Monday, 5 June 2017

Response to commentary on Blake, Stanulewicz & McGill (2017) Predictors of physical activity and barriers to exercise in nursing and medical students

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

Holly Blake
Natalia Stanulewicz
Francesca McGill

On the May 10th 2017, JAN interactive published a commentary on Blake, Stanulewicz and McGill (2017) by Chappel et al. (2017). The authors of the commentary raised two main concerns regarding the study:(1) a possible misinterpretation of physical activity (PA) as solely “formal exercise” by the participants, and (2) a questionable extrapolation of the proposal for the need for PA interventions from student to staff nurse populations.

Regarding the first concern, the IPAQ-SF has been established as a reliable measure (e.g., Craig et al., 2003), that has been employed extensively across populations, cultural groups and demographics, and is extensively utilised worldwide. It was the preferred measure for use in this study due to its short format and ease of use, and has been described as ‘the most appropriate outcome measure for clinical and research use, as it has excellent reliability and moderate correlation with accelerometry’ (Silsbury et al, 2015).

We cannot report on exactly how participants interpreted the individual IPAQ-SF items in this online survey, although the measure includes items relating to walking, and vigorous or moderate intensity activities, and examples of activities were provided. Importantly, our participants were healthcare students, who receive education and training around health behaviours as part of their studies. At the institution where the data were collected, this includes both the distinction between types and levels of PA, and the relevance of work-related PA (including incidental activities) and their contribution to overall daily activity. Therefore, recognising there will be individual variation in the retention of learning, the overall potential for misinterpretation of PA and what it entails is likely to be low, or certainly lower in this sample than for other populations. For nurses, health promotion is a core aspect of their future professional role and as such is emphasised early in the first year of training.

We accept that PA may be either under, or over-reported using self-report measures, and that objective data is required to accurately measure PA levels. We do not dispute the potential for under-reporting of PA, although a systematic review of the validity of the IPAQ-SF including 23 studies, found that in almost all of the included studies, PA was actually overestimated using the IPAQ-SF by 36-173% (Lee et al, 2011).

Chappel and colleagues were concerned about extrapolating from student nurse to nurse populations, given the likelihood of higher PA in nurses within clinical settings. However, we remain convinced that our recommendations, based on our student sample and taken in context alongside the published literature, remain highly relevant to nurses as well as students of nursing.

First, workplace PA interventions can generate benefits in a range of occupational groups (see review by Anderson et al, 2009) including occupations incurring highly physical demands, such as home care workers (Pohjonen & Ranta, 2001). Physically demanding work does not necessarily have positive effects on physical fitness and so worksite PA intervention may offer additional benefits beyond work-related activities Further, we make no claim in our article that nurses and healthcare students are one and the same, although it is of clear relevance that all of the nursing students who completed our survey were registered on courses involving integrated clinical placements, and were regularly working alongside registered nurses in diverse clinical areas; therefore it follows that they may be exposed to similar work-related physical activities, and they were asked to report their activities with relation to clinical placements as well as university time.

Second, if high levels of work-related PA are observed in nurses (note: we do not know how this compares with students PA whilst on shifts), or if registered nurses self-report higher levels of PA than student nurses, we feel it would be unwise to focus only on the differences between the two populations in debating where to target PA intervention. The published evidence suggests that barriers to exercise reported by both groups can be similar, and that many nurses and students [a] do not meet government recommendations for daily PA, [b] are overweight or obese, and [c] report that their own health habits can impede their willingness to promote PA to patients. This sits clearly in line with the national call for health improvement of the health and medical force made in the 2010 Prime Minister’s Commission on the Future of Nursing and Midwifery in England, and the current government investment in health and well-being through the NHS Five Year Forward Plan.

With efforts to increase retention of nursing graduates, there is an increasing drive to instil healthy lifestyle behaviours in student nurses to ensure a healthy public health workforce for the future. This may help to establish patterns of healthy behaviours early on that will continue into the nursing career, and be promoted to patients and their families. Patterns of health behaviours that are established early on are likely to continue beyond registration and through the nursing career. Orr et al (2014) propose that PA positively correlates with motivation, well-being, coping and positive attitude, and that these attributes in turn impact on employability, retention and absence; they advocate that poor health and well-being of nurses may present risks around fitness to practice and may even breach the Nursing and Midwifery Council (NMC) Code of Conduct. These are all relevant factors for students and nurses, and for the transition between the two roles; and so it would be challenging to claim that these populations were unrelated.

Thus, we propose that health behaviours should be advocated and supported from student through to registered nurse rather than focusing solely on [i] either group, or [ii] the potential differences in PA between groups becoming determinants of whether it is timely to offer services, to which group, and to the exclusion of the other. Because of this we strongly disagree that it is premature to advocate PA intervention for nurses in the NHS workplace informed by findings from our sample, which sits alongside a wealth of published research evidence and national government-funded workplace intervention programmes.

Both nurses and nursing students consistently report low levels of PA, high levels of overweight and obesity, and barriers to healthy lifestyles influenced by common variables such as time pressure and shift work. We now need to move forwards in supporting healthcare professionals (of the current and next generation) to make healthy lifestyle choices. In workplace health practice, service commissioners do not necessarily distinguish between nurses and trainees who are not yet registered when it comes to promoting health – they all contribute to NHS healthcare through the profession of nursing, and can all access the same workplace physical activity interventions (see Nottingham University Hospitals NHS Trust as an exemplar of NHS well-being: Blake et al, 2013) and a ‘flagship’ trust in the UK Department of Health Five Year Forward Plan.

The ultimate goal of promoting PA to nurses or student nurses is broadly the same: to protect the physical and mental health of individuals, to reduce unnecessary burden to the NHS, and to support high quality patient care.

Dr Holly Blake
School of Health Sciences
University of Nottingham, UK

Natalia Stanulewicz
Department of Psychology
Durham University, UK

Francesca McGill, RN
Alder Hey Children’s Hospital
Liverpool, UK


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