Health promoting lifestyle behaviors and associated predictors among clinical nurses in China: a cross-sectional study

Health is a global theme. More empirical evidence suggests that it is much more important to take individuals’ capacity to promote their health into consideration rather than to treat disease [1]. The rapidly growing evidence indicates that individuals could take measures to promote their health and well-being [2]. Health Promotion (HP) is one of the core determinants and strategies for individuals to facilitate and maintain their health [3], and it has become of global importance [4]. In terms of HP, it has been defined in various ways and the World Health Organization (WHO) defined it as “the process of enabling people to increase control over, and to improve, their health” [5]. In recent years, there is a great emphasis on Health Promoting Lifestyle Behaviors (HPLB). HPLB, which is one of the key concepts in the nursing field [6], is defined as individuals’ actions and beliefs on multiple levels of HP including self-actualization, physical activities/health responsibility, food choices, interpersonal support [7] to enhance or preserve the level of well-being or reduce the incidence of illness [8].

Nurses play a core role and encompass the main workforce in healthcare systems. According to the statistics of WHO, there are 43.5 million health workers worldwide, while nurses are more than 20 million [9]. Notably, more than 4 million registered nurses are in China [10]. In other words, Chinese nurses account for nearly one-fifth of global nurses. Nurses deliver diverse healthcare services in different settings as health care providers, protectors, communicators, coordinators, decision-makers, and teachers [11]. In fact, nurses are usually the first responders to different health-related conditions to promote health and rehabilitation, and prevent disease [11]. More important, Nurses usually act as a role model, a leader as well as an HP practitioner for the public in empowering and motivating individuals and communities to engage in HP decision-making, HP action and activities to promote their health condition [3, 12, 13]. Empirical evidence shows that nurses’ own health practices could largely produce an effect on the effectiveness of the health intervention provided for their clients [8].

The importance of nurses’ role in HP has been largely reported, it is believed that nurses’ role model of HP behaviors would directly or indirectly affect their clients’ beliefs or attitudes of HP [12]. Therefore, it is important to know the level of HPLB in nurses. To our best knowledge, most studies on HPLB focus on nursing students [7, 8, 13‐16] or patients [17]. There is limited evidence on HPLB in clinical registered nurses. Besides, most measurements used to examine individual HPLB do not contain the aspect of job security. Therefore, a modified Health Promoting Lifestyle Profile (HPLP) would be used to examine the HPLB of clinical nurses in China. Additionally, the current study aimed to explore the associated factors that influence the level of HPLB.

In recent years, HPLB continue to attract researchers’ attention. Nevertheless, there is limited evidence on HP in clinical nurses even though they are in a unique position in the healthcare system. Thus, our current study was designed to examine the HPLB and to explore some relative predictors for HPLB in clinical nurses in China.

In the current study, the mean score of self-actualization, health responsibility/physical activity, nutrition, job safety, interpersonal support, and overall HPLP were, respectively, 27.61(5.42), 22.71(7.77), 10.43(2.97), 22.05(3.97), 20.19(4.67) and 102.99(19.93), which indicate a moderate level of health promoting behaviors in Chinese clinical nurse. Several previous studies [7, 8, 13‐15, 21] have examined HPLB in nursing students, and their results were not consistent with our study. On one hand, the subjects we assessed were different. On the other hand, measurements used in those studies differed from those used in the current study. For example, clinical nurses are the ones who offer healthcare for their clients directly while most nursing students do not. The measurement used in our study includes a subscale of job safety. For those reasons, the findings in the current study are different from previous studies.

There is an ongoing debate on the predictors for the HPLB. In the current study, we found nightshift status was one of the main predictors of overall HPLB and subscales scores. In China, most nurses on nightshift rotation works in 3 shifts: 8am-4pm, 4pm-12mn, 12mn-8am. Usually, nurses have at least 2 days of shift working in a week. Such shifts could offer continuous care services for patients. Unfortunately, internal circadian rhythms are disrupted by those irregular working hours, which leads to sleep disorders, irregular eating habits, irregular exercise, or less motivation/empowerment to make healthier lifestyle plans [22]. For example, nurses on the night shift working are more likely to have irregular meal frequency or to skip meals [23]. Even worse, physical and mental tiredness due to nightshift rotation would directly or indirectly increase the consumption of cigarettes, alcohol, junk food [22], fast food, higher calories food, and a higher amount of snacks [23]. On one hand, they have less time to prepare a healthy diet since most of their time is spent in recovering from such irregular shift rotation. On the other hand, it is much more easily accessible and cheaper to have junk food or snacks than to have a healthy and balanced diet [23], especially at night during nurses on their night shift working. As a result, they may be exposed to inadequate fruit and vegetable intakes. In terms of physical activities and interpersonal support, irregular rotating shift work made it difficult to participate in leisure-time physical activities because they had to spend more time recovering from such an irregular rotation working schedules. As a result, they had less time or energy to hang out with family/friends or to participate to exercise schedules or other stress-reduction behaviors [24, 25]. Based on the result of the current study, we suppose that leaders should pay more attention to taking interventions to empower or motivate nurses to maintain healthy diet habits and exercise, especially focus more on shift nurses’ health promoting lifestyle behaviors. Nurse managers should also take it into consideration to arrange nightshift in a more optimal way.

Notably, the current study points out the importance of hospital level in predicting the score of subscales and the overall HPLP. Contrary to the results of Wang [26], we surprisingly found that nurses working in the tertiary hospital got the highest mean score in all subscales and the overall HJPLP. In China, hospitals are classified into 3 levels including primary level, secondary level and tertiary level. Evidence showed that nurses in the tertiary hospitals faced with a much higher level of workload [27, 28] in China because patients preferred seeking healthcare at higher level hospitals [29]. As a result, nurses in the higher level of hospital deliver wider and more comprehensive health care services to clients [30]. However, this phenomenon makes nurses face more health-related issues, which might lead them more likely to reflect on health and health promotion. Therefore, they might pay more attention to health responsibility, physical activity, and nutrition. Additionally, evidence shows that, in China, nurses in a higher level of hospitals get much more payment than those in the primary care settings [31], which allows them to behave healthier such as buying quality healthy food, exercising in the gym [26]. In fact, one of the main findings in the study was the significant relationship between income and HPLB. Specifically, higher income, higher level of HPLB, which significantly supports that improving nurses’ welfare/income might improve their HPLB. Moreover, higher level hospitals have more opportunities for continuing education [32] and support channels. In other words, nurses in a higher level of hospitals gain more opportunities to receive health-related education and to seek personal support.

Surprisingly, we found that younger nurses got the lower score while nurses over 45 years got the best performance in the survey of subscales and overall HPLB in the current study, which was different from the opinion of Conner and Norman [33]. There are limited studies on the relationship between age and HPLB. The Reason why older nurses perform better in the survey, we suppose, are as follows. Firstly, we surprisingly found that age is strongly associated with the score of nutrition in the study. In other words, age was negatively correlated with the score of nutrition. Specifically, the younger nurses were, the lower scores of nutrition they got. We suppose that, on one hand, younger nurses face frequent night shift working due to nurse staffing inadequacy in China, which leads to unhealthy eating habits. On the other hand, the culture of body image deeply impacts younger nurses. Traditionally, it has been one of the most important parts of feminine identities to keep women’s physical beauty [34]. However, the cultural standard of ideal beauty has changed from traditional mild plum bodies to thin images under the influence of the economy and cultural transformation across cultures. Evidence showed that it had been a phenomenon of pathological weight concerns [34]. Comparing with older nurses, younger nurses are more over-conscious about their body image, and there is increasing body dissatisfaction among this young nurse group. The value of “the thinner, the better” results in eating disorders such as anorexia nervosa [35] or unhealthy eating habits behaviors in order to be thin. For instance, they would be on a diet, or have diets without five groups of nutrition. Regarding self-actualization, it contains self-value, self-achievement, and self-identity. In other words, professional identity is one of the most important dimensions of self-actualization. Professional identity does not always stain the same during nurses’ careers. In fact, it has changed over time. According to a report about nurses’ development status in China published in 2017 [36], 49.7 % of nurses were not clear about their career choice. Particularly, the feeling of burnout was the strongest during the very beginning of 6 to 10 years being a clinical registered nurse which may lead to a high level of turnover intention. However, compared with younger nurses, older nurses accumulate more clinical experience, become more skilled, and gain more confidence during their career, which might increase their professional identity [37]. In terms of health responsibilities/physical activities, theoretically, younger nurses should be more energetic to participate in physical activities than older ones. In fact, younger nurses usually face more challenges and stress comparing with older ones. On one hand, they are less experienced, and they are required to be trained in order to enhance their competencies. Especially, every novice has to receive standardized in-service training in China [38]. That is to say, younger nurses have less leisure time to involve in physical activities. On the other hand, the huge shortage of nurses results in heavy burden and overwork in clinical registered nurses, which is more of concern in younger nurses. That heavy workload would impact on the HPLB in nurses was strongly supported by another finding, nurses working in the emergency and ICU where nurses face with more challenges and workload got lower scores of subscales and overall HPLB in the current study. Overall, lower professional identity, and overwork, and frequent night shift rotation due to lack of nursing staff prevent younger nurses from promoting healthy lifestyle behaviors.

The main limitation of the study is the design of a cross-sectional study. Due to the nature of the design, we could only access the data at one point in time. Besides, we could not gain more and further data, especially about nurses’ feelings or experiences on HPLB because of lacking qualitative evidence in this study. The mixed methodology could be used in future studies to take deeper insight of nurses’ HPLB. Moreover, bias might occur when participants complete such a self-reporting questionnaire.

The study aimed to examine the HPLB of Chinese registered nurses and explore relative predictors. The results indicate that nurses who participated in the study presented a moderate level of all subscales and overall HPLP. Hospital levels, nightshift status, age, and monthly income per person were predictors for all subscales and overall HPLP. This study suggests that there is an urgent need that nursing leaders and managers should focus more on nurses’ HPLB, and take measures to solve the dilemma of shortage of nurse staffing, to arrange night shift work schedules in a more reasonable way, to improve nurses’ income, and to address correct value about body image.