Table 5 Theory and processes for supporting behaviour change in the REACH-HF intervention

ACTIVE PATIENT INVOLVEMENT

(motivational interviewing [46]/Self-Determination Theory [31])

The facilitator should encourage the participant to be actively involved in the consultation. The idea is to maximise the participant’s autonomy as the main agent of change, developing intrinsic rather than extrinsic motivation. However, the consultation should be guided. Empathy-building skills (Open questions, Affirmation, Reflective listening, Summaries) and individual tailoring should be used throughout the consultations. Reflective listening may be used to direct the conversation or highlight key strengths or barriers. A collaborative/shared decision-making style is appropriate, and the facilitator may share his/her own expertise and ideas. The Ask-Tell-Discuss technique should be used to exchange information (e.g. to address misconceptions, or offer helpful new information). Overall, the participant should be increasingly empowered to take control of her/his self-care behaviour. Interactions should be encouraging, respectful and non-judgemental. The interaction should also be individually tailored to the patient’s specific information needs, beliefs, skills and priorities.

ASSESSING THE PATIENT’S CURRENT SITUATION AND NEEDS

(motivational interviewing [46], individual tailoring [65])

The facilitator should use patient-centred communication techniques (as above) which may include the Ask-Tell-Discuss and open-ended questions to explore the patient’s current situation. This should include all of the following: identify and discuss the most important issue currently for the patient, how well are they managing their fluids, how appropriately are they using medications, is there any obvious immediate clinical need, how much stress or anxiety do they have, how much physical activity are they doing and what other concerns or questions they may have.

FORMULATING AN INDIVIDUALISED TREATMENT PLAN

(Self-Regulation/Control Theory [42], individual tailoring [65])

The facilitator should use patient-centred communication techniques (as above) to formulate an appropriate treatment plan based on the patient’s current situation (as assessed above). The treatment plan will be staged over time, aiming to work on a few topics initially and introducing other elements as the programme continues. This should be set up as an experiment to see how feasible the proposed actions are and whether they help the patient’s situation. An element of guiding to ensure the inclusion of clinical priorities (e.g. medication issues, exercise) as well as patient priorities may be appropriate. The facilitator and participant should formulate a specific written action plan (using the template in the Progress Tracker) for exercise-training based on a choice of the two REACH-HF exercise-training programmes. The patient and caregiver should be ‘signposted’ to relevant sections of the manual. The facilitator may also employ some problem-solving techniques at this stage to pre-empt and address potential problems.

BUILDING THE PATIENT’S UNDERSTANDING OF HEART FAILURE/THEIR SITUATION

(Leventhal’s common sense model [29], theories of illness adaptation [14, 41])

The facilitator should elicit the patient’s and caregiver’s current understanding of heart failure and seek to build their “illness model” in terms of understanding the identity, causes, consequences, cure/control options and timeline associated with the condition. This process may take several weeks and should be reinforced as the programme progresses.

Facilitators will signpost the patient and caregiver to relevant sections of the manual, including the “Understanding Heart Failure” section and use patient-centred communication techniques (as above) to elicit and build understanding. The Ask-Tell-Discuss technique and reflective listening will be used to exchange information to reinforce elements of the patient’s understanding that predispose positive self-care behaviours (e.g. understanding the link between physical fitness and symptoms of HF). The facilitator should seek to reframe negative attitudes and exchange information to address misconceptions or address important gaps in understanding. Learning should be reflected on/reinforced at subsequent sessions.

SUPPORTING SELF-REGULATION SKILLS

(Self-Regulation/Control Theory [42], relapse prevention [66], theories of illness adaptation [14, 41])

The facilitator should discuss and encourage the use of the “Progress Tracker” workbook in the HF Manual to keep track of progress and as a way of recording and addressing any problems in completing the activities and any benefits that might be associated with the planned activities. At subsequent meetings, the facilitator and participant should review progress with all planned changes to exercise/physical activity and other self-care activities. The facilitator should reinforce and reflect on any successes. The participant and facilitator should discuss any setbacks, encourage identification and problem-solving of barriers to self-care and the patient’s plans should be revised accordingly. Reframing should be used to normalise setbacks and see them as an opportunity to learn from experience (trial and error) rather than as failures.

Problem-solving should use Open questions, Affirmation, Reflective listening, Summaries (OARS) and information exchange (Ask-Tell-Discuss) techniques to identify barriers and explore ways to overcome them. Problem-solving may specifically focus on issues of connectedness (social influences, involvement of others in supporting activities) and long-term sustainability, or on breaking the problem down into more manageable chunks.

ADDRESSING EMOTIONAL CONSEQUENCES OF HEART FAILURE

(cognitive behavioural therapy [43], mindfulness [45], theories of illness adaptation [14, 41])

The facilitator should help the patient to recognise and address any significant stress, anxiety, anger or depression that is related to having heart failure. S/he should seek to normalise such feelings and help the patient to access and facilitate use of the cognitive behavioural therapy techniques and stress management techniques contained within the manual. If depression, anxiety or other emotional problems are severe, a referral to appropriate clinical services should be facilitated.

CAREGIVER INVOLVEMENT (if applicable)

(literature on caregiver needs [15])

The facilitator should engage the caregiver as much as possible as a co-facilitator of the intervention. S/he should tailor the intervention to work with the caregiver’s abilities and availability. Person-centred counselling techniques (OARS) should be used for caregiver assessment and to exchange information to build the caregiver’s understanding of the situation and to help them recognise and manage their own health needs including mental health, physical health and social needs. He/she should facilitate a conversation between the patient and the caregiver to agree to their roles and responsibilities and how these might change if the patient’s condition declines. Attention should be given to the caregiver’s needs and concerns about being a caregiver/providing care as well as those of the patient.

The facilitator should help the caregiver to recognise and address any significant stress, anxiety, anger or depression that is related to supporting someone with heart failure and facilitate the use of the cognitive behavioural therapy techniques and stress management techniques contained within the manual as needed. This includes facilitating a referral for a carer’s assessment if the caregiver wishes, plus referral to other relevant care services as appropriate.

The facilitator should help the caregiver to prioritise and look after his/her own health and well-being.

BRINGING THE PROGRAMME TO A CLOSE

(Leventhal’s common sense model [29], theories of illness adaptation [14, 41], Self-Regulation/Control Theory [42], relapse prevention [66])

Progress should be consolidated and reinforced. Plans for long-term sustainability of activities and strategies learned for managing heart failure should be discussed. The facilitator will review progress since the start of the intervention and reinforce what has been learnt. Useful strategies that were helpful should be identified. Plans to stay well/prevent relapse should be discussed as well as “cues for action” and plans to revisit the manual in the future. The facilitator will discuss plans to sustain any new activities, identifying any potential problems and coping strategies to overcome these. The possibility of good and bad days should be discussed and normalised.