In 2011-2012, more than one-third of adults in the United States (US) over age 20 (34.9%) classified as obese. In 2011-2012, more than one-third of adults in the United States (US) over age 20 (34.9%) classified as obese (Ogden, Carroll, Kit & Flegal, 2014). More than two-thirds were overweight or obese (National Center for Health Statistics, 2011). Obesity related conditions include high blood pressure, increased cholesterol, type 2 diabetes and related complications, cardiovascular disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, and cancers of the endometrium, breast, prostate, and colon.

The U.S. obesity epidemic and escalating costs associated with treatment of obesity-related health conditions continue to be problematic (US Department of Health and Human Services [US DHHS], 2010). As increasing numbers of patients require treatment for these conditions and education about achieving and maintaining a healthy weight, it is prudent for healthcare facilities to consider addressing this problem from within. Having a healthy workforce population is important from both an employee health perspective as well as an employer economic perspective.

... nurses have a distinct opportunity to educate not only patients, but also each other, about healthy lifestyle choices that incorporate a balance of exercise and proper nutrition. For industries with aging employees, such as nursing, the goal of a healthy workforce may be even more important to mitigate health changes associated with aging and to help nurses retain their ability to manage the physical demands of caring for patients. The average age of a nurse in the US is nearing 50 years (American Nurses Association, 2011). Nurses are typically well educated about caring for patients’ obesity-related health conditions, but we may be less informed about the exercise and nutrition balance required to maintain normal weight over a lifespan. Trusted professionals such as nurses have a distinct opportunity to educate not only patients, but also each other, about healthy lifestyle choices that incorporate a balance of exercise and proper nutrition.

This article will discuss the author and her colleagues’ institutional goal to achieve a healthier workforce at Inova Loudoun Hospital in Leesburg, Virginia. The overall aim was to expose nurses to aspects of healthier lifestyle, with a primary focus on the balance of exercise and nutrition. The author and her colleagues identified selected challenges for healthy eating and developed exercise and nutrition programs with specific obesity research interventions, such as Nurses Living Fit^™, and the author will briefly discuss these to provide context. A detailed exemplar will describe the various facets of comprehensive, hospital-based wellness program, including three annual walk or run events, one full day conference, and a series of multiple exercise, yoga, and nutrition programs. The conclusion will offer implications for education and practice in the hope that our experiences may motive nurses to design exercise and nutrition programs to promote normal weight maintenance in nurses.

Challenges for Healthy Eating and Exercise

The American lifestyle provides many challenges for eating healthy foods at each meal and snack and for getting the needed amount of daily physical activity. The American lifestyle provides many challenges for eating healthy foods at each meal and snack and for getting the needed amount of daily physical activity. Common challenges to healthy lifestyle choices may include: the greater accessibility and lower price of processed and fast foods (higher in fat and calories) rather than non-processed fresh, healthier, foods; living in areas that require driving vehicles to get around versus areas that support walking or cycling to activities such as work or school; social and family structures that require child and/or elder care after work hours; a societal standard where more people are overweight/obese than normal weight; and a plethora of medications available to treat the obesity-related health conditions.

As nurses, it is important to encourage a focus on living a healthier lifestyle, as opposed to taking medications to treat obesity related conditions. While medications may be effective at treating obesity related conditions, they do not treat the underlying problem of obesity and also medications have side effects. The needed focus on living a healthier lifestyle is applicable to not only patients, but nurses as well. More needs to be done to help everyone adopt healthy lifestyle choices to achieve and/or maintain a normal weight.  The more than 3 million nurses in the US have the opportunity to educate all whose lives they touch every day; collectively as a group, nurses have a great potential to promote healthier lifestyles. The author wondered, could a workplace wellness program for nurses motivate and help them improve their own health and in the process, role model healthy behaviors to others? This led to the development of the research, previously described in separate article (Speroni et al., 2012, Speroni, William, Seibert, Gibbons & Earley, 2013), and the programs described below.

Nurses and Fitness Programs; Our Experiences

Brief Overview of Our Research Studies

As a Registered Nurse (RN) researcher, I had the opportunity to lead teams comprised of RNs, Registered Dietitians (RDs), and exercise trainers to develop and test the Nurses Living Fit™ (NLF) program in a research study. The NLF program was designed to educate nurses about the optimal balance between exercise and nutrition, ultimately to achieve and/or maintain a normal weight (Speroni et al., 2012). A total of 217 nurses enrolled in this experimental study. The NLF intervention included 12 weekly exercise sessions, 4 once monthly yoga sessions, 4 once monthly nutrition sessions, and weekly healthy lifestyle principles review. Nurses in the control group received no intervention. NLF group (n=108) participants had a greater significant decrease in body mass index (BMI) and waist circumference than the control group (n=109). The NLF program was adapted from the earlier Kids Living Fit™ (KLF) program, also tested in research studies. There was a decrease in child participant BMI and/or waist circumference for the KLF participants as well (Speroni, Earley, & Atherton 2007; Speroni, Tea, Earley, Niehoff & Atherton, 2008). Both the NLF and KLF programs are featured on the Agency for Healthcare Research and Quality (AHRQ) Health Care Innovations Exchange (Speroni, 2009). Concepts associated with the impetus of these programs are described below.

Our Philosophy for a Healthy Lifestyle through Workplace Wellness Programs

Living a healthy lifestyle is a constant choice. This choice involves momentary decisions that require an individual to always evaluate options such as consuming an extra or higher calorie food or drink, and if doing so, following through with additional physical activity to compensate for the excess. For example, if I eat that extra bagel and cookie in the break room, am I willing to take the steps instead of the elevator at work for the rest of the day, or go for a long walk after work? The exact additional amount of physical activity to find this balance is always the question.

In the NLF research, we learned that nurses wanted more personalized exercise, more nutrition education, and year round programs (Speroni et al., 2013). While living a healthy lifestyle is a personal choice, we are more likely to achieve this with peer support. Ideally, nurses can find innovative ways to work with their organization to provide workplace wellness programs, but also to help in the design of year round programs that focus on exercise and nutrition education to achieve that healthy lifestyle balance to maintain normal weight. To this end, they can achieve the goal above of improving their personal health and also impacting the health of the populations that they serve.

The key is to reach out and do something versus waiting for the perfect program to come along. 

Programs can range from those like NLF intervention discussed here, to broader workplace wellness programs offered by the institution.  Broader programs may offer preventative health, exercise classes including zumba and yoga, and seminars on diet.  These programs may also have a feature for which participating employees who experience improved health (e.g., lower blood pressure, cholesterol or weight) have resulting lower monthly employee insurance premiums. The key is to reach out and do something versus waiting for the perfect program to come along. There is no such thing as the perfect program! You create programs, participate in them, and improve either yourself, the programs, or both over time. For example, in the KLF and NLF research we found that an eight week program worked better than a 12 week program and that repeat follow-up measure results supported the need for ongoing programs to best sustain weight loss.

The KLF and NLF research were an impetus for many other non-research fitness and nutrition events and programs we designed subsequently, as described below. Our nurses told the author and her colleagues that they wanted the programs to continue, so we did just that. Later in the process, we partnered with our human resources department to expand the options and facilitate provision of the programs to all hospital employees.

Exemplar: Developing Fitness Events and Program Series for Working Nurses

This section describes the evolution of our workplace wellness offerings and specific information about the events. The exemplar will discuss planning and offering the sessions and conclude with suggestions based on lessons learned from our experiences.

Planning for Events

In 2009, 2010, and 2011, we designed and offered a 1 mile walk or run/5 kilometer walk or run event. In 2012, we developed and offered a full day healthy living conference. While these events were designed primarily to motivate nurses to become more active, we opened the program to all hospital employees, families, friends, and the community which the hospital serves. Funding for the following two activities were made possible in part by the Health and Human Services Office on Women’s Health: the 2010 Nurses Living Fit™ 2^nd annual walk / run event; and the 2012 Women’s Community Living Fit Conference. Financial proceeds from events were used for the hospital’s nursing research program which included the previously described obesity research (Speroni et al., 2012, 2013).

Early in the process of developing our programs, we convened a volunteer task force to manage all aspects of each event. This task force included members from our hospital nursing research council, nurse researchers, community members (e.g., friends and family members of hospital nurses), and the hospital’s volunteer department. We developed an itemized task list agenda that addressed all areas of event planning with a clearly delineated task, champion, and timeline for completion. Regularly scheduled meetings began approximately four months before an event and increased in frequency as the event neared.

We received administrative support, allocated by our Chief Nurse Officer, as well as support from our hospital’s marketing and mobile health departments. Our marketing department helped with marketing strategies such as website development, and event promotion that included flyer development (Figure 1) and press releases. The mobile health van provided free screenings at the events, such as blood pressure and BMI measurements and glucose screenings.

In addition to hospital level support, we also collaborated at the community level. A partnership with a local running club helped us to better understand the requirements for holding a walk/run event. Local high schools were a source of volunteers on the day of the event for the walk/run.

To fund events, we sought sponsors and donations We developed a budget and tracked revenues from event fees, sponsors, vendors/exhibitors, and donations, as well as our expenses. Typical event expenses included race packet items (event t-shirts, Nurses Living Fit™ water bottles and pedometers), printing of materials/flyers, fees for website set-up to allow credit card payment by participants, sound system rental, and portable restrooms. Donated gift cards from local grocers and national retailers, such as Target and Costco, helped us to buy the fresh fruits, other foods, and water bottles that we offered at the finish line (see Photo).

The First Step: Holding Annual Events

We held the events rain or shine, and both rain and shine we had over the years. Even with a torrential downpour for the 2010 event, our runners and walkers still came! Brief summaries of several events are offered below.

Participants who opted-in received free blood pressure, BMI, and glucose screenings, and several abnormal results led to a recommendation for follow-up care with a healthcare provider.May 2010. The 2^nd Annual Nursing Living Fit™, “Leading the Way for Women’s Health” 1 Mile or 5K Walk/Run event was held on May 23, 2010. The event offered healthy foods at the finish line, and tips for overall health and wellness. Participants who opted-in received free blood pressure, BMI, and glucose screenings, and several abnormal results led to a recommendation for follow-up care with a healthcare provider. There were 104 participants pre-registered for the event and approximately 80 additional people attended. Event winners with the fastest time were recognized at the event by gender and age groups. Seven event sponsors and 15 event exhibitors supported this event, including local physician groups, health related businesses, grocers, and national retailers.

May 2012. This event was held indoors. The Women’s Community Living Fit Conference was held on May 12, 2012, with over 100 participants, speakers, and exhibitors. Participants exercised by walking, running and performing traditional yoga, or a series of chair-based exercises (e.g., Ageless Grace). The conference featured presentations by families associated with the Washington Redskins football team, physicians, professional chefs, a Registered Dietitian, and a contestant from the television show The Biggest Loser. A local healthy foods-oriented grocer provided a chef who demonstrated how to cook a healthy meal during the lunch session. Participants received food samples and recipes. The post-event participant survey indicated favorable reviews of the day’s events. There were nine event sponsors and 13 event exhibitors, including local universities, physician groups, grocers, health-related businesses, studios, and other businesses. The figure  provides an example of the press release.

The Next Step: Offering Weekly Programs

In addition to annual wellness events, we designed and offered a series of weekly exercise, yoga, and nutrition programs at the hospital. For the yoga program series, we focused on physical postures, breath, and meditation. Some nurses had limited mobility and/or osteoarthritis or other conditions that precluded general activity or yoga. For these individuals, we offered a program that allows seated exercises. For the nutrition program series we partnered with our hospital RDs. The nutrition lectures followed the content we provided our earlier KLF and NLF research interventions (Speroni et al., 2007; 2008; 2012). We addressed basic food nutrition, serving sizes, healthy food purchases/peripheral food shopping and to avoid processed foods, healthy cooking, health eating out, and portion distortion.

Our annual events and weekly programs contained information frequently recommended to support an overall healthy lifestyle view... Our annual events and weekly programs contained information frequently recommended to support an overall healthy lifestyle view, and based on what we included in the original NLF research program (Speroni et al., 2012). Specifically, these recommendations included:

1. Regular walking with a goal of 15,000 steps per day (modified for those who cannot complete this)
2. Performing yoga at least once per week
3. Limiting fast food meals to no more than two per week (or none, if possible)
4. Drinking a recommended amount of water per day (don't mistake thirst for hunger)
5. Sleeping eight hours per night (don't mistake fatigue for hunger"

Lessons We Learned

Offering and evaluating our annual events and weekly programs over several years has led to some suggestions for others who may be considering developing wellness programs to improve workforce health. These recommendations and resources are based on our observations and post event analyses.

Frequency and timing. For weekly exercise program series, consider starting with a 12 week session offered for one hour, one to two times per week. In our experience, this timing was effective because participants could dedicate one hour of exercise one to two times per week but typically not more due to work and family commitments.

Our program evaluations suggested that we needed to offer programs at varied times including during the lunch hour, in the evening during the weekday, and on weekends. Our program evaluations suggested that we needed to offer programs at varied times including during the lunch hour, in the evening during the weekday, and on weekends. For the working nurse, it can be nearly impossible to commit to a series of tightly scheduled programs over time due to shift work; lack of ability to leave the nursing work at the time of the program; finishing a shift on time; and other work/life responsibilities. While the best time will vary by hospital and nurse type, if you are considering providing a program series, solicit input from nurses to facilitate selecting the best time option.

Location. The capacity of programs such as walk/run events or conferences can be largely limited by space. If your organization doesn't have adequate conference space to hold exercise sessions, take the program outdoors if possible. Local school tracks can be considered as an option. Some hospitals have metered walks marked out in hallways or campuses as well, including taking the steps instead of the elevator as part of the in-house exercise strategy.

Content and activities. Focus on cardiovascular training and strength training, stretching, and injury prevention. Ideally a physical therapist or fitness trainer could be available to help develop and lead exercise sessions. Nurses (or other participants) can become more aware of their actual exercise and activities by performing daily diary completion. Ask participants to wear pedometers to track total steps; gradually increase total steps over time to reach a target goal of 10,000 to 15,000 steps per day. Some may want to start with a smaller goal of 3,000 steps per day and increase total steps over time. SuperTracker (U.S. Department of Agriculture [USDA], n.d.a.) is a helpful physical activity tracker available free online.

Core strength is another content area that is very important for nurses, particularly those caring for patients who requiring assistance in transfer or moving. To improve core strength over time, it can be helpful to learn to engage our core when sitting, driving, standing, or in any position. Such engagement builds strong muscles in the body midsection and ideally can be helpful to avoid back injury. As a reminder, a simple mantra such as, “Engage your core” can be a common theme of an individual’s healthy momentary, posture and lifestyle goals.

Helpful resources. A helpful nutrition and diet related tool is the website, myplate.gov (U.S. Department of Agriculture [USDA], n.d.b.). Specifically, the portion distortion tool addresses the balance between calories in and calories out. The site also includes food and physical activity tracking tools.

Another helpful tool is the Centers for Disease Control (CDC) and Prevention’s BMI calculator (CDC, Healthy Weight, 2011). The CDC website also has useful information about the classifications of overweight and obesity, and strategies to combat obesity (CDC 2014).

In sum, for the research studies, the annual events, and the long-term programs, our goal was to expose nurses to healthier lifestyle choices with a primary focus on the needed balance between exercise and nutrition. Over the years, more than 1000 persons have participated in one or more of these hospital-based wellness offerings. We hope that our effort to conduct wellness research and develop evidence-based options has made an impact to help our nurses live a healthier lifestyle.

Conclusion: Implications for Education and Practice

Our research and subsequent wellness program development has several implications for education and practice. Educators in undergraduate and graduate nursing programs can be sure that the nursing curricula emphasizes the negative cumulative effects of a lack of exercise and/or other physical activity and inadequate nutrition over a lifespan (i.e., the resulting overweight and obesity). Since nurses in our study (Speroni et al., 2013) specifically requested additional nutrition education, it would likely be beneficial to partner with RDs to provide more nutrition-related content in nursing coursework and for practicing nurses.

There are a multitude of workplace wellness and healthy lifestyle programs that address achieving and maintaining the goal of normal weight over a lifetime; fewer evidence based programs exist. If your organization is interested in designing a healthy lifestyle program, here are a few ideas to get started.

1. Assemble an organizational task force to lead program development. Include any key stakeholders important to implementation and participation success.
2. Start by reviewing evidence based programs. Decide which components of those programs can be incorporated with relative ease by your organization, based upon existing resources and funds.
3. Determine whether the organizational budget can provide resources to successfully design, plan, implement, and evaluate a free program. A participant fee may be required. Examine potential incentives for program completion from the perspective of whether the program is free or requires a participant fee.
4. Allow your organizational task force charged with the program development the opportunity to trial the components that they believe will work in your setting.
5. Make a plan for program evaluation. Consider what outcomes you will use to determine success, such as participation rates, program completion rates, change in participant BMI and/or waist circumference, improvement in health status, or participant perception of program helpfulness to live a healthier lifestyle, be more active, and/or to provide better care to self, family, or patients.

If you have designed an innovative program, and you believe that you will have successful outcomes, consider conducting a research study to track outcomes formally. Publish your findings, sharing what worked and what didn’t work, and make recommendations for improvement. Such an effort can allow others to build upon best available evidence for nurses to design exercise and nutrition programs, whether to promote normal weight maintenance for nurses or any other area important to wellness. Whether a comprehensive workplace wellness program or a beginning exercise event and nutrition program series, start somewhere – big or small!

Acknowledgement: Inova Loudoun Hospital in Leesburg, Virginia, provided the resources for the events and programs described in this article. Sincere thanks are extended to the nursing leaders and nurses who helped. Particularly, I note the countless hours contributed by Cynthia Earley, RN, and the support of her family, and also the fundraising volunteer work coordinated by Kristin Suder, RN.

Author

Karen Gabel Speroni, PhD, MHSA, BSN, RN
Email: kgabelsperoni@smartneighborhood.net

In addition to innovating healthy lifestyle programs for children and nurses, Dr. Speroni is a research process and research infrastructure expert.  She uniquely integrates the needs and research goals of hospitals with the most pressing nursing issues requiring evaluation.  She has extensive experience in biomedical research, including evidence based practice research in hospitals, serving as a research council/nursing research council chair, clinical scientist on Institutional Review Boards, research course adjunct professor, pharmacoeconomic analyst, and pharmaceutical and device industry project director.  She has published extensively research related manuscripts, abstracts and / or book chapters.

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