Wednesday, 10 May 2017

Putting the ‘Physical’ Back into Nursing: Recognising Nursing as a Physically Demanding Occupation

Commentary on: Blake, H., Stanulewicz, N. & McGill, F. (2017) Predictors of physical activity and barriers to exercise in nursing and medical students. Journal of Advanced Nursing, 73(4), 917-929

Stephanie E. Chappel
Julie Considine
Brad Aisbett
Nicola D. Ridgers

In the April issue of JAN, Blake et al. (2017) investigated predictors of physical activity and barriers to exercise in nursing and medical students. Of specific interest are the findings related to nursing that showed close to 50% of nursing students were not meeting the national physical activity guidelines of 150 minutes of moderate-intensity physical activity a week (Department of Health 2014). Further, the most common barriers to nursing students’ engaging in physical activity were that physical activity was tiring, hard work, time-consuming, caused fatigue, and did not suit inconvenient work schedules (Blake et al. 2017). Blake and colleagues (2017) suggested that physical activity should be promoted to nursing students, and interventions should be tailored more broadly to accommodate the barriers of shift work.

However, these recommendations raise several questions. First, it is possible that physical activity, which is any movement requiring energy (Caspersen et al. 1985), was misinterpreted by the participants as exercise, which is planned physical activity (Caspersen et al. 1985), leading to an underestimation of actual activity levels. Second, physical activity occurs in a range of domains, including household duties, active transport, leisure-time and occupational activity (Hagströmer et al. 2006). The short version of the International Physical Activity Questionnaire (IPAQ) used in this work only captures a summary of all physical activity across a week and, does not separate physical activity into different domains (Hagströmer et al. 2006). The IPAQ also asks individuals to report the amount of walking completed in the last week, which can be misinterpreted as purposeful walking for exercise. Incidental walking that may occur at work (e.g., to and from a patients room; Hagströmer et al. 2006) may be under-reported. Finally, as with any subjective measure, there is potential for recall bias that can lead to an under- or over-estimation of actual physical activity levels; a limitation acknowledged by Blake et al. (2017). To avoid issues related to subjective reporting of physical activity, Blake et al. (2017) suggests future work should use objective monitoring, such as accelerometers, to more accurately capture physical activity. A particular advantage of using accelerometers would be the ability to quantify physical activity levels at work, given collected data are date- and time-stamped.

We recognise that this study was focused on students, although Blake et al. (2017) recommend that the healthcare workforce needs strategies to increase physical activity for shift workers. This conclusion raises several questions about whether nursing students are representative of a nursing workforce, and, whether data from nursing students were collected during clinical placement. Interestingly, in addition to nursing students, Registered Nurses (RNs) have also been identified as not meeting the national physical activity guidelines through their leisure-time physical activity (Naidoo and Coopoo 2007, Ahmad et al. 2015, Jung and Lee 2015), leading to a national focus on promoting nurses’ engagement in physical activity (National Insititue for Health and Care Excellence 2015). However, many of the claims that nurses do not meet physical activity guidelines and calls for increased physical activity among nurses are based on leisure-time activity alone. Given that a considerable proportion of waking hours are spent at work (Kikuchi et al. 2015), it is potentially misleading to conclude that strategies are required when occupational activity is not captured.

Although a lack of time and tiredness are consistently reported as the barriers to physical activity by both nursing students and RNs (Blake et al. 2017, Chin et al. 2016, Jung and Lee 2015), there is variability in the drivers of these barriers for physical activity. Nursing students are required to balance study, work and clinical placements that may or may not involve shift work (Blake et al. 2017). For RNs, lack of time is most likely the result of shift work as they spend majority of their waking hours at work (Kikuchi et al. 2015). Shift work also causes tiredness as sleep patterns are disrupted, yet this is further compounded by the physical demands of nursing work (Chin et al. 2016). Nursing involves several physically demanding tasks such as cardiopulmonary resuscitation, transferring patients, and pushing beds and wheelchairs. Studies have shown that in one shift nurses can lift up to 1800 kilograms (Babiolakis et al. 2015), maintain a high heart rate (51-64% maximal heart rate; Chen et al. 2011), and walk over 15,000 steps (Wakui 2000) or up to 8 kilometres (Chen et al. 2011). These physiological measures suggest that nurses are engaging in high amounts of physical activity through their daily duties and, are potentially meeting physical activity guidelines through their occupational physical activity. It is therefore too early to conclude that workplace physical activity interventions are required to increase nurses’ leisure time activity when little is known about nurses’ physical activity during a shift and the interaction between different domains of physical activity is poorly understood.

Nursing has been described as a physically demanding occupation. Yet despite the predominance of nurses in healthcare delivery, the ‘physical’ aspect of their work is poorly understood. A detailed understanding of nurses’ occupational physical activity using robust, valid measures is lacking. In order to ensure that nurses can provide the best care to their patients, there is an urgent need to understand the physical demands of nursing work.

Ms. Stephanie E. Chappel, BExSc (Hons)
PhD Candidate
Institute for Physical Activity and Nutrition (IPAN)
Deakin University, Geelong, Victoria
Twitter: @Steph_Chappel

Professor Julie Considine, PhD
Professor of Nursing
School of Nursing and Midwifery and Centre for Quality and Patient Safety Research
Deakin University, Geelong, Victoria
and Centre for Quality and Patient Safety Research – Eastern Health Partnership
Box Hill, Victoria
Twitter: @julie_considine

Associate Professor Brad Aisbett, PhD
Associate Head of School (Teaching & Learning, Exercise and Sports Science)
Institute for Physical Activity and Nutrition (IPAN)
Deakin University, Geelong, Victoria
Twitter: @BradAisbett

Dr Nicola D. Ridgers, PhD
Senior Research Fellow
Institute for Physical Activity and Nutrition (IPAN)
Deakin University, Geelong, Victoria
Twitter: @NickyRidgers


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