Making every contact count: improving surgical outcomes for patients

Introduction

Nurses in primary and secondary care who have contact with patients in the months before surgery are ideally placed to deliver health promotion information. Changes in health behaviour are likely to reduce the risk of complications and improve surgical recovery. Nurses have the knowledge and skills to have conversations with patients about health-related behaviour, and can also benefit from additional training and reflection on their own practice to build confidence in this area.

Around 10 million people undergo surgery in the UK every year, with reasons for surgical interventions ranging from cosmetic to lifesaving. Although surgery is clearly prevalent, it is important not to underestimate the risks it poses. Death following surgery is the third leading cause of death worldwide (Nepogodiev et al, 2019), and even without any complications, patients are likely to experience a significant decrease in fitness in the weeks following the surgery, as well as a general decrease in quality of life (Maillard et al, 2015).

Modifiable risk factors

Although various risk factors, such as age, gender, genetics and chronic disease, cannot be changed before surgery, many risk factors are modifiable, including:

• excess alcohol intake
• obesity
• malnutrition
• physical inactivity
• emotional instability

It is estimated that as many as nine in ten people have at least one behaviour-related risk factor that is likely to affect their outcome from surgery (NHS Digital, 2018). Supporting patients to make lifestyle changes can reduce the risk of surgical complications, including:

• chest infections
• wound complications
• cardiovascular events

This, in turn, will reduce the time spent in hospital and improve the patient’s experience. For example, a patient who reduces their alcohol intake from 3–4 drinks a day to 0–2 drinks reduces their risk of complications by 50%, and quitting smoking can reduce complications by 40–60% (Tønnesen et al, 2009). Other preoperative lifestyle changes that are associated with improved surgical outcomes include:

• having a healthy diet
• reducing malnutrition
• increasing physical activity
• improving mental health (Correia and Waitzberg, 2003; Loughney et al, 2015; Ri et al, 2017; Kassahun et al, 2022).

From the point of referral in primary care through to the anaesthetic room, nurses are ideally placed to identify risk factors and support patients to make lifestyle changes using simple techniques.

Behaviour change and making every contact count

Health promotion does not consist of simply telling patients what they should be doing ‘more’ or ‘less’ of, although, historically, that has often been the case. To truly support a patient to make a lifestyle change, the nurse should have some insight into the science of behaviour change. The COM-B Behaviour Change Wheel (Table 1) is a model of behaviour change which outlines that change will only occur if the person (patient) has the capability, opportunity and motivation to make it happen (Michie et al, 2011). The nurse is responsible for helping patients overcome the barriers in each of these elements.

‘Making every contact count’ (Public Health England, 2016) is a behaviour change initiative that uses the millions of day-to-day interactions between staff and patients to support patients in making positive changes to their physical and mental health and wellbeing.

Although the principles of making every contact count can be applied at any point in the patient’s healthcare journey, it is thought to have a successful impact in the window of time before surgery, where patients may be particularly open to positive behavioural messaging, otherwise known as a ‘teachable moment’.

Effective healthy conversations with patients can be as short as 30 seconds and have been shown to improve the likelihood of behaviour change (Moss and Bancroft, 2019).

The role of the nurse

Health promotion is a mandated element of nursing practice (Nursing and Midwifery Council, 2018), but the unscheduled ‘seizing the moment’ element of initiating healthy conversations can feel challenging, particularly if contact time is short (Parchment et al, 2021). The nurse’s ability to ask open questions, actively listen and empathise with patients is a great starting point. Here are some top tips for making every contact count and becoming competent in having effective healthy conversations:

Do the training

Training on making every contact count and having healthy conversations is free, will boost your confidence and count towards your continued professional development (see resources).

Know the information

Read up on common risk factors and how patients can overcome these. Do you know the safe drinking guidance? Are you aware of the World Health Organization’s recommendations on physical activity? What about general healthy eating recommendations? Knowing how these will potentially impact surgical recovery will help you have more effective conversations and gain trust from patients.

Have a tool up your sleeve

If you have 5 minutes or more with the patient, consider using tools, such as SMART (specific, measurable, achievable, relevant, time-bound) goals, to help structure your conversations (Stibich, 2020). Using goal-setting tools makes behaviour change more likely (Epton et al, 2017). Be confident to ask questions about the patient’s behaviour, such as ‘why do you think you have found it difficult to give up smoking in the past?’ Understanding the barriers to change will help you and the patient to identify a way forward.

Seize the moment

Rather than looking to set aside additional time with patients, ask open questions about lifestyle during routine activities, such as taking a blood pressure, walking to the scales, helping patients get dressed. It can take less than 30 seconds to initiate productive conversations and sow the seeds of change.

Do not assume what patients know

Although the majority of patients know some of the risks associated with smoking, the majority will have limited knowledge of the impact of exercise on their physical recovery from surgery or that underweight patients are more likely to have a complication. By highlighting the risk factors and planning solutions and lifestyle changes, you can make a significant difference to the patient’s post-surgical recovery.

Know where to refer and signpost patients

Know where and how to refer a patient for smoking cessation, alcohol reduction, dietary advice and mental health support. There are also many free online resources available through the Royal College of Anaesthetists, Macmillan, British Heart Foundation and Versus Arthritis (see resources) that patients can be signposted to for lifestyle advice and support.

Documentation

Where possible, document the conversations in the patients’ records. This will help subsequent health professionals continue with a similar plan and consistent messaging.

Reflect

Not every conversation will go well. If you did not get a positive response from a conversation about behaviour change, know that you have at least given the patient some information to consider, and reflect on other ways you could have asked questions and guided the discussion. Also reflect on the conversations that went well and identify why they did. This will help build your confidence and develop your own effective approach to having healthy conversations.

Reflective exercise

A 67-year-old man named John attends your pre-assessment clinic before having a bowel resection for cancer. He is well dressed and jovial. While examining him, you think you can smell alcohol on his breath. You ask about John’s alcohol consumption, and he states that he drinks three or four bottles of wine a week (one bottle of wine is equivalent to approximately 10 units) and likes a whisky ‘night cap’. He is unsure of how many units he drinks a week, he thinks he drinks about 20 units, which you know is not accurate as three bottles of wine would be equivalent of approximately 30 units of alcohol. You explain that the amount John is drinking puts him at increased risk of surgical complications and you recommend he cuts down his alcohol intake. John abruptly tells you is he not an alcoholic and ‘could stop drinking tomorrow if he wanted to’.

The risks presented by excessive alcohol consumption:

• Consumption of alcohol affects every organ in the body. Elevated alcohol intake in the weeks before surgery is likely to impact the required anaesthetic dose, increase risk of bleeding, infection, cardiopulmonary complications and delay wound healing (Tønnesen, 2003).
• Alcohol use disorder is increasing in people who are over 65 years old, with 1 in 5 people around this age drinking at harmful levels (Office for National Statistics, 2017).
• Increased alcohol intake over the age of 60 years is particularly harmful, as individuals have increased sensitivity to alcohol, often have other health conditions and are more likely to take medication that interacts harmfully with alcohol (Pozzato et al, 1995).
• People with daily high alcohol intake are at risk of alcohol withdrawal syndrome if they suddenly stop consumption, and should cut down alcohol consumption gradually (Gordon et al, 2006).

Reflective questions:

1. What tools could you use to assess John’s drinking habits? Tip: there are various types of alcohol use screening tests, including alcohol use disorders identification test (AUDIT); alcohol use disorders identification test for consumption (AUDIT C); fast alcohol use screening test (FAST)
2. How would you proceed with the conversation regarding the ‘at risk’ level of alcohol intake? Tip: Think about how John might respond to questions such as: ‘Would you consider reducing your alcohol intake before surgery?’, ‘How might you be able to reduce your alcohol intake?’, ‘Is there anything that would stop you from reducing your alcohol intake?’
3. What suggestions could you make to help John reduce his alcohol intake?
4. What else could you do to support John?