When and how to talk to a patient about their diet and lifestyle

Health promotion is an NMC requirement, but discussing weight can be difficult for nurses

• The emotive subject of a patient’s lifestyle and eating habits can be hard for nurses to approach
• NMC’s new proficiency standards require nurses to be competent in health promotion and prevention of ill health
• Experts offer advice on how to get the timing and tone of your health messages right for each patient

Broaching potentially difficult conversations about a patient’s lifestyle issues – such as diet – can be a daunting prospect for even the most experienced nurse.

But the proficiency standards the Nursing and Midwifery Council (NMC) introduced earlier this year are designed to help the whole profession get better at talking to patients about what they eat.

Health promotion and illness prevention

The NMC’s future nurse standards of proficiency for registered nurses set out the knowledge and skills nurses must demonstrate, whatever the setting.

One of the seven key areas of the standards is a focus on health promotion and preventing ill health.

• RELATED: Nursing and Midwifery Council publishes new proficiency standards

Part of this requirement is that nurses ‘identify and use all appropriate opportunities’ to discuss the impact of various lifestyle factors, including smoking, drinking and diet, on the individual's mental and physical health and well-being.

There's no doubt that poor nutrition has a major effect on public health, increasing the risk of cardiovascular disease, some types of cancer and type 2 diabetes.

Two thirds of UK adults are obese or overweight

A diet high in sugar and saturated fats, coupled with lack of exercise, can lead to obesity, which is a major public health challenge.

RCN professional lead for public health nursing Helen Donovan says: 'In terms of life expectancy, it affects so many different areas.'

Ms Donovan notes the growing incidence of obesity, with two thirds of UK adults either overweight or obese.

She says having a clear requirement in the standards for nurses to talk to patients about lifestyle – particularly diet – is a 'big plus'.

'It is new for nurse education to have this requirement so clearly defined and it is something we have been pushing for, from a public health perspective,' she explains. ‘It is an opportunity for nursing students to understand these issues.

'Having this whole area of health promotion and prevention in the NMC standards, we need to embrace it and think about it from a public health point of view and help people stop getting unwell in the first place.’

Campaigns and public health messages

Yet, striking the right tone in conveying public health messages is fraught with difficulty.

In July, Cancer Research UK drew criticism for its public awareness campaign based on the slogan ‘Obesity is a cause of cancer too’, presented in the style of a cigarette packet health warning. The point of the campaign was to highlight that obesity causes more cases of certain cancers than smoking. 

• RELATED: Readers’ panel: Is a reluctance to upset people contributing to the ‘normalisation’ of obesity?

When it comes to conversations between nurses and patients, just telling people they need to do more exercise and eat less, or more healthily, is too simplistic an approach, according to Ms Donovan.

‘A lot of health professionals’ default position is “we will just get that info in now” because that is what we need to do to.’

Gauging a patient’s receptiveness

She says nurses need to switch around this thinking and instead work with what, overall, is important to that person.

‘It is easy to talk to people about their health and to say “you need to do this, that or the other”, but we know there is lots of evidence you are wasting your time.'

Ms Donovan says nurses need to be skilled in holding conversations, talking to people at a time when they are ready and receptive to hear the messages.

• RELATED: Health promotion approaches

‘So for example, if people are eating too much and certain triggers, like key time of day, lead them to have something sweet and sugary, how can we work with them to do something else?

‘From a nursing point of view, we are wanting nurses to recognise these external influences as well those wider determinants of health.

‘While none of this is new, it is about trying to embed it from an early stage in people’s careers.’

Resources to support behaviour change

Ms Donovan recommends all nurses use an RCN resource on supporting behaviour change, which includes information about motivational interviewing.

This technique uses a ‘guiding’ style to engage people and help them find internal motivation for change, which has proved to be more effective than simply delivering or imposing advice.

Clinical trials have shown that patients exposed to motivational interviewing are more likely to enter, stay in and complete treatment, participate in follow-up visits, reduce alcohol and illicit drug use and quit smoking. 

Motivational interviewing: four essential principles

R – Resist the urge to change the individual’s course of action through didactic means, ie, teaching the ‘right way’ or method

U – Understand it is the individual’s reasons for change, not those of the practitioner, that will elicit a change in behaviour

L – Listening is important; the solutions lie in the individual, not the practitioner

E – Empower the individual to understand they have the ability to change their behaviour.

(Rollnick et al 2008)

RCN motivational interviewing resource 

Five techniques to help you support behaviour change

The RCN's online resource for supporting behaviour change looks at how nurses can use motivational interviewing techniques to help patients talk about and make positive changes. Tips include:

1. Ask open ended questions

Asking too many closed or dead-end questions can make a conversation feel like an interrogation, but open questions allow patients to tell their stories. They encourage the patient to do most of the talking. Examples include: ‘tell me what has happened since we last met’, or ‘what makes you think it might be time for a change?’

2. Listen reflectively

Listen to patients, then repeat or paraphrase their comments back to them, for example, ‘it sounds like you’re not ready to…’. Reflection helps confirm what the client is feeling and communicates that you understand what they have said. 

3. Affirm and clarify

Affirmation shows you understand and empathise with your patient's struggles. It allows you to build on their strengths and past successes, improving their sense of well-being. Clarifying shows you are listening and gives the patient an opportunity to hear what you think they said, and to respond to it.

4. Summarise

Relating or linking what patients have already expressed is an excellent way of expanding the discussion. 

5. Elicit self-motivational statements

It is your patient who must have the confidence in their ability to change, not you.

RCN supporting behaviour change resource 

Undergraduate curriculum

From this September, all adult, children’s and mental health nursing students at Sheffield Hallam University will be taught how to use motivational interviewing to support behaviour change.

The method has been taught to post-registration nursing students on the university's specialist community public health nursing programme over the past eight years.

Senior lecturer in adult nursing and specialist community public health nursing Gayle Hazelby says she is optimistic about the benefits of bringing motivational interviewing training into the broader curriculum.

She says: ‘We have just undertaken some research with specialist community public health nursing students and there is evidence motivational interviewing is making a difference to their practice and resulting in more sustained behaviour change.’

And as a health visitor, Ms Hazelby believes the new NMC health promotion and illness prevention requirement is important.

She adds: 'I come from a prevention and early intervention perspective. These standards move towards a social model of health and raising people’s awareness of the wider determinants of health and how that is affecting lifestyle choices and behaviour.’

Introducing training in higher education

However, Ms Donovan cautions there is likely to be some variation in how the issue is approached in higher education generally.

• RELATED: Why communication is important 

‘It is probably fair to say we are still not quite sure how this is going to come into the curriculum and who will be teaching it,' she says. ‘It will depend which universities have a real bias and bent towards public health promotion and health.

‘What we need to do is have conversations with people and diet is absolutely fundamental to that.’

Further information

• Future nurse: standards of proficiency for registered nurses
• Nutrition and hydration resources from the RCN
• Research from Sheffield Hallam University on using motivational interviewing in public health nursing