Nurse Education in Practice 14 (2014) 99e101
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Guest editorial
Physical fitness in pre-registration nursing students a b s t r a c t Keywords: Physical fitness Student nurses Professionalism
Background: Nurses are ideally placed to deliver health promotion interventions, including physical fitness, however evidence suggests that nurses themselves are failing to engage in healthy lifestyles; this in turn making them less likely to promote health. It would appear that some nurses are allowing their own values, beliefs and behaviours to hinder this role. We propose these nurses are in breach of the Nursing and Midwifery (NMC) code. Currently nurses self declare their fitness to practice through the NMC, however self-monitoring has been criticized for its lack of reliability. Recruitment of student nurses in the UK does not currently assess physical fitness levels in line with other professionals such as the armed forces, police or fire service. Over half the nursing workforce is now overweight or obese, with alarming levels of inactivity. Physical activity positively correlates with motivation, wellbeing, coping and positive attitude. These attributes in turn impact on employability, retention and absence. This article explores promoting health, focussing on physical activity and discusses innovative ideas to promote physical activity within the nursing Curricula. Ó 2013 Elsevier Ltd. All rights reserved.
Introduction The aim of this paper is to discuss nurse lifestyle behaviour, particularly physical activity, and its impact on health promotion. We hope ultimately to influence nurse lifestyle behaviour. It is widely acknowledged that nurses are ideally situated to promote health behaviours: however it is also recognised that many nurses fail to carry out this role despite having the knowledge to do so (Porter, 2011). It would appear that some nurses are allowing their own beliefs, values and behaviour to hinder their role in health promotion (Healy and McSharry, 2010). It is proposed that these nurses are in breach of the Nursing and Midwifery Council (2008) Code. The NMC (2010) currently require nurses to self-monitor in order to assess good character and good health. In our opinion this requires re-examination since self-reporting tools are considered to be flawed (Warner et al., 2012). Within the nursing profession, physical fitness is not assessed; this is not comparable to other public services professions. This editorial describes a research project which will be carried out to explore student nurse values, beliefs and behaviour in relation to lifestyle and which will implement the use of physical exercise champions (PECs) to increase physical activity in student nurses. Nurse values, beliefs and behaviours Health promotion, disease prevention and the care of patients who are ill are fundamental aspects of the nurse’s role (Radsma
1471-5953/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nepr.2013.10.002
and Bottorff, 2009). Nurses own health behaviour is paradoxical: the fact remains that many nurses engage in unhealthy lifestyle activities (Smith and Leggat, 2007; Zapka et al., 2009). Interestingly, although Zapka et al.’s (2009) study revealed that 37.2% of nurses in their study were overweight and 28.2% obese, a significant percentage did not perceive themselves to be so, suggesting that some nurses do not have knowledge of these parameters. Miller et al. (2008) found that 54% of their nurse participants were overweight or obese. Ninety-three percent recognised their own weight required action; however 76% admitted to not tackling the issue of overweight and obesity with patients. Similarly Radsma and Bottorff (2009), and Peate (2012) found that nurses who smoke regularly fail to promote smoking cessation with patients because they consider they are poor role models. Ironically, Radsma and Bottorff (2009) found that nurses who smoke wish to be seen as healthy individuals in the workplace and used breathe fresheners, washed their hands frequently and hid the fact they were smokers in order to hide the habit from other health professionals. Esposito and Fitzpatrick (2011) found nurses who were active themselves were more likely to engage in, and follow up, health promotion activities with patients. However in a study of over 850 nurses, Malik et al. (2011) report that almost half sampled did not participate in the recommended 30 min of moderate intensity exercise over a period of five days per week (World Health Organisation (WHO), 2011). Despite nurses being aware of the benefits of health lifestyles, McElligott et al. (2009) concur that many nurse fail to engage in exercise themselves.
100
Guest editorial / Nurse Education in Practice 14 (2014) 99e101
Fitness to practice At the point of, and when renewing registration, nurses are required to self-declare their “good health and good character” (NMC, 2010). Good health refers to having the capacity to undertake ‘safe and effective’ practice without the requirement of supervision while good character refers to conduct, ‘behaviour and attitude’ (NMC, 2010, p. 8). While the process for assessing criminality through protection of vulnerable groups screening and fitness to practice within the workplace appears to be robust, the annual declaration through self-monitoring lacks validity. In our opinion there are gaps in the process for assessing good health and good character since both are verified through self- monitoring. Self-monitoring tools have been criticised for lacking reliability (Storey and McCargar, 2012). The NMC (2008) requires nurses to promote and protect the health of those patients in their care. If nurses fail to carry out health promotion because of their own health values, beliefs or lifestyle behaviour, and thus place patients at risk, they should be referred to fitness to practice and their competence assessed. In our opinion the NMC and employers need to develop more robust processes. The general practice (GP) appraisal system does not determine validation or re-licensing but assesses and supports GPs in determining whether their continuing professional development meets requirements (Sparrow, 2008). The NMC could adopt this system, adding greater validity to the monitoring process and improving the care professionals provide to their patients (Sparrow, 2008). The current recruitment process for nursing students includes a physical screening; however it does not include the assessment of physical fitness. Other public service professions demonstrate a more structured approach. Police applicants are expected to be “physically fit and healthy” with new recruits expected to pass endurance and muscle strength tests. The Armed Forces and Fire Fighters also have minimum requirements to ensure staff is fit, safe and competent (Kuruganti and Rickards, 2004). Seventy five per cent of police officers were noted to be overweight or obese thus the Metropolitan (Greater London) Police Federation (2011) suggested an annual fitness test for police officers, with pay cuts for those who failed a timed 15 m “shuttle run” more than three times. Dempsey and Handcock (2011) reviewed the New Zealand Police Physical Competency test and exposed those with cardiovascular risk factors as being unfit for purpose. In 2009, it was estimated that 58% of NHS staff in the United Kingdom (UK) were overweight or obese with 40% partaking in physical activity on two days per week or less (Department of Health, 2009). Outside the UK, some health care providers are taking a formal stance. One hospital in Texas has stated it will not hire overweight staff, whilst in New Zealand, a British nurse has been denied emigration because the country’s Government consider her 21 stone weight could cost them thousands in future in health costs (Ford, 2009). Opportunities for educators Research studies show that nurses who engage with a healthy lifestyle are more likely to promote health to others (Puig Ribera et al., 2005; Esposito and Fitzpatrick (2011), therefore it seems obvious to ensure nursing students and ultimately nurses improve their own lifestyles and health. We argue it is time to take a more pragmatic approach to nurse education in relation to health promotion. Our research study aims to explore student nurse values, beliefs and behaviour and increase physical activity. Baseline data will be gathered in relation to physical activity and lifestyle behaviour from new volunteer nursing recruits. From this cohort,
volunteers will be asked to become student ambassadors in the form of physical exercise champions (PECs), whose role will be to empower and inspire peers. Action research will be used to evaluate the effectiveness of the PECs, initially for a year. Stakeholders include research staff, student volunteers, service users, local NHS and public health bodies and National partners. Youth Sport Scotland (2013) states that physical activity has the ability to enhance personal development in terms of improved confidence and self-esteem. It also has the potential to facilitate the development of partnership working and communication links, leadership, presentation and employability skills (Youth Sport Scotland, 2013). Conclusion Nurses are ideally placed to promote health; however it is clear that some nurses are allowing their own beliefs, values and lifestyles to hinder their role in health promotion (Healy and McSharry, 2010). We argue that these nurses are in breach of the NMC (2008) Code and should be referred to fitness to practice. Current methods for assessing good health and good character are inadequate and require updating to include more robust processes such that these nurses can be identified and supported. Physical fitness is not assessed on entry to the nursing profession; other comparable professions leave nursing behind in this aspect. In requiring student nurses to explore their own values, beliefs and lifestyles, we hope ultimately to change attitudes and behaviours.
References Department of Health, 2009. NHS Health and Well-being Report. Interim Report [Online] Available: http://www.nhshealthandwellbeing.org/pdfs/NHS%20HWB %20Review%20Interim%20Report%20190809.pdf (accessed 30.08.12.). Dempsey, P.C., Handcock, P.J., 2011. Report to the New Zealand Police. In: The Impact of SRBA and Appointments on Police Performance No. 2011. School of Physical Education, University of Otago, Dunedin, New Zealand. Esposito, E.M., Fitzpatrick, J.J., 2011. Registered nurses’ beliefs of the benefits of exercise, their exercise behaviour and their patient teaching regarding exercise. Int. J. Nurs. Pract. 17, 351e356. Ford, S. (Ed.), 2009. Nurse Stopped from Emigrating to New Zealand Due to ‘Morbid Obesity’. Nursing Times [online] Available: http://www.nursingtimes.net/ whats-new-in-nursing/primary-care/nurse-stopped-from-emigrating-to-newzealand-due-to-morbid-obesity/5001008.article (accessed 29.10.12.). Healy, D., McSharry, P., 2010. Promoting self-awareness in undergraduate nursing students in relation to their health status in relation to their health status and personal behaviors. Nurse Educ. Pract. 11 (4), 228e233. Kuruganti, U., Rickards, J., 2004. The role of human factors engineering in establishing occupational fitness standards. Int. J. Ind. Ergon. 34 (6), 451e457. Malik, S., Blake, H., Batt, M., 2011. How healthy are our nurses? New and registered nurses compared. Br. J. Nurs. 20 (8), 489e496. McElligott, D., Siemers, S., Thomas, L., Khon, N., 2009. Health promotion in nurses: is there a healthy nurse in the house? Appl. Nurs. Res. 22, 211e215. Metropolitan Police Federation, 2011. Windsor Review [Online] Available: http:// www.metfed.org.uk/support/uploads/1332426466Winsor%20II% 20Recommendations%20Table%20-%20colour%20coded.pdf (accessed 23.08.12.). Miller, S., Albert, P., Cross, C., 2008. Overweight and obesity in nurses, advanced practice nurses and nurse educators. J. Am. Acad. Nurse Pract. 20 (5), 259e265. Nursing & Midwifery Council, 2010. Good Health & Good Character: Guidance for Approved Educations Institutions. NMC, London. Nursing & Midwifery Council, 2008. The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. NMC, London. Peate, I., 2012. Do as I say not as I do. Br. J. Nurs. 21 (17), 1009. Porter, E., 2011. Public health in nursing. In: Hogston, R., Marjoram, B. (Eds.), Foundations of Nursing Practice, fourth ed. Palgrave MacMillan, London. Puig Ribera, A., McKenna, J., Riddoch, C., 2005. Attitudes and practices of physicians and nurses regarding physical activity promotion in the Catalan primary-care system. Eur. J. Public Health 15 (6), 569e575. Radsma, J., Bottorff, J.L., 2009. Counteracting ambivalence: nurses who smoke and their health promotion role with patients who smoke. Respir. Nurse Health 32 (4), 443e452. Smith, D.R., Leggat, P.A., 2007. An international review of tobacco smoking among medical students. J. Postgrad. Med. 53 (1), 55e62. Sparrow, N., 2008. Principles of GP Appraisal. Available [Online]: http://www.rcgp. org.uk/revalidation-and-cpd/w/media/Files/Revalidation-and-CPD/corpPrinciples-of-GP-appraisal.ash.
Guest editorial / Nurse Education in Practice 14 (2014) 99e101
101
Julie Orr*, Sue McGrouther1, Marie McCaig2 United Kingdom
Storey, K., McCargar, L., 2012. Reliability and validity of Web-SPAN, a web based method for assessing weight status, diet and physical activity in youth. J. Hum. Nutr. Diet. 25, 59e68. Warner, E., Wolin, K., Dustin, D., Heil, D., Askew, S., Bennett, G., 2012. Differential accuracy of physical activity self-report by body mass index. Am. J. Health Behav. 36 (2), 168e178. World Health Organisation, 2011. Non Communicable Diseases Country Profiles 2011. WHO publications, Geneva. Youth Sport Trust, 2013. Sport Changes Lives: Strategic Plan 2013e2018. Available [Online] http://www.youthsporttrust.org/media/3838495/yst_strategic_ plan_-_online_version_007.pdf (accessed 23.05.13.). Zapka, J.M., Lemon, S.C., Magner, R.P., Hale, J., 2009. Lifestyle behaviours and weight among hospital-based nurses. J. Nurs. Manage. 17 (7), 853e860.
* Corresponding
author. Tel.: þ44 1387 345805. E-mail addresses: [email protected] (J. Orr), [email protected] (S. McGrouther), [email protected] (M. McCaig).
1 2
Tel.: þ44 1387 345812. Tel.: þ44 1387 345822.
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Guest editorial
Physical fitness in pre-registration nursing students a b s t r a c t Keywords: Physical fitness Student nurses Professionalism
Background: Nurses are ideally placed to deliver health promotion interventions, including physical fitness, however evidence suggests that nurses themselves are failing to engage in healthy lifestyles; this in turn making them less likely to promote health. It would appear that some nurses are allowing their own values, beliefs and behaviours to hinder this role. We propose these nurses are in breach of the Nursing and Midwifery (NMC) code. Currently nurses self declare their fitness to practice through the NMC, however self-monitoring has been criticized for its lack of reliability. Recruitment of student nurses in the UK does not currently assess physical fitness levels in line with other professionals such as the armed forces, police or fire service. Over half the nursing workforce is now overweight or obese, with alarming levels of inactivity. Physical activity positively correlates with motivation, wellbeing, coping and positive attitude. These attributes in turn impact on employability, retention and absence. This article explores promoting health, focussing on physical activity and discusses innovative ideas to promote physical activity within the nursing Curricula. Ó 2013 Elsevier Ltd. All rights reserved.
Introduction The aim of this paper is to discuss nurse lifestyle behaviour, particularly physical activity, and its impact on health promotion. We hope ultimately to influence nurse lifestyle behaviour. It is widely acknowledged that nurses are ideally situated to promote health behaviours: however it is also recognised that many nurses fail to carry out this role despite having the knowledge to do so (Porter, 2011). It would appear that some nurses are allowing their own beliefs, values and behaviour to hinder their role in health promotion (Healy and McSharry, 2010). It is proposed that these nurses are in breach of the Nursing and Midwifery Council (2008) Code. The NMC (2010) currently require nurses to self-monitor in order to assess good character and good health. In our opinion this requires re-examination since self-reporting tools are considered to be flawed (Warner et al., 2012). Within the nursing profession, physical fitness is not assessed; this is not comparable to other public services professions. This editorial describes a research project which will be carried out to explore student nurse values, beliefs and behaviour in relation to lifestyle and which will implement the use of physical exercise champions (PECs) to increase physical activity in student nurses. Nurse values, beliefs and behaviours Health promotion, disease prevention and the care of patients who are ill are fundamental aspects of the nurse’s role (Radsma
1471-5953/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nepr.2013.10.002
and Bottorff, 2009). Nurses own health behaviour is paradoxical: the fact remains that many nurses engage in unhealthy lifestyle activities (Smith and Leggat, 2007; Zapka et al., 2009). Interestingly, although Zapka et al.’s (2009) study revealed that 37.2% of nurses in their study were overweight and 28.2% obese, a significant percentage did not perceive themselves to be so, suggesting that some nurses do not have knowledge of these parameters. Miller et al. (2008) found that 54% of their nurse participants were overweight or obese. Ninety-three percent recognised their own weight required action; however 76% admitted to not tackling the issue of overweight and obesity with patients. Similarly Radsma and Bottorff (2009), and Peate (2012) found that nurses who smoke regularly fail to promote smoking cessation with patients because they consider they are poor role models. Ironically, Radsma and Bottorff (2009) found that nurses who smoke wish to be seen as healthy individuals in the workplace and used breathe fresheners, washed their hands frequently and hid the fact they were smokers in order to hide the habit from other health professionals. Esposito and Fitzpatrick (2011) found nurses who were active themselves were more likely to engage in, and follow up, health promotion activities with patients. However in a study of over 850 nurses, Malik et al. (2011) report that almost half sampled did not participate in the recommended 30 min of moderate intensity exercise over a period of five days per week (World Health Organisation (WHO), 2011). Despite nurses being aware of the benefits of health lifestyles, McElligott et al. (2009) concur that many nurse fail to engage in exercise themselves.
100
Guest editorial / Nurse Education in Practice 14 (2014) 99e101
Fitness to practice At the point of, and when renewing registration, nurses are required to self-declare their “good health and good character” (NMC, 2010). Good health refers to having the capacity to undertake ‘safe and effective’ practice without the requirement of supervision while good character refers to conduct, ‘behaviour and attitude’ (NMC, 2010, p. 8). While the process for assessing criminality through protection of vulnerable groups screening and fitness to practice within the workplace appears to be robust, the annual declaration through self-monitoring lacks validity. In our opinion there are gaps in the process for assessing good health and good character since both are verified through self- monitoring. Self-monitoring tools have been criticised for lacking reliability (Storey and McCargar, 2012). The NMC (2008) requires nurses to promote and protect the health of those patients in their care. If nurses fail to carry out health promotion because of their own health values, beliefs or lifestyle behaviour, and thus place patients at risk, they should be referred to fitness to practice and their competence assessed. In our opinion the NMC and employers need to develop more robust processes. The general practice (GP) appraisal system does not determine validation or re-licensing but assesses and supports GPs in determining whether their continuing professional development meets requirements (Sparrow, 2008). The NMC could adopt this system, adding greater validity to the monitoring process and improving the care professionals provide to their patients (Sparrow, 2008). The current recruitment process for nursing students includes a physical screening; however it does not include the assessment of physical fitness. Other public service professions demonstrate a more structured approach. Police applicants are expected to be “physically fit and healthy” with new recruits expected to pass endurance and muscle strength tests. The Armed Forces and Fire Fighters also have minimum requirements to ensure staff is fit, safe and competent (Kuruganti and Rickards, 2004). Seventy five per cent of police officers were noted to be overweight or obese thus the Metropolitan (Greater London) Police Federation (2011) suggested an annual fitness test for police officers, with pay cuts for those who failed a timed 15 m “shuttle run” more than three times. Dempsey and Handcock (2011) reviewed the New Zealand Police Physical Competency test and exposed those with cardiovascular risk factors as being unfit for purpose. In 2009, it was estimated that 58% of NHS staff in the United Kingdom (UK) were overweight or obese with 40% partaking in physical activity on two days per week or less (Department of Health, 2009). Outside the UK, some health care providers are taking a formal stance. One hospital in Texas has stated it will not hire overweight staff, whilst in New Zealand, a British nurse has been denied emigration because the country’s Government consider her 21 stone weight could cost them thousands in future in health costs (Ford, 2009). Opportunities for educators Research studies show that nurses who engage with a healthy lifestyle are more likely to promote health to others (Puig Ribera et al., 2005; Esposito and Fitzpatrick (2011), therefore it seems obvious to ensure nursing students and ultimately nurses improve their own lifestyles and health. We argue it is time to take a more pragmatic approach to nurse education in relation to health promotion. Our research study aims to explore student nurse values, beliefs and behaviour and increase physical activity. Baseline data will be gathered in relation to physical activity and lifestyle behaviour from new volunteer nursing recruits. From this cohort,
volunteers will be asked to become student ambassadors in the form of physical exercise champions (PECs), whose role will be to empower and inspire peers. Action research will be used to evaluate the effectiveness of the PECs, initially for a year. Stakeholders include research staff, student volunteers, service users, local NHS and public health bodies and National partners. Youth Sport Scotland (2013) states that physical activity has the ability to enhance personal development in terms of improved confidence and self-esteem. It also has the potential to facilitate the development of partnership working and communication links, leadership, presentation and employability skills (Youth Sport Scotland, 2013). Conclusion Nurses are ideally placed to promote health; however it is clear that some nurses are allowing their own beliefs, values and lifestyles to hinder their role in health promotion (Healy and McSharry, 2010). We argue that these nurses are in breach of the NMC (2008) Code and should be referred to fitness to practice. Current methods for assessing good health and good character are inadequate and require updating to include more robust processes such that these nurses can be identified and supported. Physical fitness is not assessed on entry to the nursing profession; other comparable professions leave nursing behind in this aspect. In requiring student nurses to explore their own values, beliefs and lifestyles, we hope ultimately to change attitudes and behaviours.
References Department of Health, 2009. NHS Health and Well-being Report. Interim Report [Online] Available: http://www.nhshealthandwellbeing.org/pdfs/NHS%20HWB %20Review%20Interim%20Report%20190809.pdf (accessed 30.08.12.). Dempsey, P.C., Handcock, P.J., 2011. Report to the New Zealand Police. In: The Impact of SRBA and Appointments on Police Performance No. 2011. School of Physical Education, University of Otago, Dunedin, New Zealand. Esposito, E.M., Fitzpatrick, J.J., 2011. Registered nurses’ beliefs of the benefits of exercise, their exercise behaviour and their patient teaching regarding exercise. Int. J. Nurs. Pract. 17, 351e356. Ford, S. (Ed.), 2009. Nurse Stopped from Emigrating to New Zealand Due to ‘Morbid Obesity’. Nursing Times [online] Available: http://www.nursingtimes.net/ whats-new-in-nursing/primary-care/nurse-stopped-from-emigrating-to-newzealand-due-to-morbid-obesity/5001008.article (accessed 29.10.12.). Healy, D., McSharry, P., 2010. Promoting self-awareness in undergraduate nursing students in relation to their health status in relation to their health status and personal behaviors. Nurse Educ. Pract. 11 (4), 228e233. Kuruganti, U., Rickards, J., 2004. The role of human factors engineering in establishing occupational fitness standards. Int. J. Ind. Ergon. 34 (6), 451e457. Malik, S., Blake, H., Batt, M., 2011. How healthy are our nurses? New and registered nurses compared. Br. J. Nurs. 20 (8), 489e496. McElligott, D., Siemers, S., Thomas, L., Khon, N., 2009. Health promotion in nurses: is there a healthy nurse in the house? Appl. Nurs. Res. 22, 211e215. Metropolitan Police Federation, 2011. Windsor Review [Online] Available: http:// www.metfed.org.uk/support/uploads/1332426466Winsor%20II% 20Recommendations%20Table%20-%20colour%20coded.pdf (accessed 23.08.12.). Miller, S., Albert, P., Cross, C., 2008. Overweight and obesity in nurses, advanced practice nurses and nurse educators. J. Am. Acad. Nurse Pract. 20 (5), 259e265. Nursing & Midwifery Council, 2010. Good Health & Good Character: Guidance for Approved Educations Institutions. NMC, London. Nursing & Midwifery Council, 2008. The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. NMC, London. Peate, I., 2012. Do as I say not as I do. Br. J. Nurs. 21 (17), 1009. Porter, E., 2011. Public health in nursing. In: Hogston, R., Marjoram, B. (Eds.), Foundations of Nursing Practice, fourth ed. Palgrave MacMillan, London. Puig Ribera, A., McKenna, J., Riddoch, C., 2005. Attitudes and practices of physicians and nurses regarding physical activity promotion in the Catalan primary-care system. Eur. J. Public Health 15 (6), 569e575. Radsma, J., Bottorff, J.L., 2009. Counteracting ambivalence: nurses who smoke and their health promotion role with patients who smoke. Respir. Nurse Health 32 (4), 443e452. Smith, D.R., Leggat, P.A., 2007. An international review of tobacco smoking among medical students. J. Postgrad. Med. 53 (1), 55e62. Sparrow, N., 2008. Principles of GP Appraisal. Available [Online]: http://www.rcgp. org.uk/revalidation-and-cpd/w/media/Files/Revalidation-and-CPD/corpPrinciples-of-GP-appraisal.ash.
Guest editorial / Nurse Education in Practice 14 (2014) 99e101
101
Julie Orr*, Sue McGrouther1, Marie McCaig2 United Kingdom
Storey, K., McCargar, L., 2012. Reliability and validity of Web-SPAN, a web based method for assessing weight status, diet and physical activity in youth. J. Hum. Nutr. Diet. 25, 59e68. Warner, E., Wolin, K., Dustin, D., Heil, D., Askew, S., Bennett, G., 2012. Differential accuracy of physical activity self-report by body mass index. Am. J. Health Behav. 36 (2), 168e178. World Health Organisation, 2011. Non Communicable Diseases Country Profiles 2011. WHO publications, Geneva. Youth Sport Trust, 2013. Sport Changes Lives: Strategic Plan 2013e2018. Available [Online] http://www.youthsporttrust.org/media/3838495/yst_strategic_ plan_-_online_version_007.pdf (accessed 23.05.13.). Zapka, J.M., Lemon, S.C., Magner, R.P., Hale, J., 2009. Lifestyle behaviours and weight among hospital-based nurses. J. Nurs. Manage. 17 (7), 853e860.
* Corresponding
author. Tel.: þ44 1387 345805. E-mail addresses: [email protected] (J. Orr), [email protected] (S. McGrouther), [email protected] (M. McCaig).
1 2
Tel.: þ44 1387 345812. Tel.: þ44 1387 345822.
