All frontline nursing staff can incorporate brief behaviour change interventions into their clinical practice to reduce patients’ risk of long-term conditions
This is the second of two articles on how nurses can help patients improve their own health. It focuses on the role of frontline staff in integrating behaviour change interventions into their clinical work. Staff must develop competencies appropriate to the level of intervention they are offering. Opportunities to advise can be lost because of perceived barriers but many of these barriers can be overcome by using a partnership approach. The first article outlines the role of nurse leaders in helping frontline staff deliver behaviour change interventions.
Citation: Fuller S (2015) Building brief intervention into your everyday work. Nursing Times; 111: 5, 23-25.
Author: Sabrina Fuller is head of health improvement, NHS England.
- This article has been double-blind peer reviewed
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Every day nurses see evidence of how health-related behaviour makes a significant contribution to premature death and the burden of chronic ill health. Tackling smoking, alcohol misuse, and lack of physical activity and poor diet contributing to obesity could make substantial improvements to health, wellbeing, life expectancy and help reduce inequalities (World Health Organization, 2014).
Nurses are ideally placed to help patients improve their health and wellbeing. They are respected for their knowledge and expertise and have a close relationship with their patients, often built up over a long period. They usually know their patients and their personal circumstances, and have a good understanding of the context of their lives and the decisions they make about health.
Behaviour change interventions
The government’s mandate to the NHS (Department of Health, 2014), reinforced by the Five Year Forward View (NHS England, 2014), requires it to make progress in focusing on preventing illness, with staff using every patient contact as an opportunity to help them stay in good health by not smoking, by drinking less alcohol and by exercising more.
NHS England is supporting implementation of the relevant National Institute for Health and Care Excellence guidance on individual behaviour change, smoking, drinking, alcohol, obesity and physical activity as an integral part of clinical pathways, care plans and treatment.
Behaviour change interventions aim to help people with specific health conditions or behaviours that may affect their health. Competency frameworks such as that produced by NHS Yorkshire and the Humber set out the knowledge and skills a member of staff needs to be able to deliver the intervention at different levels of intensity. NICE guidance on individual behaviour change interventions (2014a), alcohol (2010), obesity (2014b) and tobacco use (2006) provide evidence that they work and are cost effective.
Very brief interventions
NICE recommends that all staff in contact with the general public be trained to deliver a very brief intervention. This is defined as an intervention taking up to two minutes that follows an “ask, advise, assist” structure - for example, recording patients’ smoking status and advising them that smoking cessation services can offer effective help to quit. Depending on patients’ response, they may be directed to these services.
Examples of opportunities for very brief interventions on smoking include:
- A practice nurse assessing a new patient;
- A district nurse changing a dressing and advising on wound healing;
- A nurse on a respiratory ward talking to a patient with chronic obstructive pulmonary disease;
- A midwife advising a mother on the effect of smoking on her unborn baby;
- A health visitor advising on protecting children in the family from exposure to tobacco smoke.
In each case, the nurse would identify whether the patients smoke, demonstrate the relevance of the habit to the outcomes of their treatment, care or future outcomes for themselves or those they care for, and offer a referral for further support for change. Box 1 lists performance criteria for nurses’ competencies.
Box 1. Very brief intervention competencies
- Is alert to opportunities for brief advice
- Explores, in a non-threatening manner, patients’ views and feelings about their lifestyle and health behaviours
- Assesses whether patients are willing to engage in a discussion about the issue:
- Those who are not willing to engage at that moment are invited to return and ask questions at any time in the future
- Those who are wiling to engage are given general health information in an empathetic, non-confrontational manner
- Signpost patients to appropriate additional support
NICE recommends that staff who have contact with patients whose behaviour, ethnicity or family history could put their health and wellbeing at risk should be trained to deliver brief intervention. A brief intervention may last anything up to half an hour and is defined as verbal discussion, negotiation or encouragement. It may also involve a referral for further interventions or more intensive support.
Examples of opportunities for brief interventions on alcohol use include:
- A nurse on a gastrointestinal ward talking to a patient with liver damage;
- A practice nurse discussing the results of an alcohol assessment with a patient on the hypertension register;
- A health visitor advising a mother who is showing early signs of neglect of her child linked to alcohol use;
- An accident and emergency nurse examining a patient who has attended repeatedly after falls when drunk.
Using a validated tool for assessing hazardous or harmful drinking, a non-judgemental approach and good listening skills, the nurse seeks to understand:
- Whether patients are aware of the potential consequences of their behaviour on their own health and wellbeing;
- Whether, and how, they were motivated to change;
- Barriers to change;
- What support they might need.
Extended brief interventions
An extended brief intervention is similar in content to a brief intervention but usually lasts more than 30 minutes and consists of an individually focused discussion. It can involve a single session or multiple brief sessions.
Extended brief interventions may be offered through weight loss or smoking cessation services, or services to support those drinking at risky levels. They are provided by a primary care local enhanced service or other commissioned services. Box 2 lists examples of performance criteria for nurses’ competencies to deliver this level of intervention.
Box 2. Extended brief intervention competencIes
- Enables patients to systematically identify their aims
- Identifies the steps needed to achieve their aims
- Establishes short-, medium- and long-term objectives
- Enables patients to select options that they can realistically implement
- Clarifies and provides accurate information about the range of support mechanisms available
NICE recommends that behaviour change specialists and treatment service providers offer high-intensity interventions for patients they see regularly and who have been assessed as at high risk of harm. This includes adults with:
- A body mass index higher than 40;
- A serious medical condition that needs specialist advice and monitoring;
- Dependencies on alcohol or other substances.
Staff delivering these high-intensity interventions will have training in an advanced set of competencies including techniques derived from cognitive behavioural therapy.
Barriers to interventions delivery
Very brief and brief interventions should be part of the routine work of almost every nurse but many opportunities to give relevant and appropriate advice are allowed to pass (Prime Minister’s Commission on the Future of Nursing and Midwifery, 2010; Jacobsen et al, 2005). Some of the potential barriers include the following:
“I’m too busy doing the day job”
One widely cited reason for not delivering brief advice is a lack of time and work pressure. This betrays a short-term focus: health-related behaviours contribute to the overall burden of illness and consequent demands on the system.
A district nurse helping a patient to give up smoking will support wound healing and reduce treatment need. If patients with diabetes are encouraged by discussion at outpatient clinics to lose weight, their glycaemic control will improve. Binge drinkers may avert future crises if A&E nurses engage them in discussions about their alcohol use.
Often the opportunity to give brief advice will present itself in a consultation or during routine nursing care. Brief and very brief interventions need not take extra time, and time spent on them is a worthwhile investment in reducing demand. Box 3 lists sources of information on training and development.
Box 3. Training and development
All nurses delivering behaviour change support should develop a level of competence appropriate to the level of intervention they are delivering (National Institute for Health and Care Excellence, 2014a). Relevant learning materials that support nurses in developing the skills required to deliver brief interventions are available on a range of topics, for example:
SeSee aSeSS See also the e-learning for healthcare learning resources offered by NHS Health England Education.
“My patient doesn’t want to change”
Willingness to change is not a fixed state but passes through a series of phases. This sequence is often described as “states of change” (DiClemente et al, 1991). Appropriate advice will depend on where individual patients are in the change process, namely whether they are in:
- Pre-contemplation (they resist change);
- Contemplation of change;
- Preparation for change;
- Maintenance of change;
While those contemplating change or who have relapsed will benefit from encouragement, and those preparing or taking action may benefit from practical support and reinforcement, those who are in pre-contemplation may benefit from empathy and understanding - simply being listened to - before they move towards contemplating change.
Patient activation is defined as individuals having the knowledge, skill and confidence for managing their health and healthcare (Hibbard and Gilburt, 2014). Those with long-term conditions who are more highly activated are more likely to engage in positive health behaviours and manage their conditions more effectively.
Several programmes have demonstrated the ability to raise patients’ activation scores. These include a focus on them gaining new skills and encouraging a sense of ownership of their health, often using peer support, health coaching and educational classes.
“People might be offended if I mention their drinking, smoking or weight”
Behaviour change interventions are much more acceptable if it is clear how they relate to the issue being treated. Above all, the efficacy of brief interventions - whether or not they produce immediate change - depends on listening to the person’s point of view, often using competencies from motivational interviewing.
Motivational interviewing was first developed for use with substance misusers. Rather than being about the health worker taking the role of expert, it is based on collaboration between the health worker and service user, drawing out service users’ ideas on change, building on their experience and emphasising the importance of their perspective and right to make their own decisions. It builds rapport and trust between the two parties, draws out the service user’s own motivation and skills for change and helps them take responsibility for change.
While this is more typical of extended interventions, there are some important transferable competencies underpinning very brief and brief interventions, such as:
- Asking open-ended questions;
- Listening reflectively;
- Using affirmation and clarification;
- Summarising and eliciting self-motivational statements (Royal College of Nursing, 2013).
For health professionals trained to be experts in health and to intervene to improve patients’ health and wellbeing, adopting a partnership approach can be challenging. However, undertaking some basic training and practising regularly with patients will soon reveal the strength of the technique and the effectiveness of collaboration between nurse and patient.
“Given my own lifestyle, I can’t be a credible role model”
The Prime Minister’s Commission (2010) stated that nurses should take responsibility for their own health and should acknowledge that they are public role models for healthy living. Patients may well question the legitimacy of a nurse who is obese, or one who smells of cigarette smoke, giving health advice. Nurses’ own lifestyles may also make them less likely to feel able to give advice.
The problem may well be less acute if nurses who are tackling their lifestyle issues briefly make reference to their own successes and failures as they empathise with their patients. Health service employers can support staff in improving their own lifestyles, for example by making healthier food and drink choices available in the workplace, or helping staff adopt more active lifestyles. NICE (2008) guidance on promoting physical health in the workplace sets out several ways they can do this, including: implementing policies that encourage active transport; giving information on opportunities for physical activity (and ensuring these are accessible to all staff, including shift workers); encouraging use of stairs rather than lifts; giving advice and support to help people plan physical activity.
Benefits of successful behaviour change interventions
There are many benefits to helping patients, service users and their carers lead healthier lifestyles. Instead of undoing the gains made through treatment and care, patients and service users are reinforcing and building on them, becoming equal partners in care with nurses. Through supporting behaviour changes nurses can make a real difference to individuals, families and communities, helping them to achieve better health, wellbeing and outcomes, along with increased independence and more years of healthy life.
- Tackling smoking, alcohol misuse and obesity can result in significant improvements to health and wellbeing
- Most nurses can use behaviour change interventions in their everyday practice
- Interventions vary from very brief to high intensity, with corresponding competencies required
- Barriers to delivering behaviour change interventions can be overcome using a partnership approach
- Employers need to support nurses to make healthy lifestyle choices
Department of Health (2014) The Mandate. A Mandate from the Government to NHS England: April 2014 to March 2015.
DiClemente CC et al (1991) The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation states of change. Journal of Consulting and Clinical Psychology; 59: 2, 295-304.
Hibbard J, Gilburt H (2014) Supporting People to Manage their Health: An Introduction to Patient Activation.
Jacobsen E et al (2005) Perspectives on lifestyle intervention: the views of general practitioners who have taken part in a health promotion study. Scandinavian Journal of Public Health; 33: 1, 4-10.
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 (2010) Alcohol-use Disorders: Preventing Harmful Drinking.
National Institute for Health and Care Excellence (2008) Promoting Physical Activity in the Workplace.
National Institute for Health and Care Excellence (2006) Brief Interventions and Referral for Smoking Cessation.
NHS England (2014) Five year Forward View.
Prime Minister’s Commission on the Future of Nursing and Midwifery in England (2010) Front Line Care: The Future of Nursing and Midwifery in England.
Royal College of Nursing (2013) Support Behaviour Change.
World Health Organization (2014) 10 Facts on the State of Global Health.