Facilitators and barriers to clincians' use of COPD action plans in self-management support: A qualitative study

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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.

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:eli.feiring@medisin.uio.no(E.Feiring).

https://doi.org/10.1016/j.pec.2019.11.002

).

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

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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.

694 E.Feiring,T.Friis/PatientEducationandCounseling103(2020)693–701

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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]).

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Fig.2.COPDActionPlanTemplate,adaptedfromCOPDActionPlanTemplate,NorwegianInstituteofPublicHealth2015(inNorwegianonly)[33].Translationbyﬁrstauthor, notauthorized,forillustrativepurposesonly.

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Fig.3.Factorsaffectingpractitioners’useofactionplansinself-managementsupport:Relationshipbetweenmainfactorsandsub-factors(adaptedfrom[30–32]).

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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 increased 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

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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.

References

[1]G.Johansson,V.Mushnikov,T.Backstøm,A.Engstrøm,J.M.Khalid,etal., ExacerbationsandhealthcareresourceutilizationamongCOPDpatientsina Swedishregistry-basednation-widestudy,BMCPulm.Med.18(2018)17,doi:

http://dx.doi.org/10.1186/s12890-018-0573-0.

[2]GOLD,GlobalInitiativeforChronicObstructiveLungDisease:GlobalStrategy fortheDiagnosis,ManagementandPreventionofCOPD,(2017).http://

goldcopd.org.

[3]S.May,J.T.C.Li,Burdenofchronicobstructivepulmonarydisease:healthcare costsandbeyond,AllergyAsthmaProc.36(2015)4–10.

[4]J.A. Wedzicha, G.C. Donaldson, Natural history of successive COPD exacerbations,Thorax67(11)(2012)935–936.

[5]Y.J.G. Korpershoek, J.C. Bruins-Slot, T.W. Efﬁng, M.J. Schuurmans, J.C.A.

Trappenburg,Self-managementbehaviourstoreduceexacerbationimpact inCOPDpatients:aDelphistudy,Int.J.Copd12(2017)2735–2746.

[6]J.C.Trappenburg,E.M.Monninkhof,J.Bourbeau,T.Troosters,A.J.P.Schrijvers, etal.,Effectofanactionplanwithongoingsupportbyacasemanageron exacerbation-relatedoutcomeinpatientswithCOPD:amulticentre randomisedcontrolledtrial,Thorax66(2011)977–998.

[7]T.Freund,M.Wensing,C.Mahler,J.Gensichen,A.Erler,etal.,Developmentofa primarycare-basedcomplexcaremanagementinterventionforchronicallyill patients at high risk for hospitalization: a study protocol, Implement. Sci. 7 (2010) 70.

[8]J.Trappeburg,T.Jaarsma,H.Os-Medendrop,H.Kort,etal.,Self-management:

onesizedoesnotﬁtall,PatientEduc.Couns.92(2013)134–137.

[9]J.J. Newham, J. Presseau, K. Heslop-Marshall, et al., Features of self- managementinterventionsforpeoplewithCOPDassociatedwithimproved health-relatedqualityoflifeandreducedemergencydepartmentvisits.A systematicreviewandmeta-analysis,In12(2017)1705–1720.

[10]N.S.Hopkinson,A.Molyneux,J.Pink,M.C.Harrisingh,Chronicobstructive pulmonarydisease:diagnosisandmanagement:summaryofupdatedNICE guidance,BMJ336(2019),doi:http://dx.doi.org/10.1136/bmj.l4486.

[11]Y.J.G. Korpershoek, Vervoort SCJM, L.I.T. Nijssen,J.C.A. Trappenburg, M.J.

Schuurmans,Factorsinﬂuencingexacerbation-relatedself-managementin patientswithCOPD:aqualitativestudy,Int.J.Copd11(2016)2977–2990.

[12]M.Howcroft,E.H.Walters,R.Wood-Baker,J.A.E.Walters,Actionplanswith briefpatienteducationforexacerbationsinchronicobstructivepulmonary disease,CochraneDatabaseSyst.Rev.12(2016)CD005074,doi:http://dx.doi.

org/10.1002/14651858.CD005074.pub4.

[13]A.Lenferink,M.Brusse-Keizer,P.D.L.P.M.vanderValk,P.A.Frith,etal.,Self- managementinterventionsincludingactionplansforexacerbationsversus usualcareinpatientswithchronicobstructivepulmonarydisease,Cochrane DatabaseSyst.Rev.8(2017)CD011682,doi:http://dx.doi.org/10.1002/

14651858.CD011682.pub2.

[14]L.Jalota,V.V.Jain,ActionplansforCOPD:strategiestomanageexacerbations andimproveoutcomes,Int.J.Copd11(2016)1179–1188.

[15]F.Davis, M.B. Risør, H.Melbye, M.Spigt, etal., Primaryand secondary clinicians’viewsonself-treatmentofCOPDexacerbations:amultinational qualitativestudy,PatientEduc.Couns.96(2014)256–263.

[16]R.Grol,D.M. Berwick,M.Wensing, Onthetrailofqualityandsafety in healthcare,BMJ336(2008)74–76.

[17]Bos-Touwen,ID,J.Trappenburg,I.vanderWulp,M.Schuurmans,N.J.deWit, Patientfactorsthatinﬂuenceclinicians’decisionmakinginself-management support:aclinicalvignettestudy,PLoSOne(2017)Doi:101371/journal.

pone.0171251.

[18]O.J.Ogunbayo,S.Russel,J. Newham,K. Heslop-Marshall,P. Netts,etal., Understandingthefactorsaffectingself-managementofCOPDfromthe perspectivesofhealthcarepractitioners:aqualitativestudy,NPJPrim.Care Respir.Med.54(2017).

[19]E.Boger,etal.,Self-managementandself-managementsupportoutcome:a systematicreviewandmixedresearchsynthesisofstakeholderviews,PLoS One10(2015)e130990.

[20]S.Mudge,N.Kayes,K.McPherson,Whoisincontrol?Clinicians’viewontheir roleinself-managementapproaches:aqualitativemeta-synthesis,BMJOpen 5(2015).

[21]H.M.L.Young,L.D.apps,S.L.Harrison,etal.,Important,misunderstood,and challenging:aqualitativestudyofnursesandalliedhealthprofessionals’

perceptionsofimplementingself-managementforpatientswithCOPD,IntJ COPD10(2015)1043–1052.

[22]N.J.Roberts,I.Younis,L.Kidd,M.R.Partridge,Barrierstotheimplementationof self-managementsupportinlongtermlungconditions,LondonJ.Prim.Care (Abingdon)5(2013)35–47.

[23]V.Braun,V.Clarke,Usingthematicanalysisinpsychology,Qual.Res.Psychol.3 (2)(2006)77–101.

[24]NorwegianDirectorateofHealth.Veilederforutviklingavkunnskapsbaserte retningslinjer.2012-IS-1870(InNorwegianonly).

[25]G.H.Gyatt,A.D.Oxman,G.E.Vist,R.Kunz,Y.Falck-Ytter,P.Alonso-Coello,etal., GRADE:anemergingconsensusonratingqualityofevidenceandstrengthof recommendations,BMJ.335(2008)924–926.

[26]NorwegianDirectorateofHealth.NorwegianNationalClinicalGuidelinesfor TreatmentofCOPD.2012-IS-2019(InNorwegianonly).

[27]GOLD,GlobalInitiativeforChronicObstructiveLungDisease:GlobalStrategy fortheDiagnosis,ManagementandPreventionofCOPD,(2011).

[28]ManagementofChronicObstructivePulmonaryDiseaseinAdultsinPrimary andSecondaryCare,NationalInstituteforHealthandClinicalExcellence (NICE),2010June.

[29]AmericanThoracicSociety/EuropeanRespiratorySociety,Standardsforthe DiagnosisandManagementofPatientsWithCOPD,(2004).

[30]S.Michie,M.M.vanStralen,R.West,Thebehaviourchangewheel:anew methodforcharacterisinganddesigningbehaviourchangeinterventions, Implement.Sci.6(2011)42.

[31]S.Michie,M.Johnston,C.Abraham,etal.,Makingpsychologicaltheoryuseful forimplementingevidencebasedpractice:aconsensusapproach,Qual.Saf.

HealthCare14(2005)26–33.

[32]J. Cane, D. O’Connor, S. Michie, Validation of the theoretical domains frameworkforuseinbehaviourchangeandimplementationresearch, Implement.Sci.7(2012)37.

[33]NorwegianInstituteofPublicHealth.COPDactionplantemplate2015(in Norwegianonly,availableathttps://www.helsebiblioteket.no/fagprosedyrer/

ferdige/kols-egenbehandlingsplan).

[34]V.S.Fan,J.M.Gaziano,R.Lew,J.Bourbeau,S.G.Adams,etal.,Acomprehensive caremanagementprogramtopreventchronicpulmonarydisease hospitalizations:arandomised,controlledtrial,Ann.Intern.Med.156(2012) 173–683.

[35]T.Forsner,J.Hansson,M.Brommels,A.ÅWistedt,Y.Forsell,Implementing clinicalguidelinesinpsychiatry:aqualitativestudyofperceivedfacilitators andbarriers,BMCPsychiatry10(2010)8.

[36]M. Barrecheguren, J. Bourbeau, Self-management strategies in chronic obstructivepulmonarydisease:aﬁrststeptowardpersonalisedmedicine, Curr.Opin.Pulm.Med.24(2018)191–198Doi:1.

[37]C.E.Bucknall,G.Miller,S.M.Lloyd,etal.,Glasgowsupportedself-management trial(GSuST)forpatientswithmoderatetosevereCOPD:randomised controlledtrial,BMJ344(2012)e1060.

[38]J. Laue,H. Melbye,M.B. Risør,Self-treatmentof acuteexacerbations of chronicobstructivepulmonarydiseaserequiresmorethansymptom recognition–aqualitativestudyofCOPDpatients’perspectivesonself- treatment,BMCFam.Pract.18(2017)8,doi:http://dx.doi.org/10.1186/

s12875-017-0582-8.

(9)

[39]L.C.Monkerud,T.Tjerbo,TheeffectsofNorwegianCoordinationreformonthe useofrehabilitationservices:paneldataanalysesofserviceuse,2010to2013, BMCHealthServ.Res.16(2016)353.

[40]K.Robinson,E.Lucas,P.vanderDolder,E.Halcomb,Livingwithchronic obstructivepulmonarydisease:thestoriesoffrequentattenderstothe Emergencydepartment,J.Clin.Nurs.27(2018)48–56.

[41]J. Dwarswaard,E.J.M. Bakker, A.van Straaa,H.R.Boeij, Self-management supportfromtheperspectivepfpatientswithachroniccondition:athematic synthesisofqualitativestudies,HealthExpect.19(2015)194–208.

[42]J.J.Francis,M.Johnston,J.Robertson,L.Glidewell,V.Entwistle,etal.,Whatis anadequatesamplesize?Operationalisingdatasaturationfortheory-based interviewstudies,Psychol.Health25(10)(2010)1229–1245.