The health and health-related behaviours of undergraduate nursing students have been widely explored and reported within the UK and internationally over the past two decades. Similar patterns emerge from these studies' findings, including a high prevalence of overweight and obesity (Blake et al, 2021), low levels of physical activity (Malik et al, 2011), unhealthy diets (Rodriguez-Gazquez et al, 2017), frequent use of tobacco and alcohol (Shekhar et al, 2022), and irregular sleeping habits (Evans et al, 2019). Behaviour change interventions intended to improve nursing students' lifestyles face a problem of low uptake (Wills and Kelly, 2017), so the authors sought to provide motivational support, as advocated by the COM-B model of behaviour change (Michie et al, 2011). However, they found that they faced a similar problem, of being unable to persuade student nurses to take advantage of the motivational support. This article reports those experiences, to inform both those seeking to improve student nurses' health and wellbeing, and those using the COM-B model for other behaviour change interventions.
In recent years, research has examined student nurses' mental wellbeing (Evans et al, 2021; Lee et al, 2022), quality of life (Damayanti et al, 2020), and level of life satisfaction (Wang et al, 2019) rather than merely focusing on unhealthy behaviours. Nursing students often experience stress due to academic demands, including placements in the hospital setting, which can have a negative impact on their physical and emotional wellbeing, resulting in ill health and course attrition (Lovegrove, 2018). Rogers (2016) highlighted that stress, burnout, and depression may affect all healthcare workers, including nurses. Although these findings may also be representative of the overall population, nurses, as frontline health promoters, should model healthy behaviours. Their participation in health activities could potentially improve patient outcomes and decrease nursing profession attrition (Dyrbye and Shanafelt, 2012).
In a longitudinal study with nursing students, Evans et al (2021) discovered a reduction in their emotional wellbeing over the 3 years despite the fact that their self-reported health had not changed, with the proportion of students at risk of major depression or psychological distress rising from a quarter to a half. They suggested encouraging physical activity since it may lower the risk of anxiety and depression and increase life satisfaction.
In a study aiming to enhance nursing students' lifestyles, Wills and Kelly (2017) assessed three interventions: an educational session on ‘healthy conversations with patients’, a step-counting accelerometer, and a personal online wellness tracker. Despite low overall engagement, the ‘healthy conversation’ session was most valued by students. Only 21% of those given accelerometers uploaded their data, with the number of days recorded for each participant ranging from 1 to 38 days, averaging 9 days of data recording per user. Of the participants, 32% downloaded the wellness tracker, with 67% of those using the website ‘a few times’, whereas 22% said they had done so only once. Wills and Kelly found that nursing students' health behaviours worsened at the start of placements but then improved and suggested scheduling support programmes for these critical periods, such as induction or placement onset when they were most needed.
In the decade since its first publication, the COM-B model (Michie et al, 2011) has become the dominant model for guiding behaviour change intervention designs across a wide range of applications. In synthesising prior studies on what makes behaviour change effective, it proposes that individuals need the capability to engage in a behaviour (C), the opportunity to do so (O), and have the motivation (M) to perform a behaviour (B). If any of these are lacking, then engagement with the new behaviour will be low. The term ‘capability’ describes whether or not the person possesses the knowledge, skills and abilities necessary to engage in a specific behaviour. The term ‘opportunity’ refers to the external factors that make the execution of a particular behaviour possible. The term ‘motivation’ refers to the internal mechanisms that affect a person's behaviour and decision-making. Austin et al (2022) identified barriers that nursing students felt were preventing them from adopting healthy lifestyles. In accordance with the COM-B model, respondents generally recognised the importance of healthy lifestyles (showing that they had the capability/C), but they felt that they lacked motivation (M) and time (restricting the opportunity/O) to adopt healthy behaviours.
If these barriers are indeed the reasons for students' failure to follow the healthy lifestyles that they recognise are desirable, then an intervention that improves their motivation and helps them fit healthy behaviours into a busy day should tackle both the M and O components, leading to an increased rate of healthy behaviours and an improvement in lifestyle. The authors set out to do this through providing students with access to a brief motivational intervention called Functional Imagery Training (FIT), which has been previously used in wellbeing and lifestyle behaviour change. Solbrig et al (2019) showed that it supported rapid and long-lasting weight-loss in a general population, and it has also been used to enhance the motivation of both novice (Rhodes et al, 2021) and elite athletes (Rhodes et al, 2018; 2020). The goal was to find out if it could be used to enhance the motivation of nursing students to engage with lifestyle-related behaviour change.
The intention was to survey nursing students, inviting those who were overweight or physically inactive to participate in motivational sessions to enhance their lifestyles. However, despite student interest and the provision of webinars and social media support by the authors, engagement in this behaviour intervention was poor. This article examines this lack of participation, exploring reasons by contrasting the minority who engaged with the non-participating majority.
Method
In this study, participants were invited to share personal data, including their weight. To ensure ethical guidelines were strictly followed, the research proposal was reviewed and approved by the Ethics Committee of the Faculty of Health and Human Sciences at the University of Plymouth. Participants were granted the autonomy to omit responses to any questions they preferred not to answer, or to discontinue the survey at any stage, should they choose not to participate further.
Participants and procedure
All 332 first-year nursing students enrolled at the University of Plymouth in October 2021 were emailed an invitation to take part in an online survey, 6 weeks after the start of their course. The survey included questions about height, weight, BMI, physical activity, overall health, motivation and barriers for leading healthy lives (as discussed in Austin et al (2022)). The 26-item WHOQOL-BREF Quality of Life Questionnaire (WHOQOL Group, 1998) was also included, to measure four different aspects of quality of life: physical health, psychological, social relationships, and environmental, scored from 0-100.
Everyone who completed the survey was entered into a prize draw to win one of four £25 Amazon vouchers. A follow-up reminder was sent out 5 days later to 267 who had not completed the survey at that point, and a second reminder 7 days after that to the remaining 233 non-responders. After four weeks, 108 had followed the link and begun the survey, 224 had not. Figure 1 shows a flowchart of engagement with this survey and subsequent stages of the intervention delivery.
Following the survey, the authors identified a subset of respondents who might benefit from an improved lifestyle. These were individuals with a BMI above 22 kg/m2 and engaged in physical activity for only 3 or fewer days a week. These respondents were invited to an online webinar and subsequently to a social media page specifically designed to align with the demands of their academic course.
Results
Online survey
Nine participants left the survey on the page where it asked for their height, weight and BMI. Of the remaining 99 participants (91 females, 8 males; mean age 26 years, SD=8.5 years) BMI was reported by 69, and was also calculated for all 99 from their reported height and weight. Three participants had wildly misreported their BMI, but the other 66 were reasonably accurate, with the largest absolute difference being 2.4 and the mean 0.5 (r=0.99). Calculated BMI (kg/m2) had a mean of 26.8 (SD=6.9), with 2% being underweight (BMI<18.5), 51% in the healthy range (BMI 18.5-24.9), 27% overweight (BMI 25-29.9) and 20% obese (BMI ≥30). Of the respondents, 62% reported being physically active on 2 or more days per week. Although this frequency aligns with the aspect of the UK national guidelines (Department of Health and Social Care et al, 2019; NHS website, 2024) that recommends adults engage in strengthening activities working all major muscle groups on at least 2 days a week, it is essential to note that the guidelines also advise 150 minutes of moderate intensity physical activity per week. The questionnaire focused on the frequency of physical activity without assessing the duration or intensity, so it is unclear if participants fully met the broader physical activity guidelines.
Almost two-thirds (65%) were motivated to lead a healthy lifestyle, and 70% reported a good or very good quality of life on a single self-report item. There was an association between motivation to lead a healthy lifestyle and quality of life, (χ2(4)=12.1, P=0.017), with a good or very good quality of life being reported by 55 (87%) of those who were somewhat or strongly motivated to lead a healthy lifestyle and 15 (71%) of those who were neither motivated or unmotivated reporting good or very good life satisfaction, but only 7 (54%) of those who were somewhat or strongly unmotivated.
On the WHOQOL scale, the mean of the four domains was 61.1 (SD=15.5) indicating a good overall perception of the particpants' position in life, although the psychological domain was rated lower than the other three (mean=49.4, SD=20.7). Although all four QoL domains inter-correlated, there was no correlation between BMI and any of the domains.
The most frequently affirmed barriers to leading a healthy lifestyle were ‘I am too tired’ (57%), ‘I have no motivation’ (53%), ‘I need to rest and relax in my spare time’ (41.5%), ‘I don't have time to be physically active’ (37.5%), ‘I can't be bothered’(29%), and ‘There is no one to be physically active with’ (25%). All other barriers were affirmed by fewer than 25% of the students.
At the end of the survey, students had a choice to opt-in to take part in a behaviour change intervention designed to improve their current lifestyles, with a guaranteed reward of £10. Of the 99 who had provided weight and height information in the survey, 12 did not reach or did not answer this question, 79 opted-in to further contact, and 8 declined.
Webinars
Of those who opted-in to further contact, 55 met the set criteria for potentially benefitting from a health-related intervention and were invited to a 45-minute online session, conducted via Zoom (see Table 1). The authors offered three webinars over 1 week, two on weekday evenings and one at the weekend to try to avoid clashing with personal or academic commitments. The webinar included guidance on setting personal goals, boosting motivation using imagery exercises based on FIT, and advice about mobile applications that could help a change in lifestyle.
Table 1. Exercise frequency by BMI of the 79 participants consenting to further contact
| ≤ 3 days exercise a week | > 3 days exercise a week | |
|---|---|---|
| BMI >25 | 29* | 4* |
| BMI 22–25 | 22* | 5 |
| BMI < 22 | 14† | 5 |
those only invited to the final webinar; the remaining 10 were only invited to the social media campaign
Five students attended the first evening webinar. A reminder email was sent out to everyone else a day before the second evening webinar, and four more students attended. The third webinar was scheduled for Saturday afternoon, and six individuals accepted the Zoom invitation, but nobody joined, so only 9 of the 55 (16.3%) who had been invited attended. The authors then invited the remaining 46 and the 14 with a BMI below 25 but 3 or fewer physically active days a week to an additional online evening session the following week. Four participated, for a final total of 13, representing 19% of the 69 who had been invited.
Two emails were received from two participants after the webinar:
‘I found your session on goal setting very eye opening and interesting, thank you so much!’
‘Thank you for the webinar yesterday, it was very insightful and I will bear in mind to continue developing and changing my personal goals to allow me to continue with them as times get busier on placement.’
Social media campaign
Following the low engagement with the online webinars, a closed Facebook Community page was created to further motivate nursing students to lead healthier lives. This page provided all the resources indicated by nursing students in Austin et al (2022) as being helpful in leading a healthier lifestyle, including food shopping lists, quick and easy exercises, podcasts, meditation, and motivational advice.
Personal invitations with a Facebook group link were emailed to all 79 participants. Initially, only four joined. Three weeks later, after direct messaging 35 participants identified through a Facebook search, three more joined. A reminder email offering a £10 Amazon voucher to joiners prompted six more to join, bringing the total to 13 (16.4% of initial contacts). Of these, six had previously attended the webinars, with three revisiting the pre-recorded webinar and three new viewers. In total, the authors were able to reach 20 students, representing 25% of the 79 who had been invited to the behavioural interventions.
Comparison of engagers and non-engagers
Of the 79 consenting students, the 59 who did not engage with the intervention did not differ in BMI to the 20 who engaged with the webinars or social media (t (34.21)=0.95, P=0.35, d=0.24); nor in motivation to live a healthy lifestyle (t (34.57)=0.08, P=0.94, d=0.02), single item quality of life t (33.58)=0.41, P=0.68, d=0.11); or the scaled WHOQOL total (t(35.04)=0.78, P=0.44, d=0.20). Chi-square tests found no significant association between engagement and 20 possible barriers to live a healthy lifestyle.
Once the study was completed the 20 students who had engaged received an email asking if they made any changes to their lifestyle as a result of taking part in this study. Two responses were received:
‘I have gone on to make some lifestyle changes … although definitely still a work in progress’
‘Thank you so much for letting me be a part of your study it was very insightful. It made me think about my lifestyle choices. Since being part of the study, I have made sure I walk more and am aiming to walk 10,000 steps a day but also making sure my goals in fitness are reasonable and giving myself time to rest and take breaks.’
Discussion
The online survey's findings confirm earlier studies' findings of a high prevalence of overweight or obese people and low levels of physical activity within the nursing student population (Malik et al, 2011; Blake et al, 2021), in line with the general population: the incompatibility of this with the need to provide good ‘health role models’ for patients is not a result of the stresses and demands of nursing per se, but is typical of the general population and apparent from recruitment onwards.
The authors also found that students generally said that they were motivated to lead a healthy lifestyle, reported a good quality of life and indicated a good overall perception of their position in life. The most reported barriers to leading a healthy lifestyle were consistent with previous research: student nurses felt too tired, lacked motivation, and had no time to make any beneficial changes in their lives. Despite this, when offered support to improve their lifestyle, few took up the opportunity, and it is difficult to identify any reasons why the majority did not engage with the support.
The authors followed the findings of their earlier research (Austin et al, 2022) and designed the intervention that previous cohorts of nursing students indicated they would implement. Despite applying the COM-B model (Michie et al, 2011) and providing nursing students with repeated opportunities to progress towards their goals, the evaluation presented here underscores a notable deficiency in the intervention's effectiveness. This incongruence implies that certain critical elements or mechanisms, possibly external to the model, were insufficiently considered or addressed in the methodology, thus inhibiting the attainment of anticipated outcomes.
According to the COM-B model, three components interact to affect behaviour: capability (physical and psychological), opportunity (physical and social), and motivation (reflective and automatic). In this study, all three criteria were met, and yet three out of four students did not engage in the behavioural interventions. The authors designed interventions that students had claimed to want to use, and that they would be capable of taking part in, by making the interactive session an online webinar, scheduled at a range of times that did not conflict with teaching, and backing it up with an asynchronous social media campaign, with a page linking to a range of resources and recordings of the webinar.
Students did not lack the capability or opportunity to engage in these interventions, and did not report lacking motivation to improve their lifestyle. The results from the survey question ‘How motivated are you to live a healthy lifestyle?’ showed that the majority of participants (64%) said they were strongly motivated or somewhat motivated to lead a healthy lifestyle. However, in a later question, lack of motivation was cited as the second biggest barrier (53%).
An email that emphasised receiving money to join the social media campaign had the best response, suggesting extrinsic motivation, which would most likely not lead to the desired outcome. According to Deci and Ryan's (1985) self-determination theory, extrinsic incentives, such as financial rewards, are contrasted with intrinsic motivation, which involves engaging in a behaviour because it is inherently satisfying and not due to external rewards or pressures. Furthermore, it seems that the intrinsic motivation to engage in physical activity was overshadowed by a more immediate desire for rest and relaxation in their free time. The students expressed a notable preference for unwinding and resting, often prioritising it over embracing a more proactive and health-oriented lifestyle.
Engagement was not related to BMI, motivation for a healthy lifestyle, quality of life, or any of the 20 potential barriers. One component that might have been missing in this intervention was a lack of social support. Focus group discussions revealed that nursing students felt a pronounced lack of companionship for engaging in physical activities (Austin, 2023). These discussions not only reinforced the students' need for companionship during physical activities but also highlighted their desire for discounted or free gym access at the university or hospital during placements.
These ‘opportunity’ obstacles may be overcome by offering free fitness courses that encourage students to go with a group of friends, making physical activity seem more beneficial and enjoyable. Despite these strategic modifications, a significant portion (one-third) of the participants persistently identified a lack of time as a barrier to behaviour change. This observation aligns with prior research outcomes, such as those documented by Thwaite et al (2020) and Blake et al (2017), reinforcing the notion that perceived time constraints remain a significant obstacle in the pathway to facilitating effective behavioural changes within this demographic.
Despite the research summarised in the introduction, and efforts to design interventions to encourage student nurses to adopt healthier lifestyles, there has been little improvement. This study indicates that offering optional support that students must choose to engage with will not succeed, given the students' belief that being healthy takes too much time and effort. Although the COM-B model identifies motivation as a prerequisite for behaviour change, it does not seem possible to improve engagement in behaviour change programmes by offering them sessions to enhance their motivation. The authors agree with Wills and Kelly (2017) that the only way to improve student nurses' lifestyles is to remove the optionality, and to integrate lifestyle awareness and self-care into the curriculum.
KEY POINTS
- Nursing students need to be healthier than the general population to act as role models for patients with unhealthy lifestyles
- Current models of behaviour change suggest that if people have the capability, opportunity and motivation to change their behaviour, then they will be more likely to do so
- The authors designed a healthy lifestyle intervention to meet these criteria, but only 25% of students engaged with it
- Lifestyle interventions need to be integrated into the nursing curriculum
CPD reflective questions
- Why do nurses need to be ‘role models’ in leading a healthy lifestyle?
- If you are involved in nurse training, how would you integrate healthy lifestyle interventions into your curriculum?
- Do you feel that nursing as a profession predisposes practitioners to adopt an unhealthy lifestyle?
- What barriers prevent nursing students from adopting a healthier lifestyle, and how can they be overcome?