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Nutrition and shiftwork: evaluation of new paramedics' knowledge and attitudes.

INTRODUCTION

Paramedics offer an essential 24-hour-a-day public health service, with shifts ranging from 8.5 to 24 hours (1). Shiftwork has been associated with nutrition-related diseases such as cardiovascular disease, obesity, diabetes, and gastrointestinal disorders (2-4). Paramedics often time their eating around the provision of patient care; this may necessitate delaying or skipping meals (1,5). This could increase health problems in this population in Nova Scotia, particularly as overweight and obesity rates in the province are 34% and 24%, respectively (1). A directed education strategy could improve paramedics' knowledge of and attitudes toward nutrition management, which in turn could reduce nutritionrelated health risks associated with shiftwork in this population.

PURPOSE

The effect of an oral education intervention on nutrition knowledge was evaluated in new paramedic employees. The evaluation involved measuring knowledge of and attitudes toward nutrition and shiftwork before and after the directed intervention.

METHODS

Setting

In Nova Scotia, paramedics enter the workforce through a new employee orientation, which occurs quarterly (6). Study participants (n=30) were a convenience sample of paramedics attending a two-week mandatory orientation.

Education intervention

The lead author (A.B.M.) gave a 15-minute oral presentation on nutrition management during paramedic shiftwork. Topics included meal and snack composition and timing, hydration, and portion control. Materials from Dietitians of Canada, Health Canada, and the academic literature were used to develop the oral education intervention and accompanying resource (3,4,712).

Design

This matched cohort study comprised three self-administered surveys. Survey 1 was completed before education, survey 2 immediately after education, and survey 3 after one month of concurrent post-education and employment experience. The surveys were designed by the lead author (A.B.M.), pilot tested for face validity by two members of the Emergency Health Services (EHS) Health and Wellness Committee, seven paramedics, and two dietitians; modifications were made to content, format, and readability. Testing bias was avoided by rewording and reordering survey questions; each survey included the same questions. Knowledge questions were multiple choice, while five attitude questions had a five-point Likert scale (5=strongly agree, 1=strongly disagree). One question and four statements were chosen a priori to assess attitudes toward healthy eating behaviour:

* Shiftwork and the development of nutrition-related health problems--"Do you think paramedics who do shiftwork are at greater risk of developing nutrition-related health problems than are workers who have a fixed daytime schedule?" This question assessed paramedics' perception of health risks associated with altered eating behaviour as a result of shiftwork.

* No packed lunch and time to purchase food--"On the shifts when I have not packed a lunch, I have been able to find the time to purchase food." This statement assessed paramedics' attitude toward their eating schedule as a result of the unpredictable nature of their work.

* Snacking and weight gain--"Snacking inevitably promotes weight gain." This statement assessed paramedics' attitude toward snacking behaviour.

* Packed lunch, maintenance of energy, and satisfaction of appetite--"When I did pack a lunch, I was able to pack a lunch that curbed hunger, maintained my energy levels, and satisfied my appetite throughout my shift." This statement assessed paramedics' attitude toward knowing how to pack a nutritious and balanced meal for work.

* Snacking to prevent fatigue and increase alertness-- "Snacking is a good thing to do because it can prevent fatigue and increase mental alertness." This statement assessed paramedics' attitude toward snacking and the maintenance of energy levels. Paper copies of surveys 1 and 2 were distributed at the orientation. Demographic information was collected in survey 1. Survey 3 contained additional multiple-choice questions about eating behaviours in the field. Attendees who consented to participate in survey 3 were sent an email with a link to an electronic survey (Opinio, version 6.4.1, 2011, Object Planet, Oslo, Norway) and given one week to complete it. Email reminders were sent twice during the week.

Consent was assumed if attendees completed the surveys; all were informed beforehand that participation was voluntary and anonymous. Written consent and the provision of an email address were the inclusion criteria for receiving an email link to survey 3, delivered 30 days after the orientation. Ethics approval was received by the Mount Saint Vincent University Research Ethics Board.

Statistical analyses

Statistical analyses were performed using Minitab (version 14.11.1, Minitab Inc., State College, PA, 2003). Surveys 1 and 2 were paired using an alphanumeric identifier for within-subject comparisons. Survey 3 data were used for between-subjects comparisons in surveys 1 and 2. One-way analysis of variance (ANOVA) was used to determine knowledge differences between all three surveys. Post hoc analysis with Tukey's honestly significant difference test was used to determine the location of these differences (13). Differences in attitude among all three surveys were assessed using the Kruskal-Wallis one-way ANOVA test (13). Statistical significance was reported at P_0.05.

RESULTS

Subjects

All 30 attendees participated in survey 1, 29 (96.7%) in survey 2, and 13 (43.3%) in survey 3. Participants were predominantly (59%) male, were practising as primary care paramedics (Table 1), and reported that they had not received this type of information previously or that they had received only a brief lecture (93.2%).

Knowledge

Mean knowledge scores increased significantly from survey 1 to survey 2. Knowledge scores decreased from survey 2 to survey 3, while scores in survey 3 remained higher than those in survey 1. A significant difference in the knowledge scores existed at the P<0.05 level for all three conditions [F (2, 68)=64.89, P=0.000].

Attitudes

No significant differences were found between attitude response scores on surveys 1, 2, and 3 for the question on shiftwork and the development of nutrition-related health problems; the statement on snacking and weight gain; the statement on a packed lunch, maintenance of energy, and satisfying appetite; or the statement on snacking to prevent fatigue and increase alertness. A significant difference was found between surveys 2 and 3 for the statement on no packed lunch and time to purchase food (Table 2).

DISCUSSION

Knowledge

This study involved examining new employees' knowledge of and attitudes toward nutrition during paramedic shiftwork, an underinvestigated area in this population. The education session was successful in improving shiftwork nutrition knowledge. Knowledge retention, identified after one month of work experience, was highest for nutrition management strategies, a finding that indicates key messages were retained.

Attitudes

Conversely, neither the education session nor employment experience had an effect on paramedics' attitudes. Before the education session, paramedics already had positive attitudes about the role of proper nutrition practices in achieving fitness for work, and therefore these were not expected to improve as a re suit of the intervention. These results may indicate that students learn informally from peers about the expectations of shiftwork, or that individuals attracted to paramedicine share similar attitudes. Peer-to-peer learning benefits for new employees entering the workforce have been described (14). Interestingly, after paramedics gained employment experience, they felt able to find time to purchase healthy food when they had not packed a lunch (Table 2). Given the unpredictable nature of paramedic shiftwork, this result was unexpected and indicates that work experience may have influenced meal timing attitudes. Rural regions of Nova Scotia received the majority of orientation attendee assignments; possibly, more time between emergency calls because of the lower population density allows paramedics to purchase healthy food.

Study limitations

While the survey was pilot tested for face validity, the questions were not rigorously assessed for content validity to measure attitude. The response rate for survey 3 was moderate. How knowledge retention and paramedics' attitudes would be affected after more than one month of employment is unknown. Given that knowledge retention occurred, however, the education session and resources could be adopted by other services as a useful assessment and fundamental education program. As this small study included participants mostly trained in Nova Scotia, we do not know whether these results could be generalized to other EMS systems. Further investigation with this population is therefore important.

RELEVANCE TO PRACTICE

Currently, Canadian EMS training programs do not include competency training on nutrition management strategies (15). Paramedicine is physically demanding and requires practitioners to maintain an able body capable of emergency medical duties. Fatigue related to work stressors may place these individuals at risk for sick time and work disability (16). In addition, mechanisms paramedics use to cope with workplace stress must be examined (17,18). Specific recommendations about nutrition and stress must be considered. Nutrition management education should be part of paramedic training and EMS new employee orientation sessions. This grassroots approach could improve nutrition practices in the paramedic workplace, which might reduce nutrition-related disease in these health care professionals.

Acknowledgements

We thank the paramedics who participated in this study, Nova Scotia Emergency Health Services Operations Management for providing in-kind support, Lynn Lawson for her advice, and the Nova Scotia EHS Health and Wellness Committee for their advice and pilot testing.

References

(1.) Poirier K. Current dietary and lifestyle habits of ground, air, and emergency dispatch paramedics and LifeFlight nurses across Nova Scotia. 2009. Located at: Department of Applied Human Nutrition, Mount Saint Vincent University, Halifax, NS.

(2.) Froy O. Metabolism and circadian rhythms implications for obesity. Endocrinol Rev. 2010;31:1-24.

(3.) Morikawa Y, Miura K, Sasaki S, Yoshita K, Yoneyama S, Sakurai M, et al. Evaluation of the effects of shift-work on nutrient intake: a cross-sectional study. J Occup Health. 2008;50:270-8.

(4.) Ribeiro DCO, Hampton SM, Morgan L, Deacon S, Arendt J. Altered postprandial hormone and metabolic responses in a simulated shift work environment. J Endocrinol. 1998;158:305-10.

(5.) Conyers MM. Investigating the perspective of emergency health services paramedics, nurses and communications officers on the effects of delaying nutrient intake as it relates to health and job performance and determining appropriate nutrition intervention strategies related to meal planning that can increase the overall nutritional health of emergency health services employees with unpredictable meal schedules. 2010. Located at: Department of Applied Human Nutrition, Mount Saint Vincent University, Halifax, NS.

(6.) Emergency Medical Care Inc. Services; 2011 [cited 2011 Jul 11]. Available from: http://www.emci.ca/about/Pages/services.aspx

(7.) Dietitians of Canada. Resources. Are there special nutritional considerations for shiftworkers?; 2010 [cited 2011 Jul 1]. Available from: http://www.dietitians.ca/Nutrition-Resources-A-Z/Factsheets/Shift-Work/ Special-Nutritional-Needs-for-Shift-Workers.aspx

(8.) Dietitians of Canada. Resources. Healthy snacks for adults; 2010 [cited 2011 Jul 1]. Available from: http://www.dietitians.ca/Nutrition-Resources-A-Z/ Factsheets/Healthy-Eating--General/Healthy-Snacks-for-Adults.aspx

(9.) Dietitians of Canada. Resources. 5 tips for healthy eating; 2010 [cited 2011 Jul 1]. Available from: http://www.dietitians.ca/Nutrition-Resources-A-Z/ Factsheets/Healthy-Eating--General/imple-healthy-eating-tips-based-on Canada%E2%80%99s-Food-G.aspx

(10.) Health Canada. Eating well with Canada's Food Guide. Ottawa: Health Canada; 2011.

(11.) Pasqua IC, Moreno CRC. The nutritional status and eating habits of shift workers: a chronobiological approach. Chronobiol Int. 2004;21(6):949-60.

(12.) Holmba U, Lowden A, Akerfeldt T, Lennerna M, Hambraeus L, Forslund J, et al. The human body may buffer small differences in meal size and timing during a 24-h wake period provided energy balance is maintained. J Nutr. 2003;133:2748-55.

(13.) De Veaux RD, Velleman PF, Bock DE. Stats: data and models. 2nd ed. Toronto: Pearson/Addison Wesley; 2008.

(14.) Best G, Hajzler D, Ivanov T, Limon J. Peer mentoring as a strategy to improve paramedic students' clinical skills. Australas J Peer Learn. 2008;1:13-25.

(15.) Paramedic Association of Canada. National occupational competency profile; 2001[cited 2011 May 6] Available from: http://paramedic.ca/nocp/

(16.) van der Ploeg E, Kleber RJ. Acute and chronic job stressors among ambulance personnel: predictors of health symptoms. Occup Environ Med. 2003;60(Suppl I):i40-6.

(17.) Bentley MA, Crawford JM, Wilkins JR, Fernandez AR, Studnek JR. An assessment of depression, anxiety, and stress among nationally certified EMS professionals. Prehosp Emerg Care. 2013;17:330-8.

(18.) Bowron JS, Todd KH. Job stressors and job satisfaction in a major metropolitan public EMS service. Prehosp Disaster Med. 1999;14:236-9.

AMANDA B. MACDONALD, BSc (Hons), RD, Department of Applied Human Nutrition, Mount Saint Vincent University, Halifax, NS; JAN L. JENSEN, MAHSR, ACP, Nova Scotia Emergency Health Services, Dalhousie university Division of Emergency medical Services, Halifax, NS; MELISSA D. ROSSITER, PhD, Department of Applied Human Nutrition, Mount Saint Vincent University, Halifax, NS
Table 1
Characteristics of new paramedic employees in Nova Sctia

Variable                             n (%)        [bar.x] [+ or -] SD

Age (years)                          29           28.3 [+ or -] 8.0
Sex
  Female                             12 (41.0)
  Male                               17 (59.0)

Type of paramedic provider
  Primary care                       26 (89.7)
  Intermediate care                  0
  Advanced care                      2 (6.9)
  Critical care                      1 (3.4)

Work experience (years)                           1.6 [+ or -] 4.5
Site region
  Central                            8 (27.6)
  Northern                           9 (31.0)
  Cape Breton                        6 (20.7)
  Western                            6 (20.7)
  Other                              0

Academic institution attended
  Maritime School of Paramedicine    18 (62.0)
  Holland College                    3 (10.4)
  Atlantic Paramedic Academy         0
  Other                              8 (27.6)

Previous nutrition education
  None                               14 (48.4)
  Brief lecture or information       13 (44.8)
    session (a)
  Formal course (formal              1 (3.4)
    lectures, readings,
    testing on information)
  No answer                          1 (3.4)

SD = standard deviation
(a) Approximately 60 minutes

Table 2
Analysis of variance comparison of
attitude questions from surveys
1, 2, and 3

Question or statement (a)            Survey   Median   Mean
                                                       rank

Are paramedic shiftworkers at        1        5.0      40.3
greater risk than non-shiftworkers   2        4.0      35.6
for nutrition-related health         3        4.0      27.2
problems?

I had time to purchase food on       1        2.0      34.3
days I didn't pack a lunch.          2        2.0      29.3
                                     3        4.0      54.7

Snacking inevitably promotes         1        2.0      39.2
weight gain.                         2        2.0      37.1
                                     3        2.0      26.3

When I packed a lunch, it curbed     1        4.0      32.4
hunger, maintained energy, and       2        4.0      40.7
satisfied my appetite throughout     3        4.0      33.6
my shift.

Snacking is good because it can      1        4.0      36.5
prevent fatigue and increase         2        4.0      34.2
mental alertness.                    3        4.0      36.3

Question or statement (a)            H (df)      p (c)

Are paramedic shiftworkers at
greater risk than non-shiftworkers   4.83 (2)    0.089
for nutrition-related health
problems?

I had time to purchase food on
days I didn't pack a lunch.          15.16 (2)   0.001

Snacking inevitably promotes
weight gain.                         4.88 (2)    0.087

When I packed a lunch, it curbed
hunger, maintained energy, and       3.53 (2)    0.171
satisfied my appetite throughout
my shift.

Snacking is good because it can
prevent fatigue and increase         0.31 (2)    0.855
mental alertness.

(a) The questionnaire question and all statements but the one on
snacking and weight gain have been edited for the sake of brevity.

(b) Responses were measured on a five-point Likert scale
(5=strongly agree, 1=strongly disagree).

(c) The alpha level was set at 0.05.
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Article Details
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Title Annotation:Report/Rapport
Author:MacDonald, Amanda B.; Jensen, Jan L.; Rossiter, Melissa D.
Publication:Canadian Journal of Dietetic Practice and Research
Article Type:Survey
Geographic Code:1CANA
Date:Jan 1, 2013
Words:2483
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