Senior nurse leaders have an important role to play in improving the health of patients and staff through the delivery of behaviour change interventions
Premature deaths could be avoided and NHS resources saved if healthcare staff provided more effective support for people to improve health-related behaviour. All healthcare staff can deliver very brief interventions, which have been proved to have a positive effect. Nurse leaders play a vital role in helping frontline staff deliver behaviour change interventions, and in ensuring support is available for staff to stay healthy. This article - the first in a two-part series - outlines the action nurse leaders need to take. Part 2 focuses on the role of frontline staff in integrating behaviour change interventions into their clinical work.
Citation: Fuller S (2014) The role of nurse leaders in improving health. Nursing Times, 111: 4, 12-14.
Author: Sabrina Fuller, head of health improvement, NHS England.
- This article has been double-blind peer reviewed
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Health-related behaviour, particularly relating to tobacco, diet, physical inactivity and harmful alcohol consumption, accounts for a significant and growing proportion of premature deaths and long-term conditions. The World Health Organization (2014) estimates that at least 80% of premature deaths from cardiovascular diseases could be prevented through modifying health-related behaviour.
In England, smoking, alcohol and obesity are key risk factors for preventable illness and premature death (Box 1), and incidence of alcohol-related harm and obesity are rising. The challenge is to reverse this trend so increases in behaviour-related ill health do not create an unsustainable burden on health and care services.
Box 1. Key risk factors in England
- Smoking is the single greatest cause of preventable illness and early death in England, from lung and other cancers, heart disease, stroke and long-term respiratory diseases.
- Alcohol is the second biggest lifestyle health risk factor after tobacco use. Regularly drinking more than the recommended limits increases the risk of hypertension, liver disease, diabetes, cardiovascular disease and cancers of the breast and gastrointestinal tract.
- Obesity is associated with increasing risk of diabetes, cardiovascular disease, high blood pressure, some cancers and osteoarthritis.
- A physically active lifestyle can reduce the risk of coronary heart disease, stroke, type 2 diabetes, some cancers, obesity, mental health problems and musculoskeletal conditions.
- Reducing vascular risk factors affects the onset and progress of vascular dementia and Alzheimer’s disease.
Source: Department of Health (2012)
Nurse leaders, whether commissioners or providers of acute, community, primary care or mental health services, must support frontline staff in working with patients, carers and service users to improve health and wellbeing. Last year’s Five Year Forward View (NHS England, 2014) makes the case for an increased focus on prevention and sets a strategic direction. Guidance from the National Institute for Health and Care Excellence, entitled Behaviour Change: Individual Approaches, provides detail on how the strategy can be implemented effectively (NICE, 2014a).
The Five Year Forward View sets out how the NHS needs to change, arguing for a more engaged relationship with patients, carers and citizens to promote wellbeing and prevent ill health. Long-term health conditions - rather than illnesses that can be treated with a one-off cure - take up 70% of the health service budget. NHS England argues that the future health of millions of children, the sustainability of the NHS and the economic prosperity of Britain all depend on a radical upgrade in prevention and public health (NHS England, 2014).
The responsibility for commissioning to improve population health passed to local authorities and Public Health England in April 2013. However, the Five Year Forward View cites a particular role for the NHS in secondary prevention, and in setting an example through supporting the health and wellbeing of its own staff.
NICE (2014a) sets out recommendations on the delivery of evidence-based behaviour change interventions. These cover the contribution of commissioners, provider organisations, managers, frontline staff and those involved in training and development. The guideline shows behaviour change interventions work and are cost effective, particularly when delivered as an integral part of clinical pathways and care plans.
Behaviour change interventions
NICE guidance on individual behaviour change (2014a), obesity (2014b), physical activity (2013), alcohol (2010) and smoking (2006) defines different levels of behaviour change interventions and how these fit within clinical pathways.
The different levels of intervention - very brief, brief and high-intensity - are described in Box 2; competency frameworks have been developed to support the delivery of each level (NICE, 2014a). All health professionals should be able to deliver very brief interventions with basic training and encouragement. As well as bespoke courses, a number of generic (Royal College of Nursing, 2013) and subject-specific (PHE, 2010) e-learning modules are available. High-intensity interventions require more advanced competencies and may be commissioned as specialist services.
Nurse leaders have considerable scope for planning prevention as an integral part of services, interventions, clinical pathways and care using an organisation-wide approach. This approach, with clear protocols for delivery of very brief to more intensive interventions, is set out in the public health guidance on alcohol (NICE, 2010).
Alcohol use screening is recommended during new patient registrations, and when screening for other related conditions, managing long-term conditions or carrying out a medicines review. This is particularly relevant where alcohol consumption may contribute to underlying determinants of diseases such as hypertension or obesity. Screening is also appropriate in sexual health and antenatal clinics or when treating minor injuries.
The guidance recommends a focus on those who may be at increased risk from harm, and those with an alcohol-related condition. These include people who have:
- Relevant physical diseases such as hypertension, gastrointestinal or liver disorders;
- Relevant mental health problems including anxiety and depression;
- Been assaulted;
- Risk factors for self-harm;
- Regular minor injuries or trauma;
- Regular contact with genito-urinary medicine clinics, or who regularly seek emergency contraception;
- Experience of or are at risk of domestic violence;
- Children involved with safeguarding agencies.
NHS settings, including primary and community healthcare, emergency departments, hospital wards, outpatients, occupational health, sexual health services, pharmacies, dental surgeries and antenatal clinics, should have clear pathways in place. Staff should be competent identifying and assessing patients who could benefit from behaviour change interventions, as well as delivering the appropriate level of intervention.
NICE recommends NHS professionals routinely carry out alcohol screening using validated tools such as AUDIT (PHE, 2008a) or FAST (PHE, 2008b). Screening is a systematic process of identifying people whose alcohol consumption places them at increased risk of physical, psychological or social problems, and who would benefit from a preventive intervention. Questionnaire-based screening is accurate, minimally intrusive and has been found to be acceptable to recipients.
If screening results point to a pattern of harmful or hazardous drinking, the guidance recommends the use of brief interventions covering the harm caused, barriers to change, practical strategies for change and goal setting. If, on review, the patient has not responded to advice, an extended brief intervention using motivational interviewing techniques is advocated. A patient assessed as alcohol dependent should be referred to specialist alcohol services.
A similar structured approach is set out for tackling obesity and smoking. The obesity pathway (NICE, 2014c) recommends that clinical judgement is used in choosing when to measure patients’ height and weight, but suggests a range of opportunities for measurement and intervention. These include when registering with a GP, at consultations for relevant conditions including type 2 diabetes and cardiovascular disease, and other relevant health checks, which may include antenatal clinics.
NICE guidance on brief interventions for smoking (NICE, 2006) recommends that GPs and other professionals working in local health services - including primary care and pharmacies - dental practices and NHS hospitals, establish monitoring systems to identify:
- Whether patients smoke;
- Whether those who smoke are interested in quitting;
- Whether smokers wish to be referred to an intensive support service such as NHS stop smoking services.
Those unwilling or unable to accept a referral should be offered a stop-smoking aid (pharmacotherapy). A range of public health-commissioned agencies offer advice and support on how to stop smoking.
Commissioning nurses: ensuring a full range of services
An effective pathway approach depends on the relevant support services being clearly defined and commissioned. Such a strategic approach is the responsibility of health and local authority commissioners, working in partnership through the local health and wellbeing board and building on local priorities in the joint strategic needs assessment and embedded in the joint health and wellbeing strategy.
NICE estimates that the annual cost to the NHS of physical inactivity is £1bn, of smoking £2.8bn, of alcohol misuse £3.6bn and obesity and overweight £6bn (NICE, 2014d). Analysis of behaviour change interventions confirms that most are cost effective. NICE assesses the health benefits of interventions in terms of the cost per quality-adjusted life year (QALY). Since 2004, NICE has used a threshold range of £20,000 to £30,000 per QALY. Brief interventions on healthy living (at various levels) are well below the NICE cost per QALY threshold (NICE, 2014a) and are therefore judged cost-effective.
NICE assesses the health benefits of new drugs and other treatments. It also assesses whether these benefits are greater than the health likely to be lost for other NHS patients as other treatments are displaced. To make this assessment NICE uses a threshold that represents how much additional NHS cost would displace an amount of health, measured by QALY.
Long-term conditions management
Supporting behaviour change is an integral part of developing health literacy and self-management of long-term conditions and is linked to the concept of “patient activation” (King’s Fund, 2014). This describes patients’ skills and confidence in managing their own health and healthcare, and patient activation measures have been validated in the UK.
Risk stratification can be used to identify those with a long-term condition and low confidence or knowledge, and who are at risk of developing comorbidities and complications. Changing health-related behaviour in this group can have a significant effect on long-term costs, through slowing or preventing disease progression.
Action to support behaviour change intervention
Updated NICE guidance sets out how organisations can ensure behaviour change interventions are delivered systematically and effectively, and directors of nursing and senior nurses have a key role in implementation (NICE, 2014a). The recommendations are that those in national and local organisations, whose employees deliver behaviour change interventions, should:
- Ensure policies, strategies and resources are in place to provide behaviour change support for staff, as well as service users. This support may take the form of workplace behaviour-change services, and helps staff and service users make healthier choices - for example, through smoke-free policies, cycle-to-work schemes, providing showers for staff use and healthy options in the staff restaurant.
- Review job descriptions and person specifications to check that they include behaviour change knowledge, skills and competencies.
- Determine which clinical staff are best placed to deliver different levels of a behaviour change intervention, and ensure those staff have the knowledge and skills or competencies needed to assess behaviours and individual needs and to deliver the intervention. They should also offer ongoing professional development on behaviour change theories, methods and skills.
- Ensure staff are aware of the importance of being supportive, motivating people and showing them empathy.
Mentors and supervisors with relevant training and experience should support staff delivering behaviour change interventions, helping them to set their own goals and providing constructive feedback on their practice.
The NHS has a responsibility to improve the health of the wider population and its own staff. Supporting people to improve their health-related behaviours will make an important contribution to the long-term sustainability of the NHS. Behaviour change interventions have been shown to work and are cost effective. The different levels of behaviour change interventions should be systematically integrated within clinical pathways and care plans. Nurse leaders have an important part to play in ensuring that staff are clear on their roles and have the appropriate level of competence, as well as support, to improve their own health and wellbeing.
Box 2. Levels of behaviour change intervention
- Very brief intervention: the clinician notes or asks about a behaviour (such as smoking), ascertains whether the person is interested in changing and whether they require any help in this, and directs them to further support. All staff should be trained and competent to deliver this level of intervention, which can take just a couple of minutes.
- Brief intervention: involves more discussion and understanding of the person’s wishes, intentions and support needs, as well as goal setting. Can be used for patients with risk factors or established illness.
- Required competencies for staff giving very brief or brief interventions include understanding the influences on health-related behaviour and good communication skills, including listening skills.
- Extended brief interventions and high-intensity interventions: used with those at higher levels of risk from their behaviour. They involve more exploration of the person’s own perspective on their health behaviour and structured goal setting, usually over a number of sessions.
- Required competencies include techniques such as motivational interviewing and cognitive behavioural therapy.
- As many as 80% of premature deaths from cardiovascular diseases could be prevented through behaviour change
- Smoking is the single greatest cause of preventable illness and early death in England
- Physical inactivity costs the NHS £1bn a year, while smoking costs £2.8bn, alcohol misuse £3.6bn and obesity £6bn
- All healthcare staff can deliver very brief behavioural change interventions
- Updated NICE guidance sets out the role of senior nurses in improving the health of patients and staff
Department of Health (2012) Annual Report of the Chief Medical Officer. Volume One, 2011. On the State of the Public’s Health.
The King’s Fund (2014) Supporting People to Manage Their Health: an Introduction to Patient Activation.
National Institute for Health and Care Excellence (2014a) Behaviour Change: Individual Approaches.
National Institute for Health and Care Excellence (2014b) Managing Overweight and Obesity in Adults - Lifestyle Weight Management Services.
National Institute for Health and Care Excellence (2014c) Identifying People Who Are Overweight or Obese.
National Institute for Health and Care Excellence (2014d) Behaviour Change: Individual Approaches - Costing Statement.
National Institute for Health and Care Excellence (2013) Physical Activity: Brief Advice for Adults in Primary Care.
National Institute for Health and Care Excellence (2010) Alcohol-use Disorders: Preventing Harmful Drinking.
National Institute for Health and Care Excellence (2006) Brief Interventions and Referral for Smoking Cessation.
NHS England (2014) Five Year Forward View.
Public Health England (2010) Alcohol IBA eLearning Course.
Public Health England (2008a) Alcohol Use Disorders Identification Test (AUDIT).
Public Health England (2008b) Fast Alcohol Screening Test (FAST).
Royal College of Nursing (2013) Support Behaviour Change.
World Health Organization (2014) 10 Facts on the State of Global Health.