Copyright © eContent Management Pty Ltd. Contemporary Nurse (2014) 49: 60–67.
Psychological determinants of exercise behavior of nursing students Joanne Chung-Yan Chan The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong; The Hong Kong Polytechnic University, Hung Hom, Hong Kong
Abstract: Background: Though expected to be role models in health promotion, research has shown that nursing stu-
dents often have suboptimal exercise behavior. Aim: This study explored the psychological factors associated with the exercise behavior of nursing students. Methods/Design: A total of 195 first-year undergraduate nursing students completed a cross-sectional quantitative survey questionnaire, which included measures of their exercise behavior, the Physical Exercise Self-efficacy Scale, and the Exercise Barriers/Benefits Scale. Results/Findings: The results showed that male students spent more time exercising and had higher exercise self-efficacy compared with female students, but there were no gender differences in the perceived barriers to or benefits of exercise. Fatigue brought on by exercising was the greatest perceived barrier to exercise, whereas increasing physical fitness and mental health were the greatest perceived benefits of exercise. Multiple linear regression showed that gender, exercise self-efficacy, perceived barriers to exercise, and perceived benefits of exercise were independent predictors of exercise behavior. Conclusion: Nurse educators can endeavor to promote exercise behavior among nursing students by highlighting the specific benefits of exercise, empowering students to overcome their perceived barriers to exercise, and enhancing students’ exercise self-efficacy.
Keywords: barriers to and benefits of exercise, exercise, exercise self-efficacy, nursing students, physical activity
L
ifestyle habits make a significant contribution to the quality of health (Bandura, 2004). According to the World Health Organization [WHO] (2007), physical activity plays a major role in health and its promotion should be a core element in public health. In addition, physical inactivity is a significant risk factor for certain mental disorders (Meng & D’Arcy, 2013). However, studies on nursing students’ health-promoting lifestyle in different cultures, such as Hong Kong, Kuwait, and Turkey, have consistently revealed that engagement in physical activity ranked the lowest among the six health-promoting domains, which also include health responsibility, nutrition, spiritual growth, interpersonal relations, and stress management (Al-Kandari, Vidal, & Thomas, 2008; Can et al., 2008; Chan & Lee, 2013; Sechrist, Walker, & Pender, 1987). Moreover, a study on Irish nursing students found that only 11% claimed to be very physically active (Mooney, Timmins, Byrne, & Corroon, 2011). Though exercise is regarded as the most effective and the most direct way to increase physical activity, little is known about the psychological mechanisms behind the adoption and maintenance of exercise behavior of healthy adults (Higgins, Middleton, Winner, & Janelle, 2014;
60
CN
Volume 49, December 2014
Zheng et al., 2010). Therefore, this study aimed to fill the research gap by examining the associations among exercise self-efficacy, perceived barriers to and benefits of exercise, and exercise behavior of nursing students. An understanding of these associations can enable nurse educators to develop strategies to enhance nursing students’ exercise behavior, which is essential for supporting a healthy lifestyle and for grooming healthy role models for health promotion. Literature review Exercise self-efficacy Social cognitive theory provides a framework for understanding the determinants and mechanisms of health promotion (Bandura, 2004). Within the social cognitive theory, self-efficacy refers to whether an individual ‘can exercise control over one’s health habits’ and outcome expectations refer to ‘the expected costs and benefits for different health habits’ (Bandura, 2004, p. 144). Exercise self-efficacy refers to an individual’s perceived capability to engage in physical activity regularly in the face of perceived barriers (Buckley & Cameron, 2011). According to Bandura (1997), there are four sources of self-efficacy information – mastery experience, vicarious learning, social
Exercise behavior of nursing students persuasion, and physiological and psychological feedback. Individuals with successful prior experience in exercising regularly, for example, are more likely to have higher self-efficacy. Observing the regular pattern of exercise of similar others, such as peers, and receiving verbal encouragement are also likely to boost self-efficacy. Furthermore, interpreting physiological and psychological feedback in a positive manner also enhances self-efficacy (Bandura, 1997). Exercise self-efficacy is associated with an improvement in exercise behavior, as well as adherence (Higgins et al., 2014; Schwarzer, Luszczynska, Ziegelmann, Scholz, & Lippke, 2008). For instance, Cramp and Bray (2011) found that exercise self-efficacy had a positive association with leisure-time physical activity in postnatal women. Poomsrikaew, Berger, Kim, and Zerwic (2012) found that exercise self-efficacy predicted exercise behavior in Thai adults. Patterson, Meyer, Beaujean, and Bowden (2014) also found that exercise self-efficacy of dialysis patients was positively correlated with their physical activity. However, little research has looked at the exercise self-efficacy of nursing students, despite their low participation in exercise and their important role in health promotion. Perceived barriers to and benefits of exercise Regarding the barriers to and benefits of exercise, the beliefs of individuals may affect their participation in physical activity (Williams, Bezner, Chesbro, & Leavitt, 2006). Research on perceived barriers to exercise has identified specific barriers for individuals from different age and ethnic groups, and across different settings. For example, for employees who had an on-site corporate fitness center, embarrassment was a determining factor for the frequency of using the fitness center (Schwetschenau, O’Brien, Cunningham, & Jex, 2008). Lack of time was an important barrier for Turkish university students (Daskapan, Tuzun, & Eker, 2006) and university students in Spain (Gómez-López, Gallegos, & Extremera, 2010). The latter group also found that a lack of social support, competence, and practicality were exercise barriers (Gómez-López et al., 2010). Non-exercising female university students in the
© eContent Management Pty Ltd
CN
United Kingdom reported physical exertion as the greatest barrier to exercise (Lovell, Ansari, & Parker, 2010). For Hispanic adults, lack of time and self-discipline, in addition to being very tired, were exercise barriers (Bautista, Reininger, Gay, Barroso, & McCormick, 2011). For pregnant women who were previously active and inactive, the top barriers to leisure-time physical activity included ‘physical activity tires me,’ ‘I am fatigued by physical activity,’ and ‘physical activity is hard work for me’ (Da Costa & Ireland, 2013). With regard to the perceived benefits of exercise, there are mixed findings on their association with exercise behavior. Nies and Kershaw (2002) found that the perceived benefits of exercise did not have an impact on the level of physical activity or exercise performance in a group of European American and African American sedentary women. On the contrary, a significant positive correlation between the perceived benefits of exercise and exercise behavior was found in Chinese older adults, as well as in registered nurses in New York (Chou, Macfarlane, Chi, & Cheng, 2006; Esposito & Fitzpatrick, 2011). Research has identified different perceived benefits of exercise for different groups. For example, undergraduate students in the United States perceived an increase in physical fitness level as the greatest benefit of exercise (Grubbs & Carter, 2002), whereas non-exercising female university students in the United Kingdom perceived physical performance as the greatest benefit (Lovell et al., 2010). An increase in fitness was perceived as the greatest benefit of exercise by pregnant women who were previously inactive, whereas improvement in the function of the heart was perceived as the greatest benefit of exercise by pregnant women who were previously active (Da Costa & Ireland, 2013). Exercise self-efficacy, perceived barriers to and benefits of exercise, and exercise behavior of nursing students Very few studies have examined the psychological factors related to nursing students’ or nurses’ exercise behavior. Luszczynska and Haynes (2009) found that student nurses in England with higher selfefficacy showed an improvement in their exercise in an intervention. Ortabag, Ceylan, Akyuz, and Bebis (2010) found that Turkish military nursing
Volume 49, December 2014
CN
61
CN
Joanne Chung-Yan Chan
students rated ‘physical performance’ and ‘preventive health’ as the highest domains of perceived benefits of exercise, whereas ‘exercise milieu’ had the lowest score among the subscales for perceived barriers. One study on female hospital nurses found significant associations between exercise behavior, perceived barriers to and benefits of exercise, and exercise self-efficacy (Kaewthummanukul, Brown, Weaver, & Thomas, 2006). In addition, the nurses pinpointed that ‘work, lack of social support, inaccessibility of exercise facilities, the cost of exercise, lack of energy and health reasons’ were barriers to exercise (Kaewthummanukul et al., 2006, p. 663). To the best of my knowledge, no study has examined the associations among exercise self-efficacy, perceived barriers to and benefits of exercise, and exercise behavior of nursing students. Thus, this study serves to fill the gap in the literature. As nursing students have to face both academic and clinical demands, their participation in physical activity and mental well-being may be threatened (Hawker, 2012). Therefore, understanding the psychological factors pertaining to the exercise behavior of nursing students is essential for exercise promotion among nursing students. Method Participants The participants were a convenience sample of first-year nursing students in a university in Hong Kong. The final sample consisted of 195 students (67 male, 126 female, and 2 unreported). Of the 192 students who reported their age, the mean was 20.13, SD = 1.25. Ethical considerations Ethical approval was obtained from a university in Hong Kong where the study took place. Measures Exercise behavior Students responded to the questions ‘Approximately how many times do you exercise per week?’ and ‘Approximately how much time do you spend on exercise each time?’ The number of times of exercise was multiplied by the number of minutes spent on exercise each time for the total number of minutes of exercise per week. 62
CN
Volume 49, December 2014
Physical Exercise Self-Efficacy Scale Students evaluated their self-efficacy in overcoming barriers to exercise using the Physical Exercise Self-efficacy Scale (Schwarzer & Renner, 2012). The scale was translated from English to Chinese. Students responded to five items, for example, ‘I can manage to carry out my exercise intentions, even when I am tired,’ on a four-point scale, with 1 = very uncertain to 4 = very certain. The final score was the sum of the five items and the range was 5–20. The validity and reliability of this scale have been demonstrated in previous studies (e.g., Brown, 2005; Poomsrikaew et al., 2012; Robinson & Wicks, 2012). In this study, the scale had high reliability (Cronbach’s alpha = 0.82). Exercise Barriers/Benefits Scale The Exercise Benefits/Barriers Scale had a total of 43 items, with 29 items for the Benefits Scale and 14 items for the Barriers Scale (Sechrist et al., 1987). The students rated their perceived benefits of exercise (e.g., ‘I will prevent heart attacks by exercising’) and perceived barriers to exercise (e.g., ‘It costs too much to exercise’) using a fourpoint scale, with 1 = strongly disagree to 4 = strongly agree. The range of scores for the Benefits Scale was 29–116 and that for the Barriers Scale was 14–56. The Chinese version of the scale was used in this study and permission was obtained from the scale’s authors. The scale demonstrated sound validity and reliability in previous studies (e.g., Sechrist et al., 1987). The reliability for both the Benefits Scale (Cronbach’s alpha = 0.91) and the Barriers Scale (Cronbach’s alpha = 0.79) was high in the current study. Following the authors’ suggestion, median substitution was used for missing items when the participants’ response rate of missing items was lower than 5%. Data collection and analysis Data collection for this study took place at a university in Hong Kong and the data was obtained from the second wave of data collection for a larger survey about the personality, stress, mental health, self-efficacy, coping, and exercise behavior of university students in Hong Kong in 2010. A convenience sample of first-year nursing
© eContent Management Pty Ltd
Exercise behavior of nursing students students was invited to participate in the study in class and the students were given a consent form to sign. The gender of the students was obtained from the first wave of data collection; two students did not participate in the first wave and thus there was no record of their gender. The students completed the questionnaire, which was written in Chinese, in class. One student did not answer one part of the questionnaire and hence that data was discarded. IBM SPSS Statistics Version 22 was used in the data analysis for the descriptive statistics, t-tests, correlational analysis, and multiple linear regression. For the multiple regression, the dependent variable was exercise behavior; the independent variables were gender, perceived barriers to exercise, perceived benefits of exercise, and physical exercise self-efficacy with age as a confounding variable. The significance level was set at p < 0.05 for all statistical tests. Results Exercise behavior and physical exercise self-efficacy The overall mean duration of exercise per week was
Psychological determinants of exercise behavior of nursing students Joanne Chung-Yan Chan The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong; The Hong Kong Polytechnic University, Hung Hom, Hong Kong
Abstract: Background: Though expected to be role models in health promotion, research has shown that nursing stu-
dents often have suboptimal exercise behavior. Aim: This study explored the psychological factors associated with the exercise behavior of nursing students. Methods/Design: A total of 195 first-year undergraduate nursing students completed a cross-sectional quantitative survey questionnaire, which included measures of their exercise behavior, the Physical Exercise Self-efficacy Scale, and the Exercise Barriers/Benefits Scale. Results/Findings: The results showed that male students spent more time exercising and had higher exercise self-efficacy compared with female students, but there were no gender differences in the perceived barriers to or benefits of exercise. Fatigue brought on by exercising was the greatest perceived barrier to exercise, whereas increasing physical fitness and mental health were the greatest perceived benefits of exercise. Multiple linear regression showed that gender, exercise self-efficacy, perceived barriers to exercise, and perceived benefits of exercise were independent predictors of exercise behavior. Conclusion: Nurse educators can endeavor to promote exercise behavior among nursing students by highlighting the specific benefits of exercise, empowering students to overcome their perceived barriers to exercise, and enhancing students’ exercise self-efficacy.
Keywords: barriers to and benefits of exercise, exercise, exercise self-efficacy, nursing students, physical activity
L
ifestyle habits make a significant contribution to the quality of health (Bandura, 2004). According to the World Health Organization [WHO] (2007), physical activity plays a major role in health and its promotion should be a core element in public health. In addition, physical inactivity is a significant risk factor for certain mental disorders (Meng & D’Arcy, 2013). However, studies on nursing students’ health-promoting lifestyle in different cultures, such as Hong Kong, Kuwait, and Turkey, have consistently revealed that engagement in physical activity ranked the lowest among the six health-promoting domains, which also include health responsibility, nutrition, spiritual growth, interpersonal relations, and stress management (Al-Kandari, Vidal, & Thomas, 2008; Can et al., 2008; Chan & Lee, 2013; Sechrist, Walker, & Pender, 1987). Moreover, a study on Irish nursing students found that only 11% claimed to be very physically active (Mooney, Timmins, Byrne, & Corroon, 2011). Though exercise is regarded as the most effective and the most direct way to increase physical activity, little is known about the psychological mechanisms behind the adoption and maintenance of exercise behavior of healthy adults (Higgins, Middleton, Winner, & Janelle, 2014;
60
CN
Volume 49, December 2014
Zheng et al., 2010). Therefore, this study aimed to fill the research gap by examining the associations among exercise self-efficacy, perceived barriers to and benefits of exercise, and exercise behavior of nursing students. An understanding of these associations can enable nurse educators to develop strategies to enhance nursing students’ exercise behavior, which is essential for supporting a healthy lifestyle and for grooming healthy role models for health promotion. Literature review Exercise self-efficacy Social cognitive theory provides a framework for understanding the determinants and mechanisms of health promotion (Bandura, 2004). Within the social cognitive theory, self-efficacy refers to whether an individual ‘can exercise control over one’s health habits’ and outcome expectations refer to ‘the expected costs and benefits for different health habits’ (Bandura, 2004, p. 144). Exercise self-efficacy refers to an individual’s perceived capability to engage in physical activity regularly in the face of perceived barriers (Buckley & Cameron, 2011). According to Bandura (1997), there are four sources of self-efficacy information – mastery experience, vicarious learning, social
Exercise behavior of nursing students persuasion, and physiological and psychological feedback. Individuals with successful prior experience in exercising regularly, for example, are more likely to have higher self-efficacy. Observing the regular pattern of exercise of similar others, such as peers, and receiving verbal encouragement are also likely to boost self-efficacy. Furthermore, interpreting physiological and psychological feedback in a positive manner also enhances self-efficacy (Bandura, 1997). Exercise self-efficacy is associated with an improvement in exercise behavior, as well as adherence (Higgins et al., 2014; Schwarzer, Luszczynska, Ziegelmann, Scholz, & Lippke, 2008). For instance, Cramp and Bray (2011) found that exercise self-efficacy had a positive association with leisure-time physical activity in postnatal women. Poomsrikaew, Berger, Kim, and Zerwic (2012) found that exercise self-efficacy predicted exercise behavior in Thai adults. Patterson, Meyer, Beaujean, and Bowden (2014) also found that exercise self-efficacy of dialysis patients was positively correlated with their physical activity. However, little research has looked at the exercise self-efficacy of nursing students, despite their low participation in exercise and their important role in health promotion. Perceived barriers to and benefits of exercise Regarding the barriers to and benefits of exercise, the beliefs of individuals may affect their participation in physical activity (Williams, Bezner, Chesbro, & Leavitt, 2006). Research on perceived barriers to exercise has identified specific barriers for individuals from different age and ethnic groups, and across different settings. For example, for employees who had an on-site corporate fitness center, embarrassment was a determining factor for the frequency of using the fitness center (Schwetschenau, O’Brien, Cunningham, & Jex, 2008). Lack of time was an important barrier for Turkish university students (Daskapan, Tuzun, & Eker, 2006) and university students in Spain (Gómez-López, Gallegos, & Extremera, 2010). The latter group also found that a lack of social support, competence, and practicality were exercise barriers (Gómez-López et al., 2010). Non-exercising female university students in the
© eContent Management Pty Ltd
CN
United Kingdom reported physical exertion as the greatest barrier to exercise (Lovell, Ansari, & Parker, 2010). For Hispanic adults, lack of time and self-discipline, in addition to being very tired, were exercise barriers (Bautista, Reininger, Gay, Barroso, & McCormick, 2011). For pregnant women who were previously active and inactive, the top barriers to leisure-time physical activity included ‘physical activity tires me,’ ‘I am fatigued by physical activity,’ and ‘physical activity is hard work for me’ (Da Costa & Ireland, 2013). With regard to the perceived benefits of exercise, there are mixed findings on their association with exercise behavior. Nies and Kershaw (2002) found that the perceived benefits of exercise did not have an impact on the level of physical activity or exercise performance in a group of European American and African American sedentary women. On the contrary, a significant positive correlation between the perceived benefits of exercise and exercise behavior was found in Chinese older adults, as well as in registered nurses in New York (Chou, Macfarlane, Chi, & Cheng, 2006; Esposito & Fitzpatrick, 2011). Research has identified different perceived benefits of exercise for different groups. For example, undergraduate students in the United States perceived an increase in physical fitness level as the greatest benefit of exercise (Grubbs & Carter, 2002), whereas non-exercising female university students in the United Kingdom perceived physical performance as the greatest benefit (Lovell et al., 2010). An increase in fitness was perceived as the greatest benefit of exercise by pregnant women who were previously inactive, whereas improvement in the function of the heart was perceived as the greatest benefit of exercise by pregnant women who were previously active (Da Costa & Ireland, 2013). Exercise self-efficacy, perceived barriers to and benefits of exercise, and exercise behavior of nursing students Very few studies have examined the psychological factors related to nursing students’ or nurses’ exercise behavior. Luszczynska and Haynes (2009) found that student nurses in England with higher selfefficacy showed an improvement in their exercise in an intervention. Ortabag, Ceylan, Akyuz, and Bebis (2010) found that Turkish military nursing
Volume 49, December 2014
CN
61
CN
Joanne Chung-Yan Chan
students rated ‘physical performance’ and ‘preventive health’ as the highest domains of perceived benefits of exercise, whereas ‘exercise milieu’ had the lowest score among the subscales for perceived barriers. One study on female hospital nurses found significant associations between exercise behavior, perceived barriers to and benefits of exercise, and exercise self-efficacy (Kaewthummanukul, Brown, Weaver, & Thomas, 2006). In addition, the nurses pinpointed that ‘work, lack of social support, inaccessibility of exercise facilities, the cost of exercise, lack of energy and health reasons’ were barriers to exercise (Kaewthummanukul et al., 2006, p. 663). To the best of my knowledge, no study has examined the associations among exercise self-efficacy, perceived barriers to and benefits of exercise, and exercise behavior of nursing students. Thus, this study serves to fill the gap in the literature. As nursing students have to face both academic and clinical demands, their participation in physical activity and mental well-being may be threatened (Hawker, 2012). Therefore, understanding the psychological factors pertaining to the exercise behavior of nursing students is essential for exercise promotion among nursing students. Method Participants The participants were a convenience sample of first-year nursing students in a university in Hong Kong. The final sample consisted of 195 students (67 male, 126 female, and 2 unreported). Of the 192 students who reported their age, the mean was 20.13, SD = 1.25. Ethical considerations Ethical approval was obtained from a university in Hong Kong where the study took place. Measures Exercise behavior Students responded to the questions ‘Approximately how many times do you exercise per week?’ and ‘Approximately how much time do you spend on exercise each time?’ The number of times of exercise was multiplied by the number of minutes spent on exercise each time for the total number of minutes of exercise per week. 62
CN
Volume 49, December 2014
Physical Exercise Self-Efficacy Scale Students evaluated their self-efficacy in overcoming barriers to exercise using the Physical Exercise Self-efficacy Scale (Schwarzer & Renner, 2012). The scale was translated from English to Chinese. Students responded to five items, for example, ‘I can manage to carry out my exercise intentions, even when I am tired,’ on a four-point scale, with 1 = very uncertain to 4 = very certain. The final score was the sum of the five items and the range was 5–20. The validity and reliability of this scale have been demonstrated in previous studies (e.g., Brown, 2005; Poomsrikaew et al., 2012; Robinson & Wicks, 2012). In this study, the scale had high reliability (Cronbach’s alpha = 0.82). Exercise Barriers/Benefits Scale The Exercise Benefits/Barriers Scale had a total of 43 items, with 29 items for the Benefits Scale and 14 items for the Barriers Scale (Sechrist et al., 1987). The students rated their perceived benefits of exercise (e.g., ‘I will prevent heart attacks by exercising’) and perceived barriers to exercise (e.g., ‘It costs too much to exercise’) using a fourpoint scale, with 1 = strongly disagree to 4 = strongly agree. The range of scores for the Benefits Scale was 29–116 and that for the Barriers Scale was 14–56. The Chinese version of the scale was used in this study and permission was obtained from the scale’s authors. The scale demonstrated sound validity and reliability in previous studies (e.g., Sechrist et al., 1987). The reliability for both the Benefits Scale (Cronbach’s alpha = 0.91) and the Barriers Scale (Cronbach’s alpha = 0.79) was high in the current study. Following the authors’ suggestion, median substitution was used for missing items when the participants’ response rate of missing items was lower than 5%. Data collection and analysis Data collection for this study took place at a university in Hong Kong and the data was obtained from the second wave of data collection for a larger survey about the personality, stress, mental health, self-efficacy, coping, and exercise behavior of university students in Hong Kong in 2010. A convenience sample of first-year nursing
© eContent Management Pty Ltd
Exercise behavior of nursing students students was invited to participate in the study in class and the students were given a consent form to sign. The gender of the students was obtained from the first wave of data collection; two students did not participate in the first wave and thus there was no record of their gender. The students completed the questionnaire, which was written in Chinese, in class. One student did not answer one part of the questionnaire and hence that data was discarded. IBM SPSS Statistics Version 22 was used in the data analysis for the descriptive statistics, t-tests, correlational analysis, and multiple linear regression. For the multiple regression, the dependent variable was exercise behavior; the independent variables were gender, perceived barriers to exercise, perceived benefits of exercise, and physical exercise self-efficacy with age as a confounding variable. The significance level was set at p < 0.05 for all statistical tests. Results Exercise behavior and physical exercise self-efficacy The overall mean duration of exercise per week was
