Communication in Smoking Cessation and Self-management : a study at Nurse-led COPD-clinics in Primary Health Care

ABSTRACTThe 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.

Intern kontroll: En fallstudie på Trafikverket

Internal control is something that’s grown more important for enterprises to keep in mind. The community is increasingly affected by the IT-development which demands a bigger degree of security. Enterprises needs to make sure that their systems are up to date and secure enough to keep it safe from unauthorized to take part of sensitive information. Internal control can exist in a major part of the work. If an enterprise have a goal for no harm or serious injury at work, internal control is necessary to reach that goal. The purpose for this essay is to examine how five different departments of Trafikverket practices internal control. How internal control is described. How the guidance from the managements is described and how it reaches the rest of the enterprise. This will lead to a proposal of improvement of the internal control at Trafikverket. We focus our frame of reference on the COSO-model and its five components. The components included in the COSO-model are control environment, risk valuation, control activities, information and communication and monitoring. The essay is a case-study of Trafikverket. We have chosen a qualitative method and interviewed five respondents from the different departments on Trafikverket. The respondents we interviewed works with internal control in their everyday work or have a god insight in the subject. We used a semi structured interview guide with questions based on the COSO framework. The results from our study shows that it exist big variations between how the departments work with internal control. It emerged that there are new guidelines for how the work should be done. This makes it necessary with education to implement the new ways to work. How the departments use the COSO-model varies. Some of them have incorporated the model in their new ways to work others have never heard of it. The conclusion of our study shows that the COSO-model and it´s components contribute to a functioning internal control. Implementing the components is important and the most important feature to good internal control is the corporate management. Education within the enterprise is the most effective way to inform the staff about the model and to implement it.