Helping students to self-care and enhance their health-promotion skills

Nurses have a public health role, requiring them to promote the health of individuals and communities and to engage at a political and policy level to improve population health. There is also a professional expectation that nurses will model healthy behaviours and take responsibility for their personal health and wellbeing. However, studies have indicated that undergraduate nurses find the academic and practice elements of their nursing programmes stressful. To manage their stress many use coping behaviours that negatively impact on their health and wellbeing and may influence their ability and willingness to effectively support health promotion in practice. It is widely recognised that environments influence health outcomes and personal health behaviours. This article addresses some of the structural causes of student nurse stress and highlights a recent educational initiative at a UK university that aims to equip student nurses with the practical skills required to engage in health promotion and thereby provide benefits for service users and student nurses alike. Public Health England’s (PHE) Nursing and Midwifery Contribution to Public Health guidance document (2013) identifies the public health role required of every registered nurse. It calls upon practitioners to address health at an individual, community and population level, helping and supporting people to maximise their wellbeing. In addition, the Nursing and Midwifery Council (NMC) (2018a: 8) requires nurses to take ‘professional responsibility to adopt a healthy lifestyle’ and within the new Standards Framework for Nursing and Midwifery Education (2018b) the NMC details the significant involvement and skills nurses must demonstrate in promoting health to people, families, communities and populations. In order to act as healthy role models and be seen as credible figures within health promotion, nurses must value themselves enough to practise self-care and demonstrate healthy behaviours. This involves nurses taking personal responsibility for their own health and embracing a healthy lifestyle (Royal College of Nursing (RCN), 2018). However, it is well documented that many registered and undergraduate nurses practise health behaviours that contribute to poor personal health (Ross et al, 2017) and may further increase their reluctance to initiate discussions on health and wellbeing (Kyle et al, 2016; Blake and Patterson, 2015) while others adopt an information-giving approach to clients, failing to recognise the complexity of behaviour change (Whitehead, 2006). It is well known that health and health behaviours are shaped and influenced by a range of social determinants (Marmot et al, 2010), which encompass the settings in which ‘people are born, live, work and age’ (Commission on Social Determinants of Health (CSDH), 2008:2; Wilkinson and Marmot, 2003). It therefore follows that to encourage and support healthy lifestyles requires a multifaceted approach for everyone—nurses included. Carlson and Warne’s (2007) review of the literature on the barriers and enablers of healthier nursing practice recognises the importance of two instrumental factors for health: the nurses’ working environment and their educational experience of health-promoting practice. This article centres on student nurses. It identifies some of the environmental and organisational influences on their health and discusses how a number of educational initiatives, including the embedding of PHE’s initiative ‘Making Every Contact Count’ (MECC) (PHE et al, 2016) within the undergraduate nursing programme, may improve the practice of promoting health and provide an opportunity for nurses to reflect upon and manage their own health.

In order to act as healthy role models and be seen as credible figures within health promotion, nurses must value themselves enough to practise self-care and demonstrate healthy behaviours. This involves nurses taking personal responsibility for their own health and embracing a healthy lifestyle (Royal College of Nursing (RCN), 2018). However, it is well documented that many registered and undergraduate nurses practise health behaviours that contribute to poor personal health (Ross et al, 2017) and may further increase their reluctance to initiate discussions on health and wellbeing (Kyle et al, 2016;Blake and Patterson, 2015) while others adopt an information-giving approach to clients, failing to recognise the complexity of behaviour change (Whitehead, 2006).
It is well known that health and health behaviours are shaped and influenced by a range of social determinants (Marmot et al, 2010), which encompass the settings in which 'people are born, live, work and age' (Commission on Social Determinants of Health (CSDH), 2008:2; Wilkinson and Marmot, 2003). It therefore follows that to encourage and support healthy lifestyles requires a multifaceted approach for everyone-nurses included. Carlson and Warne's (2007) review of the literature on the barriers and enablers of healthier nursing practice recognises the importance of two instrumental factors for health: the nurses' working environment and their educational experience of health-promoting practice. This article centres on student nurses. It identifies some of the environmental and organisational influences on their health and discusses how a number of educational initiatives, including the embedding of PHE's initiative 'Making Every Contact Count' (MECC) (PHE et al, 2016) within the undergraduate nursing programme, may improve the practice of promoting health and provide an opportunity for nurses to reflect upon and manage their own health.

Background
Undertaking a higher education nursing degree provides great opportunities but also numerous challenges. All students, in all age groups, negotiate a variety of personal adventures as they grapple with their new academic landscape, its terminology, requirements and schedules. However, in addition to the academic work, nursing students are required to undertake extensive hours in clinical placement learning, practising and being assessed on their evidence-based practical nursing skills. It is well documented that nursing students find their nurse education stressful; clinical placements are frequently mentally challenging and physically demanding (Moridi et al, 2014), while the extensive academic workload is also a major stressor (Evans and Kelly, 2004). Work by Chernomas and Shapiro (2013) identified that nursing students experience higher levels of anxiety, stress and depression than people of similar ages undertaking other university programmes or in work. Furthermore, Edwards et al (2010) reported that stress levels peak at the beginning of the third year, when they are considerably higher than at any other stage of the programme.
Nursing students experience a range of NMC-stipulated clinical placements within their degree and, although they are supernumerary to the NHS workforce, students are expected to work their weekly 37.5 hours and receive supervision according to their learning requirements and stage of learning (NMC 2018c: 6). Many clinical settings providing 24-hour care require staff to work shifts-early, late or night-which can be 12 hours in duration. Learning to adapt to shift work takes time; however, there are immediate physiological impacts on eating and sleeping patterns. In the longer term shift work has been linked to sleep disturbance, feelings of fatigue, increased anxiety, depression and chronic conditions (Harrington, 2001). The programme challenges will differ, depending on the age group of the student. Younger students will be assuming adult responsibilities and adjusting to new environments devoid of home comforts, while older students often face a continuous balancing act with family commitments (Middleton, 2018).

Organisational influences on health
As the causes of ill health become more clearly understood there is recognition that many structural factors, including the working environment, influence lifestyle choices and contribute to consequent health outcomes (Marmot et al, 2010). For registered and student nurses, the practice setting is often a busy and demanding place. This is evident from a recent survey (Jones-Berry, 2018) of almost 2000 registered nurses, which reported that 75% of respondents admitted to never having time for a break while on shift and 59% stating they go through a whole shift without being able to drink water. This raises a health concern not just for the registered nurses themselves, but also for student nurses, who are influenced by their registered colleagues. It normalises unhealthy self-care and demonstrates how disempowered nurses are in changing and managing some clinical settings. It also calls into question the organisation's interest and responsibility for the health and wellbeing of its employees.
The RCN (2018) report on nurse staffing in the NHS also highlights many concerns around unsafe and inadequate staffing and its impact on the health and wellbeing of nursing staff. Staff shortages are a major negative structural and environmental obstacle to health, which is beyond the control of the nurse employee. It is important to note that experiences of anxiety, stress and exhaustion in clinical practice are not exclusively felt by undergraduate nurses; newly graduated nurses report feeling overwhelmed by the pressures in the workplace and poorly supported by their employers, causing many to leave or consider leaving the profession in order to safeguard their own health and wellbeing (RCN, 2018).
Further evidence of organisational structural obstacles to health is demonstrated in the RCNi online survey of nurses, with 57% of the 2000 responders highlighting the lack of provision for healthy, nutritious food in their place of work (Jones-Berry, 2018). This barrier to health clearly has an impact on all who access the facilities in the health setting, but may actually be felt more acutely by the student nurse, who often has to travel long distances merely to access the required placements. In addition to the hours of work in the shift, many students have little time, energy and limited funds to shop and prepare nutritious food to take on shift or eat at the end of the shift, thereby encouraging students to access cheap fast food outlets that often specialise in unhealthy food. PHE (2013) identified the importance of the workplace for workers' health and encouraged employers to support employees' health and wellbeing in the workplace. The NHS Future Forum has also acknowledged the importance of workplace health and recognised its responsibility to first address its own organisational public health shortcomings while simultaneously encouraging the public to lead healthier lives (Bailey et al, 2012). Consequently, a variety of Commissioning for Quality and Innovation (CQUIN) targets have been implemented in an attempt to improve the health and wellbeing of the workforce and advance the public health skills of everyone working within the service. This appears to be a determined move towards the adoption of the World Health Organization (WHO) Ottawa Charter recommendation of refocusing the NHS and its resources towards a preventive and health-promoting service rather than one concentrated on acute and chronic sickness (WHO, 1986). The provision of healthy food and drink to a workforce of 1.3 million and numerous visitors offers opportunities to actively promote the health of a large percentage of the UK population (Cost Sector Catering, 2016). However, the policy appears to be taking time to implement as many hospitals seem to be struggling to meet the WHO's Standards for Health Promotion in Hospitals (2004) by decreasing the sale of unhealthy food and drinks within their settings (National Institute for Health and Care Excellence (NICE), 2016).
The promotion of health and wellbeing is a holistic concept in which empowerment and empowered relationships are seen to be core features (Carlson and Warne, 2007). The WHO (1998) defines the process of empowerment as a way for people to achieve control over the decisions and actions that influence their lives. However, there is recognition that the development of empowerment is prevented in bureaucratic settings where there is a lack of shared understanding and belief in the process. Laverack (2016) argued that hospitals are frequently bureaucratic, with hidden rigid power structures and authoritarian styles of leadership, hindering discussion, trust development and shared solutions. In contrast, empowered nurses seek to improve the culture and atmosphere of the working environment, embodying moral principles of respect for others to guide their behaviour in their working and personal lives. They encourage discussion, sharing of ideas, co-operation and innovation. Consequently, empowered nurses are more likely to value not only the health of others but also their own personal health and wellbeing, which may ultimately involve removing themselves from harmful workplaces (Kuokkanen and Leino-Kilpi, 2001). This action, although beneficial for the individual, may contribute to further staff, expertise and healthy role-modelling shortages within the workplace. PHE et al (2016) requires all health practitioners to work to reduce health inequalities and improve individual lifestyles. While there is considerable research supporting the findings that nurses understand the philosophy and principles of health promotion, nursing practice is largely limited to various forms of health education (Casey, 2007;Whitehead et al, 2008;Kemppainen et al, 2013;Shoqirat, 2014), which is recognised as insufficient to facilitate change (Kasila et al, 2018). It may be that many factors have contributed to this situation, including the healthcare culture, demanding clinical workload, nurses' own health behaviours and the lack of prominence of public health within nurse education.

Personal skills for public health
It was against this backdrop that nursing academics at a university on the south coast of the UK decided to invest in the brief intervention MECC (PHE et al, 2016) as a way of enhancing students' personal health-promotion communication skill set.
Although the second-year undergraduate health promotion unit addresses the theoretical skills and competencies nurses require to promote holistic health, student feedback illustrated that students have limited opportunities to witness registered nurses role modelling health-promotion skills in practice (Turner-Wilson et al, 2017). To overcome this deficiency the teaching team had extended numerous invitations to practitioners over many years, asking them to showcase their healthpromotion roles. Unfortunately, few practitioners accepted the invitation. In order to address this omission, all members of the promoting health teaching team undertook the MECC trainer's course and worked to embed the training programme into the second-year academic unit.
MECC (PHE et al, 2016) provides health practitioners with the skills and training to find opportunities to easily initiate conversations about health during every client contact. Within these conversations people are supported to identify their own health concerns and develop their own action plans. To work effectively within MECC, practitioners need the confidence, skills and motivation to provide opportunistic support, which empowers non-judgmental behaviour change. MECC also provides the opportunity for undergraduate nurses to reflect upon their own health behaviours and create their own personal action plans to address any identified health concerns.
MECC was initially delivered to 350 students in 2017 and a further 350 a year later, with both teaching and content evaluated positively by students at the end of the unit. Academics are currently investigating the value of the initiative for students' practice and their own health outcomes at various points following unit completion. Early indications from practice are favourable, but indicate that student nurses may require additional refresher sessions to continue to utilise the principles of the MECC programme. Although accessing brief interventions is a CQUIN activity for trusts, currently few students report witnessing the use of MECC by registered nurses.

Opportunities for health
As the new education standards come into force (NMC, 2018b) many institutions will revalidate their nursing programmes, thereby generating numerous opportunities for nurse academics to address health promotion, both within and alongside the curriculum. Initiatives to actively promote student health should be considered, such as walking seminars (held outside, to promote physical activity, critical thinking and problem solving group discussions) and stress-management workshops. Teaching and learning strategies must ensure students have the skills to move beyond a a health education style of information delivery to a more person-centred communication approach, which seeks to support service users to help them increase control over, and improve their health. In addition, nurse educators have an obligation to act as healthy role models to student nurses and lobby for universities to become health-enhancing settings, both in their policies and the environment.
Additionally, current workplace challenges provide nurses with opportunities to move beyond a health education view of health promotion, recognising the workplace as a health influencing factor and working towards this key Public Health England (2013) action area. As a way of improving their own health, safeguarding the health of student nurses and the client/patient; registered nurses and nurse leaders must lobby and work towards the creation of sustainable healthy workplaces that benefit both service users and staff.

Conclusion
Undergraduate nurse are the registered nurses of tomorrow and consequently they require nurturing and support as they navigate their nurse education, which many find stressful. Current registered nurses in practice and education unwittingly provide role modelling opportunities for undergraduate nurses. However, to be valuable and credible role models they have an obligation to incorporate evidence-based public health strategies into their everyday practice and must address personal health behaviours that contribute to poor health outcomes. In addition, nurse leaders have a responsibility to highlight the structural causes of ill health in the workplace and work with organisational partners to move beyond paying lip service to the tenets of health and wellbeing, ensuring the development of health-promoting workplace settings that improve health and minimise injury and illness for service users and staff alike.
Incorporating MECC into nurse education may improve the health outcomes and health promotion communication skills of undergraduate nurses; however, it is not possible for them to change the skills and ethos of organisations on their own. Although it is anticipated that students will be agents of change, they will require the support and encouragement of their registered nurse colleagues, nurse leaders and wider healthcare organisations to bring about sustained change. Ultimately it is hoped that the benefits of adopting a positive, preventive, proactive approach to health and wellbeing will be available to all, service users and staff alike.