Behavioural Change in Practice: Primary Care Providers’ Journey Towards Goal-Oriented Care

The case of Flanders

The drive towards more PC-IC resonates in Flanders, Belgium’s Dutch-speaking region. In 2017, a primary care reform aimed to strengthen integrated care by creating networks across health and social care sectors, centred on individuals with care and support needs. This reform introduced 60 geographically defined primary care zones (PCZs) in Flanders and Brussels, each serving 75,000–125,000 residents with tailored services. Supported by the Flemish Institute for Primary Care (VIVEL), these zones aim to foster PC-IC locally by developing care teams that support individuals “in accordance with their life goals” [22]. To encourage providers to adopt this approach, VIVEL introduced goal-oriented care (GOC) as a guiding philosophy [23]. Research on GOC adoption in Flemish primary care shows that PCPs are highly motivated but uncertain about how to shift from problem-oriented to goal-oriented care. Effective clinical integration requires both training in GOC and opportunities to apply it in practice [7]. However, a survey of 131 PCPs highlights a lack of training opportunities for GOC [11]. To address this, VIVEL developed an interprofessional pilot training on GOC, aligned with the integrated care vision [23]. Without existing literature on GOC skills, VIVEL co-developed a seven-session training program with a transdisciplinary panel of field experts. The sessions, held at the PCZ level, brought together diverse providers from the same zone to practice GOC through assignments and peer reflection sessions. Trainers with subject-matter expertise and experiential knowledge facilitated the sessions. Participants in this training are well-positioned to gain insights into the behavioural change required to move from problem- to goal-oriented care. This understanding is key to advancing knowledge on how GOC can be implemented in practice and may inform future workforce education and training [24]. Therefore, the aim of this study is to explore how PCPs experience the behaviour change process when applying GOC in their daily work.

Study Aim and Design

This study aims to answer the research question: ‘How do PCPs experience the behaviour change process when implementing GOC in their practice six months after participating in an interprofessional training on GOC?’. A qualitative generic approach [25] was used as the study design. The study design combines a deductive focus on behaviour change, using the COM-B model as a theoretical framework, with an inductive approach to studying PCPs’ experiences. In this study, the COM-B model serves as the basis for the theoretical assumptions on behavioural change [26]. The COM-B model, developed by Michie and collegues (2011), considers behaviour as the dynamic interplay of three inter-related components: capability (C), opportunity (O), and motivation (M). Behaviour occurs when an individual has the capability and opportunity to engage in the behaviour and is more motivated to carry out that behaviour than others. Capability is defined as an individual’s ability to physically and psychologically perform the behaviour, while opportunity refers to external factors that enable or prompt the behaviour. Motivation encompasses basic drives, automatic processes, and reflective processes. These elements, as illustrated in Figure 1, interact to influence behaviour change or sustain a behaviour once it has been integrated into an individual’s habitual patterns of behaviour [27]. Previous research has shown the usability of the COM-B model as a theoretical framework to gain insights into the different components impacting provider behaviour change in healthcare settings [28, 29]. Figure 1 presents an overview of the COM-B model, which served as the theoretical framework guiding the deductive component of the analysis.

Figure 1

Sampling

A purposeful convenience sample recruited PCPs trained in GOC based on their participation in the interprofessional GOC training by VIVEL. The term PCP is used broadly here to include both health and social care professionals working in primary care such as pharmacists, physiotherapists and social workers. Since 2022, VIVEL trained 50 PCPs across five PCZs in Flanders. All trainees who completed the program between March 2022 and January 2023 were invited via email to participate in a study on their GOC implementation experiences.

Data Collection

Six months post-training, focus groups were held in each PCZ where the VIVEL training took place to reduce participants’ travel. These discussions provided a space for participants to share, refine, and reflect on their experiences, making focus groups a suitable data collection method [30]. By encouraging collective sense-making, this approach aligned with the PC-IC philosophy of developing a shared vision. The focus groups captured a range of experiences, guided by the COM-B model as the theoretical framework.

A semi-structured focus group guide with five open-ended questions, revised twice for clarity and neutrality, facilitated the discussions (see Supplementary File 1). The questions explored participants’ experiences with behaviour change, including their motivation to apply GOC, supporting skills, and challenges. All focus groups were audio-recorded and transcribed verbatim.

The first author, who moderated all focus groups, had prior experience with GOC through involvement in related projects and training initiatives, which may have helped build trust with participants by providing a shared understanding of the concept. The research team included members with diverse professional backgrounds and varying levels of familiarity with GOC, which enabled critical questioning of assumptions and interpretations. This collaborative approach helped to balance the moderator’s insider perspective with external viewpoints, acknowledging that researcher influence is inherent in qualitative research.

Data Analysis

A theoretical thematic analysis following Braun & Clarke’s method was used, supporting the deductive-inductive study design [31]. Two researchers, one junior (R.H.) and one senior (P.B.), independently coded the transcripts into the COM-B model’s components: capability, opportunity, and motivation (deductive), guided by the definitions in Figure 1 [27]. Consensus on the initial coding was reached within the team. Data within each component were then coded inductively to generate initial themes.

The analysis acknowledged that coding and theme development are inherently interpretive acts. Instead of seeking a single ‘correct’ reading, dialogue between researchers with different backgrounds generated a richer, reflexive account of the data. Team discussions refined initial codes into final themes and subthemes, ensuring consistency with the theoretical framework while maintaining reflexive openness. Supplementary File 2 illustrates this process by showing how original data evolved from theoretical coding based on the COM-B model to a sub-theme and then to an overarching theme.

Participant characteristics

A total of 22 PCPs from five primary care zones participated in focus groups in June 2023, with three to six participants per zone. One focus group was conducted online due to participants’ preference. Participants represented various disciplines, ensuring a multidisciplinary perspective. Discussions lasted between 1 hour 51 minutes and 2 hours 20 minutes. Table 1 provides an overview of the participants.

In all focus groups, participants indicated a pre-existing interest and affinity for GOC, as it was already present in their work, training, or personal values. However, they expressed a need for further guidance on its practical implementation in daily practice, which remained unclear to them.

The themes are discussed in order on what participants emphasized in the results. They indicated the themes linked to the motivation component as the fundamental drivers for implementing GOC in practice. These themes will be followed by those related to capability and opportunity. Figure 2 provides an overview of the themes identified in this study presented within the COM-B model.

Figure 2

Motivation

Participants emphasized the importance of developing personal and professional awareness of their behaviour. This awareness helps them recognize how routines and emotions shape their actions, allowing for reflection on the connection between their actions, emotions, and values. Through this reflective process, they more consciously consider the relevance and meaning of their interventions, enabling them to align their behaviour with GOC principles.

Pitfalls of emotion- and habit-driven actions: The participants expressed a deeper understanding of how routines, habits, and emotions influence the behaviour changes required for implementing GOC. They recognized that embracing GOC often requires breaking away from established practices, processes and routines. Some participants noted that, they sometimes struggle to move away from a problem- or provider-driven approach. They highlighted the challenge of changing work routines, especially when quick decisions are needed. In urgent situations, they experienced that they tend to act more problem-oriented than goal-oriented. They described that it takes time to step back from initial emotional responses to reflect on a care situation. They felt that acting out of routine hinders opportunities for reflection. Finally, some participants expressed fear of deviating from their problem-oriented routines, worrying that it might lead to professional negligence toward their patients.

Acting beyond personal and professional values: Participants found that providing GOC challenged them to align actions with patient preferences. In this process of change they realized that some actions were mainly driven by their own values which might not necessarily comply with those of the patient. This awareness extended to both their professional and personal values, with values being understood as the meaningful beliefs that motivate professionals in their actions. They stressed the importance of reflecting on whether care actions align with the patient values and expectations. This led them to realize that patients’ preferences, rooted in patients’ values, might conflict with their personal or professional values. Participants emphasized the need to manage feelings of powerlessness and rise above these conflicts to deliver GOC.

Reflective practice: Participants shared that providing GOC prompted them to reflect more frequently on their professional actions and on the added value of their actions taking the patient’s preferences into account. This introspection led them to question the broader purpose of their role as a care provider, motivating them to seek innovative approaches to adapt their professional actions according to patients’ personal goals.

Escaping a narrow focus: When participants or their teams used a GOC approach in a patient’s situation this often provided them with new insights. They experienced that GOC helped them to broaden their perspective on the situation. Especially in ‘complex cases’, they felt at greater risk of acting from emotion- or habit driven routines, which causes them to lose sight of the bigger picture and the patient’s personal goals. In these complex cases, participants noted that GOC helped them to consciously reassess the relevance of specific care actions by clarifying the patient’s wishes and personal goals.

Capability

When understanding the skills and knowledge participants use to initiate behaviour change towards GOC, participants rely on the reflective process outlined in the motivational component. They consciously slow down their thinking and extend care organization to avoid a problem-based approach. Taking time to understand patients’ interests and motivations helps them better advocate for patients’ wishes in conversations with colleagues.

Asking person-centred questions: The participants indicated the application of GOC in their communication style by asking broad questions, such as asking patients about their interests and expectations. Additionally, they more frequently probed into the underlying meaning behind expectations or wishes expressed by patients. Asking ‘why’ something was important to the patient was an important way for them to gain insight into the patient’s motivation.

Maintaining comprehensive knowledge: Participants emphasized that having a broad knowledge of the various available services is supportive when addressing patients’ goals. Keeping this knowledge up to date was not easy given the rapid changes occurring in the service landscape.

Tailored communication: When engaging with patients and caregivers, participants reflected that they consciously paid attention to their body language and choice of words to establish connection and trust in the interaction. They indicated that they communicated their message tailored to the patient to maximize the chances of good understanding. Examples included adapting language to the patient’s dialect, visualizing information schematically or choosing a deliberate physical position at the table with the patient. Additionally, consideration was given to who is best positioned in the team to deliver a message, with the trust relationship primarily used as a criterion for making this choice.

Courage for patient advocacy: Participants noted that from the perspective of GOC, they felt more courageous to address meaningful matters for their patients during conversations. Particularly in discussions with colleagues, they dared to bring up meaningful issues for the patient, even if it meant engaging in debate with colleagues. Leveraging their extensive patient knowledge, they felt empowered to challenge colleagues on proposals deemed unfeasible or not aligned with patients’ goals. Participants acknowledged that this demanded assertiveness. They found that discussing concerns or considerations regarding the patient’s goals, with colleagues, caregivers, or the patients themselves, fostered a shared understanding among all parties. According to them, this facilitated the progress in the care trajectory.

Resisting the problem-oriented approach: Participants indicated that within GOC, they employed strategies to avoid reverting to a problem-oriented approach. They deliberately slowed down the process of organizing care, allocating more time for patients to consider information and proposed actions. This involved scheduling multiple appointments and encouraging reflection between consultations. Participants acknowledged that this way of organizing their work differed from their previous practice, during which they may have pressured patients more to adhere to certain treatments or advice.

Opportunity

Among factors that lie outside the participants impacting their behaviour change towards GOC, mainly social factors seem to have an impact. Support from colleagues and supervisors influences their empowerment to provide GOC. Participants fear damaging professional relationships if they pursue GOC when colleagues do not acknowledge its relevance. Additionally, organizational factors like long-term patient follow-up and the documentation of patient goals in health record system are seen to facilitate GOC implementation.

All colleagues on the same page: Participants emphasized the value of support from their supervisors. Most participants work in organizations with supervisors and felt supported and encouraged by them to explore ways to implement GOC in their work. All participants agreed that for optimal implementation of GOC, it is essential to involve all colleagues in this care approach. The support that some participants already experienced from their supervisors was seen as a prerequisite to bring the whole team on board.

Knowledge transfer: The primary strategy participants use to engage all colleagues is education. Several participants have spontaneously given presentations or shared knowledge about GOC with their colleagues.

Strength in multiple contacts: Participants acknowledged that while the initial perception of GOC as time-intensive posed a challenge to feasibility, their perspective shifted as they gained more experience. Rather than viewing time allocation as the main barrier, they emphasized the importance of continuity of care and maintaining ongoing, meaningful contact with patients. They highlighted the value of reflecting on the patient’s care journey at various touchpoints, contrasting with the view of colleagues who resisted GOC due to time constraints.

Vital role of care continuity: Participants discussed changes in government healthcare policy over the past few years, which have resulted in shorter and fewer patient contacts, posing a challenge to providing GOC. Continuity in the patient-provider relationship was deemed essential for GOC. Participants found that GOC lacks effectiveness when there is only brief, one-time contact with a patient and no further interaction. They advocated for multiple or recurring contacts with patients, either directly or facilitated by colleagues, to enable effective GOC.

Being the ‘difficult’ colleague: Participants experienced a sense of tension when engaging with partnering organizations or colleagues who operated from a different mindset or approach. In interprofessional meetings, when highlighting patient goals, they felt often as the ones asking ‘difficult questions’. While they viewed this as a crucial aspect of GOC, it led to feelings of discomfort and intimidation. Participants expressed concerns that emphasizing patient goals could strain professional relationships and potentially jeopardize collaboration with colleagues who might prioritize other aspects of care.

Valuable documentation: Participants expressed challenges in integrating GOC into their practice through proper documentation in digital health records. While both policy and supervisors emphasized the importance of recording GOC-related information, participants felt that the available systems were inadequate for capturing the nuanced and meaningful aspects of patient care. They noted that current documentation tools often overlook personal, valuable information that could benefit alignment with colleagues in providing GOC. As a result, much of the critical information remains undocumented, residing only in the minds of the practitioners.

Navigating conflicting expectations: Participants encountered challenges in providing GOC when informal caregivers had differing expectations or needs from those of the patient. In these cases, participants prioritized the patient’s personal goals, but found their ability to act constrained by the conflicting perspectives of caregivers.

Balancing patient engagement: Participants increasingly sought to involve both patients and their caregivers in healthcare decisions, noting that this shift aligns with a trend of patients advocating for themselves. However, they identified a pitfall in assuming that all patients are able or willing to express their goals. Some patients still prefer to rely on professionals or caregivers to decide for them. Similarly, caregivers accustomed to making decisions for the patient, struggled with the shift to a more patient-centred approach, where professionals involved the patient in the decision-making process. This dynamic required balancing effective involvement without overestimating the readiness of patients or caregivers for full participation.