Table 3 The CARE approach: Congratulate, Ask, Reassure, Encourage

Congratulate the patient on anything they did well. This can include taking part in the study, logging onto HOME BP, completing the first online session, monitoring their blood pressure at home or making healthy changes to their lifestyle.

Example: “Well done for taking part in this study, I think it's great that you want to learn more about self-monitoring your blood pressure and have that extra control over your health".

Praise is focussed on the process of behaviour change (e.g. “well done for monitoring your blood pressure at home”, or “great job on sticking to your physical activity goal”), rather than the person as a whole (e.g. “you’re so good at cutting down on salt”). Process focussed praise can enhance autonomous motivation [39, 40], as well as feelings of competence and relatedness [40].

Praise is also informational (“That’s great that you’ve logged on and had a look at HOME BP”), rather than controlling (“Well done you’ve logged on to HOME BP, as you should”) which also supports autonomy [32, 39]. Participants who have not engaged with behaviour changes are not pressured, as minimising pressure supports autonomy [41].

Ask the patient how they are getting on, ask if they have any questions or concerns. If they have any concerns then you can ask them what solutions they would like to try - remember the aim is for people to become their own health trainer, not to rely on others.

Example: “How have you been getting on with monitoring your blood pressure at home? How have you been finding it entering your readings on the HOME BP programme?"

Eliciting potential barriers and exploring possible solutions with patients can build more autonomous motivation [42]. This should also help patients to feel understood and cared for, which can enhance relatedness [42].

Emphasis is put on discussing the patient’s (rather than practitioner’s) ideas of possible solutions to challenges, to help build their feelings of competence and to help them to rely on themselves, rather than the practitioner, for solutions.

Reassure the patient about any concerns they have.

Example: "It's really normal for your blood pressure readings to vary day to day, that's why monitoring your blood pressure regularly at home is so useful as it gives a much better indication of your average blood pressure than one reading in the Surgery".

Acknowledging the patient’s feelings can help support autonomy [40]

Systematic review evidence indicates that cognitive reassurance (providing explanations and education) is associated with higher patient satisfaction, enablement and improved symptoms [43].

Reassurance is also associated with more patient centred care [44].

Encourage the patient to keep monitoring their blood pressure, entering their blood pressure readings into HOME BP, taking their medication and making any lifestyle changes that they discuss with you.

Example: “It would be great if you can carry on monitoring your blood pressure when HOME BP sends you a reminder to do it. This will really help make sure we can find the right medication for you, and hopefully get your blood pressure to be better controlled".

Here practitioners provide non-controlling feedback, which can help support autonomy [40]. Practitioners provide a rationale for encouraging patients to continue with a behaviour change (e.g. how much it will help their health), as this can support autonomy [42]

Encouragement is also associated with more patient centred care [44].