There are a rising number of surgical spine procedures, partially attributed to an increasingly ageing population [1]. Decompression of the spinal canal due to Lumbar Spinal Stenosis (LSS) and removing a Lumbar Disc Herniation (LDH) together constitute approximately 85% of all spinal procedures (approx. 9500 procedures/year) [2] and represent the most common spine procedures in Sweden. First-line treatment is mostly advice, physical therapy and analgesic medications [3], but the rate of surgical treatments has increased over the years [4]. There are several pathways in the healthcare system that a surgical patient takes; from the diagnostic procedure, to operative procedures, hospital admissions, discharge and subsequent recovery [5]. Because there is a high percentage of patients treated with surgery that suffers a risk of not achieving adequate benefits from the procedure and prior to the intervention it is of utmost importance that this is communicated to and understood by the patient. Given that patients’ expectations about surgery may play an important role in the recovery and later perceived quality of care, there is a significant need to understand how this could be shared with patient. The Patient-centered care is one of six fundamental aims stated by the US healthcare system [6] and suggest that informed active patients may be an effective part of facilitating good health outcomes [7]. Good outcomes are more likely if patients seek and receive help in a timely way, where the patient and healthcare professionals communicate effectively to develop a shared understanding about the problem, which can generate mutually acceptable management care plans [8], which is essential parts in nursing. The strong emphasis on engagement and patient participation in general, and shared decision making in specific, has a purpose to give the patient a voice and a choice in each unique situation. This has been widely discussed in the literature. Although, patients still describe themselves as outsiders and left in the periphery and healthcare professionals as insiders and the one with the power to decide. The question is how we could create opportunities to develop active forms of engagement and extending the capacity and the patients’ health maintenance knowledge. The fundamental change lies within the relationship between the patient and the healthcare professional, involving doing with rather than doing for, which could be described by the concept of coproduction. Coproduction argues that patients must be given the opportunity to act as co-participants, co-designers and co-producers [9]. In the conceptual model of healthcare coproduction, patients and professionals interact as participants within the healthcare system (Fig. 1). Within the space of interaction, the model explicitly recognizes different levels of a co-creative relationship. Three core concepts at different levels are defined. At the basic level, good service coproduction requires civil discourse which means a respectful and effective communication between patient and professional. The second level core concept is shared planning or co-planning that invites a deeper understanding of values and expertise. The third level is shared execution or co-execution which demands trust and mutually shared goals on responsibility and accountability of performance [8]. Still, there is a challenge in the translational gap between policy and practice since there is a matter of organizational dispositions of personal attributions and conflicting assumptions about what coproduction is [10]. Therefore, an understanding of coproduction and how to apply and understand this concept in clinical practice is needed. The aim was to use experiences from spinal surgery patients’ narratives to explore the conceptual model of healthcare service coproduction.

Fig. (1). The conceptual model of coproduction of healthcare service adapted from Batalden et al (2015) [8].

First, the results from phase one are presented with the two generic categories that emerged in the inductive content analysis. Two generic categories were found, described as “Mutual trust and respect are crucial” and “Information being given in dialogue”. Two different subcategories describe each generic category. Secondly, phase two with the linkage to the conceptual model is described.

This study explored patients’ experiences from the care process of spinal surgery, describing that mutual trust and respect as well as guidance given in dialogue are two important domains. As an illustration of how to apply the conceptual model of healthcare service coproduction, the linkage revealed descriptions of the three core concepts in the model, which could be helpful in deciding when to apply coproduction in a spinal surgery setting. The results could reinforce the conceptualization of what coproduction means and add more knowledge about the descriptions of the three core concepts.

Mutual trust and respect are crucial, interpreted as “see me”, which is one fundamental aspect in understanding civil discourse. It has been found that professional interactions are associated with increased wellbeing over time in patients living with chronic illness. Therefore, the investment in the relationships and communication between professionals and patients is of importance [18], which is in line with the core concept of civil discourse. Active communication assumes participation and production of services, active participation is needed by those that are receiving the service [19]. Healthcare services must always involve the needs of an individual or a population. This could potentially contribute to a shared aim concerning both the patient and the professional [20]. The process of coproduction must consider patients and professionals understanding of participation and engagement; forms of communication, power of dynamics that may be reconfigured throughout the coproduction of healthcare services [10]. Coproduction could also be a challenge of conventional framings of engagement and involvement as well as commonly held notions about authority and capability [10]. This is one aspect in creating work settings that could contribute to a sense of mastery in the healthcare service, when leadership in organizational management understands and facilitates the coproduction of healthcare delivery as well as knowledge development [20].

Guidance given in dialogue interpreted as “describe to me” is important in the process of co-planning and patients expressed their desire to receive an oral explanation as well as having written information. In healthcare, there are two parties (patient and provider) who need to work together in a relationship, which is central when it comes to the concept of “service”. In this relationship, an agreement on which activities is to be made should be completed to reassure coproduction. This relationship is held together by skills, knowledge, habit, and the open pursuit of truth and must carry some willingness to be vulnerable to one another. Historically, the focus has been on taking actions, visible and bounded in context and in time, whereas relationships have been assumed [20].

If people are actively involved in coproduction in their healthcare, they need good quality information about relevant options, pros and cons, and about expected outcomes. Timely information during care is still an expectation rather than a norm and therefore strategies are needed to complement and support the provision of information made by both professionals and patients if coproduction would become a reality. The lack of understandable evidence-based information and the patient role as an active contributor in their care is still emerging and sometimes growing [20]. For this role to be active, effective ways to communicate with patients and provide them with information that could facilitate their active role during treatment and recovery is needed. The need for appropriate and timely information indicates that patients’ concerns go beyond the fundamental basics of delivering appropriate care, which also has been described by others [5, 21]. Cleary, there is a need for professionals to provide information that is comprehensive and sensitive to a patient’s needs and values. Procedures could be trivial to professionals, who are used to working in a surgical environment, but this should be explained for patients who might be in a new and frightening situation. As the patients in this study described, both oral and written information was important, which has been found by others [22], yet this seems to be difficult to accomplish in practice. To be responsive to each individual unique wish about participation and need of information is fundamental if coproduction of healthcare delivery is to become a reality.

Demonstrating action according to patients’ circumstances was linked to the process of co-execution. This highlights a need to provide tailored care to each individual person per their preferences and needs, rather than adopting a “one size fits all” approach. In line with our results and the conceptual model, a review by Hopayian and Notley (2014) found strong connections between relationships and interpersonal skills and what they describe as personalized care. This is based on patients’ preferences and needs in receiving the correct information about their condition, management and self-care [23], which is connected to co-execution, which demands trust and shared goals. To accomplish this, several elements are needed to facilitate the activation of patients. First, patients must be ready; mentally and emotionally ready to engage. Then, a curiosity amongst professionals to ask questions according to patients’ circumstances and identify sources of trustworthy information is needed, but also, to participate and be present and committed in the relationship with the patient [24]. However, to simply give information is not enough and patients need to be furnished with the skills and confidence to implement the advice that has been given to them [25].

This study highlights what is needed to reach coproduction in healthcare services concerning patients with spinal disorders. Civil discourse is the essential concept, meaning the building of a strong relationship and good communication between the patient and professional to aid the understanding of patients’ unique situation. Co-planning is understood as guidance to patients by describing what and why things are happening in each situation. Co-execution is the phase in which patients are provided with proper support in understanding how to act and why, and to enable the patient to be properly prepared during the spinal surgery intervention process. The implications for nursing that we would like to propose are the development of care plans that focus on co-planning and co-execution, which are structured and customizable for each patient situation to make coproduction happen. Furthermore, when professionals give information to patients, an automatic follow-up consultation should be a requirement to assure that patients have understood and are knowledgeable about how to act if a specific situation occur, for example, complications following the surgery. The implementation of communication skills training for professionals in practical training during education and continuously during practice, for example by video-recording encounters, will help to promote civil discourse. Future research could focus on developing outcome measures for the three core aspects in coproduction to enhance the exploration and implementation of coproduction in healthcare settings.