• To recognise the role of nurses in the prevention of non-communicable diseases
• To enhance your ability to initiate and engage in effective healthy conversations with service users
• To be aware that training can provide nurses with the knowledge, skills and confidence to discuss health with service users, and that it is available to all NHS staff
Nurses in all settings have an important role in preventing non-communicable diseases such as cardiovascular disease, cancer, respiratory disease and diabetes mellitus. They have multiple daily opportunities in their practice to discuss health with people, with the aim of supporting behaviour changes that reduce the risk of non-communicable diseases and the associated health-related and economic challenges. Incorporating the principles of healthy conversations into all daily interactions provides opportunities for nurses collectively to promote health on an individual basis to millions of people. However, many nurses have not received training in such behaviour change interventions. This article explains the principles and potential benefits of healthy conversations, and emphasises the importance of training to promote nurses’ knowledge, skills, confidence and motivation to engage in such conversations.
Nursing Standard. doi: 10.7748/ns.2023.e11912Peer review
This article has been subject to external double-blind peer review and checked for plagiarism using automated softwareCorrespondence
Mills A (2023) Promoting health through nurse-led healthy conversations. Nursing Standard. doi: 10.7748/ns.2023.e11912Open access
This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International (CC BY-NC 4.0) licence (see https://creativecommons.org/licenses/by-nc/4.0/) which permits others to copy and redistribute in any medium or format, remix, transform and build on this work non-commercially, provided appropriate credit is given and any changes made indicated.
Published online: 13 March 2023
clinical - communication - health literacy - health promotion - patient education - patients - person-centred care - professional - public health - well-being
Non-communicable diseases are responsible for the deaths of 41 million people globally each year, accounting for 74% of all deaths (World Health Organization (WHO) 2022a, 2022b). The four main non-communicable diseases worldwide are cardiovascular disease, cancer, respiratory disease and diabetes mellitus. Tobacco use, unhealthy diets, physical inactivity and harmful use of alcohol increase the risk of death from non-communicable diseases.
Individual behaviour is an important factor that affects people’s overall health (National Institute for Health and Care Excellence (NICE) 2007), although that behaviour is often influenced by the social and commercial determinants of health (WHO 2021a, 2021b). The Health Survey for England 2017 (NHS Digital 2018) examined five behavioural risk factors – cigarette smoking, excess alcohol consumption, unhealthy diet, physical inactivity and obesity – and reported that 32% of adults had two of these behavioural risk factors and 19% had three or more factors.
Nurses work at an individual and community level, so are well placed to support the prevention of disease at all stages of people’s lives (Alleyne et al 2011). One way of doing this is by having healthy conversations with people they encounter in their day-to-day practice, which aim to encourage individuals to identify health issues that are important for them, support the development of health goals and ascertain timelines for action (Health Education England (HEE) 2020). This article discusses the skills and knowledge that nurses require to initiate and engage in healthy conversations effectively.
Healthcare professionals, including nurses, frequently provide advice and information to service users to facilitate behaviour change; however, it is well recognised that this approach alone is generally insufficient (Olshansky 2007, Kasila et al 2018, Hollis et al 2021). Behaviour change is complex and if healthy conversations are to be effective, they need to explore and acknowledge the complexities and context of people’s lives, recognise their personal resources or agency (one’s ability to act in a given situation) and support the development of change action plans (HEE 2020).
Healthy conversations use a person-centred approach and aim to empower people to take control of their behaviours and subsequently increase their self-efficacy and self-esteem (Black et al 2014, Hollis et al 2021). Bandura’s (1991) social cognitive theory forms the foundation for healthy conversations, recognising that personal agency regulates goal-directed behaviour, while also acknowledging that people need to believe they have the required skills, qualities and capabilities to carry out and maintain the new health behaviour (Naidoo and Wills 2016, Buckworth 2017). Healthy conversations can be achieved in as little as 30 seconds, or longer if more time is available (Aveyard et al 2012).
Making Every Contact Count (MECC) is a brief or very brief behaviour change intervention that uses the main elements of healthy conversations to discuss health with service users (HEE 2020). It is a long-term national strategy, launched in 2010, that builds on the many interactions that NHS staff have with people in their daily practice. A consensus statement on MECC was published by Public Health England, NHS England and HEE in 2016, showcasing their commitment to the intervention and their aim to upskill all NHS staff to deliver it (Public Health England et al 2016). MECC is aligned with the national and global move away from an authoritarian biomedical approach to healthcare towards a person-centred holistic approach. It seeks to explore issues that are important to an individual, rather than focusing on ‘what is the matter’ with them. Person-centred conversations aim to empower service users to take control of their behaviour by developing their self-esteem and self-efficacy (Hollis et al 2021).
MECC training provides healthcare professionals with the skills required to use time-limited opportunities efficiently and to support people to identify the health behaviours they wish to change. These may include adopting a healthy diet, losing weight, reducing alcohol intake, stopping smoking, becoming increasingly physically active or other health behaviours that are relevant and important to the person (HEE 2020). The training encourages the use of open-ended questions that start with ‘How’ or ‘What’ and aim to explore and understand the person’s situation by encouraging them to share their stories and voice their concerns, thereby providing insight into what matters to them. In contrast, closed questions merely require the person to answer ‘yes’ or ‘no’, providing little information to work with (HEE 2020). Examples of open-ended questions that might be used include:
• ‘What would you like to change?’
• ‘How will you make these changes?’
• ‘What have you tried before?’
• ‘What previously worked well for you?’
The aim of MECC is to use the many daily conversations that nurses are involved in to assist service users in making healthy choices, identifying the issues important to them, focusing on the person’s strengths and abilities, exploring the obstacles to the new behaviour, and supporting the person to devise their own solutions and action plans based on their strengths and abilities. People should also be supported to decide who will collaboratively review their change plan; some people may wish to review their plan with a trusted friend, family member or work colleague, while others may want to be supported by a healthcare professional (HEE 2020).
Ekman et al (2022) acknowledged that service users’ first impressions of healthcare professionals are crucial in determining the consequences of conversations, so it is essential they display body language that is respectful and welcoming, for example an open friendly posture and unfolded arms. It is also important that they maintain appropriate eye contact, speak at a steady pace and use a friendly tone of speech. Healthcare professionals who show empathy and take a genuine interest are regarded as trustworthy; as a result, people are increasingly likely to share their personal stories with them (Hubley et al 2021).
Nurses need to be non-judgemental, open and alert to what the person wishes to talk about. Using open questions encourages the person to contribute to the dialogue (Golsäter et al 2012) and take control of the conversation, moving away from the healthcare professional giving recommendations or offering advice and towards the person identifying potential actions and solutions themselves. Nurses should work with service users to develop behaviour goals that are SMARTER (specific, measurable, action-oriented, realistic, timed, evaluated and reviewed) (HEE 2020). (Hollis et al 2021). Nurses should avoid using statements such as ‘In my experience’, telling people what to do, and suggesting actions (Black et al 2014).
To build on an individual’s personal strengths and enhance their confidence, the nurse should use active listening skills, listen more than talk, and use open questioning to explore the importance of the new behaviour as identified by the person (Black et al 2014). At the same time, nurses need to be alert to issues, be responsive to what has worked well in the past for the person, and recognise what enablers and barriers may facilitate or hinder the change (de Normanville et al 2011).
Scriven (2017) maintained that although nurses are not trained as counsellors, to be effective in health promotion conversations they need to adopt and use counselling techniques, such as motivational interviewing and health coaching. Motivational interviewing uses empathy to reduce people’s resistance and increase their motivation for change (Rollnick and Allison 2004), while health coaching seeks to enable people to acquire and use knowledge and skills that will enable them to become active in their care and take action towards achieving their well-being goals (NHS England and NHS Improvement 2020).
Box 1 provides an example of the content of a healthy conversation a nurse could have with a service user.
A nurse could have a healthy conversation with a person diagnosed with type 2 diabetes who is not taking their prescribed medicines to manage the condition. In this situation, the nurse could support the person to develop the confidence and self-efficacy required for effective self-management of type 2 diabetes by demonstrating their knowledge of the condition, being aware of the community resources that are available and using the skills they have learned from healthy conversation training. The nurse could identify the reasons why the person is not taking their prescribed medicines, for example they might not understand the importance of taking them or might be unable to collect their prescription because of transport issues. Furthermore, the nurse can use the healthy conversation as an opportunity to discuss the importance of a healthy diet, how to shop and cook for such a diet, the value of being physically active and any additional support that could enhance the person’s well-being.
• Nurses are well placed to support prevention of non-communicable disease through healthy conversations with people they encounter in their day-to-day practice
• Healthy conversations aim to encourage individuals to identify health issues that are important for them, support the development of health goals and ascertain timelines for action
• Making Every Contact Count training provides healthcare professionals with the skills required to use time-limited opportunities efficiently and support people to identify health behaviours they wish to change
• Nurses should recognise the social and economic context of people’s lives and understand how this influences health outcomes
• Healthy conversations can enhance individual’s health literacy, which may contribute to increased knowledge, confidence in personal abilities, resilience and self-belief in their ability to make health behaviour changes
Healthy conversations provide opportunities for nurses to support people who are adversely influenced by the social and commercial determinants of health (Lathrop 2013). The social determinants of health are the factors that affect a person’s health and well-being and include political, cultural and socioeconomic factors, as well as access to healthcare, education, safe and appropriate housing, and healthy food (WHO 2021b). The commercial determinants of health include the private sector’s production and marketing of various products and activities, for example processed foods, sugary drinks, tobacco and gambling. These can negatively affect people’s health, potentially leading to non-communicable diseases such as heart disease, obesity and type 2 diabetes, as well as mental health issues (WHO 2021a).
These social, economic and commercial circumstances can inhibit behaviour change and may strengthen harmful behaviours (NICE 2007). As a first step, nurses need to be able to recognise the social and economic context of people’s lives and how this influences health outcomes (Hemingway and Bosanquet 2018). They should also be aware that sensitivity and compassion is required when discussing topics such as food poverty, suboptimal housing, unemployment and financial hardship.
It has been identified that 61% of the working-age population in England has difficulty understanding information on health and well-being, which influences their ability to manage long-term conditions, participate in health-enhancing behaviours and access services (Public Health England and Institute of UCL Health Equity 2015). Health literacy enables people to make sense of and use information, and access health and social care services, based on their knowledge and capabilities. It is helped or hindered by organisational structures and the availability of resources (WHO 2022c), and is recognised as a social determinant of health that nurses need to be aware of during healthy conversations.
Low rates of health literacy are linked to higher rates of hospital admission and readmission, increased use of emergency services for disease treatment, suboptimal health outcomes, higher mortality and lower use of preventative healthcare services (Berkman et al 2011, Cloonan et al 2013). People with low health literacy are often ashamed of their lack of understanding or low skill level (Wolf et al 2007), so if nurses are to have an effect on health behaviours they need to be approachable, make time to clearly explain issues and answer questions. Healthy conversations can enhance an individual’s health literacy, which may contribute to increased knowledge, confidence in personal abilities, resilience and self-belief in their ability to make health behaviour changes (Public Health England and UCL Institute of Health Equity 2015).
In healthy conversations there are two important elements that relate to health literacy: the nurse’s ability to communicate effectively and the service user’s capacity to understand, process and use the information. During the conversation it is important to use language that is easy to understand and avoid medical or technical jargon, abbreviations and complex terminology. Any written information that nurses provide should be clearly written and structured (Koh et al 2012). If they provide links to internet resources, the nurse should be aware of the content of the website material, how understandable it is and if the person can easily access the internet.
Nurses who are knowledgeable about local services and resources can provide people with support, information and options for improving their health (Tallon et al 2017). Several organisations provide useful information online that can support healthcare professionals to have healthy conversations with service users, including NICE (www.nice.org.uk/about/nice-communities/local-government), elearning for healthcare (www.e-lfh.org.uk/programmes/all-our-health) and charities such as the British Heart Foundation (www.bhf.org.uk/for-professionals/healthcare-professionals/resources-for-your-role/resources-for-primary-care-nurses).
In addition, social prescribing aims to connect people in primary and secondary care with sources of community support and services using non-medical interventions that seek to meet people’s physical, social and psychological needs (Rempel et al 2017). Social prescribing link workers can connect people to services within local communities such as support and information on increased physical activity, alleviation of loneliness, debt support, creative activities and volunteering, including statutory services such as housing and welfare (Islam 2020, NHS 2023). Much of what supports people’s health happens outside clinical settings (Buck and Gregory 2013), so it is important that nurses are aware of the health-enhancing services available to people in their local area.
Low confidence linked to lack of knowledge and skill base is cited by healthcare professionals as a barrier to the delivery of behaviour change interventions (Keyworth et al 2018). Additionally, the National Institute for Health and Care Research (2021) has reported that many NHS staff miss opportunities to promote health because they lack the skills to discuss sensitive issues that may cause distress. However, Public Health England (2013) guidance recognises the essential public health role of all nurses, while the Standards of Proficiency for Registered Nurses (Nursing and Midwifery Council 2018) requires nurses to actively promote the health of service users.
MECC training can provide nurses with the knowledge, skills and confidence to discuss health with service users and to support goal setting (Jarman et al 2019). This training is available in many locations across the UK, delivered online and face-to-face. MECC Healthy Conversation Skills Training is delivered across two three-hour sessions, while MECC Lite Training consists of one three-hour session (Healthy Conversation Skills 2020).
Training addresses all features and types of healthy conversations, ranging from very brief opportunistic encounters to longer discussions. It can provide nurses with the skills to develop empathic relationships, increase their confidence in identifying and creating opportunities for healthy conversations, and support them to gain an understanding of the context and lived experiences of individuals (Black et al 2014, HEE 2020). A Royal Society for Public Health (2022) report found that staff who had completed MECC for mental health training were increasingly confident and motivated to find opportunities to engage in conversations with people. Meanwhile, a study involving 108 nursing students who had completed MECC training found that 84% (n=91) valued this training, with many using the knowledge and skills they had learned with service users and in their own lives (Mills et al 2021). However, if their nurse mentors were unaware of or did not practise healthy conversation skills or MECC, the nursing students were less likely to develop these skills (Mills et al 2021).
Healthy conversations use the millions of everyday interactions between nurses and service users to improve individuals’ health and support them to make behaviour changes that will reduce the risk of non-communicable diseases. These conversations are person-centred and provide opportunities to support people with the health and well-being concerns that are important to them. Training is available to all NHS staff and aims to equip them with the skills and knowledge to engage in healthy conversations with confidence. Nurse managers and leaders should demonstrate their commitment to public health initiatives by ensuring that all nurses can access this training.
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