The impact of a team-based intervention on the lifestyle risk factor management practices of community nurses: outcomes of the community nursing SNAP trial

BMC Health Services Research The impact of a team-based intervention on the lifestyle risk factor management practices of community nurses: outcomes of the community nursing SNAP trial Bibiana C Chan 0 Upali W Jayasinghe 0 Bettina Christl 0 Rachel A Laws 2 Neil Orr 1 Anna Williams 0 Kate Partington 3 Mark F Harris 0 0 Centre for Primary Health Care and Equity, University of New South Wales , Sydney , Australia 1 Centre for Epidemiology and Evidence, New South Wales Ministry of Health , Sydney , Australia 2 Centre for Physical Activity and Nutrition Research, Deakin University , Melbourne , Australia 3 South West Sydney Local Health District , Sydney , Australia Background: Lifestyle risk factors like smoking, nutrition, alcohol consumption, and physical inactivity (SNAP) are the main behavioural risk factors for chronic disease. Primary health care is an appropriate setting to address these risk factors in individuals. Generalist community health nurses (GCHNs) are uniquely placed to provide lifestyle interventions as they see clients in their homes over a period of time. The aim of the paper is to examine the impact of a service-level intervention on the risk factor management practices of GCHNs. Methods: The trial used a quasi-experimental design involving four generalist community nursing services in NSW, Australia. The services were randomly allocated to either an intervention group or control group. Nurses in the intervention group were provided with training and support in the provision of brief lifestyle assessments and interventions. The control group provided usual care. A sample of 129 GCHNs completed surveys at baseline, 6 and 12 months to examine changes in their practices and levels of confidence related to the management of SNAP risk factors. Six semi-structured interviews and four focus groups were conducted among the intervention group to explore the feasibility of incorporating the intervention into everyday practice. Results: Nurses in the intervention group became more confident in assessment and intervention over the three time points compared to their control group peers. Nurses in the intervention group reported assessing physical activity, weight and nutrition more frequently, as well as providing more brief interventions for physical activity, weight management and smoking cessation. There was little change in referral rates except for an improvement in weight management related referrals. Nurses' perception of the importance of 'client and system-related' barriers to risk factor management diminished over time. Conclusions: This study shows that the intervention was associated with positive changes in self-reported lifestyle risk factor management practices of GCHNs. Barriers to referral remained. The service model needs to be adapted to sustain these changes and enhance referral. Trial registration: ACTRN12609001081202 Primary health care; Community nursing; Lifestyle risk factor management; Barriers - Background Lifestyle risk factors such as smoking, poor nutrition, atrisk alcohol consumption and physical inactivity (SNAP) have been identified as the main preventable risk factors for chronic diseases worldwide [1]. Reducing the prevalence of these risk factors in the population is important given that chronic disease accounts for more than 60% of the overall global burden of disease [2]. It is well recognised that to reduce the prevalence of behavioural risk factors, a wide range of interventions are required, be they related to policy, the environment or health service intervention. Primary health care (PHC) has been identified as a suitable setting to address behavioural risk factors. This relates to its accessibility and its capacity for repeated contacts with clients, which provides an opportunity to assess lifestyle risk factors, monitor progress and refer to other health professionals [3]. The evidence suggests that PHC can be appropriate for the delivery of brief lifestyle interventions as it has been shown to improve the rate of smoking cessation [4] and reduce at-risk alcohol consumption [5]. Moderate to high intensity interventions provided through PHC also show promise for improving weight, diet and physical activity for those at high risk of developing or progressing in chronic disease [6-8]. Despite the beneficial effects of risk factor management, brief lifestyle interventions are rarely implemented in PHC. It appears that assessment for lifestyle risk factors does not occur routinely and only a minority of clients receive any intervention in PHC relating to the prevention or management of chronic disease [9-12]. Furthermore, lifestyle interventions tend to be limited to asking and advising on the risks of the behaviour rather than providing assistance, referral and follow-up (the essential components of a behavioural risk modification intervention) [13-15] (Figure 1). Much of the focus of research on lifestyle risk factor management in Australian PHC has been in general practice, with little attention being paid to the other PHC settings. In 2011 there were 13,939 nurses employed in state funded community health services compared to a total of 12 576 health professionals employed in general practice [16]. Nurses working for community health services are employed in different roles across the sector. GCHNs provide care for patients recently discharged from hospital, the aged and those with chronic diseases. Although their role has been poorly researched they are in a strong position to offer lifestyle risk factor management as they [17-19]: 1. Usually see clients in their own home, allowing them to develop a broader understanding of the clients family and home environment that may benefit from lifestyle change; Assessment for SNAP risk factors as part of the routine assessment process Assessment of clients readiness to change Provide feedback on SNAP risk factors and brief advice regarding recommendations Brief stage-matched counselling for lifestyle change over at least 2 visits Refer to support services for more intensive intervention (especially high-risk clients) Follow up progress at subsequent visits Stage-matched assistance for lifestyle change Preparation/action: goal setting /action planning reinforcement, relapse prevention Figure 1 5As model of brief lifestyle intervention using the transtheoretical model of behaviour change. 2. usually have ongoing contact with patients; 3. may reach disadvantaged populations who would otherwise have limited contact with GPs; and 4. have a strong professional ethic which privileges holistic care over a strict medical model. Our previous work has demonstrated that there is a significant need for brief lifestyle interventions among the clients of GCHNs, as they carry a large burden of chronic disease and associated risk factors and these clients may also be open to changing their risk-related lifestyle practices [20]. In our previous research, we argued that to in (...truncated)