Health promotion is a key element of nursing practice, with the UK nursing regulator, the Nursing and Midwifery Council (NMC) (2018) expecting registrants, regardless of role, area of practice or position, to promote health and wellbeing at every opportunity. Health promotion should be a priority for communities, governments and health care at strategic levels. The latest figures from the NMC show there are 765 051 nurse registrants in the UK (NMC, 2024). They have an opportunity to make a difference to population health by leading in lifestyle approaches to health, health promotion and disease prevention and reversal.
Health care in the UK is changing in response to an increasing number of people living with chronic diseases and multiple, often long-term, conditions. With a stronger focus on person-centred evidence-based practice and care delivery, nurses leading in the area of health promotion based on lifestyle approaches and interventions have an opportunity to make and encourage change in people's lives.
The Institute of Medicine's The Future of Nursing report suggests that there is a need for nurses to take on leadership roles to address changes and challenges in health and social care (Institute of Medicine, 2011). There is growing demand for less institutionalised care, requiring well-educated nurses who can operate as vital members within multidisciplinary care teams and demonstrate leadership within the lifestyle approach movement. The definition of health proposed by Huber et al (2011) highlights the need for people to self-manage in the face of challenges, whether they be social, physical or emotional, adapting behaviours where needed. This definition refines and adds to the World Health Organization's (WHO) seminal definition of health as ‘a state of complete physical, mental, and social well-being’ (WHO, 1948).
Health promotion, lifestyle approaches and population health
According to the WHO (2023), 41 million people die each year from non-communicable diseases, which it highlights is equivalent to 74% of all deaths globally. Non-communicable diseases, such as diabetes and cancer, are chronic diseases that tend to be of long duration and are the result of a combination of genetic, physiological, environmental and behavioural factors (WHO, 2023). The main types of non-communicable diseases are cardiovascular diseases, cancers, chronic respiratory diseases and diabetes, with many of these conditions being exacerbated or even caused by lifestyle choices and behaviours such as alcohol use, tobacco use, physical inactivity, and unhealthy diets (WHO, 2023). One way to tackle some, if not all, of these, is through health promotion based on a lifestyle approach.
Lifestyle medicine refers to changes and modifications to a person's way of living, an approach that has gained increased recognition in recent years (Fallows et al, 2023; Shurney, 2023). According to the British Society of Lifestyle Medicine (2024):
‘Lifestyle medicine is evidence-based clinical care that supports behaviour change through person-centred techniques to improve mental wellbeing, social connection, healthy eating, physical activity, sleep, and minimization of harmful substances and behaviours.’
British Society of Lifestyle Medicine, 2024
Changes to lifestyle can positively influence multiple health conditions and overall wellbeing, leading to a growing endorsement of such strategies in global policy and research (Razavi et al, 2014; Harvey et al, 2020). Lifestyle interventions are most effective when they are not daunting. Minor and manageable changes are much more achievable, and are said to grant people a sense of purpose, accomplishment and achievement (Almansour et al, 2023).
Lifestyle nursing
According to several studies (Wilhelmsson and Lindberg, 2009; Rubio-Valera et al, 2014; Moreno-Peral et al, 2015; Phelan et al, 2018), community nursing, as one example, is an area where health promotion and lifestyle approaches may be missed, despite community nurses being ideally placed to be at the forefront of this movement and approach in nursing.
In the USA, lifestyle nursing is a growing trend (Merlo and Berra, 2022). This is because nurses occupy a strategic position that allows them to have a significant impact on people's health because their existing responsibilities involve educating patients about treatments, medications, conditions and so on.
Operating on the healthcare frontline, UK nurses – whether in schools, the community, GP practices, clinics, hospitals or industry – lead and drive lifestyle changes and approaches, and influence healthcare strategies. In their daily interactions, nurses establish trusting and non-judgmental relationships with people, gaining information about people's lives and families, including their occupations, housing situation and problems, and are therefore in a perfect position to consider the social determinants of health when encouraging lifestyle modifications and changes.
In the USA, the American College of Lifestyle Medicine (https://lifestylemedicine.org) and the UK's British Society of Lifestyle Medicine (https://bslm.org.uk) promote the role of lifestyle medicine in improving people's health and wellbeing Both organisations recognise the potential and opportunity nurses have in this area.
Consensus exists regarding the positive impact of lifestyle approaches such as regular physical activity, stress management, a nutritious diet, and avoidance or reduction of the intake of harmful substances such as tobacco and alcohol on overall health and disease prevention (Heidke et al, 2020). Nurses are ideally positioned to positively exemplify these behaviours and play a crucial role in health promotion and education related to modifiable risk factors for chronic diseases. This was highlighted by the International Council of Nurses (2010), with the goal of nurses being role models in addressing chronic conditions.
Leadership approaches
A compassionate, collective, clinical leadership approach is needed for lifestyle interventions. A collective leadership approach involves nurses and patients sharing responsibility for the success of patient care, rather than nurses taking a hierarchical prescriptive approach (Silva et al, 2022).
Kemppainen et al (2013) and, more recently, Phelan et al (2018) both suggest that nurses often miss health promotion opportunities or do not participate in health promotion for the people and communities for whom they provide care. This is, of course, a cause for concern and a considerable missed opportunity. However, this is challenged by Stanulewicz et al (2019) in their recent systematic review, who suggested that nurses are at the forefront of health promotion via lifestyle interventions and approaches, spending substantial time on this element of their care delivery to people and communities. With the correct education, knowledge, understanding and leadership skills, nurses can have a positive impact on people, communities, health and health care if they take a proactive approach, encompassing lifestyle nursing in their everyday practice and interactions.
Motivational interviewing
Wild and McGrath (2019) highlight six key areas that can have a positive impact on health promotion, on which nurses can focus:
- Health protection (such as protecting a local community from disease by encouraging parents to have their children vaccinated)
- Health care (for example, providing care for patients with specific problems, such as setting up leg ulcer clinics)
- Supporting health and wellbeing (such as encouraging patients to maintain a healthy weight during health checks)
- The life course: being aware of the different challenges patients face at different ages
- Health improvement (encouraging patients to take steps to improve their health, such as giving up cigarettes)
- Wider health and social determinants (understanding that poverty, poor housing and lack of job opportunities, for example, also affect health, and encouraging people to access other organisations for help, such as foodbanks or Citizens Advice).
Nurses can advance their leadership abilities in health promotion and lifestyle change through motivational interviewing. This is a well-recognised model based on person-centred evidence-based practice (Wild and McGrath, 2019; Nicol and Hollowood, 2019; Bennett and Lillyman, 2020; Wills, 2022). Wild and McGrath (2019) highlight that motivational interviewing is based on encouraging people to consider and explore how they feel about making changes to their lifestyle and then grants them the time to facilitate self-motivation. The key to the model's success is excellent communication skills (Wills, 2022).
The skills nurses need for motivational interviewing are:
- Asking open questions that prevent people from simply replying with ‘yes’ or ‘no’
- Having active and reflective listening skills (reflecting on what and why people are saying what they are) and
- Being able to ‘resist resistance’. Having the ability to carry on the conversation even when the person is showing resistance to the questioning or conversation flow (Bennett and Lillyman, 2020).
Self-motivation is a key element to motivational interviewing and occurs as people make decisions themselves about whether and when to make changes to their lifestyle, which avoids paternalistic and authoritarian approaches.
Nurses practising compassionate leadership relating to motivational interviewing will appreciate why people can or cannot make lifestyle changes, as well as highlighting the skills, abilities and opportunities the person has to make changes without any support or intervention. It is then up to the nurse, using his or her knowledge of lifestyle change, to guide the conversation to motivate the person by explaining how the person's skills, abilities and attributes can be best used to make small, important lifestyle changes through SMART goals. SMART goals are small, measured, achievable, realistic and timely, as described by Ryan (2015).
Much of the literature emphasises that the nurse's role in motivational interviewing is to understand and appreciate a person's reasons for resistance or acceptance of a change to their lifestyle (Wild and McGrath, 2019; Nicol and Hollowood, 2019). After this understanding is achieved through active listening (Haley et al, 2017), it requires nurses to use their clinical leadership skills to empower people, placing the person in question at the centre of the intervention and conversation. However, Bennett and Lillyman (2020) point out that, although the person in question is at the centre of the intervention, it is the nurse's role to establish the conversation flow and direction. A person might not have the same level of education and knowledge as the nurse on health promotion and good lifestyle changes and choices. And, similarly, the nurse will not have the full insight into and appreciation of the person's choices in life and influencing factors unless the time is taken by both to share and understand one another's views and perspectives.
Motivational interviewing is based on work by Prochaska and Diclemente (1986). The nurse must identify where and when a person might be ready to make a change and a transition within the stages of a change model. The model by Prochaska and Diclemente is seminal and is still used today; however, newer models are available such as the behaviour change wheel (Michie et al, 2011), which encompasses behaviour, intervention and policy categories. Discussing this with the person is key to allowing them to understand where they are on their journey to changing their lifestyle and improving their symptoms. The nurse can then guide the conversation using questions, reflections, prompts and suggestions.
An example of an approach using motivational interviewing in practice is Making Every Contact Count, an evidence-based model (Lawrence et al, 2016) that highlights and ensures that what is important to a person is the focal point of any conversation.
Advancing leadership practice
Nurses can advance their leadership abilities and practices in the areas of compassionate, collective and clinical leadership by using motivational interviewing to assist, encourage and guide people to make changes to their health and subsequently their lives. To be successful, nurses need the knowledge and understanding of what motivational interviewing is, why it is used and why it works, as well as how to practise the method, for example using a recognised change model (Prochaska and Diclemente 1986; Michie et al, 2011), to first identify a person's views about making a change. Gaining this knowledge of motivational interviewing will advance the clinical leadership of nurses who can then use this knowledge to conduct motivational interviews with people they support and also to educate and pass that knowledge on to team members and fellow nurses.
Being compassionate and taking a collective approach will be the key to motivational interviewing because it will allow people to feel that the conversations nurses are having with them and the interventions they make are putting them at the centre of the approach. People will have reasons and factors that influence them and their ability to make changes to their lifestyle. Nurses who take a collective and compassionate leadership approach will be able to show they can relate and understand this, avoiding a lack of trust or resistance. By practising compassionate and collective leadership to promote lifestyle change, nurses can dramatically enhance and advance their leadership practice for individuals, communities, healthcare systems and governments, as well as for themselves and their colleagues.
Conclusion
The number of people living with long-term chronic conditions in the UK is rising, particularly as the population ages. Healthcare providers need the education, knowledge and leadership skills to be able to encourage, support and guide people to make lifestyle changes that will benefit their overall health. Thanks to advances in research into many chronic conditions and lifestyle issues, there is a clear link between lifestyle choice and health status, which works both ways, with negative choices harming health and, likewise, positive choices leading to positive change. Nurses need to understand why some problematic choices are made in the first place, including the contributing and influencing factors, and the root causes.
Nurses are at the forefront of person-centred care, and they can advance their leadership skills through lifestyle nursing. Lifestyle nursing is a movement about being the best health promoters possible, with a proactive rather than reactive approach to health. Using clear, evidence-based models such as motivational interviewing can be the key for nurses to thrive in the area of lifestyle change. By taking a compassionate and collective approach, nurses can have a vital role to play in making positive changes to people's lives.
KEY POINTS
- Worldwide, around 41 million people die each year from non-communicable conditions
- Lifestyle approaches to nursing are key to having a positive impact on an individual's health and wellbeing, but also have a wider impact on communities and societies
- Compassionate, collective, clinical leadership approaches are key for lifestyle nursing opportunities
- Motivational interviewing is one of many interventions that nurses can consider when advocating for lifestyle and behaviour changes
CPD reflective questions
- Reflect on the challenges to lifestyle approaches. How could you overcome them?
- Consider the language that you use to explain lifestyle approaches to highlight its importance to patients
- What additional learning have you identified that you require regarding lifestyle nursing?