As nurses comprise a large human resource of hospital organizations, the maintenance of nurses’ health is essential for sustaining a healthcare workforce capable of meeting the increased demand for healthcare during the coronavirus disease 2019 (COVID-19) pandemic. Nurses’ health can also affect the quality of care and patient safety [1]. However, the health of nurses is threatened by overload, occupational stress, and exposure to infectious diseases [2,3]. Research also indicates that recent emerging infectious diseases such as the severe acute respiratory syndrome coronavirus, Middle East respiratory syndrome coronavirus and COVID-19 have affected nurses’ health [4].

Healthy behaviors are attitudes and actions that serve as core determinants of health. Nurses’ healthy behaviors are important not only because of their impact on nurses’ own health [5,6] but also because they can influence nursing performance [6,7] and health promotion practices with patients [8]. Previous studies [5-7] have indicated that nurses’ healthy behaviors include good eating habits, physical activity, stress management, job-related safety, and interpersonal relationships. Among the many studies that have highlighted the personal and professional impact of nurses’ health, some have noted that many nurses engage in negative health behaviors. In one study, more than 60% of American nurses did not engage in the recommended amount of physical activity and more than half consumed a poor-quality diet [9]. In another study, Australian nurses had a lower vegetable and fruit intake than a sample from the general population [10]. Nurses may be well aware of the importance of healthy behaviors, but they engaged in less than the recommended amount of physical activity and lacked proper nutrition, stress management, and interpersonal relations due to shift work, lack of free time, and fatigue from work overload [7,11].

Recently, the COVID-19 pandemic has exacerbated nurses’ workload globally and challenged nurses’ health through stress, burnout, depression, and infection risk [12-14]. Although the literature has reported on the negative impact of COVID-19 on nurses’ health, little is known about the healthy behaviors that nurses engage in as they attempt to manage the health challenges of the pandemic. It is vital to understand how nurses maintain healthy behaviors during this time [4], as such an understanding can suggest novel strategies for improving nurses’ health.

Some studies have shown that stress and self-efficacy are factors related to nurses’ healthy behaviors [5,15]. A systematic review found that nurses with higher stress levels were more likely to engage in poor dietary behaviors [15]. Another study reported that nurses with low self-efficacy engaged in fewer healthy behaviors during the COVID-19 pandemic [5]. Accordingly, it is believed that the nurses’ stress and self-efficacy can contribute to their healthy behaviors during the pandemic [5,15]. However, there are few studies on the relationship between COVID-19-related stress, health self-efficacy, and nurses’ healthy behaviors during the pandemic.

Moreover, previous studies have linked demographic factors such as age, marital status, and education level with nurses’ healthy behaviors [5,16,17]. Job characteristics such as hospital level, shift work, and working years have also influenced nurses’ healthy behaviors in previous studies [6,15].

There are reports that the COVID-19 pandemic has affected nurses’ professionalism [4,18,19]. Although nurses experienced the negative impacts of the pandemic such as fear and anxiety over working in unprecedented situations, they have also expressed their professional pride in engaging in authentic relationships with patients and emphasized the importance that their professional role brings to care [18]. Indeed, many nurses mobilised their nursing professionalism with a vocation and responsibility to care for patients; they made every effort to draw upon their resources to cope with the challenges imposed by the pandemic [19]. Through their responses, nurses were trying to reduce the stress of the situation and engage in healthy behaviors for coping with the pandemic [4,18]. However, little is known about the relationship between professional pride in nursing and healthy behaviors during the pandemic.

Based on the Pender’s health promotion model [20], this study presumed that COVID-19-related stress serves as a variable within the personal factors category. Additionally, health self-efficacy was considered a variable for perceived self-efficacy category, while nursing professional pride was regarded as a variable for activity-related affect category within the domain of behavior-specific cognitions and affect in the health promotion model. Therefore, this study aimed to identify factors related to nurses’ healthy behaviors that can be used to develop strategies to promote the health of nurses.

In this study, nurses’ healthy behavior scores during the pandemic were found to be higher than those in Kim’s [28] study conducted before the pandemic (57.77 vs. 53.42 points, respectively). Among the subscales of healthy behaviors, interpersonal relationships in the workplace had the highest score, while healthy lifestyle had the lowest. Although nurses on the frontline were exposed to the risk of infection and pressured psychologically and physiologically through their direct care for COVID-19 patients, they tried to accept the situation and struggled to adapt professionally [18]. Nurses’ professional motivation to provide care for COVID-19 patients and to protect themselves from infection may have promoted their healthy behaviors. During the pandemic, nurses also experienced deeper and closer relationships with patients as well as healthcare teamwork by supporting one other and other healthcare professionals [18,19], which may have led to a positive perception of interpersonal relationships in the workplace.

Even though the scores for total healthy behaviors in this current study were higher than those observed in a prior study conducted before the COVID-19 pandemic [28], the score for healthy lifestyle within the subscales was relatively low. Repeated long-term COVID-19 crises have disrupted the lives of nurses. Nurse workload and overtime have increased, whereas breaks and off-duty time have decreased. In addition, owing to the risk of spreading the infection, nurses often travel back and forth between hospitals and homes [19]. Consequently, nurses might not engage in physical activity, eat healthy foods and supplements, or have a daily routine during the pandemic. Because they are on the frontline where they are responsible for rapid responses to crises, the protection and promotion of nurses’ health are crucial in critical situations such as emerging pandemics [5]. However, the prioritization of public health during the COVID-19 pandemic has overshadowed the health maintenance needs of nurses [29]. To maintain nurses’ health during the pandemic, hospital organizations need to secure facilities for rest, programs for physical activities, and healthy food and supplements. Nurse managers also need to understand nurses’ healthy behaviors during the pandemic and encourage them to maintain a healthy lifestyle as much as possible.

In the univariate analysis, age, marital status, education level, and type of work were related to nurses’ healthy behaviors, which is a finding like that in previous studies [5,16,17]. However, in the multivariate regression analysis, only age was related to nurses’ healthy behaviors. Similarly, older nurses were reported to adhere more closely than younger nurses to healthy food recommendations in a previous study [17]. Younger nurses may benefit from hospital organizations or nurse managers with more support and guidance in promoting healthy behaviors.

In the multiple regression analysis, all main variables were also related to nurses’ healthy behaviors during the pandemic. In a previous study, stress was a key barrier to nurses’ healthy behaviors [15]. This study included COVID-19-related stress as a variable, in line with the pandemic situation. With long-lasting pandemics, nurses experience fear, fatigue, and anxiety related to infecting their family members as well as their own potential infection risk, which leads to their willingness to leave the nursing profession [18,19,30]. Additionally, the results of this study suggest that the psychological burden and physical fatigue of COVID-19-related stress impede nurses’ healthy behaviors.

In a previous study [5], self-efficacy was also found to be related to nurses’ healthy behaviors. However, the previous study [5] measured self-efficacy using the general self-efficacy scale; the current study measured self-efficacy using the health self-efficacy scale. Nurses with higher health self-efficacy exhibited higher levels of healthy behaviors, even during the pandemic. Although the COVID-19 pandemic has threatened nurses’ health and well-being [1,13], nurses who believe they can successfully maintain their healthy behaviors even with their healthcare responsibilities are more likely to sustain healthy behaviors during the pandemic. Future studies should examine the relationships among health self-efficacy, healthy behaviors, and nurses’ health status.

The current results demonstrated that nurses with higher professional pride engaged in more healthy behaviors during the pandemic. During the pandemic, nurses fighting COVID-19 on the frontline experienced feelings of pride as nurses and authentic collaboration with healthcare workers. Nurses’ opinions were respected, and the healthcare teams supported each other, unlike in the previous hierarchical system. Given the tremendous responsibility of nurses in the COVID-19 crisis, nurses have taken pride in nursing professionalism [18,19]. By working with professional pride, nurses would have been more healthy behaviors for both personal and professional reasons. While there were no prior studies similar to this study, the findings from this study imply an association between nursing professionalism pride and their ability to maintain healthy behaviors in high-risk situations like a pandemic. Furthermore, this study incorporated nursing professionalism as a variable within the activity-related affect category of the HPM. Consequently, it can be seen as a valuable variable for explaining nurses’ health promotion behaviors in future studies.

Meanwhile, hospital organizations must acknowledge nurses’ professionalism in caring for COVID-19 patients and should provide appropriate compensation that fits nurses’ professionalism, which could lead to improvements in nursing professional pride. Nurse managers should also encourage nurses to have professional pride and engage in healthy behaviors to maintain their health during the pandemic.

Although this study highlighted nurses’ healthy behaviors and related factors during the pandemic, it had several limitations. First, there may be variables not measured in this study that are related to nurses’ healthy behaviors. Specifically, aspects of the work environment were not considered. Second, the data were collected at the beginning of the 4th epidemic wave of COVID-19. Accordingly, the results may differ from other studies depending on the length of time the epidemic has been ongoing. Third, the study participants worked in general hospitals, and nurses working in hospitals dedicated to infectious diseases or public health centers were not included.

Understanding nurses’ healthy behaviors during the pandemic through current study would provide essential information to strategies about nurses’ health during future emerging infectious diseases. This study suggests that nurses engaged in more healthy behaviors during the pandemic than before it. Meanwhile, among the various subscales of healthy behaviors during the pandemic, the healthy lifestyle subscale exhibited a comparatively lower score. The COVID-19 crisis brought professional responsibility to nurses, who would otherwise have been more concerned about maintaining their own healthy behaviors to fight infection with COVID-19. However, fatigue, overwork, and precautions during the pandemic might be barriers to retain a typically healthy lifestyle. To retain nurses’ healthy lifestyles during the pandemic, organizational support is needed, such as ensuring facilities for rest or physical activities accessible from the hospital and supplying healthy food in hospitals.

The findings from this study highlighted that nurses with high professional pride were more likely to maintain healthy behaviors. To retain nurses’ healthy behaviors during the pandemic like COVID-19, the hospital organizations should establish effective strategies to enhance nursing professional pride. During the health crisis, nurses’ sacrifices and vocations have been reported and nurses have been praised by the public. It is needed to emphasise nursing professionalism to the public during the pandemic and enhance professional pride by empowering nurses’ efforts and promoting nursing values. Nurses also need to communicate the pride in their nursing professionalism to colleagues and encourage each other to maintain healthy behaviors for both their own and patients’ health.