Contribution to theoretical understanding
diabetes
DISEASE, DIABETES
As briefly noted in Our study supports and enables us to extend this previous work with more attention to temporal and teamworking considerations and the operation of interpretive emphases within complex and value-laden systems of healthcare provision. We develop here an analysis of how the interpretive emphases, value commitments and skill repertoires that health professionals bring to CSP interact with practical-situational challenges external to the health professionals involved. We also outline the implications not only for how health professionals conduct CSP conversations and follow-up consultations, but also for their scope to develop their skills with practice, for their experiences of CSP and motivation to use it over time, for the overall impact of CSP, and for health professionals’ evaluations of the approach.Table Interpretations and skill repertoires that impact enactments and evaluations of CSPImprove health and broader wellbeing, working with person’s own perspective on these.(This can include, but is not limited to, biomedical markers and risk factors).CSP allows space for and perhaps gives a formal structure to approaches to working with patients that were already of interest or being tried.OrCSP involves a significant change in approach involving a shift in values towards more sharing and a greater appreciation of working with what matters to the patient.‘Ideal’ account of CSPOrThe most positive examples of substantial improvements in patients’ biomedical markers following CSP.We take the ‘less conducive’ side first. Health professionals who view improvements in the biomedical markers of diabetes as the ultimate purpose of CSP, and who expect CSP as an intervention to deliver those improvements as a result of patients conforming to expectations that they will actively prepare for and engage in consultations and make and follow through on plans to improve their health, will have relatively little scope to see their efforts with CSP as successful when CSP ‘works’ like this for only a minority of patients. If they further (perhaps relatedly) think that CSP will only benefit patients who come to a CSP conversation already motivated to act to improve their diabetes, health professionals can quickly become pessimistic about its prospects when relatively few people arrive having written in their care planning letter or otherwise willing, ready and able to contribute ideas about what they can do. The value of CSP for people whose diabetes is currently well controlled may also seem questionable.If health professionals also consider what is unique or importantly different about CSP primarily in terms of process steps, they are less able to reason confidently about when it is appropriate to ‘skip’ certain steps – for example if goal setting and action planning is not a top priority given a patient’s current circumstances and concerns (a tick box process orthodoxy can work against the flexible responsiveness that CSP requires).If health professionals think the main reason for listening to patients is to identify scope to tailor their advice and better persuade patients to change their behaviour to improve their diabetes, then other things that patients tell them, including about other conditions, financial worries or other social concerns, can seem irrelevant to their conversations. If health professionals feel obliged to address these concerns once raised, however, more open questioning risks adding to their workload or sense of failure. The investment of professional time and energy may not seem worthwhile, especially in busy clinics and amidst concerns about the opportunity costs of the approach.If health professionals have little prior interest or learning to support their attention to patients’ psychosocial issues, they can get “stuck” quite quickly when patients are not very forthcoming in conversation. If they lack the foundation to develop their communication skills and approaches beyond those covered in the CSP training session, this can contribute to a downward spiral of professional enthusiasm and more negative evaluations of CSP.In contrast, on the ‘more conducive’ side, health professionals have much more scope to see success if they have a broader and more flexible view of the purpose of CSP, including the idea that the focus of the CSP conversation and any resulting actions should be set or strongly influenced by the patient and what is important to them. Even if a particular CSP conversation cannot be considered an unequivocal success, a broad view of purpose and valuing of the emotional, relational and perhaps intermediate experiential gains from CSP can help health professionals to accept (rather than view as a failure) when CSPs result in little immediate action or evident progress on a professionally concerning health issue. If the patient’s concerns and considered priorities had been heard, the patient was aware of any serious professional concerns, and the door had been left open for further discussion in the future, agreeing to keep important issues in view might perhaps be as far as they fruitfully could go in that consultation.If health professionals have more realistic expectations about the time frame over which any general, population-level health benefits of CSP are likely to emerge and if they recognise that these depend on multiple other influences beyond the CSP conversation (including follow-up consultations as well as patients’ circumstances and behaviours, and the not entirely linear causal connections between behaviours and health indicators) they are also less likely to be disappointed about what CSP achieves.The scope to see some success even when patients do not engage with CSP as fully as hoped or do not achieve as much health improvement as the ‘best’ examples is more likely to keep health professionals enthusiastic and motivated to continue with the approach. A sense of potential to learn and improve on enactments of CSP can also help in that regard. In our study, health professionals who expressed strong interests in the psychosocial aspects of primary care or in “people more than disease”, and those with more advanced communication skills and familiarity with reflexive, practice-based learning were also more inclined and confident to develop and refine their enactments of CSP, for example by trying out different questioning strategies. A combination of a broad sense of purpose, commitment to be flexibly and respectfully responsive to patients, and good initial skill repertoire facilitated positive development of practice over time.Our study demonstrates the complex interactions between health professionals’ interpretive emphases, value commitments and skill levels and the various challenges associated with diverse patient situations and organisational systems. It identifies potential for negative feedback loops to develop from narrow interpretations of purpose and limited initial skill sets, and for positive feedback loops to develop from broader interpretations of purpose, a stronger initial skill repertoire, and confidence and support for reflective learning and skill development.In healthcare contexts in which there is limited relational continuity in care, significant variability between the various health professionals involved in a team providing CSP will reduce the chance of any one patient from benefitting richly from a CSP conversation and from effective follow through from that conversation. Limited relational and informational continuity also reduce the scope for health professionals to see benefit from their efforts with CSP and make it less likely that patients become more familiar and comfortable with CSP approach over time. Divergence from key CSP principles is thus likely to be particularly detrimental to the overall success of the approach in such circumstances.