Stop smoking advice by practice assistants after routine cervical screening in general practice: A qualitative exploration of potential barriers and enablers

Figures & data

Table

The core team of a Dutch general practice consists of a general practitioner (GP), a practice assistant (PA), and – in most practices - a qualified nurse. In countries with similar healthcare systems, PAs are known as ‘medical assistants’, ‘medical secretaries’, ‘healthcare assistants’ or ‘allied health personnel’. The professional education for PAs consists of a three-year vocational training (‘Middelbare Beroepsopleiding’ (MBO) level four, equivalent of European Qualifications Framework (EQF) level four), which is comparable to the ‘BTEC Level three Extended Diploma’ in the U.K. or VET-diploma in Denmark. Activities for PAs vary according to practice needs. In the job description published by the Dutch National Association of General Practitioners (Landelijke Huisartsen Vereniging, LHV), an assistant’s tasks broadly cover the intake or triage of patients and providing assistance for medical or administrative and organisational tasks. Many PAs have their own consultations, for example: taking cervical smears or measuring blood pressure [i]. The knowledge, skills, and competence of PAs vary in EU member states [ii], which can partially explain differences in the deployment of PAs between countries. An average Dutch general practice employs a 1.94 full-time equivalent PA and a 0.63 fte nurse [i]. Job qualifications for practice assistant differ from those of a qualified nurse (professional education for nurses is required, at EQF level six). Qualified nurses provide protocol-based care and are specialised in chronic care management, typically for patients with diabetes, COPD / asthma, cardiovascular diseases, or vulnerable elderly [iii]. For example, the nurse can address issues such as medication use, but also engages in lifestyle counselling such as smoking cessation. Nurses work more or less independently. In general terms, nurses provide care for specific patient groups in general practice and typically do not engage in administrative tasks. In contrast, in some PAs also provide chronic care management or other case-based tasks which can overlap with those of a qualified nurse.

i Landelijke Huisartsen Vereniging, https://www.lhv.nl/service/functiewaardering-huisartsenzorg, Handleiding FWHZ_Functiewaardering Huisartsenzorg.pdf, 2019.

ii Kroezen M, Schafer W, Sermeus W, et al. Healthcare assistants in EU Member States: An overview. Health Policy. 2018 Oct;122(10):1109-1117.

iii Nederlandse Zorgautoriteit, https://puc.overheid.nl/doc/PUC_3629_22, Praktijkkostenonderzoek huisartsen 2015.pdf, 2017.

Table 1. Guide with topics used in the focus group discussions with practice assistants, nurses and general practitioners ^a.

1. Opening of the focus group - Short introduction: what is your profession, where do you work? - Provide a brief answer to the following question: ‘How is smoking status registered within your practice?’

2. Explanation of the strategy, explanation of the Ask-Advise-Connect steps ‘We would like to know how you think about the delivery of a stop smoking strategy by the practice assistant after routine cervical cancer screening in general practice. This strategy consists of three steps: asking and registering smoking status, providing brief stop smoking advice, referring smokers to the practice nurse for smoking cessation counselling.’

3. First response to the stop smoking strategy - What are your first thoughts on this strategy? - What would be a reason (not to) choose this approach? - How do you think your colleagues think about this approach?

4. In depth discussion Health behaviour - What are the tasks of the practice assistant / practice nurse / general practitioner when it comes to health behaviour change? Smoking cessation - Who’s tasks is it to register smoking status / provide stop smoking advice / deliver counselling? - How do you work with colleagues when you provide stop smoking support? - What are your experiences with smokers and with stop smoking in patients? Smoking cessation after cervical screening - How would you feel about delivering stop smoking advice after the cervical smear? - How do you expect female smokers would respond to such advice? - What do you believe could be the problems and/or benefits of this approach?

^asummarised and translated from original version in Dutch.

Table 2. Participant characteristics.

Characteristics	Participants
	(n = 19)
Gender
Female	17/19
Male ^a	2/19
Age	27–60 yrs.
Profession
Practice assistant	10/19
Nurse	3/19
General practitioner	6/19
Geographical location of general practice
Major city	11/19
Urbanised region	6/19
Rural/village	2/19
Smoking status ^b
Ex-smoker	10/19
Never-smoker	9/19
Years of working experience ^c
1	2/19
2–10	4/19
> 10	13/19
Attended courses
Stop smoking support	5/19 ^d
Motivational interviewing	5/19 ^e

^aTwo male participants were both GPs, all other participants were female.

^bThree categories: Current-smoker, Ex-smoker and Never-smoker.

^cTotal number of working years as a practice assistant/nurse/general practitioner.

^dNo practice assistants previously participated in a course on providing stop smoking support.

^eOne practice assistant previously participated in a course on motivational interviewing techniques.

Table 3. Illustrative quotations.

Level of influence & potential factors		Illustrative quotations (PA ^a, GP ^b)
Individual level – the practice assistant	The practice assistant’s professional role	#19-PA: At our practice a person’s smoking status is not registered, at least it can’t be seen immediately. Actually, we have little to do with it. Well, apart from when they say that they want to stop smoking and ask questions about how to go about it. Then we refer the patient to the practice nurse. #21-PA: First you complete the form for cervical screening: ‘Do you have symptoms. Do you smoke?’ It could easily be integrated.  #17-Nurse: I was thinking that it would generate resentment to ask about smoking after the smear. But the practice assistants from my practice said they would ask for it right away, if needed.  #21-PA: Because you can easily explain it, because of the relationship with HPV. #1-Nurse: My idea would be to put the question for smoking status on the form (for cervical screening). And to provide smokers with a leaflet or something. I believe it is quite a burden for practice assistants to have to provide this whole stop smoking advice. #4-PA: Yes, it was quite a challenge to go about it […] Those who smoke want to know why you ask. We would need interview techniques, to learn how to structure the consultation. #22-PA: Motivational interviewing, that is a must. You know, that you get trained in how you approach people. #6-PA: Yes, that you understand why people smoke and don’t start to get negative. You should be able to formulate it nicely. #9-GP: You have to think through how to approach female smokers. Simply asking for the smoking status should not at all be a problem for practice assistants […] But for the advice, maybe a chart with information could help. Also to inform the patients. #16-PA: I would prefer to only work with the questionnaire, “do you smoke, yes or no”? And that the nurse takes care of the rest, the advice and counselling and all that. #11-GP: Asking the question should not be the problem. But getting an extensive training. I don’t know. I think they (Pas) are too busy.
	Attitude towards the cervical smear as a teaching moment	#5-PA: I believe we need to make women conscious of the risks, using that specific moment […] The percentage of female smokers is high. It can serve as a moment of realisation to make it personal. #9-GP: I would be glad if the practice assistant took her time to record the smoking status as a way to make patients aware of the risks. I believe many people are aware of lung cancer and cardiovascular disease. Honestly, the risk of cervical cancer in smokers wasn’t so evident to me either. #18-GP: Many young women do not get in touch with our practice because they are healthy or only for their children. So once they are here [for the smear] you make use of that moment.
Interpersonal level – interaction between practice assistant and female smoker	Do not overwhelm	#16-PA: First, they are in a vulnerable position, literally. The explanation that they probably need at that moment: What does it (smoking status) have to do with it (smear test)? And their anxiety and stress at that moment. #3-Nurse: I think you really take them by surprise. As I see it, I believe it is better to ask permission to discuss smoking. You could even do this before the cervical smear.
	Challenging switch from smear to smoking	#4-PA: I can imagine that it can be quite a challenge if you have only recently started performing cervical smears. And having to switch from the smear to asking about that (smoking), you’re not going to be able to do it in merely 10 min. #1-Nurse: If there is a link, you can obviously use it. Women come for the cervical smear but they smoke. These things are at odds with one another, which you can easily explain. #11-GP: I believe it is good to take your time to explain the relationship between smoking and cervical cancer. And to provide some background information. In case difficult questions are asked, you can provide an answer to that.
	Beliefs about smokers and their response to stop smoking advice	Various PAs: The enhanced risk of cancer in smokers could stimulate them (smokers) to quit, and: Women could be receptive to quit advice because many of them have or want to have children or: Having an aberrant smear result would make women more receptive to quit advice, versus: Women who visit for the smear and have not experienced any major health-related problems will not change their behaviour. #8-GP: If they smoke they want to hear that they don’t have cancer. On the other hand, I don’t think they want to stop (smoking) to avoid it. They just want to hear that they don’t have it – they can then go on smoking. Stopping is a stage further, but this is true for all addictions. #10-GP: I recognise having thoughts such as: ‘it’s useless to discuss smoking because it is not the reason for their visit.’ I am actually surprised how often smokers are open to it, or at least thinking about it or dealing with it.
Workplace – organisation and attitudes at the general practice level	Nurse’s interest and availability	#20-PA: It’s noticeable that people like it if they immediately get an appointment. ‘An appointment, that’s OK.’ Because our practice nurse is only here on Mondays and Tuesdays. I think she doesn’t like to give stop smoking advice. #18-GP: The same in our practice; she didn’t choose to do it. I believe the nurse is the only bottleneck. #17-Nurse: You could schedule an appointment directly after the smear, right? #25-PA: Yes, but our nurse needs to confirm this. And if she is not motivated to do it. I mean, she should be willing to cooperate in this, for easy referral.
	General practitioner’s view on prevention	#21-PA: I talked to the boss about it once. He said: ‘You can lower cholesterol levels by 40% if you stop smoking.’ And then I said: ‘Well, then you’ve got something to do.’ Then he said: ‘But people have to choose to do so’ I was shocked about this, that you could influence cholesterol levels by 40%. I think that he was setting out the strategy. I was looking for – what do we think about this? As a practice?
	Within-practice approach to stop smoking care	#7-GP: I don’t consider us fit for primary prevention, or at least, it’s not a task for us. […], I will not start talking about smoking behaviour with a patient with knee problems. The same goes for weight, I won’t start to discuss that if someone comes with a cough. Sometimes, I try to address it if the subject is related. #10-GP: As a doctor, I see the importance of primary prevention in this relatively young group of people. I see that as a positive aspect of being a GP. That you can pick out certain patients and send them to the practice nurse and advice: do you smoke – yes or no? If you smoke, do you want to do something about it?

^aPA: practice assistant.

^bGP: general practitioner.