Important, misunderstood, and challenging: a qualitative study of nurses’ and allied health professionals’ perceptions of implementing self-management for patients with COPD

Figures & data

Figure 1 Example questions from the interview schedule.

Table 1 Participant characteristics (n=14)

Women, n (%)	14 (100)
Ethnicity, n (%)
White British	13 (93)
African Caribbean	1 (7)
Profession, n (%)
Physiotherapist	3 (21)
Respiratory research nurse	3 (21)
Practice nurse	3 (21)
Community respiratory nurse	2 (16)
Respiratory nurse	1 (7)
Nurse practitioner	1 (7)
Occupational therapist	1 (7)
Grade, n (%)
Specialized	10 (71)
Highly specialized	4 (29)
Missing information	1 (7)
Years of NHS experience, mean (SD)	18.88 (10.31)
Years of respiratory care experience, mean (SD)	7.53 (5.31)

Abbreviations: NHS, National Health Service; SD, standard deviation.

Table 2 Exemplar quotations from interviews regarding nurses’ and AHPs’ understanding of self-management and its importance

Theme	Subtheme	Participant quotation
Understanding of self-management	Importance	It’s a chronic condition that’s not going to go away. The more control they have over the disease, then the better they’ll feel in themselves, and it can obviously reduce hospital admissions and reliance on health services. It’s empowering for them … it gives them more of a voice (physiotherapist)
	Misunderstanding	Participant definitions of SM range from: Patients being able to manage themselves in the community without having to speak to or be involved with a health professional (occupational therapist) To: [self-management] means patients learn the necessary knowledge and skills to be able to cope with their disease [while] still having advice and treatment when needed (physiotherapist) I do nurse-led COPD clinics. I follow the NICE guidelines, so inhalers so I talk to them about pulmonary rehabilitation and get them referred if they’re willing … (practice nurse) I have to send them away to the stop-smoking service, rather than dealing with it myself. I just get down to the nitty-gritty, then I have to send them away, so they go off the boil. If I could deal with that myself, that would be a big help (practice nurse)

Abbreviations: AHPs, allied health professionals; SM, self-management; NICE, National Institute for Health and Care Excellence.

Table 3 Exemplar quotations from interviews regarding how nurses and AHPs currently support self-management within their daily practice

Theme	Subtheme	Participant quotation
Variable delivery of self-management	Education	It’s for the patient to recognize their symptoms: when they’re getting worse, compliance with their medication, knowing about what their condition is, and what it’s caused by (practice nurse) We provide them with information, with the leaflets we have. [They include] practical things about managing breathlessness, trying to save their energy, being aware of when they’re becoming breathless … making sure they’re taking their medication (occupational therapist) I tend to [give education] one to one, and then I back it up with booklets. I’ve got one at the moment that I give out. I talk to people about the fact that it covers all the ranges of COPD and you know a lot of the stuff might not apply, so not to get concerned by it. The most important thing is that you actually don’t just hand it over: you go through it with them so they understand where the benefits are; otherwise, the risk is it gets taken home and stuck in a drawer somewhere and never used (practice nurse) For patients, education is very generic: we cover everything really. The main things that we look at [are] quality of life and prevention of exacerbations. We obviously talk a lot around inhalers, the benefits that inhalers give, such as preventing exacerbations, why things such as nebulizers aren’t always the answer; you know, recognizing exacerbations, managing flare-ups, and knowing when to call upon other people (community respiratory nurse) There’s a lot of little handouts we give out, and just the “I’ve not read it”, “Oh, it got covered in water”, or “I’ve lost it”, you know, “Oh, another leaflet …”. Maybe that’s not the best way (physiotherapist)
	Behavior change	If they understand about their health and what they need to do to improve, that encourages them, doesn’t it? (practice nurse) You try and encourage them, you make your recommendations … but you can’t force people to do things … I will give them the information, and I think that’s all you can do (occupational therapist) Sometimes, you think [the patient] didn’t take anything on board, and then you meet them 12 months later and they say “Oh, by the way, I stopped smoking”, or unfortunately, the other extreme is that you keep seeing them in hospital (respiratory nurse) Its hard to judge [how many patients change behavior in relation to smoking]. I feel they take it on when they’re sitting next to me – they will listen, nod, and agree – but its hard to judge that really (practice nurse) If they haven’t done any exercise for a long time, it’s quite a big change of mindset, trying to break down that vicious cycle of not wanting to do any exercise ‘cos it makes them breathless can be a problem (physiotherapist)
	Collaboration	I think a lot of the time, the sputum can be addressed quite quickly, and then we get on and discussing the main [things], like activity, health promotion, and support (community respiratory nurse) Giving people strategies to be able to recognize when their disease is changing or if they’re becoming unwell with an infection and strategies to deal with that (physiotherapist)
	Other skills	I haven’t got experience of setting goals in a structured way … but that would be something that [is] part of what we do … (community respiratory nurse) No, I don’t use an action plan at the moment. I think there is a need for it … it would be nice to have something formal that you could send out with them … (practice nurse)

Abbreviation: AHPs, allied health professionals.

Table 4 Exemplar quotations from interviews regarding nurses’ and AHPs’ perceptions of challenges and barriers to supported self-management

Theme	Subtheme	Participant quotation
Challenges and barriers	Time	“There’s always the issue in general practice of what we do being managed by the QOF, so I can do the MRC scale because that’s part of the QOF … but what you don’t get so much time for is actually addressing the issues that come up” (nurse practitioner)
	Professional experience sufficient	“I’ve been here for quite a while, so I think obviously you pick up things, don’t you? I feel quite confident that I could deliver [self-management] at a basic level. I think it’s about experience … I’ve had the training I need” (occupational therapist) “I’ve got the expertise now because I have done COPD for 12 months. I am more confident” (community respiratory nurse) “I don’t necessarily feel that the [junior AHP] would have those skills, not because I don’t think they could do it, but I think it’s a training thing and its time” (occupational therapist) “I think one of the problems with … trying to educate people is when you forget you’re coming from a specialist perspective … actually a lot of the terminology that is second nature to you, a lot of ideas that are second nature … are absolutely brand new to patients” (nurse practitioner) “Walk up the stairs and come back down, up and down, and to get out for at least 20 minutes walking each day. Breathing exercises as well, I go through that with them, deep breathing exercises. I’ve had some really good results actually with that. It’s just what I have picked up myself through the years, you know” (practice nurse)
	Patients	“I’m picturing an elderly frail lady [tuts]. I just cannot picture her being motivated to act …” (respiratory research nurse) “There are some people [whose] visits to the surgery are something of a social occasion, and they enjoy coming in and they like to hand it over to you” (nurse practitioner) “I think the older generation tend to put things down to age. It becomes an excuse sometimes” (practice nurse) “One of the issues was around the ethnic patients and the problems that we used to have [with] cultural issues …” (respiratory nurse) There’s a lack of English language in this area … they’re just not very keen … and I think it’s because of the language barrier (practice nurse)

Abbreviations: QOF, Quality and Outcomes Framework; MRC, Medical Research Council; AHP, allied health professional.