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BACKGROUND: Breast cancer (BC) and its treatments decrease patients' psychological well-being. Peer support is one form of social support, but little is known about what gives rise to peer support. OBJECTIVE: The purpose of this study was to examine how peer support is constructed among recently diagnosed BC patients. METHODS: Eighteen women were randomly picked from 130 women who had received phone calls from a trained peer supporter and were invited to group interviews. In the interviews, patients discussed their cancer, peer support experiences, and social support. The transcribed data were analyzed using Braun and Clarke's thematic analysis approach. RESULTS: The construction of peer support among newly diagnosed BC patients was complex. It depended on the needs of the patient and the success of interactions. Once they had received a diagnosis, the lives of the patients changed suddenly, and patients dove into the I-we-others consideration and had a need to talk. Interaction with peer supporters gave them a chance to share their stories. At their best, interactions led to belonging, caring, and a sense of security. CONCLUSIONS: The need to be heard and seen is strong in a patient's changing health situation. Peer support plays an important role in high-standard care and in strengthening patients' self-determination. IMPLICATIONS FOR PRACTICE: Hospitals should create chances for supportive communication, and the supportive communication should be easily accessible and successful. The training of peer supporters should ensure that they have reflected on their own BC process and know how to consider the needs of newly diagnosed patients.

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The importance of intersectoral collaboration and partnership working in mental health promotion, together with the requisite competencies for effective collaboration, is widely acknowledged. This Delphi-based qualitative study examined how intersectoral collaboration and partnership work are constructed and adopted in mental health promotion practice. Descriptive data from a Delphi panel of mental health promotion practitioners working in the health sector (n = 32) were used as a data source. Thematic analysis was used to analyze the data. Applying the theory of collaborative advantage, eight themes of collaboration advantage and the related competencies were identified: management structure, leadership, communication and language, common aims, working processes, resources, trust, and commitment and determination. The themes capture the competencies required to influence and work with others to improve the mental health and wellbeing of individuals and communities. The identified theme areas can be used to inform education and training and capacity building for professional practice in mental health promotion. Future research is needed to explore other possible collaborative advantage themes in mental health promotion practice and the competencies required to facilitate effective partnerships across sectors. Further investigations are also needed on the identified theme areas in order to develop and guide capacity building and training in mental health promotion.

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Nurse-led counseling and systematic follow-up have been shown to reduce cardiovascular risk factor levels. The study aims were to investigate if cardiovascular risk factor levels could be reduced in patients with coronary artery disease with a nurse-led intervention and to report patients' evaluations of nurse-led counseling. The study design was a real-life longitudinal follow-up counseling intervention. Data were collected from November 2017 to May 2020. The nurse-led intervention and patients' follow-up time was 1 year. Of the 78 patients recruited, 74 completed the study. The most significant findings were in the levels of total cholesterol, low-density lipoprotein cholesterol, and triglycerides at every follow-up visit compared to their baseline levels and that waist circumference decreased during the 1-year follow-up. Patients assessed the quality of nurse-led counseling to be very good, though it decreased slightly during follow-up. The results suggest the integrated care path and specialized and primary care for coronary artery disease patients need further development. More research is needed on how to strengthen patients' self-management and what kind of counseling would best promote it.

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OBJECTIVE: The aim of this study was to explore patients' narratives of patient education in physiotherapy after a total hip arthroplasty (THA). METHOD: The data was collected via open thematic interviews from ten patients who had had a primary THA. The interviews were analysed using a qualitative, narrative method. RESULTS: Three story models of patient education in physiotherapy were identified: Supportive patient education in physiotherapy, Co-operative patient education in physiotherapy and Contradictory patient education in physiotherapy. The emphasis of narration in the first story model was on the trust in the guidance, functioning interaction in the second and insufficient patient education in physiotherapy in the third story model. DISCUSSION: According to the results of this study, patients with THA experience functioning interaction and trust in the patient education in physiotherapy as enhancing the rehabilitation process. Conversely insufficient patient education about exercising and follow-up physiotherapy made the patients feel insecure and according to them might have slowed down the rehabilitation process. These findings can be utilized in planning and improving patient education in physiotherapy after THA.

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AIM: To explore what thoughts, feelings, and learning processes were involved in obese participants' lifestyle change during an acceptance and commitment therapy (ACT) lifestyle intervention delivered in primary health care. BACKGROUND: Previous studies have revealed that lifestyle interventions are effective at promoting initial weight loss, but reduced weight is often difficult to sustain because of the failure to maintain healthy lifestyle changes. Achieving and maintaining lifestyle changes requires to learn self-regulation skills. ACT-based lifestyle interventions combine many self-regulatory skill factors, and the results from previous studies are promising. Research on the individual learning processes of lifestyle change is still needed. METHODS: This study investigated a subset of data from a larger web-based lifestyle intervention. This subset consisted of online logbooks written by 17 obese participants (n = 17, body mass index mean 41.26 kg/m2) during the six-week online module. The logbooks were analyzed via data-driven content analysis. FINDINGS: Four groups were identified based on the participants being at different phases in their lifestyle changes: stuck with barriers, slowly forward, reflective and hardworking, and convincingly forward with the help of concrete goals. Differences between the groups were manifested in personal barriers, goal setting, training of mindfulness and acceptance, and achieving healthy actions. The ACT-based lifestyle intervention offered participants an opportunity to reflect on how their thoughts and feelings may hinder healthy lifestyle changes and provided tools for learning psychological flexibility.

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BACKGROUND AND PURPOSE: There is limited knowledge about patients' and physiotherapists' perceptions of patient education in physiotherapy in hip arthroplasty. The aim of this study was to describe physiotherapists' conceptions of the patient education in physiotherapy needed by patients undergoing total hip arthroplasty. METHODS: The data for this qualitative study were collected using group and individual semi-structured interviews. Seven physiotherapists were interviewed. The research data were analyzed using a phenomenographic method. RESULTS: Three categories of patient education in physiotherapy in hip arthroplasty were produced and the categories formed a hierarchy. The narrowest descriptive category was Schematic physiotherapy complying with the protocol. Identifying individual rehabilitation needs was the second category, and the third, widest category was Coaching home rehabilitation. The differences between the categories were described in four themes: 1) Moving; 2) Exercising; 3) Interaction in relation to patient; and 4) Health care system. CONCLUSION: According to the results, patient education in physiotherapy optimally aims to identify patients' individual rehabilitation needs, advice on coping at home and especially helping patients to be prepared for and capable of long rehabilitation for which they are themselves responsible. These findings resulting from descriptive categories can be utilized in developing education methods and physiotherapists' competence in patient education.

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The aim of this study was to systematically review lay health worker (LHW)-led self-management interventions for adults with long-term conditions to see how the interventions have been implemented and to compose a synthesis of research findings, taking into consideration the intervention components that have been applied. We conducted systematic searches for articles published between January 2010 and December 2015 in five databases: Cochrane, MEDLINE, CINAHL, PsycINFO, and Web of Science. Forty original studies were found that met the inclusion criteria: self-management with diabetes (n = 29), cardiovascular diseases (n = 8), and those at risk of cardiovascular diseases (n = 3). These consisted of 22 randomized controlled trials and 18 other trials, with durations of 1 day to 24 months. The findings showed that the training of LHWs and the implementation of interventions varied widely. A synthesis of the implementation methods covers the background of the LHWs and the interventions as well as the components applied in each. Eight interventions had effects on physical activity and eight on nutrition behavior. The review also includes preliminary findings on intervention components effective in improving physical activity and nutrition behavior, including self-monitoring as a behavior change technique and group meetings as an intervention format. The same components and behavior change techniques were applied in effective and noneffective interventions. The review found that LHW-led interventions have potential in promoting self-management in long-term condition. In the future, a qualified and evidence-based structure for LHW-led interventions is suggested in order to improve the systematization of interventions and their effects.

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BACKGROUND: Living alone has become more common in today's societies. Despite the high number of the population living alone, research directed towards the mental wellbeing issues related to living alone has been limited. This systematic literature review aimed to assess the association between living alone and positive mental health. METHODS: We conducted searches in Medline, Web of Science, Cochrane Library, CINAHL, PsycINFO, and other complementary databases from January 1998 to May 2019. Randomised trials and observational studies investigating adults over 18 years of age and living alone (defined as living in a single household or a household size of one person) were eligible. The primary outcome was positive mental health, defined as comprising both hedonic and eudaimonic elements of mental wellbeing, and it was measured with the Warwick-Edinburgh Mental Well-being Scale and/or theWHO-5 Index. Two reviewers independently screened and selected data; one reviewer extracted data, and the second checked the extracted data. A narrative synthesis described the quality and content of the evidence. Included studies were appraised using relevant Joanna Briggs Institute checklist. RESULTS: A total of 4 cross-sectional studies (22,591 adult participants) were included after screening of 341 titles and abstracts and 46 full-text articles. These studies were conducted in Europe and were published between 2014 and 2017. The studies differed in their measurements of positive mental health (WHO-5 Well-Being Index, 3 studies; WEMWBS, 1 study), sources of data (1 regional, 1 national, and 2 European-level studies), and study populations (regional study, adults over 65 years of age; national-level study, mental health nurses over 21 years of age; European-level studies, employees between 15 and 65 years of age and adults over 18 years of age). A potential association between living alone and low positive mental health was found in three out of the four studies. Our findings were limited as the number of included studies was low and the quality of evidence varied across studies. CONCLUSIONS: This review allows a limited look at the association between living alone and positive mental health. Because the number of included studies was low and the quality of evidence varied across studies, further research is warranted.

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PURPOSE: Breast cancer is the most common cancer of Finnish women. Peer support could be a way to help breast cancer patients to deal with the disease but studies on its effectiveness have produced conflicting results. The aim of this randomized controlled trial was to study the effectiveness of peer support on health-related quality of life (HRQoL) of breast cancer patients. METHODS: Patients with recently diagnosed breast cancer at the Helsinki University Hospital were randomly allocated to intervention (n = 130) or control (n = 130) groups. The intervention group patients received peer support via telephone one to five times according to their preference. The control group received usual care only. HRQoL was assessed with generic (15D) and disease-specific (EORTC QLQ-30 and its breast cancer specific module BR23) instruments at baseline and at 3-, 6-, and 12-month follow-up points. RESULTS: The mean (SD) age of the patients was 60.0 (10.5) years and their baseline mean 15D score 0.922 (0.066). At baseline, the intervention and control groups did not differ from each other. During follow-up, the 15D score deteriorated statistically significantly (p < 0.001) and clinically importantly in both groups but slightly less in the intervention group although the difference was not significant. Regarding individual 15D dimensions, the EORTC-QLQ30, or its breast-specific module, peer support did not show any consistent advantage compared to usual care. CONCLUSION: Peer support had no clear effect on the HRQoL of breast cancer patients.

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AIMS: In this study, we aimed to investigate what competencies are needed for mental health promotion in health sector practice in Finland. METHODS: A qualitative study was carried out to seek the views of mental health professionals regarding mental health promotion-related competencies. The data were collected via two focus groups and a questionnaire survey of professionals working in the health sector in Finland. The focus groups consisted of a total of 13 professionals. Further, 20 questionnaires were received from the questionnaire survey. The data were analysed using the qualitative data analysis software ATLAS.ti Scientific Software Development GmbH, Berlin. A content analysis was carried out. RESULTS: In total, 23 competencies were identified and clustered under the categories of theoretical knowledge, practical skills, and personal attitudes and values. In order to promote mental health, it is necessary to have a knowledge of the principles and concepts of mental health promotion, including methods and tools for effective practices. Furthermore, a variety of skills-based competencies such as communication and collaboration skills were described. Personal attitudes and values included a holistic approach and respect for human rights, among others. CONCLUSIONS: The study provides new information on what competencies are needed to plan, implement and evaluate mental health promotion in health sector practice, with the aim of contributing to a more effective workforce. The competencies provide aid in planning training programmes and qualifications, as well as job descriptions and roles in health sector workplaces related to mental health promotion.

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Purpose The purpose of this study is to identify factors that foster or prevent sense of belonging among frontline and middle managers in social and health-care services in Finland. Design/methodology/approach The data have been collected among social and health-care managers ( n = 135; 64 per cent nursing managers) through two open-ended questions in a questionnaire concerning sense of community. The results of the open-ended questions have been analyzed using qualitative content analysis. Findings Among managers, six categories of factors that foster sense of belonging (open interaction, effective conversation culture, support and encouragement, common values, a shared vision of the work and its objectives and structure of leadership) and five categories of factors that prevent sense of belonging (negative work atmosphere, lack of common time, structural solutions in the organization, problems that occur in the organizational level and problems related to leadership and management) have been identified. Practical implications The resulting information can be used to develop sense of belonging among managers at all levels of organization (horizontal and vertical). Originality/value Paying attention to the quantity and quality of interaction and to structural solutions in the organization can affect the sense of belonging among frontline managers and middle managers.

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BACKGROUND: While gains in reducing smoking rates in Finland have been made, prevalence rates are still substantial. Relapse rates among smokers engaged in quit-smoking programs are high. Physical activity has been proposed as one means to help smokers manage cravings. Software and apps on mobile phone and handheld devices offer an opportunity to communicate messages on how to use physical activity to manage cravings as part of quit-smoking programs. OBJECTIVE: We aimed to test the feasibility, acceptability, usability, and preliminary efficacy of an mHealth mobile phone app, Physical activity over Smoking (PhoS), to assist smokers in quitting smoking in a randomized controlled trial. The app was designed to prompt smokers to engage in physical activities to manage their smoking cravings. METHODS: Regular smokers (n=44) attended a group-based behavioral counselling program aimed at promoting physical activity as an additional aid to quit. After quit day, participants were randomly allocated to an intervention (n=25) or to a comparison (n=19) group. Participants in the intervention group were provided with the PhoS app and training on how to use it to assist with relapse prevention. Participants in the comparison condition were provided with generalized relapse prevention training. RESULTS: Some participants reported that the PhoS app was useful in assisting them to successfully manage their cigarette cravings, although compliance across the sample was modest and participants reported low levels of usability. Participants receiving the PhoS app did not report greater abstinence than those who did not receive the app. However, participants receiving the app were more likely to report greater abstinence if they did not use pharmacological support, while those who did not receive the app reported greater abstinence when using pharmacological support. Participants receiving the app reported greater levels of physical activity than those who did not. Results revealed that the app resulted in better retention. CONCLUSIONS: The PhoS app showed some potential to reduce abstinence among participants not using pharmacological therapy and to increase physical activity. However, problems with usability and lack of effects on abstinence raise questions over the app's long-term effectiveness. Future research should prioritize further development of the app to maximize usability and test effects of the intervention independent of quit-smoking programs. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 55259451; http://www.controlled-trials.com/ISRCTN55259451 (Archived by WebCite at http://www.webcitation.org/6cKF2mzEI).

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OBJECTIVE: The objective of the present study was to explore postoperative patient education in physiotherapy from total hip arthroplasty (THA) patients' perspectives, which has been a little-studied area of research. The usefulness of rehabilitation protocols after THA has been debated over the years, and there are no clear guidelines for physiotherapy after THA METHODS: The data for the present qualitative study were collected from nine patients with THA by using individual interviews at the hospital after surgery. The interviews were audio-recorded and analysed by using a phenomenographic method RESULTS: Four different categories of postoperative patient education in physiotherapy after hip arthroplasty were produced: trust while in hospital; preparing for going home; managing at home; and regaining physical fitness. These categories were analysed through the following themes: moving; exercising; and interaction between the patient and the physiotherapist CONCLUSIONS: The postoperative patient education in physiotherapy was constructed hierarchically. According to patients' conceptions, the combination of moving and exercising elements that focused on recovery at home after the operation was essential. This requires a trusting relationship between the patient and the physiotherapist. Two critical aspects can be identified: (i) how the role of moving could shift towards preparing for going home and (ii) widening the perspective from preparing for going home to managing at home. Copyright © 2016 John Wiley & Sons, Ltd.

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AIM: The aim of this study was to assess the socio-demographic and disease-related symptoms and emotions and knowledge expectations of patients recently diagnosed with knee osteoarthritis. A further aim was to determine associations between selected demographic variables and patients' expected knowledge. BACKGROUND: Patient counselling and information provision are recommended for all patients with knee osteoarthritis. In healthcare centres, there is a good possibility to establish the knowledge expectations of patients with knee osteoarthritis during counselling. Recent empirical evidence indicates a lack of research on knowledge expectations among recently diagnosed patients with knee osteoarthritis. DESIGN: A quantitative, descriptive inquiry design was adopted. METHODS: The data were collected from 252 recently diagnosed patients with knee osteoarthritis by a postal survey in 2013, using the Hospital Patient's Knowledge Expectations Scale as well as additional questions and statements. The data were analysed using multivariate linear regression. RESULTS: Most of the respondents were female pensioners who also had other chronic diseases. Approximately half of the participants had had counselling on osteoarthritis. Knowledge expectations concerning pain management were emphasized. From the empowering knowledge perspective, the highest knowledge expectations concerned bio-physiological dimensions of knowledge, followed by ethical and financial dimensions. Age, employment status, pain and emotions of concern and hope among women and tiredness or fatigue and vocational/higher education among men were associated with knowledge expectations. CONCLUSION: Patients with knee osteoarthritis have high knowledge expectations and there is a need to improve the counselling and care of pain and tiredness or fatigue symptoms. The development of the counselling of recently diagnosed patients with knee osteoarthritis also needs further research.

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BACKGROUND: Results from studies on the effects of exercise on smoking-related variables have provided strong evidence that physical activity acutely reduces cigarette cravings. Mobile technology may provide some valuable tools to move from explanatory randomized controlled trials to pragmatic randomized controlled trials by testing the acute effectiveness of exercise on quitters under real-life conditions. An mHealth app was developed to be used as a support tool for quitters to manage their cigarette cravings. OBJECTIVE: The primary aim of this paper is to present the protocol of a study examining the effectiveness of the Physical over smoking app (Ph.o.S) by comparing the point prevalence abstinence rate of a group of users to a comparator group during a 6-month follow-up period. METHODS: After initial Web-based screening, eligible participants are recruited to attend a smoking cessation program for 3 weeks to set a quit smoking date. Fifty participants who succeed in quitting will be randomly allocated to the comparator and experimental groups. Both groups will separately have 1 more counseling session on how to manage cravings. In this fourth session, the only difference in treatment between the groups is that the experimental group will have an extra 10-15 minutes of guidance on how to use the fully automated Ph.o.S app to manage cravings during the follow-up period. Data will be collected at baseline, as well as before and after the quit day, and follow-up Web-based measures will be collected for a period of 6 months. The primary efficacy outcome is the 7-day point prevalence abstinence rate, and secondary efficacy outcomes are number of relapses and cravings, self-efficacy of being aware of craving experience, self-efficacy in managing cravings, and power of control in managing cravings. RESULTS: Recruitment for this project commenced in December 2014, and proceeded until May 2015. Follow-up data collection has commenced and will be completed by the end of December 2015. CONCLUSIONS: If the Ph.o.S app is shown to be effective, the study will provide evidence for the use of the app as a support tool for people who are trying to manage cravings during smoking cessation programs. It is anticipated that the results of the study will provide knowledge of how physical activity affects cigarette craving in real-life situations and inform the development and delivery of relapse prevention in smoking cessation treatment. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): ISRCTN55259451; http://www.controlled-trials.com/ISRCTN55259451 (Archived by WebCite at http://www.webcitation.org/6cKF2mzEI).

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OBJECTIVES: To improve understanding of how individuals at high risk of type 2 diabetes experience the risk of diabetes and how these experiences relate to the adoption of physical activity as a protective behaviour. DESIGN: A qualitative study using semi-structured interview with individuals identified by screening as at high risk of type 2 diabetes. METHODS: Fourteen individuals, aged 40-64, were interviewed twice, with a 2-year interval between. Participants' experiences of their risk of diabetes and physical activity were assessed. The transcribed interview data were analysed using inductive qualitative content analysis. RESULTS: Two themes emerged from the data: a threatening risk perception and a rejected risk perception. The threatening risk perception occurred when the risk was unexpected by the participant, but became internalized through the screening procedure. The threatening perception also involved a commitment to increase physical activity to prevent diabetes. However, short-term anxiety and subsequently emerging hopelessness were also part of this perception. The rejected risk perception involved indifference and scepticism regarding the risk. Here, physical activity behaviour and cognitions appeared to remain unchanged. Rejection also involved difficulties in accepting one's high-risk identity. The rejecting group lacked motivation for increased physical activity, while the other group showed determination regarding increased physical activity, often leading to success. CONCLUSION: Perceptions of the risk of diabetes emerged as threatening or as rejected. Participants' perceptions reflected varying and intertwining emotional, cognitive, and behavioural mechanisms for coping with the risk, all of which should be recognized in promoting physical activity among high-risk individuals. Statement of contribution What is already known on this subject? Diabetes screening has few adverse psychological effects on screened individuals. Diabetes can be prevented by increased physical activity and modest weight loss among high-risk individuals. The evidence on the effects of screening on protective behaviour is limited and inconsistent. What does this study add? High-risk individuals' threatening perception of risk appears encouraging increased physical activity. Individuals having problems in adjusting to high-risk identification may not be motivated to engage in physical activity for prevention. Failure to achieve the outcomes expected from lifestyle changes may lead people with threatening risk perception to a sense of hopelessness.

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OBJECTIVES: To develop an assessment tool for evaluating oral health promotion practices and to evaluate community-based oral health promotion practices targeted at children and adolescents with this tool. METHODS: A theoretical framework about health promotion planning, implementation and evaluation was made on the basis of a literature review. Then, information about Finnish community-based oral health promotion practices (n=12) targeted at children and adolescents was collected using semi-structured interviews. Also, related documents, for example action plans and reports, were collected when available. Next, an assessment tool based on the theoretical framework was developed, and the recorded and transcribed interview data and other documents were evaluated with this tool. RESULTS: The assessment tool proved to be practical: it pointed out the strengths and weaknesses of the practices. The tool revealed strengths in the implementation and deficiencies in the planning and evaluation of oral health promotion practices. One-quarter of the 12 practices assessed could be considered 'good practices'. CONCLUSIONS: There is a need to improve the planning and evaluation of oral health promotion practices. The assessment tool developed in this study might be useful for practitioners both in the field of oral health promotion and general health promotion.

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OBJECTIVES: This study examined counselling communication activities that were used for assessing schoolchildren's need for change of snacking habits. In addition, the schoolchildren's assessment of their need for change was explored after a follow-up year (2002-2003). MATERIAL AND METHODS: The follow-up research data included 66 counselling sessions in 2002 and 31 counselling sessions in 2003, with 31 schoolchildren. The sessions were conducted by four dental hygienists. The audio-taped data were analysed qualitatively by using content analysis. RESULTS: In 2002, the needs assessment was realized in three ways. Infrequently, the schoolchildren either disclosed their need for change or the counsellor explicitly determined the schoolchildren's need for change. Usually, however, the schoolchildren's needs assessment for change occurred through the counsellors' communication activities of assessment, advice, and change-inducing questions. In one-third of the cases, the schoolchildren's need for change remained ambiguous during the sessions in 2002. With respect to positive changes in 2003, the schoolchildren themselves were aware of the need for change. Alternatively, the sessions included change discussion that addressed readiness for change and making changes during the counselling in 2002. CONCLUSION: Our results revealed that a thorough needs assessment of schoolchildren's snacking habits provides a foundation for behaviourally focused counselling.

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OBJECTIVE: This study explored oral health counselling concerning changes of oral hygiene habits in 11- to 13-year-old schoolchildren within a theoretical framework of the transtheoretical model and the motivational interview. METHODS: The follow-up data (2002-2003) formed two sequential parts: the first part comprised 66 counselling sessions in 2002; the second part included 31 counselling sessions in 2003. Thirty-one (n = 31) schoolchildren were included in the counselling sessions that were conducted by four dental hygienists. The audiotaped and transcribed data were analysed qualitatively by using content analysis. RESULTS: In 2002, nearly every schoolchild needed to establish changes in oral hygiene habits but the assessment of schoolchildren's readiness for change often remained unclear. In 2002, giving normative advice was the most commonly used counselling strategy when addressing the need for change, but dental hygienist-centred change discussion and goal setting were also apparent and were related to the schoolchildren's rarely manifested changes of oral hygiene habits after a follow-up year. CONCLUSIONS: Our results suggest that the theoretical framework might be useful in constructing and focusing on oral hygiene counselling for schoolchildren that concentrates on the personal dynamics of change. Further qualitative research is called for.

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As a case study, this article describes a nurse's communication activity, focusing on change talk during lifestyle counseling in primary healthcare. All videotaped counseling sessions with a single patient within a period of two years were transcribed verbatim. In the analysis, an emphasis was placed on the nurse's communication activity that produced change talk, how the nurse initiated change talk, and how the patient received it. The observations provide evidence that the dilemma of simultaneously maintaining professional authority and patient perspective leads to sensitivity in lifestyle counseling. Three categories of change talk were identified: rejected, restrictive, and expansive change talk. Producing change talk is a very demanding task for counselors. It is best produced when the nurse stays within the patient's frame of reference with a combination of reflective, change-inducing questions, encouraging assessments and conversational space. On the basis of our results, we suggest that nurses need training to identify and to encourage patients' change talk and to communicate flexibly according to patients' values during lifestyle counseling. In addition, in order to insist on change talk, we need to demonstrate how change talk could be carried out so that nurses could orient to it.

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