Article Analysis 1

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H ealth promotion is an important part of a community nurse’s job role

(Lundberg et al, 2017). As a concept, health promotion has become more popular since the 1970s following a Canadian health report (Lalonde, 1974). Recent publications have shaped nurses understanding of health promotion (Polan and Taylor, 2019), defining this role as being able to empower patients to take control of their own health needs while enabling them to identify which aspects of their health are most important to them (Naidoo and Wills, 2016).

The prevalence of smoking means that almost every health and social care practitioner, including those in the community, will be involved in the treatment or management of conditions exacerbated by smoking. Smoking cessation continues to be

Smoking cessation and the health promotion role of community nurses

a goal for patients as they begin to understand the effects that smoking has on their overall health and wellbeing. It is likely that, previously, many patients were unaware of the future detrimental effects smoking would have on their health. However, there is now a movement towards preventing conditions before they develop or worsen.

BENEFITS OF STOPPING SMOKING

The benefits of smoking cessation are significant (Blomster et al, 2016; Baker et al, 2018; Barengo et al, 2019). Due to the high prevalence of smoking, community nurses care for many patients on a journey towards cessation. In the authors’ clinical opinion, they have one of the most important health promoting roles and are often involved in working in partnership with patients, highlighting how smoking cessation will be able to positively change their health. Tobacco smoking has many detrimental effects, causing it to be one of the main causes of mortality worldwide (Golechha, 2016). Smoking cessation benefits both physical and mental health. Taylor et al (2014) suggested that smoking cessation helps to relieve

symptoms of depression and anxiety, as well as improving overall psychological wellbeing.

ROLE OF COMMUNITY NURSES IN HEALTH PROMOTION

Health promotion applies to all nurses and healthcare professionals, regardless of which arena they specialise in (Raingruber, 2014). However, community nurses are often the first point of contact for many patients, so it could be argued that their health promotion role is one of the most crucial. Zandee et al (2010) studied the unique relationship between community practitioners and nursing students in promoting public health in urban areas. The research highlighted the positive health promoting outcomes of this relationship, which could be directly applied to the patient scenario included here (Mr Wilson’s care), whereby the first author was able to act independently as a health promoter under the guidance of a qualified and knowledgeable community nurse.

The Ottawa charter (World Health Organization [WHO], 1986), a founding health promotion document, identified three key roles that health promoters, including community nurses, could use to further advance their health promoting skills, namely:  Advocating  Enabling  Mediating.

Advocating is standing up for the needs of the individual and attempting to provide a healthy environment, such as a strong social background or economic conditions (Choi, 2015). Enabling is about striving to give people what they require to be successful and aims at

Tara Bright, second year adult nursing student; Teresa Burdett, senior lecturer in integrated health care, both at Bournemouth University

Community nurses are well placed to initiate health promotion, including the goal of smoking cessation. Changing health behaviours, including smoking, may be directly addressed by working collaboratively with patients to better understand their personal situation, with the hope of enabling them to engage in a productive manner in health promotion now and in the future (Lau-Walker, 2014). This paper critically discusses the first author’s health promotion role during her time as a community student nurse working in a community nursing team.

KEYWORDS:  Smoking cessation  Health promotion  Make every contact count (MECC)

Tara Bright, Teresa Burdett

SMOKING CESSATION

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ensuring people have equal access to the resources which allow them to pursue their best health (Hubley and Coperman, 2018). Finally, mediating concerns the idea that for health promotion to be successful it requires the cooperation of many groups, including the government, the healthcare sector and the media (WHO, 1986).

The Ottawa charter (WHO, 1986) has since been used to increase the population’s health potential (WHO, 2007). However, the question now is whether the charter remains as significant today (Vinko et al, 2016). Vinko et al (2016) identified that there are still many challenges to health promotion, including the obstacle of ensuring that there are enough sufficiently trained professionals. Thompson et al (2018) also concluded that there is still a way to go and that health promotion should be continually focusing on reducing the inequalities faced by the population, such as inadequate housing and poverty. These two factors clearly impacted on Mr Wilson in the patient scenario here.

Naidoo and Wills (2016) have highlighted three principles to help guide clinicians, such as community nurses, in their health promotion role to gain the best outcomes for patients, namely:  Participation  Collaboration  Equity.

Participation means the public playing a part in developing policies surrounding health promotion. A goal of partnership is ensuring that patients feel that they are able to contribute their own opinions. As a principle, partnership remains prevalent in recent literature (Gregory et al, 2018). This applies directly to Mr Wilson because the first author regularly enabled him to express his own wishes and ideas surrounding his goals around smoking cessation, thereby enhancing his own locus of control.

Collaboration is similar to the concept of participation, in that it is the process of healthcare professionals working together on

Patient scenario — Mr Wilson

As a student nurse, I had the privileged opportunity to experience community nursing first hand. The patients I met had health issues, which meant that they were unable to live independently and rarely left their own homes. For confidentiality, in accordance with the Nursing and Midwifery Council’s ‘Code of Conduct’ (NMC, 2018), the patient will be referred to as Mr Wilson to protect his identity and any personal data (Royal College of Nursing [RCN], 2016).

Mr Wilson, was visited twice a week so that the community nurses, including the first author, could advise him on self-management of his chronic obstructive pulmonary disease (COPD). Mr Wilson had always been a heavy smoker and said that he had tried unsuccessfully to stop multiple times. However, he believed that with the help of healthcare professionals he could stop. He was living in a top floor flat, which left him vulnerable should he ever need to get out. The flat itself was very cluttered and in a state of disrepair. Mr Wilson said that this was because his pension could not accommodate the repairs.

The first author recognised that Mr Wilson already had some motivation to change, but knew that she had not only to acknowledge the effects of smoking on his physical health concerning his COPD, but also to identify how his smoking was affecting his emotional, social and mental health and wellbeing. Conversations were initiated with Mr Wilson to gauge his understanding of the effects of smoking on his long-term health. By looking at all aspects of his situation, it became clear that smoking was also negatively affecting his family life. His daughter had recently given birth to a baby, Mr Wilson’s first granddaughter. However, due to his smoking, she was refusing to let him spend time with her.

Rather than being dependent on the community nurse, Mr Wilson would have loved spending more time going out with his family. The first author explained to Mr Wilson that with her mentor she would work in partnership with him towards enabling this goal to happen. Subsequently, short conversations were had with Mr Wilson at each visit about the positive effects that smoking cessation would have on his health. This also meant that he had time to think about the information he was being provided and could make his own informed decisions, and be the advocate for his own health. However, despite attempting to promote Mr Wilson’s health and wellbeing, due to the nature of the first author’s role, i.e. being a student, meant that her time in placement ended before being able to follow up on Mr Wilson’s progress. However, the community nursing team continued to work in partnership with Mr Wilson to help him reach his goals.

projects with the aim of achieving more large-scale goals, such as creating the most effective methods of health promotion (Naidoo and Wills, 2016). However, Meyer (2018) highlights that there are challenges to working in collaboration in nursing, explaining that with different stakeholders having diverse philosophies, mutual respect is required to provide the best patient care. By working in collaboration with Mr Wilson and demonstrating respect and empathy for his situation, it was

hoped that this would encourage him to open up about his feelings and make his own healthcare decisions.

Equity is about having equal access and parity to services and health care (Naidoo and Wills 2016). However, in the authors’ clinical opinion, more work is required to make this is a reality. Socio-economic factors need to be tackled to have a positive impact on the population’s health (Commission on Social Determinants of Health [CSDH],

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▼ Practice point The role of community nurses can often be the most central to health promotion because they are the professionals who have built up a rapport with patients and may be their first point of contact.

2008). While this report is useful for addressing the challenges of health equity, limitations have been noted. However, its validity is still relevant as Green et al (2019) identified that health care needs to tackle the effects of economic inequalities on a person’s health. For example, poor housing is likely to have a negative impact on a patient’s health and they will ultimately need more healthcare treatment, i.e. the various determinants of health, including social or economic factors, are equally influential (Scriven, 2017) on health as a patient’s behavioural choices. Thus, community nurses need to consider the individual situation and background of their patients before approaching health promotion.

A further principal, empowerment, has been defined by many experts throughout the years as giving patients control over their own behavioural change (Rogers, 1961; Yeh et al, 2018). The use of empowerment has been encouraged in health promotion to give people autonomy. By allowing them to take some responsibility, they develop an increase in skills and knowledge relating to their health (Powers et al, 2012). Despite this, there have been criticisms of using empowerment in health promotion. Tengland (2012) argued that the approach of empowerment in health promotion is time-consuming and therefore could cost the health service more overall. While government money may be saved if additional time is not spent with patients and they are not empowered, this will have little positive impact for the patients, directly contradicting the aims of health promotion. It is likely that patients who are not empowered to improve their health behaviours will develop more lifestyle-related

complications, increasing the burden on community nurses.

These ideas are directly relatable to Mr Wilson’s care because the community nursing team were striving to help him take control of his own health. Although the first author spent a considerable amount of time with Mr Wilson and provided him with research-based information about the effects of smoking on his health based on her training and knowledge, she did not go further and signpost him to other relevant information, but rather attempted to encourage him to be the advocate for his own health. If Mr Wilson had been readily provided with additional information, he would perhaps have been more likely to make his own decisions about what was right for him.

Todres et al (2009) said that nurses should be working to increase the autonomy of their patients, allowing them to have a greater choice and to share responsibility for decisions made. However, there will always be situations where this is not possible. For example, although receptive to health promotion advice and support, Mr Wilson had a long history of repeatedly trying to stop smoking without success.

Varley and Murfin (2014) also explained that a patient should only be approached at a time when they are ready and receptive to change, and that health promotors should not inflict their own suggestions of change onto patients (PHE, 2015b).

MAKE EVERY CONTACT COUNT

Recent guidelines known as ‘Making Every Contact Count’ (MECC) are regarded as a fundamental framework for staff to follow (Public Health England [PHE], 2016a). MECC is linked to the principle of empowerment and is defined as health and social care practitioners being confident to encourage people to change their health behaviours by delivering healthy lifestyle messages (PHE, 2016b). For a community nurse to provide the most effective health promotion, a set of skills are necessary. These include the use of

open discovery questions to allow the patient to further explore the topic, as well as spending more time listening to the patient, so they are able to make their own suggestions (PHE, 2015b).

Although MECC has been developed as the ideal standard for health promotion, in the authors’ clinical opinion, it is not easy for all community practitioners to adopt on top of their busy workloads. There are some limitations to the use of MECC. Nelson et al (2013) identified that one of the barriers to its success is practitioners’ view that adopting this method would increase workload. However, despite its challenges, MECC as a means of health promotion has been praised as being a valuable and flexible approach (Chisholm et al, 2018). That said, awareness of MECC still needs to increase. Keyworth et al (2018) found that only 41% of nurses and health visitors recognised the MECC consensus statement.

▼ MECC... The very nature of MECC means that the knowledge can be passed between practitioners to improve practice. The MECC programme is set up so that nurses or other healthcare professionals are able to attend the training and therefore become a trainer themselves to help reduce the number of people that have to be trained to implement MECC health promotion.  Have you ever considered

becoming MECC trained?  Have you or any of your

colleagues been MECC trained in the past?

 Do you know what training is available in and around your local area?

Further information about MECC training can be found on the ‘Training in MECC’ webpage at: www.makingeverycontactcount. co.uk/training/. This page has additional resources, including easily accessible e-learning and workbooks (Health Education England, 2019).

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REFLECTIONS ON PRACTICE — MR WILSON

When caring for Mr Wilson, it was important to consider the outside influences on his health, looking at his whole situation in depth, rather than just examining the effects of smoking as an individual behaviour.

The first author built up a positive professional relationship with Mr Wilson, which enabled her to understand him as an individual. This meant that he felt more open to sharing information. Indeed, DeVille-Almond (2013) found that forging a relationship with patients is one of the most effective ways for community nurses to facilitate behaviour change.

However, health promotion was a challenging new role for the first author to adopt, despite working under the supervision of her mentor and being helped with health promoting ideas beneficial to Mr Wilson. At a later visit with her mentor, it was decided to give Mr Wilson more information about services because he had chosen not to do so independently. This included the local stop smoking service, which aims to provide equal support to all patients using a variety of different methods, such as apps and websites which track progress and offer specialist advice (National Health Service [NHS] England, 2016; PHE, 2016b).

The educational approach to health promotion is when the practitioner provides knowledge and information which allows the patient to make informed choices about their care (Naidoo and Wills, 2016). It is likely that using such an approach motivated Mr Wilson further with wanting to change his behaviour. Hinchliff (2009) suggested that putting a patient in a positive

learning environment, builds a trusting relationship with the health promoter. In Mr Wilson’s case, this meant that he would have felt more able to express himself because he felt psychologically safe.

CONCLUSION

The promotion of a patient’s health and wellbeing is a vital aspect of health care. However, there are many challenges to this which are not within the healthcare arena, i.e. social determinants including poverty, unequal access to housing, food and health. Health promotion has emerged to tackle these inequalities. There is now a considerable amount of research to support both nurses and other healthcare professionals with providing the most effective health promoting care.

It is recognised that nurses should be trained in health promotion, but there is a conflict between putting limited funding into health promotion when funding challenges exist in other areas. However, change in health behaviours will benefit the patient and potentially save money for the National Health Service overall. Continual work within the health promotion arena can also significantly enhance integrated, person-centred care and help to ease pressures on community nurses and their teams.

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▼ Remember Further training will improve community nurse’s understanding of the facets of health promotion.

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▼ Practice point The nature of community nursing means practitioners working towards building partnerships with their patients.

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KEY POINTS  Patients’ health may be

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 Patients will be less reliant on the care of community nurses and primary practitioners and may seek out other care options which fit with their lifestyle.

 Not all community nurses need to undertake the additional training in health promotion, but can share their knowledge between themselves and thereby reduce their workload. This is relevant because NHS staffing pressures mean that community nurses are already limited with their time.

 Health promotion could save the NHS money by reducing the behavioural factors worsening long-term conditions, potentially reducing their need for treatment. For example, in 2015, smoking cost the NHS £2.6 billion (PHE, 2015a).

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