Delivering Health Promotion Advice in Urgent Care and Emergency Departments: Insights from the promotED Study - a sequential explanatory mixed-methods study

doi:10.21203/rs.3.rs-5288861/v1

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Research Article

Delivering Health Promotion Advice in Urgent Care and Emergency Departments: Insights from the promotED Study - a sequential explanatory mixed-methods study

https://doi.org/10.21203/rs.3.rs-5288861/v1

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Background:

Emergency department nurses and paramedics have contact with millions of people and could use these contacts as opportunities to help people improve their health. These two professional groups could identify people with modifiable risk factors and provide information, brief interventions, and signposting to locally provided services. This study aimed to investigate if and how health promotion is delivered by emergency department nurses and paramedics, and its acceptability to both the staff and patients in these settings.

Methods:

A mixed methods study consisting of an online survey with paramedics and emergency department nurses and semi-structured telephone interviews with staff and patients. The setting was the emergency departments in three NHS Hospital Trusts and four Ambulance Service Trusts in England.

Results:

Three hundred and thirty-one online survey responses, 21 virtual interviews with staff and 14 virtual interviews with patients were analysed. Three main themes emerged from the data: (1) role and relevance of health promotion provision; (2) needs and support for health promotion provision; (3) trust and receptiveness for health promotion provision.

Conclusions:

The findings of this study indicate that staff often refrain from engaging in health promotion activities due to uncertainty about whether it falls within their job responsibilities and a lack of confidence in their ability to perform these activities. Further research is needed to identify effective strategies to encourage, empower, and support staff in integrating health promotion activities into their daily routines in ways that are acceptable to both patients and staff.

Attitude of Health Personnel

Emergency Medical Services

Health Promotion

Paramedics

Qualitative Research

Surveys and Questionnaires

By focusing on prevention, health promotion activities can reduce the costs (both financial and human) of medical treatment and social care. Every 24 hours, the NHS has contact with over a million people at moments in their lives that bring home the personal impact of behaviours that cause ill health. The NHS Long Term Plan sets out practical actions to use these contacts as positive opportunities to help people improve their health.¹ Frontline NHS staff have the opportunity to recognise appropriate times and situations in which to engage individuals and help them on the path to improving their health and wellbeing. The Office for Health Improvement and Disparities, NHS England and Health Education England have produced a consensus statement describing their commitment to work together to maximise support for population behaviour change, and help individuals and communities significantly reduce their risk of disease.²

Every year 10 million 999 calls are made, and > 30% of these patients are treated and discharged at scene.³ There were 24.4 million attendances to an emergency department (ED) in 2021–2022, 80% of whom were discharged post-consultation.⁴ These statistics suggest that paramedics and ED nurses are ideally placed to reach millions of people and could use these contacts as positive opportunities to help people improve their health. These two professional groups could identify people with modifiable risk factors and provide information, brief interventions, and signposting to locally provided services. These interventions (e.g., advice and support on unhealthy alcohol/tobacco use), based on theory of change models, can be delivered when the opportunity arises. They typically take no more than a few minutes, have a low financial cost and yet can be a highly effective and efficient method of health promotion.⁵ However, a systematic review of the barriers and facilitators to effective health promotion in urgent and emergency care identified that few studies have investigated the acceptability of health promotion activities in these settings.⁶ This study aimed to investigate if and how health promotion is delivered by paramedics and ED nurses, and its acceptability to both staff and patients in these settings.

Aims, objectives and study design

This explanatory sequential mixed methods study with two work packages (WPs) aimed to determine whether and how health promotion activities are undertaken by paramedics and ED nurses and investigate ways of overcoming potential barriers. The work packages were designed to address the following objectives:

WP1 - To investigate the views of staff on health promotion activities in urgent and emergency care and explore potential barriers and facilitators for health promotion activities in urgent and emergency care.

WP2 - To investigate the views of patients on health promotion activities in urgent and emergency care and determine if they are willing to participate and engage with these conversations.

This mixed-methods study comprised an online survey and semi-structured interviews. Both the survey and interviews were open to all paramedics and ED nurses working in the participating NHS Trusts. Additionally, patients seen, treated and discharged by participating staff were eligible to participate in virtual interviews. Convenience sampling was employed.

Quantitative data was collected through the online staff survey. This informed the design of the qualitative interview questions to explain and contextualise the quantitative findings.⁷

Ethics committee approval was granted by the NHS Health Research Authority (22/EM/0283) as well as the University of the West of England Faculty of Health and Applied Sciences Research Ethics Committee (HAS.23.03.091). Participants gave informed consent to participate in the study before taking part.

Setting and population

The setting was the EDs in three NHS Hospital Trusts and four Ambulance Service Trusts in England. We worked with these seven participating NHS Trusts to ensure that all paramedics and ED nurses that they employ were aware of the study and had an opportunity to participate. Local collaborators at each Trust sent an email to all paramedics and ED nurses, promoting the study and providing a link to the study participant information sheet, consent form and online survey. The survey was also promoted through bulletins, posters and local social media channels featuring a QR code at participating sites.

Participants were required to provide electronic consent before accessing the first survey question. Eligible participants were invited to contact the research team if they were interested in participating in an interview to explore their survey responses more fully. Those who expressed interest were then contacted by a study research team member and invited to take part in an interview at a mutually agreed time. A participant information sheet, privacy notice, and consent form were emailed to participants in advance of the interview. Verbal consent was audio recorded at the beginning of each virtual interview. Recruitment advertisements included an offer of a £15 voucher as a thank you for those who completed an interview.

Additionally, participating staff provided eligible patients with study information. Patients who wished to participate completed a ‘consent to be contacted’ form. The research team contacted these patients and arranged to conduct a virtual interview at a mutually agreed time. The recruitment procedure as outlined for staff above was undertaken to inform and consent patient participants.

Patient and public involvement

A dedicated study patient and public involvement (PPI) group was formed consisting of eight contributors with recent personal experience of visiting an ED and/ or using the ambulance service. The group provided feedback on the study aims, design and patient recruitment, advised the research team in designing all patient-facing documents and were involved in the interpretation of results.

Data collection

Survey

The survey was developed by the study team based on the findings from a systematic review and scoping study on the barriers to health promotion in urgent and emergency care.^6,8 The survey was hosted on the ‘Qualtrics’ platform (Provo, Utah) and was piloted for usability and functionality within the study team and with other clinical colleagues working in urgent and emergency care. The survey was open between May 2023 and July 2023. A participant information sheet, privacy notice and consent form were integrated into the first page of the survey. The survey contained questions about whether and how staff were undertaking health promotion activities and the barriers to these activities. Questions with Likert scales and multiple-choice responses were included as well as questions with open free-text responses. The study questionnaire is reproduced in Additional file 1.

Interviews

Semi structured interviews were undertaken to investigate staff and patient experiences of health promotion activities undertaken by paramedics and ED nurses. Staff and patient interview topic guides were developed based on findings from the scoping review and early findings from the survey. The guides were reviewed by the PPI group members and piloted with both clinical colleagues and PPI members.

Interviews were conducted between September 2023 and January 2024 by experienced qualitative researchers (FG and BS) and audio recorded via MS Teams. The audio files were transcribed verbatim.

Data Analysis

Descriptive statistics were used to summarise quantitative survey responses. Free-text data were summarised and categorised.

Interview transcripts were coded and analysed by FG and BS, supported by NVivo V.12 software. An iterative process of data reduction, constant comparison, organisation, and understanding was undertaken in the thematic analysis process.⁹ This was achieved by the researchers reading the transcripts several times and then coding selections of text. Through constant comparison across transcripts, codes were then combined or superseded to create more developed themes.

The descriptive statistics and a sample of the qualitative data were shared with the study PPI group to obtain their interpretation of the results.

Survey participant characteristics

A total of 331 completed staff questionnaires from seven participating sites were received. 62% of the respondents were from the four ambulance services and 38% from the three emergency departments. There were equal numbers of male and female ambulance service respondents, however there were three times as many female ED nurse respondents than male. The respondents were mainly Band 6 staff and within the 25–44-year-old age group. Participant characteristics are described in Table 1.

Table 1

Survey participant characteristics (n = 302)
Category	Options	No.	%
Gender	Male	114	38%
	Female	180	60%
	Non-Binary	2	0.5%
	Prefer not to say	6	1.5%
	Total	302	100%
Age	18–24	26	9%
	25–34	132	44%
	35–44	80	26%
	45–54	38	13%
	55–64	18	6%
	65+	2	0.5%
	Prefer Not to say	6	1.5%
	Total	302	100%
Band	Band 3	11	4%
	Band 4	6	2%
	Band 5	77	25%
	Band 6	124	41%
	Band 7	62	21%
	Band 8	15	5%
	other	7	2%
	Prefer not to say	0	0
	Total	302	100%
Interview participant characteristics

A total of 21 staff interviews were conducted: 13 with paramedics and 8 with ED nurses. Interviews lasted between 16 and 37 minutes with a mean duration of 25 minutes. The staff interviewee characteristics are described in Table 2.

Table 2

Staff interviewee characteristics (n = 21)
Profession	Ethnicity	Sex
Front-line paramedic	White European	Female
Paramedic Band 6	White British	Male
Urgent care practitioner, paramedic	White British	Female
Paramedic Band 6	White British	Male
Paramedic Band 7	White British	Female
Band 4 Emergency Medical Technician Class 1	White British	Male
Paramedic Band 6	White British	Female
Advanced paramedic Band 7	White British	Female
Clinical research paramedic	White British	Male
Clinical grade paramedic	White British	Female
Paramedic Band 6	White British	Female
Clinical Validation Paramedic Band 7	White British	Male
Lead research paramedic	White British	Male
Emergency practitioner in ED	White British	Male
Lead EMP/EP clinician	White British	Female
Band 6 trainee advanced clinical practitioner in ED	White British	Female
Clinical/research Nurse Band 6	White British	Female
ED Nurse Band 5	White British	Male
Staff Nurse Band 5	South Asian	Female
Staff Nurse Band 5	White British	Female
Band 4 A&E Nurse Associate	White Irish	Female

A total of 14 patient interviews were conducted, lasting between 13 and 34 minutes with a mean duration of 21 minutes. Nine patient participants had been seen, treated, and discharged from an ED and 5 had been seen, treated, and discharged at home by a paramedic. The patient interviewee characteristics are described in Table 3.

Table 3

Patient interviewee characteristics (n = 14)
Ethnicity	Employment	Sex
White - British	Education	Female
Black - African	Private Nursery (Children) Worker	Female
Mixed - Asian British	Admin	Female
White - British	Chief Exec of Charity	Female
White - British	Retired	Female
South American-Brazilian	Hotel Receptionist	Male
White - British	Law enforcement response analyst	Female
North Africa	Biomedical Engineer	Female
White - British	Customer service advisor	Female
White - British	Occupational Therapist	Female
Half Arab and half African	Biochemist	Male
White - British	Civil Servant	Male
South Asian	Research Technician	Female
White - British	Unemployed	Male

Imposter interviewees

Early in the staff interview recruitment phase we became aware of several ‘red flags’ indicating that individuals contacting the study team were not employed at one of the participating NHS sites. These issues are reported more fully elsewhere. No interviews with the identified “imposter interviewees” were included in the data analysis.

Findings

Three main themes were identified from staff and patient interviews: 1) role and relevance of health promotion provision; 2) needs and support for health promotion provision; 3) trust and receptiveness for health promotion provision. The following sections present the findings in narrative form, incorporating quotes and integrating them with the quantitative results.

1. Role and relevance of health promotion provision

The relevance of health promotion in urgent and emergency care settings was discussed by all interview participants. Survey data indicated 25% of paramedics and 48% of ED nurses reported that health promotion conversations were always or often part of their job, with 8% of paramedics and 13% of ED nurses stating that they have time for health promotion conversations always or often. Whilst only a quarter of paramedics thought health promotion was relevant to the urgent and emergency care setting, half of the ED nurses in the survey thought it was relevant. Only 15% of all staff surveyed believed patients would benefit from health promotion activities.

During the interviews ED nurses reported that health promotion was part of their job and identified that these activities may reduce the number of future visits to the ED.

“...health promotion is key for prevention. We are used to dealing with the current problem, but if we became better... we can reduce exacerbation triggered by what could have been prevented.” [PARA2]

“... it will benefit their health and could result in fewer visits to the ED" [EDN8]

However, some ED nurses talked about a lack of time, mainly due to being short staffed and stated that health promotion ‘is the cherry on top’ [EDN5] that occurs only if they have time.

Staff with more clinical experience felt more comfortable having these conversations and talked about how they engage with patients. Paramedics identified that it may not be seen as part of their job as they are an emergency service. However, they stated that many of their callouts are not for emergency situations and as such there are opportunities to engage with health promotion activities.

“if it's a lower acuity presentation then it may be that the pace and kind of the pace and nature of the conversation is a bit more relaxed, and it may be that my mind will more naturally erm focus on, on ideas such as erm the reason, the kind of broader factors within health wellbeing and lifestyle that might have, have led to or contributed to their current state of health”. [PARA5]

Paramedics reported that they work to time pressures and time targets which necessitated a prompt departure from scene, and that health promotion conversations could take time.

The patients interviewed did not recall any health promotion conversations during their health care episode. They all agreed that they would find these two groups of healthcare professionals trustworthy and would be happy to engage in these conversations. Furthermore, some interviewees felt that staff had a duty to share health messages and information.

“... that conversation that might help. I would say that could calm me down more than stress about what’s going to happen. If I had that I wouldn’t have gone back to my GP so I would say during the treatment would help”. [Pt2]

2. Needs and support for health promotion provision

Twice as many ED nurse survey respondents as paramedics reported having access to materials or lists of agencies relevant to health promotion conversations. From the survey results, only 8% of paramedics and 14% of ED nurses reported being always encouraged by their managers to engage in health promotion activities. A third of the respondents reported having had health promotion training at work within the last two years. Staff reported topics they would find difficult to discuss with patients – obesity, sexual health, alcohol abuse and mental health. Some staff stated that the condition of the patient and perceived receptiveness to health promotion conversations were central to their decisions as to whether to engage in health promotion activities. In general, staff reported that they felt more confident engaging with patients on subjects such as smoking cessation, diabetes, medication adherence, falls prevention and selfcare.

Staff interviewees expressed a lack of resources such as up to date web links, QR codes, leaflets with a list of support agencies which could facilitate health promotion conversations.

“It sounds like a really silly thing but often you can’t find the leaflets, or the patients are itching to leave and then by the time you’ve found the leaflets they’ve gone or there are no leaflets, and you can’t find a printer”. [EDN7]

Staff also reported that they felt they lacked knowledge and confidence to engage in health promotion conversations.

“... don’t get taught a lot about that so that would be something that, again wouldn’t let me, it wouldn’t stop me from having a conversation with somebody, but I just wouldn’t have a lot of knowledge on that. I would have to like pass that on if you know what I mean.” [PARA4]

Staff described a lack of resources and information to share with their patients on health promotion topics. Paramedics stated that they did not know how to have these conversations and that they should be encouraged by their managers to engage with their patients in these ways as it may reduce demand on the service they provide. ED nurse interviewees generally felt supported by their departments to engage with health promotion activities but spoke about a lack of resources and information to share with their patients on health promotion topics.

Patients also recognised the importance of training.

“I believe that ambulance person, paramedic is just as well placed to give that advice, provided they’ve been given the training of course.” [Pt7]

3. Trust and receptiveness for health promotion provision

Whilst the patients interviewed did not recall any health promotion conversations during their health care episode, they did agree that they would be receptive to these conversations.

“I think you’ve got an opportunity; you’ve got a captive audience for a long amount of time and those people are probably quite bored and they are probably quite scared some of them and probably not feeling very well. Erm the opportunity to talk to medical professionals is probably a time when they are feeling quite vulnerable, they might actually be quite receptive to some healthcare advice. So, I think it is a good opportunity to talk to people.” [Pt1]

Staff felt that there were times and situations in which they would not engage in such activities. Staff reported that aggressive patients and those under the influence of alcohol were not approached for these activities and that they used their judgment to assess patient receptiveness. These statements were made in the free text boxes in the survey and were reiterated by the staff interviewees.

Patients discussed the optimal time for engaging in these conversations as being once they have been stabilised and before they are discharged. Some interviewees spoke of a lack of privacy in the ED and if family members are present, either at home or in the ED. Some interviewees did express that a lack of privacy as well as fear may act as a barrier to receptiveness in engaging with health promotion conversations. Patients expressed that they would expect staff engaging in these conversations to ‘practice what they preach.’ This was a view that some staff also echoed as they felt it otherwise may seem hypocritical.

Some staff spoke about only offering health promotion conversations to those patients they felt would be receptive, and others noted that they felt patients did not want to be lectured to and patronised, and so they did not engage with these patients.

“That kind of conversation but it can be quite difficult because especially in older adults they’ve, they already know this, they already know this information, it’s bombarded at them, it’s fired at them from the government and sometimes they don’t want to hear it from us. So yes, I find that a bit trickier, but it is possible, it is just gauging the right people.” [PARA11]

More experienced ED nurses spoke about ways in which they would build trust by engaging with their patients before having health promotion conversations.

Patients suggested that healthcare professionals could have a community presence and organise engagement events, as fire services do currently. This was expected to make them more approachable and patients more likely to accept health promotion advice from them.

The mixed-methods study design, combining surveys with qualitative interviews, offered both a broad overview and a detailed account of staff experiences. Additionally, to our knowledge, this is the first study to specifically examine patient views on health promotion in urgent and emergency care settings.

We identified several challenges related to implementing health promotion in urgent and emergency care. These included the perception of health promotion being part of the job of paramedics and ED nurses and whether it was relevant to the patients they treated, a gap in training, resources, and managerial support for health promotion, and the role of trust and receptiveness for health promotion provision.

Our findings support the limited existing literature. A systematic review highlighted a lack of evidence relating to the acceptability of health promotion in these settings.⁶

An exploratory qualitative scoping study identified an appetite for staff to undertake health promotion activities but highlighted the challenges staff perceived in doing so.⁸

The findings indicate a disparity in the perceived role of health promotion between ED nurses and paramedics. ED nurses were more likely to see health promotion as part of their role and linked it to potential reductions in future ED visits. This perspective aligns with research that highlights the preventive potential of health promotion in emergency settings, particularly in addressing issues like chronic disease exacerbations and recurring injuries.^{10,11,12,13,14} However, the perception that health promotion is not an integral part of patient care is still prevalent, as evidenced by staff participants referring to it as a "cherry on top." This may reflect the high workload and acute demands typical urgent and emergency care environments, where health promotion can be deprioritised.

The view that health promotion is not always relevant in urgent care settings was particularly pronounced among paramedics. This may be linked to the traditional perception of paramedics as primarily emergency responders although, as the results suggest, the nature of paramedic work increasingly includes non-emergency and lower-acuity cases where health promotion could be beneficial.^15,16,17 However the national paramedic curriculum guidance and The Health and Care Professions Council guidelines now see it as part of the paramedic role.^18,19

The study also highlighted a gap in training, availability of resources, and managerial support for health promotion. The lack of easily accessible resources, such as leaflets, QR codes or referral information was a recurrent issue raised by staff, limiting their ability to engage with patients on these topics. Without these materials, staff felt ill-equipped to have meaningful discussions with patients, particularly on sensitive topics such as obesity, alcohol abuse, or sexual health. The provision of these resources and better managerial support could potentially increase staff confidence and competence in these areas. These findings are consistent with previous literature on implementing health promotion strategies in healthcare settings.^20,21,22

Patients also acknowledged the importance of training, with some expressing that urgent and emergency care staff would be well-positioned to provide health advice if adequately trained since they are viewed as credible sources of health information.

Trust and receptiveness to health promotion were central to both staff and patient perspectives. Although none of the patients interviewed recalled any health promotion conversations during their care, they expressed openness to such discussions, especially when stabilised prior to discharge. This aligns with existing literature suggesting opportune moments for health promotion due to heightened patient engagement with healthcare professionals during times of vulnerability.^23,23,25,26 However, staff acknowledged that patient receptiveness could be variable and often depended on factors such as patient aggression, alcohol intoxication, and privacy concerns. Furthermore, both staff and patients emphasised that health professionals should “practice what they preach,” suggesting that personal credibility is key to the success of health promotion conversations. This concern about perceived hypocrisy has been noted in similar healthcare contexts previously.^27,28

Implications for practice

The findings of this study suggest that health promotion in urgent and emergency care is underutilised due to a combination of time pressures, insufficient training, lack of resources, and concerns about patient receptiveness. Addressing these barriers will require targeted interventions. For instance, increasing access to training and health promotion materials, as well as managerial support, could enhance the confidence and capability of healthcare professionals to engage in these conversations. Furthermore, integrating health promotion into the workflow of emergency care settings — particularly for lower-acuity or non-urgent patients who are seen, treated, and discharged — could mitigate some of the time pressures associated with emergency care.

Finally, patient acceptability of health promotion, particularly when linked to their immediate health concerns, suggests that there is significant potential for these conversations to improve health outcomes and reduce future healthcare utilisation.

Strengths and limitations

A key strength of this study was the use of mixed methodologies, combining a quantitatively analysed survey with a qualitative exploration through interviews and thematic analysis. It allowed the researchers to obtain a deeper understanding of the barriers and facilitators to health promotion activities in these care settings. We successfully recruited seven NHS sites varying in size, population, and setting, offering strong geographical representation of our study participants. Notable limitations of our study include the relatively low response rate and moderate interview sample sizes which may have limited the transferability of our findings. Our study relied on a convenience sample of research participants, which means the experiences and views reflected in our research may not be representative of all ED nurses, paramedics and patients treated by these two professional groups.

Directions for future research

Further research is needed to identify effective strategies to encourage, empower, and support staff in integrating health promotion activities into their daily routines in ways that are acceptable to both patients and staff. This could involve adapting or developing interventions specifically designed to support, educate, and motivate ED nurses and paramedics to seize opportune moments for patient engagement. By focusing on these critical interactions, such interventions can enhance the delivery of health promotion advice, ultimately improving patient health and wellbeing.

The findings of this study suggest that ED nurses and paramedics differ in their view as to whether health promotion activities are part of their role, and the relevance of these activities to their patients. However, both staff groups expressed a need for more training, resources, and organisational support. Patients expressed a willingness to receive health promotion advice from these groups of staff. Healthcare professionals in urgent and emergency care can play a crucial role in health improvement as these settings may often offer 'teachable moments.' Future research could focus on adapting or developing an intervention to better support ED nurses and paramedics in effectively engaging in health promotion activities.

Ethics approval and consent to participate

Ethical approval was granted by the NHS Health Research Authority (22/EM/0283) as well as the University of the West of England Faculty of Health and Applied Sciences Research Ethics Committee (HAS.23.03.091). Participants gave informed consent to participate in the study before taking part.

Clinical trial number

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Funding

This project is funded by the National Institute for Health and Care Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number NIHR204030). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Author Contribution

BS conceived the study and wrote the initial draft. All authors contributed to the design of the study. FG undertook the interview data collection and initial data analysis. BS and RT contributed to the data analysis and synthesis. All authors read and approved the final manuscript.

Acknowledgement

We would like to thank the staff who promoted and supported this study as well as all those who took part.

Data Availability

Data are available on reasonable request.

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No competing interests reported.

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Delivering Health Promotion Advice in Urgent Care and Emergency Departments: Insights from the promotED Study - a sequential explanatory mixed-methods study

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Data Analysis

Results

1. Role and relevance of health promotion provision

2. Needs and support for health promotion provision

3. Trust and receptiveness for health promotion provision

DISCUSSION

Implications for practice

Strengths and limitations

Directions for future research

CONCLUSION

Declarations

Clinical trial number

Consent for publication

Competing interests

Funding

Author Contribution

Acknowledgement

Data Availability

References

Additional Declarations

Supplementary Files

Status:

Version 1