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Are practice nurses obliged to maintain their own health to successfully advise patients asks Seeta Bhardwa

A recent survey found that a quarter of practice nurses are unaware of their own cholesterol level. A survey conducted by Flora pro.activ of 150 practice nurses found that there was a lack of awareness of cholesterol levels and suggested there was a need for practice nurses to understand their own cholesterol levels in order to provide the most suitable advice for their patients.

But why should primary care nurses be expected to know their cholesterol level any more than the public? While these results aren't necessarily representative of the population they do raise the valid point that monitoring these indicators of heart health such as cholesterol can predict more serious health problems. So does this mean that nurses should lead by example and prioritise their own health to present a better image to their patients?

Practice nursing is a demanding job involving long hours, more patients and little physical activity. Many practice nurses are also busy managing their family's lives, diets and health, so it is no surprise that their own health is not top of the agenda.

'Practice nursing is more of a sedentary job than the job of a ward nurse. Although they do move around a little, [practice nurses] spend the majority of their day sitting. Add that to the long hours, the lack of access to healthy foods during lunch breaks and general life stress it doesn't make for a healthy lifestyle,' says Michaela Nuttall, registered nurse and cardiovascular disease co-ordinator for Public Health Bromley.

'Nursing is a really hard job and you never get a break,' says Helen Cowan, an elderly care nurse with a PhD in cardiac pharmacotherapy. 'My colleagues always work 15-hour days without a break, so they can only do their best in looking after their own health.'

A recent survey by the HSJ found that over a third of CCGs would consider restricting or limiting services in order to save money. This could include limiting access to services based on patient health, such as if they were obese or smoked. This would also affect nurses should they become patients.1

A study in Europe found that healthcare professionals were less likely to give health advice if they perceived themselves to be in poorer health than their patients, such as being more sedentary or if they smoked. 2

This suggests that nurses might themselves feel that they were in a better position to advise patients if they were confident about their health.

Maureen Talbot, senior cardiac nurse at the British Heart Foundation, says that the updated Code of Conduct from the Nursing and Midwifery Council includes a section that could be interpreted to mean that nurses have a responsibility to maintain a good level of health. 'In the promote professionalism section, two statements', "be aware at all times of how your behaviour can affect and influence the behaviour of other people" and "maintain the level of health you need to carry out your professional role," puts the onus on all nurses to maintain a level of health in order to provide good advice to their patients.

'This is a new thing in the Code, however it does mean that a member of the public is able to hold a nurse accountable if they feel that the nurse is not in the best position to be giving out health advice. These statements can be interpreted in any way but I think that they mean that nurses do have a professional responsibility to maintain a level of health.'

The Royal College of Nursing (RCN) hosted a roundtable on 18 March with seven nurses, from different settings including practice and hospital, to discuss how nurses could maintain their own heart health as well as how best to advise their patients.

Ms Nuttall, who chaired the roundtable, believes that despite concerns about their health, practice nurses are in the best position to provide the most targeted advice for patients wishing to make a lifestyle change.

'The roundtable identified that the NHS Health checks were an opportune time for practice nurses to give out lifestyle advice,' she says. 'It is a national programme that is rolled out in most GP practices across the country. It gives people the opportunity to talk about cholesterol levels as these are included in the Health checks and it gives people the chance to talk about heart health and cardiovascular disease in general.'

Jo Yaldren, a senior lecturer at Teeside University who runs a module on cardiovascular health for nurses, says that practice nurses also have skills like motivational interviewing and developing good relationships with patients which helps them deliver this information. 'They quickly identify things to ensure that the advice they give is patient-centred and they can learn what the patient themselves actually want to change,' she says.

Conflicting evidence

Ms Cowan, says that the range of conflicting evidence from arms length bodies, journals and the media about diet and exercises' contribution to a healthy heart can mean nurses are often unsure of the best advice to give.

'Practice nurses must be less fixed on cholesterol numbers. The guidelines have changed on what cholesterol numbers should be and now there is even talk of getting rid of the numbers and introducing percentages,' she says.

'Instead, a practice nurse can advocate a healthy lifestyle by advising a healthy diet with a little bit of fat, but not a lot, and engaging in regular exercise.'

Katherine Potts, a nurse practitioner in cardiology and clinical cardiology lead in Basingstoke says nurses need better education to address these inconsistencies. 'What's lacking is a yearly update on what's changed, where we are now, what drugs are available.
I think as things change so quickly having this yearly process would be so useful for nurses.'


Due to the broad nature of the role, practice nurses are expected to have a good level of knowledge in a variety of clinical areas. This means that some of them may not have the most up to date knowledge in cardiovascular health if they do not regularly see those patients or if they don't run specialist clinics or have not completed specialist training. 'Unless a practice nurse is self-motivated to take up training herself or is employed in a practice where the GP encourages them to go for such training it may be difficult for them to update their knowledge,' says Ms Talbot.

'Once you get into primary care the ability to be released for training can be very hard and it is getting harder,' says
Ms Nuttall. 'There are always modules of online training, but that gives nurses knowledge, not always the understanding to be able to translate that back into practice. I often run training programmes myself and I have found that the value is not always in what I say but in peer interaction,' she adds.

There is currently a lack of provision for education and training for practice nurses especially for health promotion or prevention topics. This type of training should be the foundation for every practice nurse says Sarah Didymus, a community nurse who attended the RCN roundtable. 'Integrated learning with others including hospital staff is extremely useful and beneficial to follow the patient journey and learn from those who come into contact along the way – each will have a different perspective and advice,' she adds.

Ms Yaldren says that the course at Teeside University provides students with information on health promotion and models that are helpful to use. 'We know that a lot of practice nurses run cardiovascular and coronary heart disease clinics but a lot of them don't have expertise in that area,' she says.

More in-depth training can ensure that advice is tailored to a patient's own personal experience, family situation and socioeconomic environment. 'For example someone who has a low income may not want to exercise in case they injure themselves and aren't able to go to work,' says Ms Yaldren.

Regular education means that a nurse can apply this knowledge in both their personal and professional lives. Points in the NMC Code indicate that nurses do have a responsibility to look after their own health in order to be able to give good advice to their patients, and patients might be more likely to listen.

Until the NHS prioritises its staff's health, like many private companies do, practice nurses can only do the best they can under challenging circumstances to maintain their own health and inspire their patients to do the same.I N


1. A third of CCGs consider limiting access amid cash squeeze. Accessed April 2015.

2. Prevention and health promotion in clinical practice: the views of general practitioners in Europe . 2000. Elsevier.