Dorien Brouwer

122 Chapter 2.2 PART 2 In this study, the number of patients that changed their lifestyle was high in both treatment groups. In our previous study with a similar study population, only 37% of the patients changed their lifestyle [18] in contrast to 44% in the control group of the present study. This might be explained by dedicated care of the nurses in both arms of the present study. Earlier studies found a strong relation between successful outcomes of problem drinkers and the degree to which their counselors displayed the skill of accurate empathy. [46, 47] Empathy is therefore seen as the basis of successful treatment with motivational interviewing. [48] As nurses can be expected to be empathetic, their empathy may therefore contribute to the lifestyle behavior change of the patients in both groups in this study. Motivational interviewing focuses on increasing self-management by building self-efficacy. In a previous study, we found that self-efficacy for health-related behavior change was high in patients after TIA and ischemic stroke and was the strongest determinant of intention to quit smoking, increase physical activity and/or improve healthy diet. [33] However, in the present study self-efficacy was not significantly increased in the intervention group (aBeta 0.16, 95% CI -0.09-0.42), although it seemed to play a role in smoking cessation (Table 4 and 5). At present, it is not clear whether stroke patients are capable of adopting self-management. Possible cognitive problems, physical constraints and fear can affect this process. In this study, we did not assess cognition, but earlier studies showed that cognitive disorders are highly prevalent after stroke. [49, 50] Strengths of our study are the detailed description of the content of the intervention and that the nurse was well trained in motivational interviewing and was coached and evaluated by an experienced trainer during the entire study. Furthermore, we used a relevant control group as both groups were seen by a nurse specialist, one with and one without specific motivational interviewing training and coaching. Our study has some limitations. First, the duration of the intervention (three months) might have been too short. Most patients are still rehabilitating during this phase and adapting to their disabilities. Hence, lifestyle behavioral change may not be their highest priority. Furthermore, the patients experienced fear, depressive symptoms and cognitive complaints that may have complicated the counselling. These problems were expressed during the counselling sessions and had more priority for the patients than lifestyle changes, but we did not measured cognition or depression in this study. Another limitation comes with the method of inclusion and data collection. After inclusion, patients were randomized and baseline data was collected. Patients were given time to complete the questionnaire during their stay. Unfortunately, some patients withdrew immediately after inclusion, or were discharged before the questionnaires were completed. In addition, patients sometimes appeared to have too much comorbidity or the first diagnosis was incorrect. This has