.2% | 67% | |
| Alcohol | Daily | .9% | 3.1% |
| 4–6 times/week | 5.8% | 6.1% | |
| 1–3 times/week | 25% | 28.2% | |
| Once/month | 29.7% | 29.5% | |
| Never | 38.7% | 33.1% | |
| Fruit juice | Daily | 14.5% | 9.1% |
| 4–6 times/week | 18.5% | 18.5% | |
| 1–3 times/week | 37.9% | 52.1% | |
| Once/month | 18.4% | 17.2% | |
| Never | 10.7% | 3% | |
| Salad | Daily | 7.9% | 9.1% |
| 4–6 times/week | 17.1% | 18.5% | |
| 1–3 times/week | 45.4% | 52.1% | |
| Once/month | 17.6% | 17.2% | |
| Never | 12% | 3% | |
| Vegetables | Daily | 13% | 32.3% |
| 4–6 times/week | 28% | 27.9% | |
| 1–3 times/week | 42.5% | 35.8% | |
| Once/month | 10.1% | 2.3% | |
| Never | 6.4% | 1.7% | |
| French Fries | Daily | 7.4% | 0% |
| 4–6 times/week | 20.6% | 6.5% | |
| 1–3 times/week | 47.0% | 43.3% | |
| Once/month | 21.6% | 34.9% | |
| Never | 3.4% | 15.3% | |
| Potato chips | Daily | 4.7% | 0.4% |
| 4–6 times/week | 12.7% | 6.1% | |
| 1–3 times/week | 32% | 31.3% | |
| Once/month | 29.9% | 35.2% | |
| Never | 20.7% | 27% | |
| Baked crackers | Daily | 2.1% | 0.9% |
| 4–6 times/week | 7% | 2.7% | |
| 1–3 times/week | 28.7% | 24.3% | |
| Once/month | 26.9% | 29.7% | |
| Never | 35.2% | 42.4% | |
| Baked chips | Daily | 3% | 0.4% |
| 4–6 times/week | 8.5% | 2.9% | |
| 1–3 times/week | 23.9% | 20.6% | |
| Once/month | 26.4% | 25% | |
| Never | 38.2% | 51.1% | |
| White bread | Daily | 4.4% | 0.9% |
| 4–6 times/week | 9.9% | 4.6% | |
| 1–3 times/week | 32% | 26.9% | |
| Once/month | 23.2% | 21.2% | |
| Never | 30.5% | 46.4% | |
| Whole grain bread | Daily | 5.2% | 5.7% |
| 4–6 times/week | 16.8% | 14.1% | |
| 1–3 times/week | 35.7% | 40.6% | |
| Once/month | 19.8% | 22.1% | |
| Never | 22.4% | 17.5% | |
| White pasta | Daily | 2.1% | 0.4% |
| 4–6 times/week | 11.5% | 2.3% | |
| 1–3 times/week | 37% | 31.3% | |
| Once/month | 27% | 31.6% | |
| Never | 22.3% | 34.4% | |
| Whole grain pasta | Daily | 2.1% | 0.4% |
| 4–6 times/week | 5.3% | 3.2% | |
| 1–3 times/week | 28.8% | 20.3% | |
| Once/month | 21.8% | 37.5% | |
| Never | 41.9% | 38.6% | |
| Dessert | Daily | 9% | 11.7% |
| 4–6 times/week | 24% | 14.3% | |
| 1–3 times/week | 42.1% | 49.1% | |
| Once/month | 18.3% | 17.4% | |
| Never | 6.7% | 7.4% | |
| Do you currently exercise regularly (e.g. walking, jogging, aerobics, working out, bicycling, swimming, playing tennis)? | Yes | 77.7%* | 59.9%* |
| How many days per week do you exercise on average? | 0 days | 22.3% | 43.1% |
| 1 day | 8.8% | 5.4% | |
| 2 days | 14.4% | 8.8% | |
| 3 days | 22.2% | 18.3% | |
| 4 days | 12.2% | 8.7% | |
| 5 days | 13.4% | 12.3% | |
| 6 days | 3.1% | 1.7% | |
| 7 days | 3.5% | 1.7% | |
| How many minutes do you exercise per day on average? |
0 minutes | 19.8% | 43.7% |
| 1–15 minutes | 7.6% | 1.1% | |
| 16–30 minutes | 16.6% | 17.0% | |
| 31 −45 minutes | 20% | 16.1% | |
| 46–60 minutes | 24.6% | 17.4% | |
| > 60 minutes | 11.4% | 4.8% | |
| Self-reported BMI (calculated); mean (SD) | 25.54 (5.77)* | 27.85 (7.21)* | |
| Self-reported BMI category (calculated) | Underweight | 4.8% | 2% |
| Healthy weight | 51.2%* | 40.1%* | |
| Overweight | 22.2% | 25.4% | |
| Obese | 21.7%* | 32.5%* | |
= p ≤ .05 in difference between undergraduate and graduate students.
Physical activity
When asked to rate the importance of remaining physically active, no significant difference was found between undergraduate (M=4.05, SD=0.74) and graduate students (M=4.11, SD=0.93), t[461] = −0.72, p = .47). Despite this, graduate students (57%) were significantly less likely to report exercising regularly than undergraduate students (78%), χ2 (1, N=463) = 22.81, p < .01; Cramer’s V=0.22. The amount of reported time exercising per day also differed by group significantly, χ2 (5, N=463) = 41.95, p < .001; Cramer’s V=0.30. Please see Table 1 for more information.
Body mass index
A statistically significant difference in self-reported weight status was identified by academic level, t [461] = −3.74, p < .001. Mean self-reported BMI for graduate students (M=27.85, SD=7.21) was slightly higher than for undergraduate students (M=25.54, SD=5.77). Significant differences were also found between undergraduate and graduate students across reported BMI categories, χ2 (3, N=463) = 11.39, p < .05, Cramer’s V=0.16. More specifically, a significantly greater proportion of graduate students (33%) than undergraduate students (22%) reported BMIs in the obese range. By contrast, more undergraduates (51%) than graduate students (40%) reported BMIs in healthy weight range. Please see Table 1 for additional information.
Discussion
This study sought to better understand differences in self-reported health habits between undergraduate and graduate nursing students. A significantly higher proportion of graduate students reported consuming recommended daily servings of vegetables compared to undergraduates. Although not significant, graduate students reported consuming more of the healthier food options (e.g., diet sodas, unsweet tea, fruit juices, salad, vegetables, whole grain bread). Undergraduate students, on the other hand, reported higher rates of consumption of less-healthy food options (e.g., regular soda, sweet tea, energy drinks, French fries, potato chips, baked crackers, baked chips, white bread, white pasta) compared to graduate students. However, significantly more undergraduate nursing students reported engaging in regular exercise than their graduate counterparts. A significant mean difference was found between self-reported BMI of undergraduate versus graduate students, and a higher percentage of undergraduate students reported BMIs within the normal/healthy weight category and a smaller percentage in the overweight and obese BMI categories compared to graduate nursing students.
Overall, during undergraduate education, these nursing students reported a less-healthy dietary pattern but significantly more exercise, and nurses enrolled in graduate education reported a healthier dietary pattern but significantly less exercise. Thus, the most beneficial wellness plan includes attention on balancing proper diet and adequate exercise for both populations. Within our sample, only 14 (6%) under-graduate students and 15 (7%) graduate students reported consuming the recommended guidelines for fruits and vegetables, exercising at least three times a week, and having a normal/healthy BMI. Thus, approximately 6% of the entire sample reported positive self-care through healthy habits and their outcome of balancing diet, exercise, and weight-management.
Limitations
This study had five notable limitations. First, researchers relied on self-reported nutritional intake, physical activity, weight, and height which can create measurement bias, especially given the stigma associated with having overweight or obesity. Aware of this potential limitation, the study did not collect identifying information in order to increase students’ willingness to disclose sensitive and accurate information. Second, the study is cross-sectional, limiting the ability to draw temporal conclusions about patterns of health-related behaviors among undergraduate and graduate nursing students. Future research using a prospective, longitudinal design is needed to better understand the way in which health behaviors develop and are maintained throughout undergraduate and graduate nursing education. Third, the greater proportion of female to male nursing students prevented an understanding of male nursing students’ patterns. Although our sample is comparable to U.S. demographics on registered nurses (90.4% female),20 the lack of understanding surrounding male nursing-student self-care behaviors needs to be addressed. Fourth, the study did not focus on environmental, social, and economic differences between undergraduate and graduate students that may influence nutrition and activity. Future investigations on nursing-student self-care should consider incorporating such information to determine connections between variables. Finally, the study is subject to nonresponse bias due to the low response rate (11.7%). However, the sample size was substantial enough to allow the inferences reported.
Summary
This study found that self-reported BMI is significantly different in undergraduate versus graduate nursing students; additionally, significantly more undergraduate students reported a BMI in the normal range, and significantly more graduate students reported a BMI in the obese range. Undergraduate students report eating more unhealthy foods, but they report more exercise than graduate students. These health practices are valuable to inform interventions and education programs that are culturally specific to each population. By successfully individualizing wellness programs to the needs of undergraduate versus graduate nursing students, we can improve the health behaviors and overall health of all nursing students and, thus, the future nursing workforce.
Acknowledgments
The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Funding
Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH) under award number UL1TR001417.
Footnotes
Conflict of interest disclosure
In accordance with Taylor & Francis policy and our ethical obligation as researchers, I am reporting that no authors on this manuscript have a conflict of interest to disclose regarding this research.
References
- 1.Eley D, Eley R, Bertello M, Rogers-Clark C. Why did I become a nurse? Personality traits and reasons for entering nursing. J Adv Nurs. 2012;68(7):1546–1555. doi: 10.1111/j.1365-2648.2012.05955.x. [DOI] [PubMed] [Google Scholar]
- 2.McNally S, Azzopardi T, Hatcher D, O’Reilly R, Keedle H. Student perceptions, experiences and support within their current Bachelor of Nursing. Nurse Educ Today. 2019;76:56–61. doi: 10.1016/j.nedt.2019.01.032. [DOI] [PubMed] [Google Scholar]
- 3.Riley JM, Collins D, Collins J. Nursing students’ commitment and the mediating effect of stress. Nurse Educ Today. 2019;76: 172–177. doi: 10.1016/j.nedt.2019.01.018. [DOI] [PubMed] [Google Scholar]
- 4.Mellor P, Gregoric C, Gillham D. Strategies new graduate registered nurses require to care and advocate for themselves: A literature review. Contemp Nurse. 2017;53(3):390–405. doi: 10.1080/10376178.2017.1348903. [DOI] [PubMed] [Google Scholar]
- 5.Porteous DJ, Machin A. The lived experience of first year under-graduate student nurses: A hermeneutic phenomenological study. Nurse Educ Today. 2018;60:56–61. doi: 10.1016/j.nedt.2017.09.017. [DOI] [PubMed] [Google Scholar]
- 6.Pryjmachuk S, McWilliams C, Hannity B, Ellis J, Griffiths J. Transitioning to university as a nursing student: Thematic analysis of written reflections. Nurse Educ Today. 2019;74:54–60. doi: 10.1016/j.nedt.2018.12.003. [DOI] [PubMed] [Google Scholar]
- 7.Glerean N, Hupli M, Talman K, Haavisto E. Perception of nursing profession - focus group interview among applicants to nursing education. Scand J Caring Sci. 2019;33(2):390–399. January 3, doi: 10.1111/scs.12635. [DOI] [PubMed] [Google Scholar]
- 8.Escolar-Chua RL. Moral sensitivity, moral distress, and moral courage among baccalaureate Filipino nursing students. Nurs Ethics. 2018;25(4):458–469. doi: 10.1177/0969733016654317. [DOI] [PubMed] [Google Scholar]
- 9.Department of Labor US, Bureau of Labor Statistics. Registered nurses: Occupational employment and wages, May 2017. Occupational Employment Statistics. Accessed February 6, 2019. https://www.bls.gov/oes/2017/may/oes291141.htm.
- 10.Smiley RA, Lauer P, Bienemy C, et al. The 2017 National Nursing Workforce Survey. J Nurs Regul. 2018;9(3):S1–S88. doi: 10.1016/S2155-8256(18)30131-5. [DOI] [Google Scholar]
- 11.McKinney CE. Assessment of dietary behaviors of college students participating in the health promotion program BUCS: LiveWell. Published online 2013. https://dc.etsu.edu/etd/1105/.
- 12.U.S. Department of Agriculture. All about the fruit group. https://www.choosemyplate.gov/fruit. Published 2018.
- 13.U.S. Department of Agriculture. All about the vegetable group. https://www.choosemyplate.gov/vegetables. Published 2018.
- 14.Williams SG, McDermott R, Fruh S, Graves R, Hall H, Wright T, Swanzy D, Carter C. Nursing student satisfaction with daily life: A holistic approach. J Nurs Educ. 2018;57:751–755. doi: 10.3928/01484834-20181119-09. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Centers for Disease Control and Prevention. Growth chart training: Calculating BMI using the English System. Published January 23, 2019. Accessed May 6 2019. https://www.cdc.gov/nccdphp/dnpao/growthcharts/training/bmiage/page5_2.html.
- 16.Centers for Disease Control and Prevention. How is BMI interpreted for adults? About Adult BMI: Healthy Weight. Published August 29, 2017. Accessed January 14 2019. https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html.
- 17.Little R A test of missing completely at random for multivariate data with missing values. J Am Stat Assoc. 1988;83(404): 1198–1202. doi: 10.1080/01621459.1988.10478722. [DOI] [Google Scholar]
- 18.Enders C Applied Missing Data Analysis. New York: The Guilford Press; 2010. [Google Scholar]
- 19.Rubin D Multiple Imputation for Nonresponse in Surveys. New York: John Wiley & Sons, Inc; 1987. [Google Scholar]
- 20.U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, National Center for Health Workforce Analysis. Sex, race, and ethnic diversity of US health occupations (2011–2015). Published 2017. https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/diversityushealthoccupations.pdf.