Health promotion for person-centred care with Gillian Morris and Brian Webster

[Music] Let's talk nursing is brought to you by BJNinform.com, a learning platform for bite-sized evidence-based content that supports all aspects of nursing. I'm Samina Hashimi, editor of BJNinform, and in each episode I chat with experts about topics across person-centered care, nurse well-being, and career development. Together we'll explore their experiences and discuss practical tips and insights that you can apply to your nursing practice. [Music] Hello and welcome to the second person-centered care episode of Let's Talk Nursing, the BJNinform podcast. I'm joined today by Jillian Morris and Brian Webster. Jillian is a lecturer at the University of Dundee and is also a qualified advanced nurse practitioner and district nurse with a special interest in health promotion for non-communicable diseases. Brian is a registered nurse and trainee district nurse at NHST side. Brian also has an interest in health promotion and both Jillian and Brian and members of the British Society of Lifestyle Medicine. Thank you both so much for joining me. That's all right. Pleasure to be here. In this week's episode we're talking about health promotion and the lifestyle changes that nurses can recommend to improve patient outcomes. Brian and Jillian have written a great introductory article about this topic on BJNinform. They're also working on an article series about health promotion across four main types of non-communicable diseases. You can find these in-depth overviews linked in the description box. First of all, you discussed in your article that there's no universal consensus on what health promotion is. That probably makes it quite hard to define, but I was wondering whether you could give us an overview of what health promotion can mean particularly in the context of nursing? Well, I guess that you're absolutely right. There is no one agreed definition. The definitions that you see in literature have evolved over the years, particularly since the Ottawa Charter on health promotion in 1986. From here, there has been a focus on the concept of empowerment of individuals and communities to really take ownership over their health. The World Health Organization has said that health promotion really is a process of enabling people to increase control over and to improve their health, but it also acknowledges the wide range of social and environmental influences and control that people have over their ability to be healthy. It's interesting because we're still at that part from the Ottawa Charter, where there isn't an exact definition, as Joanne says, and out some research, we'll talk about actions and activities and other research, we'll talk about values and principles, and maybe it's a bit above, really, but I think what the whose definition back in 1986 said still stands, it's about enabling the person to take control and not being authorityary in about that, but quite a challenge in thing to do, which I'm sure we'll get into. Yeah, but we'll definitely discuss all the details around that. And in terms of sort of delivering health promotion, what are some of the strategies that nurses can do when promoting health? So Brian, you mentioned this briefly in your response, but what are the actions that people have spoken about? I think it's about small actions, and people tend to particularly maybe healthcare professionals think that health promotions and entity in itself, and it is, there's, you know, we have people who work so late in that area of work, but we all have an obligation and a sort of recommendation from our regulator, the NMC, to be promoting health at every opportunity. So it tends to not matter what your role is, so if you're an advanced nurse practitioner, if you're a district nurse, if you're an intensive care nurse, which might be a bit more challenging, but, you know, taking every opportunity to promote health. So I think it does scare people a little bit, just think, well, that's not me, I don't need to do that. That's not my job. You know, I'm a hospital nurse in a busy surgical ward. That's for somebody else to do, but it's absolutely not because you can use these little tools and these little tricks, you know, such as briefing interventions or motivational interviews, or two of the ones that are quite highly cited, but we've got some good articles. Well, you guys at BGNI, so I mean, on MEC, which is making every contact count, which is a part of briefing intervention. You know, so it might be that you're a surgical nurse in a busy hospital, but you know that your patients came in with a, I don't know, a smoking-related cancer. So you know, it's not about patching them up and shipping them off. You could be having that 10-minute chat about, you know, what is, what is your smoking pattern? What is your smoking hand? What can we do to maybe change that and look at that? It can be very short, very, very simple conversations, you know, it's not about a one-hour delivery of, you know, information or just giving someone a weaflet as well, which can be quite complicated and knowing the difference between, you know, handing someone a weaflet versus giving them a brief intervention. Definitely. And you mentioned the making every contact count, ask, or they're, I'll link that in the description as well, so that listeners can take a look at that if they want to. You briefly mentioned sort of tips and tricks that nurses can implement. And you mentioned like motivational interviewing. Could you explain maybe a more detailed what those look like? Yeah, definitely. So Jillian, I'll probably know a bit better than me because she's been around and nurse longer than me and lectures on these things. But, you know, emotional interviewing is all about sort of that positive outlook on the person. And what you could maybe call a bit of, you know, collective leadership hasn't highlighted what the person is good at and getting them to focus on that. It's about affirmations. So, you know, saying, you know, "Well, you were able to do X, so why don't we try Y?" Open-ended questions as well. So we wouldn't say, "Do you want to stop smoking?" Because that's not open-ended. It might be, sorry, I'm focusing on smoking here because it's the top of my mind. But, you know, it might be, "Well, how many cigarettes do you smoke a day? And could you maybe reduce that by five?" You know, or something like that. But, Jillian, have you got anything more motivational interviewing? Well, I was just going to just sort of follow up on what you were saying, Brian, because you're absolutely right about there is a myth that health promotion should take place more in primary care. But, actually, it's these really small tips that can make the difference. And people essentially need to acquire the knowledge, skills and information to allow them to make healthy choices for themselves. For example, you know, about the food that they eat or the, you know, the access to services that they are entitled to. That nurses need to be really clear and work in a person-centered way where there's equal power sharing in the relationship to let people have the confidence and their ability to make whatever changes would benefit them. So, that means a move away from this kind of biomedical approach that we still see towards a much more holistic approach. Nurses are also, my back to what our regulator tell us, to be advocates for patients' act as mediators between the patient and perhaps a federal on to other services, smoking cessation, for example, various, you know, other support services that are around. But another example, Brian talked about, about motivational interviewing, and that is a, you know, that's a certain style in itself. But it can be small things, like, for example, explaining to somebody fully how their medication works and why they're taking it and for them to then take it appropriately to the, you know, for the benefit of their health. It can also be things like understanding the impact of poverty on people and appropriately signposting to enable benefits maximization. For example, to the citizens' advice, you know, it's also a really great place to point people in the direction of thinking about myself working in advanced practice and being somebody that, you know, regularly handed out fitnotes for people about understanding the benefits of work and perhaps helping the person negotiate some kind of, you know, workplace adjustments or, you know, fees return to work rather than just signing people off. It's about understanding, you know, that to engage in work is good for people. These are just, you know, really small sort of tips that can be actually implemented into everybody's practice. And it sounds a bit like basic communication and listening skills form the baseline of providing effective health promotion. Yeah, absolutely. And I think thinking sort of broadly and when, you know, when patients are being assessed, like when they're being admitted, for example, make sure that in addition to the sort of clinical, um, history taking an assessment about understanding the importance of taking a good social history, because it's at that point where, you know, you're asking about lifestyle behaviors about occupational history, these kind of things and they will open up opportunity. ddim yn yng Nghymru, ddim yn ei ddwl, oes, oes. Mae'r gwaith sydd, oes, ac yn unrhyw, yn ddwl, oes, rydych, yn ymgy'r gwyllfa, mae'r gwyllfa. Mae'r gwyllfa, oes, rwy'r gwyllfa. Mae'r gwyllfa, oes, a fwy'r gwyllfa. Mae'r gwyllfa. Mae'r gwyllfa. Mae'r gwyllfa. Mae'r gwyllfa. Mae'r gwyllfa. Mae'r gwyllfa. Mae'r gwyllfa. Mae'r gwyllfa. Mae'r gwyllfa. Mae'r gwyllfa. a nyởdeniwll婆ri Whysioedd nhw i 헤uwlion pedoddau bod eswaeth drach diwy edrae trygrujeeth o bod os gusedig af hwn�� stations. Whithosio'r happenmol jábbaethi £2,6$ i foesau creod mo renderi £2.50$ ifar def castile yn dro yn gyd mynd i mynd i paynewnio dd Rachlyd safewis a wybodaeth drums sydd eu nenнд chyliyd! a'r yng Nghymru'r yng Nghymru'r nhw. Mae'r gyda'r yna, 'nym'r aegydaw'r llawer yng Nghymru'r nhw, mae'r aegydaw. Mae'r aegydaw'r dynod, mae'r aegydaw i'r yn dynod. Mae'r aegydaw i'r undynod. Mae'r 'na oed. offer sport, and information from the patient to be able to do that. >> I can imagine that it's quite difficult to, sort of, apply what you know about health promotion in real life situations, and a lot of that must depend on how ready the patient is to not only accept that advice, but actually implement this into their lives. So how can nurses assess readiness to change among their patients? So nurses, I guess, need to be aware of underpinning theory, because as a now-all graduate profession, everything we do is underpinned by the best available evidence, and there is a lot written around the assessment of readiness to change in patients. So there are simple tools that can be available to use, such as a readiness to change ruler, which is really a visual analogue of where the person feels how ready they are to change. The tools that are available will allow nurses to be able to predict how ready a patient feels they are to be able to make a change, and then depending on that, then that will determine the lifestyle changes that could be suggested. So for example, when you're assessing a patient and you are weighing them as part of the admission process, for example, you could say to the patient, have you thought about the benefits of perhaps losing some weight, and if you were to be interested, I could help you with that. So there are other theoretical models, Prchesca and Declimenti, for example, Becker's Health Belief model, they all explain the psychology of patients thinking around being able to make a change. I would say nurses, it's all certainly embedded in Tundra graduate programs and any sort of relevant postgraduate education, the underpinning theories really important to understand. Definitely, and I would just add that most of these things are all a cycle, aren't they? A little bit like you might drop into one part and then make your way around this model or this cycle as a person, but then you might fall off again, but that's absolutely fine. Coming and going on the model, people have things going on in their life, so it's not a fluid thing, but it's not a word descriptive thing, people will have different linear things. Yeah, that's the word, it's not linear, it's not linear, from getting from one side to the other, they might chop and change and veer and things like that. Absolutely, I think this is one of the reasons nurses are so good at relating to people, is that we're people as well and we can totally empathise with that sort of, you know, you feel of good intention and then you fall off the wagon so to speak and then you reconsider that you're going to start again and so on. So tell patients that you understand the difficulties and the challenges or that you can certainly sympathise with them. And just out of curiosity, Jillian, you mentioned it briefly in your response just now, but you talked about having to measure a patient's weight and then potentially discussing weight loss. I'm sure that comes up quite frequently in clinical settings and it must be quite a difficult conversation to broach. Do you have any advice around talking to patients about their weight? British Cymru reduced avonsag Fig, ontwys gallwn gallwn yt 겸iau cwbi Chest TRQ'r sydd ei cyb JHetym, a рис ni ni 4 i serio ų coi a fylaid I expectedio. 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Do you have any other similar or different examples? Well for me at the highest level there's clinical evidence-based clinical guidelines. So nice the National Institute of Health and Care Excellence have, you know in all of the conditions have advice about lifestyle modifications for that condition and they talk very specifically about eating a diet which is based around, you know essentially a Mediterranean type diet and then the benefits of weight loss, reducing alcohol intake, all that kind of stuff. So there are those. Nurses also need to be aware of even current recommendations. For example things like everybody should be doing 150 minutes of exercise per week. That's what the World Health Organization advise and another example would be you shouldn't be exceeding 14 units of alcohol per week and making sure that we're not drinking on successive days. That kind of thing. I as a with thinking as a clinician like to use apps or information and if we think about sources of information, not only for nurses but for patients actually like this one called NHS MSK, it's called MSK and it's for self care for people that come with you know back pain, knee pain, shoulder pain. It's developed by physiotherapists and it allows people to undertake exorfliesis to improve whatever it is that they have and other things like you know couch to five key apps for example is brilliant to get people out and moving and more obviously not appropriate for everybody but for people that were able to think about taking up something you know quite aerobic then that's a really good supportive app to recommend. Yeah and I think apps are really accessible and really easy for people to just start using and it's also I guess sort of gamification of health promotion creates that added element of motivation which is quite nice. Absolutely. Do you have any? I'm just going to see over articles. Yes. I've not really known everyone from it but I mean there probably will be some critics of our series of four articles that say this is all the same stuff JLN and Brian this is you're talking about these three changes but these three changes are the three main changes that all these non-communicable diseases are drivers of how how to reverse or at least reduce the symptoms and you know the trajectory of them and sorry I was typing there because we're trying to pull up the British Society of Lifestyle Medicine because JLN I don't know if you could remember there six pillars of lifestyle medicine off the top of your head but you know what isn't massive things it's you know it's sleep it's nutrition it's physical activity and exercise. I'm impressed with that. Yeah. I've already had an awful substance. Yeah and I don't think people including us has realized you know the sheer benefits of some of these what seem like everyday simple things like getting a good night's sleep and you know not being chronically stressed but they have massive impact on all these conditions that kind of blow your mind and every time I read something about it it blows my mind that you know having a good night's sleep can reverse hypertension for example and or have a positive impact. I wasn't a podcast yesterday on coffee having having a good impact on information and reducing information that's just amazing you know and so it's about showing people that it's you know what's not about joining the gym and eating vegetables all day every day and you know and not having any fun in your life it's not about that at all. You're right Brian and I am in in our latest article I'm started getting very excited reading about green exercise in this concept of the power of exercising outdoors and it doesn't need to be you know it can just be going for a brisk walk it doesn't have to be anything that requires expensive trainers or anything like that so it's just about absorbing the you know the feeling of the wind or the rain and listening to the birds and you know looking up at the sky that the benefits of that are when compared to indoor exercise is really quite considerable it's you know really quite powerful and it's just being mindful and aware of the impact that you have. Yeah and thank you for mentioning coffee there Brian I feel very validated in my caffeine addiction. I think that the guy or the recommendation is three to four cups a day or mug is actually three to four mugs gives you the perfect amount of polyphenols and all these amazing amazing things. I mean that's quite generous have you heard anything about tea because I feel like I drink that more than coffee actually. No. It's not actually no but I'm sure there's there's polyphenols and everything but yeah. Yeah there's antioxidants in tea there tea is good but the coffee it should be black coffee shouldn't it Brian. Yeah and there's there's a link between black coffee consumption and its ability to break down non-alcoholic fatty liver interestingly. Oh that's amazing. I'm not quite hard core enough to drink straight black coffee. I'm like, "Has black salt?" Oh I am. You're dependent on it. But there's a small lifestyle intervention that might be a briefing invention to talk about coffee and maybe just take the milk out your coffee and dark chocolate has positive effects on cardiovascular health. So if somebody likes chocolate is it that they switch to a much more cocoa based chocolate for example? We could be here for hours but red wine again is another one. It has a positive effects on the cardiovascular health in a certain quantity. So you know it isn't about stripping away the chocolate and the wine and the coffee so I think that's. And you're right Brian the Mediterranean day recommends about versions of it recommend some red wine which I'm very thankful for. We're thankful for all of these dietary recommendations. Yeah, very big size about the caffeine and I do like a bit of dark chocolate so I'm on the path to a very healthy lifestyle. And you both spoke a bit about your personal experiences with promoting healthy behaviors but I was wondering whether there was any patient or event that played a significant role in your understanding of health promotion and what lessons did you learn from this? I am as a when I was a district nurse there was an initiative in my local area to help people with pre-existing long-term conditions to help them make dietary changes and it was run by the dietic department and that to do some modules and then I was to run this little class of about I think there was about maybe eight people in it and it taught me a really hard lesson. I know I'm I mentioned at the beginning that the sort of notion or the concept of health promotion has has changed over the years and we're moved towards a much more empowering model than previously it was it was more authoritarian and I was talking about salt content to the group and about the dangers of salt and the check you know in in in processed foods for example and that we should avoid things like processed meats because they have a high salt content and they went away that day and then they came out the following week and one of the one of the people said um Chilean you know you were talking about salt being dangerous and I said yes and it said what about pepper and it really struck me that I had made sort of preconceived I had had ideas about people's level of knowledge that actually people understand what is healthy in on all different levels and that we shouldn't we shouldn't make assumptions about people's existing knowledge and I would hate you know it's really important it's really damaging to any kind of patient relationship if you come across as being packed and anything or you know it doesn't it doesn't allow that equal power in a relationship and so it really taught me a hard lesson to to be much more mindful of what people understand health to be. No I think that's a great example of really listening to people and understanding their perspective and also it's just really nice when people show curiosity and ask those questions and the worst thing you could do in that situation is shot them down and make them feel like you know they don't deserve to have any engagement with it when you know engagement is the main positive step there isn't it? Yeah no absolutely and I was saying it was it it was a great thing to do and and actually the most important thing I think that came out from that group is that they struck up our friendship circle and it comes back to what Brian was saying about social contacts and the power and the benefits of that and that they had a sense of purpose coming on to the group and they had a shared understanding of what the difficulties were in making health behavior changes and so friendships were struck from that which was really nice. Oh that sounds really nice yeah. And Brian obviously you talked about the vegetable garden is there any other example that you'd like to discuss? Yeah probably from from district nursing, but nursing in general can unfortunately be very task focused. So when I started as a trainee district nurse and previous to that as a community staff nurse, there is a lot of task focused work and it is unfortunate because case loads are so big. We know that from the Queen's nursing institute that case loads are getting bigger and bigger. So you know, you maybe don't feel that you have the time to promote health and you know, think why isn't this wound healing, you know, you're sometimes having blinkers on and just, you know, treating the wounds, but when I actually treating the wound and thinking about the other factors, but diabetes is probably one of them. So we'll say patient A and patient B. So patient A, we were given insulin a very ridiculously small amount and this hadn't been reviewed for years. You know, but nobody had thought, well, why don't we do a bigger blood test in HPA1C? We'll call it, you know, because we were task focused and we didn't think we had the time eight o'clock in the morning to think about maybe this person's in remission and maybe they can come off of this insulin. So yeah, that's my thing is trying to be a bit less task focused, but that was a good example. Patient A came off of insulin, which was amazing. And then patient B is a patient who was, you know, a housebound very isolated. We were going in and doing a lot for this patient, diabetes care and insulin delivery and wind care and all these types of things. And now that patient comes to the health center and self manages their insulin. So yeah, really good. Because we stopped looking at the task and you know, try to think, well, you know, if you walk up to the health center, that's your, you know, you're maybe 30 minutes of exercise that day as well as that green spaces, Julian said, and the exposure to the outdoors and maybe going to the shop on the way back. And, you know, there's a bit of a sense of community. So yeah, it's not bad things, you know, people don't have to change their life, you know. Definitely. Yeah. And it's so good to hear a success story around that and to see how moving away from the more task oriented system of working can actually not only streamline general processes, but also create good patient outcomes as well. So I think now we can move on to our three key actions. This is where I ask our guests to outline three important practical actions that nurses who are listening can implement into their practice. So what is the first key action that nurses can take when promoting health, Jillian, I'm going to let you take this one. Okay. So I would say that every nurse has the capacity and the ability to make tiny changes with their patients. Now that might be through brief interventions. That might be through saying to patients, did you know we had a smoking cessation nurse that came here to the practice on a Friday. It could be signposting patients to the pharmacy that offers the sort of nicotine replacement. These kind of things. Every nurse has the ability to do that. Amazing. And what is your second key action, Brian? It's your turn. Yeah. So mine's probably having an awareness of the impact of all these actions and these interactions. So go back to the personal examples we gave is really good evidence of these actions and interactions that they have because then it gives you a sense of purpose as a nurse, you know, and a sense of achievement and a sense that you've made a change. So yeah, really appreciate what you're doing. And lastly, what is the third key action you'd recommend? I'll give this one back to you, Jillian. Okay. So be armed with the facts and the, you know, have an understanding of the underpinning theory around healthy lifestyle behaviors so that you can support your patients as best you can and also to implement them into your own lifestyle. We all should be able to follow the advice we give to our patients, which is drink black coffee and eat dog chocolate. That's it. That's all there is to it. Exactly. Right. So yeah, thank you so much for sharing these actions. Sure, there are so many situations that require advice around lifestyle interventions where nurses can really implement these tips that you've you've just given. Now to wrap up the episode, we're going to take a look at a reflective exercise together. So I'm going to read out a case study. This is the same case study that Brian and Jillian included in their article, Health Promotion for Person-Centered Care on B.J. and Inform, which you can access using the link in the description box to do the exercise along with us. We'll then take a look at the reflective questions and discuss what Brian and Jillian would look for in a response. So first of all, I'll start with reading out the case study. Derek is a 53 year old man who's had a recent diagnosis of type 2 diabetes for which he requires midform and hydrochloride. This is the only medication he'll be taking, except for some analgesia he sometimes takes for back pain. He's not keen on taking the medication and would like to avoid medicines if possible. He works as an electrician and is independent in most aspects of his life. He lives alone and enjoys spending time with his friends going out for meals and alcohol. Consider how using a person-centered approach you can work with Derek to promote his health relating to his lifestyle. So before I read out the reflective questions, what are the main things that initially come to mind when you're presented with this scenario? So I think he's probably quite an active job, so that's great. So he's obviously out and about quite a bit on his feet quite a bit. So he's probably meeting quite a lot of his physical activity recommendations, but he might want to add a little bit more in. So, you know, like for example, I don't kind of walk in the dog as exercise because I would do it every day. It's about what you could do above and beyond that, perhaps, for someone who's looking to reverse his type 2 diabetes. Jillian? I would completely agree with what Brian's saying, but also I would add in that I would take a real impairment approach and I also bearing mind the person-centered nature of the assessment, ask what matters most to Derek at this point in time. Because quite often you will find that patients, the prior priorities might be a little bit different from yours and just to make sure that what you are recommending is realistic. Find out what is it that most matters to Derek? Is it, for example, treating his back pain, is it keeping him in work? Is it, you know, understanding the medication that he's taking? So that's why I would say that. So let's take a look at the reflective questions now. So the first question is given his new diagnosis, are there any approaches to health promotion that might be suited to Derek? Jillian, you mentioned an approach there, so could you expand on that and discuss what you would want to look for in a response to that question? Absolutely. I would need to, I would want to get a measure of Derek's existing understanding, what does he already know and what does he need to know to keep himself healthy and well. I would think about brief intervention in terms of trying to support a behaviour change, perhaps, and a change to his diet and whether that's giving him information, whether that's referred along to somebody else, I would make an assessment and go from there. Definitely. And the second reflective question is considering that Derek also has back pain. Are there any lifestyle changes you could educate an empowered Derek about, which would be beneficial for his diabetes as well as back pain? So you touched on this a little bit Brian, but what do you think around this question? So yeah, it probably is going to be his physical activity and exercise. So he's already doing and these are terms that we touch on in our articles because there is a bit of a difference, you know. So the fact that he is an electrician and he's got quite a way of his job. So he is probably doing quite a bit of, you know, cardio vascular things that he doesn't even realise he's doing, but his body will, when I go back to the dog walking thing, probably be used to that. So you won't really be getting these heart rate up to, you know, a wevel that's positive for him. So just encouraging him to maybe do a little bit more and dig an intake, you know, is that he could maybe arc further away from a person's house and have a bit of a walk to the person's house or, you know, little things like that is there a man's shed that he could join that have, you know, a walking group or something like that. It probably is going to be physical activity and exercise that would tackle both, but certainly a nutritional approach to the type 2 diabetes if we were only looking at that. So unfortunately, he might have to take the metaphor because these blood levels might be at that level where it's unfortunately unsafe not to, and we don't want him to end up getting other conditions from that high high levels, but reminding him that this isn't a life-long prescription. This can be changed from some nutritional changes, and that's not soups and shakes. It's a bit of a joke, but we're doing we enjoy it. You know, that could be calorie restriction, it could be fasting, it could be a mediterranean approach, but yeah, talking again, what's realistic for Derek? It might not be fasting, it might not be you know, calorie restriction. So therefore it might be adding more, you know, fruit and vegetables. But again, we'll have to think about these elf literacy. So we aren't going to talk about polyphenols and, you know, legumes and things like that. We're going to, we're going to probably have an awareness of his health literacy and go from there. We'll pick up a few fruits and vegetables from your garden. Absolutely. No, amazing. Thank you so much. Those are all really great points and definitely give a lot of food for thought, especially for our listeners who are doing the case study along with us. Great pudding. They are food for thought. So that essentially brings our episode to an end, Brian and Jillian. Thank you so much for joining me on Let's Talk Nursing. It's been such a pleasure talking to you about such a key component of providing person-centered care. Before we go, I wanted to point out that Brian has his own podcast leadership 321 about all things leadership in health care. So if this is something you're interested in, you can find a link to the podcast in the description box. Thank you both so much. It's a pleasure. Thank you. If you enjoyed this episode of Let's Talk Nursing, do follow us for new episodes and share with your colleagues. For more resources and past episodes, visit bjninform.com. Thank you so much for listening and see you next time.