TABLE 2.

Summary of included papers

Author/Country	Aim	Sample	Methods	Findings
Aranda and McGreevy (2014) England	To explore perceptions & experiences of overweight GPNs on obesity management	7 GPNs	Qualitative Interviews	Personal experience provided insights into patients emotional struggles, social stigma, factors contributing to weight gain and barriers to weight loss. 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.
Beishuizen et al. (2019) Netherland & Finland	To explore GPNs best practices in behaviour change support for integration into an online cardiac risk prevention platform	13 GPNs	Qualitative Focus groups	GPNs viewed their role as supporting patient‐led lifestyle change and identified three preconditions for supporting patients accessing an online cardiac risk prevention tool: Establishing trusting relationships and providing individually tailored support. Raising awareness of personal risk; stimulating motivation through education & coaching; managing unrealistic expectations; and preparing for challenges. Appropriate timing and monitoring via regular GPN follow‐up to promote adherence.
Bräutigam Ewe et al. (2021) Sweden	To describe GPNs general perceptions of overweight, experiences of overweight /obesity in clinical practice, & visions for working with lifestyle issues	13 GPNs	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.
Geense et al. (2013) Netherlands	To explore clinicians current health promotion activities, attitudes, main topics plus barriers and enablers of health promotion activities	16 GPs 9 GPNs	Qualitative Interviews	GPNs often gave smoking cessation and dietary advice while GPs b advised about alcohol reduction. 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) Lack of funding for programmes and GPN time; changing subsidies and requirements; inconsistent policy; and poor intersectoral cooperation. Facilitators: (1) Awareness of risk and motivation for change; patient‐led agenda. (2) Optimizing GPN role; availability and time; co‐located allied health services. (3) Lifestyle risk reduction perceived worthwhile and part of GPNs role; (4) Familiarity with patients; easy access and affordability; (5) Clear policy; incentivized participation.
Goodman et al. (2011) England	To determine the current level of GPN involvement, knowledge & attitudes toward activity promotion for older adults	391 GPNs	Quantitative Surveys	GPNs encouraged physical activity by assessing current activity; providing advice; suggesting activities; 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. Lack of time (88%) and training (58%); poor staffing; organizational constraints; referral problems; and intermittent patient contact were barriers. There was no association between GPN activity levels and activity promotion in older adults.
Hornsten et al. (2014) Sweden	To describe communication strategies used by GPNs in health‐promoting dialogues	10 GPNs	Qualitative Interviews	Five contrasting themes described GPNs communication strategies. Guiding versus Pressuring: GPNs highlighted issues and offered tailored solutions or focused on problems and demanded change. Adjusting to the patient versus Directing the conversation: GPNs either used flexible approaches and were patient‐centred or prioritized their professional agenda. Inspiring confidence versus Instilling fear: GPNs either encouraged positive choices or emphasized the severity of risks and potential illness. Motivating and supporting versus Demanding responsibility: Some GPNs overcame resistance; made change achievable; increased patient self‐efficacy while others provided information about results; and placed an onus on patients to effect change. Introducing emotive topics versus Avoiding. Some GPNs were confident to initiate discussions and used training and experience to meet resistance. Others avoided hard to raise topics, people or issues.
James et al., (2020a, 2020b) Australia	To examine what communication skills GPNs used & how these are employed to reduce lifestyle risk	14 GPNs	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. 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.	15 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.
James et al. (2021) Australia	To explore barriers & facilitators to GPNs lifestyle risk communication	15 GPNs	Mixed Methods Interviews	Barriers: (1) educational preparation, professional development and confidence affected GPNs engagement in lifestyle risk communication; (2) organizational practices, limited time and funding arrangements constrained the prioritization of lifestyle risk communication; (3) lifestyle risk prioritization was considered less relevant than other clinical tasks or patient needs. Facilitators: (1) organizational support including the availability of time, space, resources and interprofessional collaboration created opportunities for lifestyle risk communication; (2) autonomous roles, enhanced by GPNs education, experience, confidence and accountability, supported lifestyle risk communication; (3) supporting patients needs and main concerns supported lifestyle risk reduction.
Jansink et al. (2010) Netherlands	To examine barriers to lifestyle counselling of diabetic patients to inform an intervention study	13 GPNs	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. Lack of time; understanding of roles; collaborative practice; & knowledge of local resources were organizational barriers.
Keleher and Parker (2013) Australia	To explore GPNs perceptions of current & potential roles in health promotion (HP)	54 GPNs	Qualitative Surveys	GPNs described HP in the context of established roles in chronic disease management. Often opportunistic, HP activities involved patient education and brief interventions. 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	Survey 225 GPNs Interview 15 GPNs	Mixed Methods Surveys Interviews	GPNs formed 15% of the survey sample and 14% had completed post‐graduate training in cancer prevention/treatment. Financial incentives focused preventive services on smoking and cervical screening (both 96.3%), obesity (94.5%), physical activity (84.9%), diet (82.5%) and alcohol (79.4%). GPNs most often provided information leaflets (84.3%) and brief advice (83.0%) for smoking cessation; asked patients about activity levels (84.9%) and diet (82.5%); provided weight management information (51.2%) literature about diet (46.1%). Most believed they could motivate patients (99.5%); that patients accepted their role (80%); were receptive to change (60.4%); and would follow advice (78.9%). Only 58.7% felt sufficiently knowledgeable to provide education and 84.1% wanted further training in effective behaviour change methods. Interviewed GPNs stressed the need to gain trust; develop therapeutic relationships over time; & follow the patients agenda. Challenges included feeling ineffective, patient ambivalence and disadvantage.
Phillips et al. (2014) Australia	To explore how GPNs manage obesity to identify good practice & barriers to effective management	18 GPNs	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. While GPNs encouraged patient‐led behaviour change; low health literacy; unrealistic expectations; complexity of change; and GPNs lack of confidence were barriers.
Tong et al. (2021) England	To describe elements of GPNs consults for weight loss, behaviour change techniques (BCTs) & dietary/physical activity recommendations	8 GPNs	Quantitative Audiotaped consultations	Content analysis of 51 audio recorded GPN consults with overweight / obese patients. The 93‐point BCT tool was used to assess use of BCT. GPN consults per patient averaged 2.8, the mean duration per patient over a 3mth period was 36.9 mins. Weight changes measured at 3, 6 and 12 months were − 3.6% (3.5 kg), −5.5% (5.5 kg), & ‐4.2% (4.0 kg) respectively. 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. GPNs used BCT ‘feedback on behaviour’ (80.0%); ‘problem solving’ (38.0%) and ‘social reward’ (34.3%) most often. 24/30 dietary recommendations were used, most often ‘portion size’ (31.3%). 9/10 physical recommendations were used, most often ‘encouragement of walking’ (30,3%). 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	5 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.
Westland et al. (2018) Netherland	To examine self‐management topics, duration and frequency & behaviour change techniques (BCT) used by GPNs to support self‐management	17 GPNs	Quantitative Audiotaped consultations	Content analysis of 78 routine GPN consults with patients diagnosed with chronic conditions was measured against 49 health and self‐management topics (H/SM). The 93 point BCT tool was used to assess the application of BCT. GPNs briefly addressed H/SM topics including diet (76.9%); physical activity (71.8%); understanding the disease (65.4%); exacerbation management (61.5%); medication management (57.7%); symptom monitoring (41%); alcohol use (37.2%); and smoking cessation (34.6%). 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.

^a GPN, General practice nurse.

^b GP, General practitioner.

^c SES, Socio‐economic status.