Mixed methods evaluation of a digital resource to build students’ skills in ASsessing cardiovascular risk, MOtivating change, and SUStaining a healthier lifestyle in themselves and others- ASMOSUS: a study protocol

Cardiovascular diseases (CVD) are the leading cause of death globally [1]. Early identification and management of CVD risk factors are essential in the prevention of the potential complications that can arise from this non-communicable disease. Within the healthcare workforce, nurses are optimally situated to identify CVD risk factors and support people with adopting healthier lifestyles, thus reducing mortality and morbidity [2]. Patient and public compliance with advice issued by nurses is influenced by the health-related behaviours of these healthcare professionals [3]. However, literature suggests that the health of student and registered nurses in the United Kingdom (UK) is sub-optimal. Detrimental levels of obesity [4, 5], smoking [5, 6] alcohol consumption [5, 6] physical activity [5, 6] and dietary intake [6, 7] are evidenced in these populations.

Unfavourable lifestyle behaviours identified in nursing students [5, 6] have the potential to diminish their capacity to influence the adoption of cardioprotective lifestyles in others [7]. The Nursing and Midwifery Council (NMC) is the governing body that informs the undergraduate nursing curricula content across the UK but also who students must declare themselves fit to practice to on completion of their nursing program. One of the NMC proficiency standards suggests that nurses should have ‘an ability to manage their own personal health and wellbeing and make a significant contribution to health promotion.’ [8]. Health promotion is a taught element of the nursing curricula, and it is therefore unlikely that these unfavourable lifestyle behaviours can be explained by a lack of knowledge. It may be related to self-efficacy, an individual’s confidence with executing a specific behaviour [9] in influencing the ability of nursing students to implement healthy lifestyle behaviours. A correlation between health-promoting behaviour and enhanced self-efficacy has been demonstrated in nursing students [10].

It is known that student application of theory into practice can be challenging [11], with a recent study in the UK concluding that educational interventions that improve the implementation of health-related behaviours for student nurses are warranted [12]. A European study [13] found that qualified cardiac nurses felt under prepared for their role with more education required on CVD risk factor management. This is supported in a further study [14] that cites a barrier to CVD prevention in patient care is a deficit in professionals’ knowledge. It is important to narrow this knowledge gap as it appears to widen through years of practice. To address this requirement in educational improvement, the study team across Queen’s University Belfast (QUB) and Edinburgh Napier University (ENU) have co-designed and developed, with nursing students a digital resource called ASMOSUS (ASsessing cardiovascular risk, MOtivating change, and SUStaining a healthier lifestyle in themselves and others), which aims to teach students knowledge and skills in CVD risk assessment, management and cardioprotective lifestyle implementation.

The aim of this study is to carry out a mixed-methods evaluation of the impact of the ASMOSUS digital resource on the knowledge, attitudes, ability of CVD risk management and healthy lifestyle implementation of first year undergraduate nursing students at QUB and ENU.

The study objectives are to:

The study will use an explanatory sequential mixed methods design to investigate the effect of using the ASMOSUS resource as part of routine teaching for cohorts of year one nursing students across two universities (one in Northern Ireland and one in Scotland). The study objectives will be achieved in 2 phases. Phase 1 a pre-post questionnaire design and phase 2 online focus groups.

All year 1 undergraduate nursing students, across all fields (adult, learning disability, mental health, children and young people) from both QUB and ENU who receive the ASMOSUS resource via routine teaching will be eligible for recruitment. The approximate yearly intake of both universities is 1350 students. Year 1 undergraduate nursing students are the chosen population as their awareness and behaviours with regards to cardiovascular disease risk and awareness are similar to the general population characteristics. Commencing this awareness of cardiovascular disease and motivational interviewing early in their nursing programme allows for modifiable lifestyle behaviours that are not favourable to be adapted sooner.

A sample of at least 491 students is required to achieve a representative sample for Phase 1 data collection (n = 249 QUB and n = 242 ENU). Sample size was determined through a power analysis calculation using Raosoft http://​www.​raosoft.​com/​samplesize.​html, based on a total available sample size of 1350, at a confidence level of 95% and an accepted margin of error 5%. Thus ensuring that the study has a sufficient likelihood of detecting statistically significant differences between the pre and post-test responses for the Attitudes and Beliefs about Cardiovascular Disease (ABCD) Risk questionnaire [17] and the ASMOSUS Impact Questionnaire (Supplementary file 2).

In Phase 2, recruitment sample aim for four focus groups with five participants per group is n = 20 (n = 10 QUB and n = 10 ENU). The choice of n = 20 students for focus group aligns with qualitative research principles that emphasize data saturation, wherein new insights cease to emerge as the sample size increases, found to be within four to eight focus groups [18]. With a focused and homogeneous population such as nursing students, a smaller sample size can often be sufficient to capture the range of perspectives and experiences. Additionally, the focus on qualitative insights in this phase aligns well with the exploratory nature of the study’s second objective. The use of convenience sampling is pragmatic, considering that all year one nursing students will have access to the ASMOSUS resource as part of routine teaching. This approach facilitates access to participants and streamlines recruitment efforts, contributing to feasibility. Moreover, the study’s cross-university design, involving nursing students from institutions in Northern Ireland and Scotland, enhances the generalizability of the findings. This diversity of participants strengthens the study’s ability to draw broader conclusions and insights that could potentially be applicable to a wider range of nursing education contexts.

CVD is a leading concern for the health of the general population. Primary prevention is a key factor to address this issue and nurses as healthcare professionals are in a position to address this issue. Sub-optimal lifestyle behaviours in healthcare professionals [4‐7] can have a detrimental impact on patients and services users adopting changes into their own lifestyle [2], with the literature suggesting that nursing students are among those professionals. As evidenced in the UK nursing curricula [8] nursing students are empowered with the knowledge but often this does not match with their embodied behaviours. Gaining confidence in motivating change in themselves and others is key to applying CVD risk knowledge to themselves and others. The research team is hopeful that the use of the ASMOSUS educational digital resource, followed by a tutor-led workshop allowing nursing students to consolidate their learning and practice skills in Motivational interviewing, will be a step towards self-efficacy in CVD risk awareness and prevention.