This article is the last in a series exploring the role of the nurse, midwife or other health professional in public health (Craig and Senior, 2018; Senior and Craig, 2019; Senior et al, 2019). This article will explore the tools that can be used in the Making Every Contact Count (MECC) approach.
As suggested in part 3 (Senior et al, 2019), the accumulation of small changes in individual lifestyle behaviours can create significant improvements in health (National Institute for Health and Care Excellence (NICE), 2014). Nurses are ideally placed to promote, advise on and support these small changes (Lawrence et al, 2016). As with any successful intervention, the nurse–patient relationship and the delivery of person-centered care are fundamental elements. Good communication skills that draw on both verbal and non-verbal communication and listening are paramount, leading to a trusting and supportive relationship whereby delicate and personal issues may be approached confidently by the health professional.
It is worth noting that individuals are more receptive to change during times that seem significant to them. It is beneficial to prompt changes when people are at their most receptive. Such times may be prompted by external events that disrupt prevailing patterns of behaviour. There are many times or events in an individual's life that may offer effective opportunities for intervention, such as religious holidays, or the start of the week, month or year. Positive or negative life events such as becoming a parent or losing a close relative may also be moments that prompt change (Hallsworth et al, 2016).
It is important that nurses understand what motivates people to change behaviours. Behaviour change models are helpful, as suggested in part 3 of this series (Senior et al, 2019) which discussed models set out by Becker (1974); Prochaska and DiClemente (1994) also used by the Royal College of Nursing (2016), and Michie et al (2011). There is also a drive for all nurses and other health professionals to use brief interventions (Public Health England, 2013; NICE, 2014) as discussed in part 2 (Senior and Craig, 2019).
The following tools offer useful guidance. They help frame the discussion, allowing for partnership working with the patient and their family and enabling the development of the knowledge, skills and confidence to manage and make informed decisions about their own health.
The first two discussion frameworks described below are useful when providing a very brief intervention, lasting 30 seconds to 2 minutes. The third tool is useful for brief and more extended interventions.
The three As intervention
This intervention uses the three As: ask, advice, assist (NICE, 2014). ‘Ask’ refers to asking if the patient is aware of or recognises a health issue. This can include, for example, asking a patient about their smoking status during a routine admission. The ‘advice’ stage is where the nurse advises them of the risks of their behaviour, for example, the risks of smoking and that smoking-cessation services can offer effective help to quit. Dependent on the patient's response, the nurse may then have the opportunity to ‘assist’ and refer the patient to other services such as an in-house specialist smoking cessation team, pharmacy staff or a practice nurse for ongoing support.
Motivational interviewing
Motivational interviewing is an effective counselling method that involves enhancing a patient's motivation to change through the resolution of ambivalence (Hall et al, 2012). Devised by Miller and Rollnick (2012), this simplified practice of motivational interviewing offers a solution to the challenge of delivering very brief interventions in healthcare settings as it enables the nurse to ‘tailor motivational strategies to the individual's stage of change’ as seen in the Prochaska and DiClemente (1994) transtheoretical model (Hall et al, 2012).
RULE is a useful mnemonic to use in motivational interviewing:
The righting reflex relates to the notion that health professionals want to ‘fix’ problems and tend to advise patients about the steps to take to attain good health. If a patient is ambivalent about making a behaviour change, they will often resist such persuasion and will provide reasons why they must maintain their current behaviour. Resisting the righting reflex requires the nurse to suppress giving advice and instead explore the patient's motivation for behaviour change.
This will lead on to ‘understanding your patient's motivations’ as, ultimately, a change in behaviour will only be successful if it is underpinned by what the patient wants to do. Exploring the patient's desires and concerns will enable identification of potential barriers.
‘Listen with empathy’ refers back to the essential communication skills required. During the discussion there should be equal amounts of time spent talking and listening.
‘Empowering your patient’ requires working in partnership with the patient to identify how they have achieved successful changes in the past and to look at how to achieve the desired behaviour change. The nurse should be encouraging and be optimistic that the patient can achieve their goal.
The FRAMES model
This model, by Miller and Sanchez (1993), takes the form of an extended intervention, initially created as a model for alcohol treatment. The approach has now been adopted to deliver a brief intervention lasting anywhere from 2 minutes to half an hour. The model, underpinned by motivational interviewing principles, allows for a deeper conversation with the patient in order to gain insight into health-related behaviours and lifestyle choices in order to motivate and support change. The acronym FRAMES means:
In this approach, giving feedback provides an opportunity to explore the patient's frame of reference, the risks and negative consequences that may arise from the current behaviour. For example, the patient may be unaware of the risks to their health and wellbeing from being overweight.
‘Responsibility’ brings the focus back to the patient, because the individual must first take responsibility for their health behaviour and then any decisions made about behaviour change.
‘Advice’ refers to the straightforward advice given to the patient about how to modify their current behaviour, giving the patient a vision of possible change.
The ‘menu of options’ is simply that—the nurse needs to be able to provide a range of behaviour change options/strategies that the patient can choose from. The nurse should explore with the patient how to manage risk and/or relapse situations and foster participation in the decision-making process.
As eluded to earlier, ‘empathy’ is fundamental. All interactions require an empathetic, respectful and non-judgmental approach.
Delivering such an approach with enthusiasm and positive reinforcement during the discussion will promote self-efficacy. Self-efficacy is a person's belief in their own ability to achieve goals. The nurse should express optimism that the individual can modify their substance use, diet, and so on, if they choose, and express confidence in their plans.
Conclusion
Nurses, along with midwives and other health professionals, are suitably placed to offer interventions that may improve the health and wellbeing of patients and their families. Three discussion frameworks have been explored to aid and assist with the goal of changing a patient's behaviour for the better in the MECC approach.
This series has identified the current drivers for MECC, highlighted the differing approaches to brief intervention, explored the theoretical underpinnings for behaviour change and offered some practical tools that will assist nurses in their routine daily practice.