Development of a conversation approach for practice nurses aimed at making shared decisions on goals and action plans with primary care patients

The first step involved a needs assessment to identify what, if anything, needed to change and for whom. In order to gain an overview of theoretical assumptions, we first reviewed the literature about definitions, theories and models for shared decision making, goal setting/action planning, and self-management support [12]. We found that shared decision making models are mostly developed to support (medical) professionals to empower patients in making tailor-made treatment decisions [8]. These models often neglect the exploration and formulation of patients’ goals. However, in chronic care, setting goals for quality of life seems a precondition to prioritize relevant options for prevention, cure or care [10‐13]. Theories and models for goal setting/action planning describe goal setting and action planning as an iterative process, consisting of several phases. The ‘Goal setting and Action Planning Practice Framework’, developed by Scobbie, Wyke & Dixon (2010) [26], is based on a comprehensive review of goal setting theories [27‐29] and highlights the importance of exploring patients’ experiences before setting goals and then planning actions. The literature also frequently highlights that professionals need to act as coaches for their patients [20, 30‐33]. A health coach seeks to support patients in setting goals that fit their situation and motivation, and health coaching is therefore tailored to what is important for patients [20, 30, 31].

Second, we explored experiences, needs, barriers and facilitators with regard to shared decision making about goals and action plans in primary care by conducting a descriptive qualitative study. Between April and June 2013, two focus groups and three individual interviews were conducted with patients, primary care professionals and experts (total participants = 17) [34]. The primary care professionals worked in practices for family medicine, occupational therapy, physical therapy, psychology and social work. The experts had experience of patient representation, self-management support, communication between patients and professionals, patient-centred practice and shared decision making. We found mostly barriers for the implementation of shared decision making about goals and action plans with chronically ill patients in primary care [34]. Barriers were related to the difficulties professionals encounter in exploring patients’ experiences from a holistic point of view (i.e. with regard to problems in everyday life, work, emotions, coping with the disease or support from the environment), and to explore patients’ goals and preferences and set medical or non-medical goals accordingly. Other barriers for goal setting/action planning in everyday practice were the professionals’ attitudes and skills with regard to involving patients in goal setting/action planning and the complexity of tailoring shared decision making about goals and action plans to the patients’ needs, motivation and capabilities. Moreover, time was considered a significant barrier [34].

Third, we examined the current working methods with regard to shared decision making about goals and action plans by observing eight consultations between practice nurses (n = 4) and patients (n = 8). After each observation we briefly interviewed (15 min) the practice nurse and patient about their experiences of the consultations. Practice nurses were all female and had at least one year of work experience; patients were aged between 75 and 89 years and all had complex (health) care requirements. Content analysis of the eight observed consultations revealed that explicit shared decision making about goals was rare. Action plans were frequently not made explicit and no agreement on actions was reached. Nurses often used a structured biomedical protocol (e.g. a structured questionnaire) to explore patients’ problems. They then initiated discussions about possible solutions to these problems. The interviews after the consultations showed that most patients were not aware of the purpose of the consultation and they could not recall any goals or actions agreed upon. Practice nurses found it difficult to reflect on their working method. Nevertheless, they were generally satisfied with the consultations. They reported a lack of guidance/tools to explore patients’ problems from a broader perspective.

Fourth, we conducted a scoping review in order to review the content of goal setting and action planning interventions in the context of self-management [35]. We identified 58 articles reporting on interventions for goal setting/action planning. By analysing the contents of the interventions we created an overview of phases, components and strategies for goal setting/action planning. We found that most interventions were disease-specific and focused on improving one or more predefined lifestyle behaviours. Although goal setting/action planning was recognized as a complex interactive activity, few of the interventions explicitly focused on communication or shared decision making about goals/action plans or on possibilities to tailor the intervention to patients’ needs, motivation and capabilities [35].

Step two of the IM protocol identifies what should be targeted in the approach. Based on our needs assessment, the overall aim of the approach, as well as objectives, were formulated and prioritized by the advisory board of the project. The advisory board consisted of researchers, professionals or experts working for universities, primary care or patient organizations. The advisory board was closely involved in the project (from grant application to project implementation).

The overall goal of the approach was formulated as follows: practice nurses make shared decisions with their patients about goals and actions. Based on the needs assessment, we formulated four specific objectives: (1) practice nurses explore the patients’ perspectives from a holistic point of view (exploring medical symptoms, impact of the condition on everyday life/work, emotions, coping with the condition and support from the environment), (2) practice nurses explicitly formulate goals and action plans together with the patients (i.e. deciding together about goals and actions, as well as recording the goals and actions in the patient file), (3) practice nurses tailor shared decision making about goals and action plans to patients’ needs, motivation and capabilities (e.g. tailoring the communication about goals, the number and difficulty of goals and actions), and (4) practice nurses continuously reflect on their work routines and their work-related attitudes.

In the third step of the IM process, methods and strategies for the approach were chosen, which were translated into practical components for the approach in step 4 (producing programme components). Steps 3 and 4 were performed in an iterative process. This was done by a development team. The team consisted of patients, professionals and experts (on shared decision making, goal setting/action planning, self-management support, professional–patient communication, education and design) (n = 12). By involving experts from the Dutch National Health Care Institute and the Dutch College of General Practitioners we aimed to enhance national support for the project. During April 2014 and May 2015, the team met on a two-monthly basis. During step 4 (between January and June 2015) three practice nurses (two female, one male) were invited to closely collaborate with the development team. They were recruited from the researchers’ network and had over 10 years of work experience with chronically ill patients in primary care. They were asked to apply the approach, or parts of it, in their everyday practice and to share their experiences regarding the added value and feasibility with the development team. In monthly reflection meetings (n = 6), these practice nurses and the development team reflected on the experiences and further developed the approach. In addition, a pilot study was conducted to evaluate the added value and the feasibility of the approach. During January and April 2015, eight professionals (four female practice nurses collaborating with four male family physicians) were trained to use the approach and asked to apply it in practice over a period of eight weeks, with at least ten patients. After four weeks and after eight weeks, focus group interviews were conducted to explore participants’ experiences.

In steps 3 and 4 we first came up with a practical ‘framework for shared decision making about goals and action plans’, in which we combined an existing model for goal setting [26] with the three-talk model for shared decision making [8] (for further explanation see section titled ‘The conversational approach’). To support the use of the framework, we further developed a practical tool for exploring patients’ experiences, the ‘4-circles tool’ (for further explanation see section titled ‘The conversational approach’). For the pilot study we developed a training course, consisting of a 4-h workshop and a workbook. It aimed to support professionals in using the practical shared decision making framework and the 4-circles tool with their patients, and was presented by an experienced trainer, specialized in educating family medicine professionals. The training course included information on the background and theory of the approach, discussions of the approach, reflection about integrating the approach in everyday practice and role-playing exercises.

Through the close collaboration with the three practice nurses who had joined the development team and the pilot study we got more insights into the experiences with applying the framework and the 4-circles tool. We learned that all professionals experienced the approach as valuable in their everyday practice. The participants highlighted the value of being stimulated to explore patients’ experiences in greater depth. They felt that the practical shared decision making framework and the 4-circles tool led to more shared decisions and to more concrete goals/actions. However, most participants struggled to implement the approach in their everyday practice. They reported that they felt they lacked coaching skills. They needed more guidance to integrate the approach in their work routine and they experienced a lack of support for tailoring the approach to patients’ motivation and capabilities. They also hesitated to deviate from the commonly used biomedical protocol, as they felt it was their responsibility to ‘monitor’ the patients’ health status. They frequently found it difficult to deviate from their own professional ideas, as they worried that patients would make ‘wrong’ choices. They wanted more support in their learning process to become a coach for patients.

Based on these results we decided to (a) extend our conversation approach, in order to provide professionals with more support in tailoring the approach to individual patients and (b) develop a more comprehensive training course, to improve professionals’ coaching skills and change their attitudes. To this end, we expanded our development team by including a professional coaching company (Dubois & Van Rij), with extensive experience in developing training courses for professionals and which worked with an evidence-based patient profile model to support professionals in tailoring their communication to patients’ needs, motivation and capabilities.

The practical framework for shared decision making about goals and actions forms the basis of the conversation approach. It aims to facilitate professionals in going through the process of shared decision making. It is based on and combines the three-talk model for shared decision making developed by Elwyn (1999) [8] and the ‘Goal setting and action planning practice framework’ developed by Scobbie, Wyke & Dixon (2012) [26]. The framework consists of 4 phases: Preparation, Goal setting, Action Planning and Evaluation (see Table 1). Each phase involves a number of steps that the professional can perform to achieve shared decision making with patients. Depending on the patient’s situation, the framework can be flexibly applied. The time spent on each phase can vary and patients and professionals can move back and forth between the phases in an iterative manner. In addition, supportive tools can be used in the different phases. A comprehensive workbook for the professionals explains the framework, its phases and steps, and offers examples of tools and strategies. Moreover, professionals are provided with printed descriptions of example cases and a video with an example case.

This framework incorporates two tools: (1) a tool for exploring the patients’ perspectives (the 4-circles tool) and (2) a tool for identifying patient profiles in order to tailor shared decision making about goals and action plans to patients’ needs, motivation and capabilities. For the integration of the shared decision making framework and the two tools see Table 2.

The 4-circles tool (see Fig. 2) has been developed for use within the goal setting phase of the practical framework for shared decision making. It aims to support practice nurses and patients in collaboratively exploring the patients’ experiences with their condition from a holistic point of view and to facilitate a dialogue between nurse and patient about the patient’s current and desired situation (with regard to health, everyday life, social/physical environment and coping strategies). Its generic character means that the tool is not disease-specific and can be used for all chronically ill patients or other patients with complex health care requirements. It is meant to help patients gain insight into and reflect on their own situation, in order set goals (including non-medical goals) for them. The development of the 4-circles tool was inspired by A-FROM (Living with Aphasia: Framework for Outcome measurement), a tool to explore the impact of aphasia on a person’s everyday life [36]. Like A-FROM, the 4-circles tool is based on the framework of the International Classification of Functioning, Disability and Health (ICF), which presents a holistic approach to health, recognizing the interrelation between health and health-related domains [37]. The domains of the ICF have been simplified and visualized using four circles: (1) ‘My health’ represents the ICF domain of ‘Body Functions and Structures’. Within this circle, patients’ medical (physical and mental) symptoms are explored and patients are asked what they need to improve their symptoms. The questions and required professional actions from the practice nurses’ (biomedical) protocol can be asked and taken within this circle. (2) ‘My activities’ represents the ICF domains of ‘Activities’ and ‘Participation’. Patients are asked if they experience any difficulties in their everyday life activities or work activities, and if so, if they have already thought about solutions for these difficulties. (3) ‘My own way’ represents the ICF domain of ‘Personal Factors’. This circle includes questions about the way patients self-manage their condition, how they cope with the condition and what they need to improve their self-management. (4) ‘My environment’ represents the ICF domain of ‘Environmental Factors’ and explores patients’ physical and social environment, the support that patients get from their social environment and the degree of support that patients would like to get. Using this tool, the practice nurse can clarify the interrelationships among the circles (e.g. how does having problems in everyday life activities influence the patients’ self-management behaviour) and ask open-ended questions. Moreover, the tool can be used in a flexible way. The time spent discussing each circle depends on the patient, and the degree of support (e.g. the use of open or structured questions) can vary. Some patients can fill in the tool by themselves, others need more assistance. The tool can be printed on a A3 or A4 format. Notes can then be taken on the printed sheet and the patients can take it home.

To tailor the use of the practical framework for shared decision making about goals and action plans to the individual patients’ needs, motivation and capabilities we have developed a tool for identifying patient profiles (see Fig. 3). The tool is based on the theory-based patient typology by Bloem & Stalpers [38], which focuses on the role of the subjective experience of health as a motivator of patients’ health-related behaviours. The subjective experience of health is defined as ‘an individual’s experience of physical and mental functioning while living his life the way he wants to, within the actual constraints and limitations of individual existence’ [38]. As the typology focuses on patients’ experiences and motivation, it fits in well with the theoretical assumptions of shared decision making, goal setting and self-management support that are used for the conversation approach. Two key psychological determinants for the subjective experience of health have been identified by Bloem & Stalpers [38], and have been integrated in the patient profiles: (1) patients’ perceived control over the health condition and (2) patients’ acceptance of the health condition. Perceived control can be regarded as the patients’ belief that their health condition can be influenced or controlled by themselves or others. Acceptance can be interpreted as the patients’ feeling that their health condition and the possible consequences are acceptable for them personally. Based on a combination of these two determinants, four profiles have been identified, to support professionals in choosing actions and activities that may improve the patients’ subjective experience of their health [38]. As the determinants are dynamic constructs and a patient’s level of perceived control and acceptance can change with time and circumstances, patients do not have fixed positions [38].

For practical use, the four profiles have been translated into personas by Dubois & van Rij [39]. Typical behaviours for each persona have been described, as well as ways for practice nurses to adjust their communication (and the application of the practical shared decision making framework and the 4-circles tool) to the needs of each persona.