The prevalence of nutrition related ailments like obesity and cardiovascular disease has increased among health care consumers for almost a decade (Park et al., 2010). Most of these diseases normally affect the quality of the patient’s life in a manner that makes them less productive for the rest of their life (Park et al., 2008). The prevention of dietary related ailment involves modification of one’s way of life through changes in choice of food. However, patients that are affected tend not to adhere to the dietary advice in most developed countries (Graham et al., 2007). In some cases, patients that are suffering from ill-health due to poor dietary control often lack sufficient knowledge about the diet they are required to eat and are not getting accurate nutrition education from nurses and other health care workers (WaÅ›kiewicz et al., 2008).

Health promotion as stated by Cookes (1995) helps to curtail the expenses of the health care system. Warber et al. (2000) go further and declare that the rapid rise in the health care quality should not be attributed to the expensive technical know- how, but to the easy access of patients to their health care practitioners and prevention of disease through thorough promotion of health. Hu et al. (1997) and Schaller and James (2005) have recalled that the role of nutrition in promoting the health of the public, prevention of ailment and in the management of non-communicable diseases is well documented.

Nutrition is considered to be the bedrock of wellbeing and prevention of ill health in the society (Schneeman, 1996). It is also referred to as the key condition for proper growth, infection control, and attainment of quality life (Teko, 1999). It was recommended by Wynder and

Andres (1994) that as nutrition is the key to the health of the populace; it is of paramount importance for all health care providers to understand how dietary intake could have impact on people’s well being. Hunt (1995) suggested that nutrition psychotherapy should be a fundamental component of health care tradition, as it has been shown that educating patients on different aspects of nutrition is a means of reducing the cost of the management of ill-health as well as engaging in the promotion of good health.

Knowledge of nutrition is cited as a fundamental component of nursing educational curriculum, and is usually incorporated into their school programmes (La Trobe University, 2003). Schaller and James (2005) claimed that the majority of nurses that are still in school are tutored about clinical nutrition from the perspective of health in general; that is health promotion and prevention. Schaller and James, (2005) believe that being aware of the essential dietary components is one of the most crucial training student nurses should undergo. However, it has been reported by Harminder and Slhgh, (2006) that nurses have inadequate knowledge of nutrition and are not concerned about evaluating patients’ nutritional status. The idea of training nurses in nutrition is supported by the registered body in charge of the diet of patient in the United States American Dietetic Association (1998), and the Dietetic Association (1994) in the United Kingdom (UK). In addition, the UK government have put a policy in place that focuses on educating health care practitioners, including nurses and midwives on nutrition (Department of Health, 1994).

Wynder and Andres (1994) have declared that nutrition is a major manageable risk factor that could have an impact on a patient’s wellbeing; this is why its role is very crucial in health promotion and eradication of disease. Despite the availability of dieticians to counsel patients’ on the necessary diet for healthy living, nurses are also expected to provide adequate nutrition education to patients and to be familiar with the necessary danger associated with poor nutrition (Lindseth, 1990; Wilt et al., 1990; Gibbons et al., 2000). It was discovered by Lindseth, (1990); Lindseth, (1994) and Crogan et al., (2001) that the nutrition theory and knowledge to which student nurses are exposed at undergraduate level is inadequate with registered nurses receiving only a limited update to their nutritional knowledge.

Barrowclough and Ford (2001) have claimed that knowledge of nutrition is acquired by a lot of practising midwives through the media rather than through the appropriate education they ought to have received before they were qualified as a nurse in the United Kingdom. Lyu et al., (1998) also declared that nutrition education is poorly emphasized in schools of nursing in Korea and only a few of them have incorporated nutrition courses into their scheme of work. This development could result into carelessness on the part of the graduate nurses on management of patient nutritional status (Kim and Choue, 2009).

Worsley (2002) suggested that knowledge is needed to turn around people’s ways and action and is very important in influencing dietary behaviour. Nutrition education was claimed in recent studies to influence dietary habit which could be in form of reduction of cholesterol intake (Levy et al., 1993), buying nourishing and healthy food choices (Turrell and Kavanagh, 2006), reduction of fatty food intake (Kristal et al., 1990), increase intake of fruit and vegetables (Van et al., 2008; Ball et al., 2006), and weight reduction (Klohe-lehman et al., 2006). A survey carried out by Mowe et al. (2008) on healthcare professionals found out that an inadequate nutritional knowledge among health professionals could lead to bad nutritional practice which can result into impediment and delay in patient discharge from hospital. This is the reason why an exploration of the nutritional knowledge of upcoming nurses is very essential.

The literature review presents a mainstay structure for the anticipated research work, and is saddled with literatures that encompass the subject of nutritional knowledge of nurses.

The literature review will affirm that the nutritional knowledge of nurses’ in relation to people’s health is both a health and health promotion issue and will create more awareness of the essence of good nutrition in health care practice.

The aim of this study is to explore student nurses’ general knowledge about nutrition and whether the knowledge they have acquired is used in their care for patients. The objectives were defined as:

To explore student nurses level of knowledge about nutrition.

To establish the level of awareness of nutrition among student nurses and whether or not they use this knowledge when caring for patients.

LITERATURE REVIEW

Schaller and James (2005) have stated that maintaining a high quality dietary intake is fundamental for optimum wellbeing, while good dietary intake is a very crucial factor in promoting good health and disease eradication (Mowe et al ., 2008). However, while acquiring facts about nutrition is very important, knowledge alone is not adequate for dietary transformation (Hendrie et al., 2008). Indeed, Bandura in 1986 stated that behavioural change is influenced by many factors including the individual’s knowledge and that this require further exploration in order to clarify how knowledge influence people’s dietary activities. Axelson and Brinberg (1992) also postulated that acquiring an education in nutrition can have an influence on human behaviour.

Tower (1994) stated that nurses are at the vanguard of the main health care services which gives them the privilege of overseeing and organising programmes of care that best suit the well being of individual they look after. They play a crucial role in promoting and educating the patient in their care, with an understanding of the research that indicates how nutrition plays a role in people developing different types of ill health (Janet et al ., 2000). Taking account of the number of health care consumers that nurses interact with gives them the opportunity and responsibility to dissipate knowledge about nutrition to the public (Janet et al., 2000). This creates an avenue to promote health in a holistic way and also influence the decision making of patients concerning healthy eating (Janet et al., 2000).

One important way in which the health care workers knowledge and practice are influenced is through their learning programme (Morison et al., 2010). This establishes the proficiency, outlook and information they require to maintain their position as an expert in their field. Morison et al. (2010) argues that at every stage of their course, nursing students and nurses are well prepared to face the challenges of helping their patients to meet their nutritional needs (Morison et al., 2010).

Definition of Health

It is important to define what health really meant, and how it relates to nutrition and the way nurses handles the care of their patient (Ewles and Simnett, 2003; Naidoo and Wills, 2009). In order to gain a real insight into what health is within the context of this study, its definition will be viewed from the nursing point of view. It has been reported that perception of health is transferred from one generation to another, and they are embedded into the people’s cultural norms (Robertson, 1989). It was related by Downie et al. (1997) that people embrace an uncomplicated opinion about their health as well as other peoples well being which does not give a clear definition by all and sundry. Ewles and Simnett (2003) suggest that health could simply mean “not being ill”, which confirms the conceptualisation of the lay peoples perspection of referring to health as not being ill, but shaped by their understanding, experiences, and opportunities in life (Katz and Peberdy, 2000).

Health was also considered by Ewles and Simnett (2003) as the absence of disease or illness, which is improved by an encouraging analysis of health as a state of well-being, and could also be viewed by health practitioners (nurses) from the objective perspective as liberty from medically defined ailment. This must be able to face criticism and thorough analysis from people, and must reveal an encouraging health, that involves empowering and taking care of one’s life (Downie et al., 1997).

The World Health Organisation (WHO) (1946; 2006) in their description of what health is unite and goes further from the views mentioned above where genuine health is perceived as being transformed, disease free, and wellbeing is stated as:

“……a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity” (WHO, 1946, p.100).

Even though some factors that are inherited, people’s standards of living, the society they live and their cultural background as well as their level of nutritional knowledge are very vital and need to be considered when referring to the health of the populace (Duyyf, 2002).

This definition was viewed by a lot of people as a desire, .i.e. an interpretation of health that is unattainable because of its nature. It is also a definition that health practitioners are more at ease with because of the nature of its documentation. This definition of health has broadened the scope of health further from the absence of disease to embrace positive wellbeing and strongly admitting its comprehensive holistic nature, compared with viewing health from the biomedical point of view (Naidoo and Wills, 2009; Green and Tones, 2010). This biomedical model does not put into consideration all the factors that could negatively affect the health of the people because it identifies health as the absence of illness and infirmity. The bio psychosocial model of health that was proposed by Engel (1977) also suggested that emphasis is not only placed on the biological signs and symptoms, but also on peoples’ psychological state and their social factors including interactions with their family and the community at large. This paradigm brought about another definition of health stating that

“Health is a dynamic subjective concept which is influenced by an array of factors” (Daly et al., 2002, p.37).

It was argued by (Saracci, 1997) that the definitions of health, like that of the WHO definition basically link health with joy, which makes the restrictions to health endless, and turning various inconvenience into health problems (Green and Tones, 2010).

Acknowledging the boundaries of the original definition of health, the WHO modified it in 1986 to recognize the fact that:

“Health is therefore seen as a resource for everyday life, not the objective for living: it is a positive concept emphasising social and personal resources, as well as physical capabilities” (WHO, 1986).

The above definition is supported by Seedhouse (1986), where he confirmed that acknowledging individual improvement, fulfilment of indispensable requirements and the ability to acclimatize to new surroundings are essential factors for health determinant. He also argued that health is not a permanent condition that one should desire; rather health is a means to an end, which was disagreed by Naidoo and Wills (2009) who stated that health might not be a permanent state but neither is it a means to an end, but to a certain extent it is a necessity brought into limelight by the social and environmental factors which is outside the power of an individual. Despite all the criticisms of the WHO definition of health, this definition is still of great importance today and health is viewed by the organisation from the holistic point of view, which means an individual physical, mental, social, sexual, spiritual, and emotional desires, is being influenced by the peoples cultural environment (Naidoo and Wills, 2009).

Therefore it may be concluded that enhancing the health of people and the communities requires more effort than just avoiding and treating disease. It is more of a progression towards uninterrupted adaptation compared to realization of a static condition. Finally, for the purpose of this study, health will be viewed from the holistic perspective. This put into consideration the social, economic, physical, cultural and environmental factors that are beyond human control and yet may determine health (DHSSPS, 2002).

Health Promotion

Health promotion is an extensively challenged concept, which is used in numerous ways by diverse people and organisations (Tones, 2001). Promoting health is a complex issue just like defining health is not a simple issue (Edmondson and Kelleher, 2000). According to Fleming (2007), health promotion originated from health models such as the medical or the social model, which is all about health conceptualisation in the context of whether it is positive or negative; that is healthy living and absence of disease respectively (Wills and Douglas, 2008). Health promotion was developed by the Ottawa Charter with the aim of allowing it to provide individual, societal and governmental empowerment in conjunction with healthy public policy (WHO, 1986). The phrase health promotion is a new development, and is usually sighted as a way of empowering and enabling the public to be in command of their individual health and safety (Green and Tones, 2010). Ewles and Simnett (2003) also consider health promotion as the process of “improving health by progressing, supporting, encouraging and putting it on the public schema”. Health promotion was differentiated from prevention of disease by Nutbeam (1986) where he stated that they are a separate entity but complement themselves in the way their activities are being performed. He later argued that there is just a minute change in re-orientating health labour force from the idea of chronic and severe ailment towards initialising expertise and empowerment in health promotion (Nutbeam, 2008). The repeatedly quoted definition of health promotion is stated as

“the process of enabling people to increase control over and to improve their

health” (WHO, 1986).

This describes both the behavioural and the socio-environmental factors and encompasses the individuals’ action, the community, community groups, formal settings that include schools, places of work, and government at various levels. It acknowledges the fact that human health can be manipulated easily by decisions taken by other people in their absence; by involving communities in those decisions to augment and to prevent any harm whatsoever to health (Schou and Locker, 2002).

This contemporary health promotion materialized out of the need for a basic transformation in the approach to improve health and lessen health inequalities (Ashton and Seymour, 1990). Naidoo and Wills (2009) examined how the foundation of health promotion lies in the effort for hygiene transformation to fight against disease outbreak in the nineteenth century. It was declared by the authors that the public health movement was specifically associated with the idea of “enlightening the community for the excellent healthy condition” (Naidoo and Wills, 2009, p.72).The health education strategy focused on the medical model of health which mainly help to transform people’s behaviour through enlightenment and proper training.

The concept of health promotion began to materialize around the 70s as an individual discipline. Tones and Green (2004) examined how after the advent of the Lalonde Report (1974), health education was thoroughly scrutinised with a “latest idea in the significance of the environmental and societal influences on health condition” (Tones and Green, 2004, p.14). The management of the harmful effects of an ailment was not sufficient, but the introduction of the prevention of ailment of all sorts and promotion of healthy living is believed to be a way out. A researcher called Ryan was said to be the major critic of the previous health education model, where he declared that the perceived incapability of the less privilege people to change their behaviour was not as a result of their inflexibility but because of their societal and environmental situation (Ryan, 1976, cited in Tones and Green 2004, p.14). Tones and Green (2004) later put in a nutshell how the idea of behavioural change affects the concept of health promotion by summarizing it in the formula below:

“Health promotion=health education x healthy public policy” (p.14).

Since health education and health promotion is used together in the majority of the recent health promotion research that are associated to nursing, it was concluded that health education is a component of health promotion approach and they are both not a mutually dependent concepts (Casey, 2007; Norton, 1998; Whitehead, 2006; Whitehead, 2007).

The Ottawa charter (WHO, 1986) that was promulgated for health promotion helped to identify five action areas that were peculiar for the health promotion advancement. These include Building healthy public policy, creating supportive environments, strengthening community action, developing personal skills of nurses through thorough nutrition education training for optimum patient care delivery, and reorienting health services so that proper equipments and enough health personnel are put in place to take care of admitted and outpatient (WHO, 1986). Orme et al. (2007) purports that while Health promotion has brought a wealth of knowledge in its multi-faceted practice to the advancement of health and well being by extending the scope beyond the biomedical approach, there is still more to be realised from the foundation of the Ottawa Charter.

Empowerment

Empowerment is considered by some authors as an element which makes a distinction between health promotion and other public and community health communication (Ridde, 2007), while some other authors like (Wills et al., 2008; Wise, 2008) declare that the target of health promotion is to lessen the standards of health gap in minority groups which makes it differ from public health, and that it is a courageous thing to embark on since its vital aim is to transform the society.

Health inequalities was said to be the outcome of societal and political organization (Ridde, 2007) and so far the health structures is part of health determinant (Danzon, 2009), it is very important that attention is given to the health system as well as to how people use the system. Since public infirmity cannot be alleviated by improved National health system, as stated by Bambra et al. (2005), this must be the foundation on which health promotion must lay their plan, since health care is meant to be an individual right.

Health promotion is the responsibility for individuals, society, health practitioners, health care provider and the governments at large. It currently places emphasis on planning and legislative controls, as identified by community members (Milio, 1986). Collaboration of these sectors can bring about fairness in health by maximizing everyone’s chance of being healthy, but regrettably, this can elevate the political, ethical and moral problem associated with being healthy, if resources allocated for programmes are not utilised judiciously on those activities that will make great impact on the population (Humphris and Ling, 2000).

It was stated by Warber (2000) that nurses have a crucial role to play in public health nutrition programme, since they are saddled with the responsibility to take care of health care consumers and in the process highlighting the importance of health promotion through empowerment. It was also mentioned by Warber (2000) that the holistic relationship that nurse professionals have on the patient they care for, which outweighs the standard of care practiced by past medical personnel may influence the way patients decide on the kind of food that are healthy for them to consume.

Politics of Health Promotion

Ridde, (2007) has advocated for revitalization of health promotion as a means of confronting social inequalities in health. It was also identified by Scott-Samuel and Springett (2007) that the basic principles of health promotion include empowerment, involvement, enablement and social fairness; but the introduction of social fairness has caused it to be politicised. Referring to health promotion as a political or social group is an elongation of its value in the sight of the government (Raphael, 2008). Yet while health is categorised as not being politically inclined, it is always included in political campaigns. Indeed, Bambra et al. (2005) claims that all health organisations are controlled by the people that control the economy .i.e. government.

Health Promotion Approaches and Models

Health promotion practice can come in different forms, considering the location of the activity and the predisposition of the health promoter alongside the skills to be dissipated.

To achieve an optimum health promotion practice, a framework of approaches to health education practice was developed by Ewles and Simnett in 1995 and re-examined in 2003 to create five approaches to health promotion. These include the medical, behavioural change, educational, empowerment and the societal change. Since all these approach have their strengths and limitations, a blend of all the approaches may produce a good result but this framework was criticised for not recognizing how changes occur in people’s way of life (Jones and Naidoo, 1997).

Scott-Samuel and Wills (2007) also compared the contemporary health promotion approach to a ‘corpse’ and a kind of misplaced discipline which brought a limelight into health promotion in relation to the less privileged admitted into a health care home.

To ensure good practice a health promotion model must provide a theoretical framework which helps to display how things are related to one another must be employ to bring about new theoretical technique.

The Tones and Tilford (1994) model tried to express the link between health education, achievement of health, and empowerment. If inability is a major risk factor for ailment and poor health Wallerstein (1992), this could make people in the lower socioeconomic position more prone to increased death and morbidity rates (Macintyre, 1986). In order to make an accurate and an empowered decision it is necessary to be well-informed, but this can be impacted upon by the societal and the environmental factors.

Beattle (1991) also brought into the limelight a model of health promotion that endeavoured to connect health promotion approaches to political and social organization. This model is useful when attempting to balance social ethics, even if the approach is reliable or negotiable, and or in a combined state (Beattle, 1993). Beattle’s model (appendix ) has been used on several occasion in setting an approach to health promotion in colleges of higher education (O’Donnell and Gray, 1993) and also modified for use in the nursing contexts (Twinn, 1991). It was discovered that it can only be applied as a tool, and not as a guide to action, and also that some strategy may not fit into a definite quadrant which might result into an overlap.

The Health Belief Model (HBM) (Rosenstock et al., 1988) (Appendix) also made provision for an exact way of accepting and organizing personal beliefs that are significant to health behaviour. Gillam (1991) stated that the HBM has been used to predict protective health behaviour, when health practitioners (nurses) advise patient. It is understood from the perspective of the HBM that a person can indulge in health behaviour depending on how they feel about their susceptibility to a disease and if they are aware of the consequences and believe that a change in their behaviour can help to conquer the ailment.

It was declared by Janz and Becker (1984) that this model was developed to envisage precautionary health behaviours and its behavioural response to healing in chronically sick patients. This model explores how beliefs impact on behaviour (Abraham and Sheeran, 2005). In the context of nursing, what the nurses puts into practice depends on how vulnerable they recognize the patient in their care to be to the illness. This includes the nurses’ belief about the susceptibility to the illness and its predisposing factor, the anticipated severity of that incidence, the advantage of implementing self-protection and safety of the patient, and the barrier to its implementation. Where such health beliefs are understood from the Nutrition and health education or perceived symptoms perspective, it can help in stimulating healthy behavioural change (Naidoo and Wills, 2009)

In additional to this model is the “cues to action” which demonstrate a situation that a person is likely to take a defensive action if he is well informed about a probable health problem. This may come in form of a counsel from a health practitioner like nurses whose proficiency is valued and reliable (Rosenstock et al., 1988).

Humphris and Ling (2000) stated that one criticism of this model is that it focused on the ailment too much rather than on the behaviour of people who had the disease, which he attempted to predict. He also stated that behaviour is formed by external forces and individual factors such as emotional feelings and not just through the economic evaluation of the problem. It was supported by Conner and Norman (1995) that the HBM made use of an emotional construct that is reasonable and is a very good framework in health promotion.

This Health belief model is quite appropriate for this study because it tries to appreciate the problem underlying human actions, which is based on the fact that a sense of susceptibility to disease incites human behaviour (Rosenstock et al., 1988).

A different model was presented by (Ajzen and Fishbein, 1980) which is the Theory of Reasoned Action (TRA). This model is meant to predict behaviour and makes use of the beliefs held by an individual. TRA incorporates only the beliefs about an intended behaviour compared to HBM that focuses more on beliefs about the disease alone. Baranowski (1990) concluded that to have an intention to execute a health related behaviour does not predict that the action will take place. An additional variable to the Theory of Planned behaviour may explain the gap between intention and behaviour; which is perceived behavioural control (Ajzen, 1991). This shows how determined an individual that is the nurse is motivated to be in preparation to transform her performance to suite the care she is to provide for the health consumers. Conner and Armitage (1998) condemned the model for failing to embrace variables like self uniqueness, self-efficacy, past deeds, affective response and personal judgement.

LITERATURE SEARCH APPROACH

Grant (2004) declared that to achieve a wealth of appropriate literature for this study it is very important to go through several search engines. Following the guiding principle laid down by Haynes et al. (2005) and Shaw et al. (2004) the library electronic journals were search by the help of the TD Net search engine to get related health promotion journals by using terms like “knowledge of nutrition among nurses”, “Nutritional knowledge of nurses”. The search engine provided by the library gave little result. The Google scholar search engine was later employed and several papers relating to the topic were discovered. The MEDLINE search engine was also used; this assisted also to get some suitable journal necessary for the study.

Further search criteria were put into use and this brought out several relevant results that help in the organization of the literature review. At some stage in the literature search the main topic was typed into the search engine so that the papers found can be more appropriate for the study.

Definition of Nutrition

Nutrition was acknowledged by Schneeman (1995) to be a main predictor of healthy living and illness prevention. It was also referred to as the major risk factor that affects long-lasting wellbeing which should be apparent to all health care practitioners (Kleiner, 1993; Wynder, 1994). Nutrition counselling was stated by Hunt et al.(1996 ) to be a fundamental component of primary health care practice because different studies have shown that improving the nutritional knowledge of health care consumers is a reasonable way of reducing disease and the promotion of health.

Potter (2008) stated that nutrition is a foundation of excellent recuperation from sickness, and if the patient is underfed this may delay their recuperation. Amarantos et al. (2001) also declared that nutrition could be defined within the medical concept by taking account of the patient’s dietary, biochemical and medical signs. This was also established by Amarantos et al. (2001) that the dietary intake of patient can be associated with their sensory, emotional and societal facet of life. Blades (2000) confirmed that satisfactory nutrition is not all about healthy food but is more associated to the psychological well being of the patient in question. He also stated that since the period of serving food and feeding the patient is a very crucial part of being in hospital, it could also inspire happiness and contentment, which signifies a crucial stage in caring for patient (Blades, 2000).

Amarantos et al. (2001, p.55) later declared that hospital food is quite essential because it provide protection and good organization to patient hospital stay. He also affirmed that it may instill the patient with thoughts of being comfortable in the environment, if they have a degree of autonomy, privilege and choices of different varieties of food.

Nutritional support is said to be categorised as one in which reduced attention is given to during healing management and assessment in a hospital setting (Morley, 1991; Mowe et al., 2006). Even though there are numerous procedures which promote the use of systematic nutritional screening, but this has not yet being implemented globally (Elia et al., 2005).

Nutrition education and training among