Perceived acceptability of a prototype toolkit to support patients and informal caregivers to express their perspectives in palliative care conversations

TL;DR

A prototype toolkit was developed to help patients and caregivers express their views in palliative care, and it was found to be generally well-received, especially in its physical form.

Contribution

The study introduces a prototype toolkit and evaluates its acceptability for supporting patient and caregiver communication in palliative care.

Findings

The hardcopy version of the toolkit was valued more than the website version.

The toolkit may help patients and caregivers feel more empowered during healthcare conversations.

Healthcare professionals believe the toolkit could help them tailor communication and care.

Abstract

Patients and informal caregivers experience challenges to express their personal perspectives in conversations with healthcare professionals (HCPs). A prototype toolkit, which consists of a hardcopy version and a website, was developed to address their challenges. The aim of this study is to gain insight into the perceived acceptability of this prototype toolkit.

Patients and informal caregivers end users and HCPs participated in semi-structured individual or group interviews. This resulted in two databases of qualitative data which were thematically analysed.

Twenty-two end users and twelve HCPs participated in this study. There is appreciation for the content and use of the prototype toolkit, with the hardcopy version of the toolkit being valued more than the website. Moreover, the use of the toolkit may strengthen end users' power and control and may support HCPs in tailoring communication and care. End users and HCPs recommendations for implementation are to further develop the prototype toolkit, provide HCPs with information, instruction and support and create facilitating conditions in healthcare.

High appreciation of the hardcopy version and the practical value are positive indicators of end users'and HCPS perceived acceptability of the prototype toolkit. However, the content of the toolkit is experienced as being too extensive, with the hardcopy version experienced as being incomplete without the website and the website is experienced as being too complicated to use. Further development and testing of the prototype toolkit is required to increase its acceptability by end users and HCPs.

In this study a Design Thinking approach was used to test study the acceptability of a prototype toolkit by endusers and HCPs. This approach can contribute to a succesfull implementation of the toolkit and its effectiveness.

•High appreciation of hardcopy version prototype toolkit.•High appreciation of practical value prototype toolkit.•The use of the toolkit may strenghten power and control of endusers.•The use of the toolkit may support healthcare professionals to tailor communication and care.

High appreciation of hardcopy version prototype toolkit.

High appreciation of practical value prototype toolkit.

The use of the toolkit may strenghten power and control of endusers.

The use of the toolkit may support healthcare professionals to tailor communication and care.

Full text

Introduction

1

Patients with chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) and their informal caregivers (ICs) can benefit from a person-centred palliative care approach to improve both their quality of life and care [[1], [2], [3]]. Person-centred palliative care can be considered as a shared responsibility of patients, ICs and healthcare professionals (HCPs) based upon the knowledge and expertise of those involved. Patients and ICs can become experts in living with the disease whereas HCPs are expected to be experts on disease, treatment and care [[4], [5], [6]]. Knowing the personal perspectives of patients and ICs, what they value, need and prefer in their life, health and care, is an important pre-requisite to enable HCPs to provide person-centred palliative care [[7], [8], [9]].

However, not every patient and IC is willing or able to express their personal perspective in conversations with HCPs [[10], [11], [12], [13], [14]]. Due to many different personal, interactional and organisational factor patients, ICs and HCPs consider it challenging to personalise their conversations during consultations [[10], [11], [12], [13], [14], [15], [16]]. Patients and ICs experience these challenges even more so when there is a lack of empathy and a good connection with their HCP. Moreover, HCPs experience that conversation can be difficult for them when patients are passive, closed, and unable to understand or recall the information or when they have unrealistic expectations [16]. This inability and behaviour of patients is associated with lower levels of health literacy and social skills [11].

Many tools exist for patients and ICs to help them prepare for conversations with their HCPs and to facilitate these conversations [[17], [18], [19], [20], [21]]. However, these tools are often not used because for example, patients, ICs and HCPs are unaware that they exist, it is hard for patients and ICs to assess their relevance and quality (e.g. up-to-date evidence-based information from transparent and unbiased sources which can be understood by lay people [22]) and/or it is challenging to integrate these tools in the care process, for example because HCPs experience time constraints [18,20,22,23]. Since it is important to provide patients with COPD or CHF and their ICs, (hereafter end users), with relevant, high quality and accessible tools supporting them in exploring and expressing their perspective in conversations with HCPs, a prototype toolkit (MijnBlik) was developed in co-creation with end users and HCPs [15]. This prototype toolkit consists of a hardcopy version (tin box) and a corresponding website bringing existing (Dutch) tools from different sources together in one place [15]. Tools were selected based on a set of defined quality criteria; relevance in relation to experienced challenges, reliability by means of being provided by trustworthy organisations, specific for target population and setting, readable and understandable by lay people [15].

Succesful evaluation and implementation of the prototype toolkit depends, among other factors, on its acceptance by its intended receivers (end users) and intended deliverers (HCPs) [24,25]. Since we can view this prototype toolkit as a technology, the conceptualisation of acceptability according to the Technology Acceptance Model (TAM) has been initiated [[26], [27], [28]]. Acceptability of a new technology is understood as a three stage proces; 1) determinants like system characteristics, facilitating conditions, individual differences and social influences lead to the development of two beliefs of the new technology: a) it's perceived usefulness (PU) and b) it's perceived ease-of-use (PEOU). These two beliefs influence the 2) intention to use and the 3) actual usage behaviour [27,28].

Insight into the perceived acceptability of the prototype toolkit by end users and HCPs is necessary to decide whether the prototype toolkit needs to be adjusted prior to large scale evaluation and implementation [29]. Therefore, we want to explore how end users and HCPs perceive the acceptability of the prototype toolkit in view of the following questions: 1) What is and is not, appreciated about the prototype toolkit? 2) What is the perceived practical value of the prototype toolkit? 3) What are recommendations for the implementation of the prototype toolkit in conversations and organisational settings?

Method

2

Design

2.1

This study was part of a broader research and innovation project named EMPATIE which stands for “EMpowerment of PATIEnts and informal caregivers” performed in the eastern part of the Netherlands [15]. The aim of this project was to develop a supportive prototype toolkit for end users enabling them to express their personal perspective in conversations with HCPs. The first four phases of Design Thinking (DT) empathize, define, ideate, prototype, [30,31] were used to develop a prototype toolkit in co-creation with end users and HCPs [15]. The current study reports the findings concerning the fifth phase of DT wherein the acceptability of the prototype toolkit was tested by end users and HCP's prior to the evaluation and implementation of the prototype toolkit in clinical practice. From April to November 2021 we collected in-depth qualitative data via semi-structured individual and group interviews with end users and HCP's [32].

Prototype toolkit

2.2

The prototype toolkit consists of a hardcopy version and a corresponding website. The hardcopy version was developed to introduce the tools whereas the website was developed to provide easy access to free, available online tools (mijn-blik.nl). This means that the hardcopy version contains a description of the tools and that the website is required to gain access to the freely available online tools. The tools were selected based upon the selection criteria that were revealed in the first study of the project [15]. The hardcopy version is a tin box which contains an information and instruction sheet and 42 cards. Each card gives a description of a tool or some general information about the tool. The cards are bound together in four fans representing different topics based upon the user's needs and wishes [15]; namely 1) I want to say what is on my mind, 2) I want to know which questions I can ask, 3) I want to participate in the conversation about my treatment and care, 4) I want to talk about the future. The first page of the website is a welcome page with a short introduction and four tiles each of which refers to one of the four topics respectively. The colours and the pictures of the tiles correspond with the paper fans and cards of the hardcopy toolkit. End users can use the prototype toolkit to prepare themselves independently for conversations with HCPs in a self-paced manner at home.

Participants

2.3

End users

2.3.1

End users needed to be able to understand and speak Dutch without having any mental or speaking disorders such as dementia or aphasia. They also needed to be under periodical supervision of a medical specialist, general practitioner, nurse or nurse practitioner.

Different approaches were used to recruit future end users as participant for this study. Firstly, HCPs participating in the previous phases of the EMPATIE-project, recruited end users during scheduled consultations. Secondly, two national patient organisations for COPD and CHF patients and one informal caregiver organisation were asked to send out a recruitment announcement to their members. Thirdly, physical therapists specialized in rehabilitation of patients with COPD or CHF contributed to the recruitment by personally asking patients and ICs whether they were willing to participate. Fourthly, an article about the prototype toolkit was published in a local newspaper to invite people interested in receiving and testing the toolkit to contact us by mail or phone.

When end users were interested in participating in the study, researcher AO provided additional information about the project, the prototype toolkit and an individual or group interview. After verbal informed consent, AO collected demographic information and made an appointment for an individual or group interview. AO also sent a package with an information letter, an informed consent form, a return envelope and the toolkit to the home addresses of participants at least two weeks in advance of the scheduled interview. During these two weeks participants could use the toolkit in a self-paced manner at home correspondings with its intended use prior to use during conversations with HCPs. Selection for individual or group interview was based upon individual preference. The aim was to recruit at least twenty end users with an equal distribution of 1) patients and ICs and 2) diagnosis COPD and CHF.

Healthcare professionals

2.3.2

HCPs working with patients with COPD or CHF were also eligible for this study. Medical specialists and nurse practitioners working in a hospital setting, general practitioners (GPs) and nurses working in a general practice and nurse practitioners providing care at home could all be included in the study.

HCPs were recruited using different strategies: 1) HCPs, participating in (previous studies of) the EMPATIE-project, recruited colleagues within their network, and 2) a coordinator of the palliative care network approached HCPs in person and via a digital announcement in that network.

HCPs interested in participating were contacted by researcher LG or AO by phone and the same procedure for inclusion was used as described for end users. They also received an information package containing the hardcopy toolkit at least one week before the individual or group interview. During this week HCPs could assess the prototype toolkit on its intended use during conversations with end users. HCPs all provided verbal informed consent before the start of the interview.

We aimed to recruit at least fifteen HCPs with a balanced mixture of HCPs working in a general practice, hospital or providing care at home. We strived for an equal distribution of HCPs working with patients with COPD or CHF.

Data collection

2.4

The research questions in this study focus on system characteristics of the toolkit and facilitating conditions (determinants) in relation to the beliefs PU and PEOU (see Table 1).Table 1. Relation between research questions, determinants and beliefs.Table 1. Research questionsDeterminantsBeliefs

• 1.What is and is not, appreciated about the prototype toolkit? System characteristicsPU + PEOU
• 2.What is the perceived practical value of the prototype toolkit? PU
• 3.What are the recommendations for the implementation of the prototype toolkit in conversations and organisational settings? Facilitating conditionsPU + PEOU

Semi-structured individual and group interviews were performed from April 2021 until November 2021 by researchers LG or AO. A topic list for end users and one for HCPs was used for individual interviews (see Appendix A). For group interviews a script was used with questions and statements derived from these lists. The semi-interviews were performed by phone or video-calling due to Covid-19 restrictions during the inclusion period and face-to-face as soon as these restrictions were lifted. End users were interviewed at home and HCPs at home or at their office.

Data-analysis

2.5

All individual and group interviews were audio-recorded and transcribed verbatim. The transcripts were thematically analysed by researcher AO using ATLAS.ti 22. The interviews with end users and HCPs were approached as two datasets. These were analysed separately using line by line coding. Initial codes were categorised and generated into themes by AO. Multiple individual discussion between AO and researchers MU, JJ and LG were used to further review and develop these initial codes, categories and themes. Further refinement was realized through multiple discussions between all participating researchers.

Ethics

2.6

The Ethical Committee Twente declared that the Clinical Research Involving Human Subjects Act was not applicable to this research and innovation project. This study was executed according to the Declaration of Helsinki [33]. Informed consent procedures of participants were performed according to good clinical practice guidelines. Saxion University of Applied Sciences' cloud was used to store data conform the description in a data-management plan which was approved by the subsidy provider. This storage protects against loss, damage, unauthorized access and the digital aging of the data files.

Results

3

Participants

3.1

A total of 22 end users (17 patients, 5 ICs) and 12 HCPs participated in this study. For demographic information of the participants see Table 2. The five participating ICs were not related to any of the patients participating in this study, but were the partner (n = 2), an adult child (n = 2), and an adult sister (n = 1) of a patient.

Data-collection

3.2

Twenty six individual interviews and three group interviews were performed (Table 2). Three interviews with patients were performed in the presence of a spouse not participating in this study. One HCP participated in both an individual face-to-face interview and an online group interview. The median duration of the individual and group interviews with end users was 49 min (range 33–70) and with HCPs 37 min (range 10–64).Table 2. Demographic and method information participants.Table 2. CharacteristicSpecificationEnd users(n = 22)CharacteristicSpecificationHCPs1 (n = 12)DemographicDiagnosis PatientCOPD12ProfessionGeneral Practitioner2CHF25Nurse1COPD and CHF5Nurse Practitioner- COPD3- CHF4- Older adults2GenderFemale15GenderFemale11Male7Male1Age<602Age<40460–691040–49370–79750–59280–893>601Missing0Missing2Level of education^3^Secondary education7SettingGeneral Practice4Preparatory vocational education (low and medium level)11Hospital3Higher Professional education or University4Home Care5Years since diagnosis patient<15Years of experience in profession<603–546–1036–103>104>1010Missing5MethodType of InterviewIndividual18Type of interviewIndividual8⁎Group4Group5⁎Form of InterviewFace to face5Form of interviewFace to face1⁎Phone call9Phone call3Video call8Video call9⁎1HCPs = healthcare professionals.2CHF = chronic heart failure.⁎one HCP participated first in an individual interview ((face to face) and later in a group interview (video-call).

Results

3.3

Appreciation of the prototype toolkit

3.3.1

What end users and HCPs like and dislike about the prototype toolkit has been related to three themes: 1) form, 2) content and 3) use. These three themes contain respectively six, five and six categories.

What is appreciated about the form is the original and handy design of the hardcopy version, its inviting appearance and accessible lay-out. However, participants find the tin box too big since it doesn't fit through a letterbox or in a handbag or workbag. They experience the hardcopy version as being incomplete without the corresponding website since it only contains references to websites. They also perceive that the website reduces the usability of the prototype toolkit because not every end user is sufficiently skilled, or finds it too much trouble to use a computer or tablet, especially older adults and severely ill patients (see Appendix B).

What is liked about the contents are the four topics of the fans with cards that get to the heart of the matters of care and the inclusion of appealing tools on the website. In spite of this, end users and HCPs experience the content of the prototype toolkit as too comprehensive. Some end users expressed that the content of the prototype toolkit does not meet their needs because they prefer concrete information, do not feel the need to visit the website or have already discussed everything with their HCP. HCPs on the other hand believe that the sequence of topics presented does not correspond with the course of the diseases. They wonder when they should introduce the toolkit and whether they need to introduce and deliver the toolkit in one go or step by step (see Appendix B).

What is appreciated about the use is that the prototype toolkit is in general easy to use, can be used in a self-paced manner and has a broad application namely it can be used by both end users and HCPs. End users also perceive that the prototype toolkit can be used during the whole course of the diseases. However, end users and HCPs express that specific aspects of the prototype toolkit are too complex and they perceive that it takes too much time and effort to use. These aspects are primarily related to the use of the website and the introduction of the prototype toolkit and its use during consultations (see Appendix B).

Practical value of the prototype toolkit

3.3.2

This study resulted in two themes related to the assigned practical value. The use of the prototype toolkit may 1) strengthen end users' power and control, and 2) support HCPs to align with end users.

The first theme ‘strengthen end users’ power and control’ contains seven categories. First, the use of the prototype toolkit can provide end users with insight into the disease and its process, conversations with HCPs and possibilities of future care. Second, it can create end users' awareness of what to think about, what questions to ask and to whom, and what to discuss in consultations with HCPs. End users also describe that it creates awareness on how to communicate with HCPs, whereas HCPs mention aspects related to what end users can do by themselves and what is preoccupying them. Third, the use of the prototype toolkit can be experienced as confrontational, and especially the theme “talking about the future”, and can lead to certain thoughts and feelings. Fourth, it makes end users think about conversations with their HCPs and their future including end of life. Fifth, especially according to HCPs, it may provide incentives to act, such as talking to others and preparing for consultations with HCPs. Sixth, the use of the prototype toolkit can support dialogue between patients and relatives which may lead to a better understanding of each other. Finally, according to HCPs, the use of the prototype toolkit may support conversations between end users and HCPs and decision making because it may lead to asking the right questions, discussing certain topics and taking the right decisions (see Appendix B).

The second theme for using the prototype toolkit is that it may support HCPs in aligning with end users. This theme contains three categories. First, it may support dialogue between end users and HCPs because among other things, it may contribute to shared responsibility for the content of the conversation and maylead to more active participation of end users in the conversation. Second, it may support HCPs to give more power to the end users and emphasize self-management. Third, it may help HCPs to tailor care because they may respond to the care question of end users and personalise their care (see Appendix B).

Recommendations for adjustments and implementation of the prototype toolkit

3.3.3

End users and HCPs give four recommendations in relation to the adjustments and implementation of the prototype toolkit in the organisational setting.

First, they recommend adjusting the content to make it suitable for a broader target population than COPD or CHF, make it simpler and more convenient to use, make the tin box usable without the need to visit the corresponding website. They also recommend making the tin box smaller and laminating the cards.

Secondly, HCPs express that they need additional information, instruction and support in advance in order to be able to introduce and use the toolkit. They would like to receive more information about why the toolkit has been developed, which HCP is going to deliver it and to whom, when the toolkit can be introduced and delivered, what is handed over and how to integrate toolkit use into conversations with end users. They also expressed the need for preparation and support enabling them to start using the toolkit. Both end users and HCPs state that a trustful relationship is a prerequisite to introducing the toolkit and HCPs express that it is important to clarify the importance of active contribution and gaining in depth knowledge in advance.

Third, it is important that HCPs are prepared for the implications of the implementation of the toolkit. Both end users and HCPs believe that a nurse is the designated HCP to introduce, deliver and work with the toolkit because this professional has both the time and expertise. Moreover, both end users and HCPs express that successful implementation of the toolkit depends on the attitude and behaviour of doctors in general and medical specialists in particular. They need to support the use of the toolkit and need to centralize patients and ICs in both their conversations and decision making.

Finally, it is important to create the right conditions in healthcare to implement the toolkit. End users also state that it is important that the toolkit is affordable for everyone and recommend determining a price and organising a rebate for example via health insurance companies or patient organisations. HCPs express that it is important to first integrate the toolkit in their own work process and in the registration systems of their organisations (See Appendix B).

Discussion and conclusion

4

Discussion

4.1

This qualitative study explored the perceived acceptability of the prototype toolkit MijnBlik according to end users and HCPs. It sheds light on the perceived appreciation and practical value of this prototype toolkit and give directions for further implementation of the toolkit in healthcare. End users and HCPs highly appreciate the inviting appearance of the hardcopy version of the prototype toolkit and the four topics that get to the heart of the matter, although there is less appreciation for the website and the fact that the content of the prototype toolkit is too extensive. End users and HCPS are ambivalent about the usability of the prototype toolkit especially in relation to certain subgroups of end users. They are very positive about the practical value of the prototype toolkit and believe that both end users and HCPs may benefit from the prototype toolkit because it may strengthen the power and control of end users and support HCPs in tailoring communication and care to end users. End users and HCPs recommend further development of the hardcopy version of the prototype, provide more support for HCPs in using the toolkit and arranging several facilitating conditions at different levels of the care process before the toolkit can be evaluated and implemented in clinical practice.

The toolkit is useful but needs some adjustments to improve it's perceived ease-of-use

4.1.1

Based upon the expressed practical value of both end users and HCPs the prototype toolkit seems to be perceived as useful. Participants perceive that the toolkit can be used by both end users and HCPs. End users perceived that the toolkit could be used during the whole disease trajectory of COPD and CHF and also by other end users not just those with COPD and CHF. It is positive that participants perceive the toolkit as useful because according to the TAM there is a direct relationship between PU and actual use [28]. However, the toolkit needs to be adjusted prior to further evaluation and implementation because the content of the toolkit is experienced as being too extensive, the hardcopy version is experienced as being incomplete without the website and the website is experienced as being too complicated to use. Due to the direct relationship between PEOU and PU, based upon the TAM, it is important to reduce the number of tools, to make it possible to use the hardcopy version without the website, and to include easy to use online tools on the website. Besides adjusting the prototype toolkit based upon the findings of this study, it is also important to deliver the toolkit early in the disease trajectories when end users may still not have discussed everything with their HCPs.

Hardcopy version is more appreciated than the website

4.1.2

This study revealed that the hardcopy version of the toolkit is more appreciated than the website. Both end users and HCPs expressed that the website may be a problem for older adults and more severely ill patients. However, age and disease severity are not the most important factors in relation to the ability to use the internet. More important are the socio-economic status and the level of (e)Health literacy [[34], [35], [36]]. This may mean that it remains important to use different modes of delivery of the toolkit in order to address the needs of different types of individuals within the population of end users [34,35]. It also may mean that the prototype toolkit needs further development in order to increase the usability for end users with low levels of (e)Health literacy which is highly prevalent among patients with COPD and CHF [[37], [38], [39]]. Another implication of this finding is that individual differences need to be included as one of the determinants of PU and PEOU in future studies about the acceptability of the prototype toolkit.

HCPs uncertain about timing and content phasing of the prototype toolkit

4.1.3

HCPs expressed their concerns that the content of the prototype toolkit does not match the disease course of COPD and CHF. This was particularly the case in relation to the theme “talking about the future”. HCPs were uncertain about the timing and content phasing of the prototype toolkit because they were concerned about emotional burden on end users and the impact on their relationship with end users [40,41]. However, participating patients recommended delivering the complete toolkit as early as possible in the disease process although one patient, recently diagnosed with CHF, had been confused for several days after receiving the toolkit. This difference in perspective between HCPs and end users can be an illustration of social influences like subjective norms as determinants of PU and PEOU. Although it is recommended to integrate PC and Advanced Care Planning (ACP) early in the disease trajectory of patients with COPD or CHF [1,2,42,43] the readiness differs from person to person and is based upon individual preferences and disease severity [[44], [45], [46], [47]]. This implies that timing and content phasing of the toolkit needs to be tailored to each individual end user and HCP's need to be able to assess end users readiness and adjust the introduction of the toolkit and their communication accordingly [48,49]. Specific clinical indicators to initiate ACP conversations for patients with organ failure are: 1) after a period of illness, 2) after an exacerbation, 3) in a period with relative wellness, 4) in an appropriate setting with adequate time and presence of a family member [50]. These indicators can be helpful to HCPs in introducing and delivering the prototype toolkit in a timely manner to end users.

Context matters in relation to the implementation of the prototype toolkit

4.1.4

The high practical value given by both end users and HCPs indicates that the toolkit meets their needs. However, the intended use of the toolkit in clinical practice does not only depend on the system characteristics of the prototype toolkit It became clear that this also depends on the integration of the toolkit in the work process of HCPs, the registration systems of healthcare organisations and the financial rebate of the toolkit. These facilitating conditions need to be established prior to the evaluation and implementation of the prototype toolkit in clinical practice [18,20,23,51]. Further research of facilitating conditions is needed before the prototype toolkit can be implemented in clinical practice.

Strengths and limitations

4.1.5

One strength of this study was the inclusion of both end users and HCPs. This provided insight into the perspectives of intended receivers and intended delivers of the toolkit. It also made it possible to analyse similarities and differences in their perspectives. The inclusion of end users with varying time spans since diagnosis was another strength because the perceived ease of use and practical value of the toolkit may depend on the disease duration.

A limitation of this study was the existence of selection bias among both end users and HCPs. More motivated and empowered end users were included in this study probably due to the recruitment approaches used due to Covid-19. Although the intention was to recruit an equal number of patients and ICs, more patients than ICs were included. The consequence of this is that the perspective of ICs is insufficiently addressed. The majority of the HCPs were female nurses, there were only two GPs and no medical specialists. This implies that the perspective of male HCPs, GP and medical specialists, needs to be further assessed. Finally, the perceived and not the experienced acceptability of the prototype toolkit during conversations in clinical practice was evaluated in this study due to Covid-19.

Innovation

4.2

The research presented in this article outlines a qualitative evaluation of the acceptability of a prototype toolkit for patients with COPD or CHF and their ICs. The aim of the prototype toolkit is to empower patients and ICs to express their perspective in palliative care conversations with their HCPs [15]. The use of a Design Thinking (DT) approach, in which we examined the perceived acceptability of the toolbox in this study prior to the evaluation and implementation of the toolkit, is an innovative approach in palliative care research [29,52]. This approach is based upon the active engagement of relevant stakeholders in the development, evaluation and implementation of healthcare interventions [29,52]. The use of DT can result in a more useful, acceptable and effective toolkit compared to the use of less iterative and user-centred methods [52]. The evaluation of the acceptability of the toolkit by patients, ICs and HCPs can contribute to a succesfull implementation of the toolkit and its effectiveness and it does justice to the practical reality in which palliative care conversations are performed [29].

Conclusion

4.3

The high appreciation of especially the hardcopy version and the practical value are positive indicators of the perceived acceptability of the prototype toolkit. However, further development and testing of the prototype toolkit is required to increase itsacceptability by end users and HCPs. Since acceptability does not only depend on the system characteristics of the toolkit itself, it is also important to support HCPs before and during implementation, to establish facilitating conditions in healthcare and further study system characteristics, facilitating conditions, individual differences and social influences as determinants of PU and PEOU prior to the evaluation and implementation of the toolkit in clinical practice.

CRediT authorship contribution statement

Annet Olde Wolsink-van Harlingen: Writing – original draft, Visualization, Methodology, Investigation, Formal analysis, Data curation. Jan Jukema: Writing – review & editing, Supervision. Kris Vissers: Writing – review & editing, Supervision. Madeleen Uitdehaag: Writing – review & editing, Supervision, Funding acquisition, Formal analysis, Conceptualization. Jeroen Hasselaar: Writing – review & editing, Supervision. Leontine Groen-van de Ven: Writing – review & editing, Project administration, Methodology, Investigation, Formal analysis, Data curation.

Declaration of competing interest

None.