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Nurs Outlook 63 (2015) 245e254

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An eHealth education intervention to promote healthy lifestyles among nurses Yueh-Chi Tsai, MD, PhDa,b, Chieh-Hsing Liu, PhDb,* a

b

Department of Family Medicine, MacKay Memorial Hospital, Taipei, Taiwan, ROC Department of Health Promotion and Health Education, National Taiwan Normal University, Taipei City, Taiwan, ROC

article info

abstract

Article history: Received 15 May 2014 Revised 23 October 2014 Accepted 13 November 2014 Available online 18 November 2014

Background: Nurses often do not adhere to health-promoting lifestyles, compro-

Keywords: eHealth Internet Nurse education Social support

mising their health status and quality of care. This study aimed to evaluate health-promoting effects of an eHealth intervention among nurses compared with conventional handbook learning. Methods: This controlled before/after study enrolled 105 nurses, 55 in an experimental group and 60 in a control group, for 3 months of intervention. Both groups completed pre- and postintervention questionnaires of the Health-Promoting Lifestyle Profile and Short-Form Health Survey. Subjects’ height, weight, and body mass index were recorded. Discussion: The eHealth education intervention had the effect of significantly increasing nurses’ postintervention Health-Promoting Lifestyle Profile total scores. No significant changes were observed in the postintervention scores of the control group subjects. The experimental group also had significant postintervention decreases in BMI, but no similar changes were observed in the control group. Conclusions: Tailored eHealth education is an effective and accessible intervention for enhancing health-promoting behavior among nurses. Cite this article: Tsai, Y.-C., & Liu, C.-H. (2015, JUNE). An eHealth education intervention to promote healthy lifestyles among nurses. Nursing Outlook, 63(3), 245-254. http://dx.doi.org/10.1016/ j.outlook.2014.11.005.

Introduction Health care practitioners commonly fail to adhere to health-promoting lifestyles. Nurses’ scores on the “health responsibility” and “physical activity” categories of the Health-Promoting Lifestyle Profile (HPLP) were markedly lower than other categories, indicating greater disability in these areas (Tsai & Liu, 2012). These poor health-promoting lifestyles among nursing staff are associated with anxiety, gastrointestinal upset, headache, and insomnia (Tsai & Liu, 2012). Nurses’ heavy workloads and lack of work-life balance

are also associated. A survey of over 2,000 nurses in 11 countries showed that 92% reported facing time constraints, and they acknowledged that heavy workloads had an impact on the time spent with patients and overall quality of care (DeCola & Riggins, 2010). How, then, are nurses to focus on improving their own health? Various hospitals have organized health promotion policies and activities for professional staff, including programs for mental health, weight control, health promotion through exercise, and tobacco hazard control (A Health Promotion Project for Workers at National Taiwan University Hospital, 2013). In providing these programs, organizers

* Corresponding author: Chieh-Hsing Liu, 162 HePing East Road, Section 1, Taipei, Taiwan (106) ROC. E-mail address: [email protected] (C.-H. Liu). 0029-6554/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.outlook.2014.11.005

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encounter difficulties such as a lack of man power, lack of funding, staff members too busy to attend, and lack of relevant sports or catering facilities. However, that study also indicated that although hospital staff generally understand the intention of organized health-promoting activities, the participation rate still remains low (Lin, 2007). Nursing careers are characterized by huge workloads, long working hours, high work-related stress, and physical and mental exhaustion characterized as “burnout” (Aiken et al., 2011). Our previous study revealed that the extent of job-related stress among nurses is especially severe in Taiwan, and stress-related symptoms are associated with poor quality of health-promoting lifestyle behaviors (Tsai & Liu, 2012). The demands of nursing work affect nurses’ physical and mental health and may result in depression, insomnia, and gastrointestinal upset. Shift work may result in unhealthy eating habits and irregular physical activities, and, as a result, nurses may become a high-risk population for metabolic syndrome and cardiovascular diseases (Tsai & Liu, 2012). In addition, when nurses are overworked, the quality of care they provide will be affected, which poses a threat to patient safety (DeCola & Riggins, 2010). The converse is also true; reducing nurse burnout is suggested to be an effective strategy for improving nurse-perceived quality of hospital patient care (Poghosyan, Clarke, Finlayson, & Aiken, 2010). Therefore, enhancing the health of health care providers through education has clinical importance, not only for health care providers themselves but also for patients receiving care. Today’s advanced information technology offers opportunities to apply new types of targeted health-promoting education. A foremost example is eHealth. The term eHealth is defined as “the use of emerging information and communication skills, especially the use of the internet, to improve or promote health and healthcare” (Eng, 2001). Education delivered via eHealth emphasizes audience autonomy, which allows ready use of the services and tools provided by the Internet (Bashshur, Reardon, & Shannon, 2000). Using the Internet, the audience can actively search for information and generate self-care abilities in a safe, supported, and favorable learning environment. The concept of transferring the autonomy of self-care to the audience coincides with the concept of health promotion. Nguyen, CarrieriKohlman, Rankin, Slaughter, and Stulbarg (2004) applied eHealth promotion to patients with cardiovascular diseases, basing it on three major categories of applications: peer support communities, tailored education, and professionally facilitated education and support programs (Nguyen et al., 2004). To encourage nurses to develop and maintain healthy lifestyles, this study aimed to develop a health-promotion website for nurses in Taiwan and to evaluate the effects of nurses’ health promotion received via eHealth intervention compared with conventional health promotion via handbook learning.

Subjects and Methods Subject Enrollment A total of 115 study subjects were recruited from nurses in Hsin-Chu and Chia-Yi metropolitan teaching hospitals by purposive sampling from November 1, 2011 to January 31, 2012. Inclusion criteria were that subjects had to be registered female nurses working since at least September 2011 who agreed to participate in the study. Pregnant women and subjects with hyperlipidemia, hypertension, or cardiovascular disease controlled by medication were excluded. Subjects in the experimental group also had to have a personal computer and network device in their homes or living places and had to be familiar with using the Internet. One hundred five subjects were enrolled, including 55 subjects in the experimental group and 60 in the control group. The 3-month intervention period was from February 15, 2012 to May 14, 2012.

Sample Size A type I error (a ¼ 0.05 [one-tailed]), power of 0.8, and expected efficacy of 0.5 were used to calculate the minimum sample size. To detect differences between the two groups at the large effect size of 0.4 at the power of 0.95, at least 84 subjects were required. The sample size calculation was accessed using the free software G*Power 3 (Department of Psychology, http:// downloads.fyxm.net/G*Power-10787.html, freeware) as previously described (Faul, Erdfelder, Lang, & Buchner, 2007).

Ethical Considerations All enrolled subjects provided signed informed consent to participate. The institutional review board of Hsin-Chu and Chia-Yi hospitals reviewed and approved the study protocol.

Methods The study was conducted as a controlled before/after analysis using baseline and postintervention questionnaires. The experimental group was introduced to the website and became registered users able to participate in the eHealth education intervention. The control group was not registered to use the website and received only conventional handbook learning intervention. The handbook Healthy Life and Exercise published by the Health Promotion Administration, Taiwan Ministry of Health and Welfare, was mailed to control subjects who were asked to read the handbook independently. The experimental group completed baseline preintervention and postintervention questionnaires after 3 months of eHealth intervention on the website, whereas the control group completed baseline preintervention and postintervention

Nurs Outlook 63 (2015) 245e254

questionnaires after 3 months of handbook learning via stamped mail. Questionnaires included Chinese versions of the previously validated HPLP (Teng, Yen, & Fetzer, 2010) and the Short Form Health Survey (SF-36) (Li, Wang, & Shen, 2003), and the pre- and postintervention results of the two groups were compared.

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maintain healthy lifestyles, as demonstrated previously (Nguyen et al., 2004). A physician investigator, who provided consultation and participated in chat room discussions, set up the website and served as the website maintainer and administrator. The users were anonymous to the investigator, who only accessed subjects’ log-in names from the server database to identify them when necessary.

Questionnaires Website Content and Function HPLP The HPLP is a 52-item instrument that measures health-promoting lifestyles in six subscales (domains): health responsibility (9 items), physical activity (8 items), nutrition (9 items), spiritual growth (9 items), interpersonal relationships (9 items), and stress management (8 items) (Teng et al., 2010). Respondents rate the frequency of practicing each of the 52 behaviors, and scoring is based on a four-point Likert scale (never, sometimes, often, or routinely). The total score is the sum of all responses. A previously validated Chinese version of the HPLP was used in the present study to evaluate health-promoting practices among nurses. Cronbach a was 0.90 and that of subscales ranged from 0.69 to 0.87; the mean interitem correlations of the five subscales were greater than 0.3 (Teng et al., 2010).

SF-36 The SF-36 (SF-36v2 Health Survey, Second Edition; QualityMetric, Lincoln, RI) is a self-reported health survey instrument that measures eight health domains (i.e., vitality, physical functioning, bodily pain, general health perceptions, physical role functioning, emotional role functioning, social role functioning, and mental health; Li et al., 2003). It provides a psychometrically based physical component summary (PCS) and a mental component summary (MCS). Eight scaled scores are weighted sums of the items in each section; each scale ranges from 0 to 100, with 0 representing maximum disability and 100 no disability. Lower scores indicate greater disability. Scores are calibrated so that 50 is the average score or norm, which allows comparison between study subjects. The previously validated Chinese version of the SF-36 (Li et al., 2003) was used in the present study to evaluate nurses’ selfreported views of their health status. Cronbach a coefficients ranged from 0.72 to 0.88, except for 0.39 for the social functioning scale and 0.66 for the vitality scale; test-retest reliability coefficients ranged from 0.66 to 0.94 (Li et al., 2003).

eHealth Website Development This website design was based on the theory of social support (Cutrona & Russell, 1990) appropriate for adult learning principle (Kearsley, 2010), which allowed subjects to obtain health-related information through self-learning, acquire peer information exchange and emotional support, and motivate to change to and

Home Page The website was open for registration of study subjects in the experimental group from February 1 to 14, 2012; it was not open for registration of nonstudy subjects and subjects in the control group (Supplementary Figure S1; Login page). At the time of registration, the subjects were asked to provide their gender, age, education level, marital status, shift work state, and e-mail addresses and to provide written informed consent. They were also requested to set their own log-in accounts and passwords, which must be used to log in to the website during the intervention period. Therefore, the subjects were anonymous online, and investigators were blinded to their identity. However, the investigator was still able to access the server database to communicate with individual subjects if necessary, but only the log-in accounts identified the subjects, not their real names. One reason to communicate with a subject might be if the topic being discussed was not suitable for public discussion and the investigator wanted to pursue it further to fully understand the individual’s comments on the discussion board, especially if the comment had indicated negative thinking or a mental or physical problem that may require attention. In that case, the investigator was able to access the server database and contact an individual subject via e-mail (using only their log-in accounts) to obtain direct communication. The registration function was discontinued on February 10, 2012.

Magic Mirror During registration, the system was connected to the “Magic Mirror” immediately, which required subjects to sign the informed consent form and complete the pretest questionnaires online (Supplementary Figure S2; Magic Mirror). The questionnaires included the HPLP and SF-36 scales, and height and weight were recorded for the calculation of body mass index (BMI). Questionnaire answers and scores were automatically stored in the server database. The eHealth intervention for the experimental group started on February 15, 2012; at that time, the links to the preintervention questionnaires were deleted. After 3 months of intervention, links to the questionnaires were restored, and subjects were asked to complete the postintervention questionnaires. Results of the HPLP and SF-36 scales and weight were stored in the server database.

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eBooks Assistant This page adopted “tailored education,” which is one of the three major eHealth applications (Nguyen et al., 2004) (Supplementary Figure S3; eBooks Assistant). The investigator used articles, figures, or tables to present health-related information within the server database. The topics of articles were listed on the “eBooks assistant” pages, and subjects clicked on topics they wished to read and were redirected to the selected topic content. This section of the website not only allowed subjects to obtain health-related information through self-learning but also applied the “information support” approach of the social support theory (Nguyen et al., 2004). In addition, if the investigator discovered any questions raised by subjects in the “Q &A” discussion board, the related information, explanation, and evidence could be placed in the “eBooks assistant” section of the website. Subjects were reminded to click and read by the investigator.

Discussion Board These webpages present two discussion boards, which adopt two of the three eHealth applications, “peer support community” and “professionally facilitated education and support program” (Nguyen et al., 2004) (Supplementary Figure S4; Discussion Board): 1. A “group discussion board” provided peer support. Compared with face-to-face communication, it provided a more convenient and accessible discussion area, offering subjects information exchange and emotional support. Subjects could find that their peers had similar experiences, questions, and goals, and they could review the correctness of their previous behavior or the key to previous problems. Correct behavior could be learned by attempting to imitate the experience provided by their peers in a safe environment. 2. The “Q & A” discussion board provided a “professionally facilitated education and support program” and “tailored education” (Nguyen et al., 2004). It provided a discussion forum for subjects and the investigator and a channel of communication for subjects and professionals. The investigator served as a consultant and facilitator, providing respect, caring, listening (emotional support), suggestion, advice, information (information support), feedback, and recognition (selfesteem support). If necessary, subjects were referred to other professionals by the investigator (social network support).

Statistical Analysis Continuous variables are shown as means and standard deviations, and categorical variables are shown as counts and percentages. The independent t test and paired t test were performed to evaluate differences between the two groups and changes from baseline to 3 months within groups, respectively. The Fisher exact test was performed to evaluate associations within the two groups. Analysis of covariance (ANCOVA) was performed to show the effects of interventions on HPLP scores, SF-36 scores, and BMI after 3 months, with adjustment for baseline measurements. The initial ANCOVA models included both main effects and interactive effects of group and baseline measurement. Nonsignificant interaction terms were excluded from the ANCOVA model; the Johnson-Neyman procedure was performed to evaluate significant interaction terms. All statistic assessments are two sided and evaluated at the 0.05 level of significance. Statistical analyses were performed using SPSS 15.0 statistics software (SPSS Inc, Chicago, IL).

Results Subjects’ Enrollment and Baseline Characteristics A total of 115 subjects were initially recruited into the study, and 10 were excluded or did not complete the study. One male subject was excluded. Our concern was not that the data of one male nurse would skew the results, but rather that when the female nurses knew that a male nurse was participating, they might become self-conscious and adjust their own replies in the group discussion board, which would not give us reliable responses. The others were lost to follow-up because of resignation from the hospital during the study period. Finally, 105 subjects were enrolled, and their data were retained for analysis (Figure 1). Subjects’ baseline characteristics (age, education level, marital status, shift work, height, weight, and BMI) are shown in Table 1. All characteristics were comparable between the experimental and control groups ( p values > .05). The mean age of the subjects was 35 years, about 90% had a college education level, 65.7% were married, and 36.2% worked shifts (Table 1).

Website Links These webpages applied the approach of “information support” of the social support theory described previously (Nguyen et al., 2004), which allowed subjects to obtain timely health-related information through selflearning (Supplementary Figure S5; Website Links). It contained two pages of links: (a) online news: the investigator provided local and foreign online news related to health issues every day and (b) healthrelated websites, including exercise/physiology websites, Nutrition Society website, and so on.

HPLP Scores Significant differences were found between the experimental and control groups in HPLP baseline scores of nutrition and exercise domains but not in the other four domains of the HPLP ( p > .05). No significant differences were found between the two groups after the 3-month interventions. Within the groups, those in the experimental group had significant postintervention improvements in self-actualization

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Table 2 e Between-group and Within-group Comparisons of Subjects’ Pre- and Postintervention SF-36 and HPLP Scores Experimental Control p Group (n ¼ 50) Group Value (n ¼ 55)

Figure 1 e A flowchart showing the study design and subjects’ enrollment.

scores (59.8e69.5, p ¼ .003), nutrition scores (53.2e65.0, p < .001), and exercise scores (43.4e53.3, p < .001). No significant changes were observed in postintervention scores of the control group. The postintervention total HPLP score was also significantly improved in the experimental group (334.1e379.7, p ¼ .001), but no Table 1 e Between-group Comparisons of Subjects’ Baseline Characteristics Experimental Control p Group (n ¼ 50) Group Value (n ¼ 55) Age (years) 35.8 (6.2) Education level, n (%) High school 3 (6.0) College 46 (92.0) Master’s degree 1 (2.0) Marital status, n (%) Married 34 (68.0) Single 16 (32.0) Shift work, n (%) Yes 19 (38.0) No 31 (62.0) Height (cm) 157.8 (3.2) Weight (kg) 53.6 (7.1) BMI (kg/m2) 21.5 (2.7)

35.1 (5.5)

.512

5 (9.1) 49 (89.1) 1 (1.8)

.836

35 (63.6) 20 (36.4)

.638

19 (34.5) 36 (65.5) 158.0 (3.3) 54.0 (5.4) 21.6 (1.9)

.713 .662 .743 .847

BMI, body mass index. Age, height, weight, and BMI are presented as mean (SD); other data are categorical and presented as count and percentage.

HPLP scores IS Baseline After 3 months SA Baseline After 3 months SM Baseline After 3 months NU Baseline After 3 months HR Baseline After 3 months EX Baseline After 3 months Total Baseline After 3 months SF-36 scores PCS Baseline After 3 months MCS Baseline After 3 months Total Baseline After 3 months BMI (kg/m2) Baseline After 3 months

66.8 (14.1) 72.1 (13.2)

67.1 (10.9) 67.7 (12.9)

.904 .088

59.8 (14.8) 69.5 (15.9)y

65.0 (15.3) 64.5 (16.3)

.078 .118

59.3 (13.4) 64.0 (12.2)

61.4 (12.2) 59.5 (12.3)

.400 .065

53.2 (13.1) 65.0 (15.0)y

63.6 (12.4) 63.6 (13.5)

An eHealth education intervention to promote healthy lifestyles among nurses.

Nurses often do not adhere to health-promoting lifestyles, compromising their health status and quality of care. This study aimed to evaluate health-p...
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