Nursing professionals continuously are enhancing their traditional role of illness-oriented caregivers to function as health educators, helping people acquire the behaviors necessary to recover, maintain, improve, and protect their health (Bradley, 1997; Clément, Bouchard, Jankowski, & Perreault, 1995; Cloutier Laflrey, 1985, 1986a, 1986b, 1990; Macleod Clark & Webb, 1985; Martin & Panicucci, 1996; Padula, 1992; Richardson & Petrarca, 1990; Sharkey, Graham-Kresge, & White, 1995). As health educators, nurses inform people about health issues; help them understand the consequences of their health-related decisions; and facilitate and reinforce the acquisition of healthy behaviors into their daily Uves. In fulfilling the role of health educator, nurses must establish a congruence between professional interventions and personal health practices (Clarke, 1991; Connolly, Gulanick, Keough, & Holm 1997; Dines, 1994; Fridinger, Johnson, Lye Chng, & Choo, 1991; Kelley Walsh, VandenBosch, & Boehm, 1989; Kudzma, 1988). According to the available literature, the personal health practices of health professionals are a determinant of their effectiveness in counseling clients on health-related matters (Haughey, Kuhn, Dittmar, & Wu 1992). Clients seem more inclined to adopt health-related behaviors when those behaviors are practiced by health professionals involved in their promotion (Callaghan, 1995).
However, certain investigators have demonstrated that the health behaviors of nurses are not always exemplary or even different from those of the general population. The results of an American study conducted with 499 critical care nurses indicated that while some nurses reported engaging in healthy behaviors (e.g., exercising regularly, avoiding dietary fats), others reported engaging in unhealthy behaviors (e.g., inadequate sleeping, cigarette smoking) (Haughey et al., 1992).
In Utah, Pratt, Overfield, and Gill Hilton (1994) studied 94 professional nurses and 297 other women and found no statistically significant differences between the two groups related to health behaviors. These results were particularly surprising because the professional nurses reported significantly higher levels of both education and income, compared to the control group. In addition, the authors reported that the health behaviors of the women in this study were comparable to those of other American women.
Finally, in England, Callaghan (1995) studied 113 male and female nurses and reported that some of their health practices were actually below the national norms for the United Kingdom. In this regard, both Frachel (1984) and Copp (1984) suggested that it may be appropriate to determine whether nurses receive adequate health knowledge during training or whether nursing education provides for the adequate integration of this knowledge.
REVIEW OF RELATED LITERATURE
A small number of studies conducted in Canada and the United States have investigated the health behaviors of university nursing students using either cross-sectional or longitudinal designs. The cross-sectional studies compared the health-related behaviors of nursing students to those in other disciplines or in the general population. The longitudinal studies investigated nursing students' behaviors at the beginning and the end of their university programs.
Gupta, McMahon, and Sandhu (1985) investigated 486 undergraduate nursing students at the University of Windsor in Ontario and reported that the majority of these students consumed alcohol and did not engage in any regular physical activity. Some female students reported never having had a Pap screening test for cervical carcinoma or conducting a monthly breast self-examination. Dittmar, Haughey, O'Shea, and Brasure (1989) conducted a similar study of 1,081 female students from 10 nursing schools located in western New York, They reported that although the majority of students exercised regularly, slept 7 to 8 hours per night, and had annual medical and dental examinations, the typical nursing student practiced only approximately half of the 14 exemplary health behaviors that the investigators expected of them. In addition, the authors observed that while almost all students (90%) drank some alcohol occasionally, most of them (57%) consumed little or no alcohol regularly. However, approximately 25% of the drinkers consumed five or more drinks per occasion. To investigate the possibility of alcohol abuse among nursing students, Marion, Fuller, Johnson, Michels, and Diniz (1996) administered the Michigan Alcoholism Screening Test to 315 university nursing students and determined that 21.5% were probably alcoholics. In this regard, nursing students were similar to students in other undergraduate programs.
Using a slightly different approach, Schank and Lawrence (1993) compared the health-promoting behaviors of 38 nursing students and 38 non-nursing student controls enrolled in the same women's health course at a large university in the midwestern United States. They used a composite score, composed of many health-related behaviors, and found that the nursing students had significantly more healthy lifestyles than the control group. The significantly different health behaviors included alcohol use, use of illegal drugs, junk food intake, hours of sleep, and use of seat belts. The authors attributed the observed differences, to some extent, to the nursing curriculum, which included information on health maintenance and physiopathology, as well as clinical experiences (Schank & Lawrence, 1993).
However, the authors concluded there was a definite need for additional improvement if these students were to serve as role models and educators for the population at large. To investigate the health behaviors of health science students, Najem, Passannante, and Foster (1995) surveyed 835 medical, dental, and nursing students and found their health behaviors to be outstanding compared to the general public. They also observed that the nursing students smoked, drank, and thought themselves to be overweight significantly more frequently than the other health science students.
Sabina-McVety, Booth, Orban, and Richards (1988) studied the exercise habits and values of 211 Canadian undergraduate nursing students by comparing them to control data from the Canadian Fitness Survey (Statistics Canada & Health and Welfare Canada, 1981). Although the nursing students valued regular exercise more highly than the general population and described themselves as being physically active during their leisure time, they maintained only average cardiovascular fitness levels. The majority of nursing students (53.5%) were sedentary, citing inadequate time and facilities as reasons for their inactivity.
Soeken, Bausell, and Carson (1989) compared the health compliance behaviors of 139 senior nursing students to a national sample of women in the same age range. Compared to the general population, nursing students were less compliant on 12 of 19 behaviors and more compliant for only 3 behaviors surveyed. The authors suggested nursing students may have been taught by role models who focus on the difficulties of performing health behaviors or promote the importance of health behaviors, while neglecting to incorporate these behaviors into their own lifestyles.
Although the senior nursing students studied by Soeken et al. (1989) actually smoked significantly less than the control subjects, smoking remains a problem among nursing professionals. Casey, Haughey, Dittmar, O'Shea, and Brasure (1989) investigated cigarette smoking among 1,265 nursing students enrolled in two universities in the northeastern United States. They reported that while more than 90% of the students knew the pathological effects of smoking, 29.4% smoked regularly, but almost all of them had attempted to stop smoking. Among the students who currently smoked, most had either begun or increased their smoking while enrolled in nursing school.
In a longitudinal investigation, MacDonald and Faulkner (1988) compared the health behaviors of 29 (27 female and 2 male) nursing students during their first and fourth undergraduate years. The health behaviors of the fourth-year female nursing students also were compared to a similar group of 16 female volunteers majoring in education. During the 4-year program, the use of seat belts, Pap tests, and breast self-examinations increased significantly among nursing students. Although the majority of students in both groups were sedentary, and no statistically significant difference in estimated aerobic capacity (VO2 max) between nursing and education students was observed, the nursing students reported becoming more active, reduced subcutaneous adipose stores, and increased oxidative capacities during their 4 years of study.
In a controlled longitudinal study, Boyd (1988) determined the effect of nursing education on health behaviors using Hettler's (1980) multidimensional lifestyle assessment. Thirty-three (58%) nursing students and 35 (64%) non-nursing control subjects completed lifestyle questionnaires during their first and final quarters of university study. While the control group improved significantly on 2 of 11 health parameters, the nursing students improved significantly on 8 of the 11 measures including exercise, nutrition, self-care, environment, intellect, emotional factors, and occupation. The author attributed these findings to a "health profession curriculum'' (Boyd, 1988, p. 19).
The cross-sectional studies cited above reported that nursing students may not always manifest recommended health behaviors. In fact, their health behaviors were sometimes indistinguishable from those of non-health science students and the general population. However, the longitudinal studies demonstrated that nursing students tended to enhance some health behaviors during their university years and finished by engaging in healthier behaviors than their non-nursing peers. These results support Meillier, Lund, and Kok's (1997) hypothesis that university years may be an ideal time to effect positive changes in health behaviors. Despite this interesting possibility, the longitudinal studies did not investigate changes that occurred during a health science curriculum. Although the importance of acquiring good health practices for students preparing to become health educators is recognized, studies on the influence of a professional health science curriculum on student health behaviors are rare.
FRAME OF REFERENCE
Belloc, Breslow, and Hochstim (1971) conducted a breakthrough study with a random sample of 6,928 adults in Alameda County, California. Belloc and Breslow (1972) analyzed these data and determined that "common good health practice'' (p. 409), such as adequate sleep, regular physical activity, tobacco avoidance, and abstinence or moderate alcohol consumption were significantly associated with improved health, and furthermore, that the effect of these good health practices was both aggregate and accumulative but was independent of age and gender. These findings later were replicated and refined by Breslow and Enstrom (1980), Wiley and Camacho (1980), and Wingard, Berkman, and Brand (1982).
Since the classic study of Belloc et al. (1971), several texts (Badura & Kickbusch, 1991; Bracht, 1990; Evans, Barer, & Marmor, 1994; Pederson, CfNeH, & Rootman, 1994), articles (which are Usted in Table 1), and major reports (Epp, 1986; U.S. Department of Health, Education, and Welfare, 1979; World Health Organization, 1986) have supported the fact that individual behavior influences personal health. However, the degree to which knowledge may influence individual behavior still remains to be investigated.
PURPOSES OF THE STUDY
The purposes of this study were to:
* Describe the health behaviors of undergraduate students enrolled in a 3-year bachelor of science nursing program.
* Follow the evolution of these students' health behaviors as they progressed through the curriculum.
* Compare the observed health behaviors of nursing students to those of a group of non-health science undergraduates.
* Compare the health-related behaviors of both groups of university students to the general population of a similar age.
The specific health behaviors investigated are listed in Tables 1 and 2 and included sleep, eating breakfast, physical activity, tobacco and alcohol consumption, use of seat belts, breast self-examinations and clinical breast examinations, and cervical cancer (i.e., Pap) screening tests.
Sample and Milieu
This study was approved by the university health science research ethics committee. The student population under investigation consisted of an experimental group of 52 nursing students and a control group of 93 students majoring in education. The education majors were selected as control subjects because preliminary investigation determined they were mostly women and not significantly different (p *£ .05) from the nursing students in age and demographic characteristics, but their curriculum was not health oriented (Clément, Bouchard, Jankowski, Perreault, & Lepage, 1998).
Eighty-five percent of the nursing students and 100% of the education students were women. In the first year, the average age of nursing students was 20.5, and the average age of the education students was 20.3. Eighty-nine percent of the nursing students and 98% of the education students were born in Canada, and 92% of the nursing students and 98% of the education students were French speaking.
The nursing program consisted of 101 required credits. Thirty-two of these credits were in nursing-related science courses (e.g., physiology, nutrition, pathology, epidemiology). The remaining 69 credits were in nursing courses, which included 57 credits of theoretical and clinical nursing and 12 credits emphasizing the promotion of individual and community health. The education curriculum contained no health courses.
Data were collected during the fall semesters in 1992, 1993, and 1994, 1 month after classes began and registration became official. No particular measures were taken to avoid attrition, except collection of data always was conducted either before or after a required course. On each occasion, the students' informed consent was requested by the same investigator (L.W.J.), a professor who was not affiliated with either program. Participants' anonymity was preserved by means of a secret code, which consisted of a series of letters and numbers related to the name and birth date of the student's mother. The code consisted of the first letter of the mother's surname, the last letter of the mother's maiden name, the first letter of the month in which their mother was born, and the date of their mother's birth.
Health Behaviors, Desirable Practice, and Effects on Health
The type and frequency of health-related behaviors were determined using 44 of the 136 questions of the Health Behavior Questionnaire, developed by Santé Québec for the 1987 Quebec Health Survey (QHS) (Ministère de la Santé et des Services Sociaux (1987). The QHS was inspired by the 1979 Canadian Health Survey, which in turn, was based on the classic work of Belloc and Breslow (1972). The reliability and validity of the QHS was determined by pretesting with a jury of experts before use with a sample of 19,724 subjects. The instrument since has acquired additional validity through many years of successful use in population surveys. The 44 questions were selected because they emphasized individual behaviors correlated with good health (Table 1).
The 44 questions selected for this study consisted of fillin (e.g., How many hours per day do you usually sleep?), yes or no (e.g., Do you currently smoke cigarettes?), and multiple-choice questions (e.g., Do you eat breakfast ___ ? a each day, b. once in a while, c. rarely, d. only during weekends), which permitted categorization and analysis of the responses, as performed by Ministère de la Santé et des Services Sociaux (1987). Each item was scored individually, and no attempt was made to produce a composite health score.
As shown in Table 3, 179 of 193 (92.7%) nursing and 218 of 226 (96.4%) education students initially completed the questionnaire. In the third year of the study, only 52 of the original 193 nursing students (26.9%) and 93 of the original 226 education students (41.1%) participated. During this 3-year longitudinal study, enrollments in nursing and education at tibie university decreased by 26.4% and 25.6%, respectively.
Percentages by Year of Nursing Students, Education Students, and Quebec Population Ages 15 to 24 Engaged in the Designated Health Behaviors
The rather dramatic attrition observed during the third year seems to be the result of several factors. Some students left the university, others transferred to different faculties, while for third-year nursing students, low attendance at theoretical third-year courses is traditional. Furthermore, the survey coincided with a busy period in students' Uves, which included employment interviews and graduation photographs. Finally, some students could not remain after class to complete the questionnaire due to professional or family obligations.
For each of the nine behaviors (Table 1), the raw data were grouped dichotomously according to the number of subjects who reported practicing the desirable health behavior (e.g., nonsmoker versus smoker). These data were converted into percentages of each student group by year (Table 2) and analyzed using both descriptive and inferential statistics. The significance of the differences between student group proportions was determined using a Pearson's chi-square test. In addition, both groups were compared to the general Quebec population, ages 15 to 24, using data available from both the 1992 to 1993 Quebec Health Survey ( Santé Québec, 1995), for six behaviors, and the 1987 Québec Health Survey (Ministère de la Santé et des Services Sociaux, 1987) for three behaviors. The significance of the observed percentages for the experimental and control groups versus the general population also was ascertained using a Pearson's chi-square test. The level of significance was established at 5% (p =£ .05).
At the beginning of their studies, a strong majority of nursing students reported they always wore a seat belt when travelling by motor vehicle (94%), ate breakfast daily (88%), did not smoke (88%), exercised for 15 minutes or more at least once per week (81%), and either did not drink or drank alcohol in moderation (80%). Only a minority of students reported conducting monthly breast self-examinations (27%).
During the 3 years of observation, no statistically significant differences in the designated health behaviors of nursing students were observed (p =s .05). As shown in Table 2, 88% to 94% always used seat belts when travelling by motor vehicle, 79% to 88% ate breakfast daily, 88% to 90% did not smoke, 67% to 81% engaged in at least minimal physical activity, and 80% to 93% consumed little or no alcohol. Whereas 67% to 81% of nursing students reported having had a Pap test and 75% to 77% had had a clinical breast examination within the past 2 years, only 27% to 43% conducted monthly breast self-examinations. During the 3 years of observation, no statistically significant differences were observed between the health behaviors of students in nursing and those in education.
In comparing the university students to the general population (Table 2), it was observed that the percentages of both nursing and education students that smoked cigarettes and drank alcohol were significantly lower than that of the general population. In addition, a significantly greater percentage of university students had regular Pap tests and clinical breast examinations. The percentage of nursing students who slept a minimum of 7 hours per night was significantly lower than that of the general population, but a significantly greater proportion ate breakfast daily. During the study, both the percentage of nursing students engaging in minimal physical activity and the percentage of education students eating breakfast daily decreased and became insignificantly different from the general population. During the second and third years, the percentages of nursing students conducting monthly breast self-examinations increased from 27% to 41% and 43%, respectively. These values were significantly higher than the 18% reported for the general population.
Numbers and Percentages of Students (Participants and Registered) Voluntarily Completing the Health Behavior Questionnaire by Group and Year of the Study
The attrition rates observed during the 3 years of this longitudinal study were high among both groups of students under investigation (73.1% for nursing students and 58.9% for education students). This attrition may have biased the results.
This longitudinal study found that the percentage of nursing and education students engaged in the nine selected behaviors were not significantly different and remained quite consistent during their 3 undergraduate years. Both student groups reported greater involvement in the nine health behaviors, compared to the general population. The nursing students tended to manifest greater variability in their health behaviors, compared to the control group of education students. Consequently, they were observed more frequently to be significantly different from the general population.
Except for inadequate sleep, the health behaviors of nursing students compared favorably with the general population. Although the need for sleep varies among individuals, studies on the subject agree that 7 to 8 hours of sleep each night is associated with well-being and longevity (Belloc & Breslow, 1972; Breslow & Breslow, 1993; Frederick, Frederichs, & Clark, 1988). Pilcher and Huffcutt (1996) suggested that a lack of sleep can substantially affect mood, as well as individual motor and cognitive functions. Inadequate time for sleep, apparently related to academic demands and social pressures, often is observed among college and university students at the beginning of their studies (Pilcher, Ginter, & Sadowsky, 1997). Surprisingly, after 2 years of studies in health science, 29% of the nursing students still failed to get a wiimmtim of 7 hours of sleep per night. This observation is consistent with previous reports of nursing students by Najem et al. (1995) and Sabina-McVety et al. (1988).
Although the percentages of nursing students practicing the designated health behaviors did not change significantly during the period of observation, certain tendencies, consistent with the notion of inadequate time, were noted. Ine percentage of nursing students eating breakfast daily was significantly higher than the 64% reported for the general population but had decreased from 88% to 79% from 1992 to 1994. Similarly, the percentage of nursing students engaging in a minimum of 15 minutes of weekly exercise decreased from 81%, which was significantly higher than the general population, to 67%, which was not significantly different from that of the population. Lack of time and convenient access to adequate facilities are the reasons most frequently given for failing to exercise (Gupta et al., 1985; MacDonald & Faulkner, 1988; Sabina-McVety et al., 1988). Because all the students in this study had liberal access to a modern, fully equipped university sports center, the reduced activity level of the nursing students during the third year may reflect inadequate time for exercise.
The percentages of nonsmokers among both groups of university students was significantly higher than for the general population. The lack of any statistically significant difference between the nursing and education students for this behavior and the fact that 10% of the third-year nursing students were habitual smokers demonstrates that knowledge does not directly influence behavior (Meillier et al, 1997). While the percentage of nursing students who smoked remained essentially constant, those who consumed little or no alcohol increased from 80% to 93% and became significantly different from that of the general population. The percentage of nursing students who regularly smoked cigarettes and drank alcohol in this sample is less than had been previously reported by Casey et al. (1989), Dittmar et al. (1989), Gupta et al. (1985), and Marion et al. (1996). The facts that 82% of the education students and 90% of the nursing students did not smoke and 93% of both student groups drank little or no alcohol suggests that this generation understands the need to protect their health by avoiding unhealthy substances and habits, and may reflect Canadian laws, which are attempting to limit harmful behaviors (e.g., smoking in public places, drinking while driving),
Wearing a seat belt when travelling in a motor vehicle prevents trauma and death associated with road accidents (Cambell, 1984; Evans, 1987; Hargarten & Karlson, 1994; Orsay et al., 1988). In addition, not wearing a seat belt has been linked to a profile of risk-taking behaviors such as cigarette smoking and excessive alcohol consumption, particularly among adolescents and young adults (Jonah, 1986; Maron et al., 1986; Pate, Heath, Dowda, & Trost, 1996). While nursing students in general may not be involved in high-risk behaviors, approximately 10% do not use seat belts, despite a strictly enforced Quebec law.
Concerning women's health issues, approximately 80% of the women in both student groups had Pap tests and clinical breast examinations every 2 years. This percentage was significantly higher than the approximately 60% rate reported for the general female population. This may be the result of a Canadian public health policy that emphasizes women's health and convenient access to the university health clinic. Although the percentage of education students conducting monthly breast self-examinations was not significantly different from the 18% of the general population, and actually decreased from 25% to 20% during the study, the percentage of nursing students conducting monthly breast self-examinations increased from 27% to 43%, which was significantly greater than the general female population and approximately twice that of the education students.
Similar improvements in the health behaviors of female nursing students have been reported by both Boyd (1988) and MacDonald and Faulkner (1988). The observed improvement in performance of monthly breast self-examinations among nursing students may be the consequence of being immersed in the academic milieu of nursing school and being exposed to many feminine role models. The curriculum, which in this case provided students with both theoretical knowledge and clinical experiences specifically about women's health issues, may have facilitated the adoption of positive health practices among this group of young women.
The generally healthy behaviors of the students in this study and, to a certain extent, the Quebec population ages 15 to 24, may reflect the influence of a national system that emphasizes health promotion and facilitates access to health care through prepaid provincial insurance. However, on admission to the university, both nursing and education students manifested certain health behaviors that were significantly different from the general population (i.e., they ate breakfast more regularly, smoked and drank alcohol less, had more frequent Pap tests and clinical breast examinations). This observation may simply support the fact that higher education correlates with better health.
Although, on admission, the nursing students did not get the recommended amount of sleep, 81% engaged in a minimal amount of physical activity, whereas education students exercised no more than the general population. While some authors, such Lawrence and Schank (1993), have wondered whether health-oriented programs (e.g., nursing) preselect or recruit young adults with good health behaviors, the results of this study fail to identify any differences that could be interpreted as substantially better health practices among the nursing students. In fact, the consistent lack of sleep reported by approximately 30% of the nursing students is consistent with previous accounts of unhealthy behaviors among nursing students (Dittmar et al., 1989; Gupta et al., 1985; Marion et al., 1996).
During the investigation, no statistically significant changes in health behaviors were observed but apparently, as time constraints increased, education students tended to skip breakfast, whereas nursing students tended to decrease their amount of regular exercise. In this way, both groups' percentages became indistinguishable from that of the general population. Nursing students continued to get an inadequate amount of sleep but continued to eat breakfast daily. In addition, the percentages of nursing students that drank little or no alcohol and conducted monthly breast self-examinations tended to increase. The lack of any significant differences or immediate improvements in the health-related behaviors of nursing students, compared to the education students, may indicate that a 2-year concentrated academic health science experience was insufficient to produce desirable modifications in health behavior.
In this regard, Meillier et al. (1997) pointed out that favorable changes in health behaviors involve a complex amount of interactions among factors such as knowledge, attitudes, self-confidence, social influence, previous experience, and the opportunity for change. In this study, the nursing students reported exemplary health behaviors but did not get adequate sleep or sufficient exercise. Both of these inadequacies probably reflect time constraints related to the academic and social commitments of university life. Accordingly, appropriate health behaviors related to increased sleep and regular exercise may become apparent when the opportunity becomes available after graduation.
Health education is a lifelong process. University studies in nursing provide an opportunity to change certain habits and represent a particular means of enhancing students' health knowledge. This enhanced knowledge may manifest itself in behavioral changes that may occur immediately or later in life, as opportunities become available. Opportunities for change may be related to health or to other determinants, such as social situations or financial circumstances, which in turn, may influence individual health habits in positive or negative directions. In that respect, being exposed to the academic milieu of nursing school may have facilitated the adoption of monthly breast self-examinations among the nursing students, while excessive academic demands may have motivated them to begin skipping breakfast, as well as sleep and exercise less.
These findings emphasize the importance for nursing programs to offer students current information on health, help them integrate and apply this information, and in the words of Meillier et al. (1997), "keep students' soil fertile" (p. 50) so they will be ready when a cue to action directed toward healthy behaviors arises in their immediate academic life or subsequently during their career.
These findings also support the necessity for the academic environment to foster desirable health behaviors. To that effect, it would seem appropriate for nursing programs to provide students ample time for good health habits, such as sleeping at least 7 hours per night, eating breakfast daily, and exercising regularly. In addition, these results support the need for nursing students to learn and experience taking good care of themselves so they can advise and help clients effectively on health-related matters.
It would be interesting to conduct in-depth qualitative interviews with nursing students to discover and investigate their motives for changing health-related behaviors, particularly regarding sleep, nutrition, and exercise, as they progress through their university program. Finally, it also would be of interest to survey these students some years after graduation to identify any additional behavior changes that may occur after they have begun their careers.
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Health Behaviors, Desirable Practice, and Effects on Health
Percentages by Year of Nursing Students, Education Students, and Quebec Population Ages 15 to 24 Engaged in the Designated Health Behaviors
Numbers and Percentages of Students (Participants and Registered) Voluntarily Completing the Health Behavior Questionnaire by Group and Year of the Study