Putting “what matters to you?” into practice: a focused team-based ethnographic study on goal-oriented care

Abstract

Background

As healthcare systems transition toward person-centred integrated care (PC-IC), goal-oriented care (GOC) has gained prominence as a conceptual approach to aligning care with what matters most to patients. However, there is limited empirical insight of how GOC is enacted in daily practice and what competencies this requires from providers. This study explores how primary care providers enact GOC in daily practice to inform future training and competency development.

Methods

A focused, team-based ethnographic approach was used, combining non-participant observations with short reflective interviews. Primary care providers were purposively sampled from a cohort who completed interprofessional GOC training, ensuring disciplinary diversity. Data were analysed using thematic analysis to identify behaviours and competencies underpinning GOC in practice.

Results

Providing GOC requires competencies beyond knowledge or task-specific skills, and is enacted through contextual, relational, and reflective competencies. Providers showed contextual awareness by linking care actions to patients’ lived experiences and personal goals. They built relational trust through open, authentic, and non-hierarchical communication to co-create care decisions with patients. Reflective competence was shown when providers reassessed care decisions in light of patient goals, assumptions, and team input.

Conclusions

These findings highlight the importance of strengthening reflective competencies in training of primary care providers. In practice, this entails supporting providers to reflect on their professional responsibilities, alongside those of the other disciplines they work with in health and social care; and critically engage with assumptions. This reflective capacity is key to embedding GOC in daily practice and aligning care with what truly matters to patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-025-03165-6.

Background

Healthcare systems worldwide are transitioning toward person-centred integrated care (PC-IC) to better support individuals with complex and long-term care needs [1, 2]. Within this shift, goal-oriented care (GOC) has emerged as a promising approach to align care with what matters most to patients [3]. By focusing on patients’ personal goals and preferences, GOC aims to foster more meaningful and coordinated care. A recent concept analysis by Boeykens and colleagues describes GOC as an iterative and stepwise process, consisting of three key stages: goal-elicitation, goal-setting, and goal-evaluation [4]. During goal-elicitation, providers seek to understand patients’ lived experiences and perspectives. In the goal-setting phase, goals are jointly defined and care actions are planned accordingly. Finally, goal-evaluation involves reviewing the relevance of care actions and adjusting goals where needed.

Despite this conceptual clarity, many primary care providers (PCPs) report difficulties in putting GOC into practice, including challenges in communicating with patients about goals and translating these into concrete care plans. While interest in GOC among professionals is growing, empirical insight into the specific competencies required to enact GOC effectively in daily practice remains limited [5–7]. In line with contemporary competency-based education literature and the World Health Organization (WHO), competencies can be understood as the ability to integrate knowledge, skills, and attitudes, and that become visible through context-specific performances in practice [8, 9]. However, a clearly specified set of competencies for GOC has not yet been articulated. Existing literature often describes GOC-related competencies in broad terms—such as “communication” or “collaborative skills”—without offering the detail needed to guide training or assessment [10, 11]. This lack of specificity is, in part, due to the limited empirical work on how GOC is put into practice in real-life settings [12].

Retrospective interview studies offer valuable insights, but often fail to capture the contextual nuances and dynamic behaviours that underpin how GOC is enacted in practice. In this study, enactment refers to how GOC takes shape through professionals’ concrete actions and interactions with patients, rather than as a predefined procedure to be implemented. By focusing analytically on enactment, this study seeks to generate detailed insights into how professionals attempt to enact GOC in their daily interactions with patients [13, 14]. This is particularly relevant in primary care, where professionals are frequently the point of contact for individuals with complex and chronic health needs. In such settings, providers are not only required to manage clinical problems, but also to coordinate care, build long-term relationships, and navigate social and emotional dimensions of care. As a result, the demand for integrated and person-centred approaches like GOC is especially pressing in primary care contexts [15].

In Flanders (the Dutch-speaking region of Belgium), early policy incentives to promote PC-IC in Flemish primary care have encouraged some PCPs to adopt GOC in practice [16]. These early adopters provide a unique opportunity to observe how GOC is enacted in real-world settings. To examine how PCPs enact GOC in practice, this study adopts a social interactionist perspective, drawing on Goffman’s dramaturgical framework as a sensitising lens [17]. This framework views professional behaviour as a relational performance that unfolds in two complementary spaces: frontstage—in the presence of patients, where providers manage their role and communication—and backstage—outside the patient’s view, where preparation, coordination and reflection occur [18, 19]. In this study, we observed frontstage patient–provider encounters and, through follow-up interviews, elicited provider accounts of backstage considerations (e.g., preparation, coordination, documentation) shaping those encounters.

Observing and analysing providers’ frontstage work can offer bottom-up insights into the specific behaviours and underlying competences required to support GOC in practice. Understanding how PCPs show GOC in practice can help bridge the gap between conceptual models and the way GOC as a practice becomes embedded in everyday professional routines. Understanding the operational work through which PCPs enact GOC can provide initial behavioural insights into the competencies needed in practice. These insights may support the future development of competency-based training tailored to primary care. Therefore, this study aims to answer the following research question: “What behaviours do primary care providers show when providing goal-oriented care in their practice?”

Methods

Aim

The aim of this study was to understand how primary care providers enact GOC in their daily practice. The research question of this study therefore was: “What behaviours do PCPs show when providing GOC in their practice?”. The unit of analysis was provider behaviour in GOC, meaning the observable ways in which providers enact GOC during patient-provider encounters, complemented by insights from short reflective interviews that illuminated the reasoning behind these actions. We use the term behaviour pragmatically to refer to how professionals enact GOC in interaction with patients, recognising that such actions are relational and context-dependent [19, 20]. Broader contextual dynamics, such as team relationships or organisational influences, were acknowledged but lay beyond the scope of this analysis.

Design

This study used a focused team-based ethnographic approach [21, 22] to explore how GOC is enacted in primary care practice. Given the current lack of knowledge regarding the observable behaviours associated with GOC in practice, ethnography provides a suitable methodological approach for exploring GOC in real-world settings. Ethnographic research entails the researcher’s immersion in a specific social context in order to gain an in-depth understanding of participants’ behaviours and the meanings they ascribe to the research phenomenon [21]. Focused ethnography, a pragmatic form of ethnography investigates a clearly defined issue within a specific setting [23]. In this study, focused ethnography was used to explore the provision of GOC in daily practice, concentrating on key individuals and situations where the phenomenon unfolds [22]. Additionally, this study employed a team-based approach, meaning that data collection and analysis were conducted collaboratively by a group of researchers.

Setting

In Flanders, a primary care reform was launched in 2017 with the specific aim of promoting collaboration among PCPs and further enhancing the focus on patients’ personal goals and preferences. This reform led to the establishment of 60 primary care zones (PCZs) in Flanders and Brussels. These zones are geographically defined, each serving a population of approximately 75,000 to 125,000 residents, and consist of PCPs providing locally organized primary care services tailored to individuals’ healthcare needs. The Flemish Institute for Primary Care (VIVEL) supports PCPs through various initiatives linked to policy, education and supporting innovations [24]. One of these initiatives has been organizing interprofessional training on GOC since 2021. As a pilot project, VIVEL trained fifty PCPs from five PCZs in Flanders between 2021 and 2023, with ten participants from each zone.

Sampling

Participants for this study were recruited via purposeful sampling. The PCPs who had completed the interprofessional GOC training organized by VIVEL between 2021 and 2023 formed the cohort for recruiting participants. Within this cohort of trained professionals, PCPs were selected using maximum variation sampling to ensure a diverse sample in terms of discipline. Providers were invited by email to participate in the study, with the requirement that they had active patient contact to focus on professional behaviour during patient-provider interactions. Providers without active contact with patients were excluded. Each participant was expected to consent to at least one observation in their professional context, whether this involved a fixed primary care setting (e.g., a community health centre, a physiotherapy practice, a day centre) or a mobile form of primary care provision such as a home visit.

Data collection

Data were collected through non-participant observations combined with brief follow-up interviews. This approach enabled the researcher team to combine an ‘etic’ lens—observing how GOC was enacted in practice—with insights from providers themselves, who reflected on their own actions and reasoning during the observed encounters. Observations were documented through detailed field notes and a structured observation framework (Additional file 1) focusing explicitly on participants’ behaviours related to GOC. To capture participants’ insights, short reflective interviews were conducted immediately after observation sessions. A brief interview guide (Additional file 2) served as a starting point from which more in-depth questions emerged in response to observed interactions. These interviews, audio-recorded and transcribed verbatim, allowed participants to discuss and reflect on their experiences of applying GOC, thereby enhancing their self-awareness and enabling deeper exploration of GOC practices [22].

Prior to data collection, a group of junior researchers – five healthcare professionals (R.H., M.D., A.D., E.D., F.J.) led by R.H. – undertook a reflective observation training. Four were occupational therapists, while one had a background in social work and psychology. All were participating in the research team as part of a time-limited research internship during this study and contributed to data collection and preliminary analysis under supervision. The team members had advanced knowledge of GOC and received additional training before engaging in fieldwork. Given the importance of reflexivity in ethnographic research, two training sessions were organized to establish a shared understanding of GOC, practice observational techniques, and refine note-taking skills. A concept analysis of GOC by Boeykens and colleagues was used as a reference to support this shared understanding [4]. Observational techniques and note-taking were practiced using videos of simulated primary care situations. These sessions enabled researchers to critically reflect on their observational skills and biases, ensuring transparent and coherent documentation [25, 26].

To build trust—a key aspect of ethnographic research—participants were consistently paired with the same researcher, who scheduled sessions via email or phone based on participants’ availability and preference. An observation session was defined as the period during which the researcher was present in the participant’s work context on a given day. Within a single session, multiple observations of different interventions could take place. In addition, each participant was observed at least once by their assigned researcher and the lead researcher (R.H.). This ‘double observation’ approach enhanced reflexivity within the research team by fostering shared perspectives and interpretations of observed phenomena [27]. The iterative combination of observations and reflective interviews contributed to a thick description, crucial for robust ethnographic analysis.

Data analysis

A six-phase codebook thematic analysis, as outlined by Braun and Clarke (2006), was applied to ensure a rigorous and systematic approach [28, 29]. To increase transparency, we provide a worked example of the analytic pathway (raw data → condensed meaning unit → code(s) → subtheme → theme) in Additional file 4. The process began with data familiarization, where researchers extensively reviewed transcripts and field notes to develop a deep understanding of the data. Coding then followed a structured, team-based process. Each researcher independently coded data from one participant they observed and one observed by a colleague, ensuring all data were double-coded. The coding pairs subsequently met to compare and refine their initial codes, compiling them into an initial codebook. This codebook was iteratively refined and used as a practical tool to facilitate shared engagement with the data and guide reflective team discussions, rather than applied deductively or for the purpose of assessing coding reliability [29]. The remaining data were coded using this shared codebook, with researchers analysing both their own and colleagues’ observations to maintain consistency and depth (see Additional file 3 for detailed coding distribution). The team met four times to review coding progress, discuss explored patterns, refine the codebook, and assess data saturation. Finally, the lead researcher (R.H.) conducted a final review to further refine and nuance the coded data. Coding relevance was judged in relation to the enactment of GOC. For example, the code “conscious use of telephone and computer” was applied only when the observer and/or participant judged the action to contribute to GOC; routine computer use was not coded as such. Differences in interpretation were surfaced in team meetings, resolved by returning to the data, and documented in brief reflexive memos.

Once coding was complete, codes were clustered into preliminary subthemes and themes. Observational and interview data were analysed in relation to one another. The two data sources were therefore treated as complementary and synthesised during theme development, rather than as separate datasets to be compared. This approach ensured consistency across data sources and enhanced the interpretive depth of the findings. A two-step review process of the preliminary (sub)themes was then conducted. First, the research team internally discussed the created themes in a dedicated meeting. Second, a synthesized member check was performed with interested participants through individual online meetings via Microsoft Teams. In these sessions, the lead researcher presented synthesized findings, and participants provided feedback on clarity, alignment with their experiences, and any missing elements. This approach ensured accurate and equitable representation of participant input in finalizing the results [30–32]. Following this review, final (sub)theme names and definitions were collaboratively refined, ensuring clarity and internal coherence. The analysis concluded with the writing phase, in which findings were synthesized into a coherent, analytical narrative, integrating direct quotes and examples from both observational and interview data.

Results

Sample

A total of sixteen PCPs were observed for 203 h over 34 days within a four-month period (February 2024 – May 2024). The participants had diverse professional backgrounds, including physical therapy (n = 6), social work (n = 3), nursing (n = 3), nutrition (n = 1), general practice (n = 1), speech therapy (n = 1), and mental health care (n = 1). During the observations, 161 distinct patient-provider encounters were attended. Ten of the sixteen participants took part in the member check, held in July 2024, three months after data collection. An overview of the observed providers and observation days is presented in Table 1.

Table 1.

Overview of participants

Number Participant	Profession	Work context	Number of observation days (and hoursa)	Number of observed patient-provider contacts
1	Physiotherapist	Multidisciplinary independent practice	4 (14 h)	20
2	Pedagogue	Mental health outreach team	3 (34 h)	5
3	Dietician	Multidisciplinary independent practice	2 (16 h)	4
4	Social worker	Home care for people with acquired brain injury	4 (26h30)	11
5	Social nurse	Multidisciplinary organization for elderly and people with disabilities	4 (21h30)	9
6	Social worker	Centre for social welfare services	2 (6 h)	0b
7	Speech therapist	Monodisciplinary independent practice	3 (23 h)	16
8	Family physician	Multidisciplinary independent practice	5 (36 h)	65
9	Nurse	Monodisciplinary independent practice	2 (8 h)	18
10	Social worker	Health insurance company	2 (6 h)	6
11	Nurse	Mental health outreach team	1 (4 h)	2
12	Physiotherapist	Multidisciplinary independent practice	1 (2 h)	1c
13	Physiotherapist	Multidisciplinary independent practice	2 (2 h)	2c
14	Physiotherapist	Multidisciplinary independent practice	2 (1h30)	2c
15	Physiotherapist	Multidisciplinary independent practice	2 (1h30)	2c
16	Physiotherapist	Multidisciplinary independent practice	1 (1 h)	1
Total			34 daysc (203 h)	161

^aHours include both direct observation of patient–provider encounters and intermediate periods spent accompanying providers between visits or during informal workplace interactions

^bNo patient-provider encounters could be observed for this participant due to cancellations by patients. However, the participant was retained in the study, and patient cases were discussed during the interviews

^cThe total number of days here is 34 instead of 40, because participants P12 to P16 are colleagues who were sometimes observed in the same interactions and spaces. Therefore, days on which two or more participants were observed were not counted multiple times in the total

Data analysis identified that providers integrate GOC into their daily practice by: striving to understand the whole person, practicing an equal partnership, and engaging in continuous reflection for meaningful care. Each of these themes is further elaborated through three subthemes that capture more concrete components of behaviour. The following section presents each theme and its underlying subthemes in detail, supported by illustrative excerpts from field observations and interviews with providers. A coding tree illustrating these themes and their subthemes is provided in Additional file 5.

Theme 1: striving to understand the whole person

Health care providers actively engaged in strategies to develop a holistic understanding of their patients, extending beyond clinical concerns to encompass aspects such as their life circumstances, emotions and social context. Providers gather broad knowledge on their patients within their broader network of current and past care and support (sub-theme: understanding the patient’s journey), while simultaneously exploring the patient’s interests and wishes (sub-theme: engaging with what matters). By shifting beyond purely clinical conversations to meaningful dialogue about what matters most to patients, providers tailored their care to align with individual needs and values. Additionally, providers pay close attention to patients’ emotions and reasoning processes, enhancing their empathy and enabling mutually supported agreements (sub-theme: exploring emotions and reasoning).

Understanding the patient’s journey

Providers took deliberate steps to grasp how patients navigate the healthcare system and engage with other professionals. To prepare for encounters, they reviewed patient records and revisited past decisions to refresh their understanding and ensure continuity in care discussions. During interactions, they explicitly asked about the patients experiences across care settings, paying close attention to patients’ narratives of previous encounters. For example, during a home visit, a social worker (P4) assisting a recently discharged stroke patient with administrative tasks such as paying bills and scheduling appointments asked about the patient’s contact with the community nurse. Because the man had recently fallen several times at home—possibly linked to alcohol abuse and memory problems leading to missed medication—the social worker inquired about the frequency of nurse visits and what the patient expected of this support. Although such inquiries extended beyond the social worker’s primary administrative role, they illustrated attentiveness to the patient’s wider care network. By integrating such knowledge, providers adapted their approach to each patient’s unique trajectory.

Engaging with what matters

Beyond understanding healthcare journeys, providers sought to recognize the person behind the patient. Knowing the patient beyond health-related concerns allowed providers to interpret patient reactions and align care actions with the patient’s broader life goals. For example, during a home visit to check a fingertip wound, a home care nurse (P6) not only focused on medical care but also engaged with Adil’s wish to play guitar again.

Adil: “I’ve been looking for something to cover my finger so I could play my guitar again.”

P6: “That must exist, let’s see [She browses online, then turns the screen toward Adil:] “Look, here’s something meant for toes, but you could use it for your finger.”

Adil: “I might prefer something made of leather.”

P6: “I see — the wound is healing nicely, but you probably still can’t play without a bandage. Let me try wrapping it to see if that works.”

P6 wraps his finger, and Adil gets his guitar and tests playing with the bandage.

In understanding what matters to their patients, healthcare providers gathered personal information like hobbies, social interests, and recent life events to ensure that care decisions reflected the broader context of patients’ lives. Social care providers similarly integrated medical knowledge into their support strategies, transcending professional boundaries to achieve a holistic perspective. For example, during a conversation with Hannah—a former teacher who developed severe physical limitations following an aneurysm—a provider (P5) invited her to reflect on her current needs while also acknowledging her role as a caregiver to her seriously ill husband. At one point, Hannah asked: “What are our options for getting care at home?”. To this, P5 responded: “What matters most is not the services on offer, but what you feel you need. You should ask yourself: what do I want? Think about what makes your day meaningful.“. In the interview afterwards, P5 explained how Hannah, despite her neurological impairments, still wished to be present for her husband and expressed this through cooking and baking for him. Instead of focussing solely on Hannah’s medical limitations, the provider recognized how these personal goals shaped what mattered most in her daily life.

Interview with P5: “…when she worked at school, she did some small administrative tasks, but the filtering of stimuli made it hard for her to manage that. We might be able to get support to help her return to those tasks at school, but for now, she mostly wants to be at home. Now, she mainly wants to be there for her husband, just to be present. She loves cooking and baking, that’s now her way of caring for him.”

Providers highlighted that before being able to provide GOC with new patients, they need to establish a personal connection with them. Observations revealed that when eliciting personal goals, providers rarely use the term ‘goals’ explicitly. Instead, they used open-ended questions like “What makes a good day for you?” to elicit meaningful outcomes.

Exploring emotions and reasoning

Providers showed notable attention to the patient’s emotions, using them as cues to uncover underlying concerns, fears and motivations. By responding to emotions with curiosity rather than immediate problem-solving, they deepened their understanding of patients’ perspective. For example, during a conversation with Rebecca about her adult son Liam, a social worker (P10) noticed Rebecca’s growing emotional distress as she described her son’s financial struggles and began to cry.

P10: “What might help you feel less worried?” Rebecca continues to speak about the relational dynamics with her son.

P10: “And do you know what’s making his head (referring to Liam) feel so occupied?”

Rebecca: “I haven’t asked that yet.”

P10: “I understand that you feel responsible for paying his bills. If he’s open to financial help, that’s definitely possible.”

This example illustrates how a provider, through careful attention to verbal and non-verbal cues, ensures that patients feel heard, respected and actively involved in shaping their care experiences. Instead of rushing to solutions, the provider adopted an exploratory role, asking about the patients’ emotions and reasoning while facilitating practical next steps.

Theme 2: practicing an equal partnership

Providers consistently took steps to build relationships with patients that appeared equal, respectful, and collaborative. Rather than positioning themselves as distant experts, providers sought to become companions in care. This approach to partnership was not only visible in communication styles (sub-theme: adapting communication to build connection), but also in the way providers presented themselves (sub-theme: bringing authenticity into care partnership), shared responsibility, and supported patient autonomy (sub-theme: empowering patient in decision making).

Adapting communication to build connection

Communication was consistently observed as fundamental to fostering partnership. Providers adjusted their verbal and non-verbal communication, tone and body position to match the patient’s style and comfort level. This includes using familiar words, avoiding overly clinical jargon, and modifying their pace of speech. Non-verbal cues, such as matching their posture to that of the patient (e.g., sitting at eye level) and minimizing distractions (e.g., putting away phone or computers) were used to convey presence and attentiveness. In several cases, providers used local dialects or regional expressions, as a conscious strategy to strengthen rapport and ensure comprehension. One general practitioner (GP) emphasized this during a home visit:

Interviewer: "I noticed you adjust your language to match your patients'. Is this intentional?"

P8: "Absolutely. If I used standard Dutch during home visits, many wouldn't understand me. Our population here is diverse, but especially with older people, communicating in our local dialect is crucial. They simply don’t hear you otherwise. Being able speaking their dialect, I see patients relax and open up faster.”

Moreover, providers were careful to ensure that patients remained central in the conversation, especially when informal caregivers or colleagues were present. They addressed patients directly, used brief gestures or eye contact to capture their attention, and allowed extra time for responses. These moments illustrated how they created space for the patient’s voice, often by letting them speak uninterrupted and reinforcing that their contribution mattered. Beyond linguistic adaptations, providers also made subtle relational gestures to strengthen connection. For instance, they adopted patients’ greeting rituals or home habits during house visits, showing respect for personal routines. According to providers, those actions can foster familiarity and mutual respect.

Bringing authenticity into care partnership

Authenticity, expressed through honesty and emotional openness, plays a key role in establishing an equal partnership. Providers openly shared emotions whether concern, happiness, or uncertainty, demonstrating that they are engaged human beings rather than detached professionals. Some also share personal experience to foster connection:

Interview with P6: “I’m not going to be someone who asks clients a thousand questions but never answers any myself. I also have a life. If I arrive by bike and they ask, ‘Are you having a bad day?’, I’ll answer honestly.”

Providers described how showing openness and acknowledging their own limitations helped humanize the relationship and strengthen mutual trust, allowing patients to see them as genuine partners in care. Another key aspect of authenticity is the non-judgmental position providers adopted. Rather than moralizing or pressuring patients, this way of engaging allows them to support patients in making their own choices. This is illustrated in a consultation where a GP offered a cervical smear to a patient, however, the patient declined:

P8 to Nadia: “Okay, your body, your choice.”

Rather than insisting, the GP acknowledged the patient’s autonomy while leaving space for future conversations. The GP explained through interview that her response was grounded in the long-term knowledge that she had about that patient’s context and preferences.

Interview with P8 on the case of Nadia: “She’s a sixty-year-old woman in a monogamous relationship; the risk is low. And even if she did develop cancer, I know she’d rather not know about it… I’ve had this conversation with her a thousand times…”.

Empowering patient in decision making

Acknowledging the inherent power imbalance in healthcare relationships, providers took active steps to empower patients. They ensured transparency in information sharing, breaking down complex medical concepts into accessible explanations using metaphors, visuals or simplified language. Providers described trying to foster empowerment by involving patients in care decisions. Instead of prescribing solutions, they encouraged patients to weigh options and take initiative in co-creating care plans that felt achievable and meaningful to them. This is made visible in a consultation with a patient experiencing muscle pain:

P8: "Would you feel comfortable going to the physiotherapist?"

Nadia: "Couldn’t you just prescribe a pill or something?"

P8: "Yes, I can prescribe paracetamol, and that will relieve the pain. But if the pain doesn't improve after one week, will you call me again?"

Nadia agrees

After this consultation we asked P8 in an interview whether it isn’t frustrating to give patients the final choice about their treatments, knowing the choices they make, sometimes won’t solve the cause. She responded:

Interview with P8 on the case of Nadia: “No, that doesn't frustrate me. It really helps me beforehand to explore: 'What do you think about it?'. Currently, she's not motivated for physiotherapy, but if she returns next week still in pain, she'll realize the medication didn't help and might have become motivated for physiotherapy.”

By respecting the patient’s readiness for change, the provider allows them to take ownership of their health decisions without coercion. Furthermore, consent is always explicitly sought before any intervention. This respectful negotiation reinforced the patient’s central role and the collaborative process of care planning.

Theme 3: continuous reflection for meaningful care

Providers engage in continuous reflection to ensure that care actions remain relevant and aligned with patient needs. This reflective process occurs not only during patient encounters but also before and after them (sub-theme: collaborative reflection on care & life goals), both individually and in collaboration with colleagues (sub-theme: interprofessional reflection). Reflection serves as a crucial mechanism for evaluating whether care remains meaningful and responsive to what matters most to the patient (sub-theme: self-reflection for meaningful care).

Collaborative reflection on care and life goals

Given that most interactions took place within an ongoing care relationship, providers regularly revisited previously discussed goals with patients to assess their continued relevance. These reflective conversations followed a structured approach: reviewing past steps, exploring necessary adjustments, and collaborative setting new goals. As one provider explained, they viewed this process as a way to strengthen patients’ sense of agency while supporting continuity of care:

P5 to Hannah: “Shall we plan to meet again in a month? If you feel the need to talk earlier, that’s fine too. I’d like to offer you the space to meet now and then.”

When patients struggled to recall the reasoning behind previous decisions, providers summarized prior discussion and engaged them in new plans. These discussions addressed not only goals but also feasibility, timing, and responsibilities. By the end of the encounter, providers typically recapped agreed-upon actions and clarified accountability, reinforcing the collaborative nature of care planning.

Self-reflection for meaningful care

The interviews revealed how providers engage in self-reflection especially when faced with moments of tension, uncertainty, or patient resistance. Rather than rigidly adhering to medical recommendations, they described weighing clinical actions against the broader context of a patient’s life. Such decisions were shaped by their understanding of the patient’s values and coping strategies. For example, a GP discussed André, an older patient with persistent respiratory symptoms whom she sees on a weekly basis for follow-up. Clinically, she considered referring him to a pulmonologist, but her in-depth understanding of his priorities led to a different course of action:

Interview with P8 on the case of André: “I might normally refer André to a pulmonologist since I’m quite sure there is something concerning his lungs, but knowing him, I understand that staying at home and pottering around in his shed is his main priority. If I provide a formal diagnosis, I risk collapsing his entire world.”

This highlights how providers did not merely acknowledge clinical needs but weighed them against patients’ personal priorities, demonstrating a nuanced and relational approach to care. Instead of viewing patient resistance as opposition, providers use these moments for self-reflection asking themselves: ‘What triggered the emotional response?’ or ‘What values or assumptions are at play?’. This self-reflection allows them to remain flexible, non-judgmental, and attuned to the broader meaning of their role in a patient’s life.

Interprofessional reflection

Recognizing that practicing GOC is embedded within a network of professionals, providers reflect not only on their own roles but also on those of their colleagues. They carefully consider who is best positioned to support a patient’s goals and work to ensure a shared understanding within the team. During a multidisciplinary meeting about and with Samuel, a newly admitted care facility resident,, his daughter expressed the wish to take her father to a restaurant. This request initially raised safety concerns among the nurses. Recognizing its emotional significance for both Samuel and his daughter, the provider (P5) carefully balanced clinical concerns with meaningful care in the team:

Nurse: ‘Okay, but what if he chokes there? There are no medical aids available. Here, we have an aspirator. If he chokes here, we can intervene immediately—but not there.’

P5: “Perhaps we could first try a takeaway meal from (name restaurant) so that we can be present in case you (looks at Samuel) would choke?”

P5 to the daughter: “Do you understand why we would prefer to try eating here first?”

Interview with P5 on the case of Samuel: “The daughter was very emotional, she has a brain tumour, and things aren’t going well. I mainly supported the idea because it’s something she truly wants to do with her father…Who are we to decide what is safe or not? Because I know both her and his background, I feel we should go the extra mile to make this happen.”

Additionally, providers take concrete steps to maintain relational continuity—for example, such as ensuring follow-up appointments with the same professional whenever possible. They described these efforts as ways to safeguard patient-provider trust and minimise disruption caused by staff changes. Interprofessional reflection, therefore, was not merely about logistical coordination but about fostering shared responsibility for keeping patient goals at the centre. It underscored that meaningful care does not emerge solely from individual expertise but from how teams collectively reflect and adapt in practice.

Discussion

This study explored how primary care providers enact GOC in their daily practice. The findings suggest that enacting GOC relies on a distinct set of behaviours that go beyond knowledge or task-specific skills. These behaviours point towards a set of underlying competencies that appear important for providing GOC in real-world interactions. First, providers demonstrated contextual awareness and integrative thinking, meaning, they actively situated patients within their broader life and care networks. Rather than making decisions in isolation, they assessed how medical actions aligned with patients’ lived experiences and personal goals. This was evident when providers weighted the benefits of clinical interventions against what was meaningful to the patient, often adapting their approach based on personal histories, values and social circumstances. Second, providers showed relational and communicative competence by seeking to build trust, adapting their communication styles to create space for patients’ voices. They engaged in non-hierarchical, open-ended conversations, asking questions and inviting patients’ input rather than prescribing care decisions. This was not just about effective communication but also an attitude of authenticity and equality, as providers sought to create space for patients to define what mattered most to them and to ensure their concerns were acknowledged. Third, providers engaged in ongoing reflections, reassessing the relevance of care decisions in light of the patient goals, their own assumptions and team dynamics. This reflective competence was evident when they paused to consider whether a healthcare recommendation truly aligned with a patient’s priorities or when they adjusted their decisions based on input from colleagues. Their ability to question and refine their actions, rather than following rigid protocols, enabled them to aim to tailor care to the personal goals of each patient. Together, these behaviours illustrate how GOC is enacted in practice, emphasizing flexibility, responsiveness, and deep engagement with patients’ lived realities.

The competencies identified in this study share commonalities with those described in research on patient-centred and person-centred care, yet they also reveal important differences that deepen our understanding of what is required for GOC. Patient-centred care (PaCC) has been defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions” [33]. Communication competencies that support PaCC, such as using understandable language, avoiding jargon, adjusting speech pace, and paraphrasing [34], closely align with the communication strategies observed in this study. For instance, both approaches emphasise encouraging patients to tell their story and fostering decision making through dialogue. These competencies resonate strongly with the theme of “practicing an equal partnership” identified in our findings, where providers use communication as a tool to co-create a care plan supported by the patient. However, PaCC often retains a problem-oriented focus, with communication largely directed towards addressing the patient’s health concerns or limitations [34–36]. This contrasts with GOC’s explicit prioritisation of what is meaningful to the patient as the moral compass for care decisions, encouraging professionals to reflect on their actions and, when needed, to deviate from clinical guidelines to stay aligned with patients’ personal goals [37, 38].

Similar overlaps and distinctions emerge when comparing GOC with person-centred care (PeCC). PeCC “highlights the importance of knowing the person behind the patient in order to engage the person as an active partner in his or her care and treatment” [12, 33]. Literature reviews have identified shared competencies across these approaches, such as showing empathy, respect, and commitment, and advocating for the patient’s needs within care teams [10, 13]. Our study also found that providers consciously brought patients’ goals to the attention of colleagues, reinforcing this advocacy role. Yet, PeCC distinguishes itself from PaCC by shifting from aiming for a functional life towards supporting a meaningful life [13], a shift echoed in GOC’s moral prioritisation of patients’ goals over those set by professionals. Importantly, while both patient- and person-centred care have heavily focused on communication competencies, our findings point to reflective competence as a crucial, yet underexplored, element in operationalising GOC. Existing training and assessment frameworks for PeCC primarily target communication skills and empathy [39–43], but rarely include competencies for reassessing goals or reflecting on professional assumptions and team dynamics. Only a minority of studies have acknowledged self-reflection as integral to patient- or person-centred care [13, 44, 45]. Our findings, therefore, provide an important contribution by highlighting reflective competence as a distinguishing feature of GOC. The need for reflective skills becomes especially evident in primary care contexts where patients’ goals challenge professional roles or organisational structures. For example, Naldemirci and colleagues showed how professionals struggled to translate patients’ non-medical goals into actionable care plans when using narrative elicitation [46]. This illustrates that tools for eliciting goals, such as narrative interviews, require not only communication skills but also reflective capacities to navigate goals that fall beyond the provider’s formal scope of practice. Therefore, strengthening reflection as a core competency among PCPs may be key to further operationalising person-centred integrated care.

When reflective competencies seem to be essential for providing GOC, this raises critical questions about how we could prepare future professionals for this role. The concept of the T-shaped professional offers a useful lens for considering educational strategies. T-shaped professionals are characterised by deep disciplinary expertise (the vertical bar of the ‘T’) combined with the ability to collaborate across disciplines and integrate diverse perspectives (the horizontal bar) [47]. Providers in this study embodied both depth and breadth. Conversations about life goals, daily routines, or psychosocial needs often required providers to step beyond traditional professional boundaries without abandoning their specialist knowledge. This balanced integration of depth and breadth seems vital for operationalising GOC in complex care environments. Educational initiatives aiming to foster GOC competencies, therefore, need to go beyond communication training alone [36, 48]. They should intentionally cultivate a reflective mindset and create learning environments that support critical reflection on one’s role, assumptions, and decision-making processes [49]. Additionally, interprofessional education may provide a meaningful context for teaching GOC, as it exposes students to the diversity of expertise and perspectives required to engage in GOC, while also fostering collaborative reflexivity, as highlighted by our findings.

Finally, the findings of this study prompt critical thinking about how GOC can be evaluated in practice. Given the prominence of reflective competence in GOC, important questions arise about the visibility of these competencies to external observers or evaluators. Drawing on Goffman’s dramaturgical framework introduced earlier [18], our study revealed that GOC unfolds across both frontstage and backstage domains. While providers visibly adjusted their tone, language, and posture to empower patients during encounters, they also engaged in behind-the-scenes reflections, deliberated over complex decisions, and reconsidered earlier care plans based on evolving insights. These backstage components, though essential to GOC, often remain invisible—unless explicitly explored through in-depth conversations, as in our study. This invisibility raises challenges for evaluating GOC. Observation-based assessments commonly used in patient-centred care [50] may overlook the reflective processes underlying GOC. Likewise, patient-feedback evaluations may fail to capture competencies that remain outside the patient’s view. Therefore, future research should address both dimensions of GOC. First, exploring patients’ experiences of GOC could clarify which provider behaviours contribute to those experiences. Integrating patient perspectives into evaluation tool development is essential, given patients’ central role in GOC [43]. Second, evaluators and researchers must consider the invisible yet crucial backstage components of GOC, raising questions about how it can be meaningfully recognised, measured, and supported in practice.

Strengths and limitations

The use of a team-based ethnographic approach enabled intensive data collection within a limited time frame—an essential feature given the dynamic context of primary care policy development in Flanders. Working with multiple researchers not only increased feasibility, but also enhanced reflexivity within the research team, a central principle in qualitative research [27]. Prior to data collection, the junior researchers completed reflective observation training and developed a shared codebook to guide thematic analysis [51], promoting analytical rigour and consistency [52, 53]. Methodological triangulation was further strengthened by combining an ‘etic’ lens (non-participant observations by the researcher) with insights from participants (follow-up interviews) during fieldwork, and by conducting member checks after data collection [31]. This study examined one side of a relational phenomenon: the provider perspective on how GOC is enacted. Our findings thus speak to providers’ actions, intentions, and sense-making, rather than patients’ subjective experiences. Future work should include patients’ accounts to capture the full dyad and to examine how GOC as a practice becomes embedded in everyday professional routines. Participants were purposefully recruited from a trained cohort of primary care professionals with advanced knowledge of GOC. This ensured a shared conceptual understanding between researchers and participants, and enabled reflective insights during follow-up interviews. While this relatively homogeneous sample supported in-depth analysis, it may limit transferability. As early adopters, these providers may exhibit competencies not yet representative of the broader primary care workforce. With disciplinary diversity and varied care settings, our sample supports a broad understanding of GOC in primary care. Still, given the heterogeneity of primary care practice, other competencies may emerge in settings or populations not captured here. Because organisational conditions differ in secondary and tertiary care, GOC may manifest differently there, warranting further research across care levels. Finally, the collaborative nature of the research team enabled a substantial volume of observation hours, resulting in a rich dataset across a wide range of interactions. This breadth strengthens the credibility of the findings on how GOC is enacted in daily practice.

Conclusions

This study shows that GOC is not merely about communication or planning, but is enacted through contextual, relational, and reflective competencies. Providers reported to continuously reflect on patient goals, assumptions, and care plans—often in ways that remain hidden from standard training and evaluation tools. To truly embed GOC in primary care, healthcare education and training must go beyond communication skills and clinical reasoning. Cultivating reflective capacity is essential to prepare (future) professionals to reflect on their responsibilities alongside those of the other disciplines they work with in health and social care, question assumptions, and engage meaningfully with what matters most to patients.

Abbreviations

PC-IC

Person-centred integrated care

GOC

Goal-oriented care

PCPs

Primary care providers

WHO

World Health Organization

PCZs

Primary care zones

VIVEL

Flemish Institute for Primary Care

GP

General practitioner

PaCC

Patient-centred care

PeCC

Person-centred care

Authors’ contributions

All authors contributed to the development of the study design. RH led a team of junior researchers (MD, AD, ED, and FJ) who joined the research project through a time-limited internship and were involved in conducting the data collection and analysis. RH also led the writing of the manuscript, with all other authors providing critical feedback on multiple drafts. All authors read and approved the final manuscript.

Funding

This study was supported through a PhD fellowship granted to the first author by Ghent University. No external funding or involvement from third-party organizations was received for the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.

Data availability

The datasets of the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study received ethical approval from the Ethical Committee of Ghent University (ONZ-2023-0447). Participating PCPs provided written informed consent. Patients and caregivers present during observations were orally informed about the research and gave their oral consent for the researcher’s presence. The study was conducted in accordance with the Declaration of Helsinki.

Consent for publication

All participants consented to the use of pseudonymized data in publications related to the study, as stated in the informed consent form approved by the Ethical Committee of Ghent University (ONZ-2023-0447).

Competing interests

The authors declare no competing interests.