Supporting nurse health champions

In efforts to respond to key government public health initiatives for settings-based health promotion, the ‘Workplace Health Champion’ role has emerged as a method of promoting health within the UK healthcare setting. Health promotion techniques used by these individuals are based on psychological theories that are known to motivate people to change behaviours associated with ill-health. Health Champions, like NHS Health Trainers, assist individuals in setting personal goals to change behaviours thus encouraging empowerment and individual sense of control over personal health and well-being. This article describes the developing role of NHS Health Champions in the public health agenda. Nurses are well placed to promote healthy lifestyles to their patients and clients although evidence suggests that healthcare staff do not always heed their own advice, despite being viewed as role models for health amongst the general public. Nurses are proposed here as both targets and facilitators of health promotion and are advocated as ideal workplace health champions within the NHS. This might be achieved through structured educational training in health improvement for nurses and other healthcare professionals. We propose that health service managers consider supporting healthcare professionals to become workplace health champions.

Health Trainers', mapped onto National Occupational Standards as outlined by 'Skills for Health' working with the UK Department of Health and the British Psychological Society. The role was targeted to address inequalities in health 1 and these individuals aim to change the behaviours of some of the most hard to reach people. Health Trainers work with clients on a one-to-one basis to assess their health and lifestyle risks and signpost them to the NHS and other community services that may help them to initiate health behaviour change. Since 2005, 126 Health Trainer services have been developed, covering 88 per cent of primary care trusts across the UK 2 . An evaluation of stakeholder perspectives on a Health Trainer initiative has clearly demonstrated the potential to help individuals to access support and services in local communities 3 .

Promoting health in the workplace with health champions
Historically, health at work has predominantly been addressed reactively and has focused on health and safety legislation, policy and occupational health service management of work-related illnesses 4 . Increasingly, pressure is mounting on employers to be more proactive in addressing workplace health through health and wellness promotion and preventative measures 5 . It is also now perceived by many that all organizations have a 'corporate social responsibility' to promote the health of their employees 6 , whilst meeting corporate goals such as increasing presenteeism, reducing absenteeism and improving staff morale. In line with the health-promoting hospitals movement, the UK NHS, as Europe's largest employer, must take particular responsibility to this effect, since NHS staff are public 'exemplars' for health behaviours. Workplace wellness schemes are continually being established in many NHS and corporate environments and are dedicated to improving health attitudes, health behaviours and health knowledge in order that employees may make informed choices about their lifestyles 6,7 . Such schemes often rely on the support of local 'Health Champions': individual employees who understand the importance of employee health and well-being, and who actively promote health behaviours within the organization and may also, like Health Trainers, work with other employees on a one-to-one basis. They can assist not only in encouraging others to look after their health, but also in supporting the development of a 'health-promoting culture' within workplaces, promoting skill development in workplace health and well-being within the organization. These individuals have a personal interest in promoting health to others, although this signposting role does not currently have formal health qualification as a pre-requisite. Nevertheless, providing structured training to such individuals in a NHS setting would further convince healthcare employers of the benefits of the workplace Health Champion role, the potential for continuing professional development for staff and the potential benefits to the organization of supporting individual staff members to engage in such roles. Furthermore, those staff already educated in health promotion, such as nurses, would be ideally placed to be supported in developing a workplace Health Champion role.

Nurses as 'targets' and 'facilitators' of health promotion
UK government policy on public health clearly highlights the important role of nurses in contributing to the public health agenda, and all nurses are encouraged, regardless of workplace or discipline, to develop their public health role 8 . Specifically, this means working with patients and clients to promote healthier lifestyles and tackle some of the underlying causes of poor health, particularly of those least well off 8 . Despite this, the findings of a review of health promotion in a nursing practice setting 9 suggested that much nursing-related health practice is firmly located in reactive ill health and disease risk-specific preventative locations and that many nursing 'health-promotion' strategies were in fact 'out-of-step' with wider health-promotion agendas and communities 9 . This suggested that reform was needed for practitioners to be equipped with the necessary resources and skills to engage with other health-promotion agencies.
More recently, the UK Department of Health argued that since frontline NHS staff are in a key position to advise patients about health and lifestyle issues, they can also function as important role models in the promotion of government health messages 10 and, for the general public, they are often seen as an important point of reference for healthy behaviours 10,11 . Despite this, nurses do not always practice what they preach.
The nursing role can be both physically and mentally demanding and nurses have high levels of sickness absence, and are at risk of poor health and burnout 12 . Furthermore, recent investigations have suggested that despite significant education on health issues, nurses do not necessarily engage in healthy lifestyle behaviours themselves [13][14][15] and do not necessarily demonstrate an improved health profile compared with the general public 15 or other professions 14 . Since nurses are public role models for health, it is proposed that nurses and other healthcare staff should practice what they preach, and transfer their knowledge to their own health behaviours, becoming both 'facilitators' and 'targets' for health-promotion practices. This is important, since nurses' health practices have been associated with their tendency to raise lifestyle issues with patients 16 .
Indeed, targeting the health of NHS staff has become a national priority 10 and therefore encouraging nurses to engage in healthy behaviours, become NHS workplace Health Champions and promote healthy choices amongst their peers, as well as their patients, would seem an appropriate and timely initiative.

Workplace educational training initiatives
Given the importance of workplace Health Champions in supporting changes in organizational health culture and employee attendance at workplace wellness programmes, there is an increasing need to recruit individuals into these roles and, as outlined previously, there is a strong argument for developing nurse workplace Health Champions within the workforce. The role and responsibility of organizations to develop and implement workplace health-promotion initiatives in a healthcare setting has already been acknowledged 17 . Health Champion educational training initiatives represent an effective and sustainable way for organizations to directly benefit from the desirable outcomes arising from creating and maintaining a healthy workforce.
As Whitehead's 9 review suggests, nursing practice needs to re-focus reactive ill health and disease risk-specific preventive locations towards equipping nurses with the necessary resources and skills to engage with other health-promotion agencies. One method by which this could be achieved is through structured workplace health champion training for healthcare practitioners in preventative practice that may also be located in NHS and other healthcare workplace settings.
Nurses represent the largest occupational group within the NHS and so training nursing staff as workplace Health Champions makes organizational sense. In fact, surveys have shown that nurses exhibit a relatively poor health profile 14,15 and it therefore seems even more appropriate to reinforce the importance of healthy lifestyle behaviours in this role model group, and set standards for health behaviours as early as possible in the nursing career. Targeting such training initiatives pre-registration essentially supports the development of a 'new generation' of public health workforce, which lends support to the national NHS Health Trainer initiative in the UK, and substantiates the growing demand for NHS workplace health champions. Such training has implications not only for the health of individual NHS staff, which is an important current focus, but also impacts on quality of patient care and NHS resources 10 , supports government drives towards workplace health (and therefore population health improvements) and sustains the image of the NHS as a health-promoting employer.

Royal Society for Public Health: Level 2 Award in Health Improvement
Next is the focus on how this might be achieved. Workplace Health Champion roles and NHS Health Trainer roles are steadily increasing in number across the UK, and unified training is essential for ensuring individuals adopting these positions have the fundamental knowledge required of the role, send a consistent health message out to others and are quality assured.
The Royal Society for Public Health (RSPH) continues to raise the profile for health promotion in the UK and recognizes good practice in workforce development through the recently launched 'Health Promotion and Community Well-Being Organization and Partnership Awards', in collaboration with the Faculty of Public Health, the UK Public Health Register and the Institute of Health Promotion and Education 18 . The RSPH offer the Level 2 Award in Understanding Health Improvement 19 , which is the ideal vehicle, providing a stepping stone through which individuals may be supported to follow a path to becoming a Health Champion, or to pursuing further study to become a Health Trainer and gain nationally recognized credit for their achievements along the way. This qualification is currently delivered in various geographical regions across the UK, by RSPH-registered centres, including both public and private sector organizations. The course provides participants with a grounding in the key concepts of health and well-being, in barriers to initiating and maintaining lifestyle changes, in handling confidential or sensitive information and in methods by which to encourage others to make healthy lifestyle choices and evaluate programmes for change. Specifically, the award aims to 'equip candidates with knowledge and understanding of the principles of promoting health and wellbeing, and of how to direct individuals towards further practical support in their efforts to attain a healthier lifestyle' 19 .
Although the number of organizations offering this award is increasing, delivery in healthcare organizations for the purpose of supporting workplace Health Champions is limited, and to our knowledge the award has not previously been offered to pre-or post-registration nurses as continuing professional development within a university healthcare setting. However, supporting healthcare students to undertake this award could potentially impact significantly on future health outcomes for the NHS and other healthcare employees. We feel this is an ideal way to intervene early in order to influence health-promotion practices on a large scale by developing a new generation of workplace Health Champions already trained by the time they become qualified nurses and NHS employees.

Shaping the future: Curriculum development and interprofessional learning
This training can therefore support both workplace Health Champions and those wishing to pursue the NHS Health Trainer role. The Health Trainer initiative has already made a positive contribution to health improvement 4,20 and has the potential to have a significant impact on health outcomes, particularly in deprived communities -this RSPH award can act as a stepping stone towards qualification as a NHS Health Trainer and will continue to support this national initiative. In our context, we have focused on the use of the RSPH award to support the training of nurse workplace Health Champions. However, since these are generic roles for individual employees of any occupational background, we advocate interprofessional training with this award. Indeed, initiatives to encourage partnership working aim to improve interprofessional relationships and these are key for the improvement of public health 21 .
There has been recent emphasis on interprofessional learning opportunities for healthcare students in higher education 22 and, in our setting, this training encourages information exchange between healthcare professionals and healthcare students. A review of evaluations of interprofessional education has shown that fewer than 30 per cent of interprofessional learning studies included pre-registration students and this education was not frequently delivered in a university setting 23 . We have addressed this in the delivery of workplace Health Champions training. Offering such training supports the growing concept of 'healthy universities' and supports key parallel agendas in the UK, identified by Dooris and Doherty 24 , relating to recruitment, retention and experience, widening participation through flexible learning opportunities and reducing health inequalities, employee performance and productivity related to workplace health 25 , personal and collective well-being, sustainable development and corporate social responsibility 25 . It also contributes to enhancing quality, reputation and distinctiveness in the higher education 'market'. Our first delivery of this training to qualified nurses, healthcare students and NHS employees of diverse occupational backgrounds has proven a success.

Conclusion
In line with the combined concepts of the health-promoting university, the health-promoting hospital, the nurse's role in improving population health and developing curricula to reflect the national drive towards public health, we should be aiming to initiate and promote radical health-promotion reform, moving beyond the traditional view of the nurse in a health education role to clients and patients, to set the example for 'healthy settings' and incorporate nurse workplace Health Champions within the UK NHS workforce. Health Champion training can be offered as continuing professional development for post-registration nurses, or embedded within the pre-registration nursing curriculum. Training opportunities should not be limited to the UK, or indeed the nursing profession, and should include all healthcare occupational groups, and healthcare students as the public health workforce of the future. Health services managers should consider supporting their employees to undertake workplace Health Champion training.

Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.