Should nurses be expected to act as role models of a healthy lifestyle? A study found that opinions on the matter differ widely among participants talking from different viewpoints
Should nurses be expected to be role models for healthy lifestyles? Although this expectation is often expressed in policy documents and professional journals, there is little research on whether it is reasonable and realistic. This article discusses the related arguments and reports on a study on the issue conducted with six stakeholder groups, which found there is no agreement on whether nurses should be expected to be healthy role models, and that a more considered approach to improving nurses’ lifestyles is needed.
Citation: Kelly M (2017) Should nurses be expected to role model healthy lifestyles to patients? Nursing Times [online]; 113: 10, 46-48.
Author: Muireann Kelly is a PhD student at the School of Health and Social Care, London South Bank University.
Whether they like it or not, nurses are often expected to be public role models for healthy lifestyles. This expectation is frequently highlighted in nursing policy and discussed in professional publications, but what does it mean? How should frontline nurses meet this expectation in everyday practice? There has been little research on the topic; it is mainly covered in opinion pieces, commentaries or readers’ panels (Shepherd, 2017; Peate, 2015; Carryer, 2012; Naish, 2012). A group of researchers decided to investigate the views of different stakeholder groups on the subject.
What the policy says
In the UK, the Nursing and Midwifery Council includes role modelling as a statutory requirement in its competence standards, stating that all nurses must “take every opportunity to encourage health-promoting behaviour through education, role modelling and effective communication” (NMC, 2014). Guidance, such as the “Leading Change, Adding Value framework for nursing, midwifery and care staff” (Cummings, 2016), calls on nurses to take responsibility for their own health to practise safely and effectively, and maximise their positive impact on population health. As part of an international effort to combat chronic disease, the International Council of Nurses has stated that nurses should eat healthily and exercise appropriately (2010).
The arguments for and against
Three arguments are often proposed for the expectation that nurses should be healthy role models. First, nurses should have healthy lifestyles that can be seen as credible by patients when engaging in health promotion and behaviour-changing initiatives such as “making every contact count” (NHS Yorkshire and the Humber, 2010).
As the largest workforce in healthcare, they are well-placed to advise patients on lifestyle; however, if they are unhealthy themselves, nurses might avoid raising lifestyle issues for fear of being seen as hypocrites, and patients might ignore advice given by visibly unhealthy nurses (Speroni et al, 2012; Hicks et al, 2008). This is particularly important given the high global prevalence of personal unhealthy behaviours reported by nurses (Lobelo and de Quevedo, 2016; Smith and Leggat, 2007).
The second argument is that nurses should have healthy lifestyles to be efficient, resilient and able to cope with the demands of their jobs (Kushner and Ruffin, 2015). This is important to reduce sickness absence and improve retention in an ageing workforce, at a time when nursing faces a recruitment crisis (Royal College of Nursing, 2015).
The third argument is that having a healthy lifestyle is a professional expectation. Given their professional knowledge and health literacy, nurses should “know better” than to live unhealthily. Nurses have an ethical duty to practise what they preach because this is socially expected of them as a professional group (While, 2014).
The expectation for nurses to be healthy role models has also been criticised. Shift work, stress, workloads and the emotional labour of nursing can make it particularly difficult for nurses to make healthy lifestyle choices (Buchvold et al, 2015; Nahm et al, 2012). In addition, some patients may find it easier to relate to someone who also struggles with lifestyle issues and understands the difficulty of changing behaviour (Aranda and McGreevy, 2014).
The aim of this study was to investigate the views of different stakeholders on the expectation that nurses should role model healthy behaviours. As there are contradicting views on the subject, it was important to consider a range of opinions, so the study was designed as a Policy Delphi study. While Delphi studies focus on understanding shared views and aim to reach agreement, Policy Delphi studies explore areas of agreement and disagreement in opinion (Meskell et al, 2014) and are considered appropriate for complex health policy issues, where there are often no right or wrong answer (Rayens and Hahn, 2000).
Two rounds of the Policy Delphi process were conducted. The first used open-ended telephone interviews to explore stakeholders’ opinions; interview questions were developed from a review of the literature. Themes emerging from the first round informed the design of the second, which used an online survey to examine commonalities and differences of opinion within and between stakeholder groups. More detail on the study design can be found in Kelly et al (2017a).
Unlike traditional Delphi studies, which recruit experts in a particular field, Policy Delphi studies recruit participants because of their professional or educational background and/or also because they are people who contend with the end products of policy and have opinions (Meskell et al, 2014; Landeta, 2006).
We used purposive sampling to recruit people from different backgrounds who have a stake in and influence the role of nurses (Table 1); 25 participants took part in the first round and 17 in the second (eight were lost to attrition).
There was no shared view of the expectation for nurses to be healthy role models, either within or between stakeholder groups. Practising nurses and student nurses did not perceive being a healthy role model as part of their professional duties. Student nurses in particular felt that nursing was “just a job” and that leading a healthy lifestyle was a personal matter.
Some stakeholders from all groups saw the image of a perfectly healthy nurse role model as unrealistic and unhelpful. Behaviour change was considered to be more complex than the assumption that, if nurses displayed healthy lifestyles, patients would be motivated to follow suit. Some felt that the ideal role model was a nurse who had struggled with unhealthy behaviours but eventually made a successful change – for example, an ex-smoker. Practising and student nurses felt that having good know-ledge and skills to communicate with patients and advise them on adopting healthier behaviours was more important than having a healthy lifestyle.
The patients viewed unhealthy nurses negatively, questioning the credibility and competence of those who were visibly unhealthy. Although they appeared to conflate health with a healthy appearance, they did expect nurses to “practise what they preach” and were in favour of a stricter monitoring of nurses’ lifestyles (for example, using explicit behavioural requirements at pre-registration selection and regular physical fitness appraisals post-registration).
The practising and student nurses strongly expressed that they could not be expected to be healthy role models because the environments they work or train in do not support healthy lifestyles.
Practising nurses said they wanted employers to prioritise nurses’ health by encouraging and supporting lifestyle changes and addressing job-related pressures. However, some participants from the service users and education groups felt that nurses needed to take more personal responsibility for their health-related behaviours.
Stakeholders from all groups felt that greater support for healthy lifestyles at work and healthier workplace norms would help nurses lead healthier lives.
This study examined how the expectation for nurses to be healthy role models was understood by stakeholders from different backgrounds. Participants reported different understandings and there was disagreement as to whether nurses should be expected to be healthy role models. This lack of agreement suggests that the expectation of the nurse as a healthy role model is unlikely to be implemented in practice.
Apart from those in the service users group, stakeholders felt it was unrealistic to expect nurses to be perfectly healthy role models. Practising and student nurses reported that leading a healthy lifestyle was a matter of individual choice rather than professional duty. If nurses do not feel they have a professional duty to be healthy role models, removing workplace and/or organisational barriers to adopting healthy lifestyles may be more productive than attempting to change how nurses view expectations of them.
The frontline nurses in the study perceived their workplaces as unhealthy and thought employers should do more to help nurses have healthy lifestyles. NHS employers and organisations are being encouraged by a Commissioning for Quality and Innovation (CQUIN) payment to support staff’s health (NHS England, 2016) by helping staff to lead healthy lives, and tackling organisational barriers that make it difficult for nurses to achieve this. Nurses work in many different services and settings, yet most interventions aimed improving their lifestyles are aimed at those in hospitals. Initiatives targeting nurses should be accessible to all parts of the workforce.
One argument in favour of nurses being healthy role models is that it enables them to be seen as credible communicators of public health messages. Service users in this study reported that they would be less willing to follow advice from visibly unhealthy nurses and would question their competence. Although nurses’ professional behaviours – such as providing compassionate, evidence-based care – may define the patient experience, it may also be influenced by whether nurses are visibly healthy (Hicks et al, 2008).
A recent systematic review (Kelly et al, 2017b) found few studies of patients’ views on health professionals’ lifestyles and health promotion practice. Further research is needed to better understand patients’ perspectives on nurses’ health promotion practice.
Although the expectation for nurses to be healthy role models is often discussed in policy and professional literature, until this study there had been no research on how this expectation is understood by, and whether it is shared between, stakeholders in nursing. The study has shown there is no agreement on what a healthy nurse role model should look like, but that is not to say that nurses’ lifestyles are not important.
Rather than a sweeping call for nurses to be healthy role models, a more considered approach to discussing and improving nurses’ lifestyles is needed, which recognises the challenges nurses may face. Nurses are the largest workforce in the NHS, so any attempt to improve their lifestyles would improve the population’s health.
- The expectation that nurses should be healthy role models has not been explored in research
- Some think that nurses should adopt healthy lifestyles to be credible when engaging in health promotion, and able to practise safely and efficiently
- Some patients question the competence of a visibly unhealthy nurse, but others find it easier to relate to someone who also struggles with behaviour change
- There is no consensus on whether nurses should be healthy role models
- Employers need to remove workplace barriers that make it difficult for nurses to adopt healthy lifestyles
Aranda K, McGreevy D (2014) Embodied empathy-in-action: overweight nurses’ experiences of their interactions with overweight patients. Nursing Inquiry; 21: 1, 30–38.
Buchvold HV et al (2015) Associations between night work and BMI, alcohol, smoking, caffeine and exercise - a cross-sectional study. BMC Public Health; 15: 1112.
Carryer J (2012) Love the body you’re in. Nursing Review; 9 March.
Cummings J (2016) Leading Change, Adding Value: A Framework for Nursing, Midwifery, and Care Staff. London: NHS England.
Hicks M et al (2008) Nurses’ body size and public confidence in ability to provide health education. Journal of Nursing Scholarship; 40: 4, 349-354.
International Council of Nurses (2010) Delivering Quality, Serving Communitites: Nurses Leading Chronic Care. Geneva: ICN.
Kelly M et al (2017a) Should nurses be role models for healthy lifestyles? Results from a modified Delphi study. Journal of Advanced Nursing; 73: 3, 665-678.
Kelly M et al (2017b) Do healthcare professionals’ own health behaviours impact on patient outcomes? A systematic review. International Journal of Nursing Studies; Epublication ahead of print. DOI
Kushner J, Ruffin T (2015) Empowering a healthy practice environment. Nursing Clinics of North America; 50: 1, 167-183.
Landeta J (2006) Current validity of the Delphi method in social sciences. Technological Forecasting and Social Change; 73: 5, 467-482.
Lobelo F, de Quevedo IG (2016) The evidence in support of physicians and health care providers as physical activity role models. American Journal of Lifestyle Medicine; 10: 1, 36-52.
Meskell P et al (2014) Insights into the use and complexities of the Policy Delphi technique. Nurse Researcher; 21: 3, 32-39.
Nahm ES et al (2012) Nurses’ self-care behaviors related to weight and stress. Nursing Outlook; 60: 5, e23-31.
Naish J (2012) Tackling a weighty issue. Nursing Standard; 26: 23, 20-21.
NHS England (2016) NHS Staff Health & Wellbeing: CQUIN Supplementary Guidance.
NHS Yorkshire and the Humber (2010) Prevention and Lifestyle Behaviour Change - A Competence Framework.
Nursing and Midwifery Council (2014) Standards for Competence for Registered Nurses.
Peate I (2015) Health and wellbeing: giving weight to the argument. British Journal of Nursing; 24: 2, 73.
Rayens MK, Hahn EJ (2000) Building consensus using the Policy Delphi method. Policy, Politics, and Nursing Practice; 1: 4, 308-315.
Royal College of Nursing (2015) A Workforce in Crisis? The UK Nursing Labour Market Review 2015. London: RCN.
Shepherd E (2017) Patients matter most but staff matter too. Nursing Times; Editor’s comment, 10 January 2017.
Smith DR, Leggat PA (2007) An international review of tobacco smoking research in the nursing profession, 1976-2006. Journal of Research in Nursing; 12: 2, 165-181.
Speroni KG et al (2012) Effect of Nurses Living FitTM exercise and nutrition intervention on body mass index in nurses. Journal of Nursing Administration; 42: 4, 231-238.
While AE (2014) Are nurses fit for their public health role? International Journal of Nursing Studies; 51: 9, 1191-1194.