Nurses can benefit from good, sound nutrition to help them lead healthy lives. Nurses play an integral role in healthcare whether they are working at the patient bedside, caring for patients in a physician office, or providing care and education as part of public health. They are caregivers, lifesavers, cheerleaders, confidants, trusted resources, and so much more. This is why it is so important for nurses to take care of themselves as well. Nurses can benefit from good, sound nutrition to help them lead healthy lives.

As nurses care for people, they may face multiple occupational and personal stressors, such as caring for patients who are seriously ill, sleep deprivation due to variable and long work schedules, and addressing family responsibilities. It is not difficult to imagine why nurses often place the health of others before their own health, but this is where a change in thought is required. When healthcare professionals, such as nurses, care for their own health, it is reasonable to think that this will help them to better care for patients. Good nutrition is a simple yet integral part of healthy behavior that can be easily incorporated into the daily routine of a nurse. For example, healthy food choices may help to manage stressors, maintain weight at a healthy level, and improve energy levels.

Research has demonstrated that nurses have concerns about both providing complex nutritional information to patients and patient perceptions of their body image. In addition to the importance of nutrition for the good health of nurses, it is often nurses who provide nutrition assessment and/or education to patients. In this role, they provide information about nutrition to patients, but also serve as role models. Research has demonstrated that nurses have concerns about both providing complex nutritional information to patients and patient perceptions of their body image (Bjerrum, Tewes, & Pedersen, 2011; Ilmonen, Isolauri, & Laitinen, 2012).

Eating for good health is one important way that nurses can reduce the impact of stressors on the body and positively influence their health, hopefully improving their satisfaction with both work and life in general. This article reviews two common nutrition related areas of concern to nurses, stressors, inflammation, and nutrition and sleep and eating patterns, that can lead to obesity. Knowledge and attitudes about nutrition education are also briefly discussed. Finally, the article offers a review of nutrition basics for nurses and suggestions to avoid potential food pitfalls common for nurses.

Stressors, Inflammation, and Nutrition

Impact of Stressors and Inflammation

...healthy food choices may help to manage stressors, maintain weight at a healthy level, and improve energy levels. Most people experience stressors throughout life in both professional and personal settings. Stressors can be psychological and physiological. One explanation for stressors is a pathological process that is a reaction of the body against external and abnormal conditions that require physiological regulation (Romeo, Warnberg, Gomez-Martinez, Diaz, & Marcos, 2008). When a person undergoes a stressful event or situation, changes will occur within the body. These physiological changes may have some positive effects in the short term, such as boosting the immune system, but the long term effects can lead to impaired immune functions and changes in hormone secretion (Romeo et al., 2008).

One belief is that stressors can influence nutrition intakes and body composition. Chronic distress from one or more stressors has been associated with increasing appetite and increasing preference for high fat and high sugar foods (Barrington, Beresford, McGregor, White, 2014). These behaviors tend to feed into one another, making a vicious cycle that is difficult to break unless the stressor is removed. If stress levels remain high, a person often feels hungry and eats more, especially more of the foods that are high in sugar and fat. High sugar and high fat foods tend to have greater calorie levels, but less beneficial nutrients such as vitamins and minerals. This pattern leads to a greater likelihood of fat deposition to cause obesity. The final part of this cycle is that obesity is linked to the development of other chronic conditions such as cardiovascular disease, Type 2 diabetes, and osteoarthritis (CDC, 2012).

...stressors can influence nutrition intakes and body composition. Obesity is now classified as a disease and is currently rampant in the United States (American Medical Association, 2013). In 2012, the Centers for Disease Control and Prevention (CDC) estimate that approximately 34.9% of adults in the United States are obese (CDC, 2012). This affects the cost of healthcare, as individuals who are obese have medical costs that are significantly higher than people of normal weight (CDC, 2008). Obesity is classified as an actual physiological stressed state that involves physical, psychosocial, and emotional influences. (Dandona, Aljada, Chaudhuri, Mohanty, & Garg, 2005)

When the human body is in a continual stressed state, such as with obesity, this can lead to an increase in chronic inflammation. Overweight and obese patients are a physical stressor to nurses when providing patient care as the nurse is often responsible for moving or lifting these patients. This may lead to increased occupational injuries for nurses. However, obesity is a personal concern for nurses as well, due to poor nutrition habits and other lifestyle choices. The effects of poor nutrition in nurses will be discussed later in the article.

One outcome of chronic inflammation is oxidative stress. Oxidative stress occurs when an overproduction of byproducts from normal cellular metabolism causes damage to components of the human body such as deoxyribonucleic acid (DNA), lipids, and proteins (Sies, Stahl, & Sevanian, 2005). This is very poor for the body and can affect metabolism and how food is utilized as a fuel.

Impact of Nutrition on Inflammation and Oxidative Stress

The key to good nutrition, and the modulation of stressors and inflammation, is to have healthy nutrient intakes before any chronic conditions develop. Nutrients are very powerful in the body and can help to decrease inflammation and subsequent oxidative stress (Sies et al., 2005). Examples of nutrients thought to be beneficial to decrease the effects of stressors and inflammation are antioxidants and fatty acids. Conversely, an intake of foods high in other fats and sugars, as described in this cycle above, do not support the modulation of stressors and inflammation (Barrington et al., 2014). This section briefly describes the potential impact of these nutrients on stressors and inflammation.

Antioxidants. Foods high in antioxidants are especially effective in decreasing inflammation and subsequent oxidative stress. An antioxidant is anything that can prevent or inhibit oxidation (Benzie, 2000). Antioxidant nutrients include Vitamin C, Vitamin E, and carotenoids.

Foods that are rich in antioxidants are predominantly fruits and vegetables, but also include some nuts and oils. For example, citrus fruits are high in Vitamin C; almonds and sunflower oil are good sources of Vitamin E; and orange or yellow vegetables are high in carotenoids. Research suggests that obtaining antioxidants directly from food sources offers more protection against development of chronic diseases, as opposed to supplementing one’s diet with purified antioxidants such as supplements (Rink et al., 2013). There are many theories about why this increased protection occurs, but most likely it is due to the synergistic effect that results from multiple nutrients available from food. In other words, taking just one vitamin or mineral in the form of a supplement may be less effective than eating food filled with many nutrients that help one another to be absorbed and used by the human body (Rink et al., 2013).

Fatty acids. Antioxidants are not the only defense to inflammation and oxidative stress. It is just as important to include some fatty acids in the diet. It is likely that most people have heard that it is necessary to eat fish every week, but why is this recommended? Fish, especially fatty fish like tuna and salmon, are good sources of eicosapentaenoic acid (EPA) and docosahexanoic acid (DHA) (Vannice & Rasmussen, 2014). EPA and DHA are otherwise known as omega-3 polyunsaturated fatty acids. In the body, these polyunsaturated fatty acids can help modulate inflammation and increase cell growth, hence also fighting oxidative stress. Research indicates that consuming two servings (3 ounce portions) of fish each week is effective in decreasing inflammation (Vannice & Rasmussen, 2014). This reduction in inflammation in turn has positive effects in the body, such as decreasing blood pressure and decreasing risk of developing cardiovascular diseases (Houston, 2013).

Fats and sugars. On the other hand, foods such as red meat or other foods high in fat and sugar are not considered very beneficial to health. As stated previously, the presence of life stressors tends to be associated with an increased intake of high fat and high sugar foods which lead to obesity (Barrington et al., 2014). Therefore, it is prudent to limit intake of high fat and high sugar foods as part of the daily diet. An analysis of data from the Nurses’ Health Study looked at red meat intake, inflammation, and glucose metabolism (Ley et al., 2014). The study showed that a greater intake of red meat was associated with higher levels of inflammatory markers in the blood. Another interesting outcome was that substituting an alternative protein source (e.g., poultry, fish or legumes) for a serving of red meat caused a decline in the inflammatory markers in the blood (Ley et al., 2014). Red meat does not have to be entirely eliminated from the diet, but this study does suggest increased inclusion of protein sources other than red meat in the diet.

Sleep and Eating Patterns

...long hours and variable shifts impact the sleep cycle of a nurse and this variability does not have a positive effect on personal health. Nursing is a twenty-four hour, seven days a week profession. Certainly there are some exceptions to this rule, but most nurses work weekends, holidays, and variable shifts. This means that many nurses are required to work evening and night shifts, often twelve hour shifts, and even variable schedules (when a nurse may work daytime hours one day and a few days later work all night). These long hours and variable shifts impact the sleep cycle of a nurse and this variability does not have a positive effect on personal health. The full impact of poor sleeping patterns is beyond the scope of this article, but this section will consider how poor sleeping patterns may interact with nutrition.

Quality sleep (at least 7-8 hours) is as important to health as nutrition and exercise (Ohlmann & O’Sullivan, 2009). Sleep is needed to repair the physical body and maintain emotional balance. Circadian rhythms regulate many biological processes such as sleep-wake cycles, hormone secretion, and energy metabolism (Pan, Schernhammer, Sun, & Hu, 2011). These circadian rhythms are controlled by a biological clock which is located in the brain and is influenced by natural dark and light cycles. Severely or consistently interrupted circadian rhythms may lead to adverse health effects.

Research has demonstrated that lack of sleep with disruption of circadian rhythms may have significant health related outcomes, such as chronic diseases and/or obesity. Research has demonstrated that lack of sleep with disruption of circadian rhythms may have significant health related outcomes, such as chronic diseases and/or obesity. In a study conducted by Pan et al. (2011) regarding rotating night shift work and risk of Type 2 diabetes, researchers found that women with more years of rotating night shift work were more likely to have a higher body mass index (BMI) and were at increased risk of developing Type 2 diabetes. This research indicated that the disruption to circadian rhythms during a rotating night shift schedule may have been associated with a decrease in leptin; an increase in glucose and insulin levels; and an increase in arterial blood pressure (Scheer, Hilton, Mantzoros, & Shea, 2009). Further research has demonstrated that when sleep is restricted, leptin levels decrease and ghrelin levels increase (Ohlmann & O’Sullivan, 2009). Leptin is a hormone responsible for promoting satiety, or a sense of feeling full, whereas ghrelin is a hormone responsible for stimulating appetite. These types of hormonal patterns or imbalances are likely responsible for the patterns of increased intakes of calorie-dense, high carbohydrate foods experienced when a person has not had adequate sleep. Similar to the cycle described above related to stressors and consumption of high fat and/or high sugar foods, this irregular sleep and subsequent hormone imbalance pattern also contributes to obesity and development of chronic diseases. Thus the nurse who frequently works variable shifts, or does not get adequate sleep due to long working shifts, is at increased risk of hormonally developing poor eating patterns and adiposity or obesity (Pan et al., 2011; Ohlmann & O’Sullivan, 2009; Scheer et al., 2009).

Sleep deprivation not only has negative effects on health. It may also impact a person’s work ability, also a serious concern for nurses who must care for patients with accuracy and excellent judgment. A nurse who is continually sleep deprived may be making more mistakes, errors that could be life threatening for a patient. Signs of sleep deprivation include depending on an alarm clock to wake up, being addicted to caffeine or other stimulants, making frequent mistakes, feeling depressed or uptight, and frequent illness (Ohlmann & O’Sullivan, 2009).

One way to decrease sleep deprivation is exercise, which tends to improve sleep quality. Recognizing the desire for high calorie, high carbohydrate, and/or high caffeine foods when sleep deprived is important as well. When this behavior or craving is acknowledged, healthier food selections can be made – choices that will help combat feelings associated with sleep deprivation. It can be helpful to eat routine meals that are well balanced (e.g., a meal that contains lean protein, high fiber carbohydrates and foods rich in vitamins and minerals like fruits and vegetables). Even when working night shift, the goal should be routine meal patterns in order to avoid excessive nutrition intakes and reliance on stimulating foods such as caffeine. Most importantly, make sleep a priority.

It is important to remember that quality sleep, along with exercise and healthy food choices, all contribute to personal health. It is important to remember that quality sleep, along with exercise and healthy food choices, all contribute to personal health. However, the topic of nutrition and health is not exclusive to either a nurse’s personal or professional life; there is overlap in these roles. Nurses consider nutrition and health on a personal level, but also in the realm of education for patients. The next section briefly discusses some research related to nurses’ knowledge and attitude about nutrition education.

Nurses’ Knowledge and Attitudes about Nutrition Education

Nutrition is a vital piece of healthcare, and providing nutrition education rests on the shoulders of all healthcare providers. Other healthcare professionals such as physicians and dietitians provide nutrition education, but the nurse is expected to support and reinforce nutrition education. For example, nurses need to know nutrition basics for practice applications such as completing nutrition screening for hospital admission or counseling a new mother on the benefits of breastfeeding.

Nutrition is a part of nursing curricula, whether as a stand-alone course or integrated into multiple courses. The increase in chronic disease rates has led to nurses providing even more nutrition education as part of patient care. The question then arises – how knowledgeable do nurses feel about nutrition and are they comfortable providing nutrition education? Ilmonen et al. (2012) studied nutrition education practices of nurses in mother and child health clinics. The majority of nurses reported nutrition as part of their nursing education, but they did not feel it was sufficient. They expressed a need for more extensive nutrition education to support their nursing practice. In this same study, approximately 60% of the nurses reported nutrition counseling was challenging because of inadequate knowledge of nutrition and difficulties in cooperating with clients. These findings support the need for further nutrition training and education for nurses. In another study, a training program with a significant nutrition focus was provided to nurses from each ward within a hospital (Bjerrum et al., 2011). After the training program, nurses reported increased awareness about the importance of ensuring nutrition for patients and they seemed more aware of the complexity of nutrition problems.

...nurses and other healthcare professionals need to feel comfortable discussing the treatment and management of obesity with patients. One of the largest health related epidemics in the United States today is obesity (Jensen et al, 2013). Obesity is a topic that nurses are frequently required to address with patients, especially when dealing with the management of chronic conditions such as diabetes or cardiovascular disease. A study by Brown and Thompson (2007) found that primary care nurses felt obesity was an awkward and sensitive issue to discuss with patients. This study also found that nurses were challenged to establish trusting relationships with patients when discussing obesity management. Educating obese or overweight people on how to manage weight has been a sensitive topic for many years. As far back as 1998, a study published by Wright found that nurses reported discomfort when advising patients who are overweight. These studies support the idea that obesity remains a stigmatized condition by the public, yet obesity rates continue to increase. With the newer idea that obesity is characterized as a chronic condition or disease (Jensen et al, 2013), nurses and other healthcare professionals need to feel comfortable discussing the treatment and management of obesity with patients.

It is not unreasonable to think that the body weight of nurses may affect how nurses provide care to patients or how patients perceive the care a nurse provides. One study found that people in the public were less confident in an overweight nurse’s ability to provide education on diet and exercise and were more confident to receive diet and exercise education from a normal weight nurse (Hicks et al., 2008).  It is concerning that some research indicates that body size and/or weight does affect the public’s perception of ability to provide medical care and education because this may not be directly related to a healthcare provider’s knowledge of a subject (Hicks et al., 2008).  

Nurses and other healthcare providers are cognizant of their weight and image. Research has indicated that nurses with a higher BMI have reported feeling self-conscious about their own body size when discussing obesity with patients; nurses with a higher BMI reported feeling guilt that they were not good role models for patients (Brown & Thompson, 2007). On the other hand, nurses with a lower BMI had concerns that they lacked empathy or authentic experience when discussing obesity with patients (Brown & Thompson, 2007). In order to provide successful nutrition education, it is important to establish a trusting relationship between the patient and the nurse, preferably without a focus on the weight of the nurse.

In sum, nurses are an integral part of the healthcare team, and as such it is imperative to provide appropriate, additional nutrition education for nurses to help them have confidence and be successful in their role as a significant patient educator. The following section offers some basic information about nutrition for nurses that can be helpful as they speak with patients about nutrition-related health concerns and as they make personal food choices.

Nutrition Basics for Nurses

Nurses, and other healthcare providers, encounter barriers to healthy eating just as patients do. Nutrition can be difficult to understand today because there is so much information available. There are hundreds of books, websites, diet plans, television shows, and apps – it is hard to know which are based on valid, evidenced-based nutrition principles and which are not. Nurses are required to learn about nutrition, either while taking coursework for a nursing degree or when learning how to screen patients for nutrition problems. Yet, in my practice working alongside many nurses, I have noticed that it often seems to be challenging for them to translate that nutrition knowledge as part of a personal healthy lifestyle. Nurses, and other healthcare providers, encounter barriers to healthy eating just as patients do.

The concept of nutrition has many facets. To get the most benefit from healthy eating habits, it is important to incorporate all of these facets daily. Several basic nutritional principles, such as consistency, portion size, and variety, can help nurses and patients alike to make healthier food choices.

Consistent Intake

One of the most critical points of healthy nutrition is to have consistent nutrition intakes. This means that most days a person should eat routine meals and/or snacks. When the human body is consistently fed, it will better utilize the nutrients instead of storing nutrients for possible later use, which often translates to more fat stores or adiposity (Mahan, Escott-Stump, & Raymond, 2012). This principle applies regardless of work shift – day or night. If a nurse works night shift, routine meals and snacks should be eaten during awake time just as if the nurse was working the day shift.

Portion Size and Caloric Intake

Another key to success is portion size and knowing just how much is appropriate to eat. One of the most common mistakes with meal planning is inaccurate portions and the belief that more calories are needed than are actually necessary for health. Many equations exist to calculate individual calories; most will factor in height, weight, age, and physical activity level (Mahan et al., 2012). When calculating calories, it is important to know what variables (e.g., height, weight, age) go into the equation and that the equation has been validated to more accurately estimate energy needs. There is no perfect equation for calculating calories, so the recommended daily calories obtained from any equation should only be used as a reference point to provide guidance. The best way to have calories calculated is to meet with a registered dietitian who will have the knowledge necessary to ensure that the calories recommended are truly appropriate for a particular individual.

There are many ways to measure portion sizes, but the following points may make this task a bit simpler. First, food labels are there to provide information to the consumer, so it is important to use them. The portion size of a food can be found on the Nutrition Facts panel (Food and Drug Administration [FDA], 2014). All other nutrition information listed on the Nutrition Facts panel pertains to the portion size listed for that food item. This allows the consumer to know how many calories, and how much protein, fat, carbohydrates, and other nutrients, are eaten with the reported portion of the food. Second, a common error may occur if a person eats more than the portion size listed on the Nutrition Facts panel. This must be accounted for by the consumer calculating portion size. For example, a person may wish to make a sandwich with two slices of bread. On the Nutrition Facts panel the serving size is listed as one slice, and in that one slice of bread there are 110 calories. When the sandwich is made with two slices of bread, this will provide 220 calories because there are two servings of bread in the sandwich. All other food items within the sandwich, between the two slices of bread, will contribute calories as well. This concept appears simple, but frequently the serving size is overlooked. Many more overall calories; and grams of fat and carbohydrate are consumed unknowingly, leading to excessive calorie intakes. Excessive nutrition and calorie intakes add up to increased risk of obesity.

Variety and Preparation

Variety is essential to meal planning, to balance meals and help control portion sizes. Variety means that vegetables, fruits, grains or starches, dairy, and meat should be included in the daily meal plan. This clearly implies that eating unlimited amounts of any particular food is not recommended (Mahan et al., 2012).

Grains or starches should be in the form of whole grains that are higher in fiber such as whole wheat bread, brown rice, or whole grain pasta. Dairy should be low fat or fat free such as skim milk or yogurt made with non-fat milk. Meats should be lean and prepared in cooking methods other than frying such as boneless skinless chicken breasts or pork tenderloin. It is beneficial to eat whole fruit instead of fruit juice. Both fruit and fruit juice count as a serving of fruit, but an apple has much more fiber, vitamins and minerals than a small serving of apple juice. Also, the apple will provide a better sensation of feeling full. It is appropriate to enjoy vegetables both raw and cooked, but be careful to not add extra calories with butter or cheese sauces.

Fruits, vegetables and fish are high in antioxidants that can help to reduce inflammation and oxidative stress (Sies et al., 2005). It is a good idea to eat a variety of fruits and vegetables if possible because incorporating choices of different colors (e.g., orange, red, green, purple) offers a variety of nutrients that are beneficial for health. Foods considered rich antioxidant sources include spinach, cantaloupe, sweet potatoes, sunflower seeds, and peanuts.

A study by Rink et al. (2013) demonstrated that when subjects consumed five or more servings of fruits and vegetables per day they saw higher plasma and serum concentrations of antioxidants and lower biomarkers of oxidative stress. This finding is significant because it offers a relatively easy way to decrease the oxidative stress response in the body. Eating more fruits and vegetables will also tend to decrease caloric intake while helping a person to feel full and satisfied.

In order to get the most benefit from fish, it must not be fried. Frying fish increases the fat and calories, but it does not increase the amount of beneficial fatty acid compounds in the fish. Studies indicate that using fish to replace other high fat meats in the diet does help to decrease inflammation (Vannice & Rasmussen, 2014). Consider substituting other non-meat protein sources for high fat meats. Using lean meats and legumes, such as black beans or soybeans, instead of high fat meats helps to decrease calorie intake and may help to decrease inflammation (Ley et al., 2014). For example, try to have a black bean burger instead of a ground beef burger.

Tips to Avoid Potential Food Pitfalls

Awareness of a few simple strategies can help resist temptation and encourage healthy eating habits at work. Deciding to eat healthy takes commitment and planning. Nurses can be challenged by this due to long work shifts or working nights and weekends. But there are several actions that nurses can take to avoid the potential food pitfalls associated with occupational stressors such as shiftwork. Food pitfalls common in healthcare settings may include going to the cafeteria or local fast food restaurant to purchase food for meals and breaks, which often encourages overconsumption or an unbalanced meal. Another food pitfall is visiting the vending machine or gift shop to get that sweet food or calorie rich coffee that is “needed” to get over a stressful patient situation. A food pitfall can even be the “thank you” treats brought in by patients and clients or food provided by product vendors. Awareness of a few simple strategies can help resist temptation and encourage healthy eating habits at work.

Planning and Packing

To eat healthy when working a twelve hour shift or when going into the physician or public health office for the day, the nurse can benefit by having a plan for his or her meals. This is best accomplished by packing the majority of food that will be eaten during the work day. Packing meals allows the nurse to control the ingredients within the meal, assure that there is an adequate variety of food available, and helps the nurse to avoid food pitfalls.

Drinking Water

It is also important to take water to drink. Many calories are mindlessly consumed from beverages such as soda, cappuccino, or sports drinks. Water has no calories and is very good for the body.

Having One Treat

Certainly it is acceptable to indulge slightly and have a small serving of a treat brought in by a patient who appreciates the care received from a nurse. But, it is not a healthy choice to eat multiple servings of the treat and risk very excessive calorie intake. Make a plan to share the kindness (i.e., treat) with all of the office or facility staff to remove and reduce temptation to over consume.

Conclusion

It is time for nurses to take care of themselves and one facet of that care is good nutrition. Nursing is a tough job requiring extensive knowledge, quick thinking, patience and compassion. Nurses work long hours in rigorous demanding environments and with people they often do not even know until a particular moment of medical distress. The presence of physical and psychological stressors is certainly a major component of being a nurse. All of these factors can put nurses at risk of developing inflammation, oxidative stress, and obesity. This in turn often leads to chronic health conditions such as diabetes and cardiovascular diseases. These are the same diseases about which nurses are often trying to educate patients on a routine basis.

Nurses are on the front line in healthcare; as they adopt healthy living practices, the patients they care for may be more inclined to adopt healthy choices as well. It is time for nurses to take care of themselves and one facet of that care is good nutrition. As discussed in this article, there are many ways to achieve a healthy diet.  But the bottom line is that consistency of nutrition intakes, portion sizes, and variety are integral strategies for managing personal nutrition and health. Empowering nurses with knowledge about how nutrition impacts the human body and how healthy food choices can improve their personal health will hopefully help them to embrace positive eating habits. When nurses have healthy habits, such as a varied diet and adequate sleep, they, too, can feel better and decrease risk of developing chronic diseases.

Nurses are on the front line in healthcare; as they adopt healthy living practices, the patients they care for may be more inclined to adopt healthy choices as well. The goal of any healthcare provider is to improve the lives of other people. Nurses can do that even more effectively by taking the lead and deciding that healthy living is as important to them as it is for the people they care for on a daily basis.

Author

Denise Reed MS, RD, LD
Email: dreed8@ashland.edu

Denise Reed is a Clinical Assistant Professor in Dietetics at Ashland University in Ashland, Ohio. Prior to becoming an instructor in dietetics she worked for many years as a clinical nutrition manager and critical care dietitian for a Level 2 trauma hospital. While in clinical dietetics, Denise chaired and served on multiple medical staff committees and was responsible for clinical nutrition policy development for the institution. Denise is active in professional organizations such as the Academy of Nutrition and Dietetics and the American Society of Parenteral and Enteral Nutrition. She continues to work in clinical dietetics and takes an active role in providing practical nutrition education to practicing nurses as well as nursing students.

© 2014 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2014