The current study describes the systematic, evidence-based and theory-informed approach to developing a tailored workplace intervention that aims to change nurses’ eating and physical activity behaviours. The intervention has been rigorously developed to reflect current best-practice in intervention development [20,23,28]. It is anticipated that by adopting a systematic, evidence-based and theory-informed approach for intervention development the capacity to effectively change nurses’ eating and physical activity behaviours will be improved. To change nurses’ eating and physical activity outcomes, the intervention is specified by nine intervention functions, seven policy categories and consists of 22 evidence-based and theoretically underpinned BCTs.
It is unclear at this stage whether the depicted scenario is superior to other potential options. A digital mode of delivery of BCTs targeting individual level determinants of eating and physical activity behaviours is expected to enhance the potential for equitable intervention delivery. Nurses’ values and preferences should also be used to guide decisions around what workplace intervention mode of delivery to take forward. Adopting a person-centred approach and basing the intervention development on nurses’ views is anticipated to enhance the likelihood that the intervention will be accepted and ultimately effective . Evidence generated from our formative work indicates that approximately three in every four nurses would be willing in principle to participate in a randomised controlled trial of a workplace eating and physical activity intervention. Improving participation among nurses is particularly important given reports that of all healthcare professional groups working in hospitals, nurses have the lowest participation in workplace health promotion activities, despite displaying the highest rates of obesity and overweight .
Several aspects of the developed intervention are innovative. For example, few studies have proposed to change nurses’ beliefs about consequences. The intervention will enable nurses to adopt comparative imagining of future outcomes (in the form of online group-based motivational interviewing sessions), an effective technique for changing eating and physical activity behaviours [34,35]. Additionally, the intervention will use social support to change emotional responses. It is widely recognised that for initiating and sustaining health behaviour change, positive types of social support from friends, family and colleagues is particularly important . Online (in the form of an online support community tailored to the preferences and characteristics of nurses specifically) and face-to-face sources of social support both appear to help people maintain long-term health behaviour changes .
To ensure implementation success, consideration should also be given to the affordability, practicability, effectiveness/cost-effectiveness, acceptability, side-effects/safety and equality (APEASE) of the intervention. By using this APEASE criteria (Table 5) , additional insights can be made to inform a tailored intervention package and implementation strategy. For instance, implementing many of the environmental changes will require large numbers of stakeholders at multiple levels of influence to also change their behaviour. Reluctance or inability of stakeholders to introduce environmental changes may limit the feasibility, acceptability and practicality of implementing environmental changes. Assessing the extent to which stakeholders such as hospital chief executives and department managers would be supportive of potential changes to the hospital environment is an important step in the development of an effective intervention implementation strategy . As they are likely to be the agents who will decide on implementation options, an assessment of their views may provide an avenue for enhancing their ‘buy-in’ and advocacy.
Strengths and limitations
The present study applied a theoretical and evidence-based approach to behaviour change. Determinants of two target behaviours (i.e. eating and physical activity) were identified and mapped to appropriate intervention functions, policy categories and BCTs to develop a specified workplace behaviour change intervention tailored for nurses. In line with dual-process or dual-systems theories of behaviour , it is important to highlight that the determinants identified within this study represent the perceptions of nurses and as such reflect only those that operate with some degree of conscious awareness. There may be additional determinants shaping nurses’ eating and physical activity behaviour, beyond their awareness that have not been captured (e.g. unconscious biases towards eating behaviours or activities). The selection of intervention functions and policy categories was undertaken in the intervention development process to facilitate a precisely specified and parsimonious intervention. In retrospect, this step in the development process was less directive than expected. It was found that any proposed intervention might incorporate all the available intervention functions and policy categories. This was the first application of the BCW and TDF together to the development of a workplace eating and physical activity behaviour change intervention. Hence, deciding on the most appropriate intervention functions and policy categories in the context of limited prior guidance available may be one reason for the lack of brevity.
An alternative and perhaps more useful approach would have been to proceed directly from the behavioural diagnosis using the TDF (steps 1 and 2) to selecting BCTs for the intervention. Notwithstanding this, by reporting the intervention development steps completely and transparently, hypothesised mechanisms of behaviour change in any resulting intervention could be tested in a definitive clinical trial . Such sharing of best practice in intervention development can contribute to a cumulative understanding of eating and physical activity behaviour change in nurses, thereby increasing the value of this research and the proposed interventions replication potential . The methods used for operationalising BCTs were subjective. It is therefore possible that another research team would yield different ideas for how best to operationalise the BCTs. Standardised and transparent methods to report BCT operationalisation will need to be established to ensure this phase of the intervention development process can be replicated.
Implications for research
Given the increased scrutiny being placed on the ease with which published results can be reproduced or replicated , the intervention development methods presented in this study represent an important contribution to knowledge. They have the potential to avoid research redundancy. An exploration of nurses’ preferences for the best modes of delivery for these BCTs (e.g. face-to-face such as one-on-one or group, print or web) and intervention intensity (e.g. contact frequency, number of contacts, contact time) is warranted to further optimise the intervention development process.
Implications for practice
The workplace intervention developed in this study is now ready for formal evaluation in a trial and might have the potential in future to markedly impact upon employee absenteeism, presenteeism, productivity and retention outcomes [41,42] and overall quality of care . Highlighting the possible financial returns for employers on investment in health interventions may serve to increase uptake of the developed workplace intervention among healthcare organisations. The intervention meets expert recommendations on promoting employee health in the UK National Health Service system . It therefore represents a practical application through which healthcare organisations can improve nurses’ eating and physical activity practices.