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Table 6 Summary of findings as related to the NPT framework

From: Achieving Good Outcomes for Asthma Living (GOAL): mixed methods feasibility and pilot cluster randomised controlled trial of a practical intervention for eliciting, setting and achieving goals for adults with asthma

NPT category

Patients

Professionals/practices

Coherence: Meaning and sense making by participants

After some initial uncertainty, many were able to set goals that ranged from everyday changes to more major challenges. The relevance of asthma to the goals was not always clear.

Nurses understood the concept of goal elicitation and understood its value but struggled with processing and prioritising the goal information and negotiating an action and coping plan within the timeframe of the review.

 

Patient 901 Female 47 years

“….it was quite clear and the way it then broke down so you actually really had to think about what it is that's limiting ….. it did actually make you think much more deeply about how you went about these things and therefore what were the key things that were holding you back.”

Patient: 103 Male 81 years

“Yeah, it was easy to understand. The hard bit was to try and find an answer! ”

Patient 1002 Male 57 years

“Oh it was good. It was about what I do, about my lifestyle. So, yes, it was ….pertaining to my life and what asthma had done to it. ….it just came out, just flowed out.”

Patient 901 Female 47 years

“I thought it was very interesting, it was very difficult to work out what your goals were and then to think how asthma might affect them. Like, for instance, I've got ‘get fit’ there; I don't care about being fit, being fit is to enable me to do lots of other things, so I was getting confused with what was a goal, what did I really want to do and what were the mechanisms for getting there, which I think later on it pulled out, but on the first page I was getting very confused with those.”

Nurse 102

“…it was good because it made them (patients) think more about how they felt.”

“it was helpful in the sense that they (patients) told us a lot more than we would normally ask.”

Nurse 103

“it’s a good idea. It’s very thorough; it’s looking at the whole person and not just looking at the disease…”

“…we tend to do the same core questions in the basic review…. I think it’s unlikely for us to be able to deal with other issues unless it’s been a very straightforward asthma review.”

“I don’t think …we would really ever go into their life goals unless it cropped up, saying that ‘I really want to do this but I can’t because of my asthma’. … I don’t think is something that we’d… discuss, …probably due to time restraints…”

Cognitive participation: Commitment and engagement by participants

Few patients volunteered for the study, perhaps reflecting unfamiliarity with the concept of goal setting, though 15 of the 18 patients participants remained committed throughout.

Nurses were enthusiastic about the concept which they perceived resonated with their role in providing self-management support.

 

Patient 101 Female 22 years

“I have just finished university myself and had to do a research project and I'm more than happy to participate in anything that might make a difference to someone in the future.”

Patient 103 Male 81years

“I don’t mind taking part…I know when I had my pacemaker fitted I was asked a load of questions and I agreed…No, I think if I’m being helped then I return the help in some way … and I think that’s what one should do.”

Nurse 101

“we already do self-management plans and discuss their future plans and how to deal with their symptoms and how to deal with life in general …”

Nurse 3

“I … think it's because I would like to…see their control better, try and make their quality of life better, and help the patient to understand what asthma is. It's their disease, it's their illness, and therefore make them able to manage it themselves.”

“I've enjoyed it. … it was stressful at the very beginning…before we actually saw our first patients…but…I kind of settled down and thought, actually…there's nothing more to this than what I've been doing.”

Nurse 6

“…made me a bit more aware… looking more objectively at the patient and their work…it…changed my way of thinking…that was good.”

Collective action: The work participants do to make the intervention function

Patients generally attempted to complete the pre-consultation goal setting exercise, but opinions about whether this was a useful task ranged from ‘insufficiently motivating’ ‘useful clarification’, ‘already clear about my goals’ ‘not sure I have/want goals’.

The organisational processes (exacerbated because of trial recruitment processes) were complex and did not go smoothly. The task of assimilating and discussing goals substantially increased the workload for the nurses who struggled with the demands on their time.

 

Patient 107 Female 70 years

“…… it gave me an opportunity to sit down and think things out a bit more clearly …… it made me prioritise much more……. I had a lot more aims and goals before I narrowed it down……”

Nurse 10

“….what was the process again? We got the amount of patients that were due and then there were certain criteria, that’s right. And then in the office they got the patients …. and then I had to go through the list and check it..…quite a lengthy process really trying to find the patients that were eligible…… we always seem to be behind in getting the letters out because the admin staff are that busy and I was that busy….”

Nurse 102

“It just took up a bit more time… I went over, because of the things that they put down, you know, I would never talk about losing weight, well I would talk about losing weight to asthma patients if they're very heavy and obese, but diet and stuff isn't something that I would bring up in an asthma clinic. So I went over because I talked about things.”

Reflexive monitoring: Participants reflect on or appraise the intervention

The goal-focussed review was experienced as being more holistic, person-centred and partnership-based

Nurses did not believe that the goal-setting intervention significant changed how the review was conducted – though it substantially disrupted their appointment schedule.

 

Patient 1002 Male 57 years

“…it brought to life what…nobody else has ever asked. it …opened my eyes to my asthma and now I think I’m in control of it rather than asthma being in control of me.”

Patient 1201 Female 55 years

“…basically what this has done is…reminded me that I don’t pay close enough attention to matching being good to myself, being kind to myself, with my conditions. And that I actually have to actively look after myself, not take it for granted, be sensible about using the medication appropriately, monitoring how I’m doing …[it] focused me on that.”

Patient 101 Female 22 years

“I think it changed what we’d done in our asthma appointments ….because it gave it more of a focus…which is quite important.”

Patient 901 Female 47 years

“…I thought it was very useful, it was like having a life coach on the NHS! It felt much more like a team, felt much more that she knows who I am and therefore we’re working together on my health rather than me doing what I'm told and being monitored.”

Nurse 10

“… I think it’s quite lengthy…and …a bit difficult…it was all about his medication and his work….his goal was to be able to do his job without being so short of breath. I found it quite difficult actually…I don’t know if it was because [it’s]… down in black and white….what he wants…you kind of think oh God am I going to be able to actually sort for this for him…”

Implementation

  
 

Patient 901 Female 47 years

“I suppose it’s difficult with studies but I suppose if it had been brought up rather than on quite a long letter, which it was wasn’t it, a reasonably long letter…and then there's forms to sign and there's a whole lot of barriers, and because it’s a study that's why it happens, but if it had been brought up perhaps when I’d gone in to see the nurse as a start off section, then that might have made people more responsive cause they didn't have to trawl their way through all the…words.”

Nurse 9

“…I think it was the time when we first started … it was near the end of the financial year for the GPs then the start of the beginning, so a lot of our patients had been seen at the beginning of the year [spring/summer of the previous year] and it was only those that hadn’t been seen and they were down the line of possibly being exception coded anyway. So these were the patients that hadn’t turned up at the last two or three. So the selection wasn’t good.”

Nurse 3

“I did have an option but I didn’t really have an option because the GP who's interested in asthma had ticked the box and sent it off and then I probably got - I got told about two days before, by the way we've done this and we would like you to do it. So, in hindsight, I read the information…”

Nurse 3

“I think probably you know how we got the goal flier, I think putting that in and getting them just to contact myself to discuss it further… the patients were saying it was too wordy for them and they … I suppose it’s something unknown to them as well but they just didn't read it …too many words.”

Nurse 8

“…people weren’t too sure how connected it was with the practice…they knew they'd got an invitation from us but then they got this other thing from the University and they weren’t sure, they kind of came along to me to ask me was I involved in that, but by the time they'd asked me it was too late …if you could simplify the paperwork and the process of it for patients, or even the initial contact could even be ‘if you're interested in this contact the practice nurse’ and they would at least understand that it’s something we were involved in, because … they know that we manage their asthma and they're almost a bit suspicious of anybody else who might be coming in.”

Nurse 3

“…after the review I would ask them why they had decided not to take part. … I think they thought it was more than just a couple of phone calls…I think they thought there would be more into it. Whether they'd had - you know, they get so many questionnaires and things and projects to follow up and things like that, so I think they maybe thought it was more involved. …if …you had just a sheet of paper that said, this will involve a telephone call which will last ten minutes. You'll see your asthma nurse for a normal asthma [20:00] review and then we’ll follow it up afterwards…”