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• To recognise barriers to nursing students’ health promotion practice
• To read about nursing students’ and practice supervisors’ views and attitudes towards students’ health promotion practice
• To be aware of evidence-based resources that may be included in a toolkit to enhance nursing student’s health promotion practice
Health promotion should underpin undergraduate nursing curricula but approaches to teaching nursing students about health promotion vary widely and are rarely evaluated. A practice development project was undertaken to develop a toolkit of resources that would enhance the health promotion practice of nursing students on placements in community settings. The project was a collaboration between a community public health nursing team and a university in the south west of England. It involved students from one cohort of first-year children’s nursing students and practice supervisors from a community placement setting. The authors used an emancipatory practice development methodology to explore the views and attitudes of five nursing students and 11 practice supervisors. The findings were used to develop a toolkit of resources that could enhance nursing students’ health promotion practice.
Primary Health Care. doi: 10.7748/phc.2023.e1812
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondencerebecca.reynolds@plymouth.ac.uk
Conflict of interestNone declared
Reynolds R, Neill S (2023) Developing a toolkit to enhance nursing students’ health promotion practice. Primary Health Care. doi: 10.7748/phc.2023.e1812
AcknowledgementsThe authors would like to thank the nursing students and community public health nursing team who participated in this practice development project
Published online: 19 October 2023
Health promotion should be embedded in nurse education and population health should underpin undergraduate nursing curricula (Lasater et al 2020). However, approaches to teaching nursing students about health promotion vary widely and are rarely evaluated (Mooney et al 2011). Mooney et al (2011) ascertained that nursing students lacked confidence in undertaking health promotion and that this was partly due to a lack of focus on health promotion in nurse education.
Between January 2020 and January 2021, a practice development project was undertaken by a community public health nursing team and a university in the south west of England to develop a toolkit of resources that would enhance nursing students’ health promotion practice. The project involved students from one cohort of first-year children’s nursing students on a placement in the community public health nursing team as well as practice supervisors from the placement setting.
Health inequalities are avoidable, unfair and result in systematic differences in health, for example in life expectancy, between different groups of people. The term can also refer to differences in the factors that affect people’s health, such as access to and quality of care, behavioural risks to health and wider determinants of health (Williams et al 2022). A report published ten years after the Marmot Review, which examined differences in health and well-being among social groups in England, ascertained that the previous decade had been marked by deteriorating health and widening health inequalities (Marmot et al 2020). Life expectancy had stalled, inequalities in life expectancy had increased between deprived and wealthy areas and the inequalities in healthy life expectancy were steeper than the inequalities in life expectancy.
The UK government’s Levelling Up white paper announced a future strategy to reduce gaps in health outcomes, with a focus on prevention and addressing disparities by ethnicity, socioeconomic background and geography (Department for Levelling Up, Housing and Communities 2022). One of the white paper’s stated missions is to improve healthy life expectancy and narrow the gap in healthy life expectancy between areas where it is highest and areas where it is lowest.
Healthcare professionals have an important role in addressing health inequalities, notably by incorporating evidence-based interventions into their daily practice (Office for Health Improvement and Disparities 2022). They can use their routine interactions with patients to help them make positive changes to their physical and mental health and well-being, which is the basis of Making Every Contact Count (MECC), an approach that draws on the principles of behaviour change to engage people in conversations about their health using brief or very brief interventions (Public Health England 2016).
‘Promoting health and preventing ill health’ is one of the seven platforms of the Standards of Proficiency for Registered Nurses (Nursing and Midwifery Council (NMC) 2018). According to the NMC (2018), nurses’ role includes:
• Improving and maintaining the mental, physical and behavioural health and well-being of people, families, communities and populations.
• Supporting and enabling people to make informed choices about how to manage their health to maximise quality of life and improve health outcomes.
• Preventing and protecting people against disease and ill health.
• Engaging in public health, community development and global health agendas and in the reduction of health inequalities.
However, there are many obstacles to nurses delivering health promotion interventions, including organisational culture, heavy workloads, a lack of practical resources, a focus on disease-oriented tasks and a lack of support from management (Kemppainen et al 2013, Lee et al 2013). According to the Royal College of Nursing (2016), the top three challenges to nurses delivering public health services are a lack of resources, deficits in knowledge, training and skills and issues related to commissioning.
There is a gap between nurses’ professional responsibility to promote health and how it is applied in practice, with some nurses adopting attitudes in direct conflict with their responsibilities – for example, stereotyping, moral judgment and deferred responsibility (Nolan et al 2012, Coll et al 2016, Garry and Boran 2017, Marent et al 2018). Such attitudes could adversely affect nursing students’ learning opportunities during placements and emphasise the importance of positive attitudes for the development of health promotion practice.
An exploration of nursing students’ attitudes to health promotion found they considered it less important than other aspects of nurses’ role and that they did not prioritise it over clinical tasks (Mooney et al 2011). Gormley and Melby (2020) found that nursing students tended to have unhealthy lifestyles and lower levels of physical activity than recommended, as well as suboptimal knowledge of the risk of obesity (Gormley and Melby 2020). This is supported by Bak et al (2020), who found that nursing students’ behaviours in relation to diet, substance use and exercise were often suboptimal which could undermine their ability to influence others to adopt positive health behaviours.
Darch et al (2019), who investigated nurses’, nurse educators’ and nursing students’ perceptions of being healthy role models, found that nursing students did not necessarily think that their health behaviours affected their ability to promote health. Participants reported inadequate understanding of health promotion and a lack of healthy lifestyle content within undergraduate nurse education. They also had differing views about whether they should be healthy role models and some considered that modelling healthy behaviours would not in itself influence behaviour change in others (Darch et al 2019).
Other barriers to nursing students’ engagement in health promotion include lack of knowledge and lack of time (Bak et al 2020, Gormley and Melby 2020). Nursing students have emphasised the importance of working with skilled practitioners and having effective role models to support their health promotion practice (Gale et al 2016, Darch et al 2017, Bak et al 2020, Gormley and Melby 2020).
• Nursing students can develop their health promotion knowledge and skills during community placements
• Nursing students in this project were confident about their health promotion knowledge and skills, but less confident in their ability to communicate on health promotion topics
• Educational materials packaged as toolkits can support translation of knowledge into practice and promote the use of evidence-based interventions
• Health promotion resources toolkits for nursing students should contain information to reinforce and complement their knowledge and guide their skills acquisition
Community settings can offer high-quality learning to nursing students (Gale et al 2016, Shivers et al 2017), but not all students have a positive experience on community placements (Murphy et al 2012, Ridley 2012). Some authors have suggested that learning is maximised if a role and learning opportunities for the student have been determined before the start of their placement (Baglin and Rugg 2010, Brady et al 2019, Connor 2019). Health visitors mentoring nursing students during placements have attributed the quality of students’ experience to preparation but have also highlighted concerns about their capacity to support students (Ridley 2015).
The aims of this practice improvement project were to:
• Evaluate the health promotion knowledge and skills of first-year undergraduate children’s nursing students.
• Explore the opportunities for, and challenges of, nursing students gaining experience in health promotion practice during placements in community settings.
• Develop a resources toolkit that would enhance nursing students’ health promotion practice during placements in community settings.
An emancipatory practice development methodology was used. Emancipatory practice development focuses on translating evidence into practice and defining and contextualising best practice locally to ensure it is implemented (Shaw 2013). It is a bottom-up approach that involves collaboration and shared decision-making between stakeholders and therefore facilitates a sustainable transformation process (Bradd et al 2017).
The Model for Improvement, an approach to continuous improvement where changes are tested using plan, do, study, act (PDSA) cycles (Langley 2009), was used to structure the practice development project and address potential challenges in its design, delivery and sustainability.
The development of the resources toolkit was informed by the data collected from nursing students and practice supervisors using two separate questionnaires. The questionnaires were developed, and the responses analysed, using the COM-B model (Michie et al 2011), a framework for understanding behaviour change. The COM-B model posits that behaviour change is generated by the interplay of three essential conditions (Michie et al 2011):
• Capability – the individual’s psychological and physical capacity to engage in the behaviour, including having the necessary knowledge and skills.
• Opportunity – the factors that lie outside the individual that make the behaviour possible or prompt it.
• Motivation – the brain processes that lead to the behaviour, including conscious decision-making, habitual thought processes, emotional responding and analytical decision-making.
Eleven nursing students and 42 practice supervisors (who were all health visitors) were identified in the placement setting. The two separate questionnaires were piloted with three students and three practice supervisors from similar sample groups to the study population. The pilot showed a need to simplify questions to make it easier to quantify and compare responses. This led to a reduction in the number of free-text questions and an increase in the number of multiple-choice questions and questions using Likert-type rating scales.
An online questionnaire was chosen as the data collection method to facilitate engagement and because the project was undertaken during a period of lockdown prompted by the coronavirus disease 2019 pandemic. All potential participants – 11 nursing students and 42 practice supervisors – received an email with a link to the online questionnaire inviting them to take part. Five nursing students and 11 practice supervisors completed the questionnaires.
Table 1 shows the structure and content of the questionnaires.
| Section | Nursing student questionnaire | Practice supervisor questionnaire | Condition of behaviour change* |
|---|---|---|---|
| Section 1 | Capability | ||
| Section 2 | Opportunity and motivation | ||
| Section 3 | Views on a selection of health promotion resources and their inclusion in a resources toolkit | Opportunity | |
According to the COM-B model (Michie et al 2011)
The responses to the questionnaires were analysed using the COM-B model (Michie et al 2011) and each condition of behaviour change – capability, opportunity and motivation – was considered in relation to the design and content of the resources toolkit. Responses were used to identify barriers and facilitators to the implementation of the toolkit. Data analysis led to the development of a first version of the toolkit.
The project was categorised as a service evaluation according to the Health Research Authority decision tool (hra-decisiontools.org.uk/research) so did not require approval from a research ethics committee. The project was approved by the project supervisor at the university and the practice area managers.
The questionnaires were anonymous and no personal or demographic data were collected. As the nursing students were from the project lead’s faculty (the first author, RR), the voluntary and anonymous nature of the project was emphasised, and they were assured that participation would not influence their studies or assessments. No incentives were offered.
Potential participants were given information about the purpose of the project and were told that their confidentiality would be respected, that they could withdraw at any time and that data would be stored securely. They were then asked to give informed consent.
Students were asked to self-assess their knowledge and skills against the NMC (2018) proficiencies relating to health promotion and criteria drawn from the Healthy Child programme (Office for Health Improvement and Disparities 2023). All five students ‘somewhat agreed’ or ‘strongly agreed’ that they had the knowledge and skills required for all proficiencies and criteria.
Students were also asked to self-rate their confidence in their knowledge of 18 health promotion topics and their ability to communicate on those topics (Figure 1). Most students were ‘somewhat confident’ or ‘very confident’ in their knowledge of most topics. However, higher numbers of students rated themselves as ‘not so confident’ or ‘not at all confident’ in their ability to communicate on the listed topics.
Students were presented with a list of health promotion activities and asked which ones they were involved in. The students were mostly involved in activities using printed materials and displays and undertook minimal digital health promotion activities. Students were also asked how confident they were in using different methods of undertaking health promotion activities. They were most confident in using printed materials, small group discussions, social media and mobile applications (apps) or online resources and least confident in using individual discussions, large group discussions and public events.
In section 2 of their questionnaire, practice supervisors were asked to indicate what level of involvement they thought nursing students were capable of in a range of health promotion activities. One of the practice supervisors did not respond to all of the options in section 2, therefore that participants’ data were removed from this section. Responses for ten practice supervisors are shown in Figure 2.
In section 2, both groups were also presented with a list of factors that could influence students’ health promotion practice and were asked to indicate how much they agreed that these factors influence students’ health promotion practice. Their responses are shown in Figure 3.
Participants were presented with a range of suggested health promotion resources – shown in Box 1. The 11 practice supervisors felt that all resources were of value and could be included in the toolkit. The five nursing students placed more value on the national guidance and online training modules than on the local resources and templates and guides. Neither group recommended any additional resources.
National guidance
• All Our Health framework – collection of resources: www.gov.uk/government/collections/all-our-health-personalised-care-and-population-health
• Department of Health and Social Care – campaign resource centre: campaignresources.dhsc.gov.uk
• Healthy Child Programme – schedule of interventions: www.e-lfh.org.uk/pathways-healthy-child
• Public Health England – rapid review of the evidence base for the Healthy Child Programme: www.gov.uk/government/publications/healthy-child-programme-rapid-review-to-update-evidence
• Nursing and Midwifery Council – social media guidance: www.nmc.org.uk/standards/guidance/social-media-guidance
Online training modules
• NHS England elearning for healthcare – All Our Health: www.e-lfh.org.uk/programmes/all-our-health
• NHS England elearning for healthcare – Behaviour Change Literacy: portal.e-lfh.org.uk/Component/Details/595670
• NHS England elearning for healthcare – Health Literacy programme: www.e-lfh.org.uk/programmes/healthliteracy
• National Centre for Smoking Cessation and Training – training modules for very brief advice on smoking cessation: elearning.ncsct.co.uk/england
Local resources
• Link to information on local services and groups
• Information on local public health team
• Local health needs assessment data
• List of local groups and organisations offering opportunities for health promotion activities
Templates and guides
Abbott et al (2012), Davenport et al (2016) and Lane-Martin (2019) have described health promotion initiatives undertaken by nursing students which students evaluated positively and which had deepened their learning and increased their self-esteem. However, these initiatives were resource heavy and required large amounts of time and engagement, with implications for workload and sustainability.
Educational materials packaged as toolkits can be effective strategies for increasing professional awareness, translating knowledge into practice and promoting the use of evidence-based interventions (Giguère et al 2012, Barac et al 2014). However, there is limited evidence on the components of an effective toolkit for healthcare practice. Clear presentation is essential for ease of access and to increase motivation and capability, while an excessive number of resources can make users unsure which ones to use. Yamada et al (2015) and Davis et al (2017) suggested that toolkits should have a target audience, be succinct and clear and incorporate tested resources.
In this project, analysing participants’ responses using Michie et al’s (2011) COM-B model enabled the authors to develop a first version of a resources toolkit for enhancing nursing students’ health promotion practice.
Overall, the five nursing students appeared to be confident in their health promotion knowledge and skills. This finding did not align with the fact that they were in their first year of undergraduate nurse education but could be explained by Proctor’s supervision alliance model (Proctor 2001), according to which students in the early stages of an education programme do not recognise their deficits in knowledge and understanding.
The five nursing students were much less confident in their ability to communicate on health promotion topics, which did align with the fact that their clinical experience was limited. An optimal health promotion resources toolkit needs to contain information that will reinforce and complement students’ knowledge and guide them in acquiring and implementing skills, particularly confidence.
The five nursing students were confident in using printed materials for undertaking health promotion activities, which aligned with the fact that they were mostly involved in activities using such materials. The five students were also confident in using social media and apps or online resources, despite having little involvement in digital health promotion activities. This could suggest that they may be influenced by their learning experiences outside of educational settings, including in their personal lives. The practice supervisors, however, believed the students would need high levels of supervision to use social media or apps for health promotion activities. The discrepancy in views could indicate a lack of confidence among the practice supervisors in using social media as a health promotion platform and/or concerns about maintaining personal and professional boundaries (Geraghty et al 2018). If this is the case, they may benefit from further training in this area.
Students and supervisors agreed that more support and supervision were needed to enable students to use high-skilled techniques such as motivational interviewing. This should be considered when selecting resources for a health promotion toolkit for nursing students, for example online training in motivational interviewing and brief and very brief interventions.
Nine of the 11 practice supervisors (82%) strongly agreed that student motivation and student attitude are factors that influence nursing students’ health promotion practice. Four of the five nursing students (80%) strongly agreed that supervisor workload, student training, student confidence, role models in practice and access to current information are factors that influence their health promotion practice. It appears that each participant group tended to consider that the most influential factors were those that were out of their control. Resources selected for a health promotion toolkit should address attitudes among students and supervisors to improve students’ motivation to engage in health promotion activities and supervisors’ motivation to create opportunities for students to do so.
The project was conducted with a small group of nursing students and practice supervisors in one placement setting, so the findings are not generalisable. Participants self-selected, which increased the risk of response bias (Polit and Beck 2018). When responding to the questionnaire, participants did not have the opportunity to clarify the questions. Responses may have been limited by the inclusion of rating scales and multiple-choice statements, reducing the richness of the data (Polit and Beck 2018). Students’ responses could have been influenced by social desirability bias (Paulhus 1984) as they knew the project lead.
Based on the responses of practice supervisors, the first version of the toolkit included all the resources suggested in the questionnaire, which were evidence based and available online for free. Further evaluation will enable fine tuning of the selection of resources and identification of others that could be added. Further rounds of PDSA cycles (Langley 2009) will be required to audit the use of the toolkit, while a pre-post intervention study would be needed to assess its effects on nursing students’ health promotion practice. Qualitative research could be used to explore nursing students’ motivation to use resources toolkits in their health promotion practice.
Healthcare professionals have an important role in addressing health inequalities, therefore health promotion should underpin undergraduate nurse education. One way for nursing students to develop their knowledge and skills in this area is to undertake health promotion activities during community placements. A community public health nursing team and a university in the south west of England collaborated on a practice development project that explored the views and attitudes of nursing students and practice supervisors regarding students’ health promotion practice. The COM-B framework for understanding behaviour change was used to analyse participants’ responses to questionnaires and each condition of behaviour change – capability, opportunity and motivation – was considered to develop a toolkit of resources that could enhance the health promotion practice of nursing students on placement in community settings.
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