Facilitators and barriers to clinicians ’ use of COPD action plans in self-management support: A qualitative study
Eli Feiring*, Tori Friis
DepartmentofHealthManagementandHealthEconomics,UniversityofOslo,Oslo,Norway
ARTICLE INFO
Articlehistory:
Received25July2019
Receivedinrevisedform4October2019 Accepted2November2019
Keywords:
COPD Exacerbations Actionplans Self-management COM-B Implementation Qualitative
ABSTRACT
Objective:Writtenactionplansforpatientswithchronicobstructivepulmonarydisease(COPD)aimat early recognition of exacerbations and self-initiation of interventions. Previous research suggest underuseofCOPDactionplans.Wewantedto1)examinewhichfactorscliniciansinspecialisthealthcare perceivedasinfluencingclinicians’useofwrittenactionplansinCOPD-selfmanagementsupportand2) proposeaframeworkforunderstandingthefactorsaffectingclinicians’useofactionplansinroutine practice.
Methods: We performed a theory-driven retrospective qualitative study. Documentary data were collectedtodescribetheCOPDactionplanincontext.In-depthinterviewswithclinicians(n=8)were carriedout.Interviewdatawerethematicallyanalyzed,usingapredeterminedmodelforunderstanding behavior.
Results:Ourstudyrevealedthatanumberoffactorsinfluencedclinicians’useofactionplans,including theircapabilities(knowledgeandskillstoidentify“therightpatient”andtoindividualizetheplan template)andmotivations(beliefs,reinforcements,andemotionss.a.frustration,fear,anddistrust), togetherwithorganizationalandsocialopportunities(resources,patient,andGPpreferences).
Conclusion: A multilevelunderstanding offactorsthataffectclinicians’useofactionplansinself- managementsupportisneeded.
Practiceimplication:Theproposedframeworkcanbeusedtoguidefutureinitiativestopromotetargeted self-managementsupport.
©2019TheAuthor(s).PublishedbyElsevierB.V.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).
1.Introduction
Chronicobstructivepulmonarydisease(COPD), aprogressive respiratorydiseasethatovertimeresultsinstructuralchangesin theairwaysand limitedairflowtothelungs,is associatedwith significantmorbidity and mortalityand contributes toreduced qualityoflife,increasedhealthcarecosts,andincreasedburdenon healthcaresystemsworldwide[1–3].Oneimportantaimofdisease managementistopreventexacerbations,which areepisodesof acute symptom worsening. Exacerbations have considerable negativeimpactonpatients’ qualityof life and aretheleading causeofhealthcareutilizationandcostsinCOPDcare[2].Some patientsacrossseverities areparticularly susceptible toexacer- bations and at greater risk of faster disease progression [4].
Prevention, early recognition, and appropriate intervention are important to reduce rates and severity of exacerbations [2].
However,patientsdonotalwaysrecognizesymptomdeterioration andarethuslikelytobehospitalizedforapotentiallyavoidable cause[5–7].
Inanefforttoincreasepatients’understandingofthedisease process, self-management has gained increased relevance in clinical practiceaswellas inpolicyand research[2,8–10]. The development of a writtenaction plan hasbeen suggested asa centralpartofself-management;aCOPDactionplanaimsatearly recognition of symptoms and self-initiation of interventions, which are identified as two important self-management skills [11].ACochraneReviewfrom2016concludedthat COPDaction plans reducethe likelihood of hospital admission and increase treatment of exacerbations with corticosteroidsand antibiotics [12].AnotherCochraneReviewfrom2017supportedthesefindings andconcludedthatself-managementinterventionsthatincludea COPD action plan are associated with increased health-related qualityoflifeandlowerprobabilityofrespiratory-relatedhospital admissions. A very small but significantly higher respiratory- relatedmortalityratewasfound[13].
Abbreviations: COPD, Chronicobstructive pulmonary disease; COM-B, The capability,opportunityandmotivationbehavioralmodel; TDF,TheTheoretical DomainsFramework.
* Correspondingauthorat:EliFeiring,DepartmentofHealthManagementand HealthEconomics,UniversityofOslo,POBox1089Blindern,0317Oslo,Norway.
E-mailaddress:[email protected](E.Feiring).
https://doi.org/10.1016/j.pec.2019.11.002
0738-3991/©2019TheAuthor(s).PublishedbyElsevierB.V.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/
).
ContentslistsavailableatScienceDirect
Patient Education and Counseling
j o u r n a l h o m e p a g e : w w w . e l s ev i er . c o m / l o c a t e/ p a t e d u c o u
WhiletheserecentreviewsrecommendthatCOPDactionplans should be utilized in self-management support, studies have shownthatonlyaminorityofpatientsactuallyhaveanactionplan andfurther,thatpatientswithaplanadheretoitinabout40%of exacerbations [14]. These findings suggest that there is a gap betweenexpertopinionaboutself-managementinterventionsand whatisavailableinroutinecare[15].
It is well known from implementation research that the implementation and use of guidelines, such as action plans, generallyfacesbarriersthatneedtobeidentifiedtooptimizeuse [16].Thereis,however,littleresearchonpractitioners’perspec- tivesonthefactorsaffectingCOPD self-managementin general [15,17–21]andevenlessonclinicians’perspectivesonthefactors affectingtheuseofanCOPDactionplaninparticular(butsee[22]).
Theaimofthepresentstudywastoelicitclinicians’perceptionsof factorsbelievedtoinfluenceclinicians’useofwrittenCOPDaction plansin self-managementsupport in specialist care. Exploring these views systematically may help decision-makers and cliniciansidentifyandunderstandboththefacilitatorsandbarriers toclinicians’useofactionplansandfocusonwhichofthefactors areessential. Thisapproach willinform futureinterventions to improve self-management support for patient suffering from COPD.
2.Methods 2.1.Studydesign
The study was designed as a theory-driven retrospective qualitativestudy.Datawerecollectedpurposively,andinterview datawereanalyzedthematically[23].Weusedapredetermined behavioral-analyticmodeltoaidanalysis.
2.2.Studycontext
This study was conducted in Norway (see Table 1 for an overviewoftheideologicalgrounding,fundingandorganisationof the Norwegian NHS and COPD in Norway). National clinical guideline development is the responsibility of the Norwegian Directorateof Health. The developmentof guidelinesfollows a standardizedmodel thataims at independence,highreliability, transparencyinprocessandinclusivenessbyvariousstakeholders, rigorinmethodology,andsystematicuseofevidence[24,25].
2.3.Dataselection
Weemployeddatafromtwodifferentsources.First,weutilized documentarydata, such as the National Clinical Guidelines for TreatmentofCOPD[26]andtheguidelines’mainreferences[27–29]
todescribethewrittenCOPDactionplanincontext.
Secondly, interviewdatawerepurposivelycollectedthrough individualin-depthinterviewswitheighthealthcarepractitioners fromfour specialist healthcare institutions located in different partsofNorway.Theinstitutionswerecontactedbecauseofinitial knowledgethattheyusedCOPDactionplansandincludedin-and outpatientcare,acutecare,andrehabilitation.Further,contentand
volumeofpatienteducationvariedacrosssites;shortprograms focusedonteachingpatientstheactualuseof theCOPDaction plan, while extensive programs incorporated education on the COPD action plan within a broad self-management education program. Participantswereidentifiedby theinstitutionsthem- selvesandincludeddoctors(n=2)andnurses(n=6),allfemale, withextensiveexperiencewithtreatmentofCOPDpatients.They wereallfamiliarwithCOPDactionplans.
2.4.Datacollection
Documentarydatawerecollectedtoaidthedescriptionofthe COPD action plan as part of a nationally and internationally developedframeworkforguidanceonCOPDmanagement.
Individualqualitativeinterviewswereconductedface-to-face attheparticipants’workplaceandaudiotapedandtranscribedby one oftheauthors (TF).The interviewstookplace in 2017and lasted about 30–40minutes. Interviews were semi-structured withopen-endedquestionsandfollowedaninterviewguidethat covereddifferentaspects,suchas:Patientgroupcharacteristics;
Self-managementeducation;ApplicationoftheCOPDactionplan;
Follow-upsandupdatingoftheCOPDactionplan;Communication withotherhealthcareinstitutions;andIndividualperceptionsof theCOPDactionplan.
2.5.Dataanalysis
Documentarydatawerecloselyread todescribethewritten COPD action plan in context. Interview data werethematically analysedindependentlybybothauthorsanddiscussedtoenhance the credibility of the analysis. Using thematic analysis [23], transcriptswereanalysedinsixsteps:(i)closereadingofdata,(ii) initialcodingbasedonapredeterminedanalyticalframework,(iii) dataorganizing,(iv)themereviewing,(v)definingrelevantthemes andsub-themesbasedontheframework,and(vi)writingupthe findings. Any arising disagreement between the two authors regarding data coding and interpretation was resolved through discussion.
Wedevelopedtheanalyticalframeworkindependentlyofthe analysisofthedatatoaiddatacodingandinterpretation;seeFig.1 for illustration. Implementation of clinical guidelines, such as guidelines for self-management support, depends on clinician behavior.Tobetterunderstandclinicianbehavior,weutilizedthe COM-Bmodel.ThismodeltheoriseshowCapability,Opportunity andMotivationinteracttoproduceBehavior[30]andprovidesa framework for understanding factors that might facilitate or hamperbehavior.Capabilityistheindividual’spsychologicaland physicalcapacitytoengageinanactivity,andincludesreasoning, knowledgeandskills.Opportunityconsistsofphysicalandcultural -socialfactorssuchasenvironmental,organizational,andsocial contextand resourcesthatlieoutside theindividualthatmake behavior possibleor prompt it.Motivation is the reflectiveand automaticprocessesthatdirectbehavior.Thesethreeconditions canpotentiallyinfluenceeachotherindifferentways.Capability andopportunitycaninfluencemotivation,andenactingabehavior canaltercapability,motivationandopportunity.
Table1
Studysetting:Norway.
Ideology Healthcare
system funding
Specialistcare Primarycare COPD
Egalitarian.Need- based,universal healthcare.
Tax-financed. Stateresponsibility.Fourhealth regions.Freeatthepointofaccess.
Municipalityresponsibility.GP:privateactors, contractswithmunicipality.Smallout-of-pocket sumateachvisit.
App.5%oftheadultpopulation.
COPDisthethirdleadingcauseof death.
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To provide an even more granular understanding of these conditions,theTheoreticalDomainsFramework(TDF)wasused [31].TDFwasoriginallydevelopedasatheoreticalframeworkto viewthecognitive,affective,social,andenvironmentalinfluences onbehaviorchange.Theversionutilizedinthisstudycategorises 14domainsrelevanttobehavior,referredtointhefollowingasTDF (v2) [32]. The combined framework recognizes that behavior dependsnotonlyontheknowledge,attitudes,andmotivationof theindividualbutisalsoinfluencedbythespecificintervention andtheorganizationalandsocialcontext.
Forthepurposesofourstudy,theanalyticalframeworkused specifiedpre-definedfactorsandsub-factorstosortthetextduring thecodingprocess.Attheendofthisprocess,compellingquotes wereselectedtoillustratetheidentifiedfactors.Transcriptswere returnedtoparticipantsforcommentsandcorrections(member checking). Transcriptsrelevanttoillustrate factors perceivedto influenceCOPDactionplanuseweretranslatedtoEnglish.
2.6.Ethicalapprovalandinformedconsent
IncompliancewithNorwegianlegislationonethicsinresearch, the study was regarded as health service research and was approvedbytheNorwegianDataEthicalApproval:DataProtection Official for Research, Norwegian Social Science Data Service (Projectno.53,629).Eachparticipantprovidedwritteninformed consenttoparticipate.Alldocumentswerepubliclyavailableand didnotrequirepermissiontoaccess.
3.Results
3.1.AbriefdescriptionoftheCOPDactionplantemplate
TheNationalClinicalGuidelinesforTreatmentofCOPDwere developedandimplementedin2012[26].Recommendationswere
basedoninternationalsystematicreviews,inparticularthe2011 GlobalStrategyfortheDiagnosis,ManagementandPreventionof COPD,the2010NICErecommendations,andthe2004American ThoracicSociety/EuropeanRespiratorySocietystandards[27–29].
Thus, COPD management guidance was embedded in a wider international context.However,minimalevidencewasavailable forsomeoftherecommendations,forexample,withregardsto self-management strategies. Here, the development group’s experience and opinions about what constituted good practice wereusedtodeveloprecommendations.
Anexacerbationactionplantemplatewasdevelopedasoneof severalkeyelementsofself-managementsupport[33], whichis presentedforillustrativepurposesinFig.2.Thetemplateishalf completedandcanbepersonalizedandprintedforthepatientto takeaway.Acolorcodesimilartothatofatrafficlightisusedto visualize different phases of disease based on symptoms and indicatesrecommendedactions.Greencolordescribesastablestate, whileyellowandredcolordescribesmildtosevereexacerbation.For example,apatient intheyellowzonethathasexperiencedworsening ofsymptomssuchasdyspnoea,sputumvolumeandsputumcolor fortwodays,isrecommendedtoinitiatestandingprescriptionsfor corticosteroids,suchasprednisoneandantibiotics.Thepatientis nowintheredzoneandisrecommendedtocontactthedoctorafter twotothreedaysifmedicationhashad littleornoeffector,if symptomsbecomescritical,calltheemergencynumber.Non-core elements of self-managementare likewise described, including differentphysicalandbreathingexercises.
3.2.Clinicians’perceptionsoffactorsaffectingclinicians’useofaction plans
Theresults,i.e.,factorsperceivedtoaffectclinicians’useofthe COPDactionplaninself-managementsupport,aresummarized inFig.3.
Fig.1.Analyticalframework:Relationshipbetweenmainfactorsandsub-factorsthatmayfacilitateorhinderbehavior(adaptedfrom[30–32]).
Fig.2.COPDActionPlanTemplate,adaptedfromCOPDActionPlanTemplate,NorwegianInstituteofPublicHealth2015(inNorwegianonly)[33].Translationbyfirstauthor, notauthorized,forillustrativepurposesonly.
696 E.Feiring,T.Friis/PatientEducationandCounseling103(2020)693–701
Fig.3.Factorsaffectingpractitioners’useofactionplansinself-managementsupport:Relationshipbetweenmainfactorsandsub-factors(adaptedfrom[30–32]).
3.2.1.Cliniciancapabilityregardingself-managementsupport Thequalitativeinterviewdatasuggestedthatthecliniciansall endorsedtheideathatself-managementwasanimportantaspect of care. Theyfirmly believed in patienteducation. A recurrent theme in the interviews was the perception that clinicians’ knowledge about COPD, and their skills and confidence in supportingself-managementforthis groupofpatients, waskey tofacilitate theuse of COPD actionplans. For example, it was pointedoutthatactionplansshouldbepersonalized;theclinicians alltoldhowvitalitwastoadaptthegeneralrecommendationsto the specific patient. Thus, they underscored that having the relevantskills was essential to construct and individualize the writtenactionplan.
Theplanshouldbetailoredtothepatient.Therearesomestandard phrasestouseaskeywords,butit(theplan)shouldbepersonalized.
Thepatientsshouldbeabletorecognizethemselves.(Clinician5) Further, the clinicians stressed the importance of assessing patientcapabilitiesandhighlightedtheneedfor“findingtheright patient.”
Thepatient(...)hastobealertandoriented.Sheneedstohave some understanding of symptoms (and) to have experience with exacerbationssothatsheunderstandswhatitis(...)Sheneedstobe abletoperformtherecommendationsthatarewritten.(Clinician5) Theintervieweeshadaclearviewofwhattypeofpatientsthe COPDactionplanwouldbesuitableforandwhotheywouldnot offeritto.
Therearesome(plans)whereIjustfillinthegreenandyellow zones,andinthe redzoneIwrite,“Contact thedoctoronday 1.00 (Clinician2)
3.2.2.ClinicianmotivationforuseofCOPDactionplans
The interviewees assumed that COPD action plans would benefit the patients, both physically and emotionally, if the patientswereeducated byexperiencedstaff and usedtheplan correctly.
Ihaveseenmany(patients)thathavebeenhospitalizedagainand again,andthentheyhavebeengivenanactionplanandtheyhave learnt about the disease, what signs to be aware of. They start treatment at an earlier stage, and they don ’t become so sick.
(Clinician2)
Perceivedadvantagesofusingactionplansincludedimproved patientunderstandingofsymptomsand,subsequently,improved healthoutcomes.Thesebeliefsweregroundedindifferentsources, such as clinical studies, the wide use of COPD action plans internationally, and feedback from patients. However, while biomedical outcomes were important, useof action plans was also seen as a means to strengthen patients’ overall self- managementskillsandself-confidence.
Thosepatientsthathaveusedit(theactionplan)seemverypleased and a lot more self-confident. They start taking medications themselves.(Clinician3)
Additionally, it was emphasized that COPD action plans increased patients’ independence in various ways, physically andpsychologically. Some ofthe interviewees referred totheir experiencefromclinicalpractice;oneexamplethatwasgivenwas theopportunityfacilitatedbytheactionplanforpatientstogoon holidaywithouthaving toworryabout thepossibility ofbeing hospitalizedabroad.Anotherexamplewasthatpatientsfeltsafe duringpublicholidayswhentheGPwasdifficulttoreach.These experienceswereperceivedashighlymotivating.
Nevertheless, some of the interviewees acknowledged that therewasalackofsystematicevidencefromtheirownpractice abouthowandtowhatdegreeactionplanswereactuallyusedby thepatients.Yet,misuseofmedicationswasaknownproblemin theirexperience,aswaspatients’misunderstandingsabouthowto usethemedication.
Ihaveseenpatientscontinuetouseprednisolonebecausetheyfeel theygetbetterusingit.Itisimportanttowatchoutforsuchthings.
(Clinician1)
One of the interviewees pointed out that there was little knowledge about how patients felt after discharge. She had observedthatsomepatientsfeltlesssafeathomeandthattheplan wasnotusedasrecommended.
Thepatientsays,No,Ididn’tuseit(theactionplan).Ididn’tfeel safe,soIcalledmydoctorinsteadtogetaCRP.(Clinician4)
Others said that they couldget frustrated and disappointed whentheyexperiencedalackofpatientcompliance,becausethey putalotoftimeintoteachingthepatientsabouttheplan.These negativeemotionswereperceivedtoactasabarriertocontinued useoftheplans.
They(thepatients)seemtoforgeteverythingabouttheplan.It’s notused.(Clinician2)
Further,acommonthemeintheinterviewswasfearofpatients misinterpreting symptoms. The interviewees talked abouthow onemajorfocusareawastomakesurethatpatientsknewtocall theirGPwhentheyexperiencedmoresymptoms.Forexample,it wasrecognizedthattheuseofactionplanswasnotnecessarily harmlessandthatassessingwhentoinitiatemedicationcouldbe difficultforthepatient.Oneoftheintervieweesmentionedone study in particular that showed an increased mortality rate (referringtoastudybyFanetal.[34])andsaidthatshehadmade changestothewaysheusedtheplan.
Heartandlung(...)Therearemanysimilarsymptoms.Ifthey (thepatients)havechestpainandswollenfeet,thentheymustcontact thedoctoratonce.Iftheybecomeacutelyworse,theymustcontactthe doctor, so that they are not trying and trying (...) or call the emergencynumber.(Clinician6)
3.2.3.Organizationalpreparedness
Theintervieweeshighlightedthatorganizationalsupportwasa keyfactorcontributingtotheuseofself-managementinitiativesin generalandCOPDactionplansinparticular.Oneexamplewasthe establishment of working groups that developed COPD action planstofitthelocalsettingatthedifferentsites.Theinterviewees alldescribedhowlocaladaptationandasenseofownershipwere important as facilitators to the use of the action plan. Local adaptation was also thought to contribute to organizational processesregardingallocationoftimeandresponsibilities.Patient educationwasexperiencedastimeconsuming,andsomeofthe interviewees accentuated how organizational ownership in- creased investment from the organization in dedicated time resources.Further,acleardivisionofroleswasseenasenabling use.Atallsites,nursesledmostofthepatienteducationinitiatives whiledoctorswereresponsiblefordiscussingtheactualplanswith thepatientsandapprovingtheuse.
A recurrent theme in the interviews was, however, the challenges resulting from giving the patient responsibility for information-sharingbetweenlevelsofcare.
WestillhavetohandoutprintssuchastheCOPDactionplan,and wetellthepatient,“Hereyouhavetwoorthreecopies.Youtakeone yourself, you give one to your GP and one to your pulmonary practitioner.YourGPissupposedtodoyourfollow-ups.”(Clinician4) The lack of a formal organizational strategy regarding coordination and information-sharing between specialist and primarycarewasseenasamajorbarriertouseofaCOPDaction plan.
Thepatienthasonlythispieceofpaper.Maybehebringsit(tothe GP)andtalksaboutit,maybenot.(Clinician5)
Further,intervieweesreportedthata lackof communication betweenlevelsofcarewasaconcernbecausetheydidnotknow whetherGPshadadequateknowledgeabouttheCOPDactionplan andfelttheycouldnottrusttheGPstouseit.
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Ihaveneverseenthatit(theactionplan)hasbeenupdatedbyaGP.
(Clinician8)
The lackof institutionalized update procedures and worries abouttheconsequencesthereof, wasperceivedasanimportant hindrance regarding clinicians’ use of action plans in self- managementsupport.
Patientsareinformedthatit(theplan)isonlyvalidaslongasthey feelsafeusingitandthat ithastobeupdatedbyadoctor.Ifnew medicinesareprescribed,it(theplan)shouldbeupdated.Thatisthe weakestpoint.(Clinician2)
4.Discussionandconclusion 4.1.Discussion
Byusingatheory-basedapproachforunderstandingbehavior, thisstudyhasidentifiedarangeoffactorsperceivedbycliniciansin specialisthealthcare toinfluence clinicians’ useofCOPD action plans.Previousstudies[15,22]havedescribedfactorsperceivedby clinicianstohindertheiruseofwrittenactionplans.Theseinclude patient-relatedfactorssuchaspoorcompliancewiththeplanned courses, inappropriate useof medication, inabilitytorecognize symptoms,andriskofside-effectsfromthemedication,aswellas structuralconstraintssuchasalackoftimetoselectpatientsand provideeducationandlackofsupportstaff.Inaddition,alackof knowledgeofhowtoconstructawrittenactionplanswasfoundto hamper use [22]. Further, identifying the most appropriate patients for the self-management approach, i.e., patients with considerableunderstandingoftheirillnessandcapacityforself- management,hasbeensuggested tofacilitate theuseofaction plans[15].Otherstudieshave,however,underscoredthatadopting a person-centered approach to the management of chronic conditionsmaybedifficultformanyclinicians,particularlywhen educationandmotivationdonotleadtothedesiredoutcomes[20].
Ourfindingssharecommonalitieswiththesestudies.However, thepresentstudyadds topreviousresearchby suggestingthat threefactorsmaycounteractbarrierstoclinicians’useofaction plansasidentifiedinpreviousstudiesandinourstudy.First,to overcomebarriersconcerninglackofconfidenceinconstructinga writtenactionplan,itisimportantthatclinicianshavetherelevant capabilitiesregardingself-managementsupport,i.e., areknowl- edgeableandskilled.Second,organizationalopportunitiesinthe form of local adaptation may facilitate leadership, designated resources, and time to prioritize patient education. Previous studieshave reportedthat ownershipin the interventionis an importantfactorintheuseofguidelinesand research[35];our findingsalignwellwiththis.Adaptationtolocalcircumstanceswas pointedoutbyourintervieweesasasignificantcontributortoa sense of ownership. Ownership was again identified as an importantenablerinimplementing actionplansas partofself- managementsupport.Third,previousresearchhasconcludedthat clinicians’lackofconfidenceinpatients’self-managementskills negatively affects engagement in self-management [21,22].
Individualized and tailored strategies for self-management are likelytoimproveinterventioneffectiveness[9,36].Itisknownthat certain sub-groups of COPD-patients may benefit from self- management more than others [37]. To distinguish one such groupfromanother,arangeofpatient-relatedfactorshasbeenput forward to explain any variation: experience with disease, heterogeneityofexacerbations,acceptanceofillness,trivializing symptoms, feelings of fear and anxiety, ambivalence toward treatment, beliefs regardingtrust, self-managementmotivation, andatendencytopostponemakingdecisions[11,15,17,38].These canleadtotwoimportantbarrierstoclinicians’useofactionplans:
first,theirfeelingsoffrustrationandtreatmentfutilityassociated withnon-compliersand,second,theirfearofpatients’misuseor
erroneoususeofmedications.Ourstudysuggeststhatclinicians cancounteractthesedifficultiesbybeingcapableandmotivatedto find“therightpatient”andgeneratingpersonalizedactionplans.
However,adifficultbarriertoovercomeinthesettingstudied was the need for better cooperation, communication and information sharingacrossspecialistand primarycarelevels.In Norway, primary and specialist care are institutionalized at different organizational levels and financed through different budgets.Coordinationbetweenthetwolevelshasprovendifficult [39].Yetitisessentialthatorganizationalandsystemlevelfactors that hinder use of COPD action plans are given attention.
Coordinationbetweenlevelsofcareshouldbeaddressedinfuture studiesofCOPDself-managementsupport.
It is well known that different stakeholder groups identify differentself-managementoutcomesasimportant[11,38,40,41].A recentstudyconcludedthathealthpractitionersvalueimproved biomedical markers, self-efficacy, and understanding of the diseaseandseeadherencetobesthealthcareadviceasessential [19].Topatients,factorssuchasindependenceandhavingchoices arehighlyappreciatedandgoodself-managementmeansadapting adviceinordertolivewell.Differentunderstandingsofoutcome importance indicate that interventions at the clinician level to increase the use of COPD action plans may have unintended consequences regarding other stakeholders’ behavior. Future researchonself-managementimplementationshouldstudythe interactionandconsequencesofdifferentstakeholderviews.
Anovelaspectofourstudyistheuseoftheoryinafieldthathas largelytakenempiricapproachestoresearchingtheuseofself- management initiatives. The theoretical framework provides a systematicidentificationofpotentiallymodifiablefactorsthatmay affectclinicians’useofCOPDactionplansandmakesitpossibleto compareourresultswiththoseofotherstudies.Further,itmay supportthetransferabilityoffindingsandanticipationofhowthe future use of self-management strategies may unfold. Our engagement withtheoryis a strength of thepresent study. At thesametime,however,thisstudydesignmayhaveledustomiss aspects ofbarriersand facilitatorstotheuseof actionplansas conceptualcategorieswerepre-established.
Inqualitativestudies,samplesizeisoftenjustifiedonthebasis ofdatasaturation,sothatnonewadditionaldataarefoundthat developaspectsofaconceptualcategory[42].Becausethepresent studywas theory-driven,weaimedat perceptionswithinthe categoriesandstrategicallyrecruitedparticipantsfromdifferent institutionalandgeographicalsettingsandwithdifferenteduca- tional backgrounds. Although the number of interviewees was small,weareconfidentthatabroadrangeofrelevantaspectshas beencoveredandthatweachievedanadequatesampleforcontent validity.
Werecruitedtheintervieweesfrominstitutionsthatreported theuseofCOPDactionplansbecausewewantedparticipantswith knowledge aboutthesubject matter. However,the studybears someriskofselectionbias.Wedidnotincludeinstitutionsthat haveexplicitlychosennottouseCOPDactionplans.Further,the intervieweesmaybebiasedbysocialdesirability.Wecannotknow whetherthefactorsidentifiedasperceivedbarriersandfacilitators toclinicians’useofactionplanswillbeidentifiedassuchinactual practice. Thus, we may have underestimated the challenges of usingactionplans.
ThestudywasconductedinNorwayandfurtherresearchneeds tobedonein othersettingstoassess thetransferabilityof the findings.
4.2.Conclusion
This study offers a theoretically informed approach to examiningfactorsperceivedbycliniciansinspecialisthealthcare
asinfluencingclinicians’useofwrittenactionplansinCOPD-self managementsupport.Arangeoffactorsisidentified,relatingto clinicians’ capabilities and motivation, and organizational and socialopportunities.Thestudymayhelpidentifyandunderstand whichfacilitators and barrierstoclinicians’useof actionplans cliniciansassessasimportantandinformfutureinterventionsto improveself-managementsupport.
4.3.Practiceimplications
The present study underscores the need for a multilevel understandingoffactorsthataffectclinicians’useofCOPDaction plans.Barriersatthepatient,practitionerandorganizationallevels mustbeidentified.Theproposedframeworkcanbeusedtoguide futureinitiativestopromotetargetedself-managementsupport andtacklethegapbetweenwhatisadvocatedinclinicalguidelines andwhatisavailableinroutinesettings.
Conflictofinterest None.
CRediTauthorshipcontributionstatement
EliFeiring:Conceptualization,Datacuration,Formalanalysis, Methodology, Supervision, Writing - original draft. Tori Friis:
Conceptualization,Datacuration,Writing-review&editing.
Acknowledgements
Wethanktheparticipantswhogenerouslygavetheirtimeto contributetothisresearchandthereviewerswhoprovidedhelpful commentsonanearlierdraft.Thisresearchdidnotreceiveany specificgrantfromfundingagenciesinthepublic,commercial,or non-profitsectors.
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