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.

This dissertation is a participant observer’s account of implementing a multisite, randomised controlled trial within Her Majesty’s Prison Service. It adds to a scarce literature detailing the steps involved in implementing experiments in custodial settings by providing a candid account of the route from planning to successful implementation. The randomised controlled trial was designed to evaluate the effectiveness of the Sycamore Tree Programme. This programme’s goal is to teach prisoners the wider harm of crime and includes a face-to-face meeting between a victim of crime and the participating offenders. It derives its rehabilitative potential from restorative justice and seeks to foster hope that change is possible for offenders, thus aiding them to desist from crime. Its development and theoretical basis are described for the first time. In an in-depth narrative the dissertation details how at every stage strategies were developed to manage participant procurement, random assignment, maintaining treatment integrity, and preparing for final outcome measurements. The randomised controlled trial was designed to produce an individual experiment in eight prisons. These will be combined in a meta-analysis as well as analysed as a pooled sample. Overall the implementation process took close to two years and involved a charitable body, Her Majesty’s Prison Service, the National Offender Management Service, and two police forces. This work has demonstrated how the unstable nature of English prison populations and the risk-averse climate must be addressed when conducting experiments in that environment. It has also illustrated the gap between the rhetoric of evidence-based policy and the facilitation of research designed to seek that evidence. Nevertheless, developing trusting relationships and combining rapidly learnt skills with inherent abilities ensured that the evaluation methodology was supported and protected through the various challenges it met. Finally, the dissertation suggests conditions for closer collaboration between government executive bodies and researchers that might increase the number of experiments undertaken in prisons. It also aims to encourage researchers that prison experiments, although not easy, are feasible, defendable, and, above all, worthwhile.