Health professionals act as guides to patients in understanding and accepting their health issues and in maintaining and improving their health prospects. As part of the infrastructure delivering healthcare they are acutely aware of the opportunities and limitations inherent within their immediate health delivery system, wider NHS and social care and the logistics, education, financial impact for all involved.
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Introduction
The following interviews explore the unique ‘insider’ perspective of health professionals exposed repeatedly to the realities of self-management navigated by individuals with bronchiectasis. The health professionals reflect on the barriers and opportunities to self-management in bronchiectasis. This part of the qualitative evaluation continues to utilise the post-positivist theoretical framework employed in the previous two sections. Advantage has been taken of the flexibility of the thematic analysis method used here in a simpler format more akin with the positivist methodology of the quantitative chapter. The aim being to seek exploratory and explanatory healthcare-centred insight into what may have obstructed or been missed opportunities in the development and evaluation of the BET intervention. Finally, this data is considered in order to obtain pointers to guide future bronchiectasis self-management development.
Methods
Below the Consolidated criteria for Reporting Qualitative research (COREQ) is a framework providing a checklist for reporting qualitative studies (374). The framework is used here to provide the reader with a detailed account of the interviewing of health professionals who were steering group advisors to the BET study to understand and explore their observations of the barriers and opportunities for self-management of bronchiectasis in this region.
COREQ is designed to provide a highly contextual view of the research conducted. The first domain evaluates the research team and reflexivity. The researcher/interviewer is female and reflexive aspects of occupation experience and training are presented earlier in this chapter. The relation of the researcher to the interviewees was of PhD student and junior colleague. The interviewees were specialist advisors to the BET study and as such had been highly attuned to the concept and evaluation of self-management and in relation to their patients with bronchiectasis. The steering advisors met six monthly to discuss progress of the BET study and self-management in healthcare and research literature. Both interviewees were aware of the interviewer’s goals, they had been involved in the BET protocol design which stated the objective of interviewing health professionals as part of the study. The interviewees were aware of the researcher/interviewers vested interest in the topic and appeared highly motivated to take part.
Page 150 of 288 The theoretical framework employed in these in-depth interviews was a post- positivist one (321). Thematic analysis was initially used deductively to identify the barriers and opportunities for self-management.
The Participant selection was purposive. The two health professionals invited to be interviewed were uniquely placed due to their dual roles as specialists encouraging self-management of bronchiectasis and steering group advisors to the BET study. Their steering roles provided an extended period during which to consider bronchiectasis self-management and to observe what facilitated or obstructed their patients in being able to self-manage. Their healthcare roles, independently of the study, pivot on informing and supporting self-management and enhancing self-sufficiency in managing bronchiectasis to maintain quality of life. The specialist consultant is male aged in the range 40 to 50 and the specialist nurse/community matron is female and aged in the range 60 to 70. The method of approach for invitation was face-to-face at the conclusion of a BET steering group meeting. A convenient time was arranged by telephone to suit the interviewees. The interviews were conducted in the environment chosen by the interviewee (options offered were in a meeting room away from the healthcare environment, in an office at work or at the interviewees’ choice of other venue). The interviews were digitally recorded, transcribed and transcripts reviewed by the interviewees (member checking) no changes in the form of redactions, clarifications or enhancements were requested and the interviewees felt that they had nothing to add. Only two interviews were sought to permit in-depth evaluation of possible moderators and confounders to the study and to consider future directions for research into self- management for this patient group. No further interviews were planned or conducted (recent university and hospital research studies shared during monthly updates reported the difficulty of obtaining feedback from health professionals particularly during flu season).
Only the participant and the interviewer were present during the recorded interviews. Both interviewees are senior clinicians with more than ten years specialist experience and are both prescribers. For data collection both interviewees were provided with the same interview question which was:
What is your personal opinion based on your interactions with patients of the barriers and opportunities for bronchiectasis self-management?
Page 151 of 288 The interviewees were allowed to pursue this topic as they chose with minimal interviewer interaction other than a few requests for elaboration or clarification where needed. The interviews were audio recorded. No repeat interviews were felt necessary by the interviewer or interviewees. Field notes were made during the interview, both participants initially aware of the novel situation of being audio recorded but quickly relaxing when relating observed patient behaviours.
The duration of the interviews was very different, the consultant interview conducted during work hours lasted fifteen minutes and was interrupted by urgent requests. The community matron interview away from her workplace and outside working hours lasted fifty minutes and was uninterrupted. The interviews concluded at the convenience of the interviewee. Data saturation is unlikely to have been achieved. The purpose of these interviews was to explore bronchiectasis self-management in light of the quantitative findings of BET.
Data analysis was conducted by the researcher/interviewer. The data was deductively coded by the interviewer and codes reviewed by both interviewees. The coding is very simple and relates to barriers and opportunities for bronchiectasis self-management. Barriers and opportunity coding were applied deductively. Excel was employed to manage the data due to its accessibility to the interviewees and interviewer, its flexibility as a data-management tool and the familiarity and proficiency of the researcher employing it.
The interviewees provided feedback on analysis and were present when it was discussed at a BET steering update (individual quotes were not reported during the meeting though codes and themes were discussed).
Quotations have been used to illustrate important topics within the chapter and the barrier and opportunity codes used to explain these.
Findings
Training
Findings that were consistent to both professionals related to health professional training, both individuals being part of informal peer supportive specialist training groups for continuing professional development.
Page 152 of 288 Multi-disciplinary health professionals undergo highly structured clinical training in order to qualify in their profession and to provide evidence based clinical treatment to health service users (375). Post qualification their knowledge and skill maintenance and improvement relies on individual practitioner motivation, opportunity and ability to select, fund and undertake continuing professional development whilst maintaining everyday practice. There is a lack of framework to guide knowledge acquisition for staff at all levels, generalist and specialist who are expected to seek information independently on a piece by piece. The National Institute for Health and Care Excellence (NICE) was established to help encourage equity of health delivery in the UK through high quality clinical guidance now recognised internationally. NICE provide easily accessible information to drive ‘Quality, innovation and value for money’ (376) in the British National Health Service. The latest information relating to bronchiectasis represents guidance on antimicrobial prescribing for acute exacerbation published in December 2018 (377). In Bronchiectasis the British Thoracic Society guidelines both 2010 and 2018 do provide an excellent source of information (1, 20) the latest guideline consists of over sixty pages in a dense, information-rich written format with extra appendices. It is encouraging to see that a short course is taking place in May 2019 to ‘ensure respiratory teams in the UK deliver optimal care to patients with bronchiectasis in line with the new BTS Guideline.’ The cost of the course is £320 for non-BTS members and lasts a day provided at one centre and date only in the UK. For primary care staff justifying the cost, travel and expenses and obtaining time away from work to attend may be challenging where training budgets are highly scrutinised. For secondary care the issues related to justifying training may be similar and depend on whether there is bronchiectasis specialist service able to send a representative. The programme content is perhaps aimed more at specialist hospital teams. No webinar, video-conference, or other online materials are available at present that might make the information more accessible to a diversity of multi-disciplinary, commissioning or patient support and education groups. A two page summary for the general public has been made available in a written format.