Key learning points:
- Nurses don’t always have a structured approach in promoting exercise
- Simply talking to patients can make them more aware of their health behaviour
- Motivational interviewing has proven successful in encouraging exercise
The rising prevalence of obesity and preventable chronic disease has led to global concern about physical inactivity. There is increasing attention on how to promote active lifestyles through multiple settings and agencies and how these efforts should be maintained across the lifecourse. Engaging in regular physical activity, even on a relatively small level, can reduce the risk of more than 20 chronic conditions including coronary heart disease, stroke, type 2 diabetes, obesity, some cancers, musculoskeletal conditions and mental health problems. Promoting physical activity across the lifespan is therefore essential for lifelong wellbeing and reducing the burden of disease. Reducing excessive sedentary behaviour (time spent sitting or lying down) is equally as important, since it is not only associated with overweight and obesity as risk factors for chronic disease, but is an independent risk factor for ill-health, irrespective of a person’s overall level of physical activity.
The role of nurses
Community and primary care nurses are at the forefront of population healthcare and the role of the nurse has significantly evolved to include preventive care, health coaching and chronic disease management.
Primary care practitioners do demonstrate enthusiasm for physical activity promotion. A study conducted in Scotland1 showed that the majority of practice nurses (88%) and health visitors (90%) surveyed would be likely to recommend all apparently healthy adult patients to take moderate exercise. However, their knowledge about recommendations and physical activity promotion appears to be inadequate. Only 9% of practice nurses and 11% of health visitors correctly described current physical activity recommendations for adults. While a study in England found that nurses did not have a structured approach when promoting physical activity to older people, and had limitations in their knowledge and skills of physical activity promotion.2
This is further complicated by recent changes in UK physical activity guidelines from the Department of Health and NICE.3 Although general knowledge about them was shown to have increased, disadvantaged population groups seem to be less knowledgeable,4 further demonstrating the need for healthcare professionals to be fully informed.
What nurses can do
Simply talking to patients about how active they are in everyday life can trigger awareness about personal health behaviour. Nurses can play an important role in inspiring and motivating patients to adopt positive attitudes, and providing support when patients have negative attitudes, or naturally occurring lapses.
Nurses may draw on national educational initiatives (eg Change4Life), where the key message is to eat well, move more and live longer, and use it as a basis for assessment and advice. Discussions with patients should focus on identifying and addressing barriers, encouraging patients to set achievable goals and monitor their achievements. They should aim to build an individual’s self-efficacy (or confidence) for activity, which is important in making lasting behavioural changes.
Clinical judgment should always be used alongside recommendations. Activity goals must be realistic and sensitive to culture and personal factors. Changes in activity for some may be as simple as chair-based exercises, or incremental increases in activities of daily living such as housework, gardening, or using the stairs. Nurse-led activity interventions in primary care are diverse, but examples include walking interventions5 and health coaching telephone calls.6
Who you should be targeting
The majority of adults and many children are insufficiently active. As such, every opportunity should be taken to discuss and assess physical activity with all patients. NHS England advocates ‘making every contact count’ and provides advice on how to implement this concept, with practical tools and resources.7 Particular care should be taken when advising vulnerable groups (eg older adults, children and those with cognitive impairment), while health inequalities means that some population subgroups may warrant particular attention.
Physical activity levels are known to reduce during adolescent years and the transition into young adulthood, and in general, women are less active than men which may be associated with the onset of family responsibilities, pregnancy or the menopause. Physical inactivity and obesity are known to be higher in certain ethnic minority groups, and are often higher in people living in low-income households, and in people with lower levels of education.
The recommended activity
There is guidance from the chief medical officer on the volume, duration, frequency and type of physical activity required across the lifespan to achieve general health benefits.8 Current guidelines recognise the importance of lifelong daily physical activity, allow greater flexibility for how recommendations might be achieved, describe the role of both moderate and vigorous activity (and how they might be combined), and advocate minimising sedentary behaviour. While the nurse should tailor advice on a case-by-case basis, it is proposed that all individuals should aim to engage in at least the appropriate level for their age.
The guidance covers:
- Early years (under five years): Physical activity is encouraged from birth, particularly through active play and water-based activities; those capable of walking unaided should be physically active daily for at least 180 minutes, spread throughout the day.
- Children and young people (five-18 years): All should engage in moderate to vigorous physical activity daily for at least 60 minutes and up to several hours. Vigorous intensity activities, including those that strengthen muscle and bone, should be incorporated on at least three days per week.
- Adults (19-64 years): All should be active daily and accumulate at least 150 minutes of moderate-intensity activity, or 75 minutes of vigorous activity (or moderate and vigorous activity combined), in bouts of 10 minutes or more over a week. Activity to improve muscle strength should be undertaken on at least two days per week.
- Older adults (65+ years): Should aim to be active daily, accumulating at least 150 minutes of moderate-intensity activity in bouts of 10 minutes or more over a week. For those already active at moderate intensity, comparable benefits might be achieved through 75 minutes of vigorous-intensity activity spread across the week or a combination of moderate and vigorous activity. Activity to improve muscle strength should be undertaken on at least two days a week; those at risk of falls should incorporate activity to improve balance and co-ordination on at least two days a week.
More interventions
NICE guidelines for treating over-65s9 and for adults3 recommend health professionals do the following:
- Identify adults who are inactive. This could be done during consultations, waiting times, health checks or a session for management of a long-term condition. Activity levels should be (sensitively) assessed and recorded, using validated tools.
- Deliver brief advice and follow up. Adults assessed to be not meeting the recommendations should be encouraged to increase their activity levels, as appropriate to their health status, circumstances and preferences. Local opportunities should be promoted, such as gyms and sports centres, exercise classes and walking groups. A record should be kept of discussions and the patient given a written summary of advice and goals; these should be followed up at future opportunities.
- Incorporate brief advice into commissioning. Brief interventions on physical activity should be incorporated in care pathways for chronic conditions (eg coronary heart disease, stroke, type 2 diabetes and mental health problems) and services for populations at risk of inactivity (eg over-65s, those with disabilities or those from ethnic minority groups).
- Have systems to support brief advice. Read codes will help to identify opportunities for assessment and advice. Keep up-to-date details about local facilities. Standardised assessment tools such as the General Practice Physical Activity Questionnaire (GPPAQ) will equip nurses with the knowledge to identify and monitor those who are inactive and make recommendations.
- Training requirements for primary care practitioners. This should cover: definitions of physical activity and current guidance; ‘at-risk’ populations; physical activity assessment; understanding misconceptions about physical activity; best methods of delivering brief advice and motivating behaviour change.
Very brief interventions are gaining popularity because of their scalability and practicality. Pears et al10 have demonstrated the acceptability and feasibility of four very brief interventions, all of which take around five minutes to deliver in a primary care preventive health check:
- Motivational intervention.
- Action planning intervention.
- Pedometer intervention.
- Physical activity diary intervention.
Motivational interviewing techniques have demonstrated positive outcomes for adopting and sustaining new behavior. The aim is to help patients to consider their actual health behaviour, and their desired behaviour. Patients are encouraged to focus on the improvements they can make for themselves, and to set their own goals, rather than being instructed on what to do. The interviewing techniques can be challenging to apply, and booster sessions following initial training might help.
References
1. Douglas F, van Teijlingen E, Torrance N et al. Promoting physical activity in primary care settings: health visitors’ and practice nurses’ views and experiences. J Adv Nurs 2006;55:159-68.
2. Goodman C, Davies SL, Dinan S et al. Activity promotion for community-dwelling older people: a survey of the contribution of primary care nurses. Br J Community Nurs 2011;16:12-7.
3. NICE. Physical activity: brief advice for adults in primary care. May 2013. nice.org.uk/guidance/ph44/resources/physical-activity-brief-advice-for-adults-in-primary-care-1996357939909 Accessed 22 September 2016.
4. Knox EC, Esliger DW, Biddle SJ et al. Lack of knowledge of physical activity guidelines: can physical activity promotion campaigns do better? BMJ Open. 2013;3):e003633. doi: 10.1136/bmjopen-2013-003633.
5. Beighton C, Victor C, Normansell R et al. It’s not just about walking…..it’s the practice nurse that makes it work: BMC Public Health 2015;15:1236. doi: 10.1186/s12889-015-2568-6.
6. Eakin EG, Hayes SC et al. Healthy Living after Cancer: a dissemination and implementation study evaluating a telephone-delivered healthy lifestyle program for cancer survivors. BMC Cancer 2015;15:992. doi: 10.1186/s12885-015-2003-5.
7. NHS England. Making Every Contact Count 2014. england.nhs.uk/wp-content/uploads/2014/06/mecc-guid-booklet.pdf Accessed 22 September 2016.
8. Department of Health (2011). Start Active, Stay Active: A report on physical activity from the four home countries’ Chief Medical Officers. 11 Jul 2011 gov.uk/government/uploads/system/uploads/attachment_data/file/216370/dh_128210.pdf Accessed 21 September 2016.
9. NICE. Mental wellbeing in over 65s: occupational therapy and physical activity interventions, October 2008. nice.org.uk/guidance/ph16 Accessed 22 September 2016.
10. Pears S, Morton K, Bijker M et al. Development and feasibility study of very brief interventions for physical activity in primary care. BMC Public Health 2015;15:333.
