Understanding how general practice nurses support adult lifestyle risk reduction: An integrative review

Abstract Aim To review the literature exploring how general practice nurses support lifestyle risk reduction. Design Integrative literature review. Sources CINAHL, Emcare, MEDLINE, Proquest and Scopus were searched for peer‐reviewed primary research published in English from 2010 to 2022. Methods Sixteen papers met the inclusion criteria and were assessed for methodological quality using the Mixed Methods Appraisal Tool. Findings were extracted and thematically analysed. Results Four themes described general practice nurses: (1) Establishing relational connections; (2) Empowering active participation; (3) Engaging mutual motivation and (4) Enabling confident action. General practice nurses used complex interpersonal, risk communication and health coaching skills to build collaborative partnerships that supported patients' self‐determination and self‐efficacy. While mutual motivation and confidence were reciprocally enabling, gaps in skills, experience and knowledge plus time, resource and role constraints limited general practice nurses' ability to support lifestyle risk reduction. Conclusion General practice nurses play a key role in lifestyle risk reduction. Ongoing education, funding, organizational and professional support are needed to enhance their commitment, confidence and capacity. Impact What problem did the study address? While general practice nurses play a key role in health promotion and risk reduction, their potential is yet to be fully realized. Research examining methods by which nurses working in general practice support lifestyle risk reduction is limited. What were the main findings? Successful interactions depended on personal, professional, organisational and systemic factors which either enhanced or inhibited relational quality, shared decision‐making, mutual commitment, and nurses' confidence and capacity to address lifestyle risks. Targeted professional development and peer mentoring are needed to build proficient practice. Where and on whom will the research have impact? Understanding how general practice nurses support risk reduction can inform policy and identify training and support needs to advance their skills and role. Research exploring synergies between themes may illuminate this process.

million to diet, 2.84 million to alcohol use and 1.26 million to physical inactivity (Ritchie & Roser, 2018). While a raft of prevention and control initiatives have reduced smoking rates, tobacco use is still a leading cause of illness. Meanwhile, progress on dietary risk and inactivity has been limited and inaction on alcohol remains widespread (Department of Health, 2021;WHO, 2020).
Approximately 80% of Australia's burden of disease is attributed to chronic illness, 38% of which may be prevented by addressing lifestyle risks (Bartlett et al., 2016). Enhancing health literacy, promoting healthy behaviours and facilitating risk reduction can prevent, delay and slow the progression of many chronic conditions (Royal College of General Practitioners [RACGP], 2016). The benefits of risk screening, targeted health education, brief interventions, lifestyle prescription, behavioural counselling and referrals generated by primary care providers have been established (Department of Health, 2021). Nevertheless, historic underinvestment, fragmented policy, leadership inadequacies and focus on treatment have been persistent barriers thus clinical support for lifestyle risk reduction remains suboptimal and inconsistently applied in usual care (James et al., 2018). Renewed policy directions propose greater investment to improve social determinates of health, boost action to reduce lifestyle risks, and enable the health workforce to work to their full scope to promote health and prevent illness through multidisciplinary care (Department of Health, 2021). Greater adoption of primary health care approaches (WHO, 2020) including increased availability of primary care services and enhanced capacity and skills of health professionals is key to advancing this agenda (Department of Health, 2018).

| Background
Over 80% of Australians see a general practitioner (GP) at least annually, thus primary care is an important setting that provides opportunities to identify lifestyle risk and support behaviour change that enhances health outcomes (Halcomb et al., 2015). Changing patients risk behaviours requires sustained strategies including individual assessment, patient education and health coaching, goal setting, referral and follow-up (Harris et al., 2017;RACGP, 2015).
However, workforce shortages, system inefficiencies, maldistribution of services, growing health inequities and demand for chronic disease management (CDM), particularly in rural areas, continue to constrain capacity for preventive health activities (Department of Health, 2021). Like the United Kingdom, Europe and New Zealand, Australia has increased the numbers of general practice nurses (GPNs) to support the medical workforce and increase access to primary care services (James et al., 2018). With an estimated 63% of general practices employing a nurse, general practice nursing is currently the fastest growing area of the health system. Comprising mainly baccalaureate-trained registered nurses, general practice nursing falls within the domain of primary health care. These nurses have clinical roles in population health, health promotion, disease prevention, risk factor screening and CDM (Australian Primary Health Care Nurses Association, 2018; . Nurses working in collaboration with GPs can increase the capacity for preventive care in general practice by facilitating risk assessment, promoting risk reduction strategies through health education and self-management and supported behaviour change (Halcomb et al., 2014;Harris et al., 2017). Nurses spend more time with patients than GPs, communicate more effectively and elicit greater engagement with clinical care. Regular contact with at-risk patients enables GPNs to establish relationships that facilitate lifestyle risk communication (James et al., 2018). Clinically and economically effective and sustainable interventions provided by GPNs that facilitate risk reduction, build health literacy and promote self-management are acceptable to patients and clinicians (James et al., 2018). Even so, role ambiguity, lack of career framework, insufficient pre-clinical preparation and experience, and inadequate organizational support continue to limit the expansion and optimization of the GPN role James et al., 2018).
Opportunities exist to strengthen and advance GPNs' role in health promotion and prevention, especially in rural and remote areas where the prevalence of chronic illness and lifestyle risks is greatest . To date, preventive research has focused on interventions targeting specific conditions or single risk factors. Further research is needed to understand how preventive interventions may be more broadly and effectively implemented in routine primary care (Marks et al., 2020). Exploring how GPNs' currently support lifestyle risk reduction can furnish insights to inform Impact: • What problem did the study address?
While general practice nurses play a key role in health promotion and risk reduction, their potential is yet to be fully realized. Research examining methods by which nurses working in general practice support lifestyle risk reduction is limited.
• What were the main findings?
Successful interactions depended on personal, professional, organisational and systemic factors which either enhanced or inhibited relational quality, shared decisionmaking, mutual commitment, and nurses' confidence and capacity to address lifestyle risks. Targeted professional development and peer mentoring are needed to build proficient practice.
• Where and on whom will the research have impact?
Understanding how general practice nurses support risk reduction can inform policy and identify training and support needs to advance their skills and role. Research exploring synergies between themes may illuminate this process. policy and curriculum developments and strengthen organizational supports aimed at optimizing the GPNs' role and advancing best practice.

| Aims
This integrative review aims to explore how GPNs support adult patients to reduce lifestyle risks associated with chronic disease.

| Design
An integrative review was chosen to allow the synthesis of papers reporting diverse research methodologies. The approach described by Whittemore and Knafl (2005)

| Search methods
The search strategy involving keyword searching of CINAHL, Emcare, MEDLINE, ProQuest and Scopus databases ( Figure 1) for peer-reviewed primary research papers published in English from January 2010 to February 2022. Papers reporting GPNs' (registered nurses) interactions with adults to reduce lifestyle risks were included. Due to differences in scope of practice, papers focused on nurse practitioners, specialists and enrolled nurses were excluded (Table 1). Due to resource constraints and the likelihood that peer-reviewed papers would be more robust, the grey literature was not included in the search strategy. Hand searching of the reference lists of included papers and key journals yielded no additional papers.

| Search outcomes
Database searching identified 771 potentially relevant records from CINAHL, Emcare, Proquest; Medline; and Scopus databases which were exported into EndNote X9 (The Endnote Team, 2013).
Following the removal of 369 duplicates and 248 non-original research and 33 non-relevant papers, the titles and abstracts of 121 papers were reviewed against the inclusion/exclusion criteria by two authors (MM and EH). Twenty-five full-text papers were then independently screened by all authors, 16 of these met the inclusion criteria ( Figure 2).

| Data abstraction and synthesis
Findings from included papers were abstracted into a summary table to facilitate comparison (Table 2). Following methods described by Braun and Clarke (2006), inductive analysis involved immersion in the data to identify patterns and relationships between them across the data set. Initially, recurring concepts were coded and then collated into preliminary themes which were reviewed, defined and labelled. Analysis and synthesis of refined themes were verified by all authors (Whittemore & Knafl, 2005).

| Establishing relational connections
Establishing cooperative relationships was considered foundational to risk reduction interventions and was, therefore, a central concern in many papers (Beishuizen et al., 2019;Bräutigam Ewe et al., 2021;Hornsten et al., 2014;James et al., 2020b;Keleher & Parker, 2013;McIlfatrick et al., 2014;Phillips et al., 2014).  Qualitative Interviews • Personal experience provided insights into patients emotional struggles, social stigma, factors contributing to weight gain and barriers to weight loss.

| Empowering active participation
• GPNs a were conscious of how their weight impacted professional credibility; were sensitive about initiating discussions and drew on personal understandings and experiences rather than strictly adhering to guidelines. Qualitative Interviews • GPNs indicated that schools and mass media; regulation of the food market; and health promotion beyond healthcare objectives were arenas for expanding HP at a societal level.
• GPNs reported that positive interactions; tailored interventions; and collaborative care were conducive to lifestyle change. However, uncertainty about implementing guidelines plus ethical and cultural issues were challenges.
• GPNs perceived that the degree of patient motivation determined outcomes. While motivating resistant patients was difficult, positive results were professionally rewarding.
• GPNs stated that patients were responsible for their health choices and that parents needed to role model health behaviours. Nevertheless, GPNs recognized the impacts of education, health literacy, SES. • Barriers and facilitators related to (1) patients; (2) practitioners/practice settings; (3) provider attitudes; (4) programmes and (5) health care systems/government policy.
• Barriers: (1) comorbidities; low SES c and health literacy; and complexity of behaviour change.
(2) Lack of skill, time, interdisciplinary collaboration, facilities, and referral options; difficult to measure results; incongruent personal behaviour and professional roles; demotivation due to disappointing results.
(3) Perception that patients are unwilling; low priority; focus on treatment; scepticism. (4) Lack of availability, accessibility, proven efficacy and discontinuity of local programmes. (5)  and referring patients to specialist services.
• GPNs were confident to provide appropriate activity advice to uncomplicated sedentary patients but not to patients with chronic conditions.
• There was no association between GPN activity levels and activity promotion in older adults. Mixed Methods Video observations • GPNs explored lifestyle risk by informally building rapport; determined the agenda by assessing lifestyle behaviours, risk factors or following GP referral; affirmed and encouraged healthy choices; clarified priorities; and confirmed understanding using reflective listening.

Author/Country
• Opportunities for further exploration, agenda-setting and education were sometimes missed; confidence & importance levels were not assessed; GPNs often did not summarize patient priorities.
• When they occurred, discussions related to patient choice, goal setting and action planning were prolonged. Closed questions and statements were sometimes used to present options. Reflective, affirming statements were used to show empathy for barriers to change.
James et al., (2020a, 2020b) Australia To explore GPNs perceptions of interactional factors that support lifestyle risk communication.

GPNs
Mixed Methods Interviews • Communication ranged from patient-led to the use of scare tactics. Most GPNs adapted their communication style and information according to patient needs and capacity.
• Approachability and relational continuity helped GPNs establish rapport, trust and familiarity necessary for ongoing, open dialogue.
• Successful discussions depended on the patients motivation, readiness and capacity to prioritize lifestyle change. Some GPNs initiated discussions and addressed barriers to change whereas others responded only when patients indicated readiness to change.
• Patient lack of awareness of the GPN role led to misconceptions that reduced the duration and content of lifestyle communication. Qualitative Interviews • GPNs felt they had insufficient knowledge to provide diet and physical activity counselling, were unmotivated and considered lifestyle counselling ineffective.
• GPNs had difficulty adapting communication; resisting directive approaches; maintaining appropriate expectations; developing action plans; and involving patients in decision-making.
• GPNs believed patients lacked insight and knowledge about their health; made excuses; and were noncompliant. Low literacy and SES; social and cultural influences; addiction and relapse; and psychological issues were perceived barriers for patients. • Most described a potential to work beyond the management practices that defined their role and directed their work. Opportunities for expanded roles in HP included conducting lifestyle clinics and groups sessions; implementing recalls and reviews; delivering smoking cessation programmes; building therapeutic relationships; and facilitating multidisciplinary care.
• Funding structures and GP support were important enablers of GPN role expansion.
• Resistance to expanding roles; inadequate knowledge, skills, time and appropriate space; poor organizational capacity and interprofessional collaboration were common constraints.

McIlfatrick et al. (2014)
Ireland To examine clinicians current and potential roles, explore facilitators/ barriers & identify strategies to overcome difficulties in cancer prevention

GPNs
Mixed Methods Surveys Interviews • GPNs formed 15% of the survey sample and 14% had completed post-graduate training in cancer prevention/treatment.
• Only 58.7% felt sufficiently knowledgeable to provide education and 84.1% wanted further training in effective behaviour change methods. Qualitative Interviews • GPNs routinely provided weight advice to patients who attended for CDM, were newly diagnosed or presented with weight-related problems. Opportunistic weight discussions were thought to alienate patients and endanger therapeutic relationships.
• Familiar therapeutic relationships facilitated openness and honesty. Personal experiences were used to demonstrate empathy.
• GPNs were confident to assess patient readiness for change and motivational interviewing strategies were used to assess patients motivation, expectations and confidence.
• Self-esteem and self-image were explored, immediate benefits of lifestyle change were highlighted, and goals were linked to relevant life events.
• GPNs provided individually tailored dietary advice; promoted activity patients enjoyed; tailored suggestions to address barriers; and emphasized small, sustainable changes increasing in intensity over time. Self-monitoring options and smart technology were sometimes suggested.

TA B L E 2 (Continued)
• 29/93 BCT were used at least once; 3.9 BCT were used per consult per patient; and 10.6 BCT were used per patient overall.
• Longer consults and No. BCT used were positively associated. There was no significant correlation between the average No. of BCTs / diet and activity recommendations per consult and weight change.

Walters et al. (2012)
Australia To investigate potential roles for GPNs in health mentoring (HM) for chronic disease self-management

GPNs
Mixed Methods Surveys Interviews • GPNs were surveyed prior and interviewed following HM training.
• Pre-training: GPNs indicated a high degree of role engagement, autonomy, collegiality, organizational support and collaboration.
• Lifestyle advice was usually provided during consults for CDM and less often in routine care.
• The importance of respecting patient preferences and working in partnership was recognized. Nevertheless, GPNs said they generally told patients what to do.
• GPNs confidence in setting health goals, developing action plans and mentoring patients through difficulties was mixed.
• Post-training: GPNs wanted HM approaches embedded in routine care and recognized a need for frequent, regular contact however heavy workload and low task priority were barriers. • BCT were applied implicitly. Most GPNs (n = 11) 'reviewed behaviour goal(s)' and 'gave feedback on behaviour' most often; the majority (n = 13) 'gave information about health consequences' least often.
• GPNs rarely assisted with goal setting and action planning. While barriers to change were discussed, strategies for overcoming them were not explored.   Keleher & Parker, 2013). However, financial incentives and organizational priorities frequently influenced nursing activities (Hornsten et al., 2014;McIlfatrick et al., 2014;Walters et al., 2012). Resistance to role expansion plus poor interprofessional and intersectoral collaboration were common constraints (Geense et al., 2013;James et al., 2020b;Jansink et al., 2010;Keleher & Parker, 2013). General practice nurses called for greater organizational support and prioritization of prevention, more collaborative interdisciplinary relation-   et al., 2021). Nurses using behaviour change techniques most often provided 'feedback on outcomes of behaviour', 'reviewed behaviour goal(s),' and engaged in 'problem solving' (Tong et al., 2021;Westland et al., 2018). While some nurses were confident to motivate patients (Beishuizen et al., 2019;Goodman et al., 2011;McIlfatrick et al., 2014;Phillips et al., 2014), observational studies showed general practice nurses often did not assess patients' self-confidence, explore barriers to change or identify strategies to overcome them (James et al., 2020a;Westland et al., 2018). Tong et al. (2021) similarly noted that, despite longer consultation times, nurses' use of behaviour change techniques was infrequent and variable. Reciprocally low motivation, negative attitudes and experiences and poor results were frustrating, causing some nurses to limit their involvement in lifestyle risk reduction (Aranda & McGreevy, 2014;Geense et al., 2013;Hornsten et al., 2014;James et al., 2020b;Jansink et al., 2010;McIlfatrick et al., 2014;Phillips et al., 2014).

| Enabling confident action
Once motivated, patients were sometimes described as holding unrealistic expectations and lacking confidence and capacity to overcome obstacles to change (Beishuizen et al., 2019;Phillips et al., 2014). Therefore, nurses needed to negotiate realistic, actionable goals that were linked to patients' priorities (Beishuizen et al., 2019;Hornsten et al., 2014;James et al., 2021;Jansink et al., 2010;Phillips et al., 2014). Continuing conversations were necessary to attain a level of health literacy and risk awareness that stimulated readiness to change (Bräutigam Ewe et al., 2021;James et al., 2020b;Phillips et al., 2014). Providing personalized information, advice and education were considered essential nursing skills that increased patients' knowledge and ability to reduce lifestyle risks (Beishuizen et al., 2019;Hornsten et al., 2014;James et al., 2020a;James et al., 2021;Keleher & Parker, 2013). In routine consultations, lifestyle advice was often related to diet and physical activity (Geense et al., 2013;Phillips et al., 2014;Tong et al., 2021;Westland et al., 2018). Tong et al. (2021), for example, observed that portion control and encouragement of walking were the most common dietary and physical activity recommendations provided.
Nevertheless, many GPNs felt they lacked the time, knowledge, skills and confidence to provide effective lifestyle education (Bräutigam Ewe et al., 2021;Geense et al., 2013;Goodman et al., 2011;James et al., 2021;Jansink et al., 2010;Keleher & Parker, 2013;Phillips et al., 2014), and opportunities were sometimes missed (Hornsten et al., 2014;James et al., 2020a;McIlfatrick et al., 2014;Tong et al., 2021). James et al. (2021) highlighted that educational preparation, continuing professional development and confidence affected the level of nurses' engagement and many expressed a desire to develop their knowledge and skills. As one small study showed, nurses' confidence to support goal setting improved following training in health coaching methods. Nevertheless, their efforts were limited due to a lack of follow-up training and organizational support (Walters et al., 2012).
Several papers described enablement strategies including goal setting, action planning, monitoring patients' progress and referring them to other providers for additional support (Bräutigam Ewe et al., 2021;Geense et al., 2013;Goodman et al., 2011;Hornsten et al., 2014;James et al., 2020a;Phillips et al., 2014;Westland et al., 2018). Nurses reported that devising achievable, goal-focused plans that detailed measurable actions and outcomes, and enabled monitoring and follow-up, while effective, was also time and skill intensive (Goodman et al., 2011;James et al., 2020a;Phillips et al., 2014;Walters et al., 2012). Many nurses were not confident with these processes (James et al., 2020a;Jansink et al., 2010;Walters et al., 2012). When negotiating actions, small changes increasing in intensity over time were usually suggested. Outcomes were evaluated in terms of negotiated targets (Goodman et al., 2011;Phillips et al., 2014). Few papers described nurses advocating the use of self-monitoring tools to enhance self-management (Beishuizen et al., 2019;Phillips et al., 2014;Westland et al., 2018).
Regular follow-up encouraged adherence and motivation while also enabling monitoring of progress and support for patients experiencing difficulties (Beishuizen et al., 2019;Phillips et al., 2014).
However, nurses reported issues with referral pathways and lack of suitable, affordable and available local services (Bräutigam Ewe et al., 2021;Geense et al., 2013;Goodman et al., 2011;Jansink et al., 2010). While opportunities existed for general practice nurses to take a greater role in arranging recalls, follow-ups and multidisciplinary care (Keleher & Parker, 2013),   (2017) and Vallis et al. (2018), nurses in this review believed they respected patients' autonomy and endeavoured to involve them in decisionmaking. However, they recognized that they also tended to engage in communication that involved the use of advise, direct, instruct and control type strategies. Kozlowski et al. (2017) confirm that authoritative, pessimistic and dismissive attitudes, lack of confidence in interventions, and low priority for risk reduction are often related.

| DISCUSS ION
This presents opportunities to enhance future practice through education that builds and maintains GPNs' motivation, communication skills and confidence with participatory approaches (Vallis et al., 2018;WHO, 2021).
Similarly, while motivational interviewing enabled GPNs to assess patients' risk awareness, readiness and confidence to reduce risks (James et al., 2018;Lambrinou et al., 2019), these skills were generally underdeveloped and underutilized. As James et al. (2018) indicated, ongoing training and support are needed to maintain proficiency in these complex skills. Likewise, although nurses strove to tailor information, health education and interdisciplinary support to promote patients' health literacy, self-efficacy and independence The availability of nurses in general practice, nurses' confidence in the value and efficacy of risk reduction interventions, collaboration with enthusiastic colleagues and organizations that prioritized risk reduction and optimized GPNs' roles were potent facilitators.
Nevertheless, current funding structures, management practices and organizational cultures continue to restrict GPNs' role, scope and autonomy of practice, reinforcing task-focused practice . As Desborough et al. (2018) and James et al. (2018) recommend, issues related to GPNs' role and training, time, funding and organizational support must be addressed to optimize future clinical practice about lifestyle risk reduction. Despite the reported acceptability and effectiveness of nurse-led lifestyle risk reduction, evidence remains unclear and research elucidating the successful elements of such interventions is needed (Stephen et al., 2022).

| Limitations
Despite its contribution, the relatively small number of studies and the narrow geographic distribution of papers retrieved and included in this review may be a limitation. Broader inclusion criteria were considered, however the volume of results and emphasis on interventions rather than interactions made this strategy unsuitable.
Additionally, the grey literature was not included due to the lack of peer review and rigour in reporting. While providers in other primary care settings also support lifestyle risk reduction, continued expansion of nursing in general practice justified the focus of this paper. Although other nursing professionals may also play a role in risk reduction, this review focused on the role of registered nurses who form the majority of the GPN workforce.

| CON CLUS ION
This review corroborates evidence for relationship-centred care and reinforces the important role of GPNs in cultivating collaborative relationships that promote shared decision-making, readiness for change, health literacy and enhanced capacity for risk reduction.
Findings confirm synergistic relationships between patient participation, motivation and confidence and nurses' attitudes toward patients and interventions as well as their interpersonal, risk communication and care planning skills. As previous research has shown, lack of prioritization, time, training, funding, interprofessional collaboration and organizational support must be addressed to enhance GPNs' roles and motivation, and to equip them with the knowledge, skills and resources they need to effectively support lifestyle risk reduction. This review also highlights a gap in understanding synergistic processes involved in lifestyle risk reduction support provided by nurses in general practice. Further research may provide a theoretical conceptualisation of the process and inform strategies that strengthen GPNs' involvement, competence and confidence in the area of lifestyle risk reduction.

AUTH O R CO NTR I B UTI O N S
All authors have agreed on the final version and meet at least one of the following criteria (recommended by the ICMJE*): (1) substantial contributions to conception and design, acquisition of data or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content.

MM has been supported by an Australian Government Research
Training Program Doctoral scholarship.

CO N FLI C T O F I NTE R E S T
No conflict of interest has been declared by the authors.