The study was performed at Institute of Health and Care Sciences, The Sahlgrenska Academy at Göteborg University, Göteborg, Sweden

Support received from the Swedish Research Council, K2003-27VX-14636-01A, the Swedish Heart and Lung Foundation, Pfizer Inc, the Research Department, Primary Health Care, Region Skåne and the Swedish Society of Hypertension.

Background

The aim of counselling in hypertension care is to reduce the risk factors for cardiovascular complications, such as stroke and coronary diseases. The risk factors are smoking, high alcohol consumption, overweight, sedentary lifestyle, lipid disturbances and perceived high level of stress (₁). Counselling in a patient-centred way is designed to facilitate the active involvement of the patient to manage the illness. In this context of risk factor management, this means performing self-care to change behaviour (₂). In the literature, patient, person and client centredness are used interchangeably. Kasch & Dine (₃) use the word person centredness and define it as a nursing action that “encourages the patients to disclose how they see their own world, what they are experiencing, and the meanings these experiences have for them”. The key is to understand the patients' experiences from their own point of view by encouraging them to express their ideas, feelings and expectations. McCormack (₄) has a more philosophical view and argues that the heart of person-centred nursing is being in a relationship with other persons, being in a social world, being in the patient's context and recognising and respecting the patient to preserve the patient's sense of self. This represents a shift from an authoritarian delivery model to a participatory model in which patients are encouraged actively to participate in decision-making processes with the emphasis on an equal partnership (₅). According to the Swedish National Board of Health and Welfare (₆), the care of patients should emphasise concordance and the patient should receive individualised information about his state of health and opportunities for treatment (₇).

Health education is an activity designed to enhance health by increasing the patient's theoretical and practical knowledge in order to bring about a change in attitude towards health and health behaviour (₈). Using this perspective creates the basis for a discussion with the patient with the aim of motivating lifestyle changes. There is evidence that patient-centred approaches lead to increased patient satisfaction and adherence and improve health outcomes (₉, ₁₀). The absence of training and lack of confidence in the skills and knowledge to counsel patients have been cited as reasons for not performing prevention counselling (₁₁). A Cochrane Review (₁₂) assessed interventions to promote patient centredness and intervention studies of patient centredness for health care providers. The results showed that patient-centred training for providers with or without the use of behaviour-specific materials in the consultations might lead to significant increases in patient centredness and have a positive impact on patient satisfaction with care. More intervention studies of patient centredness were requested. The aim of the study was to analyse how nurses used patient-centred counselling with hypertensive patients after consultation training.

Method and material

As part of a larger randomised, controlled project, the SOPHI study (Sjuksköterskans omvårdnad av patienter med hypertoni (Nursing management of patients in hypertension care)), a request for participation in the study was made to nurses working at nurse-led clinics for hypertension through an inventory of Swedish health centres with nurse-led clinics. Nurses in the control group did not record any consultations and nothing from their work is reported here. Nineteen of 31 nurses in the intervention group were finally able to participate in the consultation training. Reasons for not being able to participate were not getting permission from the head of the health centre, being understaffed or family considerations. The participating nurses were 38 to 59 years of age (m=47) and had been working for four to 36 years (m=20) since their registration. The nurses had been working at the nurse-led clinic for hypertension from one to 16 years and 13 of them had special education for working in primary health care. The special education, public health, is a one-year training course on which health promotion, patient education and strategies to help patients to develop self-care activities are emphasised.

The training took the form of a residential course lasting three days on three occasions during the winter of 2003 and 2004 with five, six and eight participants on each occasion. The main content of the course was patient centredness for health behaviour change (₁₃), the stages of change model (₁₄), guidelines for cardiovascular prevention (₁), lifestyle factors, and pharmacological treatment. What was meant by patient centredness for health behaviour change is shown in Table 1. The nurses were, for example, encouraged not to feel uncomfortable about silent moments and to use expansive ways of putting questions such as “Tell me more...”. To get practice, consultations between the nurses and simulated patients were video-recorded in small groups. To assess the nurses' performance, the Prismatic model (₁₅), which contains patient perspectives, time spent, social perspectives, gender aspects, agendas, medical aspects, explanations and body language, was used. Furthermore the use of the stages of change model was evaluated. Assessments of the counselling training were made during the recordings and then once more at playback with two supervisors participating.

Figure 1

Table 1: Description of every part of patient centredness () and the various categories. To define the whole of the counselling, the categories “closed question” and “disregard” were added as expressions of when patient centredness was not present.

To assess the effects of the training, the nurses in the intervention group audio-recorded consultations with two patients at their regular nurse-led clinic before and after the intervention. The patients were to be diagnosed with hypertension with or without medication. They could have had hypertension for a long time or have been diagnosed recently and there were no specific requirements with respect to gender or age. The first appointment between the patient and the nurse was audio-recorded. This was set, as it is expected that an assessment of the patient's individual risk profile will be performed at the first consultation. The audio-recordings after the intervention, also at the patients' first appointment, were made within three months after the training. Thirty-six recordings before (one of the recordings before the training was lost due to technical problems) and 35 after the intervention were transcribed verbatim (₁₆) (Table 2). Before transcription, the recordings were listened to by the researchers (ED, AB, KK) in order to obtain a first impression of the consultations. After the transcription, one of the researchers (ED) edited the transcriptions while listening to the recordings, corrected words/passages that had not been heard correctly and changed the names of people and places to maintain confidentiality. The transcriptions were then read several times. The researchers (ED, KK) listened to the recordings and validated the transcriptions independently. The words were counted and assessments of the open and closed questions were made.

Figure 2

Table 2:Transcription guideline ().

The analysis of the recordings was performed using content analysis (₁₇) with QSR NUD*IST Vivo 1.2 software. As patient centredness contains specific elements that were going to be studied, these elements were put into categories (Table 1). The passages in the text that related to counselling about risk factors and behavioural change were first identified for analysis as belonging to the area of non-pharmacological treatment, i.e. smoking, alcohol, weight, exercise, blood lipids and stress. In these passages, the elements of patient centredness expressed by the nurse were then identified and coded into the predefined categories. The coded passages in the text, the units, could be a sentence, several sentences or just some words and these passages sometimes needed to be seen in their context in order to be assessed as being relevantly coded. After all the recorded consultations were coded, the coding was started again with the first coded consultations to check for any inconsistency in the coding procedure. The main coding was performed by one researcher (ED) and three researchers (ED, AB, KK) were engaged in discussions about identifying text for coding and the features of the categories. The coded excerpts were also compared to verify any inconsistency in the coding. When the categories were identified in the recordings, the result was put together in a diagram to look for any pattern that might emerge (Table 3 and Table 4). A comparison was made to see whether there was any difference in the counselling before and after the intervention for each nurse.

Figure 3

Table 3: Examples from the diagram where no obvious differences in the pattern of using patient centredness could be detected before and after the training. The figures represent the number of times in each consultation the categories could be identified when lifestyle changes were counselled.

Figure 4

Table 4: Examples from the diagram where differences in patterns of using patient centredness could be detected before and after the training. The figures represent the number of times in each consultation the categories could be identified when lifestyle changes were counselled. A cipher is put in the first column for nurse E to indicate that no units for coding patient centredness could be found.

Ethics

This multi-centre study was approved by the Local Ethics Committee at the Faculty of Medicine, Göteborg Ö363-00, and the heads of the health centres were asked to make a supplementary application for the areas not included in Göteborg's area of responsibility. The nurses and patients participated after written informed consent. The audio-recordings and transcriptions were treated with confidentiality.

Results

The number of turns (a person's uninterrupted utterance) increased, even for the shortest consultations. The range of the number of words in the turns decreased for both nurses and patients after the training (Table 5). Findings from different parts of patient centredness are presented with examples and excerpts (all from after the training with the exception of Excerpt 2).

Figure 5

Table 5: Description of the length, number of words and turns in the consultations.

Open and closed questions

Expansive and provocative questions, reflections and pauses

Identification of threats to health, perceived vulnerability and disregard

Relevant knowledge, opportunities, weighing up and identification of beliefs about treatment

Negotiating reasons and goals for change, where to begin and what to change

Summaries

Overall pattern

Discussion

The most obvious result of this study was that the nurses gave individually adapted information more frequently. The consultations became more focused, with greater scope for interaction. The number of turns increased, even for the shortest consultations, and the range of the number of words in the turns decreased There was no change in the use of open and closed questions, identifying threats to health and perceived vulnerability or helping the patient to see opportunities. There were no more summaries after the training. Weighing up the pros and cons and identifying beliefs about non-pharmacological treatment increased slightly. Negotiating reasons for and where to begin behavioural change was used half as often after the training. Expansive questions, provocative questions and identifying goals or setting goals for behavioural change were used sparsely both before and after the training. No disregard of patient's questions was found after the training.

Counselling in hypertension care is a complex task, as there are various risk factors that have to be dealt with (₁₈). To our knowledge, patient-centredness in nurses' counselling after counselling training has not previously been studied using qualitative methods. In many cases, different instruments to quantify the degree of special features of the counselling have been used in studies evaluating education in patient centredness and counselling (₁₉), but, to obtain as much information as possible, we used both a quantitative and qualitative analysis method on the data (₂₀). It was of interest to study both how the nurses changed their way of counselling and to what extent. To define reliability, the coding was checked for inconsistencies, discussions were held between researchers about the coding strategy and the validity was defined by the categorisation of patient centredness with reference to a definition and the results of the analyses are described with excerpts (₁₇).

In this study, we wanted to investigate the first meeting between nurse and patient where non-pharmacological treatment is introduced. The nurses recorded their consultations in daily practice with different patients with very varied risk factors, situations at home, personalities and ways of dealing with life, which makes every consultation unique (₂₁, ₂₂). It is this complex situation the nurses have to deal with in their daily practice. Another way to design the study could have been to use simulated patients, which would have made it easier to control different variables. The pro with our design is that it is possible prospectively to follow up the result of the intervention. The patients will be followed up for two years with laboratory and lifestyle variables.

Most of the nurses had been working for several years and had a well-established, agenda-driven strategy, which does not appear to be easy to change (₂₃). Some nurses did change some strategies and there were instances in which even a satisfactory patient-centred approach was disrupted and affected in a negative way. To prevent inferior ways of counselling being established, counselling training could take place in undergraduate education, followed by recurrent training sessions later in working life (₂₄). Another aspect of consultation training is that it takes time to get acquainted with the learning situation and to feel comfortable with feedback from teachers and group members. It might therefore be necessary to have series of training sessions to achieve a patient-centred counselling style (₂₅, ₂₆). Furthermore, not all of the nurses had the special education (public health) for working at health centres, which might have an effect on their approach in the consultations.

In a review of evaluations of communication training programmes in nursing care (₂₇), a limited effect on the nurses' counselling was found, a finding that is similar to our findings. There is a problem in interpreting data from before and after intervention, as simple maturation could also explain some of the differences. We encouraged the nurses to put the patient in the centre and assess the patient's personal risk profile on the first visit. Some nurses, who had a very open-minded attitude to how much and about what the patient talked, assimilated a new structure, where they sensitively kept the counselling more condensed and focused, and this resulted in fewer words in overall terms and less long turns of several hundred words both for themselves and the patients. As a result of this, the longest lectures containing a great deal of information delivered by the nurse decreased and turned into a more individually adapted way of giving information. These findings are in accordance with Burnard and Morrison's findings (₂₈) relating to what nurses attending counselling skills workshops described themselves as being: mostly informative, supportive and good at offering advice. It would be interesting to assess whether consultation training during undergraduate education, followed by recurrent training sessions later in working life, is a better way of achieving patient centredness in consultations.

Conclusions

As a result of the training in patient centredness the nurses acquired an individually adapted way of giving information and increased negotiations about the reasons for and where to begin behavioural change.

Acknowledgements

Correspondence to

Eva Drevenhorn The Sahlgrenska Academy at Göteborg University Institute of Health and Care Sciences Box 457 SE-405 30 Göteborg Sweden E-mail: eva.drevenhorn@comhem.se Phone: +46-31-773 60 58 Fax: +46-31-773 77 50