The impact of a brief lifestyle intervention delivered by generalist community nurses (CN SNAP trial).

BACKGROUND: The risk factors for chronic disease, smoking, poor nutrition, hazardous alcohol consumption, physical inactivity and weight (SNAPW) are common in primary health care (PHC) affording opportunity for preventive interventions. Community nurses are an important component of PHC in Australia. However there has been little research evaluating the effectiveness of lifestyle interventions in routine community nursing practice. This study aimed to address this gap in our knowledge. METHODS: The study was a quasi-experimental trial involving four generalist community nursing (CN) services in New South Wales, Australia. Two services were randomly allocated to an 'early intervention' and two to a 'late intervention' group. Nurses in the early intervention group received training and support in identifying risk factors and offering brief lifestyle intervention for clients. Those in the late intervention group provided usual care for the first 6 months and then received training. Clients aged 30-80 years who were referred to the services between September 2009 and September 2010 were recruited prior to being seen by the nurse and baseline self-reported data collected. Data on their SNAPW risk factors, readiness to change these behaviours and advice and referral received about their risk factors in the previous 3 months were collected at baseline, 3 and 6 months. Analysis compared changes using univariate and multilevel regression techniques. RESULTS: 804 participants were recruited from 2361 (34.1%) eligible clients. The proportion of clients who recalled receiving dietary or physical activity advice increased between baseline and 3 months in the early intervention group (from 12.9 to 23.3% and 12.3 to 19.1% respectively) as did the proportion who recalled being referred for dietary or physical activity interventions (from 9.5 to 15.6% and 5.8 to 21.0% respectively). There was no change in the late intervention group. There a shift towards greater readiness to change in those who were physically inactive in the early but not the comparison group. Clients in both groups reported being more physically active and eating more fruit and vegetables but there were no significant differences between groups at 6 months. CONCLUSION: The study demonstrated that although the intervention was associated with increases in advice and referral for diet or physical activity and readiness for change in physical activity, this did not translate into significant changes in lifestyle behaviours or weight. This suggests a need to facilitate referral to more intensive long-term interventions for clients with risk factors identified by primary health care nurses. TRIAL REGISTRATION: ACTRN12609001081202.

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

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.

Is there scope for community health nurses to address lifestyle risk factors? the community nursing SNAP trial.

BACKGROUND: This paper examines the opportunity and need for lifestyle interventions for patients attending generalist community nursing services in Australia. This will help determine the scope for risk factor management within community health care by generalist community nurses (GCNs). METHODS: This was a quasi-experimental study conducted in four generalist community nursing services in NSW, Australia. Prior to service contacts, clients were offered a computer-assisted telephone interview to collect baseline data on socio-demographics, health conditions, smoking status, physical activity levels, alcohol consumption, height and weight, fruit and vegetable intake and 'readiness-to-change' for lifestyle risk factors. RESULTS: 804 clients participated (a response rate of 34.1%). Participants had higher rates of obesity (40.5% vs 32.1%) and higher prevalence of multiple risk factors (40.4% vs 29.5%) than in the general population. Few with a SNAPW (Smoking-Nutrition-Alcohol-Physical-Activity-Weight) risk factor had received advice or referral in the previous 3 months. The proportion of clients identified as at risk and who were open to change (i.e. contemplative, in preparation or in action phase) were 65.0% for obese/overweight; 73.8% for smokers; 48.2% for individuals with high alcohol intake; 83.5% for the physically inactive and 59.0% for those with poor nutrition. CONCLUSIONS: There was high prevalence of lifestyle risk factors. Although most were ready to change, few clients recalled having received any recent lifestyle advice. This suggests that there is considerable scope for intervention by GCNs. The results of this trial will shed light on how best to implement the lifestyle risk factor management in routine practice.

Development and early experience from an intervention to facilitate teamwork between general practices and allied health providers: the Team-link study.

BACKGROUND: This paper describes the development and implementation of an intervention to facilitate teamwork between general practice and outside allied and community health services and providers. METHODS: A review of organizational theory and a qualitative study of 9 practices was used to design an intervention which was applied in four Divisions of General Practice and 26 urban practices. Clinical record review and qualitative interviews with participants were used to determine the key lessons from its implementation. RESULTS: Facilitating teamwork across organizational boundaries was very challenging. The quality of the relationship between professionals was of key importance. This was enabled by joint education and direct communication between providers. Practice nurses were key links between general practices and allied and community health services. CONCLUSIONS: Current arrangements for Team Care planning provide increased opportunities for access to allied health. However the current paper based system is insufficient to build relationships or effectively share roles as part of a patient care team. Facilitation is feasible but constrained by barriers to communication and trust.

Finding common ground? Evaluating an intervention to improve teamwork among primary health-care professionals.

OBJECTIVE: Multidisciplinary care has been shown as the most effective option for chronic disease. The aim of the Team-link study was to assess the effectiveness of an intervention to improve teamwork among general practitioners (GPs), practice staff and allied health professionals (AHPs). This paper describes changes to teamwork using qualitative data collected in the study. DESIGN: Qualitative data about changes in internal and external professional collaboration were collected from facilitators' observations, GPs' reports and responses to a survey of AHPs assessing multidisciplinary teamwork. SETTING: Multidisciplinary teams within general practices and external collaborations with AHPs including dietitians, diabetic educators, exercise physiologists, podiatrists, psychologists and physiotherapists. PARTICIPANTS: GPs, practice nurses, practice staff, AHPs. INTERVENTION: A 6-month intervention consisting of an educational workshop and structured facilitation using specially designed materials, backed up by informal telephone support, was delivered to 26 practices. MAIN OUTCOME MEASURE: Data were analysed thematically using an approach based on identifying actors and associated collaborative actions. RESULTS: New and enhanced communication pathways were observed between GPs, practice staff, patients and AHPs following the intervention. The enhanced information sharing expedited communication and improved interprofessional collaboration within general practices and with AHPs. There was evidence of increased patient participation and empowerment in the care process and improved collaboration by practice staff and allied health providers. CONCLUSION: The Team-link intervention improved professional collaboration among GPs, practice staff, AHPs and patients, increasing understanding and trust and enhancing multidisciplinary teamwork for chronic disease care in primary care settings.

An efficacy trial of brief lifestyle intervention delivered by generalist community nurses (CN SNAP trial).

BACKGROUND: Lifestyle risk factors, in particular smoking, nutrition, alcohol consumption and physical inactivity (SNAP) are the main behavioural risk factors for chronic disease. Primary health care (PHC) has been shown to be an effective setting to address lifestyle risk factors at the individual level. However much of the focus of research to date has been in general practice. Relatively little attention has been paid to the role of nurses working in the PHC setting. Community health nurses are well placed to provide lifestyle intervention as they often see clients in their own homes over an extended period of time, providing the opportunity to offer intervention and enhance motivation through repeated contacts. The overall aim of this study is to evaluate the impact of a brief lifestyle intervention delivered by community nurses in routine practice on changes in clients' SNAP risk factors. METHODS/DESIGN: The trial uses a quasi-experimental design involving four generalist community nursing services in NSW Australia. Services have been randomly allocated to an 'early intervention' group or 'late intervention' (comparison) group. 'Early intervention' sites are provided with training and support for nurses in identifying and offering brief lifestyle intervention for clients during routine consultations. 'Late intervention site' provide usual care and will be offered the study intervention following the final data collection point. A total of 720 generalist community nursing clients will be recruited at the time of referral from participating sites. Data collection consists of 1) telephone surveys with clients at baseline, three months and six months to examine change in SNAP risk factors and readiness to change 2) nurse survey at baseline, six and 12 months to examine changes in nurse confidence, attitudes and practices in the assessment and management of SNAP risk factors 3) semi-structured interviews/focus with nurses, managers and clients in 'early intervention' sites to explore the feasibility, acceptability and sustainability of the intervention. DISCUSSION: The study will provide evidence about the effectiveness and feasibility of brief lifestyle interventions delivered by generalist community nurses as part of routine practice. This will inform future community nursing practice and PHC policy. TRIAL REGISTRATION: ACTRN12609001081202.

Patient and practice characteristics predict the frequency of general practice multidisciplinary referrals of patients with chronic diseases: a multilevel study.

OBJECTIVES: Chronic diseases require a multidisciplinary approach to provide optimal patient care in general practice. In Australian general practice, this usually involves referral to an allied health provider outside the practice. This study explored the patient and practice factors associated with referral of patients with diabetes, ischaemic heart disease (IHD) or hypertension to external allied health providers (AHPs). METHODS: A multilevel analysis of data collected as part of a quasi-experimental study was conducted in 26 practices in Sydney. The frequency of patient-reported referral to AHPs 6-months post-intervention was measured against patient and practice characteristics assessed by patients and practice staff questionnaires. FINDINGS: Seven per cent of the total variance in the referrals was due to differences between practices and 93% attributed to differences between patients. Previous referral, age over 45 years, multiple conditions, longer illness duration, poor mental and physical health were associated with the likelihood of referral to AHPs but not socio-economic status, patient self-assessment of care and the intervention. Those attending practices with over three GPs were more likely to be referred. CONCLUSIONS: Referral to multidisciplinary care for patients with long term conditions was appropriately linked to the complexity, duration and impact of these conditions. The lack of association between the intervention and the frequency of referral suggests that factors other than knowledge and communication such as the accessibility of the allied health services may have been more important in determining referral.