Lenzen et al.

BMC Health Services Research (2018) 18:891

https://doi.org/10.1186/s12913-018-3734-1

RESEARCH ARTICLE Open Access

Development of a conversation approach

for practice nurses aimed at making shared
decisions on goals and action plans with
primary care patients
Stephanie Anna Lenzen1,2* , Ramon Daniëls3, Marloes Amantia van Bokhoven2, Trudy van der Weijden2
and Anna Beurskens1,2

Abstract
Background: Primary care nurses play a crucial role in setting personal goals and action plans together with
chronically ill patients. This may be a challenge for practice nurses, who are often trained to adopt protocol-based
work routines. The aim of this study was to systematically develop a conversation approach, and a corresponding
training course, for practice nurses aimed at making shared decisions about goals and actions with their chronically
ill patients.
Methods: The 6-step iterative Intervention Mapping protocol was used as a framework. This paper describes
the first four steps of the protocol. After the first step, in which literature studies as well as qualitative studies
were conducted, the overall aim and objectives for the approach were formulated (step 2). In step 3, methods and
strategies for the approach were chosen, which were translated into practical components in step 4. In addition, a pilot
study was conducted.
Results: The main objectives of the approach focus on the ability of practice nurses to explore the patients’
perspectives from a holistic point of view, to explicitly formulate goals and action plans, to tailor shared decision
making about goals and action plans to individual patients, and to continuously reflect on work-related attitudes. The
approach consists of a practical framework for shared decision making about goals and actions. The framework involves a
tool for exploring patients’ perspectives and a tool for identifying patient profiles, to facilitate tailoring shared decision
making. A comprehensive training course for practice nurses was developed.
Conclusion: We systematically developed a conversation approach, involving a practical framework with
several tools, which aims to support practice nurses in making shared decisions about goals and actions with
their patients. As practice nurses need support in their learning process to be able to share decisions with
patients, we also developed a comprehensive training course for them. The approach and the training course
were developed in close collaboration with important stakeholders. Some critical factors for the implementation of the
approach were revealed. These factors will be addressed in the next step, a process evaluation (not part of this paper).
Keywords: Conversation approach, Shared decision making, Goal setting, Practice nurses, Primary care, Self-
management

* Correspondence: [email protected]
1
Research Centre for Autonomy and Participation for People with a Chronic
Illness, Zuyd University of Applied Sciences, Nieuw Eyckholt 300, 6419, DJ,
Heerlen, the Netherlands
2
Department of Family Medicine, CAPHRI School for Public Health and
Primary Care, Maastricht University, Maastricht, the Netherlands
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
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(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Lenzen et al. BMC Health Services Research (2018) 18:891 Page 2 of 11

Background complex and often struggle to elicit patients’ views and

One of the major challenges for the primary care sector achieve mutual understanding and agreement about
is the steady increase of people living with one or more goals and action plans [16, 17]. Furthermore, profes-
chronic conditions, which has led to a growing interest sionals hesitate to involve patients in sharing decisions
in effective self-management support for patients within about goals and actions, as they assume that their pa-
primary care [1, 2]. Self-management is defined as ‘the tients are not able to make the right decisions [17–19].
degree to which a chronically ill patient is able and will- There is currently a lack of practical frameworks and
ing to control his or her daily life’ [3, 4]. tools for supporting professionals in going through the
Self-management and self-management support involve process of shared decision making with patients in
not only medical management, but also maintaining and complex health care situations [10].
changing life roles (social self-management) and dealing In Dutch primary care, as in many other countries, practice
with emotional consequences of the disease (emotional nurses play a role in supporting patients’ self-management.
self-management) [5]. They see patients with chronic diseases on a regular basis
Self-management includes goal setting and action plan- and are mandated by the family physicians to apply most of
ning. Goal setting is a collaborative process of agreement the long-term condition management [20–22]. However,
on health-related goals between the health care profes- practice nurses in family medicine usually work according to
sional and the patient [6]. Action planning is a collabora- fixed protocols that mainly focus on medical management.
tive process of agreeing on a course of actions to achieve a Their tasks often involve monitoring and recording
goal, addressing details such as what, when, where and disease-specific outcomes and they sometimes regard provid-
how often’ [7]. Goal setting and action planning require ing self-management support as something that increases
professionals and patients to share decisions. The shared their workload [23, 24]. This medical, protocol-based work
decision making model is widely recognized as a way to routine conflicts with making shared decision about patients’
support patients in decision making [8]. It is defined as ‘an individual goals and action plans.
approach where clinicians and patients share the best The primary aim of this study was to systematically
available evidence when faced with the task of making de- develop a conversation approach, and a corresponding
cisions, and where patients are supported to consider op- training course, for practice nurses working in primary
tions, to achieve informed preferences’ [8]. A widely used care, aimed at making shared decisions about goals and
model for shared decision making is the three talk model actions with their chronically ill patients. The Interven-
developed by Elwyn et al. [8]. The three talk steps are: (1) tion Mapping (IM) protocol was used as a guidance, as
choice talk: making sure to the patient that reasonable op- it provides a systematic process for development, imple-
tions are available, instead of just one option; (2) option mentation and evaluation [25].
talk: providing detailed information about options and (3)
decision talk: considering preferences and deciding what Development of the conversation approach
is best. Shared decision making is thought to lead to more Intervention Mapping describes a six-step iterative process,
patient autonomy and may lead to better health outcomes with each step consisting of tasks that inform the next step.
[9]. Recently the shared decision making model is mostly The six steps are: (1) logic model of the problem, (2)
applied in curative settings to make decisions about programme outcomes and objectives, (3) programme de-
preference-sensitive treatment options. However, it may sign, (4) programme production, (5) programme imple-
also be valuable in chronic care, as it highlights and ex- mentation plan, and (6) evaluation plan. The IM protocol
plains the process of supporting patients in considering highlights the involvement of key stakeholders in every
options and as it focuses on the collaboration between step, as well as the importance of tailoring the approach to
professionals and patients [10–13]. local needs and available resources. Moreover, theory and
To put shared decision making into practice profes- evidence are integrated throughout the whole process [25].
sionals need to have relational and communicative com- The present study involved steps one to four of the IM
petencies (e.g., creating an environment for effective protocol and thereby focuses on the development process
communication and interaction, listening to the patient, of the approach; the implementation plans and the evalu-
assessing the patient’s situation, including patient’s social ation of the approach are not part of this paper. The follow-
environment and context) [14]. Moreover, professionals ing section presents the methods and results of steps one
need to be able to self-reflect on their practice and to four. See Fig. 1 for an overview of the process, showing
stimulate patients to reflect on the process and outcomes the methods and results for each step.
of decision making throughout the whole process [15].
In routine care professionals often struggle to imple- Step 1: Logic model of the problem
ment shared decision making (about goals and action The first step involved a needs assessment to identify
plans). They experience it as time-consuming and what, if anything, needed to change and for whom. In
Lenzen et al. BMC Health Services Research (2018) 18:891 Page 3 of 11

Fig. 1 Overview of methods and results for steps one to five of the IM protocol

order to gain an overview of theoretical assumptions, we in setting goals that fit their situation and motivation,
first reviewed the literature about definitions, theories and health coaching is therefore tailored to what is
and models for shared decision making, goal setting/ac- important for patients [20, 30, 31].
tion planning, and self-management support [12]. We Second, we explored experiences, needs, barriers and
found that shared decision making models are mostly facilitators with regard to shared decision making about
developed to support (medical) professionals to goals and action plans in primary care by conducting a
empower patients in making tailor-made treatment deci- descriptive qualitative study. Between April and June
sions [8]. These models often neglect the exploration 2013, two focus groups and three individual interviews
and formulation of patients’ goals. However, in chronic were conducted with patients, primary care professionals
care, setting goals for quality of life seems a precondition and experts (total participants = 17) [34]. The primary
to prioritize relevant options for prevention, cure or care care professionals worked in practices for family medi-
[10–13]. Theories and models for goal setting/action cine, occupational therapy, physical therapy, psychology
planning describe goal setting and action planning as an and social work. The experts had experience of patient
iterative process, consisting of several phases. The ‘Goal representation, self-management support, communica-
setting and Action Planning Practice Framework’, devel- tion between patients and professionals, patient-centred
oped by Scobbie, Wyke & Dixon (2010) [26], is based on practice and shared decision making. We found mostly
a comprehensive review of goal setting theories [27–29] barriers for the implementation of shared decision
and highlights the importance of exploring patients’ making about goals and action plans with chronically ill
experiences before setting goals and then planning ac- patients in primary care [34]. Barriers were related to
tions. The literature also frequently highlights that the difficulties professionals encounter in exploring pa-
professionals need to act as coaches for their patients tients’ experiences from a holistic point of view (i.e. with
[20, 30–33]. A health coach seeks to support patients regard to problems in everyday life, work, emotions,
Lenzen et al. BMC Health Services Research (2018) 18:891 Page 4 of 11

coping with the disease or support from the environ- making about goals and actions to patients’ needs,
ment), and to explore patients’ goals and preferences motivation and capabilities, (b) viewing goal setting and
and set medical or non-medical goals accordingly. Other action planning as one iterative process and (c) explo-
barriers for goal setting/action planning in everyday ring patients’ experiences from a holistic point of view,
practice were the professionals’ attitudes and skills with professionals struggle to put this into practice. Moreover,
regard to involving patients in goal setting/action plan- professionals and patients experience difficulties in mak-
ning and the complexity of tailoring shared decision ing goals explicit and experience a lack of time for goal
making about goals and action plans to the patients’ setting. Nurses are not always aware of the process of
needs, motivation and capabilities. Moreover, time was shared decision making about goals and action plans
considered a significant barrier [34]. and therefore find it difficult to critically reflect on their
Third, we examined the current working methods with own working methods. Available interventions for goal
regard to shared decision making about goals and action setting/action planning mostly focus on changing life-
plans by observing eight consultations between practice style behaviour and less on a broader holistic perspective
nurses (n = 4) and patients (n = 8). After each observa- on goals or on communication and shared decision
tion we briefly interviewed (15 min) the practice nurse making about goals and actions.
and patient about their experiences of the consultations.
Practice nurses were all female and had at least one year Step 2: Programme outcomes and objectives
of work experience; patients were aged between 75 and Step two of the IM protocol identifies what should be tar-
89 years and all had complex (health) care requirements. geted in the approach. Based on our needs assessment,
Content analysis of the eight observed consultations re- the overall aim of the approach, as well as objectives, were
vealed that explicit shared decision making about goals formulated and prioritized by the advisory board of the
was rare. Action plans were frequently not made explicit project. The advisory board consisted of researchers, pro-
and no agreement on actions was reached. Nurses often fessionals or experts working for universities, primary care
used a structured biomedical protocol (e.g. a structured or patient organizations. The advisory board was closely
questionnaire) to explore patients’ problems. They then involved in the project (from grant application to project
initiated discussions about possible solutions to these implementation).
problems. The interviews after the consultations showed The overall goal of the approach was formulated as
that most patients were not aware of the purpose of the follows: practice nurses make shared decisions with their
consultation and they could not recall any goals or ac- patients about goals and actions. Based on the needs as-
tions agreed upon. Practice nurses found it difficult to sessment, we formulated four specific objectives: (1)
reflect on their working method. Nevertheless, they were practice nurses explore the patients’ perspectives from a
generally satisfied with the consultations. They reported holistic point of view (exploring medical symptoms, im-
a lack of guidance/tools to explore patients’ problems pact of the condition on everyday life/work, emotions,
from a broader perspective. coping with the condition and support from the envir-
Fourth, we conducted a scoping review in order to onment), (2) practice nurses explicitly formulate goals
review the content of goal setting and action planning and action plans together with the patients (i.e. deciding
interventions in the context of self-management [35]. together about goals and actions, as well as recording
We identified 58 articles reporting on interventions for the goals and actions in the patient file), (3) practice
goal setting/action planning. By analysing the contents nurses tailor shared decision making about goals and ac-
of the interventions we created an overview of phases, tion plans to patients’ needs, motivation and capabilities
components and strategies for goal setting/action (e.g. tailoring the communication about goals, the num-
planning. We found that most interventions were ber and difficulty of goals and actions), and (4) practice
disease-specific and focused on improving one or more nurses continuously reflect on their work routines and
predefined lifestyle behaviours. Although goal setting/ac- their work-related attitudes.
tion planning was recognized as a complex interactive
activity, few of the interventions explicitly focused on Step 3 and 4: Programme design and producing of
communication or shared decision making about goals/ programme components
action plans or on possibilities to tailor the intervention In the third step of the IM process, methods and strategies
to patients’ needs, motivation and capabilities [35]. for the approach were chosen, which were translated into
practical components for the approach in step 4 (producing
Conclusion step 1 programme components). Steps 3 and 4 were performed in
To conclude, although theories and models about shared an iterative process. This was done by a development team.
decision making, goal setting and action planning high- The team consisted of patients, professionals and experts
light the importance of (a) tailoring shared decision (on shared decision making, goal setting/action planning,
Lenzen et al. BMC Health Services Research (2018) 18:891 Page 5 of 11

self-management support, professional–patient communi- 4-circles tool led to more shared decisions and to more
cation, education and design) (n = 12). By involving experts concrete goals/actions. However, most participants
from the Dutch National Health Care Institute and the struggled to implement the approach in their everyday
Dutch College of General Practitioners we aimed to practice. They reported that they felt they lacked coach-
enhance national support for the project. During April ing skills. They needed more guidance to integrate the
2014 and May 2015, the team met on a two-monthly basis. approach in their work routine and they experienced a
During step 4 (between January and June 2015) three prac- lack of support for tailoring the approach to patients’
tice nurses (two female, one male) were invited to closely motivation and capabilities. They also hesitated to
collaborate with the development team. They were re- deviate from the commonly used biomedical protocol, as
cruited from the researchers’ network and had over 10 years they felt it was their responsibility to ‘monitor’ the
of work experience with chronically ill patients in primary patients’ health status. They frequently found it difficult
care. They were asked to apply the approach, or parts of it, to deviate from their own professional ideas, as they
in their everyday practice and to share their experiences re- worried that patients would make ‘wrong’ choices. They
garding the added value and feasibility with the develop- wanted more support in their learning process to
ment team. In monthly reflection meetings (n = 6), these become a coach for patients.
practice nurses and the development team reflected on the Based on these results we decided to (a) extend our con-
experiences and further developed the approach. In versation approach, in order to provide professionals with
addition, a pilot study was conducted to evaluate the added more support in tailoring the approach to individual pa-
value and the feasibility of the approach. During January tients and (b) develop a more comprehensive training
and April 2015, eight professionals (four female practice course, to improve professionals’ coaching skills and
nurses collaborating with four male family physicians) were change their attitudes. To this end, we expanded our de-
trained to use the approach and asked to apply it in practice velopment team by including a professional coaching
over a period of eight weeks, with at least ten patients. After company (Dubois & Van Rij), with extensive experience in
four weeks and after eight weeks, focus group interviews developing training courses for professionals and which
were conducted to explore participants’ experiences. worked with an evidence-based patient profile model to
In steps 3 and 4 we first came up with a practical support professionals in tailoring their communication to
‘framework for shared decision making about goals and patients’ needs, motivation and capabilities.
action plans’, in which we combined an existing model
for goal setting [26] with the three-talk model for shared The conversation approach
decision making [8] (for further explanation see section The final conversation approach includes a practical
titled ‘The conversational approach’). To support the use ‘framework for shared decision making about goals and
of the framework, we further developed a practical tool actions’.
for exploring patients’ experiences, the ‘4-circles tool’
(for further explanation see section titled ‘The conversa- Practical framework for shared decision making about
tional approach’). For the pilot study we developed a goals and actions
training course, consisting of a 4-h workshop and a The practical framework for shared decision making about
workbook. It aimed to support professionals in using the goals and actions forms the basis of the conversation ap-
practical shared decision making framework and the proach. It aims to facilitate professionals in going through
4-circles tool with their patients, and was presented by the process of shared decision making. It is based on and
an experienced trainer, specialized in educating family combines the three-talk model for shared decision making
medicine professionals. The training course included in- developed by Elwyn (1999) [8] and the ‘Goal setting and
formation on the background and theory of the ap- action planning practice framework’ developed by
proach, discussions of the approach, reflection about Scobbie, Wyke & Dixon (2012) [26]. The framework
integrating the approach in everyday practice and consists of 4 phases: Preparation, Goal setting, Action
role-playing exercises. Planning and Evaluation (see Table 1). Each phase involves
Through the close collaboration with the three prac- a number of steps that the professional can perform to
tice nurses who had joined the development team and achieve shared decision making with patients. Depending
the pilot study we got more insights into the experiences on the patient’s situation, the framework can be flexibly
with applying the framework and the 4-circles tool. We applied. The time spent on each phase can vary and pa-
learned that all professionals experienced the approach tients and professionals can move back and forth between
as valuable in their everyday practice. The participants the phases in an iterative manner. In addition, supportive
highlighted the value of being stimulated to explore pa- tools can be used in the different phases. A comprehensive
tients’ experiences in greater depth. They felt that the workbook for the professionals explains the framework,
practical shared decision making framework and the its phases and steps, and offers examples of tools and
Lenzen et al. BMC Health Services Research (2018) 18:891 Page 6 of 11

Table 1 Practical framework for shared decision making about Table 2 Integration of the practical framework for shared
goals and actions decision making with the tools
Phase Explanation Practical framework for shared Tools
decision making about goals
1 Preparation Informing the patient about the aim of the
and action plans
consultation.
Inviting the patient to ask questions or 1 Preparation
raise points for discussion.
2 Goal setting 4-circles tool to Patient profiles
2 Goal setting A Exploration explore the patient’s to adjust the
B Giving Information situation and goals communication
A Exploration Exploring the patient’s current and desired
C Formulating goals and coaching to
situations.
the individual
3 Action planning patient
B Giving Information Giving information tailored to the patient. A Choice talk
C Formulating goals Supporting the patient in formulating B Option talk
feasible goals. C Decision talk
3 Action planning 4 Evaluation 4-circles tool to
monitor and
A Choice talk Making sure the patient knows that he/she evaluate the patient’s
has a choice. goal achievement and
B Option talk Discussing possible options for actions with to reset goals
the patient.
C Decision talk Deciding on actions together with the
patient.
International Classification of Functioning, Disability
4 Evaluation Continuously reflecting on the patient’s
progress, and adjusting goals and actions.
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
strategies. Moreover, professionals are provided with have been simplified and visualized using four circles:
printed descriptions of example cases and a video with an (1) ‘My health’ represents the ICF domain of ‘Body
example case. Functions and Structures’. Within this circle, patients’
This framework incorporates two tools: (1) a tool for medical (physical and mental) symptoms are explored
exploring the patients’ perspectives (the 4-circles tool) and patients are asked what they need to improve their
and (2) a tool for identifying patient profiles in order to symptoms. The questions and required professional ac-
tailor shared decision making about goals and action tions from the practice nurses’ (biomedical) protocol can
plans to patients’ needs, motivation and capabilities. For be asked and taken within this circle. (2) ‘My activities’
the integration of the shared decision making framework represents the ICF domains of ‘Activities’ and ‘Participa-
and the two tools see Table 2. tion’. Patients are asked if they experience any difficulties
in their everyday life activities or work activities, and if
Tool for exploring patients’ experiences: 4 –circles tool so, if they have already thought about solutions for these
The 4-circles tool (see Fig. 2) has been developed for use difficulties. (3) ‘My own way’ represents the ICF domain
within the goal setting phase of the practical framework of ‘Personal Factors’. This circle includes questions
for shared decision making. It aims to support practice about the way patients self-manage their condition, how
nurses and patients in collaboratively exploring the pa- they cope with the condition and what they need to im-
tients’ experiences with their condition from a holistic prove their self-management. (4) ‘My environment’ rep-
point of view and to facilitate a dialogue between nurse resents the ICF domain of ‘Environmental Factors’ and
and patient about the patient’s current and desired situ- explores patients’ physical and social environment, the
ation (with regard to health, everyday life, social/physical support that patients get from their social environment
environment and coping strategies). Its generic character and the degree of support that patients would like to
means that the tool is not disease-specific and can be get. Using this tool, the practice nurse can clarify the in-
used for all chronically ill patients or other patients with terrelationships among the circles (e.g. how does having
complex health care requirements. It is meant to help problems in everyday life activities influence the patients’
patients gain insight into and reflect on their own situ- self-management behaviour) and ask open-ended ques-
ation, in order set goals (including non-medical goals) tions. Moreover, the tool can be used in a flexible way.
for them. The development of the 4-circles tool was in- The time spent discussing each circle depends on the
spired by A-FROM (Living with Aphasia: Framework for patient, and the degree of support (e.g. the use of open
Outcome measurement), a tool to explore the impact of or structured questions) can vary. Some patients can fill
aphasia on a person’s everyday life [36]. Like A-FROM, in the tool by themselves, others need more assistance.
the 4-circles tool is based on the framework of the The tool can be printed on a A3 or A4 format. Notes
Lenzen et al. BMC Health Services Research (2018) 18:891 Page 7 of 11

Fig. 2 The 4-circles tool

can then be taken on the printed sheet and the patients health condition. Perceived control can be regarded as the
can take it home. patients’ belief that their health condition can be influ-
enced or controlled by themselves or others. Acceptance
Tool for tailoring the use of the practical shared decision can be interpreted as the patients’ feeling that their health
making framework: Patient profiles condition and the possible consequences are acceptable
To tailor the use of the practical framework for shared for them personally. Based on a combination of these two
decision making about goals and action plans to the in- determinants, four profiles have been identified, to sup-
dividual patients’ needs, motivation and capabilities we port professionals in choosing actions and activities that
have developed a tool for identifying patient profiles (see may improve the patients’ subjective experience of their
Fig. 3). The tool is based on the theory-based patient health [38]. As the determinants are dynamic constructs
typology by Bloem & Stalpers [38], which focuses on the and a patient’s level of perceived control and acceptance
role of the subjective experience of health as a motivator can change with time and circumstances, patients do not
of patients’ health-related behaviours. The subjective ex- have fixed positions [38].
perience of health is defined as ‘an individual’s experi- For practical use, the four profiles have been translated
ence of physical and mental functioning while living his into personas by Dubois & van Rij [39]. Typical behav-
life the way he wants to, within the actual constraints iours for each persona have been described, as well as
and limitations of individual existence’ [38]. As the ways for practice nurses to adjust their communication
typology focuses on patients’ experiences and (and the application of the practical shared decision
motivation, it fits in well with the theoretical assump- making framework and the 4-circles tool) to the needs
tions of shared decision making, goal setting and self- of each persona.
management support that are used for the conversation
approach. Two key psychological determinants for the The training course about shared decision making
subjective experience of health have been identified by for practice nurses
Bloem & Stalpers [38], and have been integrated in the The training course aims to improve practice nurses’
patient profiles: (1) patients’ perceived control over the coaching skills with regard to making shared decisions
health condition and (2) patients’ acceptance of the with their patients and to stimulate them to continuously
Lenzen et al. BMC Health Services Research (2018) 18:891 Page 8 of 11

Fig. 3 Patient profiles

reflect on their work routines and their work-related atti- effective method for behaviour change [42]. Moreover,
tudes. It consists of a one-day training session, individual training at the nurses’ worksites is thought to enhance the
on-the-job coaching (three weeks after the one-day train- integration of the skills into routine work [43]. By also fo-
ing session) and a follow-up meeting (two months after cusing on exchanging experiences between practice
the one-day training session). The trainer is a professional nurses, the course intends to facilitate critical reflection
coach with 20 years of work experience. Throughout the on their work-related attitudes [44].
training period (two months), the coach can be contacted
by phone or email for questions or further advice. During Discussion
the one-day training session, participants are introduced This paper has described the systematic development
to the concepts of coaching and shared decision making process and the content of a conversation approach and
and are trained to use the practical framework for shared a corresponding training to help practice nurses working
decision making with the 4-circles tool and the tool for in primary care make shared decisions with their chro-
identifying patient profiles. The training is provided by nically ill patients about goals and actions. We came up
means of information giving, discussions, role-plays and with a practical framework for shared decision making
demonstrations of skills. In addition, participants are about goals and actions, and two tools to support the
provided with a workbook containing information on the use of the framework (a tool for exploring the patients’
content of the training, as well as a link to a video demon- perspective and a tool for identifying patient profiles in
strating the use of the conversation approach. The individ- order to tailor goal setting/action planning). We also de-
ual coaching takes place three weeks after the one-day veloped a training course for practice nurses, focusing
training session by means of a worksite visit. The coach on the coaching skills and attitudes needed to put the
observes two – four consultations of each practice nurse, approach into practice.
and has a coaching session (30–60 min) with the nurse A strength of our conversation approach is the
immediately after the consultations. The coach gives combination of the traditional medically focused shared
feedback on the nurse’s performance during or after the decision making model with the goal setting framework
consultations, tailored to the nurse’s needs. The coaching [8, 26]. Most of the existing models for shared decision
can also involve role modelling. The coaching sessions making have been developed for the purpose of making
also involve setting educational goals for the practice medical treatment decisions and are difficult to apply in
nurses. During the follow-up meeting with all participants chronic care [10]. Within chronic care, the desired
(four hours), experiences are exchanged and role-plays health state and the patients’ goals are frequently less
and demonstrations of skills are provided. Overall, the clear and will differ between individuals and at different
training course uses training methods found to be effec- points in time [45]. Patients can experience and define
tive for improving professionals’ skills. Role-playing and their health differently than from the medical viewpoint,
demonstrations of skills in actions, as well as constructive and frequently also have non-medical goals [46, 47]. For
feedback from peers and skilled facilitators, have proved most chronically ill patients, dealing with emotional reac-
to be effective in improving practice nurses’ communica- tions (emotional self-management) and adjusting social
tion skills [40, 41]. The use of role modelling has proved roles (social self-management) are as important as dealing
to be important for professional development and an with medical instructions and lifestyle recommendations
Lenzen et al. BMC Health Services Research (2018) 18:891 Page 9 of 11

(medical self-management) [34, 48, 49]. Therefore, pilot studies, and we therefore developed a more
patients’ goals need to be explored explicitly [46, 47]. A comprehensive training course for practice nurses,
goal setting phase prior to the phase of making shared also incorporating individual on-the-job coaching, in
decisions about actions is therefore indispensable in which practice nurses can reflect on their professional
chronic care. self-concept with an experienced coach. Additionally,
Another strength of the approach is its flexible charac- we incorporated more opportunities for exchange be-
ter, as the process may vary regarding the amount of tween practice nurses and for reflections about pro-
time spent on the different phases of shared decision fessional identity, as interaction with other nurses and
making, the degree of support professionals provide to sharing experiences in a reflective way was found to
patients and the tools that professionals can use within contribute to the development/adjustment of profes-
each phase. As the experiences of health and quality of sional identity [44].
life of chronically ill patients and their goals vary over Nonetheless, when aiming to implement the approach
time, the framework highlights the importance of regu- it is essential to pay more attention to integrating the
larly exploring the patients’ experiences and constantly approach into the structured protocols and to the
adapting to each individual patient [46, 47]. In order to nurses’ attitudes towards shared decision making. A ne-
support professionals in doing this, our conversation ap- cessary future step is to make an implementation plan
proach includes two easy-to-use tools. Practical tools for that focuses on processes and conditions that facilitate
shared decision making are thought to facilitate over- the integrating of shared decision making in routine care
coming the difficulties professionals experience in shar- and tailoring training to the individual professional’s
ing decisions with patients [18]. learning needs.
However, during the development process we re- As regards the development process, we think that
vealed some critical factors for the implementation it is a strength that we involved different stake-
plan of the approach. It became clear that the pro- holders, as well as experts in different fields, profes-
fessionals struggled to integrate the framework and sionals and patients throughout the process. We
the tools into their everyday practice. They needed developed, evaluated and adapted the approach to-
more guidance to integrate the framework into their gether with future users (practice nurses), and used
existing fixed protocols and work routines. Although the IM protocol as a guideline. While the steps of
they appreciated the tools, they hesitated to deviate the IM protocol are described in a linear order, the
from their current working methods and their own planning process is, in fact, iterative [25]. However,
professional ideas about ‘what’s best for the patient’. during the process of development we pilot-tested
The practice nurses seemed to struggle with a pro- and adjusted the approach only in step four of the
fessional role conflict. Faced with the changing role IM protocol. More frequent testing of the approach
for nurses in primary care (from medical expert to in several shorter iterative cycles, for example by
coach), nurses may feel uncertain about their profes- combining the IM protocol with user-centred design
sional identity [50]. Nurses’ professional identity is methods, would probably have given us more infor-
defined as ‘the values and beliefs held by nurses that mation about the feasibility of the approach in
guide their thinking, actions and interactions with practice.
the patient’ [44, 51]. A professional identity is devel-
oped and shared among members of a profession,
through training, qualifications and socialization Conclusions
[48]. It reflects the nurses’ professional self-concept, We systematically developed a conversation approach,
and hence their own beliefs about their roles, values consisting of a practical framework with several tools
and behaviours, as well as the public’s image of the that aim to support practice nurses in making shared
profession [44]. decisions on goals and actions with their patients. As
In the needs assessment phase of our study, espe- practice nurses need support in their learning process to
cially in the qualitative studies, we concentrated on be able to share decisions with patients, we also deve-
experiences and problems with regard to shared deci- loped a comprehensive training course for nurses. We
sion making and goal setting for practice nurses in developed the approach and the training course in close
primary care. We identified the influence of the skills collaboration with major stakeholders. During the deve-
and attitudes the professionals need for shared deci- lopment process some critical factors for implementa-
sion making, and obtained less information about the tion of the approach were revealed. These critical factors
difficulties practice nurses experience in changing will be addressed in the process evaluation plan, aiming
their role in primary care, i.e. adjusting their profes- to evaluate the feasibility and added value of the ap-
sional identity. These difficulties emerged during the proach and the training course in routine primary care.
Lenzen et al. BMC Health Services Research (2018) 18:891 Page 10 of 11

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