French healthcare professionals' perceived barriers to

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Nursing and Health Sciences (2017) ••, ••–••

Research Article

French healthcare professionals’ perceived barriers to and motivation for therapeutic patient education: A qualitative study Sophie Lelorain, PhD,1†

Adeline Bachelet, MSC,1 Nicole Bertin, RN2 and Maryline Bourgoin, RN2

1

University of Lille, CNRS, Teaching Hospital of Lille, UMR 9193 - SCALab - Cognitive & Affective Sciences and 2Teaching Hospital of Lille, Transversal Unit of Patient Education, Lille, France

Abstract

Therapeutic patient education is effective for various patient outcomes; however, healthcare professionals sometimes lack the motivation to carry out patient education. Surprisingly, this issue has rarely been addressed in research. Therefore, this study explores healthcare professionals’ perceived barriers to and motivation for therapeutic patient education. Healthcare professionals, mainly nurses, working in different French hospitals were interviewed. Thematic content analysis was performed. Findings included a lack of skills, knowledge, and disillusionment of the effectiveness of therapeutic patient education were features of a demotivated attitude. In contrast, a positive attitude was observed when therapeutic patient education met a need to work differently and more effectively. A key factor motivating professionals was the integration of therapeutic patient education in routine care within a multidisciplinary team. To keep healthcare professionals motivated, managers should ensure that therapeutic patient education is implemented in accordance with its core principles: a patientcentered approach within a trained multidisciplinary team. In the latter case, therapeutic patient education is viewed as an efficient and rewarding way to work with patients, which significantly motivates healthcare professionals.

Key words

health personnel, patient-centered care, self-management support, thematic analysis, therapeutic patient education.

INTRODUCTION Therapeutic patient education (TPE) refers to programs that help patients to acquire or maintain the skills they need to manage life with a chronic disease in the best possible way (World Health Organization, 1998). TPE targets both self-care skills, such as preventing complications, and life skills, such as managing emotions. TPE programs follow four steps: (i) a semi-structured interview with patients to understand their educational needs (ii) the establishment of negotiated educational goals with patients, (iii) TPE activities corresponding to the set goals are performed, and (iv) patient learning is evaluated (French National Authority for Health, 2007). In France, TPE programs must comply with national requirements, for example, they must be multidisciplinary, an educational record must be created and updated for each patient, and only healthcare professionals (HCPs) trained in TPE can carry out the program. French programs are subject to annual and quadrennial assessments by health authorities, which are based on detailed reports written by the HCPs involved. Standalone educational activities, which are not Correspondence address: Sophie Lelorain, Univ. Lille – SCALab – Sciences Cognitives et Sciences Affectives, F-59653 Villeneuve d’Ascq cedex, France. Email: [email protected] Received 24 October 2016; revision 13 March 2017; accepted 14 March 2017

© 2017 John Wiley & Sons Australia, Ltd.

structured within a full program, are also possible but are not funded by health authorities. French TPE is very similar in nature to the self-management education programs found in other countries. Whatever its structure or designation by different countries, the favorable effect of patient education has increasingly been demonstrated in meta-analyses of many diseases. For example, patient education is reported to have improved emotional wellbeing in breast cancer patients (Matsuda et al., 2014), reduced emergency department visits and hospital admission in chronic obstructive pulmonary disease patients (Tan et al., 2012), reduced glycated hemoglobin and fasting blood glucose levels in type 2 diabetes patients (Steinsbekk et al., 2012), and reduced headache frequency and disability in adults with migraines (Kindelan-Calvo et al., 2014). Therapeutic patient education is therefore of utmost importance to patient quality of life and health. However, from a physician’s point of view, HCPs’ motivation as well as TPE implementation and sustainability in French hospitals cannot be taken for granted (Fournier et al., 2014; Rey et al., 2016). This situation does not seem specific to the French context or to physicians. A literature review of 32 studies primarily of nurses, but also including some physicians, concluded that in several cases TPE was not considered by HCPs to be part of routine care but rather was dependent on other work demands doi: 10.1111/nhs.12350

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(Friberg et al., 2012). These international studies included Australia, Canada, China, Finland, Hong-Kong, Sweden, Turkey, and the United States, and in various hospital wards. More recent studies corroborate this finding. In Sweden, only 50% of nurses give TPE a high priority in their daily work (Bergh et al., 2014), while in Taiwan, nurses from various specializations have difficulty providing patient education, partly because of their excessive workload (Che et al., 2016). This situation is thus challenging for TPE managers and for maintaining TPE programs in routine care. However, the issue of keeping HCPs motivated toward TPE in spite of their difficult work environment has been surprisingly rarely been addressed in TPE literature.

Study aim We explored HCPs’ experience, mainly in terms of barriers to and motivators for TPE, in order to identify solutions for greater HCP involvement. Applying the self-determination theory to TPE (Deci & Ryan, 2008), it was expected that HCPs with autonomous motivation would be committed, in the educational activities or identified with the value of TPE thereby fully integrated it within their professional identity.

METHODS Design A generic qualitative methodology was required to investigate HCPs’ feelings about and experiences of TPE. In order to make HCPs comfortable about participating in the study whatever their motivation level and experience of TPE, we chose individual interviews rather than focus group discussions. We felt that HCPs would speak more freely in this setting rather than with other colleagues as they could be apprehensive about their judgment.

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Data collection Two research associates, each with a Master’s Degree in Psychology and unfamiliar with TPE at the time of the study, carried out the interviews. Most interviews were conducted face-to-face at the participant’s workplace or home, in a private room. Seven interviews were carried out by phone. The interviews took place between April and July 2015. They ranged from 15 to 55 min (mean 28 min) and were audio recorded with the participant’s agreement. The interview guide was semi-structured, with the following open-ended questions: • Tell me about your history in TPE: how did you come to TPE? • What is your role in TPE, what do you do? • What is your experience in and feelings about TPE? • What are your motivations for and barriers to TPE? • How is TPE integrated in your department? • What do your colleagues, who are not involved in TPE, think about it?

Participants The inclusion criterion included involvement in educational activities, whether in a TPE program or in standalone educational activities. A convenience sample of 27 HCPs participated in the study. Eight professions, including nurses dieticians, Psychologists, Physicians, Nursing assistants, Podiatrists and Sport instructor were represented. A variety was chosen to obtain a representative perception of TPE from all involved professions. Theme saturation was reached after the 27 interviews. Participants were from eight different hospitals of the northern region, with the majority from Lille and Arras hospitals, and from nine different departments, mainly diabetes and obesity departments. The majority were female participants who had received TPE practitioner training or a university degree and had recently participated in a TPE program (Table 1).

Procedure Data analysis

Healthcare professionals were recruited in two ways. First, the study was proposed to HCPs involved in TPE programs in the obesity and diabetes departments of hospitals in Lille and Arras. These departments were chosen because of the extent of their educational activity. Second, the study was proposed to HCPs following a TPE in-service training course delivered by the University of Lille. This enabled us to reach people from six other hospitals in the region. Two research associates contacted willing HCPs to arrange a date, time, and location for an interview.

Thematic content analysis, that is, systematically identifying and grouping the themes addressed in the corpus, was performed using NVivo 10 software (QSR International, Melbourne, Australia) . Themes were inductively derived from the data according to Braun and Clarke’s (2006) six steps, summarized in Figure 1 and Table 2. Steps 3 and 4 are the core of the analysis. For this reason, three researchers were involved in steps 3 and 4, which gave rise to many exchanges to reach a final agreement between researchers.

Ethical considerations

RESULTS

All participants gave their written informed consent to participate in the research and be recorded. Confidentiality was guaranteed. The review board of the TPE Transversal Unit of the Regional Teaching Hospital of Lille (approval number 2015-UTEPquali-V2) and the directors of the TPE in-service training delivered by the University of Lille approved the study.

Table 3 provides an overview of the results. Four aspects were identified: regulatory aspects, organizational aspects, attitudes toward TPE, and the integration of TPE in care. The first two are barriers while the latter two provide divergent perspectives among HCPs (i.e. barriers or motivators). For reasons of clarity, barriers and motivators are presented separately.


Therapeutic patient education

Table 1.

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in TPE; we are asked for figures, statistics, results, which are not always possible or even relevant. (Psychologist 21)1

Sample characteristics

Characteristic

Percentage (n)

Location Lille hospital Arras hospital Valenciennes hospital Other hospitals Private practice Department Diabetology Obesity Rheumatology Miscellaneous (psychiatry, neurology, geriatrics, dialysis, dermatology) Profession Nurse (including one TPE program coordinator) Dietician Head nurse (also coordinator of TPE programs) Psychologist Physician Nursing assistant Podiatrist Sport instructor HCP training in TPE None TPE awareness day (one day of training) TPE practitioner training (40 h = the minimum for performing TPE) TPE university degree (300 h) Experience in patient education Less than 5 years More than 5 years Gender Female TPE organization Validated TPE programs Standalone educational activities

44 (12) 22 (6) 11 (3) 19 (5) 4 (1)

Head nurses and physicians who write reports for regional authorities acknowledged that they had difficulty in assessing TPE sessions correctly because of a lack of time and skills for this task. The issue of TPE evaluation even has a negative effect: Because of this issue of TPE assessment, we think about TPE in the wrong way: instead of thinking of what is good for patients, we have to think of what can be done that will be easily assessed. Some teams have done great things … [which] is nonetheless difficult to demonstrate, and it is very demotivating for them. (Nurse 3)

55 (15) 19 (5) 7 (2) 19 (5)

33 (9) 19 (5) 15 (4) 11 (3) 7 (2) 7 (2) 4 (1) 4 (1) 19 (5) 4 (1) 44 (12) 33 (9) 67 (18) 33 (9) 81 (22) 74 (20) 26 (17)

HCP, healthcare professional; TPE, therapeutic patient education.

BARRIERS TO THERAPEUTIC PATIENT EDUCATION (TPE) Four dimensions of barriers emerged: constraints related to the requirements stipulated by the health authorities, organizational constraints, TPE as a destabilizing activity, and the lack of involvement and acknowledgement by other people.

Constraints related to the authorities’ requirements

Organizational constraints Healthcare professionals have difficulty organizing TPE group sessions. As most patients work and have a family life, it is not easy for them to come to hospitals for TPE. Even reaching patients on the phone to arrange TPE sessions is difficult: The organization of sessions requires a great deal of time and energy and, too often, patients end up not coming. We do not have a TPE secretary. Some nurses state that, if they had the choice, they would not participate in a TPE venture a second time. (Head nurse 1) Organizational constraints were also noted. Because of high turnover in teams and the legal necessity for a multidisciplinary team of trained HCPs in TPE, it was reported that it was difficult to bring together HCPs for TPE at the same time. Furthermore, HCPs acknowledged that on busy days, they gave priority to routine care over TPE for day patients; TPE sessions were then cancelled.

TPE as a destabilizing activity Some HCPs expressed fear of lacking knowledge about a disease or treatment, and failing to know what to do in specific patient situations. One psychologist, talking about himself and nurses, stated: Performing TPE is like testing oneself, it challenges our disease-related knowledge, and patients’ experiences are sometimes far from what my colleagues know how to address. There is a gap between the general situation that they know and the particular situation that each patient brings to them. (Psychologist 19) A fear of being uncomfortable with the management of a group of patients, an unusual activity in which they lacked confidence, was also reported:

The HCPs complained a great deal about the administrative burden of TPE programs. Most HCPs found the requirements of regional health authorities unrealistic and disconnected from practical reality. The evaluation of TPE sessions, required by regional authorities, was also pointed out as difficult: TPE results or benefits for patients are not always quantifiable. But now, we are asked to formalize everything

We have not been taught to manage a group; it’s something you learn by doing. And it’s not easy, it’s different each time. One day all the patients are shy, you have to drag information out of them, the next day one patient monopolizes the session. Interesting, but complicated! (Dietician 23) 1

Participant number.


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Figure 1.

Description of the analytical process following the recommendations of Braun and Clarke (2006).

Disillusionment was also a strong demotivating factor for some HCPs. The HCPs with a predominantly medical view of TPE (i.e. focusing on disease and treatments) were the most disappointed by it and felt it was unable to promote the expected patient behavior. These HCPs did not question themselves as educators nor their TPE practices. In their speech, we can hear their disappointment that TPE does not yield the same results for everyone and that not all patients are motivated to take care of themselves. The disappointed HCPs do not seem to consider that one aim of TPE is to motivate patients to take care of themselves, taking into account their priorities and concerns: I had hope in TPE, I thought it would work but in fact it depends on the patients. I thought patients would be very motivated as, in our department, we have time for TPE, we have TPE dedicated nurses. I thought the TPE results would be better but in the end patients come back and we have the feeling that everything they have been told is gone and forgotten. (Nurse 11) Some HCPs also stressed that TPE results were not tangible in the short term. They regretted that there was no followup of patients, which would reveal patient progress. This lack of feedback was discouraging and frustrating, particularly in view of the heavy organizational and relational involvement that TPE implies, as described by a physician: TPE is a time-consuming and demanding activity, we give a great deal of ourselves, much more than if we keep our distance with patients. Paternalists say to patients: ‘You have to do this and this and this,’ that’s easy! (Physician 2) © 2017 John Wiley & Sons Australia, Ltd.

Lack of involvement and acknowledgement At the institutional level, HCPs regret that TPE is not funded like ordinary care, which subsequently conveys the idea that it is less valuable. As a participant summarized, TPE costs more than it earns. At colleague level, HCPs explained that some of their colleagues were not interested in TPE and considered it useless. Some interviewees even confessed that colleagues who do not approve of TPE sometimes hindered their progress: For my colleagues, TPE is a cushy job: you speak with patients and do nothing. I tried to distance myself from their criticism, but it was hard at the beginning. (Nurse 8) As many HCPs highlighted, this lack of cooperation or teamwork hinders the success of TPE: My colleagues have a totally different view of care. It is really difficult because I work with a patient and have the feeling that there is a progression, and then they see the patient and undo everything we have done. (Nurse 14) TPE [must be performed] on a daily basis. HCPs should say more or less the same thing during the patients’ whole hospitalisation. Fundamentally [the core of TPE] is teamwork. I think that without that, we have little impact. (Podiatrist 6) The lack of teamwork and cohesion in the philosophy of care came up often in the interviews as a very demotivating factor for initiating and maintaining TPE. The resistance also seemed to come from the collaborative and multidisciplinary nature of TPE. The sharing of knowledge and skills is not always welcomed:


Table 2.

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Illustration of the analysis steps Steps

What is looked at in the raw data?

1. Familiarization with the data

Each transcript as a whole

2. Generating initial codes

Each sentence one after the other

Analysis Jot down notes in memos, which summarize the main ideas and striking elements of the interview E.g. “Interview 14. A very motivated person in performing TPE but who also acknowledges the difficulty to maintain motivation because other colleagues do not believe in TPE and make it ridiculous. In addition, a lot of time spent in the interview about the need for TPE in order to provide good patient care in diabetes. I have the feeling throughout the interview that this HCP is proud of performing TPE, it seems to me that TPE is a good thing for her self-esteem: it needs to be checked”

14 code 57: a very different view of care from colleagues Interview 14: “My colleagues have a totally different view of care. It is really difficult because I work with a patient and have the feeling that there is a progression, and then they see the patient and break everything we have done!” Interview 26: “TPE is beginning slowly to be part of care in our ward. Physicians are starting to address patients to TPE, but you know…, it has a way to go, HCPs must have received official training, other are reluctant, they don’t want to hear about it”

3. Searching for themes

4. Reviewing themes

14 code 58: Colleagues break the work done

26 code 76: Slow progression of TPE in ward

26 code 77: Needs for official training 26 code 78: Some reluctant HCPs

8 code 37: Colleagues severely criticize TPE 8 code 38: Difficulty to distance oneself from criticism at the beginning

Interview 8: “For my colleagues, TPE is a cushy job, you speak with patients and do nothing. I tried to distance myself from their criticism, but it was hard at the beginning.” Discarded at this step except Similar codes are clustered together: 14 code 57, 14 code 58, 26 code 78, 8 code 37 if there is a doubt about the In several interviews, colleagues seem to be an obstacle. A possible theme initial idea behind a code could be “Obstacles from colleagues”. Although we (coders) all have identified a theme related to colleagues, question about the level of abstraction of this theme fueled the discussions: the theme seemed close to another theme “lack of acknowledgement by others”. However, after discussion, we agreed that “lack of acknowledgement” was a broader theme which also encompasses the monetary value of TPE, as well as the reluctance of colleagues to share skills and knowledge. Another discussion also emerged about whether we should merge or not “obstacles and criticism” with “colleagues do not want to share skills and knowledge”. However, “obstacles and criticism” was judged more aggressive than “do not want to share”, which was rather a fear of losing power with sharing than a direct opposition. For these reasons, the two subthemes were not merged. If the thematization was good, clustered codes should be homogenous within a We verify that the majority theme and most of TPE-related codes should be included in one of the of the corpus is included in generated themes. Lastly, themes should not overlap. thematization and that nonincluded codes are really off topic. (Continues)


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Table 2. (Continued) Steps

What is looked at in the raw data?

5. Defining and naming themes

Corpus is again probed to find compelling extract examples for each theme

6. Producing the report

Table 3.

Analysis

At this step, it must be easy to define and name themes. If it is not the case, it will be necessary to step back to step 4 or even 3. Final thematization: ➜Integration of TPE in care ➜Lack of involvement and acknowledgement by others ➜TPE not funded like ordinary care ➜Obstacles from and criticism by colleagues ➜Colleagues do not want to share skills and knowledge Compelling extract examples are selected and finally analyzed; The final analysis relates back to the research question and a scholarly report is produced.

Overview of the results Regulatory aspects

Organizational aspects

Attitudes toward TPE

Barriers

- Writing programs - Annual and quadrennial assessments - TPE assessment - Red tape burden

- Bringing patients to hospital for TPE - Turnover in HCPs - HCPs not yet trained in TPE - Lack of time - Priority given to routine care over TPE

Motivations

None

None

-TPE as a destabilizing activity - Lack of confidence - Fear of lacking medical knowledge - Discomfort with patient groups - A demanding activity requiring more involvement with patients - Disillusionment - TPE does not fit HCP expectations - TPE results are not tangible TPE meets a need to work differently and more effectively - TPE is an opportunity to learn medical and treatment-related knowledge - TPE helps to understand how patients function - TPE enables better relationships and communication with patients - TPE is an appropriate way to support patients

Integration of TPE in care -Lack of involvement and acknowledgement by others - TPE not funded like ordinary care - Obstacles to and criticism by colleagues - Colleagues do not want to share skills and knowledge

A rewarding activity -Multidisciplinary work - Rewarding to work with physicians - New autonomy and responsibilities give a feeling of pride - Good feedback from physicians - Good feedback from patients regarding both care and medical aspects

HCPs, healthcare professionals; TPE, therapeutic patient education.

With TPE, we are seen as interfering. When we do educational diagnoses, they do not like it. The psychologist says ‘That’s not your business, that’s the work of psychologists’ and the physician says ‘The medical field is mine, you’re not going here, and anyway, what are you going to do with the medical information?’ (Head nurse 12)

the relational skills required for TPE, whether for face-to-face contact or to lead groups, were not seen as obstacles but rather as essential components for effective care. TPE was seen as an excellent opportunity to learn: What motivates me for TPE is learning things. I do not want to wait 20 years before I can say ‘Oh yes, I have eventually figured out how patients function.’ (Physician 10)

MOTIVATORS FOR TPE The two main motivating factors were: (i) the need to work differently and more effectively, and (ii) the view of TPE as a rewarding way of working.

Need to work differently and more effectively For HCPs, TPE meets a need for different and better care. In this respect, knowledge of diseases and treatments, as well as © 2017 John Wiley & Sons Australia, Ltd.

My motivation is a different relationship with patients. I have worked here for 20 years, so as to technical issues, I have examined the question from all sides, I needed a change. (Nurse 3) Motivated HCPs strongly believed in TPE as an appropriate way to support patients in their chronic illness. The idea that patients benefit from TPE came up extensively in their discourses:


We had big trouble with adolescent diabetic patients who did not adhere to treatment. TPE training helped me a lot, I wanted to work differently. Now, I start with what teenagers are interested in, and communication is much better. (Nurse 18)

A rewarding activity For some HCPs, TPE was a meaningful and rewarding activity. They found it very satisfying to work hand in hand with physicians (for nurses) or with nurses (for nursing assistants) and a variety of HCPs. TPE was perceived as blurring the hierarchical boundaries between professions, which are still very strong in French hospitals. Some HCPs were also proud of the special status that TPE gave them: TPE was my idea but I was given carte blanche at the level of both medical and paramedical teams, which is very rewarding. And also to be acknowledged thanks to the TPE university in-service training course, it’s important. (Nurse 18) For a minority of HCPs’, mostly nursing assistants, the activity of educating patients was also perceived as rewarding in itself: My motivation was to be able to give information to patients, to advise them. (Nursing assistant 4) Finally, meaningful and rewarding feedback also came from the patients themselves, either because better patient-provider relationships were reported in TPE settings or because better medical results were attributed to TPE: Physicians see what we do, we have good feedback from patients. When they come back satisfied with the care and with decreased glycated hemoglobin, it’s rewarding, we have brought something to these patients. (Nurse 11)

DISCUSSION One of the main motivations of HCPs is the endorsement of TPE as valuable and effective to patients (Svavarsdóttir et al., 2015; Rey et al., 2016). In our sample, the HCPs with a primarily medical view of TPE were disappointed in this regard. In fact, different HCP perspectives of TPE have been identified (van Hooft et al., 2015). For example, some HCPs focus on treatment adherence in a rather medical approach, whereas others see TPE as a real collaboration with patients to find agreement between the patient’s life and treatment goals for a more patient-centered approach. In practice however, TPE is actually rarely tailored to patients’ goals (e.g. Mosnier-Pudar et al., 2010; Stuckey et al., 2015), TPE endpoints are mostly related to treatment adherence or selfcare (Idier et al., 2011; Fonte et al., 2014), and psychological issues are not a priority for most HCPs in TPE (Holt et al., 2013; Bergh et al., 2014). Some HCPs may genuinely think that they adopt a patientcentered approach when they actually do not (Friberg et al., 2012; McGowan, 2013), even after attending a TPE training course (Deccache et al., 2009). From the literature, the failure of TPE occurs because patients are judged to be too severely

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ill, or too little educated or motivated to benefit (MosnierPudar et al., 2010; Fall et al., 2013; Ghorbani et al., 2014), as was the case for some of our interviewees. This view is contrary to the mission of expert educators who recommend to tailoring TPE to each patient’s needs, levels, and motivation so that TPE efficiency is guaranteed, even if this involves a different logistical organization of TPE according to patients’ needs (Fall et al., 2013; Svavarsdóttir et al., 2015). The working conditions in which TPE is conducted do not foster a patient-centered approach. First, program tailoring is hindered by the extensively reported lack of time (e.g. Ghorbani et al., 2014; Stuckey et al., 2015), and conditions are hardly compatible with HCPs’ empathy (e.g. Brown et al., 2011; Stuckey et al., 2015). Second, the transferability of TPE skills into the patient’s actual life and the involvement of the patient’s significant others in TPE,remains a challenge (Holt et al., 2013; Stuckey et al., 2015). Strikingly, almost no HCPs talked about transferability in our study, as if transferability was not part of TPE. In fact, this is what is really at stake. Another very important point explaining the divergent attitudes toward TPE was the extent to which TPE was fully integrated by the whole team (and not one or two HCPs only) in usual patient care. As intuited by many HCPs in our study, TPE cannot fully impact on patients unless it is a real multidisciplinary intervention with HCPs working hand in hand (Lagger et al., 2010; Quaschning et al., 2013). This cooperation within and between teams is difficult and yet very important for HCPs’ satisfaction (Atefi & Abdullah, 2014). To some extent, it implies a sharing of knowledge and skills between different professions, which is sometimes perceived as a loss of power by those higher up in the hospital hierarchy and therefore not dared by those lower in this hierarchy (Le Rhun et al., 2013; Rey et al., 2016). Our sample reported that the sharing of knowledge and skills was not always welcomed. This lack of HCP cooperation is often compounded by a lack of acknowledgement and support of TPE at financial, scientific, organizational, peer, and managerial levels, a situation also reported by our interviewees (e.g. Bergh et al., 2012; Friberg et al., 2012; Rey et al., 2016). This lack of support is all the more unfortunate as TPE is a challenging activity regarding both medical knowledge and group facilitation skills (Boström et al., 2014; Ghorbani et al., 2014; Svavarsdóttir et al., 2015, 2016). Expertise and skills have been shown to be related to HCPs’ motivation, thus a lack of support to develop skills can only lead to demotivation (Koch et al., 2014).

Limitations and strengths Almost all interviewed HCPs worked in a hospital. Different barriers to and motivations for TPE may have been found in a non-hospital setting. The variety of included professions and hospitals is, on the contrary, a real asset that guarantees that our results are not specific to an institution or profession. However, as in many previous studies, most participants in our study were nurses, so a thorough analysis by profession could lead to different results for each profession. Further studies specifically on dieticians, psychologists, physicians and sport instructors are warranted. © 2017 John Wiley & Sons Australia, Ltd.

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The French context of the study should also be kept in mind, particularly the barriers resulting from regulatory aspects specific to French legislation. Finally, two possible biases may have oriented the results. First, although we insisted on the confidentiality of the interviews, some interviewees seemed reluctant to speak freely when interviewed face-to-face at their workplace. Managerial issues may have been concealed by interviewees who were afraid to speak overtly of their managers in TPE. We found the telephone interviews more personal and authentic and we eventually preferred this method in spite of missing non-verbal information. Second, two of the researchers involved in the analyses have worked in a TPE unit; therefore we cannot rule out that personal experience may have influenced the analysis in spite of careful adherence to the analytical process.

Implications for practice Three avenues for progress are proposed for TPE managers. First, they need to make sure that HCPs have the right educative stance and ability to enable TPE to be tailored to patients’ needs. Specific and continuing training could be designed for this purpose. Second, more psychosocial endpoints could be introduced in TPE assessment and more feedback provided to HCPs about TPE results in order to keep them motivated. Finally, the divergent attitudes of HCPs toward TPE could be the result of unequal emotional resources of HCPs to handle the various TPE-related challenges. For example, in an experimental study, emotional resources maintained participant motivation to help others, even when they were not successful at the first attempt (Agnoli et al., 2015). Psychologists could design and perform interventions to develop and foster HCPs’ emotional skills, such as emotion regulation. In fact, these skills have been positively associated with nurses’ motivation (Garrosa et al., 2011; Donoso et al., 2015) and practice performance (Rankin, 2013; Lee et al., 2015) and are advocated for the patient-centered approach so important for TPE (Freshwater & Stickley, 2004).

CONCLUSION The self-determination theory fits our data well: HCPs’ motivation for TPE seems strongly related to the value and effectiveness they confer on TPE. The perceived value and effectiveness are weakened by a lack of: TPE recognition, a patient-centered approach, teamwork, together with organizational problems.

ACKNOWLEDGMENTS This research was funded by the Regional Teaching Hospital of Lille via the UF2383-MAT 016 73 758 dedicated position created for TPE research. We would like to thank Professor Pierre Fontaine for his support of this research.

CONTRIBUTIONS Study Design: SL, MB, NB. Data Collection and Analysis: AB, NB, SL, MB. Manuscript Writing: SL, MB. © 2017 John Wiley & Sons Australia, Ltd.

S. Lelorain et al.

DISCLOSURE None.

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