This essay provides a reflective account of the delivery of an opportunistic smoking cessation intervention. In constructing this account, Gibbs (1988) model of reflection has been utilised, which incorporates the following components: description; feelings; evaluation; analysis; conclusion; and action plan.
Whilst shadowing a practice nurse, I was provided with the opportunity to implement a brief smoking cessation intervention with a patient. The patients name will not be used, in respect of confidentiality (NMC Code, 2008; NHS Confidentiality Code of Practice, DH 2003), however, for the purpose of this reflection she will be referred to by the pseudonym Sarah. Sarah is a 65-year old female presenting with a number of health issues. She is an overweight smoker who has recently been diagnosed with chronic obstructive pulmonary disease (COPD), a lung disease characterised by the narrowing of the airways. COPD also refers to chronic bronchitis and emphysema, the latter of which Sarah has been diagnosed with. It is emphysema that is Sarah’s primary health problem at present.
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The health promotion strategy adopted was a brief intervention comprising motivational interviewing (Rollnick, Miller and Butler, 2007), which took place within the practice surgery as part of Sarah’s consultation. Motivational Interviewing is a directive patient-centered style of counselling designed to help people resolve ambivalence about behavior change, such as smoking cessation.
Alongside motivational interviewing, some specific props and teaching aids were utilised, including the provision of evidence-based information, the creation of a COPD self-management plan (British Lung Foundation, 2010), and details of helpful resources Sarah could utilise for further support. This included the Surrey NHS Stop Smoking Service (www.surreyquit.net), which offers free NHS support tailored to the individual (i.e. weekly clinic visits or telephone contact).
I was initially quite anxious about this health promotion opportunity, as I was not confident in my ability to provide constructive support in the limited time we had. However, on initiating a conversation with Sarah, using open questions as recommended within motivational interviewing, the anxiety disappeared as I listened to Sarah’s story. Active listening requires concentration, which in turn focused me on how I might be able to help Sarah. In establishing that Sarah was concerned for her grandchildren, who stayed with her quite frequently and were thus around second hand smoke, this provided an anchor to facilitate the development of Sarah’s motivation to change. In turn, this anchor also provided me with a patient-centred method for relieving my fears, since I had found a way of engaging Sarah in the process.
Interestingly, as Sarah’s motivation grew, so did my own motivation to ensure that Sarah gained as much from this brief intervention as possible. With every question that I could answer, I gained in confidence and enjoyed my role as ‘educator’ and ‘learner’ within the collaborative partnership between myself and Sarah. In this sense, the collaborative approach that underlies motivational interviewing and much of healthcare practice today can benefit both the patient and healthcare provider.
My overall feelings regarding the interaction with Sarah are one of fulfilment. I feel I positively contributed to this patients increased resolve to stop smoking for both herself and her family.
Motivational interviewing was selected as the most appropriate health promotion intervention for Sarah for a number of reasons. Firstly, evidence regarding behaviour change and, in particular, smoking cessation, shows that level of motivation is an important factor in devising the best health promotion method or teaching plan for a patient (Prochaska, DiClemente, and Norcross, 1993). This approach takes into consideration humanist learning theory and the principles of self-directed learning.
According to Prochaska et al.’s (1983) five stages of behaviour change, Sarah currently resides in stage 2 of the following stages: Stage 1 (pre-contemplation) is when the individual does not intend to change behaviour; Stage 2 (contemplation) is when an individual is considering change; Stage 3 (preparation) is serious resolve to embark on smoking cessation; Stage 4 (action stage) is the first few crucial weeks and months where an individual is actively taking positive actions towards smoking cessation; and Stage 5 (maintenance) is about 6-months to 5-years after the initiation of the smoking cessation decision, where behaviour change has been sustained.
Being in the contemplation stage suggests that Sarah still has some unresolved ambivalence about change and thus needs help moving to stage 3, where she can start to prepare for smoking cessation. If I had started to help Sarah plan for smoking cessation before she was ready, this could have been detrimental in both the short- and long-term. For example, it has been shown that overcoming the hurdles associated with smoking cessation can increase an individual’s self-efficacy (i.e. confidence) in their ability to succeed at their quit attempt, which in turn acts to reduce the likelihood of a relapse and increase the likelihood of long-term sustained smoking cessation (Schnoll et al., 2010). If Sarah was pushed towards a quit attempt before prepared, her risk of relapse would have been high; this would have ultimately reduced her self-confidence to try again.
The transition from the contemplation stage to the preparation stage has been cited as being critically important to the outcome of quit attempts (Prochaska, DiClemente, and Norcross, 1993), as has the fact that healthcare professionals can be extremely influential at this stage Long et al., 1996). I considered motivational interviewing to be key to influencing Sarah’s decisions regarding smoking cessation since it was designed specifically to help people resolve ambivalence about behavior change, which is the main characteristic of people in the contemplation stage of motivation. Motivational interviewing can achieve the resolve of ambivalence by avoiding confrontation and guiding people towards choosing to change their behavior themselves.
I was aware that motivational interviewing would need to be accompanied by detailed education about smoke-related health issues and the likely course of COPD, together with possible complications and its association with increased morbidity and mortality. Sarah is an intelligent individual and keen to receive such information and reading material. Unfortunately, however, I was unable to answer all of her questions. In particular, I could not answer her questions regarding the pathophysiology of smoking. Unanswered questions can act as a barrier to progress, something which I do not wish to produce in a patient who requires such barriers removing. Fortunately, I was able to answer Sarah’s questions whilst referring to an educational information leaflet. I do, however, feel that I would have been able to engage with Sarah more effectively if it had not been necessary for me to focus my attention on the leaflet before me.
It became apparent throughout the consultation that although Sarah was most certainly considering quitting smoking, she possessed some traits that might hinder her efforts. In particular, Sarah appeared to have an external health locus of control. This means that she attributes control over her behaviour to external factors as opposed to internal factors. It is well documented within the literature that an internal locus of control is more productive to behaviour change and healthier lifestyle choices (Wallston and Wallston, 1978; Tones et al., 1992). Taking this into consideration, I was mindful to acknowledge Sarah’s control over her choices. In one instance, I used her husband as an example since Sarah had informed me that her husband had quit smoking. I asked her how he managed to achieve this and in recognising her husband’s role in his own smoking cessation, Sarah appeared to be adjusting her locus of control towards a more internal one.
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Nevertheless, Sarah’s self-efficacy remained low throughout the consultation despite attempts to boost her confidence. It is believed that increased self-efficacy, which can be achieved via motivational interviewing, is an important factor involved in the success of smoking cessation (Brown et al., 2003; Karatay et al., 2010), thus I felt this was an important aspect to include in Sarah’s self-management care plan – to set herself an achievable goal each week that would gradually build her confidence.
The Department of Health have been working with the NHS, patients, and healthcare professionals since 2005 to develop a strategy to improve the care and outcomes of people with COPD (DH, 2010). This strategy places a large focus on the prevention and treatment of smoking, as well as the importance of providing patients who have COPD with behavioural support and access to stop smoking services.
The Department of Health (2009) have produced guidance on effective stop smoking services, offering three levels of behavioural intervention: brief interventions (level one); intensive one-to-one support and advice (level two); and group interventions (level three). In terms of level one, brief interventions, the National Institute of Clinical Excellent (NICE) have published guidelines and recommendations for smoking cessation (NICE, 2004). Furthermore, previous UK guidance has emphasised the importance of offering opportunistic, brief advice to encourage all smokers to quit and to signpost them to resources and treatments that might help them (West, 2005).
They Department of Health guidance states that all smokers should be advised to quit and asked if they are interested in quitting; this is unless there are exceptional circumstances such as other medical conditions that might hinder smoking cessation. Those who are interested in quitting should then be offered a referral to an intensive, level two, support service such as NHS Stop Smoking Services. Sarah was referred to the Surrey service and informed of the success rates found for NHS Stop Smoking Services. There is evidence that such services are effective in the short-term (4-weeks) and the long-term (52-weeks); indeed, between 13-23% of successful short-term quitters remain abstinent at 52-weeks (NICE, 2007).
Approximately 900,000 people in England and Wales have been diagnosed with COPD (NICE, 2004) and it is the fifth most common cause of death in the UK, resulting in over 30,000 deaths annually (National Statistics, 2006). By 2020, it is estimated that COPD will be the third most common cause of mortality worldwide (Lopez et al., 2006). Smoking is the largest risk factor for developing COPD, with 20% of long-term smokers eventually developing clinically significant levels of the disease and 80% developing lung damage (Garcia-Aymerich et al., 2003). These statistics highlight the urgency of grasping opportunistic health promotion and utilising brief intervention skills to help deliver the DH strategy and improve the care and outcomes provided to people with COPD.
Delivering brief opportunistic interventions for smoking cessation requires an approach that does not create defensiveness but develops a patient/provider partnership conductive of the patient making their own decisions, with support, as to their lifestyle. Motivational interviewing and consideration of individual patient characteristics and traits (i.e. locus of control, stage of readiness to change, etc.) provides a method of achieving this partnership within limited time and resources, as is often the case in busy healthcare environments. Learning the skills within motivational interviewing will add to a healthcare professional’s repertoire of techniques for supporting patients through behaviour change, as I found in the case reflected upon within this essay.
The UKCC Code of Professional Conduct (1992) proposes that nurses should “maintain and improve her professional knowledge and competence.” In relation to my own knowledge and competence in opportunistic health promotion, I have recognised that I need to increase my skills for nurturing patient self-efficacy. Patient confidence is fundamental to successful behaviour change and although I feel satisfied with my approach to Sarah, it would have been useful to have possessed a larger repertoire of techniques for enhancing self-efficacy.
I could also benefit from a greater understanding of the pathophysiological mechanisms by which smoking causes COPD. Sarah was particularly interested in the physiological effects of smoking and whilst I could offer her basic information verbally, I needed to refer to information leaflets for more detailed insight, which disrupted the ‘flow’ of conversation.
I have started to explore these issues via a search of the literature on behaviour change and health promotion. As part of this search, I have come across the concept of ‘implementation intention’ (Gollwitzer, 1999). The theory behind this concept is that in order for someone to implement a desired behaviour, it is necessary for them to devise a specific plan that will increase their intention to pursue that behaviour (Gollwitzer and Sheeran, 2006). This is an interesting technique that could be integrated into motivational interviewing and health promotion via the self-management care plans currently provided. I intend to explore this further and to discuss it with a superior.
Using Gibb’s reflective model to structure this account has helped me to recognise my strongest skills and those that require further development. I will endeavour to take a proactive approach to utilising this greater insight into my professional abilities.
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