Communication StudySequence-analysis of video-recorded practitioner–patient communication about smoking in general practice: Do smokers express negative statements about quitting?
Introduction
Evidence-based guidelines for smoking cessation care recommend general practitioners (GPs) and practice nurses (PNs) to routinely ask patients about smoking, advise smokers to quit, assess their motivation to quit, assist them with quitting, and arrange follow-up support [1], [2]. A full implementation of these ‘5 As’ significantly improves smoking abstinence rates [3], [4], [5] and is cost-effective [6].
Nevertheless, GPs and PNs (see Appendix 1 for a description of PNs’ role in Dutch general practice) report various barriers to the implementation of these guidelines during routine consultation [7], [8], [9], [10], [11], [12]. Although patients state that they are willing to discuss their smoking behaviour during a practitioner-initiated dialogue [13], GPs and PNs report that smokers regularly express negative statements regarding quitting during unsolicited dialogues about smoking, such as a lack of motivation or discipline to quit [7], [8], [9], [10], [11], [12]. These negative statements about quitting impede a structural implementation of guideline-recommended smoking cessation care [7], [8], [9], [10], [11], [12]. GPs report a limited range of skills for dealing with these negative statements [8] and consequently tend to avoid these negative statements to preserve a good doctor–patient relationship [14], [15]. This factor is one of the reported reasons for the gap in evidence-based practice regarding the provision of guideline-recommended smoking cessation care in Dutch general practice. The results show that, for example, 79% of all smokers and 40% of smokers who discuss smoking with their GP do not receive advice regarding quitting smoking [16]. Therefore, we aim to provide more insight into the interaction between primary care professionals and smokers during unsolicited dialogues about smoking. These insights may result in recommendations for primary care professionals for how to address smokers’ negative statements regarding quitting and help them to fully implement guideline-recommended smoking cessation care.
Until now, very few studies have examined the interaction between primary care professionals and smokers. Previous studies have focused on the way patients react if GPs link their health issues to their smoking [17] or if they are counselled to quit smoking based on their readiness to quit [18]. According to our knowledge, no studies have examined the responses of smokers if professionals apply a guideline for smoking cessation care. Moreover, the impact of these responses on professionals’ continuation of guideline adherence is unknown. More insight into this interaction may contribute to strategies that can benefit the implementation of smoking cessation counselling in general practice.
Therefore, we assessed the extent to which: (i) professionals use the 5 As for smoking cessation care, (ii) patients who smoke express negative or positive statements about quitting if professionals use these 5 As, and (iii) professionals continue or discontinue their use of the 5 As after patients express a positive or negative statement about quitting. Based on the literature, we hypothesised that an unsolicited conversation about smoking would cause negative statements from patients about quitting. Furthermore, we hypothesised that patients’ negative statements about quitting would hamper the continuation of guideline adherence, whereas patients’ positive statements about quitting would facilitate it. Because knowledge and skills regarding lifestyle counselling are highlighted in the ‘competence profile’ of PNs [19], we hypothesised that patients’ negative statements about quitting would be less likely to hamper guideline adherence in dialogues with PNs compared to dialogues with GPs.
Section snippets
Study setting, participants and design
A cross-sectional study was conducted in which we examined video-recordings of random real-life routine consultations in general practice. Video-taped consultations are regularly used to observe lifestyle counselling [20], [21], [22], [23], [24], [25] and can provide a complete record of what actually happens during consultations and be viewed repeatedly [26]. Videos were collected (nationwide) and archived by the Netherlands Institute for Health Services Research (NIVEL). Consultations with
Sample characteristics
Table 1 shows the duration of the consultations and dialogues about smoking and the characteristics of the patients, GPs and PNs who were enrolled in the study. In total, we coded 1424 speech units (mean 27.4 speech units per smoking dialogue, range 4–118), of which 727 were of professionals (51.1%, mean 14.0 speech units per smoking dialogue, range 2–55) and 697 were of patients (48.9%, mean 13.4 speech units per smoking dialogue, range 1–63).
Professionals’ smoking cessation care
Overall, half of the speech units of professionals
Main findings
The present study aimed to provide insight into the professional–patient interaction during unsolicited dialogues about smoking. First, we assessed the extent to which primary care professionals use the 5As for smoking cessation care during unsolicited dialogue about smoking. We found that GPs mainly focused on asking their patients about smoking and PNs on assisting patients with a quit attempt. Overall, little attention was paid to advising smokers to quit, to assessing their motivation to
Conflicts of interest statement
The authors declare that there are no conflicts of interest.
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