The population in the UK is living longer, but many people, especially those living in deprived communities and with vulnerability, are living with poorer health throughout life (Public Health England (PHE), 2018). Although smoking rates have reduced in the UK, it is still the leading behavioural risk, followed by poor diet, physical inactivity, risky drinking and drug abuse (NHS, 2014). Prior to the COVID-19 pandemic, data from 2019 indicated that approximately 22% of deaths in those aged under 75 years in the UK were considered avoidable; of these, 64% were preventable and the remaining 36% were considered treatable (Office for National Statistics (ONS), 2021). Preventable mortality is defined as deaths that can be mainly avoided through effective public health and primary prevention interventions. This globally recognised definition of avoidable mortality was introduced by the Organisation for Economic Co-operation and Development (OECD) in 2019.
It is well known that good health is not consistently distributed across populations, and that deprived communities experience disproportionate levels of ill health (Institute of Health Equity, 2020). Differences in health among population groups were first raised as long ago as the Black Report (Townsend et al, 1988) and, most recently, in the Marmot review 10 years on (Institute of Health Equity, 2020), the impact of the COVID-19 pandemic has sharply focused attention on inequalities and their influence on health outcomes. Health inequalities are avoidable and unfair differences in the health status between groups of people or communities (PHE, 2017). To have value and be effective for patients, nursing health interactions must recognise the influence of the social determinants of health on health behaviours.
Some 301 491 nurses work in the NHS (NHS Digital, 2021), contributing to a large proportion of the healthcare workforce. As nurses have a public health responsibility, providing services directly to patients, they are well placed to promote health and wellbeing with patients and move the emphasis away from merely treating sickness (Department of Health and Social Care (DHSC), 2013). PHE's Nursing and Midwifery Contribution to Public Health guidance document (PHE and DHSC, 2013) also stresses the importance of the public health role required of every registered nurse. In addition, the Nursing and Midwifery Council (NMC) (2018) identified the skills and knowledge that undergraduate nurses must evidence in promoting health and preventing ill-health to people, families, communities and populations.
Health promotion is a broad concept, with the overall aim of helping people gain better control over of their health and improve it (World Health Organization (WHO), 1998). Nurses have the potential to provide effective person-centred health promotion directly to the people they serve. Health promotion involves a layered understanding of the influences of the social determinants of health, which include the individual's social context, situation, motivation and points of view (Olshansky, 2007). However substantial research, including Kemppainen et al's (2013) integrative review of the literature, indicates that, although nurses have an academic understanding of health promotion, most nursing practice is largely restricted to health education and information giving. Merely advising people on what they should and should not do does not acknowledge the complexity of health promotion (Olshansky, 2007) and, on its own, is frequently acknowledged as being inadequate for behaviour change (Kasila et al, 2018). In addition, although nurses are more likely to apply a holistic lens when caring for people, demonstrating an understanding of the impact of the social determinants of health requires working in partnership with a range of other organisations and agencies to ensure that the necessary support and resources are available to patients, their families and carers (Phillips et al, 2020).
Healthy conversations or making every contact count training provides healthcare workers with the skills and knowledge to use everyday interactions with people to promote health and wellbeing and signpost to appropriate resources or services (Royal Society for Public Health, 2015). Healthy conversations take a holistic, patient-orientated approach. Patient participation is vital, as the aim is to understand how the individual experiences health and what steps they may want and can take to improve their health. Individuals are encouraged to develop their own action plans for health with the support of healthcare staff.
The aim of the study described in this article was to investigate the value and use of Making Every Contact Count Healthy Conversation skills for student nurses 1 year after module delivery. Nurse academics working at a university on the south coast of UK worked closely with Health Education Wessex for this study. Practical ‘healthy conversation’ skills were embedded into the second year health promotion module. The brief intervention Making every contact count (MECC) (PHE et al, 2016) was chosen, as it was in use in the local trusts, and the training provides practitioners with skills and a clear framework for initiating and navigating healthy conversations and supporting people develop their own health action plans. To deliver the training, all members of the academic team completed the MECC trainers' course.
Methodology
Ethics approval for the study was granted by the university ethics committee. Adult nursing students who had received MECC training in the health promotion module were invited to participate in the study. An online questionnaire was designed based on the key themes that emerged from a focus group attended by five volunteer students. A total of 350 students were invited to complete the online questionnaire. A link to the online questionnaires was sent 1 year after the delivery of the health promotion module by email. The email informed students that their participation was voluntary and anonymous.
The questionnaire
Ten questions were posed in the online questionnaire. Some questions had multiple parts. Participants were initially asked to confirm that they had attended the health promotion module which incorporated MECC (yes/no). They were then asked to report their use of healthy conversation skills using a 4-part Likert scale: ‘Yes, I use the skills regularly’, ‘Yes, I use the skills occasionally’, ‘No, I have not used the skills yet, but I plan to when the opportunity presents’ and ‘No, I do not feel able to use the skills’.
Students who had used healthy conversation skills were asked to briefly describe a scenario where the skills were used. Participants were then asked to indicate how helpful the healthy conversations training and framework was for initiating conversations with people; three categories were provided-‘very helpful’, ‘helpful’ and ‘not helpful’. Participants were then asked if they found the training useful for helping people develop personal health action plans, for which possible answers were ‘very useful’, ‘useful’ or ‘not useful’. Participants were also asked if they experienced any difficulties using the healthy conversation skills (yes/no). Then, students were asked to elaborate on their answers and identify the challenges they had faced when using healthy conversation skills, using free text. They were asked to report if they had used their healthy conversation skills with the staff they worked with, and three responses were provided: ‘yes’, ‘no’ or ‘I have spoken about healthy conversations with my mentor’. The next series of questions then asked students to identify, in free text, what steps the academic teams, their placements, their nurse mentors or they themselves could take to help them further develop and practise their healthy conversations skills. The final question asked the participants if the training had made them think about their own health and, if so, what changes they had made.
Findings
In total, 108 students completed the online questionnaire (response rate, 31%). All the students who completed the questionnaire had received the healthy conversations training embedded into the academic module.
Student nurse use of healthy conversations
Some 22% (n=24) stated that they use healthy conversation skills regularly, while 45% (n=49) students stated they use the skills occasionally. Further, 25% (n=28) reported that they have not used the skills yet but plan to when the opportunity arises, and 9% (n=10) said they did not feel able to use the skills.
Scenarios where students used healthy conversations skills
Students identified a wide range of different placement settings and situations where they used healthy conversation skills.
- Helping patients stop smoking, asking them what they wanted
- When at placement helping in the vascular clinic
- Talking to a patient about their blood pressure
- While suggesting simple exercises to improve function and muscle strength in the legs
- When encouraging a patient to eat more vegetables while discussing his food choices during a health check in a prison environment.
‘I found a perfect opportunity to open a conversation about quitting smoking and how to get help.’
Many students linked the setting to the activity and demonstrated the effective use of open discovery questions to ensure they had a clear understanding of the patient's situation.
‘Recurrent patient visiting the hospital ward, used MECC to try and find out more information of home life, trying to find out why kept coming back into hospital.’
‘I have used it when someone was unable to think of a logical way to achieve a goal they wanted.’
‘I used it as a prompt for questions, so they could answer themselves; it broke down the situation into smaller, bite-size pieces. The person had anxiety and depression.’
The use of healthy conversation skills was not restricted to clinical settings, and some students said they used the skills with their families and friends.
‘Letting a friend talk to me when they are ready about making lifestyle changes, but I have been mentioning facts at every interaction.’
Other students used their knowledge of local facilities and resources to support patients outside of acute settings.
‘On placement I have signposted patients to live well Dorset/steps 2 wellbeing or cocaine anonymous if they said they wanted help to change.’
Several students acknowledged that they felt sufficiently confident to use the skills consistently in their practice.
‘Every day when in practice, you are always promoting health and the importance of looking after yourself.’
Initiating healthy conversations and helping people make their own health action plans
Most respondents found that the skills they acquired in the healthy conversations training were very helpful or helpful in starting healthy conversation (84%, n=91), while 13% of the students (n=15) did not find the skills useful. Over three-quarters (82%, n=89) of the students found the skills and framework they acquired were very helpful or helpful in supporting people to develop their own action plans, while almost a fifth (19%, n=21) reported that they did not find the skills useful.
Barriers to using healthy conversation skills
Almost a third of the students (29% n=32) reported that they experienced barriers and challenges to the implementation of healthy conversations skills, while 67% (n=73) reported no challenges. The most commonly cited barriers were lack of time, lack of knowledge of local services and lack of mentor knowledge or role modelling of healthy conversation skills (Box 1).
Box 1.Barriers to the use of healthy conversation skills
| Not enough time |
| Lack of knowledge on local resources |
| Feeling hypocritical |
| It is a skill that requires practice |
| Circumstances often do not make it possible |
| Having the confidence to approach the intervention and being prepared to be able to answer all the questions they may ask |
| My mentor does not understand or know about healthy conversation skills or framework |
| Healthy conversation skills not valued in practice |
Facilitating student use of healthy conversations
Respondents cited several enablers to the use of healthy conversations skills, the most frequently cited of which was ensuring that mentors had the training and role modelled the skills, so that students could watch and then practice with support (Box 2).
Box 2.Enablers to implementing healthy conversation skills
| Practice and use every opportunity |
| Working with nurses who have the skills |
| More information on what services and resources are available locally |
| Regular training, with new tips to aid memory |
| Posters with key principles |
| Train all mentors |
| Incorporate into all academic modules |
Using the principles of health action planning in self-care
Over two-thirds (65%, n=71) of the respondents reported that acquiring healthy conversation skills and knowledge had made them think about their own health, and many had implemented actions. Some of the students identified specific health behaviours they wanted to change and how this contributed to supporting others in health behaviour changes.
‘Losing weight and taking more exercise. This has rolled out into encouraging family members to do the same.’
‘When I started university, I was a smoker. Although I was already aware of the dangers of smoking, I did not change my behaviours; however, since learning about brief interventions, I have made the change and have quit smoking.’
‘I have reduced my alcohol intake and do think more about my diet.’
A number of students mentioned the importance of creating a realistic plan of change, involving taking one step at the time and identifying achievable goals.
‘It has helped me to make more realistic, manageable goals.’
‘It has helped me set meaning(ful) goals about my weight.’
Others acknowledged that the training had made them more aware of their own health.
‘Made me think how I can make my own life healthier.’
‘It has made me more self-aware.’
Other comments indicated that students often felt deceitful when talking to a patient about health changes when the nurse was not role modelling these healthy behaviours. This devaluing of health raised self-awareness around the implications of a nurse's role in care and health promotion.
‘It makes me think, if I am not looking after myself, how can I help someone?’
‘Feeling hypocritical.’
The key findings of the study are summarised in Box 3.
Box 3.Summary of key findings
| 67% (n=73) of students stated that they used healthy conversation skills in their practice |
| Healthy conversations skills were used in a wide range of contexts and settings |
| Healthy conversations skills were used with families and friends |
| Some students used knowledge to signpost patients to local facilities and resources |
| 84% (n=91) of students stated that the healthy conversation skills were very helpful or helpful in opening conversations about health |
| 82% (n=89) of students stated that the healthy conversation training was helpful or very helpful for supporting people to create their health action plans |
| Barriers to health conversations were identified (Box 1) |
| Enablers to health conversations were identified (Box 2) |
| 65% of students stated that the training had encouraged them to think about their own health; while some had made positive changes, others felt dishonest |
Discussion
Nurses are in the advantaged position of delivering care to many people often on an individual basis. These patient interactions provide nurses with opportunities to engage in health promotion. During the delivery of the module, healthy conversation skills were role modelled by academics and practised by students with their peers. However, student nurses wanted to see healthy conversation skills role modelled by nurses in practice. Several students acknowledged that they saw occupational therapists and physiotherapists use the techniques, but not registered nurses, and, importantly, often not their mentors. Cruess et al (2008) stressed the importance of role modelling for students' clinical competence and confidence. Some students stated that if their mentor did not use the approach or know of the approach, they were less likely to adopt the practice. For many students, this factor seems to have a profound effect on their confidence with the technique and practical application in daily interactions. Other students acknowledged that their mentors were not aware of MECC, and it would be useful for both the student and the mentor to have access to a shared resource which captured the stages of MECC, with prompts for the different phases within the directed conversation. NHS England (2014) acknowledged that a range of organisational support factors are required to influence the implementation and roll-out of MECC within healthcare settings. However, despite various CQUIN incentive schemes, many frontline registered nurses have not attended healthy conversation training. This may be linked to staff shortages, inability to release staff from busy front-facing settings or other training taking priority.
Lack of time to engage in healthy conversations was a commonly raised barrier, often also cited by other healthcare students (Royal Society for Public Health, 2013). It may be that students had not seen healthy conversations role modelled in a time-efficient way by nurses in their placement, so they failed to recognise that the intervention could be seamlessly used within a clinical activity, thereby ensuring effective use of time. The NMC (2018) Standards Frameworks for Nursing and Midwifery Education stipulated that student nurses must demonstrate considerable skills in promoting health to people, families, communities and populations. To achieve these skills practice is required, the current BSc (Hons) Nursing is split equally between theory and practice, and nurse leaders and senior nurses in clinical settings must prioritise the importance of healthy conversations for all nurses, thereby helping students develop and practise the required skills.
Much of what supports healthy lives occurs outside healthcare settings (Buck and Gregory, 2013), and it is important that nurses are aware of the wide range of health-enhancing services available to people in the local area. Many councils are developing digital wellbeing directories, which capture a range of health-creation services and resources within their localities. Healthy conversations provide opportunities to share relevant, up-to-date information on the diverse support available.
Numerous studies demonstrate the impact of undergraduate nurse education on stress and its subsequent impact on student health behaviours (Moridi et al, 2014; Health Education England, 2019; Mills et al, 2020). The healthy conversation training and its practice provides students with the opportunity to reflect and, in some cases, take control and make changes to their own health behaviours. However, several studies have acknowledged that many registered and undergraduate nurses have lifestyles which predispose them to poor health outcomes (Ross et al, 2017), which may make them less likely to engage in healthy conversations (Blake and Patterson, 2015; Kyle et al, 2016). In this study, several students stated that they felt deceitful or hypocritical when discussing lifestyle changes with patients when they themselves did not role model these behaviours. However, a recent systematic review (Kelly et al, 2017) identified that capable and confident nurses are more likely to discuss lifestyles with patients regardless of their own health behaviours. Healthy conversation training has the potential to improve nurses' confidence, skills and motivation to provide opportunistic support and non-judgemental lifestyle discussions. Therefore, access to training for all nurses may improve health promotion skills and confidence, enabling them to discuss healthy lifestyles with patients and also to address their own health behaviours.
Recommendations
The recommendations from this study indicate that it is not possible for nursing students to act as agents of change without the support of their nurse mentors in practice. Therefore, nurse leaders in all healthcare settings must demonstrate their commitment to public health by attending healthy conversation training and ensuring easy access to the training for all nurses, especially those providing mentoring services to students, while healthy conversation training should be included within nurse education.
KEY POINTS
- Nurses are well placed to engage in public health and health promotion activities as they experience direct patient contact as part of their healthcare role
- Healthy conversation skills are vital for the health promotion role of nurses
- Nurse leaders in all healthcare settings must ensure that all nurses, particularly nurse mentors, have access to healthy conversation training
- This training provides the skills and knowledge to support non-judgemental opportunistic conversations about health and wellbeing with patients
- Students struggle to use the skills in practice if their mentors are not knowledgeable or trained in healthy conversation skills.
CPD REFLECTIVE QUESTIONS
- Why is it important for nurses to move away from a health education style of practice to one with a health promotion focus?
- What are the social determinants of health and why is it vital that nurses are aware of their influence?
- Why should nurses make use of every patient interaction to discuss health and wellbeing in a non-judgemental way?
- How can mentors support students develop healthy conversation skills?