What next for behaviour change professional development in general practice? Insights from an environmental scan and workshops

Background A key role of general practice professionals (that is, GPs, and general practice nurses [GPNs]) is to support patients to change behaviours. Traditional approaches to assisting patients with, and learning about, behaviour change have modest outcomes. Aim To explore behaviour change with GPs and GPNs and the availability of related professional development (PD) opportunities. Design & setting Multi-methods study comprising an environmental scan survey of behaviour change tools and PD opportunities, and online workshops with Australian GPs and GPNs. Method Survey data were analysed using qualitative content analysis, informing the design of the workshops. Workshop data included observation, note-taking, and collaborative reflection, which were analysed thematically and synthesised with survey data. Results The survey had 18 complete responses. For the two virtual workshops, workshop 1 had 16 participants and workshop 2 had eight participants. There was diversity in awareness of existing behaviour change tools and resources. Preferences for future tools and PD opportunities related to specific aspects of its design, content, activities, and delivery. The following three themes developed from the workshop data: recognising the importance of relationships; recognising the importance of continuity; and keeping context in mind. In the absence of tools and resources, GPs and GPNs discussed behaviour change as something that occurs best through a patient-centred alliance that is continuing, respectful, grounded in trust and an understanding of their patient, and prioritises patient autonomy. Conclusion Future general practice behaviour change PD should support clinicians to ‘assist’ patients and recognise the social and contextual influences on behaviour.


Introduction
Behaviour change is crucial for preventative health care worldwide. 1,2In Australia, approximately 38% of the total burden of disease is preventable. 3A nutritious diet, physical activity, and reduced use of alcohol, tobacco, and other drugs can improve mental and physical health. 4GPs and GPNs are at the front-line of Australia's health system. 5Approximately nine in 10 people see a GP each year who are commonly the first point of contact for supporting health. 5he Royal Australian College of General Practitioners (RACGP) has published guidelines (the Red Book) 4 outlining the roles and responsibilities of general practice teams, including GPs and GPNs, in facilitating behaviour change. 4GPs' focus on behavioural counselling and risk assessment, whereas GPNs' key roles include educating patients, and conducting follow-ups. 4Despite this delineation of tasks, there is a lack of clarity and confidence among some practitioners regarding their responsibility for delivering behaviour change interventions. 6Some GPs and GPNs have exhibited a lack of confidence in their ability to influence patient behaviours. 7,8General practice constraints, such as a lack of time and resources, and consultation dynamics make behaviour change interventions challenging for GPs and GPNs.Moreover, complex societal determinants of health, such as income, housing, employment, and public health policy, may require specialist skills for priority populations. 9,10ommon behaviour change consultation strategies in general practice include the following: the 5As framework; 11 person-centred care; 12 a strengths-based approach; 13 the stages of change (transtheoretical) model; 14 and the behaviour change wheel. 15The 5As framework ('ask, assess, advise, assist, and arrange' in Australia) has been described as 'the universal approach to practising the art of enhancing behaviour change'. 11A recent qualitative study reported that general practice clinicians have diverse understandings of the 5As framework and apply it variably in practice. 6It is a model that can assist with understanding the process that occurs between a clinician and patient for behaviour change.Some professionals in general practice believe that the available strategies are only helpful for those learning the basics of supporting patients in behavioural change (that is, university students). 6ittle is known about what, if any, behaviour change resources are available to GPs and GPNs, and if these differ in application with priority patient populations.Additionally, the preferences of GPs and GPNs for behaviour change education and PD are unknown.This study aimed to address these knowledge gaps through an international environmental scan and virtual workshops.

Research questions
The research questions for this study were as follows: 1. What support is available for GPs and GPNs working with priority populations to provide high quality, evidence-based behaviour change consultations to patients?2. What are the perspectives and preferences of GPs and GPNs for behaviour change education and PD?
Priority patients include people from low-income, rural, or culturally and linguistically diverse communities, and First Nations people, where the social and cultural determinants may impact health behaviours and service utilisation.

Research paradigm, methodological overview, and study design
This multi-methods study was situated within the pragmatic paradigm, 16,17 with a relativist perspective, prioritising a qualitative approach. 18Each phase informed the next.An international environmental scan survey 19 explored existing behaviour change learning platforms; preferences for format and content; and needs for future PD opportunities.Two online workshops followed the analysis of the scan.

Purpose
The environmental scan survey aimed to identify resources, organisations, and tools assisting primary care professionals in learning about behaviour change and/or delivering behaviour change interventions.Environmental scan surveys are commonly used to supplement systematic reviews of the literature or conducted as a formal part of programme planning. 19,20This method identifies what is relevant in practice through wide-scope screening. 19,20

Recruitment and sample
Participants were identified through an iterative process involving research team members and established professional networks.The research team included practising GPs, dieticians, a psychologist, academics, a social worker, and medical students.These researchers collaborated to develop a list of clinicians, leaders, researchers, advocates, and policy influencers in general practice and primary care whose contact email was publicly available.Potential participants were emailed the survey link, and encouraged to share it with their colleagues, allowing recruitment to snowball.

Survey design and data collection
A brief (10-minute) online survey (Supplementary Box 1) was collaboratively developed and hosted on LimeSurvey.All researchers participated in drafting the survey.Before delivery, the survey was pilot tested through group cognitive interviewing. 21The survey started with questions about the availability of behaviour change tools and PD resources.Then, participants responded to demographic questions such as sex, primary care role, and experience.The survey remained active for 7 weeks.

Data analysis
Open-text responses were extracted to an Excel spreadsheet and inductive qualitative content analysis was conducted to organise data into concepts reflecting a condensed, broad description of the results. 22Surveys without any responses to questions about behaviour change tools and PD opportunities were classified as incomplete and discarded.BB read and reflected on the survey data in the context of the research questions to prepare for organisation.The key concepts in each question informed the unit of analysis (that is, descriptions of PD organisations and behaviour change tools).After data familiarisation, BB organised the data into groups and developed codes that distilled the text groups into broad concepts.We employed qualitative content analysis specifically to develop broad descriptive concepts.All researchers debriefed and reflected on the evolved concepts and the data associated with each concept.This informed the design and development of the workshops.

Design
Workshop 1 focused on behaviour change understandings and workshop 2 centred on reflections of a case study and preferences for the format of behaviour change PD opportunities.Both workshops used breakout rooms for smaller group discussions.

Recruitment and sample
Eligible participants were practising GPs and GPNs in Australia.Recruitment was conducted through advertisements on social media, researcher professional networks, and professional newsletters.Recruitment snowballed through professional networks.An AUD$150 e-gift card honorarium was provided.

Data collection
Data collection and analysis included observation, reflection, and discussion by the researchers.Both workshops (lasting around 90 minutes) had a maximum of 20 total participants, and at a minimum more GP and GPN participants than investigators.The workshops were recorded via a videoconferencing platform and saved to a password protected shared drive.We documented de-identified reflections and observations in a shared Google document.
Workshop 1 included a short reflection on behaviour change theories.This was followed by a facilitated breakout session to discuss behaviour change, including the implementation challenges, preference for learning about skills, key behaviour change topics for learning, and ideas for supporting resources.Participants rejoined the larger group to share stand-out ideas from their discussion.
Workshop 2 began with a recap along with a case study.This was followed by a facilitated discussion in breakout rooms where participants discussed their reflections.Participants rejoined the larger group and shared key reflections before the facilitator concluded the session.

Data analysis
Data analysis was iterative and started simultaneously with data collection.Team meetings were held to discuss, debrief, and reflect on the workshops.The researchers reflected on audio-recordings of the workshops and the audio-recordings were transcribed using Otter and reviewed by ES, JA, and TLC.Following an inductive approach, workshop data were coded, and codes were organised to develop initial themes (ES, JA, TLC).This process was supported by field notes from workshop facilitators.ES presented the themes to the broader investigator team at a team meeting in which the themes were discussed and finalised.

Environmental scan
The environmental scan survey was sent to 345 participants and associations (Society for Academic Primary Care, World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians [WONCA], RACGP, and Australian Association for Academic Primary Care [AAAPC]) across five countries (Australia, New Zealand, UK, US, and Canada) between March 2022 and April 2022 (n = 18 complete responses; n = 28 incomplete responses that were discarded).All responders were from Australia (13 females, eight males), including practising GPs (n = 7), GP academics (n = 6), clinical governance manager (n = 1), healthcare manager (n=1), medical education content developer (n = 1), nurse educator (n = 1) and telephone counsellor (n = 1).All responders had tertiary education qualifications: post-graduate degree (n = 17) and undergraduate degree (n = 1).

Virtual workshops
Two 90-minute virtual workshops occurred on 27 April 2022 and 8 June 2022.A total of 30 participants registered to attend Workshops 1 and 2 combined.Workshop 1 had 16 participants (13 GPs, 3 GPNs), while workshop 2 had eight participants (two GPNs and six GPs), with seven participants having attended the previous workshop (workshop 1), and one new attendee.Illustrative quotations are provided below by GPs or GPNs.

Availability of behaviour change tools and professional development opportunities
Environmental scan findings in Table 1 illustrated that healthcare professional organisations were frequently identified by participants to provide behaviour change PD opportunities (n = 11).Participants commonly identified behaviour change tools as programmes (n = 4) and frameworks (n = 11).Some participants were unaware of organisations providing PD opportunities (n = 4) or tools for behaviour change (n = 4).
Workshop participants noted a lack of availability of PD opportunities about behaviour change.One participant said: 'There's not a flood of offers for that sort of training, especially now.We used to have a better set up with divisions of general practice … to support more education, specifically, and supporting practice nurses.' (GPN1)

Preferences for behaviour change tools and professional development
Environmental scan findings in Table 2 showed participant preferences for PD opportunities in design (n = 13) (for example, time, remuneration, access), content and activities (n = 12) (for example, resources, language, small group learning), and delivery (n = 4) (for example, professionalised, patientled).Similar aspects were identified as important to make behaviour change tools most useful: design (n = 21), content (n = 6), and delivery (n = 5).
Workshop participants noted their interest in PD linked to specific topics, so that clinicians who had a specific interest (for example, obesity) could be exposed to relevant learnings.One participant noted that behaviour change is 'so deeply embedded in everything that we need to do as GPs' (GP3).
Barriers to attending PD included lack of paid time for nurses, which was seen as costly, and the need for their role to be covered in their absence.One GPN talked about using YouTube: 'I'll just kind of self-research that stuff … but it's not formal.'(GPN1) GPs echoed this approach.Participants spoke about relying on skills they picked up informally.
'I think with the behaviour change aspect, I'm using the skills that I've learnt elsewhere, that actually, I don't really look for resources …' (GP2) Others had a preference to learn in an interactive format or from a mentor, in person, rather than through reading.One participant said:

Themes from the virtual workshops
The following three main themes, which relate to successful behaviour change consultations, were developed from the analysis of the workshop data: (1) recognising the importance of relationships; (2) recognising the importance of continuity; and (3) keeping context in mind.These themes reflected participants views on core topics for future behaviour change education and PD to support GPs and GPNs working with priority patient populations.One GP participant expressed the importance of patient autonomy and patients leading goal setting:

'It's about the person. It's about the patient. It's their life. They have to buy-in and they have to drive it … You can't achieve anything with patients unless they're actually willing to participate.' (GP4)
Participants acknowledged that providing behaviour change support may require a sensitive approach.Raising the topic of behaviour change at an inappropriate time runs the risk of negatively impacting that relationship, making it impossible to address behaviour change needs: 'You've got someone, they know [smoking is] bad for them, and that you think that they should quit.But … if they said they're not even interested or open to that, you're actually just going to alienate them more, or get them offside or disrupt the therapeutic alliance by talking to them about it.And it will come across as more criticism or judgement … You've got to build that space where they are receptive first.' (GP4)

Leading team-based care
In addition to the clinician-patient relationship, team-based care was thought to contribute to successful behaviour change consultations.Participants highlighted the importance of patients building connections with other health professionals.As patients often see a variety of healthcare professionals, incorporating behaviour change as part of GP-led, team-based care can be useful to assist patients with behaviour change: 'It's acknowledging the practice team and the skills to support someone.It was acknowledging that we have that capacity within that practice and let's actually utilise those skills and feedback -good feedback mechanisms with the patient and the GP who is managing the care of that patient.' (GPN1) 'Recognising that it is never a one-off conversation, it's often not just one practitioner that will make the change.That … the broader discussion and having support from multiple people can make a big difference.'(GP4) Theme 2: Recognising the importance of continuity Continuity was viewed as enhancing understanding of patient perspectives, improving capability to deliver long-term behavioural support, and in some cases clinicians to incorporate the to be open facilitators, encouraging in-depth discussions among participants while maintaining a degree of separateness from the data.

Comparison with existing literature
This study, aligning with a recent global literature review, identified a lack of behaviour change tools for use with priority patient populations. 25Participants tended to recognise health professional organisations (for example, RACGP) as providers of behaviour change PD, although some participants were unaware of any existing tools and resources, with an explicit lack of tailored support for GPNs.These findings suggest that evidence-based tools and behaviour change education opportunities are currently underutilised in general practice, and this is a persistent theme across medical education. 26ncreasing the availability of evidence-based tools and education opportunities, and increasing their accessibility by consolidating them, will help to better support general practice clinicians and improve patient outcomes.
In Australia, general practice features a diverse workforce serving varied populations across a range of contexts. 5Study participants acknowledged that they work with individuals and families whose behaviours are influenced by complex societal factors, such as advertising, and social and cultural determinants.Participants warned against the individualisation of behaviour in general practice PD and clinical practice, and called for a greater emphasis on recognising context.These powerful contextual factors that were outside of the GP's control were perceived to make the use of behaviour change tools and PD opportunities less relevant.More research is needed to understand and respond to these powerful contextual factors in general practice.General practice research is currently underfunded, particularly in rural and remote areas where health outcomes are notably poorer than urban areas. 27quitable funding is needed to enable research and evaluation in areas where ill-health behaviours are prevalent and care services are limited, such as rural and remote health contexts.

Implications for research and practice
Participants relied on their individual strengths to inform behaviour change efforts, rather than searching for tools and additional PD opportunities.They initiated behaviour change efforts based on strong relationships (with patients and the clinical team), and self-confidence in clinical skills to use the 5As, 11 especially 'ask' and 'assess'.However, we observed a gap in participants' confidence to build on their strengths and actively support patients towards change (that is, 'assist and arrange').A recent content analysis of the Red Book, using the 5As, found that mentions of 'ask and assess' (n = 102) were disproportionately higher than 'assist and arrange' (n = 34). 28This gap was more pronounced in the preventative care guidelines for Aboriginal and Torres Strait Islander people ('ask and assess' n = 259 versus 'assist and arrange' n = 22). 28Survey responses identified clinical guidelines and tools as available behaviour change resources, stressing the importance of language in resources.To enhance general practice clinicians' strengths and support behaviour change efforts, future resources should encompass all 5As, including the 'assist' and 'arrange' components.
Participants infrequently described strategies to 'assist' patients, focusing on delivering behaviour change efforts at various stages across the care continuum to nurture clinician-patient relationships.A sample of 2010 GPs who entered in the Australia-wide RACGP Alcohol and Other Drugs GP Education Programme were least confident to 'assist' patients compared with other 5As components. 29In practice, general practice clinicians have been less successful in 'assisting' patients and 'arranging' care. 30This is critically important as care that includes the 'assist' component is more likely to lead to changes in patient behaviour. 31Future education opportunities should build on general practice clinicians' strengths by emphasising skills, confidence, and knowledge around the 'assist' aspect of facilitating behaviour change.
In conclusion, this study has provided new insights into understanding behaviour change in general practice.Increasing the availability and accessibility of evidence-based tools and behaviour change education opportunities in general practice is needed.When developing new behaviour change resources, consideration should be given to the design, content and activities, and mode of delivery.Future general practice behaviour change PD should build on GP clinicians' strengths by supporting them to 'assist' patients, avoiding the individualisation of behaviours and consider the contextual influences on behaviour.

4 6 Delivery• 5 PD = professional development Research Brickley B
If we were to create a behaviour change tool, what should we consider to make it most helpful to you? (viable responses n = 32) Incorporated into routine practice or existing systems • Ongoing evaluation et al.BJGP Open 2024; DOI: 10.3399/BJGPO.2023.0187Theme 1: Recognising the importance of relationships Building trust and focusing on patient goals Effective clinician-patient relationships were felt to contribute to successful behaviour change consultations.Participants viewed a trusting clinician-patient relationship as important to facilitate behaviour change.It was thought that by building trust and rapport with patients, clinicians would be better placed to understand patient needs and influence their readiness to change behaviours.Participants reported that once trust is established, then clinicians can tailor behaviour change communication based on patients' priorities, values, and motivations: '… That's the key, developing that relationship and building that trust to then explore with them what are they wanting to do.' (GP4) General practice clinicians spoke of drawing on their relationship with patients, and approaching behaviour change through a strengths-based framework that is responsive to patient circumstances, values, and goals: '… [it] is about relationship, which is about curiosity, respect, being with the person where they're at.And through that you can sometimes start to understand what their values are … what's important to them, what they have the confidence to do, and what they want to change when they are ready to do that.'(GP5)

Table 1
Environmental scan results: awareness of existing behaviour change tools and organisations that provide behaviour change professional development opportunities Research'... it's quite useful to see someone do it well, then, obviously, you do your best to emulate it.'(GP3)

Table 2
Environmental scan results: preferences for new behaviour change tools and behaviour change professional development opportunities