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• To recognise that emergency nurses have an opportunity to integrate health promotion in the care they provide
• To understand the barriers to health promotion in emergency care settings
• To consider how you could provide further health promotion to patients in your practice setting
Background Emergency departments (EDs) afford ‘teachable moments’ for health behaviour change, but staff may not see themselves as public health practitioners and it can be challenging to undertake health promotion activities in emergency care settings. Furthermore, the evidence on health promotion in these settings is limited.
Aim To investigate the views and experiences of emergency nurses and ambulance service paramedics regarding health promotion in emergency care settings.
Method A convenience sample of emergency nurses (n=3) and ambulance service paramedics (n=3) was recruited. An inductive and descriptive qualitative study design using semi-structured interviews and thematic analysis was employed.
Findings The participants understood health promotion and were willing to have conversations about it with patients. However, they cited several barriers to health promotion, including understaffing, a lack of understanding of the relevance of health promotion among staff, a lack of training and information, and the sensitivity of topics such as body weight and sexual health. Lack of time was not cited as a barrier.
Conclusion There are opportunities for developing the health promotion aspect of practice in emergency care settings, where staff and patients would benefit from a more structured, system-wide approach to health promotion.
Emergency Nurse. doi: 10.7748/en.2023.e2156Peer review
This article has been subject to external double-blind peer review and checked for plagiarism using automated software
Schofield B, Hoskins R, Rolfe U et al (2023) Health promotion in emergency care settings: investigating staff views and experiences. Emergency Nurse. doi: 10.7748/en.2023.e2156Acknowledgements
The authors wish to thank the study participants, who were working under huge pressure at the time of data collection due to the coronavirus disease 2019 pandemic
Published online: 18 April 2023
Health promotion is not a new concept; the first international conference on this subject was held in 1986 (World Health Organization (WHO) 1986, 2023) and Wanless (2002, 2004) emphasised the importance of health promotion and disease prevention in the early 2000s. However, it remains highly relevant for addressing public health issues. Health promotion is defined as ‘the process of enabling people to increase control over, and to improve, their health’ (WHO 1986), and it can lead to more appropriate use of healthcare resources by encouraging people to adopt healthier lifestyles and reduce their risk factors for developing disease.
Emergency care and public health share similar goals for improving health (Bensberg and Kennedy 2002, Phillips and Laslett 2022), and emergency departments (EDs) afford ‘teachable moments’ for health behaviour change (Flocke et al 2014). Emergency care staff have the opportunity to make health promotion an integral part of the care they provide. However, they may not see themselves as public health practitioners and EDs can be challenging environments in which to undertake health promotion activities (Flocke et al 2014).
All health and social care staff are encouraged to talk to patients about health promotion and it is important that they have the competence and confidence to have these conversations, encourage patients to adopt healthier lifestyles and direct them to local services that can support them. Health promotion has become an essential role of nurses, as emphasised by the Nursing and Midwifery Council (2018) in its standards of proficiency for registered nurses, while in ambulance services increased attention is being given to the role of paramedics in health promotion (Cromar-Hayes 2020). However, there is limited evidence on health promotion in emergency care settings, particularly in the paramedic profession. Schofield and McClean (2022) noted a lack of evidence on whether and how paramedics deliver health promotion interventions, and how acceptable these interventions are to staff, patients and families.
• Emergency nurses and ambulance service paramedics need to be trained and supported to undertake health promotion activities
• Employers have a central role in ensuring staff are aware of the public health benefits of health promotion interventions in emergency care settings
• A more structured, system-wide approach to health promotion in emergency care settings is required
Major risk factors for premature deaths in England identified by the Global Burden of Disease Study 2016 include high blood pressure, smoking, suboptimal diet, alcohol use, obesity and drug use (Steel et al 2018). Two further major risk factors for suboptimal health outcomes are air pollution and lack of exercise (Institute for Health Metrics and Evaluation 2023). Health promotion interventions include having conversations with patients about how they can improve their health and well-being by addressing these risk factors.
Front-line healthcare staff are well placed to recognise appropriate times and situations for having health promotion conversations with patients. Every 24 hours, the NHS comes into contact with more than one million people (NHS 2019) and these contacts are potential opportunities for staff to deliver health promotion interventions. This idea is at the centre of the Making Every Contact Count (MECC) approach, which involves the delivery of short, person-centred interventions during everyday clinical encounters to assist patients in adopting healthier lifestyles (Public Health England (PHE) 2016). The overall aims of MECC are to promote behaviour change at population level and help individuals and communities reduce their risk of disease (PHE 2016).
The MECC approach targets public health priorities – such as encouraging physical activity, reducing smoking, alcohol misuse and obesity, and promoting mental health – through the use of techniques such as brief interventions (PHE 2016, National Institute for Health and Care Excellence (NICE) 2023). Brief interventions are short discussions between a healthcare professional and a patient intended to motivate the patient to change behaviours that put their health at risk (Senior and Craig 2019). They generally consist of a few minutes spent discussing a health topic, providing information and advice, supporting goal setting, encouraging change, signposting and referring for further support (NICE 2023).
While EDs have been viewed as treating acute illness and injury rather than addressing risk factors for the development of disease, they can be suitable environments for health promotion for several reasons, including that (Phillips and Laslett 2022):
• Emergency care and health promotion share similar goals for improving the health of individuals and communities.
• Emergency care staff are a credible and trusted source of health information.
• EDs provide an entry point to healthcare.
• EDs have an existing infrastructure for health promotion, such as planning processes and community networks.
Cross (2005) recommended increasing emergency nurses’ post-registration education on health promotion and continuing to explore their role in, and perceived barriers to, health promotion. Chacha-Mannie et al (2019) conducted a qualitative study examining the attitudes of 204 patients with high-risk health behaviours and 14 nurse practitioners towards brief health promotion interventions in nurse-led minor injury units, walk-in centres and urgent care centres. The authors found that brief health promotion interventions such as screening, advice, leaflets and referrals were acceptable and they recommended training, support, resources and pragmatic policies to help nurse practitioners integrate health promotion interventions into care provision.
Studies have found brief interventions on alcohol use delivered in EDs to be effective (Schermer et al 2006, Academic ED SBIRT Research Collaborative 2007). One study noted a reduction in alcohol consumption in an intervention group who had received a brief intervention and a written handout, compared with a control group who had received the written handout only (Academic ED SBIRT Research Collaborative 2007). In a prospective randomised clinical trial, Schermer et al (2006) found that patients who had received a brief intervention on alcohol use during a trauma centre admission – following a motor vehicle collision – were less likely to be arrested for driving under the influence of alcohol within three years of discharge compared with patients who had received standard care.
Not all researchers have demonstrated the superiority of brief interventions delivered in EDs for reducing alcohol consumption. D’Onofrio et al (2008) conducted a randomised clinical trial to determine the efficacy of brief interventions on alcohol use delivered by emergency care staff to patients engaging in hazardous or harmful drinking, comparing the intervention group with a control group receiving standard discharge instructions. At 12 months, the number of weekly drinks and the number of monthly binge-drinking episodes were lower than at baseline in both groups, so there was no difference in efficacy between the brief interview and the standard discharge instructions.
In a US study, the introduction of a public health promotion specialist in the ED to provide brief interventions was shown to have a positive effect on patient satisfaction (Rega et al 2012). In another US study, patients and visitors in several EDs were asked what they preferred to receive health education about (Kit Delgado et al 2010). The topics they were most interested in were stress, depression, exercise and nutrition, rather than topics such as substance abuse and injury prevention, which emergency care staff tend to discuss more often with patients. Most patients and visitors appeared to prefer traditional health education tools such as books and brochures, as opposed to novel tools such as digital platforms and online sessions (Kit Delgado et al 2010).
In Australia, work was undertaken to explore opportunities for health promotion in seven EDs and a framework for health-promoting emergency departments has subsequently been developed (Bensberg and Kennedy 2001, 2002, Bensberg et al 2003). The potential for EDs to provide health promotion opportunities was described as resulting from efforts to combine the ‘spectrum of health and disease’ encountered in EDs with ‘strategies for health promotion’. The framework provides a basis for emergency care staff to integrate health promotion and primary and secondary prevention in their work (Bensberg and Kennedy 2001, 2002, Bensberg et al 2003).
To investigate the views and experiences of emergency nurses and ambulance service paramedics regarding health promotion in emergency care settings.
Given the limited literature on the topic, an inductive and descriptive qualitative study design using semi-structured interviews and thematic analysis was chosen over a quantitative approach. Qualitative research tends to involve small numbers of participants studied intensively, with a focus on their lived experience.
An interview topic guide (Box 1) for the semi-structured interviews was developed with input from the ambulance trust’s patient and public involvement (PPI) group. The members of the PPI group were invited to an online meeting about the study and agreed to provide input. They were also consulted on the study’s subject area and on the participant information sheet and consent form.
• Introduce yourself, check that the participant has read the information sheet and confirm receipt of their signed consent form
• Allow time for discussing the study and the interview in case the participant needs further information or has questions
• Investigate the participant’s views and experiences regarding health promotion using questions such as:
• How are you involved in emergency care provision?
• What do you understand by ‘health promotion’?
• What are your views on the provision of health promotion advice as part of your job?
• In your opinion, who is best placed to provide health promotion advice to patients in your work setting and why?
• Do you think something needs to be changed in your work setting to encourage staff to provide health promotion advice and if so, what?
• Can you describe a situation where you would be unable or unwilling to provide health promotion advice?
• Thank the participant for their time
Direct enquiry was used to recruit a convenience sample of emergency nurses and ambulance service paramedics. Paramedics were recruited from one NHS ambulance trust and nurses were recruited from the ED of one of the hospitals served by that ambulance trust. The two trusts sent emails to all their paramedics and emergency nurses about the study, while posters and leaflets advertising the study were placed in staff rooms at each site. Staff interested in participating were asked to contact the researchers.
Data collection took place between September 2020 and December 2020. The interviews were conducted by the lead author (BS) over the telephone as opposed to face to face because of the social distancing measures prompted by the coronavirus disease 2019 (COVID-19) pandemic. The interviews were audio recorded digitally and transcribed verbatim.
Thematic analysis was employed, which uses an iterative process of data reduction and comparison (Braun and Clarke 2006). The anonymised interview transcripts were thematically coded by hand, and the codes organised into themes, by the lead author. Two of the interviews were double coded independently by two of the authors (RH and UR) to assess inter-coder agreement.
Analysis was ongoing throughout the data collection process so that emerging themes could be fed back into the next interviews. The researchers held meetings to discuss the coding process and emerging themes. The themes were presented to the PPI group and the conversations between the researchers and PPI group members contributed to data synthesis and interpretation.
Approval for the study had been obtained from the Health Research Authority and ethics committee approval had been obtained from the South Central – Hampshire A Research Ethics Committee (20/SC/0182). Approval to interview NHS staff had been obtained from the research and development teams at the two participating trusts.
Once potential participants had agreed to take part in the study, they were sent copies of the participant information sheet and the University of the West of England privacy notice for research participants. They were given the opportunity to ask questions and then asked to complete and sign a written consent form. Consent forms were scanned and emailed to the lead author ahead of the interviews.
Six emergency care staff were interviewed – three emergency nurses and three ambulance service paramedics. Two main themes emerged from analysis of the data:
• Health promotion as part of the role of emergency care staff.
• Barriers to health promotion in emergency care settings.
All participants displayed an adequate understanding of health promotion, describing it as providing health education, empowering patients to manage their conditions and directing patients to external support services in their communities:
‘Taking the opportunity, opportunist moment sort of interventions, when you can discuss with the patients health behaviours that may be risky or they may need signposting about, giving them information to help them make those decisions themselves, to enhance their health.’ (Nurse 3)
All participants thought that health promotion was part of their role and acknowledged its positive effects on individuals. The three participating nurses expressed the views that senior nurses who see and discharge patients in the ED are well placed to undertake health promotion activities and that junior nurses may be more task orientated and may not use their contacts with patients to undertake health promotion activities:
‘Because as a clinician who sees the patient, I would have chatted to the patient, I would have taken history and know more about the patient, and I will have that picture of what’s wrong with the patient. So I think we are the best people to give health promotion to patients and usually the other thing is patients will confide in you, after you’ve seen them as a clinician… and they usually follow those instructions because you would have built trust.’ (Nurse 1)
‘Yes, I like health promotion. I find it quite kind of satisfying. You’ve got patients that don’t understand something and you’re able to talk to them about it and hopefully improve their life by just that one callout. Because sometimes it’s not an emergency at all and it turns out that they actually just don’t know how to use their inhaler, or they don’t understand something. So yeah, I think I use it quite a lot in my job.’ (Paramedic 3)
There were perceptions among participants from both professions that not all their colleagues held similar views. Some participants stated that it is important that staff understand the relevance of health promotion in emergency care, because health promotion activities are usually regarded as activities that take place in primary care.
Participants from both professions expressed concern that they lacked training in having health promotion conversations with patients and knowledge of the wide range of topics they might have to discuss. Some participants stated that they felt comfortable discussing topics they had gained knowledge about from researching them of their own accord:
‘It’s difficult for me to tell whether I’ve learnt it myself or whether somebody taught me it, I can’t be specific about that.’ (Paramedic 2)
‘Obviously doing any additional learning which then you could bring into your job role. I don’t know if this is classed as health promotion really, but [for a] mental health patient I had the other day I learnt a new breathing technique thing to do the other day and I did it with her and it worked really, really well. I went through another one with her as well and she said that was really helpful and she was going to use that in the future. But that’s something I learnt outside of actual being at work.’ (Paramedic 3)
All participants stated they would find it useful to undergo health promotion training and have access to an online handbook with up-to-date advice for patients. Some participants expressed an interest in topic-specific training and in having leaflets to give to patients before discharge. Participants recognised the need for an organisation-wide approach to staff training and the provision of information and signposting for patients. All three participating nurses thought that waiting areas could be better used, for example to display posters and leaflets on health promotion:
‘Whether that’s through our annual mandatory training, like a training package or a presentation on local services that are available that we could have to hand. Or just having more communication or contact numbers or direct numbers for referrals that we can make as paramedics, because sometimes I find the barrier is that to do a referral to that service, it has to go via the GP. So if we could be the direct referral to say an alcohol service or a smoking service then that would cut out the middle person and we could just put our referral in straightaway.’ (Paramedic 1)
‘I guess from my point of view, I think if ED staff were given specific information that they could provide to patients I think it would be useful because it’s not a clear standard at the moment to be saying everybody knows [to] have your five fruit and veg a day and things like that. But actually, if somebody was to ask me “okay so what’s in one of those promotions?”, I wouldn’t necessarily know off the top of my head. That’s why I think something like patient leaflets or something like that would be useful.’ (Nurse 2)
Participants talked about topics that could be too sensitive to discuss with patients. Most participants said smoking cessation was a regular topic in health promotion conversations. They also felt able to discuss alcohol use without feeling intrusive because alcohol use is recorded when taking a patient’s history. Topics that most participants described as too sensitive to discuss included body weight and sexual health. There was a fear of offending patients if talking about body weight:
‘We’re probably really rubbish at giving advice about reducing weight, about weight reduction. I think my colleagues – and that would include myself I’m sure – find that a very difficult and different conversation to have, in the health education perspective, because you certainly don’t want to ask [or] discuss that too early on, when you’re taking the history, their social history – whereas you would with alcohol and smoking, you would just ask them.’ (Nurse 3)
‘Probably sexual health I guess, as in safe sex practice… especially if that’s not necessarily related as well to what they’ve come in [about], I think that would seem a bit random to just come out with it.’ (Nurse 2)
One of the participating nurses, however, said they felt confident discussing body weight, which they thought was appropriate if it could be related to the patient’s condition, particularly if weight management could directly influence recovery. That participant stated that building a relationship with the patient even during a short consultation was central to easing the potential discomfort felt at broaching a sensitive topic such as body weight.
Participants indicated that understaffing could be a barrier to health promotion activities. However, they did not cite lack of time as a barrier and many participants expressed the view that time spent on educating patients could have longer-term benefits by reducing people’s need for emergency care in the future:
‘The more we can teach and support, the more people are going to stay at home.’ (Paramedic 3)
While participants acknowledged that all patients seen in the ED by nurses and all those treated at home by paramedics would probably benefit from health promotion conversations, they recognised that patients would need to be receptive to such conversations for them to have an effect. Participants identified that they would be reluctant to discuss health promotion with rude and aggressive patients. They acknowledged that not all their colleagues undertake health promotion activities and that employers have a central role in ensuring that staff are aware of the health promotion potential of their role and of the longer-term benefits of health promotion for patient health and staff workload:
‘I would say it probably is dependent on the individual how much importance they place on health promotion.’ (Nurse 3)
This study investigated the views and experiences of three emergency nurses and three ambulance service paramedics regarding health promotion in emergency care settings. By using an inductive and descriptive qualitative approach, the researchers gained in-depth insights into the views of a small number of emergency care staff, revealing to what extent they saw health promotion as part of their role and what they considered to be barriers to health promotion in their practice setting.
The study findings showed that participants saw health promotion as part of their role and did not appear to consider lack of time as a barrier to its delivery. They appeared willing to undertake, and often did undertake, health promotion activities but did not always feel confident doing so and reported that not all their colleagues shared their views and practices.
Participants mentioned several potential barriers to health promotion in emergency care settings, including:
• Staff’s lack of understanding of the relevance of health promotion in emergency care.
• Staff’s lack of training in having health promotion conversations with patients and lack of knowledge and information on relevant health topics.
• Junior staff potentially being more task orientated than senior staff and therefore less likely to have conversations with patients that lead to health promotion opportunities.
• The lack of an organisation-wide approach to health promotion in terms of staff training and delivery.
• Certain topics being perceived as too sensitive to discuss with patients, notably body weight and sexual health.
• The fact that not all patients will be receptive to health promotion conversations.
Participants recognised that engaging patients in health promotion conversations, providing them with educational material and signposting them to external sources of support can have long-term benefits in terms of reducing people’s need for emergency care in the future. They also recognised the importance of building a trusting relationship with patients. If a trusting relationship has been established between a professional and a patient, a ‘teachable moment’ is more likely to occur. To gain patients’ trust, it is important to avoid judgmental language and attitudes and to ask them about their goals and preferences (Flocke et al 2014, Allinson and Chaar 2016, Dang et al 2017).
The findings of this study are supported by previous research showing that ED nurses see health promotion as part of their role (Bensberg and Kennedy 2001, 2002, Bensberg et al 2003, Cross 2005, Schermer et al 2006, Academic ED SBIRT Research Collaborative 2007, D’Onofrio et al 2008, Kit Delgado et al 2010, Rega et al 2012, Chacha-Mannie et al 2019). The literature is more limited regarding the role of paramedics in health promotion, despite the College of Paramedics (2015) including health promotion in the scope of paramedic practice, health promotion featuring as a topic in undergraduate paramedic degrees, and ambulance services acknowledging the need to use contact time with patients to promote their health and well-being (Association of Ambulance Chief Executives 2017). The three paramedics interviewed in this study appeared open to the idea of undertaking health promotion activities but highlighted the need for support from employers.
There are opportunities for developing the health promotion aspect of work in emergency care settings. Patients and staff would benefit from a more structured, system-wide approach to health promotion. Employers need to provide staff with training, support and resources to enable them to incorporate health promotion activities into routine care. This should include in-house training, support from managers and health education tools such as leaflets and apps.
The study involved a small number of emergency care staff from two staff groups only. The views of other staff, patients and families were not investigated. The participants had volunteered to take part, which could have introduced a bias, and the sample may not be representative of all emergency nurses and ambulance service paramedics. All participants were from a single geographical area of England, so the findings may not be transferable to other regions and countries of the UK.
In this small qualitative study, six emergency care staff shared their views and experiences of health promotion in an ED and an ambulance service. They all considered health promotion to be part of their role but also identified numerous barriers to its delivery in emergency care settings. Emergency care staff may lack the willingness, confidence, training, support and resources required to have health promotion conversations with patients.
The study findings could inform the design of further research to investigate the barriers to health promotion in emergency care settings and improve staff’s willingness and ability to undertake such activities in those settings.
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