Allnurses research findings. Dietary Behaviors and Shift Work; Boston-Based Nurses

RNsoonNP

Dietary Behaviors and Shift Work; Boston-based Nurses

Lena Kil, Nancy Nguyen, Ji Whang

Simmons College

NURS 508 Scholarly Inquiry II: Summer 2018

Abstract

Background. About 60% of nurses reported inadequate knowledge of nutrition (Reed, 2014). Nurses often perform unhealthy lifestyle behaviors, which are primarily a cause of working irregular shifts (Han et al, 2015). Shift work is a possible risk factor for unhealthy dietary behaviors associated with the nursing profession. There is an abundance of literature that explores how different shift schedules may impact nurses' health, but few studies specifically examine how different shift schedules influence nurses' nutritional intake.

Aim. The purpose of this research study is to explore shift work and its' effect on dietary and lifestyle habits of Registered Nurses in the Boston area.

Method. A cross-sectional survey evaluated a total of 19 Boston Registered Nurses from July 1 to July 22 of 2018, using the Qualtrics survey program. The Allnurses.com database was utilized to reach this target group of Registered Nurses. Descriptive analysis was conducted on the data due to the small sample size and was done via SPSS.

Results. The average BMI of the participants is 28.24, which is in the overweight category. The majority lacked workplace support to promote a healthy diet and felt that shift work made it difficult to maintain a healthy diet. On average, the participants of this study do not consume the recommended dietary allowance of nutrition, do not sleep the recommended number of hours, have high alcohol consumption, and lacked dietary support from their facilities.

Conclusions. Additional research needs to be conducted in regional areas where nursing populations are high to identify variations that may affect lifestyle behavior differences. Institutes that employ nurses need to implement interventions to encourage their nursing staff to establish healthier dietary habits.

Introduction

From October 2013 to October 2016, the American Nurses Association (ANA) in collaboration with Pfizer conducted a nationwide health-focused survey to over 14,000 nurses and found that nurses have a 30% less nutritious diet than that of an average American (American Nurses Association & Insight Consulting Group, 2016). This finding is concerning because nurses are the largest subset of workers in America's Healthcare system (U.S. Bureau of Labor Statistics, 2015). Poor quality eating patterns are correlated to a significant risk of developing chronic diseases such as, cardiovascular disease, hypertension, type 2 diabetes, and cancer (U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2015), as well as job dissatisfaction in the form of burnout, increased stress, and high turnover rates (Kurnat-Thoma et al, 2017). Although nurses may be knowledgeable in health promotion practices such as healthy eating, physical activity, stress management, and sleep hygiene, this knowledge does not necessarily translate into nurses' own self-care (Ross et al, 2017). About 60 percent of nurses reported inadequate knowledge of nutrition (Reed, 2014). Nurses often perform unhealthy lifestyle behaviors, such as minimal exercise, poor dietary habits, lack of involvement in leisure activities, which are primarily a cause of working irregular shifts (Han et al, 2015). There is an abundance of literature that explores how different shift schedules may impact nurses' health, but few studies specifically examine how different shift schedules influence nurses' nutritional intake.

The purpose of this research study is to explore how Boston, Massachusetts nurses' dietary habits differ amongst shift schedules (rotating schedule with night shifts, rotating schedule without night shifts, and fixed schedule [either day, evening, or nights]) and the factors (e.g. personal preference, available foods, workplace resources etc.) that contribute to their diet. The dietary behaviors data that will be collected from this study will also be compared to the general public of the United States using data gathered by the USDA and CDC. Massachusetts has approximately 137,388 active registered nurses and licensed practical nurses in 2016 (Commonwealth of Massachusetts, 2016). There are two dozen hospitals in the greater Boston metropolitan area (Brownlee, 2012). Focusing this research project on the city of Boston, where it is an urban environment with many practicing nurses, is important because this study's findings may be applicable to other large cities in the United States. It is essential to promote healthy eating behaviors for nurses, in order for them to provide quality patient care and implement these healthy dietary practices to their patients. As the most trusted profession (Brenan, 2017), nurses serve as good health role models for the general public.

The objectives of this study are to explore two research gaps: (1) To examine if there are contributing factors to shift work and nutritional status, mealtimes, snacking behaviors, and body mass index (BMI) among Boston-based nurses. (2) To explore how Boston-based nurses compare nutritionally against the dietary guidelines and the average American diet.

Potential interventions to enhance nurses nutritional intake are, creating policies to provide healthy schedules for nurses (Han et al, 2015), increasing participation of nurses involved in planning workplace health programs aimed at reducing poor dietary habits (Phiri et al, 2014), nurse leaders acting as role models to lead healthier lifestyle choices and also act as advocates for systematic changes to remove workplace hazards (Ross et al, 2017), more extensive nutrition education for nurses, promoting awareness of nutrition educational resources outside the workplace, and providing healthier food alternatives and workshops geared toward promoting lifestyle education recommendations for night shift workers.

Research Question

How are the dietary behaviors of Boston regional nurses affected by their work schedule?

Working Definitions

This study allowed both night and day shift nurses to participate in the survey. Day shift includes working between 7:00 AM and 3:00 PM with rotating without nights and fixed (no night) shifts. Night shift includes working between 7:00 PM and 7:00 AM with rotating with nights and fixed (only nights) shifts.

Literature Review

Unhealthy Eating Behaviors in Night Shifts

Unhealthy eating behaviors have been found to be a contributor to unhealthy dietary habits of night shift nurses. Many night nurses are typically unable to take meal breaks during their workday due to busy schedules and have to resort to unhealthy nighttime snacks (Han et al, 2015). Night time workers have to organize their meal times for irregular hours which can lead to irregular eating habits than those who work during the day (Altenburg de Assis et al, 2003). Nurses who work rotating shifts with nights were found to have irregular meals (87%) more often than nurses who work rotating shifts without nights (66%) (Han et al., 2015). Only 21% of rotating night nurses were found to consistently eat 3 meals a day, compared to nurses not working night shifts (40%) (Han et al., 2015).

The data for the long-term effects of eating habits for rotating night shift workers remain unclear due to many potential confounders that may affect the dietary habits of nighttime workers. Further research and discussion need to occur to fully understand the phenomena that occur between night shift work and BMI.

Poor Diet Quality

Japanese female nurses aged 20-59, 1179 day workers and 1579 rotating shift workers, were studied using self-administered questionnaires including dietary intake (Tada et al, 2014). Shift workers consumed significantly higher amounts of sugar-sweetened beverages than day workers. Higher consumption of sugar-sweetened beverages was associated with rotating shift work and higher BMI (Tada et al, 2014).

One hundred and fifty female nurses aged 20-49 years were recruited from Ain Shams University Hospitals, Egypt, from January to March 2016: 64 day shift and 86 night shift. Diet type was assessed by interview questionnaire. Triglyceride (TG), low-density lipoprotein (LDL) and high-density lipoprotein (HDL) were measured in all nurses (Gadallah et al, 2017). The predictors of high TG level were ages 30-39 and â‰¥ 40 years and night shift. The only predictor of high LDL level (> 130 mg/dl) was age â‰¥ 40 years. An unhealthy diet and night shift were predictors of risky HDL levels. The findings emphasize that night shift nurses are at risk of abnormal lipid profile (Gadallah et al, 2017).

However, another study found no differences between day and night shift with regard to sleep and diet quality among nurses. Data on nurses (n = 103) working either a day or night shift from two Midwestern hospitals were obtained from August 2015 to February 2016. The instruments used were the Diet History Questionnaire and the Pitsburg Sleep Quality Index. Independent samples were used to examine differences in diet and sleep quality by work shift schedule (Beebe et al, 2017). There were no statistically significant differences between nurses working day or night shift and sleep quality (P = 0.0684) and diet quality (P = 0.6499). There was a significant difference between both BMI (P = 0.0014) and exercise (P = 0.0020) with regard to diet quality. BMI and sleep quality were also significantly associated (P = 0.0032) (Beebe et al, 2017).

Increased BMI with Night Shift Workers

Levels of BMI are found to be statistically higher in nurses who work night or mixed shift schedules than among day workers (Smith et al, 2013). Some studies have shown a high prevalence of obesity in night shift workers than in day or evening shift workers (Griep et al, 2014). One study looked at chronic night work and its association with BMI among registered nurses in Brazil. Their findings suggest that chronic night shift work plays a role in increased BMI, and working long weeks (specifically with night shifts) can lead to exhaustion and fatigue due to insufficient recovery time (Griep et al, 2014).

Another study focuses on obesity among nurses who work the night shift and the author states that swing shift and night shift work disrupts circadian rhythms and results in a slowed resting metabolism (Williams, 2017). The exact mechanism for why night shift work contributes to obesity still remains unclear, but the current proposition is that there is reduced leisure-time, physical activity, increased alcohol consumption, difficulty in maintaining a healthy diet or increased consumption of energy-dense foods to combat fatigue, and reduced amount and/or quality of sleep (Griep et al, 2014).

However, obesity resulting from night shift work may be a trend that is complicated by social standards and practices. Research by Han et al, (2015) found night nurses in Seoul, South Korea had a higher percentage of underweight (22%) compared to those who work morning and evening shifts (9%), which is contrary to western studies who report higher percentages of obesity among night nurses. Because of these findings, obesity in night shift nurses may be contributed by American traditions and dietary options rather than working the night shift itself. Although South Korean night nurses also exhibit unhealthy snacking behaviors, the types of foods available and the societal acceptance of being obese and overweight in America may contribute to the higher percentage of obese and overweight nurses. Further investigation is needed to determine the difference between the obesity rates in the two countries and the overall contributing factors to this phenomena.

Insufficient Sleep

Sleep insufficiency is to "not obtain restorative sleep" and is becoming a public health problem which can lead to cardiovascular morbidity and metabolic disorders (obesity, diabetes, heart disease, hypertension) (Perry et al, 2013). Nurses working 12-hour shifts typically complain of fatigue and insufficient/poor-quality sleep due to short sleeping periods between shifts which leads to becoming progressively sleepier each shift, and night nurses being sleeper toward the end of the shift (Brown et al, 2012). Psychosocial factors such as self-esteem, job stress, and the number of night shifts were positively related to insomnia, with physical activity having the most influence (Jung & Lee, 2014). Weight gain occurs due to food intake being more than necessary to offset the energy costs of sleep, and it can become exacerbated if physical exhaustion from sleep loss leads to reduced physical activity (Markwald et al, 2012). Women, in particular, are highly susceptible to weight gain from insufficient sleep. Women who had adequate sleep maintained weight, whereas insufficient sleep led to weight gain (Markwald et al, 2012). However, a study by Huth et al (2012) found that sleep quality was not significantly correlated with elevated BMI >30, indicating other factors may be contributing to obesity during night shift work.

Pathologies Related to Chronic Night Shift Work

PepÅ‚oÅ„ska et al (2015) studied 724 female nurses and midwives from 2008-2011. They found cumulative night shift work significantly increased BMI, waist circumference, and, hip circumference. Night shift work was directly associated with obesity in nurses working 8 or more night shifts per month (PepÅ‚oÅ„ska et al, 2015). Moreover, working the night shift is associated with the accumulation of abdominal fat specifically, a risk factor for diabetes and other metabolic disorders (PepÅ‚oÅ„ska et al, 2015).

All-cause and cardiovascular disease (CVD) mortality were significantly increased among women with â‰¥5 years of rotating night shift work, compared to women who never worked night shifts in a prospective cohort study of 74,862 registered U.S. nurses from the Nurses' Health Study (Gu et al, 2015). However, there was no significant association between rotating night shift work and all-cancer mortality or mortality of any individual cancer, with the exception of lung cancer (Gu et al, 2015).

Limitations of the Literature

The study by Altenburg de Assis et al (2003) had a small sample size (n=66). The study samples of all the examined literature focused on specific populations. With the exception of Gu et al (2018) and Smith et al.'s (2013) large sample sizes (n= 69,269 and n= 9,29, respectively), the other samples may not be representative of their entire targeted population. Therefore, the results are not generalizable. The validity of all the examined research studies is questionable as all implemented surveys required participants' self-report. Responses are subjective and could not be accurate, i.e. nurses reporting a healthier than actual diet for fear of being negatively judged or false perception of dietary habits.

Methodology

A quantitative cross-sectional study utilizing a survey via Qualtrics, a research software provided by Simmons College, was conducted. Data will be collected by the completion of a self-report and anonymous survey designed after elaborate literature review related to eating habits and health habits of nurses. The survey had a total of 42 questions that were in multiple choice, short answer, and select all that apply format, and one optional free response. The questions inquired about demographic factors, shift schedule, employment status, height and weight, meal-time behaviors, snacking behaviors, alcohol consumption, hours of sleep, and nutritional support participants may receive from the facility they work in.

The link to the survey was posted on the nursing forum, Allnurses.com, from July 1, 2018 through July 22, 2018. Participation is voluntary and anonymous. The targeted study population is nurses who are employed in the greater Boston metropolitan area, between the ages of 21-64, and there is no limitation on racial, ethnic group, or gender. Inclusion criteria for this study are as follows: current nurse licensure, current employment as a nurse (full-time, part-time, per diem), and current employment in a Boston-based facility. Dietary behaviors of the participants will be compared to the 2015-2020 Dietary Guidelines for Americans by the United States Department of Agriculture (USDA). Plans for dissemination include presenting findings at the end of the Scholarly Inquiry II class session and posting findings on Allnurses.com (as per agreement to utilizing their nursing database).

Ethical Considerations

Participants were informed about the study via the Allnurses.com forum post and consent form found at the beginning of the survey, who were informed that involvement was voluntary, anonymous, and they could withdraw at any time without consequences. All participants consented to the study on the consent form. No special class of subjects such as fetuses, pregnant women, children, minors, prisoners or other institutionalized individuals, or other vulnerable populations will be involved in this research. Permission to conduct the research study was approved by the Simmons institutional review board and permission to post the survey link on the nursing forum, Allnurses.com, was granted by the website's administrators.

Data Analysis

Dr. Strowman of Simmons College aided in making the survey and analyzing the data, utilizing the statistical analysis software SPSS. The preliminary survey was tested in the Scholarly Inquiry II class to determine the validity and reliability of the survey. Descriptive analysis of the data was conducted to identify any trends between shift work and dietary behaviors. Some of the open-ended responses will be utilized for discussion. Themes were not utilized for this research as response rates were low.

Limitations of the Study

The study sample is not representative of the nursing population in Boston, but a convenience sample. This method of sampling and the study's small sample size (n= 19) limits the generalizability of the results. Descriptive analysis was conducted due to the small sample size. Because this study chose to look at all shift types, it was difficult to ascertain which shifts resulted in which dietary and lifestyle behavior. Instead of looking at specific shift types, this study has chosen to look at dietary and lifestyle behaviors across all shift types. Another limitation of the study could be that the collected data may be inaccurate because survey items were measured only by self-reports and some questions on the survey were skipped, leading the researchers to make assumptions during data analysis. On question 36 of the survey, 6 did not have a response, which the researchers assumed the answer to be 'no' if they chose 'not applicable' on question 37, and a 'yes' if they chose an answer other than not applicable.

Results

The sample study consisted of 19 nurses who are employed in a Boston-based facility. The age in this sample group ranged from 22 to 57, with the mean age being 35. The mean BMI of the 19 nurses is 28.24. Majority of participants (47.4%) identified as white. 73.7% of participants have a Bachelor's degree and 26.3% have an Associate's degree. None of the claim to have a diploma, Master's, or Doctorate's degree, and most are currently not students (68.4%). The majority of participants (68.4%) do not have children at home. Most have 1-5 years of nursing experience (31.6%). Of the study sample, 36.8% have fixed shift schedules with no nights and 94.7% are employed full-time. 26.3% of the participants work fixed shifts with nights and 15.8% work rotating with nights. The majority reported drinking alcohol, with 47.7% regularly consuming 'a moderate amount' of alcohol and 42.1% consuming 'a little' alcohol. 36.8% perceived 'probably not' getting enough sleep and 21.1% 'definitely not' (Table 1-1).

The study results show that 52.6% of the nurses perceive their general health status as 'good' and 31.6% perceive it as 'fair' 36.8% reported not currently attempting to improve their diet but want to in the future, and 31.6% answered 'yes' to currently attempting to improve their diet. 36.8% answered 'no' to having regular routine meals and 21.1 % answered 'sometimes'. 63.2% of the participants reported skipping lunch with 'lack of time' (63.2%), 'irregular work schedule' (47.4%), and 'tired' (42.1%) being the top reasons for missing meals. 57.9% reported 'sometimes' overeating (Table 2-1).

Regarding snacking behaviors of the nurses, 42.1% 'rarely' snack on healthy foods and 57.9% 'sometimes' snack on unhealthy foods. 31.6% of the participants consume snacks most often in the evenings, followed by 21.1% during the afternoon and night. The most reported reason for snacking is 'hunger' (89.5%), then 'taste' (78.9%), followed by to 'reduce stress' (42.1%) (Table 2-2).

For consumption of nutrients, the study results showed that 21.1% of the participants consumed the recommended dietary allowance (RDA) of vegetables every day. On a daily basis, 15.8% consumed the RDA of fruits, 36.8% consumed the RDA of grains, 21.1% consumed the RDA of dairy, 42.1% consumed the RDA of protein, and 0% consumed the RDA of healthy oils. In terms of sweets consumption, 42.1% of the nurses reported exceeding the RDA of sweets '3-4 times a week'. 47.4% reported exceeding the RDA of fatty foods '3-4 times a week'. In regards to fast/instant foods, 42.1% of the study population answered consuming it '1-2 times a week', followed by 31.6% answered 'less than once a week' (Table 2-3).

Regarding workplace health promotion, 21.1% of the participant reported 'Yes' to nutritious meals offered at work while 31.6% reported 'No' to the variable; 26.3% reported workplace does not offer meals. 84.2% reported workplace does not provide any resources to promote a healthy diet and 52.6% reported workplace does not promote a healthy diet. The results also show that 57.9% of the nurses reported that they are not trying to improve their diet while other nurses are trying to improve it by using resources like 'online research' (26.3%), 'suggestions from other individuals' (15.8%), 'phone applications' (10.5), 'nutritionist or other healthcare professional' (10.5%), and 'News and magazines' (5.3%). 21.1% reported 'definitely yes' to believe that shift causes difficulty in maintaining a healthy diet, and 36.8% reported 'probably yes' to the variable (Table 3).

A free response option was available for our respondents. However, due to the small sample size, themes were not defined but three common categories emerged from the provided responses: skipping meals due to lack of time and/or heavy workload, snacking to satisfy hunger, and inconsistent meal times amongst night shift nurses.

Skipping meals due to lack of time and/or heavy workload

This category emerged nurses reporting that they miss meals from either insufficient time to consume a meal during their shift and/or heavy workload that prevents them from eating. A participant states, "we are only allotted 30 minutes for mealtime, which is not enough time to eat." Another describes "my eating habits at work are dependent on how smoothly the shift is. If the shift is smooth... I can focus on eating a full lunch... When the shift is busy, I don't have time to eat/get food from the cafeteria... I try to time manage as much as possible in order to eat lunch, but sometimes I get too busy."

Snacking to satisfy hunger

Related to the first category, most nurses reported snacking in place of their meals. One nurse reports, "I snack throughout my shift and at home because it satisfies my hunger and allows me to get all my proper nutrition."

Inconsistent meal times amongst night shift nurses

The night shift nurses and a nurse who occasionally works the night shift in this study described having inconsistent meals and eating snacks throughout the shift rather than a meal. Examples of statements include: "working full-time night shifts makes it incredibly difficult to maintain a consistent meal plan", "I don't really eat meals during work because I feel nauseous, so I mostly snack throughout the shift", and "the night shifts throw my eating schedule off."

Discussion

The purpose of this study was to examine the relationship between shift work and dietary behaviors of Registered Nurses in Boston. One important finding of this study is the mean BMI among all shift workers. NIH defines the following categories for BMI: 30 obese, and >40 as extreme obesity (Overweight and obesity statistics, 2014). Although the study cannot conclusively suggest that certain shift work causes higher BMI, the results show that regardless of the shift that was worked, the average BMI of all the nurses who participated in this survey is overweight (BMI 28.24 Â± 5.43). It is possible to suggest that a high number of nurses in the Boston area are overweight or obese. According to the CDC (2017), the average American BMI is 28.9 which is comparable to the mean BMI 28.24 of the nurses in this study. These statistics show that regardless of the nursing training in Boston, BMI levels are comparable to the average American public.

Lifestyle behaviors are also key indicators for BMI status. 100% of this study's participants report sleeping less than 7 hours a night. The CDC (2015) recommends adults to sleep 7 or more hours of sleep for "best health and wellbeing" and a study by Beccuti and Pannain in 2011 suggests evidence that links poor sleep quality to obesity (Sleep and Sleep Disorders; Beccuti & Pannain, 2011). The study by Beccuti and Pannain in 2011 also suggests that sleep is an important modulator for glucose metabolism, and sleep loss could alter metabolism resulting in "decreased glucose tolerance, decreased insulin sensitivity, increased evening concentrations of cortisol, increased levels of ghrelin, decreased levels of leptin, and increased hunger and appetite" (Beccuti & Pennain, 2011, p.1). Among the participants of this study, hunger was the top reason for snacking behaviors (89.5%) and could possibly due to poor sleep behaviors. 57.9% of respondents also state they either 'do not' or 'sometimes' have a regular routine for meals, but 57.9% show to eat 3 meals a day with lunch being the most common meal to be skipped (63.2%). Only a minority of nurses also report eating the RDA of vegetables, fruits, grains, dairy, proteins, and healthy oils. Fruits and healthy oils seem to be the highest food categories that respondents report eating less than once a week (21.1% and 21.1%, respectively) and grains and protein to be the highest categories that are eaten every day (26.8% and 42.1%, respectively) (Table 2-3). From this study, there is not enough data to conclude the correlation of RDA and shift work, but it can be purported that grains and proteins are the easiest to consume, and may also be contributing to the high BMI of nurses. However, the convenience of foods may not be a contributing factor as the majority of participants eat fast/instant foods only 1-2 times a week (42.1%, table 2-3). Poor sleep caused by shift work may be the initial stressor that triggers these cascading factors that lead to obesity, however additional research needs to be done to find conclusive evidence.

The majority of the participants believe that shift work causes difficulty in maintaining a healthy diet and their workplace does not promote a healthy diet. However, the majority of the nurses are not trying to improve their diet and the majority of workplace does not provide any resources to promote a healthy diet. From this research study and previous studies done, nurses sometimes fail to engage in healthy behaviors and the environments in they work in may also contribute to poor health behaviors. Workplace supports need to be in place to allow nurses to personally and professionally be "active partners who promote and foster self-care and wellness" (Ross et al, 2017, p. 3).

Conclusion

According to the findings of the study, many nurses do not participate in maintaining a healthy diet and a healthy lifestyle. There was insufficient data to conclude whether night shift work is correlated to poorer lifestyle habits, but the results showed that on average, all nurses regardless of shift work do not eat the recommended dietary allowance for nutrient intakes, have insufficient sleep, and are overweight. A finding from this study is that the majority of nurses were in the overweight category. Many studies identify night shift nurses to be at a higher risk for obesity, however, the majority of participants in this survey were morning shift workers and results indicate a high level of obesity within that group. There are many studies conducted on the relationship between night shift work and negative dietary behaviors, but additional focus should also be placed on morning shift workers to identify potential risk factors.

Additional research should also be conducted in regional areas with high nursing populations. Cultural variations among populous medical towns in America could potentially show differences in nursing behaviors regarding their lifestyle and dietary choices. Practitioners in these areas should be aware of these potential differences and accommodate accordingly.

The competing demands of the nursing workplace and a lack of time and support are the precipitating factors to these health concerns, but the majority of nurses report that they are not supported by their workplace to promote healthy lifestyle behaviors. Therefore, the workplace needs to make these concerns a priority through nursing awareness and education to counter these risk factors. For instance, nurse leaders can make information about healthy lifestyles available to staff nurses; ideally, nurse leaders will actively encourage and model healthy behaviors for their nursing workforce (Ross et al, 2017). Additionally, more extensive nutrition education and promoting awareness of accessible nutrition educational resources outside the workplace (e.g. The American Nurses Association's Healthy Nurse Healthy Nation initiative) should be encouraged in order for nurses to establish healthier dietary habits.

Appendices

Survey

Dietary Habits of Boston Nurses

Consent Form

This is a research project being conducted by Lena Kil, Nancy Nguyen, and Ji Whang, who are students at Simmons College. You are invited to take a survey that we are conducting on the dietary habits of nurses who are based in Boston. We are interested in learning about how dietary habits differ among shift schedules. Please answer as many of the following questions as you wish based on your own experience. Your participation is voluntary. You may decline to participate or discontinue your participation at any time. If there are any questions you do not feel comfortable answering, you may skip them. Your decision to participate, not participate, or to withdraw at any time from this study will in no way affect you. The survey should take you about [5-10] minutes to complete. All responses will be kept completely confidential and will only be used for the purposes of this study. If you have questions about the research, please contact Lena Kil at [email protected]. Also you may contact my faculty advisor, Professor Rissmiller. Her email address is [email protected]. If you have any questions about your rights as a human subject, you may also contact the Human Protections Administrator in the Office of Sponsored Programs at Simmons College at 617-521-2415. We thank you for participating in this survey.

I consent (1)
I do not consent (2)
Are you currently a Registered Nurse in the Boston area?
- Yes (1)
- No (2)

Q1 What is your age? (Please enter numbers only, no text).

_____________________

Q2 What is your race?

Asian (1)
American Indian and/or Alaskan Native (2)
Black or African American (3)
Native Hawaiian or other Pacific Islander (4)
White (5)
Multiple races (7)
Other, please specify (6) ____________

Q3 What is your highest degree achieved?

High School Diploma (1)
Associate's (2)
Bachelor's (3)
Master's (4)
Doctorate or Post-Master's Degree (5)

Q4 Do you have any children under the age of 18 currently living at home?

Yes (1)
No (2)

Q5 Are you currently a student?

Yes, full time (1)
Yes, part time (2)
No (3)

Q6 How many years of RN experience do you have?

Less than 1 year (1)
1-5 years (2)
6-10 years (3)
11-15 years (4)
More than 15 years (5)

Q7 What type of shift do you work?

Rotating with nights (1)
Rotating without nights (2)
Fixed (no nights) (3)
Fixed (only nights) (4)
Currently not working (6)
Other, please specify (5) ________________________

Q8 What is your employment status?

Full-time (32-40 hours) (1)
Part-time (24-31 hours) (2)
Per diem (3)
Currently not working (4)
Other, please specify (5) ____________________

Q9 What is your weight (pounds)? (Please enter numbers only, no text).

____________________________________

Q10 What is your height (inches)? (Please enter numbers only, no text).

____________________________________

Q11 How would you rate your general health status?

Poor (1)
Fair (2)
Good (3)
Very good (4)
Excellent (5)

Q12 Do you have a regular routine for meals?

Yes (1)
No (2)

o Sometimes (3)

Q13 How many meals do you eat a day?

1 meal/day (1)
2 meals/day (2)
3 meals/day (3)
4+ meals/day (4)
Irregular (5)

Q14

How often do you eat the recommended total daily amounts of vegetables (2-3 cups)?

less than once a week (1)
1-2 times a week (2)
3-4 times a week (3)
5-6 times a week (4)
Everyday (5)

Q15 How often do you eat the recommended total daily amounts of fruits (2 cups)?

less than once a week (1)
1-2 times a week (2)
3-4 times a week (3)
5-6 times a week (4)

Q16 How often do you eat the recommended total daily amounts of grains (6 ounces)?

less than once a week (1)
1-2 times a week (2)
3-4 times a week (3)
5-6 times a week (4)
Everyday (5)

Q17 How often do you eat the recommended total daily amounts of dairy (3 cups)?

less than once a week (1)
1-2 times a week (2)
3-4 times a week (3)
5-6 times a week (4)
Everyday (5)

Q18 How often do you eat the recommended total daily amounts of protein (5½ ounce)?

less than once a week (1)
1-2 times a week (2)
3-4 times a week (3)
5-6 times a week (4)
Everyday (5)

Q19 How often do you eat the recommended total daily amounts of oils from nuts, seeds, seafood, olives and avocados (2 tablespoons)?

less than once a week (1)
1-2 times a week (2)
3-4 times a week (3)
5-6 times a week (4)
Everyday (5)

Q20 How often does your daily consumption of sweets exceed 10 or more percent of your caloric intake?

less than once a week (1)
1-2 times a week (2)
3-4 times a week (3)
5-6 times a week (4)
Everyday (5)

Q21 How often does your daily consumption of fatty foods exceed 10 or more percent of your caloric intake?

less than once a week (1)
1-2 times a week (2)
3-4 times a week (3)
5-6 times a week (4)
Everyday (5)

Q22 How often do you consume fast/instant foods? (Includes foods that are from fast food restaurants, are microwaved, canned, or pre-packaged).

less than once a week (1)
1-2 times a week (2)
3-4 times a week (3)
5-6 times a week (4)
Everyday (5)

Q23 Do you often skip breakfast?

Yes (1)
No (2)

Q24 Do you often skip lunch?

Yes (1)
No (2)

Q25 Do you often skip dinner?

Yes (1)
No (2)

Q26 If yes, what are your reasons for skipping meals? (Select all that apply).

Irregular work schedule (1)
Lack of time (2)
Habitual (3)
Tired (4)
For weight control purposes (5)
Lack of appetite (6)
I don't skip meals (7)
Other, please specify (8) _________________________

Q27 How often do you overeat?

Never (1)
Rarely (2)
Sometimes (3)
Often (4)
Very often (5)

Q28 How often do you snack on healthy foods?

Never (1)
Rarely (2)
Sometimes (3)
Often (4)
Very often (5)

Q29 How often do you snack on unhealthy foods?

Never (1)
Rarely (2)
Sometimes (3)
Often (4)
Very often (5)

Q30 When do you snack most often?

Morning (after breakfast) (1)
Afternoon (after lunch) (2)
Evening (after dinner) (3)
Night (after 10PM) (4)
I don't snack (5)
Other, please specify (6) _______________________

Q31 Reasons for snacking (Select all that apply).

Habit (1)
Hunger (2)
Impulsively (3)
Reduce stress (4)
Taste (5)
I don't snack (6)

- Other, please specify (7) _____________________

Q32 On average, how much alcohol do you consume?

Never drinker (1)
Former drinker (2)
A little (3)
A moderate amount (4)
A lot (5)

Q33 On average, how many hours of sleep do you get a night?

Less than 4 hours (1)
4-5 hours (2)
6-7 hours (3)
8-9 hours (4)
more than 9 hours (5)

Q34 Do you feel that you get enough sleep?

Definitely not (1)
Probably not (2)
Might or might not (3)
Probably yes (4)
Definitely yes (5)

Q35 Does your workplace offer nutritious meal options?

Yes (1)
No (2)
Sometimes (3)
My workplace does not offer meals (4)

Q36 Does your workplace provide resources to promote a healthy diet?

Yes (1)
No (2)
I don't know (3)

Q37 If yes, please specify how your workplace promotes healthy dietary behaviors (select all that apply).

Educational resources on healthy eating posted throughout the workplace (1)
Classes on healthy eating offered (2)
Work site health promotion programs (3)
Healthy foods available in the cafeteria (4)
Healthy foods available in vending machines (5)
Not applicable; my workplace does not attempt to promote healthy dietary habits (6)
Other, please specify (7) _________________

Q38 Do you believe your workplace attempts to promote healthy dietary habits have made a positive impact on your diet?

Definitely not (1)
Probably not (2)
Might or might not (3)
Probably yes (4)
Definitely yes (5)
Not applicable; my workplace does not attempt to promote healthy dietary habits (6)

Q39 Are you making any efforts to improve your dietary habits?

Yes (1)
No, I am content with my diet. (2)
No, but I want to improve my diet in the future. (3)

Q40 If yes to the previous question, what resources are you using to improve your dietary habits? (Select all that apply).

Workplace resources (1)
Online research (2)
Phone applications (3)
News and magazines (4)
Nutritionist or other healthcare professional (5)
Suggestions from other individuals (6)
Not applicable; I am not trying to improve my dietary habits (7)
Other, please specify (8) __________________

Q41 Do you think the shift you work makes it difficult to maintain a healthy diet?

Definitely yes (1)
Probably yes (2)
Might or might not (3)
Probably not (4)
Definitely not (5)

Q42 Please share any comments related to your job position, dietary habits, and/or suggestions you think would be helpful to our research study, regarding dietary habits of Boston Nurses.

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