Health and the workplace

Promoting health in any workplace setting has been a national and international priority for many years. In 1986, the Ottawa Charter for Health Promotion was established to achieve health for all people by the year 2000 and beyond (WHO 1986). The Ottawa Charter states that: ‘Health is created and lived by people within the settings of their everyday life; where they learn, work, play, and love’ (WHO 1986).

The Ottawa Charter, alongside the WHO (1981) Health for All strategy, which was launched in 1979 and indicated the need to bring health within the reach of all populations, gave rise to the Healthy Settings movement (WHO 2024b). This movement promoted settings-based approaches to health promotion that are holistic and multidisciplinary. Settings in this context are defined as: ‘The place or social context in which people engage in daily activities in which environmental, organizational, and personal factors interact to affect health and wellbeing’ (WHO 2024b) and include environments such as hospitals, schools and universities, villages and cities.

In the public sector, the Academy of Medical Royal Colleges, the Royal College of Nursing and the Allied Health Professions Federation made a collective commitment to support the Public Health England (2019) healthy workplaces agenda, through a consensus statement for action on health and work (Academy of Medical Royal Colleges et al 2019). As part of this consensus statement, these organisations committed to working individually and collaboratively to enable all healthcare professionals to understand:

Importantly, the consensus statement included a commitment to enable all healthcare professionals to ‘recognise their own role to support healthy and safe working environments, looking after their own health and wellbeing and those of their colleagues’ (Academy of Medical Royal Colleges et al 2019).

Health promotion and self-care

Health promotion is a central part of the nursing role in the UK. Promoting health and preventing ill health is one of the main domains in the Nursing and Midwifery Council (NMC) (2018a) Standards of Proficiency for Registered Nurses, which states that nurses must be able to ‘understand and apply the aims and principles of health promotion, protection and improvement and the prevention of ill health when engaging with people’. However, this understanding may not always translate into self-care (Ross et al 2017).

Obesity is a significant public health concern as a leading cause of death globally. It is associated with the development of long-term conditions such as type 2 diabetes, cardiovascular diseases and cancers (Safaei et al 2021), resulting in a substantial economic burden (Tremmel et al 2017). Obesity statistics published in the 2021 Health Survey for England estimated that 26% of the population had obesity and a further 38% were overweight, totalling around 64% with either overweight or obesity (Baker 2023). Evidence suggests that rates of overweight and obesity among nurses are equivalent to, or higher, than the general population. For example, in an analysis of data from the 2012 Health Survey for England, Kyle et al (2017) reported that the prevalence of obesity among nurses was 25%. In a similar study using data from the 2012 Scottish Health Survey, Kyle et al (2016) calculated that the prevalence of overweight and obesity among nurses in Scotland was 69%.

Various survey-based studies have identified that a high proportion of nurses and nursing students in England are overweight or have obesity, engage in low levels of physical activity and consume an ‘unhealthy’ diet (Malik et al 2011, Blake and Patterson 2015, Blake et al 2017, 2021, Austin et al 2022). An unhealthy diet in this context means they do not consume the UK government recommended daily intake of ‘five a day’ (that is, five 80g portions of a variety of fruit and vegetables per day) (Office for Health Improvement and Disparities 2023) and consume foods that are high in fat and sugar.

The high prevalence of overweight, obesity and unhealthy diets observed in nursing student populations (Blake et al 2017, 2021, Austin et al 2022) suggests that patterns of behaviour, such as consuming unhealthy foods and engaging in low levels of exercise, may be established early in nurses’ careers. This may also be exacerbated by nursing students’ lack of knowledge about the risks associated with obesity (Gormley and Melby 2020). Such behaviour patterns may have implications for future practice, as there is some evidence to suggest that obesity and unhealthy diet habits in nursing students predicts negative attitudes towards, and low confidence in, delivering health promotion to patients (Blake et al 2021). Unhealthy diet and obesity have also been found to adversely affect nurses’ willingness or ability to promote healthy eating to patients, as well as their confidence in whether patients will heed healthy eating advice (Blake and Patterson 2015).

Nurses as role models for health

There has been ongoing debate in the nursing literature regarding whether nurses should act as role models for health (Rush et al 2005). Darch et al (2019) noted that UK government and international professional policies have established an expectation that nurses should act as healthy role models. However, since the evidence discussed in the previous section suggests that dietary habits, engagement in physical activity and rates of overweight and obesity in nurses are largely comparable with those of the general population, it could be argued that some nurses are not necessarily role models for the healthy behaviours they are expected to promote.

Survey-based studies on health promotion practice have reported that views of nurses and nursing students on acting as role models for health align with professional expectations (Blake and Patterson 2015, Blake et al 2017). However, other studies have reported that nurses and nursing students share the same challenges regarding their health as the rest of society and that they have diverse views about whether they should be expected to act as healthy role models (Darch et al 2019). Moreover, some nurses feel that it is unacceptable for there to be professional expectations relating to their personal behaviours (Kelly et al 2017, Wills et al 2019).

Nurses’ views on whether they should be expected to act as role models for health may influence the health promotion advice they provide to patients and the way in which patients receive, and heed, such advice. For example, Blake et al (2021) explored whether obesity and dietary habits were related to attitudes towards healthy role modelling and health promotion practice among 346 nursing and midwifery students. The researchers reported that those who held positive attitudes towards acting as healthy role models were more likely to display positive attitudes towards, and engage in, health promotion practices with patients.

Blake et al (2021) also identified that respondents who were overweight or had obesity were less likely to believe that nurses or midwives should be role models for health and more likely to have negative attitudes towards health promotion practice compared with those of a healthy weight. There may be various reasons for this, including a lack of confidence in engaging in health promotion practices with patients relating to diet or weight management.

In a survey undertaken by Wills and Kelly (2017) involving 196 nurses, many of those with self-reported obesity said that their weight status made it challenging for them to discuss weight-loss and healthy lifestyles with patients.

In another survey of nurses with self-reported obesity (n=71), Wills et al (2019) reported that 48% of respondents perceived that their weight status made the public less likely to trust their public health messages. Blake et al (2021) found that nurses who consumed a healthier diet and had a lower body mass index (BMI) reported greater confidence that patients would heed their health promotion advice compared with nurses who consumed a less healthy diet and had a higher BMI.

Barriers and enablers to healthy eating at work

If nurses are to act as role models for health, and/or maintain the level of health they need to carry out their professional roles – as stipulated by the NMC (2018b) – they need to be able to prioritise self-care, including at work.

Marko et al’s (2023) systematic review of 29 qualitative, quantitative and mixed-method studies exploring healthy eating in hospital nurses (n=8,024) categorised the main barriers and enablers as environmental, organisational, interpersonal and intrapersonal (Box 1). The reviewers suggested that factors within these groups can all interact; for example, eating healthily while at work may be challenging for a busy nurse who is working night shifts, has low personal motivation to eat healthily, has easy access to unhealthy foods at work and is influenced by social norms (for example, consuming food gifts provided by patients or family members) (Marko et al 2023).

Research involving nurses in various countries and across healthcare settings has identified more barriers than enablers of healthy eating at work (Nicholls et al 2017, Uchendu et al 2020). These barriers may be challenging to overcome, particularly for newly registered nurses. For example, Han et al (2019) reported that novice nurses often experienced difficulties with engaging in, or maintaining, healthy behaviours at the same time as negotiating a new workplace. Therefore, there is a need for healthcare organisations to make healthy choices an easier option for the nursing workforce.

Supporting healthy eating at work

An evaluation of a five-year NHS workplace wellness intervention – which included health campaigns, health promotion activities and access to exercise facilities – found that an increased proportion of staff reported positive dietary habits (for example eating the government recommended five a day portion of fruit and vegetables), as well as increased physical activity and reduced sickness absence (Blake et al 2013). The NHS sickness absence rate in England in February 2024 for nurses and health visitors was around 5% (NHS Digital 2024), so any workplace intervention that may reduce this figure could result in significant cost savings.

There is a lack of published evidence that focuses specifically on healthy eating and/or weight management interventions for nurses. Stanulewicz et al’s (2019) systematic review of 136 studies of lifestyle health promotion interventions for nurses found that only nine of these studies focused on healthy eating. The interventions explored in the studies included: online or face-to-face education on nutrition or healthy eating; skills development, for example cooking classes; behavioural strategies, for example monitoring dietary habits and exercise, goal setting and creating self-care or action plans; and the provision of physical resources, for example water bottles, sandwich boxes and ‘healthy’ cookbooks (Stanulewicz et al 2019). Several of the studies adopted more than one intervention or approach, with some of them focusing on exercise and diet.

Most of the interventions led to improved self-reported dietary habits or nutritional intake (Stanulewicz et al 2019). However, the tools used to measure the improvements varied, while only two of the studies were randomised controlled trials and the other seven studies had no comparison group, meaning the evidence on effectiveness of the interventions was drawn from studies with methodological limitations (Stanulewicz et al 2019).

The international literature is also limited, although some evidence from Denmark has indicated that the provision of healthy meals to nurses during their working hours could improve the quality of their dietary intake (Leedo et al 2017), while a study undertaken in Singapore reported that weight loss in nurses may be achieved using a weight management coaching mobile app (Lim et al 2022). Given the lack of high-quality studies on interventions to support healthy eating in nurses, it has not yet been established which interventions are effective for different nursing roles and workplace contexts.

A useful resource for nurses may be Health and Wellbeing at Work for Nurses and Midwives (Blake and Stacey 2022), a book co-edited by the author of this article. The book contains strategies for promoting physical and mental well-being and explores various aspects of self-care, including how to manage shift work – a factor that has been identified as having a significant role in the development of obesity in nurses (Zhang et al 2020). It also includes examples of effective practice, such as a weight management programme at an NHS trust delivered as part of a workplace wellness programme that led to several staff members, including nurses, losing more than 5% of their body weight. Personal case studies are also included, such as one written by a former chief nursing officer for Scotland who describes how her own effort to become more physically active was a catalyst for engaging nurses in a walking initiative – the ‘Step Count Challenge’.

There is a need for interventions to support healthy eating and weight management in nurses, and it may be beneficial if such interventions are introduced during preregistration nurse education programmes. This may help to support a healthy nursing workforce and contribute to high-quality health promotion practice.

Table 1 suggests individual and organisational approaches for improving healthy eating in nurses. The information is informed by the author’s expertise and the references cited in this article.

Conclusion

Health promotion is a central aspect of nurses’ roles, but their knowledge may not always translate into self-care. In addition, some evidence suggests that nurses who are overweight or have obesity may lack confidence in delivering health promotion to patients.

The health and well-being of the nursing workforce is vital to ensure delivery of high-quality healthcare services, yet there are various barriers to making healthier choices at work for nurses. Although further literature on interventions to support nurses’ health at work is required, there are various approaches that individual nurses and healthcare organisations can take to promote healthy eating and well-being in the workplace.