Communication in smoking cessation and self-management : a study at nurse-led COPD-clinics in primary health care

The general aim of this thesis was to investigate behavioral change communication at nurse-led chronic obstructive pulmonary disease (COPD) clinics in primary health care, focusing on communication in self-management and smoking cessation for patients with COPD. Designs: Observational, prospective observational and experimental designs were used.

Methods: To explore and describe the structure and content of self-management education and smoking cessation communication, consultations between patients (n=30) and nurses (n=7) were videotaped and analyzed with three instruments: Consulting Map (CM), the Motivational Interviewing Treatment Integrity (MITI) scale and the Client Language Assessment in Motivational Interviewing (CLAMI). To examine the effects of structured self-management education, patients with COPD (n=52) were randomized in an intervention and a control group. Patients’ quality of life (QoL), knowledge about COPD and smoking cessation were examined with a questionnaire on knowledge about COPD and smoking habits and with St. George’s Respiratory Questionnaire, addressing QoL.

Results: The findings from the videotaped consultations showed that communication about the reasons for consultation mainly concerned medical and physical problems and (to a certain extent) patients´ perceptions. Two consultations ended with shared understanding, but none of the patients received an individual treatment-plan. In the smoking cessation communication the nurses did only to a small extent evoke patients’ reasons for change, fostered collaboration and supported patients’ autonomy. The nurses provided a lot of information (42%), asked closed (21%) rather than open questions (3%), made simpler (14%) rather than complex (2%) reflections and used MI non-adherent (16%) rather than MI-adherent (5%) behavior. Most of the patients’ utterances in the communication were neutral either toward or away from smoking cessation (59%), utterances about reason (desire, ability and need) were 40%, taking steps 1% and commitment to stop smoking 0%. The number of patients who stopped smoking, and patients’ knowledge about the disease and their QoL, was increased by structured self-management education and smoking cessation in collaboration between the patient, nurse and physician and, when necessary, a physiotherapist, a dietician, an occupational therapist and/or a medical social worker.

Conclusion: The communication at nurse-led COPD clinics rarely involved the patients in shared understanding and responsibility and concerned patients’ fears, worries and problems only to a limited extent. The results also showed that nurses had difficulties in attaining proficiency in behavioral change communication. Structured self-management education showed positive effects on patients’ perceived QoL, on the number of patients who quit smoking and on patients’ knowledge about COPD.

List of scientific papers

I. Österlund Efraimsson E, Klang B, Larsson K, Ehrenberg A, Fossum B. Communication and self-management education at nurse-led COPD clinics in primary health care. Patient Educ Couns. 2009 Nov;77(2):209-17.
https://doi.org/10.1016/j.pec.2009.03.033

II. Österlund Efraimsson, E., Fossum, B., Ehrenberg, A., Larsson, K,. Klang, B. Use of Motivational Interviewing in smoking cessation at nurse-led Chronic Obstructive Pulmonary Disease clinics. [Submitted]

III. Österlund Efraimsson, E., Ehrenberg, A., Fossum, B., Larsson, K,. Klang, B. Nurses’ and patients’ communication in smoking cessation at nurse-led COPD clinics in primary health care. [Submitted]

IV. Österlund Efraimsson, E., Hillervik, C., Ehrenberg, A. Effects of COPD self-care management education at a nurse-led primary health care clinic. Scand J Caring Sci. 2008. 22(2): p. 178-85.
https://doi.org/10.1111/j.1471-6712.2007.00510.x