Knowledge, attitudes, and behaviors of nursing professionals and students in Beijing toward cardiovascular disease risk reduction†
Article first published online: 15 MAR 2011
Copyright © 2011 Wiley Periodicals, Inc.
Research in Nursing & Health
Volume 34, Issue 3, pages 228–240, June 2011
How to Cite
Wu, Y., Deng, Y. and Zhang, Y. (2011), Knowledge, attitudes, and behaviors of nursing professionals and students in Beijing toward cardiovascular disease risk reduction. Res. Nurs. Health, 34: 228–240. doi: 10.1002/nur.20431
This survey was a sub-project of the program, “Cardiovascular Health Education Training Program for Health Care Professionals in the Community in China,” sponsored by a joint fund of the Ministry of Health of People's Republic of China and the Bristol-Myers Squibb Foundation of the United States. We would like to thank all the nurses who participated in this survey. We also would like to extend our thanks to all the nursing executives in the two nursing schools and two affiliated hospitals, and in particular to Ms. Li Yao, Vice Director of the Nursing Center of Chinese Ministry of Health. We would especially like to thank Dr. Valerie Swigart from the University of Pittsburgh School of Nursing, a dedicated, patient, kind, and humorous editor, for her extended work on the revision and editing of this manuscript.
- Issue published online: 2 MAY 2011
- Article first published online: 15 MAR 2011
- Manuscript Accepted: 2 FEB 2011
- Ministry of Health of People's Republic of China
- Bristol-Myers Squibb Foundation of the United States
- knowledge attitude and behavior;
- cardiovascular diseases;
- risk factors reduction;
- lifestyle modification
The rising incidence of cardiovascular disease (CVD) in China intensifies the need for effective health education for CVD risk reduction. The purpose of this study was to develop a description of nurses' knowledge about, attitudes toward, practice behaviors, and personal lifestyle behaviors related to CVD risk reduction. We surveyed 273 staff nurses, 35 nursing faculty, and 139 nursing students in Beijing. Most nurses could identify common risk factors for CVD and had positive attitudes toward CVD risk reduction. However, less than 58% of the respondents could correctly answer questions about evidence-based recommendations for CVD risk reduction. This sample of Chinese nursing professionals and students lacked knowledge critical to providing guidance to individuals with or at risk for CVD. More intensive and creative approaches to the education of nursing professionals regarding CVD risk reduction are recommended. © 2011 Wiley Periodicals, Inc. Res Nurs Health 34:228–240, 2011
With the rapid growth of the economy in China, the Chinese people have become more sedentary, and their diet has become more energy-dense (Popkin, 2008; Tudor-Locke et al., 2007). This has resulted in an increased incidence of cardiovascular disease (CVD) in the population (Popkin, 2008; Z. Wu et al., 2001). CVD is the leading cause of death in China, accounting for approximately 33% of all deaths in rural areas and 39% of deaths in urban areas; over 3 million Chinese people die of CVD each year (Ministry of Health, Research Center for Cardiovascular Disease Prevention and Treatment, 2007 [Ministry of Health, 2007]).
The most prevalent CVD risk factors in Chinese adults aged 35–74 years are dyslipidemia (53.6%), smoking (34.4%), obesity (28.2%), hypertension (26.1%), and diabetes mellitus (5.2%; Gu et al., 2005; Ministry of Health, 2007). Lifestyle modifications, such as smoking cessation, dietary fat and cholesterol reduction, exercise, and weight control are important components of treatment for reducing mortality rates due to CVD (Al-Omran, 2007; Chobanian et al., 2003). Such lifestyle modifications could increase life expectancy by 9.3 years (Ezzati et al., 2003).
Health education is one of the most promising approaches to promoting lifestyle modification (Doroodchi et al., 2008; Shibayama, Kobayashi, Takano, Kadowaki, & Kazuma, 2007). Professional nurses are responsible to provide health education to facilitate such life style changes (Ben-Sefer, 2009; Chinese Nursing Association, 2008). Nurses are expected to have knowledge of current evidence-based recommendations and interventions for preventing or treating CVD. Yet, the literature evaluating nurses' knowledge of CVD prevention and treatment is sparse. Early research conducted in the United States indicated that nurses and graduate nursing students had insufficient knowledge regarding CVD risk reduction and prevention (Engler, Engler, Davidson, & Slaughter, 1992; Wilt, Hubbard, & Thomas, 1990). However, we know little to nothing about Chinese nurses' knowledge of CVD prevention and treatment.
Providers' attitudes toward CVD risk reduction affects both their practice behaviors, such as suggesting patients reduce cholesterol intake, and their personal behaviors, such as maintaining optimal body weight. McDermott et al. (2002) demonstrated that attitudes toward the importance and effectiveness of risk factor interventions influenced whether healthcare providers initiated CVD risk factor reduction education with patients. Patients' observations and perceptions of the healthcare provider's attitudes, behaviors while interacting, and personal health-related lifestyle influence patients' confidence in their provider and their receptivity to CVD risk prevention education (Geirsson, Bendtsen, & Spak, 2005; McFall, Nonneman, Rogers, & Mukerji, 2009; Rogers et al., 2006).
Despite the increasing morbidity and mortality due to CVD in China and the potential for nurses to be instrumental in providing education to help reduce this threat, no published study was found reporting Chinese nurses' knowledge, attitudes, practices, and personal behaviors related to CVD risk reduction. To effectively plan for nurses' education and roles in national programs for CVD risk factor reduction in China, the current state of Chinese nurses' knowledge of CVD risk factor reduction, their attitudes towards this issue, their current practice behaviors related to CVD risk reduction, and their personal adherence to CVD risk factor reduction need to be investigated.
The goal of this study was to describe the knowledge of, attitudes toward, practice, and personal behaviors (KAB) related to CVD risk factor reduction in a sample of hospital-based nurses, nursing faculty, and student nurses in Beijing (China). We posed the following research questions: In each of these three groups (a) What is the level of knowledge regarding CVD risk factors and preventive care? (b) What are the attitudes toward CVD risk factor reduction? (c) What do the nurses report as their practice behaviors regarding CVD risk reduction education? and (d) How do the nurses describe their personal lifestyle behaviors related to CVD risk reduction?
Study Design, Setting, and Subjects
We used a descriptive cross-sectional design. The target population was practicing nurses employed at two acute care hospitals, nursing students who were finishing their final clinical practicum prior to graduation from two university nursing schools in Beijing, and nursing faculty from the same two nursing schools. The later two groups were targeted because nurses' most commonly mentioned source of health information is professional training (Nowak, Harrison, & Hutton, 2007).
The goal of the current study was to describe KAB related to CVD risk factor reduction in nursing professionals and students in Beijing (China). We used a random sampling technique stratified to sample nurses with different work experience who might have different levels of KAB regarding CVD risk reduction. Moreover, different work experiences could lead to a bias, either overestimating or underestimating the average KAB related to CVD risk factor reduction. We separated the hospital-based practicing staff nurses into three strata according to their working unit: (a) cardiovascular (CV) and related units (cardiac, neurology, endocrine, and rehabilitation) where patient education about CVD risk factors and lifestyle modification would be expected to be a routine part of nursing care, (b) other medical units where education about prevention and treatment of CVD was not routinely provided, and (c) other surgical units where education about the prevention of CVD was not routinely provided in China.
The department of nursing at each of the two participating hospitals provided a list of names of nurses for each stratum; a number was assigned to each nurse on the list. Nurses were randomly selected from each list using a random numbers table. Nurses who were unlicensed (prior to 2008, new nurses had to work in hospitals for 1 year before they were qualified to take the licensure examination), worked in the outpatient department, were off duty at the time the questionnaires were distributed, or who were unwilling to participate were excluded. The faculty and nursing students were a convenience sample. All faculty and students who met the inclusion criteria and were present in the schools at the time the questionnaire was distributed were recruited.
Our sample was obtained through administrative support from the associate deans of the two university nursing schools and the directors of the departments of nursing in both hospitals. We determined the number of respondents based on our primary focus of assessing Chinese nurses' knowledge about CVD risk reduction. The expected average correct rate for answering the knowledge items was used to estimate the sample size necessary. Based on a previous study of physicians using a similar questionnaire (Wang, Gao, & Wu, 2001), we expected a 70% average correct rate for answering CVD risk factor knowledge questions. To estimate a 95% confidence level for a total width of .2, sample sizes of 82 from each stratum were needed (41 from each hospital), with a total sample size of at least 246 staff nurses. The sample size of staff nurses was expanded to 300 to ensure at least 246 usable questionnaires from staff nurses for final analysis.
All participants were assured by the associate deans and directors that only the research team would know whether they chose to participate and the results of the questionnaire. They were also assured that their participation and the results of their questionnaire were confidential and had no influence on their performance assessments. The institutional review board of the university reviewed and approved the conduct of this study.
The questionnaire for this study was adapted from an assessment used in the Cardiovascular Health Education Training Program for Health Care Professionals in the Community in China. That assessment was developed by the Department of Epidemiology of the Cardiovascular Institute at Fu Wai Hospital of the Chinese Academy of Medical Sciences. It was used to evaluate the effectiveness of a 1-year Cardiovascular Health Education Training Program for over 1,600 physicians and has been described elsewhere (Chen, Luang, & Zang, 2001; Deng, Liu, Shi, & Wu, 2006; Y. F. Wu, Wang, & Gao, 2004).
Modifications were made to the questionnaire so that it assessed knowledge and practice behaviors consistent with the scope of nursing practice in China (Regulations of Nurses, 2008). Items currently pertinent only to physicians' practice were removed (e.g., “List five anti-hypertensive agents that you commonly prescribed for your patients”). Items testing knowledge about CVD risk factors and risk reduction were based on the Seventh Report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure (JNC7; Chobanian et al., 2003) and the European Guidelines on Cardiovascular Disease Prevention in Clinical Practice: Third Joint Task Force of European and other Societies on Cardiovascular Disease Prevention in Clinical Practice (JTF3; Backer et al., 2003).
The principal investigator wrote an additional six items to test nurses' attitudes toward their health education role and perceived barriers to providing health education for patients' CVD risk reduction. The items were dichotomized for simplicity because our research was focused on whether to institute a training program for nurses on health education. We needed to know whether the nurses knew certain information. Because all three groups had similar educational backgrounds, we concluded that the wording of the questionnaire was appropriate for all three groups. The questionnaire was pre-tested for clarity of the items by 10 staff nurses who were similar to the study sample in demographic background and who worked at an affiliated hospital that was not a site for our study.
To assess content validity, a panel of 10 experts who held full-time appointments in the cardiac unit of a university-affiliated teaching hospital (not a site for our study) assessed the questionnaire using the method suggested by Polit and Beck (2006). The experts were 5 cardiologists (1 chief physician and 4 attending physicians) and 5 nurses with over 9 years of CV care experience. The experts rated each item for its relevance to KAB related to CVD risk reduction using a 4-point Likert-type scale where: 1 = not relevant, 2 = somewhat relevant, 3 = quite relevant, and 4 = highly relevant.
The content validity index (CVI) was used as a measure of content validity. To calculate the CVI for each item (i-CVI), the ordinal scale was dichotomized into relevant (rating either 3 or 4) and not relevant (rating either 1 or 2). The i-CVI's were computed as the number of experts giving a rating of either 3 or 4 divided by the total number of experts. To calculate the CVI for the total scale as well as for the three subscales (knowledge, attitude, and behaviors), we used the average CVI (CVI/Ave), which is defined as the average proportion of items rated as 3 or 4 across the 10 experts. The CVI/Ave for the total scale was .916, and for the three subscales (knowledge, attitudes, and behavior) CVI/Aves were .859, .960, and .968, respectively.
The final version of the questionnaire containing 78 items, was completed using paper and pencil, and required approximately 30 minutes to complete. Demographic data accounted for 12 of the 78 items. Twenty-eight multiple-choice questions assessed knowledge of CVD risk factors and target goals for risk reduction (e.g., “What is the daily recommended dietary fat intake?”). Four multiple choice answers were offered. The correct answer was subsequently coded as positive, and the other answers were coded as negative or incorrect.
Four items were used to discern nurses' attitudes toward specific lifestyle modifications. For example, we asked the nurses to respond to the question, “What statement best describes your attitude toward smoking cessation?” The respondents could select: (a) smoking is harmful to everyone so every person who smokes should stop smoking, (b) smoking is harmful just to some people so it is not necessary to stop smoking, (c) smoking is not a harmful habit so people should not stop smoking, (d) I have no attitude toward smoking cessation. The first option (a) was coded as positive and the others as negative. Six additional items focused on nurses' attitudes toward their roles in CVD prevention and barriers to providing health education.
Nineteen items were used to learn about the nurses' practice behaviors related to interacting with patient's needing CVD risk reduction. Eighteen items were phrased so that participants indicated how they would behave or act in common situations. For example: “You are caring for a patient with CVD. She is 10 kg (or 22 pounds) overweight. What would you do?” (a) Strongly suggest that the patient lose weight. (b) Suggest that the patient lose weight. (c) Have no suggestions. (d) Pay no attention to the issue. Options (a) and (b) were coded as correct, and options (c) and (d) as incorrect. A single item asked the nurses to respond either yes or no as to whether they conducted health education during their practice.
Nine items on the questionnaire asked about personal lifestyle behaviors and health data adhering to JNC7 and JFT3 recommendations. This section included four multiple choice items. For example, one question asked how frequently the respondent had exercised, doing activities—such as, but not limited to walking, playing ping-pong, or swimming—for at least 30 minutes a day in the last month. Options were almost never, occasionally, 1–3 times per week, and 4 times or more per week. The last answer was the only answer considered positive. The last five questions were fill-in-the-blank items where respondents were asked to provide their height, weight, BP value, the date when the BP was measured, and when blood lipids were last checked. Cronbach's alphas for the knowledge, attitude, and behavior scales were .81, .86, and .79, respectively.
Data Collection Procedures
One member of the research team was responsible for the distribution of the questionnaires. For the staff nurses in the two hospitals and the faculty in the two schools, the research team member went to each hospital unit or school in the morning for a period of 1 week for each hospital and 1 day for each nursing school, distributed the questionnaires to each individual, explained the purpose of the research, and provided instructions according to the pre-defined protocol noted below. Nursing students received the questionnaires at a regular meeting in their schools.
Instructions were as follows: “If you decide to participate in this study, please complete this questionnaire independently and answer all the questions. If you do not know the correct answer, guess. Please do not check reference materials or ask other staff members for an answer. The research team member will return to your work unit near the end of your shift. If you have chosen to complete the questionnaire, you can return it to the research team member at that time. You may be asked to complete any incomplete answers. Submitting your completed questionnaire to the research team member constitutes consent for participation in this study.” The nurses completed the questionnaires during their work shift. The research team member then located each individual, checked the questionnaire for completion, and asked the participant to respond to any unanswered items. A small incentive gift (about 3 Yuan or $.5 U.S.) was offered when the questionnaire was received.
Data analysis was completed using the Statistical Package for the Social Sciences (SPSS, Version 11.5 for Windows). Items assessing KAB were counted as either positive (correct or reflecting a positive attitude) or negative. Categorical data were compared among the staff nurses, nursing faculty, and nursing students using a chi-squared test for an r × k contingency table. Cramer's V partitioning of chi-squared was performed whenever a significant difference was indicated to determine which cells had contributed to the significant difference. A likelihood ratio test and Fisher's exact test were performed whenever there was an expected cell value <5. A p-value <.05 was considered significant in all analyses.
Three hundred staff nurses were randomly selected for participation, and 182 nursing faculty and students were approached. Four hundred forty-seven questionnaires were distributed. Thirty-five persons (27 staff nurses, 3 faculty, and 5 students) were off duty or refused to participate. Of the 447 questionnaires distributed, 100% were completed and returned. Two hundred seventy-three questionnaires were completed by staff nurses: 88 (32.2%) by CV nurses, 93 (34.1%) by other medical nurses, and 92 (33.7%) by other surgical nurses. Thirty-five questionnaires were completed by nursing faculty, and 139 questionnaires were completed by nursing students. The high completion rate we attained is not unusual for studies in China, especially studies of Chinese nurses. Our procedure of requesting completion at the time the questionnaire was returned, plus the cultural inclination of the Chinese nurses to “follow through with the work at hand” contributed to this exceptional completion rate. The characteristics of the sample are shown in Table 1.
|Characteristics||Total, N (%)||Staff Nurses, n (%)||Nursing Faculties, n (%)||Nursing Students, n (%)|
|Sample size||447||273 (61.1)||35 (7.8)||139 (31.1)|
|Mean age (SD)||26.6 (6.2)||28.2 (5.7)||33.2 (9.6)||22.1 (1.3)|
|Middle rank or higher||146 (47.4)||138 (50.5)||8 (22.9)|
|Primary rank||162 (52.6)||135 (49.5)||27 (77.1)|
|ADN or above||313 (70.0)||139 (50.9)||35 (100.0)||139 (100.0)|
|Diploma||134 (30.0)||134 (49.1)||0||0|
|Years in work|
|≤5 years||271 (60.6)||118 (43.2)||14 (40.0)||139 (100.0)|
|>5 years||176 (39.4)||155 (56.8)||21 (60.0)||0|
|≥6 Months of working in cardiac and related unitsb||119 (26.6)||103 (37.7)||7 (20.0)||9 (6.5)c|
|CE on CVD preventive knowledge||69 (15.4)||46 (16.8)||3 (8.6)||20 (14.4)|
Knowledge of CVD Risk Factors
As shown in Table 2, more than 70% of respondents in each group (staff nurses, faculty, and students) knew most of the CVD risk factors. However, fewer of the respondents correctly identified that decreased high-density lipoprotein cholesterol and isolated systolic hypertension also were risk factors for CVD. Compared to the nursing staff and student groups, nursing faculty had a higher rate of correct responses to the item “a lack of physical activity could increase the risk of CVD” (p < .05).
|Risk Factors||Total, N (%)||Staff Nurse, n (%)||Faculty Member, n (%)||Nursing Student, n (%)||χ2-value||p-Value|
|Increased TC level||436 (97.5)||266 (97.4)||35 (100.0)||135 (97.1)||.996||.608|
|Increased LDL-C level||334 (74.7)||205 (75.1)||25 (71.4)||104 (74.8)||.221||.895|
|Decreased HDL-C level||222 (49.7)||140 (51.3)||18 (51.4)||64 (46.0)||1.058||.589|
|Isolated systolic HTN||186 (41.6)||106 (38.8)||15 (42.9)||65 (46.8)||2.411||.300|
|Lack of physical activity||383 (85.7)||225 (82.4)a||35 (100.0)b||123 (88.5)||9.113||.010|
|Overweight/obese||443 (99.1)||271 (99.3)||35 (100.0)||137 (98.6)||.861||.650|
|Smoking||432 (96.6)||262 (96.0)||35 (100.0)||135 (97.1)||1.695||.428|
|Heavy alcohol consumption||439 (98.2)||269 (98.5)||35 (100.0)||135 (97.1)||1.737||.419|
|High salt intake||440 (98.4)||269 (98.5)||35 (100.0)||136 (97.8)||.891||.640|
|High saturated fat intake||405 (90.6)||247 (90.5)||33 (94.3)||125 (89.9)||.637||.727|
|Male over 45-year old||412 (92.2)||252 (92.3)||34 (97.1)||126 (90.6)||1.653||.438|
|Postmenopausal female||342 (76.5)||208 (76.2)||30 (85.7)||104 (74.8)||1.886||.389|
|CVD family history||436 (97.5)||264 (96.7)||34 (97.1)||138 (99.3)||2.574||.276|
Only about one third (averaged across all items) of the respondents could identify most of the target goals for risk factor reduction (ranging from approximately 13% to 57% for each group; see Table 3). Staff nurses had a lower correct response rate in answering how to calculate body mass index (BMI) than university faculty and nursing students (p < .05). Faculty members had a lower correct response rate when identifying the criteria for obesity in terms of BMI than did staff and students (p < .05). Students were the most successful (p < .05) at identifying the level of systolic BP that indicates a need to recommend lifestyle modifications to lower it.
|Target Goals||Total, N (%)||Staff Nurse, n (%)||Faculty Member, n (%)||Nursing Students, n (%)||χ2-value||p-Value|
|How to calculate BMI||204 (45.6)||104 (38.1)ab||20 (57.1)||80 (57.6)||16.083||<.001|
|Overweight criteria in terms of BMI||172 (38.5)||111 (40.7)a||5 (14.3)b||56 (40.3)||9.394||.009|
|Daily recommended salt intake (≤6 g/day)||249 (55.7)||157 (57.5)||17 (48.6)||75 (54.0)||1.254||.534|
|Daily recommended fat and cholesterol intake|
|Dietary fat ≤30% of total calorie||193 (43.2)||115 (42.1)||20 (57.1)||58 (41.7)||3.025||.220|
|Dietary saturated fat <10% of total calorie||167 (37.4)||92 (33.7)||13 (37.1)||62 (44.6)||4.681||.096|
|Cholesterol <300 mg||59 (13.2)||34 (12.5)||6 (17.1)||19 (13.7)||.634||.728|
|Daily alcohol intake <30 g of ethanol||362 (81.0)||219 (80.2)||27 (77.1)||116 (83.5)||.989||.610|
|Blood pressure control for HTN|
|SBP <140 mmHg||219 (49.0)||137 (50.2)||18 (51.4)||64 (46.0)||.722||.697|
|DBP <90 mmHg||202 (45.2)||121 (44.3)||16 (45.7)||65 (46.8)||.226||.893|
|SBP <130 mmHg for patient with HTN and DM||135 (30.2)||86 (31.5)||9 (25.7)||40 (28.8)||.687||.709|
|DBP <80 mmHg for patient with HTN and DM||83 (18.6)||55 (20.1)||5 (14.3)||23 (16.5)||1.250||.535|
|Start life-style modification for BP control when BP is|
|SBP 120-139||218 (48.8)||125 (45.8)b||13 (37.1)b||80 (57.6)||7.158||.028|
|DBP 80-89||158 (35.3)||97 (35.5)||10 (28.6)||51 (36.7)||.817||.665|
|Goals for CVD patient to control Blood cholesterol|
|TC <180 mg/dl||104 (23.3)||67 (24.5)||8 (22.9)||29 (20.9)||.702||.704|
|LDL-C <100 mg/dl||97 (21.7)||60 (22.0)||9 (25.7)||28 (20.1)||.542||.762|
Attitudes Toward CVD Risk Factor Reduction
The majority of the respondents had positive attitudes toward CVD risk reduction and lifestyle modification, and they believed that they were capable of (in other wards, having the skills and knowledge) providing health education for CVD prevention and treatment (Table 4). Staff nurses were significantly more likely than students to have positive attitudes toward smoking cessation and knowing one's own blood lipid levels (p < .05). Nursing faculty members were significantly more likely than staff nurses to believe that nurses have the skills and knowledge to provide health education (p < .05).
|Positive Attitude||Total, N (%)||Staff Nurse, n (%)||Faculty Members, n (%)||Nursing Students, n (%)||χ2-value||p-Value|
|Must quit smoking||410 (91.7)||255 (93.4)b||34 (97.1)||121 (87.1)||6.3261||.042|
|Can drink alcohol moderately (<30 g day)||362 (81.0)||219 (80.2)||27 (77.1)||116 (83.5)||.989||.610|
|Knows own BP||443 (99.1)||270 (98.9)||35 (100.0)||138 (99.3)||.492||.782|
|Knows own blood lipid level||420 (94.0)||260 (95.2)b||35 (100.0)||125 (89.9)||7.0171||.030|
|Nurses are capable of providing HE||396 (88.6)||234 (85.7)2a||35 (100.0)||127 (91.4)||7.8021||.020|
Attitudes Toward Perceived Barriers to Providing Health Education
As shown in Table 5, the three most commonly mentioned barriers to providing health education in CVD prevention and treatment were lack of time, patients' unwillingness to change their lifestyles, and lack of physicians' support. Staff nurses were more likely to report a lack of time as a barrier to providing health education than nursing faculty (p < .05).
|Barriers||Total, N (%)||Staff Nurses, n (%)||Nursing Faculty, n (%)||Nursing Students, n (%)||χ2-value||p-Value|
|Lack of time||280 (62.6)||175 (64.1)a||15 (42.9)||90 (64.7)||7.541||.023|
|Lack of physicians' support||193 (43.2)||112 (41.0)||12 (34.3)||69 (49.6)||1.413||.493|
|Patients unwilling to accept HE||81 (18.1)||51 (18.7)||4 (11.4)||26 (18.7)||.886||.642|
|Patients unwilling to change lifestyle||257 (57.5)||151 (55.3)||17 (48.6)||89 (64.0)||.928||.629|
|HE not used as a criteria of performance assessment||155 (34.7)||78 (28.6)ab||16 (45.7)||61 (43.9)||11.366||.003|
Practice Behaviors Directed Toward CVD Risk Reduction
About three-fourth of the staff nurses, nursing faculty, and nursing students indicated that they made suggestions to patients with CVD to modify their lifestyles with regard to smoking cessation, weight loss, and limitation of salt, saturated fat, and cholesterol (Table 6). Fewer than half of all participants, however, reported suggesting to patients with CVD that they exercise regularly. Likewise, nurses were not inclined to provide suggestions for lifestyle modification to patients not presenting with CVD or diabetes (30–46% and 7–26%, respectively). Staff nurses and nursing faculty members reported less likelihood of providing patients with health education in their practice than students (p < .05).
|Lifestyle Modification||Patient Diagnosis||Total, N (%)||Staff Nurse, n (%)||Faculty Members, n (%)||Nursing Students, n (%)||χ2-value||p-Value|
|Smoking cessation||CAD||370 (82.8)||231 (84.6)||29 (82.9)||110 (79.1)||1.939||.379|
|DM||249 (55.7)||151 (55.3)||21 (60.0)||77 (55.4)||.284||.868|
|Others||96 (21.5)||59 (21.6)||9 (25.7)||28 (20.1)||.522||.770|
|Weight loss||CAD||281 (62.9)||169 (61.9)||27 (77.1)||85 (61.2)||3.339||.188|
|DM||192 (43.0)||104 (38.1)a||23 (65.7)b||65 (46.8)||10.852||.004|
|Others||42 (9.4)||26 (9.5)a||8 (22.9)b||8 (5.8)||8.0231||.018|
|Regular exercise||CAD||164 (36.7)||92 (33.7)||16 (45.7)||56 (40.3)||3.053||.217|
|DM||199 (44.5)||111 (40.7)||21 (60.0)||67 (48.2)||5.806||.055|
|Others||93 (20.8)||62 (22.7)||9 (25.7)||22 (15.8)||3.204||.202|
|Limited salt intake||CAD||374 (83.7)||220 (80.6)||30 (85.7)||124 (89.2)||5.128||.077|
|DM||132 (29.5)||75 (27.5)||11 (31.4)||46 (33.1)||1.464||.481|
|Others||34 (7.6)||24 (8.8)||2 (5.7)||8 (5.8)||1.4501||.484|
|Limitation saturated fat||CAD||377 (84.3)||227 (83.2)||30 (85.7)||120 (86.3)||.760||.684|
|DM||242 (54.1)||153 (56.0)||19 (54.3)||70 (50.4)||1.199||.549|
|Others||57 (12.8)||38 (13.9)||4 (11.4)||15 (10.8)||.870||.647|
|Limitation cholesterol||CAD||384 (85.9)||227 (83.2)||30 (85.7)||127 (91.4)||5.137||.077|
|DM||237 (53.0)||152 (55.7)||17 (48.6)||68 (48.9)||1.990||.370|
|Others||50 (11.2)||30 (11.0)||5 (14.3)||15 (10.8)||.3471||.841|
|Provides HE on CVD prevention and treatment||326 (72.9)||189 (69.2)b||22 (62.9)b||115 (82.7)||8.604||.014|
Personal Behaviors Related to CVD Risk Reduction
As shown in Table 7, 95% of the nurse participants did not exercise 4 or more days a week for at least 30 minutes a day. Over 70% had failed to obtain an assessment of their blood lipids within the previous 5 years. Nursing faculty members were more likely to limit saturated fat intake than student nurses (p < .05), and staff nurses were more likely than students to have had their lipids checked within the last 5 years (p < .05).
|Lifestyle||Total, N (%)||Staff Nurses, n (%)||Faculty Members, n (%)||Nursing Students, n (%)||χ2-value||p-Value|
|Alcohol intake1||41 (9.2)||35 (12.8)b2||2 (5.7)||4 (2.9)||11.4753||.003|
|Overweight3||41 (9.2)||32 (11.7)||1 (2.9)||8 (5.8)||5.7533||.056|
|Exercise >3× week||21 (4.7)||13 (4.8)||2 (5.7)||6 (4.3)||.1283||.938|
|Limit saturated fat||254 (56.8)||161 (59.0)||25 (71.4)b||68 (48.9)||7.096||.029|
|Limit cholesterol||244 (54.6)||146 (53.5)||24 (68.6)||74 (53.2)||2.998||.223|
|BP checked within last 2 years||401 (89.7)||245 (89.7)||33 (94.3)||123 (88.5)||2.9484||.229|
|Blood lipids checked within last 5 years||129 (28.9)||105 (38.5)b||8 (22.9)||16 (11.5)||35.191||<.001|
Morbidity and mortality from CVD in China are on the rise (Ministry of Health, 2007). Conversely, during the last 3 decades the age-adjusted death rates from stroke and coronary heart disease in the United States have declined by 60% and 50%, respectively (Chobanian et al., 2003). Improved treatment of CVD and its risk factors are reasons for the favorable trends seen in the United States (Chobanian et al., 2003). The increased role of nurses in patient education and counseling has contributed to the dramatic decrease in morbidity and mortality of CVD in the United States and other developed countries (Bosworth et al., 2008; Groeneveld, Proper, van der Beek, Hildebrandt, & van Mechelen, 2010; van Zuilen, Wetzels, Bots, & Blankestijn, 2008). If these findings are transferable, Chinese nurses' efforts could help decrease the morbidity and mortality due to CVD in the Chinese population.
Our results show that the majority of Chinese nursing professionals and students in Beijing were knowledgeable about most of the common CVD risk factors. Fewer than one-half of the participants, however, knew the target goals for risk reduction (e.g., only 13% of participants had knowledge of the daily recommended intake of cholesterol). An explanation for these findings is that CVD risk factors have been well-established for decades, have frequently appeared in public media, and are used in daily practice (Bellicha & Mcgrath, 1990; Brownson et al., 1996; Jabbour et al., 2003). Conversely, the recommended target goals for risk reduction involve specific numbers and facts that the nurses are currently not using in daily practice, making them difficult to remember. Knowing the exact goals for CVD risk factor reduction and lifestyle modification, however, is a necessary component of patient teaching to prevent and treat CVD. Although knowledge is not the only element to ensure effective teaching, it is essential.
The nursing faculty member participants, the most educated of the groups, also demonstrated lack of knowledge of target goals of risk reduction. On some items, such as obesity criteria (BMI), they scored lower than staff nurses or nursing students. The most probable reason for this knowledge deficit is the limited numbers of faculty members that regularly teach about CVD prevention and treatment. In addition, they usually do not provide direct CVD health education. All three groups of Chinese nurses in this study, therefore, need periodic education about CVD prevention and treatment. Improving the KAB of nursing faculty members could influence nurses' preparation for a more active and effective role in health education and counseling patients with or at risk of CVD (Nowak et al., 2007).
Despite insufficient knowledge, 89% of the participants believed that nurses were capable of providing health education and 73% reported that they provided health education on CVD risk factor reduction in their practice. This is consistent with the results of Gillis, McDonald, and MacIsaac's (2008) study of 157 registered nurses in Canada that demonstrated that nurses' confidence levels in patient care were not correlated to their knowledge level. Effective patient education about CVD risk reduction, however, requires providers to have positive attitudes and actions as well as the commitment to update their knowledge with current evidence for use in their health education efforts (Chobanian et al., 2003).
Findings from our study revealed that nurses may have knowledge of a risk factor, however, other factors may influence the use of that knowledge. Although 86% of the nurse respondents knew that “lack of physical activity” was a risk factor for CVD, only 37% of the respondents recommended an exercise program to patients and provided instruction regarding exercise. One reason for this paradox may be related to the Chinese culture. Chinese people traditionally believe that patients need rest when they are hospitalized. It is usually unacceptable to the patients and their families if a hospitalized patient is instructed to participate in physical exercise, especially when the patient is being treated for CVD. Another reason for the discrepancy may be that nurses fail to recognize the benefits of exercise even independent of weight loss (Ross & Janiszewski, 2008).
Lifestyle modification and CVD risk reduction health teaching should not only target patients with CVD but also individuals at high risk. In China, there are approximately 350 million smokers, 260 million overweight or obese people, 160 million people with dyslipidemia, 160 million people with hypertension, and 20 million persons with diabetes (Ministry of Health, Research Center for Cardiovascular Disease Prevention and Treatment, 2006). This indicates a great need for education about prevention of CVD that can be delivered to large numbers of people and is yet effective. Our findings show that although most nurses recommended lifestyle modifications to patients with CVD, less than one-half of the respondents provided health teaching to patients admitted with other diseases. These results suggest that either nurses are not fully aware of who needs lifestyle modification teaching or some other factors (such as time or focus on more immediate problems) interfere with attention to CVD preventative education.
Nurses with personal lifestyles consistent with defined CVD risk reduction standards could provide a role model for patients. Role modeling is one strategy for increasing the effectiveness of health education (Chobanian et al., 2003). In our study, only 5% of the nurses met the accepted standards for exercise prescribed by U.S., Chinese, and European medical committees (Backer et al., 2003; Chobanian et al., 2003; Graham et al., 2007). Only about half of the respondents' reported limiting saturated fat and cholesterol intake in their diets. Moreover, only about 29% of the nurses had had their blood lipids checked within 5 years. Scholte op Reimer et al. (2006) noted similar results in a survey of CV nurses from Switzerland and 27 other countries, indicating that challenges in maintaining a healthy lifestyle are not unique to Chinese nurses.
Time constraints were the most often reported barrier preventing nurses from providing patient education in hospitals. This is consistent with the findings from previous studies conducted in other cities in China (Chan, Sarna, Wong, & Lam, 2007), the United States (Barber-Parker, 2002; Chobanian et al., 2003; Wilt et al., 1990), Canada (Gillis et al., 2008), and the United Kingdom (Casey, 2007). Increasing the number of hospital staff nurses could result in nurses having more time to provide CVD education. This issue is especially important in China where the most consistent source of education about CVD is the hospital nurses because cardiac rehabilitation programs do not yet exist.
The other two commonly mentioned barriers for providing CVD preventive instructions were lack of physicians' support and patients' unwillingness to change their lifestyle habits. Similar results were noted in a study conducted in Hong Kong, China (Choi, Hui, Lee, & Chui, 2009). One reason for this may be that neither physicians nor patients consider health education to be part of nurses' responsibilities. In China, nurses' roles have traditionally been concerned with carrying out physicians' orders and administering medications (Choi et al., 2009). To be accepted as health educators, Chinese nurses need to be well prepared to provide CVD risk reduction education and demonstrate improved outcomes resulting from the educational interventions.
There were several limitations to the current study that need to be addressed. We only recruited nursing professionals and students in Beijing from two nursing schools and two hospitals—one affiliated with each school. This limits extrapolating these findings to all nursing professionals and students in China. The recruitment strategy may also have introduced selection bias, resulting in an overestimation of CVD prevention and treatment knowledge because the two nursing schools and the two urban university-affiliated hospitals are recognized as the top nursing schools and hospitals in China. Random sampling, however, was used for staff nurses to insure representative responders. Our findings about attitudes and behaviors are based on self-report, which also may introduce bias leading to an overestimation of positive attitude and behaviors. Moreover, this study was descriptive and intended only to offer a profile of Chinese nursing professional's and student's KAB regarding CVD risk reduction.
We still do not know whether Chinese nurses provide effective health teaching for CVD risk reduction for their patients. We know little about what factors influence nurses' health education competency or motivation to maintain a healthy lifestyle themselves. Further studies are needed using more objective measurements to explore the issues of nurses' perceived and exact competencies, to explore factors that may influence nurses' health teaching competency and role modeling, and to examine the effect of health education on reducing CVD risk.
Although these Chinese nursing professionals and students in Beijing were enthusiastic and confident about providing health education on CVD risk reduction and lifestyle modification, they were not adequately prepared for this role. Nurse educators, researchers, and leaders need to focus on innovative ways of teaching both nurses and patients about CVD risk reduction. Periodic continuing education to provide updated information and to reinforce the importance of knowing the guidelines and standards of CVD prevention and treatment could improve the knowledge of staff nurses and faculty members.
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