Nutrition-related knowledge, beliefs and practices of Australian nursing staff.

Abstract

Objective: The purpose of the study was to examine the general food and nutrition-related beliefs and knowledge of nursing professionals attending post-partum women.

Design: Data were collected by self-administered questionnaire.

Subjects: Three hundred and sixty-two hospital-based nursing staff responsible for the care of post-parturient women.

Setting: Eight metropolitan and regional hospitals in Queensland and three maternity hospitals in Canberra.

Main outcome measures: Beliefs, opinions and intentions relating to food, nutrition and weight; knowledge of requirements of core foods; and sources of nutrition information.

Statistical analysis: Standard statistical tests were used to measure frequencies and assess bivariate relationships.

Results: Almost all participants (97.8%) were confident they could give good advice to their patients about a healthy balanced diet. The majority (65.5%) reported providing such advice at least weekly, 27.9% daily, and 19.5% rarely or never gave nutritional advice. The food-related beliefs of most participants (>85%) were in line with current knowledge for 78% of questions. However, their knowledge of core food requirements for adults was inadequate; only 0.6% gave correct answers to all four food intake questions, 16.8% gave three correct answers, 62% two and 20.7% one correct answer. The most commonly cited sources of nutrition information were professional training (51.4%), reading (38.7%), media (14.9%), self-education and work-related experience (10.8%), dietitian (10.5%), school (7.5%), family (6.4%) and dieting (5.0%).

Conclusion: Nursing staff frequently provide nutritional advice to post-partum women. There is a need to ensure such information is accurate. Further research should explore ways in which this can be achieved.

Key words: belief, food, knowledge, nursing staff, nutrition.

INTRODUCTION

A substantial proportion of the disease burden in Australia is related to poor nutrition and inadequate levels of physical activity and thus is preventable. (1,2) For example, it has been estimated that only a small weight loss (5 kg) among overweight and obese Australians would reduce the diabetes-associated health-care costs by $45.1 million per year (3) and the health-care costs of colorectal, breast, lung and prostate cancers could be reduced by $58.8 million per year by increasing the intake of vegetables in the community. (4)

In order to improve the health of Australians, health authorities have developed nutrition (5-7) and physical activity guidelines, (8) a national nutrition policy, (9) and strategies to support this policy. (1,10) Included in the strategies to ensure good nutrition and maintain a healthy weight is the dissemination of these guidelines and more general nutrition knowledge to health professionals. (1,10)

In Australia, mothers are the major providers of food for their families, (11) and women appear to be motivated to change during pregnancy and in the post-partum period. (12) Previous research with post-partum women has shown that although most of them believed they could provide a healthy balanced diet for their families, their knowledge of food intake recommendations was inadequate. (13) There is a wide variety of nutrition-related advice available in the community from a number of sources including: health promotion messages, industry-sponsored messages, health professionals, media, books and magazines. The women in the study cited many of these as their sources of nutrition information. However, such information is not always accurate and can be conflicting, thus causing confusion. (14)

Nursing staff are considered to be a credible and reliable source of health information (15,16) and most post-partum women come into contact with nursing staff. Thus, some nutrition-related questions were included in a larger study examining the health-related beliefs, knowledge and practices of professionals attending women in the post-partum period. (17) This work reports on the nutrition component of that survey.

METHODS

Participants

Data were collected by questionnaire from hospital-based nursing staff responsible for the care of post-parturient women in eight metropolitan and regional hospitals in Queensland (Cairns, Townsville, Mackay, Rockhampton, Gold Coast and Brisbane) and three hospitals in Canberra. Because of the relatively small size of the ACT when compared with Queensland, the survey was conducted in all of the local maternity hospitals that were operational in August 1998. In Queensland, the survey was conducted, between March 1999 and April 2000, in the largest maternity hospital (based on number of deliveries) in each town. Participants included midwives, registered nurses and enrolled nurses who regularly worked in the obstetric and postnatal wards of these hospitals.

Study design

After obtaining ethics approval from the James Cook University Ethics Committee and the Ethics Committee of each of the participating hospitals, lists of all relevant nursing staff were provided to the researchers by the Human Resources Management Sections of the hospitals. A four-page questionnaire, a cover letter explaining the purpose of the study and a reply paid envelope were mailed to the work addresses of those on the lists provided (n = 635). Reminder letters were posted to non-respondents in the Queensland component of the study, three to four weeks later, in order to increase the response rate. Reminder letters were not distributed in the earlier study conducted in the ACT. Participants were initially assigned identification numbers (ID) so that non-respondents could be identified, thus reducing the need to cause inconvenience to those who had already replied. However, to maintain confidentiality, only ID numbers were entered into the database and analyses were performed using only these ID numbers.

The questionnaire

The questionnaire sought information about health-related knowledge, beliefs and practices and included demographic questions. Results of some questions relating to sun exposure have been published previously. (17) The nutrition component of the questionnaire included questions relating to: beliefs about food (nine questions; Table 1), body image issues (two questions), knowledge of core food requirements for adults (four questions; Table 2), sources of nutrition information (one question) and confidence in giving nutritional advice (one question). Most of these questions have been previously described in detail in a study of nutrition-related knowledge and beliefs of post-partum women in Brisbane and Canberra. (13) The possible answers for the questions relating to beliefs about food, body image issues and confidence in giving nutritional advice were: agree, not sure, disagree, while numbers of serves per day (with the serve size explained) were given for the core food requirements. The question seeking sources of nutritional information was open-ended.

Questions on the core food requirements for adults included fruit, vegetables, protein-containing foods and cereal foods and were based on the National Health and Medical Research Council recommendations. (18) The questions, which have been reported previously, (13) were: 'how many pieces of fruit should an adult eat daily' (options were 1, 2, 3, [greater than or equal to]4, it is not necessary to eat fruit); 'how many serves of vegetables should an adult eat daily' (one serve vegetables = half a cup; options were 1-2, 3-4, 5-6, [greater than or equal to]7, it is not necessary to eat vegetables); 'how many serves of protein should an adult eat daily' (meat, fish, chicken, eggs and dried beans are protein foods; options were 1, 2, 3, 4, it is not necessary to eat protein foods); and 'how many serves of cereal foods should an adult eat daily' (a cereal food = one slice of bread or half a cup of rice or pasta or breakfast cereal; options were 1-2, 3-4, 5-6, [greater than or equal to]7, it is not necessary to eat these foods). The calcium-containing food group was not included because of the need to limit the length of the questionnaire and because it was considered that nursing staff attending pregnant and post-partum women would be well aware of the requirements for calcium-containing foods.

Analysis

Basic frequencies were calculated for all relevant variables and chi-squared tests were used for comparative analyses. Questions about core food requirements were analysed to provide the median and interquartile range of the responses, and the percentage of correct answers together with the 95% confidence intervals is also reported. The following answers were accepted as correct: [greater than or equal to]2 serves of fruit; [greater than or equal to]5 serves of vegetables; 1-2 serves of protein; [greater than or equal to]7 serves of cereal foods per day. Further information about the serve sizes and number of serves is presented in the 'Discussion'. Analyses were conducted using Intercooled Stata version 4.0 (Computer Resource Center, Santa Monica, CA, USA). A significance level of 0.05 was chosen a priori.

RESULTS

Response rate

The overall response rate was 57% (n = 362) comprising 59% (n = 286) in Queensland and 50.6% (n = 76) in the ACT. Response rates were similar for north Queensland (56.1%, n = 96), central Queensland (60.5%, n = 49) and southern Queensland (59.7%, n = 141).

Participant profile

The majority of respondents were qualified midwives (Queensland 81.5%, ACT 96.1%). Other respondents described themselves as registered nurses (Queensland 11.2%, ACT 1.3%), enrolled nurses (Queensland 3.5%, ACT nil), student midwives (Queensland 1.7%, ACT 1.3%), maternity nurses (Queensland 1%, ACT nil), neonatal nurses (Queensland 0.7%, ACT 1.3%), or assistants in nursing (Queensland 0.4%, ACT nil). More respondents from Queensland (92%) than the ACT (51%) were employed in the public sector, with the remainder working in the private hospital system. Age and time since completion of training of the Queensland nursing staff have been reported previously, (17) with 271 of them reporting an average age of 40 years (range 21-66 years) and 279 of them reporting the time since completion of training as an average 14.8 years (range 0-40 years). These data were not collected for participants in the ACT.

Body image and food-related beliefs

About one-third of these nursing staff believed that 'raw sugar is better for you than white sugar', with more participants from Queensland than the ACT holding this belief (36% vs 17%; P = 0.02) (Table 1). As there were no other statistically significant differences in the responses of the two groups of participants, the results have been pooled for presentation (Table 1). More than half (56%) of the participants did not think that 'nuts are fattening'. All participants responded to the comment 'magazines make too much of having a slim body' with 337 (93.1%) agreeing with the statement while 16 (4.4%) disagreed and 9 (2.5%) were unsure. Of the 361 who responded to the comment 'to be fashionable and look nice a woman must be thin' 22 (6.1%) agreed while 335 (92.8%) disagreed and 4 (1.1%) were unsure.

Knowledge about core food requirements

All but two participants reported that daily consumption of fruit, vegetables, core cereal foods and a protein food was desirable, with one believing that fruit was not necessary and the second believing that protein-containing foods were not necessary. Only 27.5% of these nursing staff correctly stated the number of serves of vegetables and 1.7% correctly stated the number of serves of cereal foods an adult should eat daily (Table 2). More than a quarter (28.2%) thought that an adult should eat more than two serves of protein-containing foods per day. Overall, two (0.6%) of these nursing staff gave correct answers to all four food intake questions, 16.8% gave three correct answers, 62.0% two and 20.7% one correct answer.

In response to the comment 'I am confident I can give good advice to mothers about a healthy balanced diet', 353 (97.8%) of the 361 who answered the question agreed, while 3 (0.8%) disagreed and 5 (1.4%) were unsure. Almost two-thirds (65.5%) of the participants reported providing nutritional advice at least weekly (27.9% daily, 37.6% weekly and 15.0% monthly). Only 19.5% rarely or never gave nutritional advice. There was no significant difference in the frequency of advice given by those who were confident in giving nutritional advice and those who were not (P = 0.093).

More midwives than other nursing staff reported giving nutritional advice at least weekly (midwives 69.4%, other nursing staff 43.6%; P = 0.005). There were no significant differences between the two groups in: their confidence in giving nutritional advice, their beliefs about food, their attitudes to body image, or their knowledge of core food requirements for adults. Likewise there were no significant differences for these issues between those who frequently gave nutrition advice and those who did not.

Sources of nutrition information

The most commonly cited source of nutrition information was professional training (51.4% of all participants) with this category consisting of: university studies, nursing studies, midwifery training, diabetes education, other professional courses, in-services, lectures and seminars, textbooks, medical literature, journal articles, and National Heart Foundation and World Health Organization guidelines. The second most commonly cited source of such information was reading (38.7%). This category included books, leaflets and reading (not otherwise specified). Other sources were: general media (14.9%), self-education and work-related experience (10.8%), dietitian (10.5%), school (7.5%), mother/family eating habits/parenting (6.4%) and dieting/weight loss group (5.0%). Within the group citing the media as a source of nutrition information, 9.7% specified magazines while 5.8% specified television. Eleven per cent of the participants reported a number of other assorted sources of nutrition information. The question was open-ended with multiple responses being permitted, and 50 participants did not answer the question. There were no significant differences between sources of nutrition information between those who frequently gave nutrition advice and those who did not.

DISCUSSION

The major finding of the present study was that although almost all the nursing staff surveyed were confident they could give good advice about a healthy balanced diet, and the majority provided such advice at least weekly, there appeared to be a number of gaps in their nutrition-related knowledge. This is of particular significance as it has been shown that nurses are a trusted source of health information, (17) and women appear to be motivated to change during pregnancy and in the post-partum period. (12) Therefore, it is important that information provided by health professionals is accurate.

The National Health and Medical Research Council has established recommended food intakes for children, adolescents, adults and older Australians. (5-7) The serve sizes of cereal foods used for the present study were from the 1995 core food recommendations, (18) because the Australian Guide to Healthy Eating (19) had only recently been published when the present study was undertaken and we considered that these nursing staff were more likely to be familiar with the older serve sizes. In the Core Food Groups developed in 1995, (18) one serving of cereal foods was defined as: one slice of bread; half a cup of rice; half a cup of pasta; or half a cup of breakfast cereal, whereas in the Australian Guide to Healthy Eating published in 1998 (19) the serve sizes of cereal foods were doubled (two slices of bread or one cup of rice, pasta or breakfast cereal). Thus the overall change in recommended daily consumption of cereal foods was increased by the equivalent of one slice of bread, while the size of one serve of cereal foods was halved. Combining the options given in the questionnaire with the current recommendations for core food intake (19) led to accepting the following answers as correct: at least two serves of fruit, at least five serves of vegetables, one to two serves of protein foods and at least seven serves of cereal foods per day. Because of the response options available, there were more opportunities for 'correct' answers for fruit and vegetables than for cereal products, which may have resulted in a small bias away from correct answers for cereal foods.

The majority of these health professionals correctly identified the recommended daily intake for fruit and protein foods for adults, but not for vegetables and cereal foods, which was similar to results from a study among postpartum women. (13) Furthermore, about a quarter of the participants were aware of the recommendations for the consumption of vegetables (compared with 15% of postpartum women in the earlier study (13)) and only a few (1.7%) correctly identified the requirement for cereal foods. Therefore, while these nursing staff did not consider core foods to be fattening, many appeared to be unaware of the minimum daily serves of core foods recommended for a healthful diet.

When the responses to questions about beliefs about food and body image were compared with those of post-partum women in the earlier study, (13) a similarly high proportion disagreed with the statements that 'red meat is bad for you' and 'to be fashionable and look nice a woman must be thin' and agreed that 'magazines make too much of having a slim body'. In contrast, more of the nursing staff responded appropriately to other common nutrition myths such as 'raw sugar is better for you than white sugar, nuts are fattening' and 'most people need to take vitamin and mineral pills'. Thus, while overall, nurses appeared to have a better understanding of nutrition myths and dietary recommendations than post-partum women, a deeper understanding of nutrition and knowledge of food intake recommendations would ensure that the information they pass on to their patients is accurate.

Even though these respondents were confident that they could give good nutritional advice and the majority reported providing such advice at least weekly, confidence was not a good measure of knowledge. Interestingly, the majority of these nursing staff reported regularly providing such information to their patients, yet in an earlier study only 4% of post-partum women identified health professionals as their source of nutrition information. (13) Further research is required to explore this disparity. Although midwives gave nutritional advice more often than other nursing staff, neither their beliefs about food and body image nor the quantity of core foods they suggested as daily requirements for adults differed significantly from those of other nursing staff. The lack of knowledge about core food requirements is of particular concern, as these health professionals regularly provide information about nutrition to their patients. It is also a lost opportunity as there are many more nurses than dietitians in Australia, and thus they have the potential to disseminate such information widely. However, interventions are required to ensure that the information they pass on to their patients is accurate and current.

These nurses cited their major sources of nutrition information as formal and professional education and reading a range of materials including books, magazines and journals. However, a substantial number did not specify their reading matter. Although the sources of nutrition information identified here may not be sufficiently detailed, and further exploratory studies may be required to determine the methods of information transfer that are likely to be the most successful and the most acceptable to the target group, they nevertheless provide some possibilities.

Many of these nurses obtained their nutrition knowledge during their formal nursing training. Therefore, it is important to ensure that new recommendations are systematically released to all nursing schools at the same time as they are released to other health professionals and educational institutions. Both general nutrition knowledge and public health recommendations change with time as science progresses. It is therefore also important to identify possible mechanisms to provide regular nutrition updates to these health professionals.

These nursing staff reported that reading journal articles, books, other written material and professional in-services were sources of nutrition knowledge. It is important to determine why dietitians appear to provide nutrition information to such a small proportion of these nursing staff although there are dietetic departments in all of the public hospitals surveyed and most of the private hospitals have consultant dietitians. Regular nutrition updates (in-services) by dietitians in the work place would help to ensure that nursing staff have current and accurate nutrition information. Nutrition specialists could also write short, but regular segments for nursing journals or newsletters. This written material may be most useful if written in lay terms to enable nursing staff to use it directly with their patients, rather than needing to translate the information for the general public.

This exploratory study was one component of a larger study, and thus had a number of limitations including the number of questions that could be incorporated. Specific sources of ongoing education were not sought. However, such information is essential to ensure that interventions can be appropriately targeted. Although the response rate was low, the size of the sample was reasonable, and there is no reason to suppose that those who responded were particularly different in their nutrition knowledge as the questionnaire was a general health survey, with the questions about nutrition appearing on the second last page. Finally, while the whole population in the ACT was surveyed, the sample in Queensland was not random, but included the nursing staff from selected hospitals. Therefore, the findings cannot be extrapolated to all Australian nurses or even all midwives. Nevertheless, the results do imply that, at least in those states, interventions may be appropriate.

This exploratory study has shown that nursing staff regularly provide nutritional advice to their patients and that they feel confident in doing so. However, there appear to be some gaps in their knowledge and their information may be outdated. While further studies are required to determine the nature of the advice given, it does seem that some intervention would be useful to both the nurses and their patients. Such intervention may also help disseminate correct information about food requirements and other nutrition-related messages more widely, as there are many more nurses than dietitians. Further work is needed to determine: the nature of nutrition advice given by nurses, their knowledge gaps, topics the nurses would find helpful in updates and their preferred learning modalities. In the meantime, from the results of the present study, it seems that updating knowledge of recommended core food intake and some of the nutrition myths via training institutions, in-services and articles in nursing journals and newsletters would commence this process.

In an obesogenic environment, (20) in which the incidence of obesity and the related chronic diseases is rising, (21) physical activity is declining, (22) balancing time between work and family is becoming increasingly difficult, (23) people are cooking less (24) and children are increasingly targeted by advertising, including food advertising, (25) resulting in fewer meals being prepared at home, (26,27) guiding principles, such as those developed by the National Health and Medical Research Council become even more important. Future research should explore whether nursing staff are aware of these issues and whether they need to address them when providing advice to post-partum women in their care. As women in the pregnancy and the post-partum periods are particularly interested in the health of their families, (12) it is important that health professionals attending them have the knowledge to take advantage of this opportunity for health promotion.

ACKNOWLEDGEMENTS

We would like to thank the Human Resources Departments of the hospitals in the study for providing lists of possible participants and the nursing staff who took the time to answer the questionnaires. This work was funded by grants from Queensland Health and the Parkes Bequest at James Cook University. Madeleine Nowak is funded by a Research Fellowship from the Queensland Cancer Fund.

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Madeleine NOWAK, Simone HARRISON and Lesley HUTTON

School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, Queensland, Australia

M. Nowak, PhD, APD, Research Fellow

S. Harrison, PhD, MPH, Principal Research Fellow

L. Hutton, B Psych, Research Officer

Correspondence: M. Nowak, Skin Cancer Research Group, School of Public Health, Tropical Medicine and Rehabilitation Sciences within the North Queensland Centre for Cancer Research, James Cook University, Townsville, Qld 4811, Australia. Email: [e-mail]

Table 1 Beliefs about food and supplements of nursing staff from
Queensland and the ACT

                                      Responses              Comparison
                          Agree       Disagree    Unsure     by state
Statement            N    No. (%)     No. (%)     No. (%)    P-value

Everyone needs to    361    4 (1.1)   355 (98.3)   2 (0.6)   0.751
  add salt to their
  food
People should not    360  308 (85.6)   45 (12.5)   7 (1.9)   0.898
  eat the fat on
  meat
Red meat is bad for  361   11 (3.1)   339 (93.9)  11 (3.1)   0.468
  you
Raw sugar is better  361  121 (33.5)  192 (53.2)  48 (13.3)  0.022*
  for you than
  white sugar
Bread is fattening   360   14 (3.9)   345 (95.8)   1 (0.3)   0.380
Potatoes are         361    7 (1.9)   348 (96.4)   6 (1.7)   0.365
  fattening
Bananas are          361   10 (2.8)   345 (95.6)   6 (1.7)   0.757
  fattening
Nuts are fattening   361  147 (40.7)  202 (56.0)  12 (3.3)   0.255
Most people need to  362   23 (6.4)   325 (89.8)  14 (3.9)   0.504
  take vitamin and
  mineral pills

*P < 0.05.
N is the total number of participants who answered each question.

Table 2 Knowledge of core food requirements for adults among nursing
staff from Queensland and the ACT

                                                          95% CI of
                        Median (IQR) of  Percentage of    correct
                        answers          correct answers  answers

'How many pieces of     3 (2, 3)         96.7 (n = 361)   94.9-98.5
  fruit should an
  adult eat daily?'
'How many serves of     3.5 (3.5, 5.5)   27.5 (n = 360)   22.9-32.1
  vegetables should
  an adult eat daily?'
'How many serves of     2 (2, 3)         71.7 (n = 361)   67.1-76.3
  protein should an
  adult eat daily?'
'How many serves of     3.5 (3.5, 5.5)    1.7 (n = 361)    0.4-3.0
  cereal foods should
  an adult eat daily?'

95% CI = 95% confidence interval; IQR = interquartile range.