Journal of Nursing Education

Major Article 

Healthy Lifestyle Behaviors and Health Promotion Attitudes in Preregistered Nurses: A Questionnaire Study

Holly Blake, PhD, CPsychol; Natalia Stanulewicz, MA; Katherine Griffiths, MNursSci



Nurses report inadequacies in health promotion practices. This study investigated attitudes toward being role models for healthy eating, and examined predictors of health promotion attitudes in preregistered nurses.


A questionnaire was completed by 493 preregistered nurses. Measures included health promotion attitudes, healthy lifestyle index, self-esteem, and body satisfaction.


Preregistered nurses (89.5%) felt that nurses should be role models for health. However, 37% had a negative health promotion attitude and were more likely to be dissatisfied with their body and lead less healthy lifestyles. Most preregistered nurses (96%) felt that delivering health promotion would be a key element of their job and held positive health promotion attitudes. Healthy lifestyle was the most consistent significant predictor of health promotion attitude.


Preregistered nurses with an unhealthy lifestyle and lower self-esteem held a more negative health promotion attitude. Intervention is needed to support preregistered nurses in making healthy lifestyle choices, improving their self-perception and health promotion attitude. [J Nurs Educ. 2017;56(2):94–103.]



Nurses report inadequacies in health promotion practices. This study investigated attitudes toward being role models for healthy eating, and examined predictors of health promotion attitudes in preregistered nurses.


A questionnaire was completed by 493 preregistered nurses. Measures included health promotion attitudes, healthy lifestyle index, self-esteem, and body satisfaction.


Preregistered nurses (89.5%) felt that nurses should be role models for health. However, 37% had a negative health promotion attitude and were more likely to be dissatisfied with their body and lead less healthy lifestyles. Most preregistered nurses (96%) felt that delivering health promotion would be a key element of their job and held positive health promotion attitudes. Healthy lifestyle was the most consistent significant predictor of health promotion attitude.


Preregistered nurses with an unhealthy lifestyle and lower self-esteem held a more negative health promotion attitude. Intervention is needed to support preregistered nurses in making healthy lifestyle choices, improving their self-perception and health promotion attitude. [J Nurs Educ. 2017;56(2):94–103.]

Excess weight and obesity are major population health issues in the United Kingdom (National Obesity Forum, 2014) and worldwide (James, 2004), with devastating effects for individual health, health care services, and the economy. As advocates for health, nurses play an important role in health promotion and the reduction of population obesity (Prime Minister's Commission, 2010). As such, patients view nurses as role models for health (Blake, 2014). Nurses generally agree with this view, and recognize that their lifestyle choices can influence those of their patients (e.g., poor diet and smoking) (Blake & Harrison, 2013). However, nurses often do not lead healthy lifestyles themselves (McElligott, Siemers, Thomas, & Kohn, 2009), which can negatively influence care quality (Hebert, Caughy, & Shuval, 2012; Lobelo, Duperly, & Frank, 2009) and their credibility (Blake & Harrison, 2013), as health care professionals who lead healthy lifestyles are more likely to deliver health promotion to patients than those who do not (Hebert et al., 2012; Lobelo et al., 2009). Nurses have reported previously that being overweight or engaging in unhealthy behaviors would reduce their willingness to promote health promotion to their patients (Blake & Patterson, 2015).

Although nurses largely agree that it is important for them to make healthy lifestyle choices, this view does not necessarily translate into a healthier nursing workforce. In the United Kingdom, the Department of Health (2009) reported that 58% of nurses working for the National Health Service (NHS) were overweight, with 25% being obese. This is close to the amount of people with body mass index (BMI) >25 in the general U.K. population −61.7% (Public Health England, 2015), which is concerning taking into account the health-related education and training that nurses receive. Still, overweight and obesity remain prevalent among pre-registered (i.e., student) and registered (i.e., qualified) nurses (Blake, Mo, Lee, & Batt, 2012; Department of Health, 2009). Dietary habits are less than exemplar among nurses, specifically among preregistered nurses, as many of them do not achieve healthy eating recommendations set by the NHS (Malik, Blake, & Batt, 2011). This occurrence is attributed to working or having placements in a shift-type occupation in an environment providing unhealthy food options (Phiri, Draper, Lambert, & Kolbe-Alexander, 2014). Although a proportion of nurses perceive that being a healthy role model to patients is unimportant and would not affect patients, the evidence suggests that this may be the minority view, more likely to be expressed by those who have an unhealthy weight and engage in negative lifestyle behaviors (Blake & Harrison, 2013; Blake & Patterson, 2015). The Prime Minister's Commission (2010) stated that nurses should take responsibility for their own health, although continued efforts need to be made to support nurses in making healthier lifestyle choices, and raise awareness among health care professionals about healthy lifestyles and the potential influence of their choices on care quality. This applies equally to preregistered nurses as the next generation of health care professionals.

Research suggests that self-esteem and self-perception may play a key role both in the adoption of personal health behaviors and in nursing practice, as individuals with higher self-esteem generally have greater self-confidence, are more assertive, and hold more positive attitudes toward healthy eating and exercise (Spurgas, 2005). Self-esteem in nurses may be important for their professional role, as greater self-esteem relates to professional nursing values and the successful delivery of patient care (Iacobucci, Daly, Linedell, & Griffin, 2013; Randle, 2003). An early meta-analysis showed that self-esteem was lower in individuals with a higher BMI than in those with a healthy weight (Miller & Downey, 1999).

However, understanding of the relationship between self-perception in nurses, their BMI and healthy lifestyle behaviors (related to diet and physical activity habits), and their health promotion attitudes (HPAs) is currently limited. As preregistered nurses comprise the future NHS workforce, a better understanding of these issues within this population would allow for a timely introduction of changes to nursing education that would promote healthy lifestyles, build self-esteem, and positively affect HPAs for the future.

The aims of the study were (a) to investigate preregistered nurses' opinions of being role models for healthy eating and their attitudes and confidence toward giving health promotion advice; and (b) to investigate the relationship between BMI, self-esteem, self-perception, healthy lifestyle, and attitudes toward health promotion.


Ethical approval was granted by the local institutional review board in March 2014. A paper questionnaire survey was distributed between May and July 2014 to all preregistered nurses within a single institution (N = 868). The completion of the study was voluntary and anonymous. Informed consent was assumed from return of the questionnaire.


Five constructs were measured in this study: (a) demographics, (b) self-reported healthy lifestyle index combining diet and physical activity habits, (c) HPA (including Likert scale and three binary questions), (d) self-esteem, and (e) body satisfaction.

Demographic information was collected to determine representativeness of the sample: gender, year of birth, branch of nursing, year of study, degree specification, and self-reported height and weight measurements, from which BMI was determined using the formula kg/m2 (World Health Organization, 2014).

Healthy lifestyle was reported by each participant through their responses to the questions created by the authors, starting with how healthy they considered their own diet to be. Preregistered nurses scored this item on a scale of 1 = not at all to 10 = extremely healthy. Participants also reported how many portions of fruit or vegetables they consumed in a typical day (from 0 to >5). In the United Kingdom, the government recommends consumption of five portions of fruits or vegetables per day (Ashfield-Watt, Welch, Day, & Bingham, 2003). For the purpose of this study, a higher amount of fruits and vegetables in one's diet was considered to indicate a healthier lifestyle. Finally, participants were asked about their level of physical activity with the statement, “Think about all the physical activity you do in a typical week. Do you get a total of 2 hours and 30 minutes of moderate aerobic activity (e.g., brisk walking) every week?” The authors coded participants who did not meet the physical activity (PA) recommendations of the UK Department of Health at the time of the study as 0 (i.e., at least 30 minutes of moderate physical activity for five days per week) (Department of Health, 2011), and those who did as 1. The rationale being that meeting these daily requirements is deemed to be beneficial, and not meeting them may be detrimental to health. All of the three variables above were combined to create a healthy lifestyle index. For the purpose of this study, it was considered that the higher the score on this index, the healthier was the reported lifestyle. Although a healthy lifestyle includes a diverse range of behaviors, to meet the study aims, the authors focused only on reported diet and physical activity. In this context, the term healthy lifestyle acted simply as a descriptor of attainment of UK recommendations for diet and physical activity.

Participants were asked to complete a series of 14 statements to establish their views about nurses as role models for health, and their attitudes toward health promotion; consistent with study aims, these had a specific focus on weight management, obesity, and physical activity habits. Items and scale characteristics are described in Table 1.

Items Creating Health Promotion Attitude Scale, With Scale's Descriptiona

Table 1:

Items Creating Health Promotion Attitude Scale, With Scale's Description

Participants completed the Rosenberg Self-Esteem Scale (Rosenberg, 1965), the most widely used (Marsh, Scalas, & Nagengast, 2010) and validated (Sinclair et al., 2010) measure of self-esteem. The scale is comprised of 10 statements, where individuals indicate their agreement or disagreement on a 4-point Likert scale. Total scores range from 0 to 30; the higher the participant's score, the higher their self-esteem. Those with a score below 15 were considered to have low self-esteem. The scale has high test–retest reliability and low social desirability (e.g., McMullen & Resnick, 2013). The level of reliability of this scale was satisfactory, with Cronbach's alpha = .86.

Self-perception was measured using the Stunkard body image scale (Stunkard, Sorensen, & Schilsinger, 1983)—a commonly used measure of body satisfaction consisting of nine male and female schematic figures ranging from underweight to overweight. Participants were asked to select the figure that most closely represents their actual body size and one that mostly represents the size they would like to be. The discrepancy between the perceived and ideal size is the measure of body dissatisfaction. The scale has established validity and test–retest reliability (e.g., Lynchet et al., 2008).

Data were analyzed using IBM SPSS® statistics version 22.0 software. All data were input manually, and a 10% data check was conducted. Analyses include descriptive statistics, chi-square tests, Pearson's product–moment correlations, independent groups t tests, one-way ANOVAs, and linear and binary regression models. The significance of the results was determined at the level of p < .05 (Fisher, 1956).


This section provides information about sample demographics (Table 2) together with results demonstrating variables affecting preregistered nurses' attitude toward health promotion (Tables 35). Of the 868 preregistered nurses invited to participate, 535 responded (61%), but 42 (8%) did not provide height and weight and were not included in the analysis. The final sample was 493 (57%)preregistered nurses.

Demographic Characteristics of Nursing Students Who Fully Completed the Studya

Table 2:

Demographic Characteristics of Nursing Students Who Fully Completed the Study

Relationships Between Study Variables (Partial Correlations), With Age and Gender Controlled for (n = 457)

Table 3:

Relationships Between Study Variables (Partial Correlations), With Age and Gender Controlled for (n = 457)

Linear Regression Models Predicting Health Promotion Attitude (for Full Sample and Overweight/Obese Subsample)

Table 4:

Linear Regression Models Predicting Health Promotion Attitude (for Full Sample and Overweight/Obese Subsample)

Binary Regression Coefficients for Models Predicting Feeling Competent in Delivering Health Advice (n = 457)

Table 5:

Binary Regression Coefficients for Models Predicting Feeling Competent in Delivering Health Advice (n = 457)

Sample Characteristics

Respondents were 493 preregistered nurses (62% response rate; 90% women) from all 4 years of a degree program. A high women-to-men ratio is typical for this career setting. The mean age of the sample (M = 25.36 years; SD = 6.42 years; range = 20 to 56 years) reflected a typical preregistered nursing population. Twenty-eight percent of the sample was classified as overweight or obese according to the BMI category (n = 139). As the sample of underweight pre-registered nurses was small (n = 27, 6%), and evidence exists that people tend to underestimate their weight and overestimate their height (Engstrom, Paterson, Doherty, Trabulsi, & Speer, 2003), underweight and healthy weight participants were grouped together for analyses (n = 354, 72%). Overweight and obese participants were significantly older than participants classified as having healthy weight or those underweight (t[176.15] = −5.38, p < .001], and included smaller percentage of women (χ2 = 4.77, p = .03), but there were no differences in the year of study distribution (χ2 = .73, p = .87) or the nursing branch distribution (χ2 = 4.78, p = .092). Age and gender were controlled for in the analyses of group differences (Table 2).

Almost one third (32%, n = 160) of the preregistered nurses did not meet the government guidelines for physical activity (i.e., a minimum of 30 minutes of moderate physical activity on at least 5 days per week; Department of Health, 2011), and these were mostly the overweight or obese nurses (χ2 = 7.16, p = .007).

Only 18% (n = 90) of the full sample consumed the recommended five pieces of fruits or vegetables per day. Despite this, 47% (n = 230) of nursing students viewed their diet as rather healthy (i.e., equal or higher than 7 on the 10-point healthy diet scale). Preregistered nurses with a healthy weight or who were underweight were more likely to perceive their diet (F[1,490] = 5.67, p = .018), as well as their lifestyle (F[1,487] = 3.93, p = .048), to be healthy, compared with the overweight or obese students. Body dissatisfaction was prevalent with 84% (n = 414) of the preregistered nurses expressing dissatisfaction. The overweight or obese participants expressed a higher level of body dissatisfaction than those with healthy BMIs or who were underweight (F[1,486] = 87.67, p < .001]. Of the preregistered nurses, 19% (n = 95) were classified as having low self-esteem (M = 16.23, SD = 2.50), although there were no differences in self-esteem based on BMI classification (F[1,479] = 3.02, p = .083). However, a significant difference exists in HPA (F[1,476] = 4.30, p = .04), depending on BMI classification.

On average, the attitudes toward health promotion of pre-registered nurses were more likely to be negative or neutral rather than positive (M = 2.22, SD = 0.52; range 1 to 4, where 1 = strongly negative, and 4 = strongly positive), as more than one third (n = 175, 35%) of the preregistered nurses scored ⩽2, where 2 represented a rather negative attitude. Only 7% (n = 35) scored ⩾3, demonstrating positive attitude, whereas the remainder (58%, n = 269) scored in between, demonstrating a rather neutral attitude.

Relationships Between Variables

Attitude toward HPA among preregistered nurses was positively and significantly correlated with healthy lifestyle (r = .23, p < .01), and self-esteem (r = .20, p < .01). This suggests that preregistered nurses with a healthier lifestyle and those with higher self-esteem are more likely to hold positive attitudes toward health promotion. In the full sample, a trend exists toward a significant relationship between HPA and BMI (r = –.09, p = .052). Similarly, a significant relationship was found between HPA and body dissatisfaction (r = −.11, p = .02). These partial correlations (controlling for age and gender) are shown in Table 3.

Multivariate Regressions

Age, gender, BMI, healthy lifestyle, body dissatisfaction, self-esteem, and year of study were entered into a multiple linear regression model predicting the HPA of preregistered nurses (Table 4). The overall model was significant (F[7,453] = 6.97, p < .001) and explained 10% of the variance in HPA. The only significant predictors were self-esteem (β = .19, p < .001) and healthy lifestyle (β = .21, p < .001). The same analysis (Table 4) was undertaken with only the overweight or obese subsample (n = 127). Here, the overall model was significant (F[7,119] = 4.11, p < .001), and explained 20% of the variance in HPA. The significant predictors in the model were again self-esteem (β = .17, p = .04), and healthy lifestyle (β = .32, p = .001), with an additional influence of body dissatisfaction (β = −.25, p = .009).

Finally, the preregistered nurses responses to three yes-or-no statements about their HPA (separate to HPA scale) were analyzed. Where possible (given adequate sample sizes), binary logistic regression models were conducted. In circumstances where sample sizes were small, the percentage comparison and qualitative results were reported.

Feeling Competent in Giving Health Advice. One hundred thirteen (23%) preregistered nurses reported that they would not feel competent giving health advice. These students were predominantly from years 1 (30%), 2 (40%) and 3 (27%), with fewer not feeling competent in year 4 (3%). The year of study, age, gender, BMI, self-esteem, body dissatisfaction, and healthy lifestyle were entered into a regression model predicting a participant's response to the statement, “I would feel competent in giving health advice.” For the preregistered nurses, the year of study may be an important factor about their feelings of competence, given that placement exposure is limited in year 1 and increases throughout the training. The overall model was significant (χ2 = 15.95, p < .03), explained 5% of the variance (Nagelkerke R2 = .051), and correctly classified 76.1% responses. The only significant predictor for the feelings of competence was healthy lifestyle (B = –.12, p = .003; Wald = 8.80; odds ratio = .89) (Table 5). Results showed an additional potential impact of the year of study on feeling competent; as expected, preregistered nurses felt more competent the further they progressed in their course (B = −.23, p = .10; Wald = 2.69; odds ratio = .79). These results were corroborated by the provided open-ended responses, since Feelings of Struggling Oneself With a Healthy Diet, Not Doing It Myself, and Following a Healthy Lifestyle Myself were recurring themes for preregistered nurses sharing perceptions of their own incompetence and competence in giving health promotion advice to others.

Delivering Healthy Eating Advice as a Nurse. Only 4% (n = 20) of the preregistered nurses thought that healthy eating promotion would not be part of their job role. The open-ended responses indicated these participants held the belief that health promotion was solely the role of another health care professional (i.e., dietician).

Perceptions Toward Being Role Models for Health. Only 10% (n = 51) of participants stated that preregistered nurses should not be role models for health. The analysis of the open-ended responses indicated that the majority of participants held a belief that nurses would not be good health models if they lead an unhealthy lifestyle—for example, if they smoke, eat unhealthily, do not exercise, or are overweight. Some preregistered nurses indicated that a lack of adequate knowledge about health behaviors might be a barrier toward them being a health role model.


This study investigated preregistered nurses' opinions of being role models for healthy eating and their attitudes and confidence toward giving health promotion advice. Predictors of HPAs were examined.

As part of their training, the preregistered nurses in this study had all been educated on the U.K. government guidance for healthy eating (e.g., consuming a minimum of five pieces of fruit or vegetables per day), and physical activity (e.g., undertaking at least 30 minutes of moderate-intensity physical activity, 5 days per week). Although they would be expected, as nurses, to promote this lifestyle advice to patients, many of the preregistered nurses in this sample were not achieving these guidelines. An exceptionally high proportion of the sample (83%) did not meet generic government recommendations for healthy diet, although just under half the sample believed that they consumed a healthy diet. Over one quarter of the sample was overweight or obese, and around one third did not meet government recommendations for physical activity. This is based on self-reports that are more likely to overestimate healthy eating and physical activity behaviors and underestimate weight, rather than the reverse (especially among obese participants) (Lichtman et al., 1992). Those preregistered nurses who were overweight or obese were more likely to be inactive and have poorer dietary habits. In addition, approximately one fifth of the preregistered nurses had low self-esteem. More than three quarters were dissatisfied with their body, and body dissatisfaction was specifically prevalent among those who were overweight or obese.

This study shows that unhealthy lifestyle behaviors, unhealthy weight, and low self-esteem are directly related to negative HPAs in preregistered nurses. This is alarming, as a great number of preregistered nurses appeared to lead unhealthy life, have unhealthy weight, and be body dissatisfied. In those who were overweight or obese, body dissatisfaction also predicted negative HPAs.

The relationship between healthy lifestyle and HPAs was the most consistent finding across multiple analyses, regardless of whether the participant had a healthy or unhealthy BMI. These results corroborate previous work with nursing samples that advocates the importance of nurses leading a healthy lifestyle to promote health practices to others (Fie, Norman, & While, 2012), avoid feeling hypocritical when giving health advice (McCann, Clark, & Rowe, 2005), and be seen as a credible source of health information (e.g., Rush, Kee, & Rice, 2005). Nevertheless, leading a healthy lifestyle and maintaining a healthy weight is recognized to be a complex task for those in shift-working professions (Berger & Hobbs, 2006).

This study showed that preregistered nurses with a healthier lifestyle felt more competent to deliver health promotion. As would be expected, feelings of competence for health promotion also increased with a greater level of training from progression through the course. However, year of study did not show a significant effect in any of the other analyses, suggesting that the level of exposure to clinical placements and university training was relevant only to feelings of competence in health promotion and not with other attitudes toward health promotion and healthy lifestyle behaviors.

Regarding the delivery of healthy eating advice, the majority of the preregistered nurses felt that the promotion of healthy eating would be an important aspect of their role as a qualified nurse. A minority held the view that promoting a healthy diet should be undertaken by dieticians. Although this view was held by a small number of individuals, it is perhaps important to investigate this further if the next generation of nursing professionals are indeed to make every contact count (NHS Yorkshire and the Humber, 2011).

The majority of the preregistered nurses in this study thought that nurses should be role models for health, which is consistent with previous findings (e.g., Blake et al., 2011). In addition to focusing on the health behaviors of preregistered nurses, a small number of participants reported that a lack of personal knowledge and understanding about health behaviors could be a barrier to the realization of this. There may be a need to increase the focus on healthy lifestyle behaviors within nursing education not only related to patient health promotion but also the translation of this knowledge to the nurse's own behaviors.

The association between body dissatisfaction, BMI, and negative HPAs in those who were overweight or obese is concordant with previous research showing that preregistered nurses with a BMI >25 are more likely to express negative attitudes toward being role models for health than those with healthy a BMI (Blake & Harrison, 2013). Some participants that expressed a negative HPA gave specific reasons for this, relating to their own body weight or self-perception, such as “being overweight,” “obese,” or “having poor self-body image.” Conversely, it was found that self-esteem has a positive relationship with HPA among preregistered nurses. As such, building self-esteem and improving self-perception in this population may help to foster a positive HPA. This needs to be tested further, as the correlational data described here do not allow for the assessment of cause and effect. In addition, the measurement of self-esteem might be investigated further using job role-specific measures.

Overall, the authors propose that encouraging and facilitating healthy lifestyle behaviors and building self-esteem amongst preregistered nurses may help to generate and sustain a positive HPA. These positive attitudes may then be taken forward by nurses' postregistration, and enhance feelings of competence in delivering health promotion as they gain further experience in clinical settings. Supporting preregistered nurses in making healthy diet and exercise lifestyle choices may help to enhance body satisfaction, specifically in those who have negative self-perception; in the current study, these individuals tended to be those who were overweight or obese. This may have further secondary benefits for fostering a positive HPA. This task is complex, although educating preregistered nurses about healthy lifestyles, facilitating healthy choices, and fostering self-esteem and positive self-perception might be a first step toward achieving a healthier nursing workforce in the future.

This important goal might be accomplished through a combination of education, training, and services to support health and well-being in nurses. First, nursing curriculum should be reviewed to ensure that healthy lifestyle behaviors are embedded in two ways: (a) knowledge about the importance of healthy lifestyle behaviors for health, including understanding the government recommendations for healthy lifestyle behaviors to effectively promote health to patients; and (b) understanding the importance of translating health promotion knowledge to nurse's own lifestyles, the potential influence of personal lifestyle choices on nurse's own health, and the influence of nurses as role models on patient care (i.e., potential influences on patient care through their own willingness to promote health to patients, or the patients heeding their advice). The former is usually included within preregistration curriculum, although opportunities may exist to enhance training around health promotion further, such as using simulation methods for preregistered nurses to gain confidence in health promotion practice. Training on the translation of knowledge to personal lifestyle choices, and the potential influence of the nurse's health behaviors on patient care, is rarely embedded within taught courses. A clear need exists to incorporate additional training on how preregistered nurses can develop and sustain healthy lifestyle behaviors themselves, and how this might be achieved while at work, at university, or on busy practice placements. Some early efforts were made to address this need, such as through electronic learning tools offered in some institutions to promote health among student and registered nurses in Taiwan (Hsiao et al., 2005; Yu & Yang, 2006).

More recently in the United Kingdom, online packages have been developed to promote health and well-being in nurses and other frontline health care professionals (Blake & Gartshore, 2014). Online interventions offer flexibility for balancing training on healthy lifestyle around the time requirements of academic study and clinical placements. The authors advocate for this form of training to be routinely offered to preregistered nurses, registered nurses acting as placement mentors, and nurse educators supporting nurse training. It may be important to consider the health behaviors and attitudes of nurse educators and registered nurses acting as placement mentors. These individuals act as role models for their students' future nursing practice (Campbell, Larrivee, Field, Day, & Reutter, 1994), and their own attitudes and lifestyle behaviors may exert an influence on behaviors and views developed by preregistered nurses.

In addition to providing education and training, services should be offered that support the preregistered nurses in adopting healthy lifestyle practices. Such interventions might be especially fruitful, as students spend a high proportion of their daily hours within the university setting. For example, this might include provision of accessible exercise facilities or places to be physically active, encouragement of incidental physical activities (e.g., using the stairs instead of the lifts), lunchtime walking groups, pedometer challenges, health checks, healthy food options, and weight management programs. Again, online health behavior change interventions have shown to be effective in health care and academic settings and may provide opportunities for reaching those who are working shifts in hospital settings (Greene et al., 2012).

Our findings from a British sample of preregistered nurses have implications for nursing education worldwide and for the development of initiatives in educational and health care settings to support the next generation of nurses in developing sustainable healthy lifestyle behaviors. In the United Kingdom, the NHS currently advocates that all health care professionals should make every contact count (NHS Yorkshire and the Humber, 2011) in promoting positive health behaviors to patients and clients, as part of a nationwide initiative to improve population health. This preventative approach is advocated within nursing education around health promotion, with relation to patient care. However, this approach could be applied directly to academic settings by nursing faculties taking every chance to raise preregistered nurses' awareness of health promotion in their own life. Making every contact count should be continually emphasized in nursing education because health care students' knowledge about health behaviors does not necessarily translate into practice (Sajwani et al., 2009).

With regard to services and interventions, positive steps might include offering healthy meal options (found to be successful in workplace settings) (Agarwal et al., 2015) or introducing university-based lifestyle interventions targeted specifically to preregistered nurses (Luszczynska & Haynes, 2009). Individual behavior change is more likely to be facilitated and sustained in health promoting environments (Larson & Story, 2009), and settings-based approaches have been applied successfully in other workplaces (Quintiliani, Poulsen, & Sorensen, 2010). Supporting healthy universities' initiatives and improving facilities accessible to preregistered nurses may have the potential to positively influence their lifestyle choices. However, few studies have concentrated on the effectiveness of educational, institution-based interventions targeted specifically to preregistered nurses and nurse educators, and this is likely to be because such initiatives are not common.

In the United Kingdom, the health promoting university initiative—a settings-based approach to health promotion within universities—was proposed over 15 years ago (Dooris, 2001), but an inconsistency still exists across the United Kingdom in the provision of health-promoting environments for university students. In addition, health care students often struggle to access mainstream university facilities when they are working shifts on placements, or if they are physically based in hospital sites for their education and training. In some regions, health care students and educators based on hospital sites may have access to workplace well-being programs delivered for NHS employees. For example, Nottingham University Hospitals NHS Trust, United Kingdom (NUH NHS, 2015) delivers a pioneering health and well-being program for its employees where a vast array of health-promoting facilities and services are accessible to more than 14,000 hospital staff, as well as health care students and educators based on their sites. Following the NHS England (2014) Five Year Forward View, £5 million has been recently invested in exemplar NHS trusts for enhancing their workplace initiatives to support and improve physical and mental health in hospital employees. Overall evaluation of the UK Five Year Forward View is forthcoming. However, evaluations of the existing initiatives delivered by the exemplar hospital trust have shown that health care employees, as well as health care students and university employees based on their sites, engage in and value these initiatives (Blake & Batt, 2015; Blake, Bennett, & Batt, 2014; Blake, Suggs, Coman, Aguirre, & Batt, 2016) and that they are perceived to be financially sustainable (Lee, Blake, & Lloyd, 2010).

More research is needed to determine how best to build confidence for health promotion practice in preregistered nurses, support the translation of their knowledge and training around healthy lifestyle into their own lives, and determine the effectiveness of various interventions and services to support preregistered nurses in making healthy lifestyle choices. Finally, a limited understanding exists of the potential effects of nurse educators' and clinical nurse mentors' lifestyle behaviors and attitudes on those of their students, and this topic should be considered in future studies.


The findings reported in this article are based on self-reported cross-sectional data from a sample of preregistered nurses at a single institution, although participants were based in multiple hospital sites and the demographics and health lifestyle profile of the sample were broadly comparable with samples of preregistered nurses in previous studies (Malik et al., 2011). The healthy lifestyle index was a simple measure targeted only to diet and physical activity behavior and does not include other aspects of healthy living. Finally, the measure of HPA is relatively new and requires validation and reliability analyses for use in future studies.


In this study, preregistered nurses' HPAs depended on their own health-related dietary and physical activity practices and self-perception. Educating preregistered nurses about the importance of their own health and well-being and facilitating healthy lifestyle choices at university, on placements, and in their personal lives is an essential but complex task for the future. Improving the health and well-being of preregistered nurses may help to foster positive self-perception and HPAs that may ultimately have an affect on future patient care. Preregistered nurses should be equipped with early training around core concepts of a healthy lifestyle, including diet, physical activity, and weight management. Professional training on personal health and well-being should be widely offered and ideally embedded within nursing curriculum. Educational institutions should seek to generate a health-promoting culture and facilitate healthy lifestyle choices among preregistered nurses as the next generation of nurses, nurse educators, and placement mentors.


  • Agarwal, U., Mishra, S., Xu, J., Levin, S., Gonzales, J. & Barnard, N.D. (2015). A multicenter randomized controlled trial of a nutrition intervention program in a multiethic adult population in the corporate setting reduces depression and anxiety and improves quality of life: The GEICO study. American Journal of Health Promotion, 29, 245–254. doi:10.4278/ajhp.130218-QUAN-72 [CrossRef]
  • Ashfield-Watt, P.A.L., Welch, A.A., Day, N.E. & Bingham, S.A. (2004). Is ‘five-a-day’ an effective way of increasing fruit and vegitable intake?Public Health Nutrition, 7, 257–261. doi:10.1079/PHN2003524 [CrossRef]
  • Berger, A.M. & Hobbs, B.B. (2006). Impact of shift work on the health and safety of nurses and patients. Clinical Journal of Oncology Nursing, 10, 465–471. doi:10.1188/06.CJON.465-471 [CrossRef]
  • Blake, H. (2014). Nurses recognise their own health can affect care quality. Nursing Times, 110, 7.
  • Blake, H. & Batt, M.E. (2015). Employee perceptions of pedometer walking intervention in a hospital workplace. International Journal of Health Promotion and Education, 53, 1–14. doi:10.1080/14635240.2015.1016621 [CrossRef].
  • Blake, H., Bennett, E. & Batt, M.E. (2014). Evaluation of occupational health checks for hospital employees. International Journal of Workplace Health Management, 7, 247–266. doi:10.1108/IJWHM-07-2013-0027 [CrossRef]
  • Blake, H. & Gartshore, E. ( 2014, December. ). Development and evaluation of an online learning tool to enhance knowledge of workplace wellness in healthcare disciplines. Paper presented at the 10th UK Society for Behioral Medicine Annual Scientific Meeting. , Nottingham, UK. .
  • Blake, H. & Harrison, C. (2013). Health behaviours and attitudes towards being role models. British Journal of Nursing, 22, 86–94. doi:10.12968/bjon.2013.22.2.86 [CrossRef]
  • Blake, H., Malik, S., Mo, P.K.H. & Pisano, C. (2011). ‘Do as I say, but not as I do’: Are next generation nurses role models for health?Perspectives in Public Health, 131, 231–239. doi:10.1177/1757913911402547 [CrossRef]
  • Blake, H., Mo, P.K.H., Lee, S. & Batt, M.E. (2012). Health in the NHS: Lifestyle behaviours of hospital employees. Perspectives in Public Health, 132, 213–215. doi:10.1177/1757913912457309 [CrossRef]
  • Blake, H. & Patterson, J. (2015). Paediatric nurses' attitudes towards the promotion of healthy eating in children and their families. British Journal of Nursing, 24, 108–112. doi:10.12968/bjon.2015.24.2.108 [CrossRef]
  • Blake, H., Suggs, L.S., Coman, E., Aguirre, L. & Batt, M.E. (2016). Active8! Technology-based intervention to promote physical activity in hospital employees. American Journal of Health Promotion. Epub ahead of print. doi:10.4278/ajhp.140415-QUAN-143 [CrossRef]
  • Campbell, I.E., Larrivee, L., Field, P.A., Day, R.A. & Reutter, L. (1994). Learning to nurse in the clinical setting. Journal of Advanced Nursing, 20, 1125–1131. doi:10.1046/j.1365-2648.1994.20061125.x [CrossRef]
  • Department of Health. (2009). Healthy weight, healthy lives: two years on. Retrieved from
  • Department of Health. (2011). UK physical activity guidelines. Retrieved from
  • Dooris, M. (2001). The “Health Promoting University”: A critical exploration of theory and practice. Health Education, 101(2), 51–60. doi:10.1108/09654280110384108 [CrossRef]
  • Engstrom, J.L., Paterson, S.A., Doherty, A., Trabulsi, M. & Speer, K.L. (2003). Accuracy of self-reported height and weight in women: An integrative review of the literature. Journal of Midwifery & Women's Health, 48, 338–345. doi:10.1016/S1526-9523(03)00281-2 [CrossRef]
  • Fie, S., Norman, I.J. & While, A.E. (2012). The relationship between physicians' and nurses' personal physical activity habits and their health-promotion practice: A systematic review. Health Education Journal, 72, 102–119. doi:10.1177/0017896911430763 [CrossRef]
  • Fisher, R.A. (1956). Statistical methods and scientific inference. New York, NY: Hafner.
  • Greene, G.W., White, A.A., Hoerr, S.L., Lohse, B., Schembre, S.M., Riebe, & Phillips, B.W. (2012). Impact on an online healthful eating and physical activity program for college students. American Journal of Health Promotion, 27, e47–e58. doi:10.4278/ajhp.110606-QUAN-239 [CrossRef]
  • Hebert, E.T., Caughy, M.O. & Shuval, K. (2012). Primary care providers' perceptions of physical activity counselling in a clinical setting: A systematic review. British Journal of Sports Medicine, 46, 625–631. doi:10.1136/bjsports-2011-090734 [CrossRef]
  • Hsiao, Y.C., Chen, M.Y., Gau, Y.M., Hung, L.L., Chang, S.H. & Tsai, H.M. (2005). Short-Term effects of a health promotion course for Taiwanese nursing students. Public Health Nursing, 22, 74–81. doi:10.1111/j.0737-1209.2005.22111.x [CrossRef]
  • Iacobucci, T., Daly, B., Linedell, D. & Griffin, M. (2013). Professional values, self-esteem and ethical confidence of baccalaureate pre-registered nurses. Nursing Ethics, 20, 479–490. doi:10.1177/0969733012458608 [CrossRef]
  • James, P.T. (2004). Obesity: The worldwide epidemic. Clinics in Dermatology, 22, 276–280. doi:10.1016/j.clindermatol.2004.01.010 [CrossRef]
  • Lance, C.E., Butts, M.M. & Michels, L.C. (2006). The sources of four commonly reported cut off criteria: What did they really say?Organizational Research Methods, 9, 202–220. doi:10.1177/1094428105284919 [CrossRef]
  • Larson, N. & Story, M. (2009). A review of environmental influences on food choices. Annals of Behavioural Medicine, 38(Suppl.), S56–S73. doi:10.1007/s12160-009-9120-9 [CrossRef]
  • Lee, S., Blake, H. & Lloyd, S., (2010).The price is right: Making workplace wellness financially sustainable international. Journal of Workplace Health Management, 3, 58–69. doi:10.1108/17538351011031948 [CrossRef]
  • Lichtman, S.W., Pisarska, K., Raynes-Berman, E., Pestone, M., Dowling, H., Offenbacher, & Heymsfield, S.B. (1992). Discrepancy between self-reported and actual caloric intake and exercise in obese subjects. The New England Journal of Medicine, 327, 1893–1898. doi:10.1056/NEJM199212313272701 [CrossRef]
  • Lobelo, F., Duperly, J. & Frank, E. (2009). Physical activity habits of doctors and medical students influence their counselling practices. British Journal of Sports Medicine, 43, 89–92. doi:10.1136/bjsm.2008.055426 [CrossRef]
  • Luszczynska, A. & Haynes, C. (2009). Changing nutrition, physical activity and body weight among student nurses and midwives: Effects of a planning intervention and self-efficacy beliefs. Journal of Health Psychology, 14, 1075–1084. doi:10.1177/1359105309342290 [CrossRef]
  • Lynch, E., Liu, K., Wei, G., Spring, B., Kiefe, C. & Greenland, P. (2008). The relation between body size perception and change in body mass index over 13 years: The coronary artery risk development in young adults (CARDIA) study. American Journal of Epidemiology, 169, 857–866. doi:10.1093/aje/kwn412 [CrossRef]
  • Malik, S., Blake, H. & Batt, M. (2011). How healthy are our nurses? New and registered nurses compared. British Journal of Nursing, 20, 489–496. doi:10.12968/bjon.2011.20.8.489 [CrossRef]
  • Marsh, H.W., Scalas, L.F. & Nagengast, B. (2010). Longitudinal tests of competing factor structures for the Rosenberg self-esteem scale: Traits, ephemeral artifacts, and stable response styles. Psychological Assessment, 22, 366–381. doi:10.1037/a0019225 [CrossRef]
  • McCann, T., Clark, E. & Rowe, K. (2005). Undergraduate pre-registered nurses' attitudes toward smoking health promotion. Nursing & Health Sciences, 7, 164–174. doi:10.1111/j.1442-2018.2005.00228.x [CrossRef]
  • McElligott, D., Siemers, S., Thomas, L. & Kohn, N. (2009). Health promotion in nurses: Is there a healthy nurse in the house?Applied Nursing Research, 22, 211–215. doi:10.1016/j.apnr.2007.07.005 [CrossRef]
  • McMullen, T. & Resnick, B. (2013). Self-esteem among nursing assistants: Reliability and validity of the Rosenberg self-esteem scale. Journal of Nursing Measurement, 21, 335–344. doi:10.1891/1061-3749.21.2.335 [CrossRef]
  • Miller, C.T. & Downey, K.T. (1999). A meta-analysis of heavyweight and self-esteem. Personality and Social Psychology Review, 3, 68–84. doi:10.1207/s15327957pspr0301_4 [CrossRef]
  • National Obesity Forum. (2014). State of the nation's waistline. Obesity in the UK: Analysis and expectations. Retrieved from
  • National Health Service. (2015). Hospital trust to lead drive to improve health among NHS staff. Retrieved from
  • National Health Service England. (2014). Five year forward view. Retrieved from
  • National Health Service Health Education England. (2016). Making every contact count. Retrieved from
  • National Health Service Yorkshire and the Humber. (2011). Prevention and lifestyle behaviour change: A competence framework. Retrieved from
  • Nottingham University Hospitals National Health Service. (2015). NUH leads the way with workplace health. Retrieved from
  • Phiri, L.P., Draper, C.E., Lambert, E.V. & Kolbe-Alexander, T.L. (2014). Nurses' lifestyle behaviours, health priorities and barriers to living a healthy lifestyle: A qualitative descriptive study. BMC Nursing, 13, 38. doi:10.1186/s12912-014-0038-6 [CrossRef]
  • Prime Minister's Commission. (2010). Front line care: The future of nursing and midwifery in England. Report of the Prime Minister's commission on the future of nursing and midwifery in England 2010. Retrieved from
  • Public Health England. (2015). UK and Ireland prevalence and trends. Retrieved from
  • Quintiliani, L., Poulsen, S. & Sorensen, G. (2010). Healthy eating strategies in the workplace. International Journal of Workplace Health Management, 3, 182–196. doi:10.1108/17538351011078929 [CrossRef]
  • Randle, J. (2003). Changes in self-esteem during a 3 year pre-registration diploma in higher education (nursing) programme. Learning in Health and Social Care, 12, 51–60. doi:10.1046/j.1473-6861.2003.00037.x [CrossRef]
  • Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton University Press. doi:10.1515/9781400876136 [CrossRef]
  • Rush, K.L., Kee, C.C. & Rice, M. (2005). Nurses as imperfect role models for health promotion. Western Journal of Nursing Research, 27, 166–183. doi:10.1177/0193945904270082 [CrossRef]
  • Sajwani, R.A., Shoukat, S., Raza, R., Shiekh, M.M., Rashid, Q., Siddigue, M.S. & Kadir, M. (2009). Knowledge and practice of healthy lifestyle and dietary habits in medical and non-medical students of Karachi, Pakistan. Journal of the Pakistan Medical Association, 59, 650–655.
  • Sinclair, S.J., Blais, M.A., Gansler, D.A., Sandberg, E., Bistis, K. & LoCicero, A. (2010). Psychometric Properties of the Rosenberg Self-Esteem Scale: Overall and across demographic groups living within the United States. Evaluation & The Health Professions, 33, 56–80. doi:10.1177/0163278709356187 [CrossRef]
  • Spurgas, A. (2005). Body image and cultural background. Sociological Inquiry, 75, 297–316. doi:10.1111/j.1475-682X.2005.00124.x [CrossRef]
  • Stunkard, A.J., Sorensen, T. & Schilsinger, F. (1983). Use of the Danish Adoption Register for the study of obesity and thinness. Research Publication - Association for Research in Nervous and Mental Disease, 60, 115–120.
  • World Health Organization. (2014). Health promotion. Retrieved from
  • Yu, S. & Yang, K.F. (2006). Attitudes toward web-based distance learning among public health nurses in Taiwan: A questionnaire survey. International Journal of Nursing Studies, 43, 767–774. doi:10.1016/j.ijnurstu.2005.09.005 [CrossRef]

Items Creating Health Promotion Attitude Scale, With Scale's Descriptiona

1.Health promotion should be part of a nurse's job role.
2.Nurses I have worked with on placement give sufficient health promotion advice.
3.Nurses I have worked with on placement take all opportunities to give health promotion advice.
4.Nurses are good role models for health.
5.I think I will find it hard to promote health behaviors if I do not carry them out myself.
6.Overweight or unhealthy nurses are seen to be less competent at their job.
7.Being a healthy weight is important for certain roles as a nurse.
8.Patients will find it easier to connect with me if I display health behaviors that are perceived to be of a real person rather than idealistic.
9.I feel under pressure to be a role model for health.
10.Patients will find it easier to take my advice if I am seen to be following it myself.
11.All nurses should have a healthy diet and exercise regularly.
12.I would not take healthy eating advice from an overweight nurse.
13.The level of obesity in this country concerns me.
14.I have had adequate education to give effective health promotion advice.

Demographic Characteristics of Nursing Students Who Fully Completed the Studya

VariableFull Sample, N = 493Underweight or Healthy Weight, n = 354 (72%)Overweight or Obese, n = 139 (28%)p
Mean age25.36 (SD = 6.42; n = 490)24.22 (SD = 5.06; n = 353)28.31 (SD = 8.34; n = 137)<.001
Female gender90% (n = 444)92% (n = 326)86% (n = 119).03
Year of study
  Year 123% (n = 114)24% (n = 85)21% (n = 29)
  Year 243% (n = 212)43% (n = 153)43% (n = 60)
  Year 332% (n = 156)31% (n = 109)34% (n = 47)
  Year 42% (n = 10)2% (n = 7)2% (n = 3).87
  Adult65% (n= 318)65% (n = 232)63% (n = 87)
  Child17% (n = 81)18% (n = 63)13% (n = 18)
  Mental health19% (n = 93)17% (n = 59)24% (n = 34).09
Met physical activity requirements68% (n = 333)72% (n = 253)59% (n = 81).007
Mean number of fruit and vegetable portions per day3.11 (SD = 1.43; n = 493)3.11 (SD = 1.45; n = 353)3.12 (SD = 1.41; n = 137).68
Perception of diet healthiness6.07 (SD = 1.61; n = 490)6.14 (SD = 1.57; n = 326)5.86 (SD = 1.71; n = 139).018
Healthy lifestyle (physical activity and fruits and vegetables and diet healthiness)9.85 (SD = 2.88; n = 487)9.96 (SD = 2.82; n = 352)9.55 (SD = 3.00; n = 135)<.05
Self-esteem1.62 (SD = 0.25; n = 479)1.63 (SD = 0.25; n = 345)1.60 (SD = 0.23; n = 134).08
Body dissatisfaction0.90 (SD = 1.16; n = 486)0.63 (SD = 1.11; n = 351)1.61 (SD = 0.99; n = 135)<.001
Health promotion attitude2.22 (SD = 0.52; n = 476)2.24 (SD = 0.53; n = 343)2.15 (SD = 0.50; n = 133).04

Relationships Between Study Variables (Partial Correlations), With Age and Gender Controlled for (n = 457)

1. Health promotion attitude.20**−.11*−.09.23**
2. Self-esteem−.02−.11*.03
3. Body dissatisfaction.40**−.08
4. Body mass index−.15**
5. Healthy lifestyle

Linear Regression Models Predicting Health Promotion Attitude (for Full Sample and Overweight/Obese Subsample)

Variable (Model R2= .10)aFull Sample (n = 461)Overweight/Obese Sample (n = 127)

Bp95% CIBp95% CI
Constant<.001.70, 1.74.09−.15, 1.92
Age.02.65−.006, .01−.05.58−.01, .01
Gender−.02.69−.19, .13.01.96−.24, .25
Body mass index−.01.91−.01, .01.12.22−.01, .04
Body dissatisfaction−.08.09−.10, .01−.25.01−.25, −.04
Self-esteem.19<.001.22, ., .75
Healthy lifestyle.21<.001.02, ., .08
Year of study.01.83−.05, .07.04.64−.08, .13

Binary Regression Coefficients for Models Predicting Feeling Competent in Delivering Health Advice (n = 457)

VariableBSEWald Statisticp95% CIOdds Ratio
Body mass index., 1.061.01
Body dissatisfaction., 1.451.11
Self-esteem., 3.031.22
Healthy lifestylea−.12a.04a8.80a.003a.82a, .96a.89a
Year of study−., 1.05.79
Age−., 1.03.99
Gender−.44.421.11.29.28, 1.46.64

Dr. Blake is Associate Professor of Behavioral Science, School of Health Sciences, Queen's Medical Centre; Ms. Stanulewicz is doctoral student, School of Psychology, University of Nottingham; and Ms. Griffths is Staff Nurse, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, Nottinghamshire, United Kingdom.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Natalia Stanulewicz, MA, doctoral student, School of Psychology, University of Nottingham, Nottingham, Nottinghamshire, NG7 2RD, United Kingdom; e-mail:

Received: June 15, 2016
Accepted: October 26, 2016


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