Keywords
Chronic Obstructive Pulmonary Disease, patients, professionals, Pulmonary Rehabilitation Programme, Nominal Group Technique
Chronic Obstructive Pulmonary Disease, patients, professionals, Pulmonary Rehabilitation Programme, Nominal Group Technique
No changes were suggested by reviewer 1. In response to reviewer 3, we have added more details in the Discussion regarding the limitations of the study to address the queries made (socio-demographics, largely male sample). We have also added some details to clarify the issue of ‘learning’ and the impact of independence on the significant others in the discussion.
In response to the second reviewer, we have made a number of changes to the manuscript and have also posted a response in the review comments.
We have added a couple of sentences at the end of the Introduction to clarify the nature of the NGT work and its quantitative aspects within our study. We have also included additional information to the first paragraph of the Discussion to elaborate upon this.
The legend of Table 4 has now been corrected in line with the text to illustrate that we had 12 responses, equating to a 60% response rate. We have also corrected Table 1 using the correct date of completion of the PR programme (2010 not 2005).
Finally, we have added more information under participants to illustrate the multi-disciplinary make-up of the PR programme being delivered at the Health Board to explain why the professional group was made-up of numerous professionals as opposed to being predominantly made-up of physiotherapists.
See the authors' detailed response to the review by Amanda Stears
See the authors' detailed response to the review by Pat G. Camp and Carmen Sima
Chronic Obstructive Pulmonary Disease (COPD) is a progressively disabling condition characterised by impaired respiratory function associated with physical limitations and psychological co-morbidity1. COPD results in a reduced capacity for functional activities and performance of daily activities with a corresponding impairment in Health Related Quality of Life2. Current figures show 900,000 people have been diagnosed with and are receiving treatment for COPD within the United Kingdom3. However, due to under reporting or under diagnosis, the actual number of those suffering with COPD is estimated to be as high as 3 million4. Stopping smoking is crucial and is the only intervention that influences the natural history of lung deterioration, with current pharmacological treatment being aimed at reducing symptoms and exacerbations5.
Pulmonary Rehabilitation Programmes are multi-disciplinary interventions individually tailored to optimise each patient’s physical and social performance. Rigorous evidence from randomised controlled trials demonstrates that Pulmonary Rehabilitation Programmes for COPD can improve dyspnoea, exercise tolerance, Health Related Quality of Life, and reduce the number of days spent in hospital and the utilisation of healthcare resources6–8. Pulmonary Rehabilitation Programmes have been shown to be cost-effective and are now recommended for all patients who remain breathless despite optimal bronchodilators, irrespective of severity and age6–9. Pulmonary Rehabilitation Programmes are also being effectively applied to non-COPD causes of pulmonary impairment10.
There are now specific guidelines and recommendations in the United Kingdom regarding Pulmonary Rehabilitation Programmes, including how to select patients, the timing and number of sessions, intensity and type of exercise, the key educational, psychological and behavioural components, oxygen supplementation and outcome assessment7,8. Research exploring the benefits following Pulmonary Rehabilitation Programmes has predominantly been quantitative in nature. There have been some qualitative studies with COPD patients, but these have focused largely on specific aspects of patient experience11,12 and barriers to participation in Pulmonary Rehabilitation Programmes or other self-management programmes13,14. There has been some exploration of the effectiveness of self-management programmes from the patient perspective15–17. However, none of these studies have combined patient, carer, and professional perspectives, particularly in an in-depth analysis regarding the long-term impact of Pulmonary Rehabilitation Programmes in relation to personal needs and issues such as perceived patient benefits, and expectations and challenges of Pulmonary Rehabilitation Programmes. It has been recognised that a better understanding of how Pulmonary Rehabilitation Programmes improve Health Related Quality of Life could affect the future design of programmes, enhance measurement tools for Health Related Quality of Life and more appropriately support the specific needs of patients15,17,18.
Consensus methods are techniques used to gain opinions and views from appropriate experts regarding the current position in a particular field. They provide a mechanism for assimilating and synthesising information, particularly where published information may be inadequate or non-existent19. The purpose of consensus methods is to reach an agreement on a particular issue. Consensus methods can also mitigate some of the problems sometimes associated with group decision-making processes. In particular, where dominant views may lead the process and crowd out other perspectives19.
Nominal Group Technique is one of the commonly used consensus methods within healthcare and medical settings. The technique was first developed as an organisational planning technique by Delbecq et al. in the 1970s20. The Nominal Group Technique normally involves four main phases: a nominal phase, during which each individual silently considers the issues under deliberation; an item-generation phase, during which each individual discloses the results of their deliberation to the group; a discussion and clarification phase, during which the group assures itself that it has understood the items that have been advanced; and a voting phase, during which the items are evaluated and the issue is decided (e.g. a ranking exercise). Nominal Group Technique promotes individual contributions allowing each individual the opportunity to voice their opinions. Factors that would normally inhibit participation are therefore avoided and even the more reticent group members are encouraged to participate in all phases21.
By adopting a mixed methods design, employing qualitative and quantitative methods during consultation with mixed stakeholder groups, and by including a modified Nominal Group Technique component as described previously22, we aimed to provide a picture of the perceived benefits and challenges of Pulmonary Rehabilitation Programmes for COPD patients. The purpose of this chosen approach was to employ combined quantitative and qualitative methods in order to gain a common consensus regarding the relative importance of the issues generated. Here we report the quantitative aspect of the Nominal Group Technique activities, whereby the most favoured rank is selected as being the most important.
Following regional ethics and research and development approval, a series of consultation workshops were held between January and December 2012, in a District General Hospital in Wales, United Kingdom, serving a mixture of urban and agricultural communities. The hospital delivers a regular Pulmonary Rehabilitation Programme which includes 18 sessions of outpatient multidisciplinary input from occupational therapists, physiotherapists, dietetics staff, physicians, specialist respiratory nurses, social workers and a smoking cessation counsellor. The content and timings of the Pulmonary Rehabilitation Programme is evidenced-based and is tailored to individual requirements and personalised goal setting.
We recruited across one Health Board (two hospitals) South West Wales, United Kingdom that serves 385,000 people and included patient, professional and significant other groups, to ensure we included a wide range of views, experience and knowledge of COPD and Pulmonary Rehabilitation Programmes.
Patients with COPD who were currently participating in or who had completed a Pulmonary Rehabilitation Programme within the last 2 years were approached to participate in the study, with most being approached in their last Pulmonary Rehabilitation Programme session. Information sheets were given to patients for their significant others (husbands, wives, partners, friends, carers or family members) inviting them to contact the researcher if they wished to participate. The Health Board adopts a multi-disciplinary team approach to the delivery of their Pulmonary Rehabilitation Programmes and all professionals who were identified as playing a significant role in the delivery of the Pulmonary Rehabilitation Programmes and the treatment of COPD patients (occupational therapists, physiotherapists, respiratory consultants, respiratory team administrators, pharmacists, counsellors, psychologists, and specialist respiratory nurses) were approached to participate in the study. All 20 participants (8 patients, 8 professionals and 4 significant others) provided written informed consent.
Our aim was to gain an understanding of the positive and challenging aspects of Pulmonary Rehabilitation Programmes for patients with COPD and to gain a consensus regarding what constitute the most important aspects of Pulmonary Rehabilitation Programmes.
Nominal Group Technique consensus exercises were carried out as one aspect of a multi-layered, mixed-method consultation during three half-day workshops (one with professionals, one with COPD patients, and one with the significant others of patients). Based on guidance in the literature for optimal numbers for qualitative group consultations, we aimed to recruit six participants to each of the three workshops23.
Each workshop was made up of three parts. Part one began with a broad discussion that examined the nature and content of Pulmonary Rehabilitation Programmes through a semi-structured group interview. The second part involved more extensive discussion with participants. Having attended a Pulmonary Rehabilitation Programme, participants were encouraged, using personal examples to describe what the Programme meant to them. This included exploring their perceived views regarding the benefits and challenges of Pulmonary Rehabilitation Programmes and impact on patient Health Related Quality of Life. An adapted Nominal Group Technique exercise was employed in the final part of the workshop. The focus of this stage was to address the following question with participants: “what are the positive, and what are the challenging aspects of Pulmonary Rehabilitation Programmes for the treatment and rehabilitation of COPD patients?” During the Nominal Group Technique exercise, issues that were raised in the early parts of the workshop were refined and condensed into a list of approximately ten positive and ten challenging aspects. At the end of the workshop, participants were asked to rank these aspects in order of significance (Steps 1–7, leading to Output 1, Figure 1). The generation of the positive and challenging aspects of the Pulmonary Rehabilitation Programme using Nominal Group Technique followed the standard approach outlined in previous work22.
The data generated from each Nominal Group Technique activity (Output 1, Figure 1) were collated for each consultation workshop. Median ranks with interquartile ranges were calculated using SPSS version 19 for each of the aspects on the positive and challenging lists and a consensus ranked list was produced based on these final median ranks.
Following the consultation workshops we adapted the Nominal Group Technique method as previously described22 in order to include an additional multi-group ranking round (Steps 8–10, Figure 1). The lists of positive and challenging aspects of a Pulmonary Rehabilitation Programme produced following the three workshops were organised into a series of over-arching themes under which the positive and challenging aspects fitted (Step 8, Output 2, Figure 1). Rigour was maintained throughout the process of theme generation, by adhering to recommended qualitative data reliability and validity techniques24–26. An independent analysis of the lists generated from the workshops was carried out by two of the study team in order to identify the key over-arching themes. This process involved deletion of duplicate items and amalgamation of items where overlap was clear. A final set of common themes was independently generated by a third member of the team. This reflected and amalgamated the thematisations of the first two.
Following the generation of themes, all the original workshop participants were sent a pack of A5-sized cards. Each card carried a broad theme as a header under which were listed the associated set of positive and challenging aspects. As with the earlier workshop Nominal Group Technique activity, participants were asked to rank the themes in order of importance: with ‘1’ representing the theme they regarded as being most important and subsequent ranks signifying the themes of diminishing importance (Step 9, Figure 1)22. The ranked cards were returned by participants in a pre-paid envelope.
The data from the returned cards were analysed using SPSS version 19 in order to calculate the median ranks and interquartile ranges (IQR) for each of the themes. A final consensus ranked thematic list was produced based on these median ranks (Step 10, Figure 1). This was the list produced for discussion and dissemination ensuring veracity within the method and enabling cross-consideration of themes and aspects by team members from Stage 1 thematisation undertaken within a group setting, to Stage 2 thematisation, undertaken by individual participants, post-consultation workshop.
Notes and audio recordings from the three consultation workshops were transcribed. These transcripts were subjected to thematic and summative analysis to extract relevant information related to each of the generated themes27,28. The detailed content relating to each theme was extracted from the individual transcripts and was built up to articulate fully the set of aspects that it contained and to clarify any anomalies or ambiguities29. The final output of the consultation workshop was a ‘thematic template’ that ranked each theme in order and that provided a qualitative in-depth elaboration of the content contained within each theme.
We recruited a total of 20 participants across the three consultation workshops (see Table 1). Thirty three positive and 35 challenging aspects of Pulmonary Rehabilitation Programmes were produced in total for the three workshop group. The ranked list for each of the consultation workshops is illustrated in Table 2.
Individual assimilation produced similar lists of common broad themes that were refined to seven (Output 2, Figure 1). The seven themes were: the patient, physical health, mental health, knowledge and education, the programme, professionals and significant others and the future (see Table 3).
Fourteen of the 20 attendees at the three workshops returned the packs of cards. Two were incorrectly completed, resulting in 12 evaluable responses (60%).
Following thematic ranking, the theme that was regarded as most important was the patient, followed by physical health. Jointly ranked as third were: mental health and knowledge and education. The programme and professionals and significant others were jointly ranked as fifth, with the future ranked as the least important theme (Table 4).
In summary, the patient detailed how the patient’s health and wellbeing changed for the better over the course of Pulmonary Rehabilitation, and how patients were encouraged to gain confidence, to demonstrate a commitment to improving their own health, and to adopt a broader outlook on ongoing healthcare needs and expectations. Physical health illustrated how learning to breathe “properly” had a profound impact on patients, not only because breathing well is vitally important to their health and quality of life, but also because breathing “properly” is something that needs to be learnt. Mental health highlighted that bringing patients together enabled them to appreciate that they were not alone in their feelings and experiences. Knowledge and education emphasised the ability of Pulmonary Rehabilitation Programmes to create a learning environment, lasting for many weeks, within which patients are educated about their illness, and are able to develop new techniques to manage and cope. In the programme, patients, professionals, and significant others all emphasised positive outcomes for patients attending Pulmonary Rehabilitation Programmes for the duration and in the longer-term: physically, mentally, and socially. Professionals and significant others discussed how patients regarded the professionals as “caring” and “friendly”, treating them with “dignity” and “respect”, and that this created a welcoming and safe environment that enabled them to feel “cared for” and “at ease”. With respect to the theme of the future, participants emphasised a plethora of benefits that could be directly attributed to Pulmonary Rehabilitation Programmes, including improved health outcomes, enhanced quality of life, fewer hospital admissions, less time spent in hospital and consequently health care financial savings.
We identified important aspects of Pulmonary Rehabilitation Programmes for the treatment of COPD from the point of view of a mixed population group of patients, professionals and significant others. Using a modified Nominal Group Technique exercise delivered during innovative consultation workshops, we produced a novel ranked thematic list that encompassed the important positive but also challenging aspects of Pulmonary Rehabilitation Programmes. The final priority list created by the Nominal Group technique exercise was not intended to be a statistically robust representation of the data, but rather a method to facilitate the broad identification of priorities. The extension of the traditional Nominal Group Technique approach by employing a thematic stage was designed to allow us to explore the more detailed rationale for the prioritised list generated.
There was a surprisingly diverse range of generated aspects (Table 2) across the three workshops. The professional outputs were focused on pragmatic service delivery, with a clear goal of patient improvement, education and attitudinal change. The patients focused not only on physical improvements but also on improving mental strength, morale and self-esteem. Although all patients were positive about Pulmonary Rehabilitation Programmes, they also highlighted the challenges faced by some of them in attending them, which included an occasional lack of privacy, instances of poor communication, inadequate venues for certain activities (e.g. a public area of a hospital corridor to perform shuttle walk tests) and being daunted by the prospect of exercise and gym work. These findings are in accord with previous literature, which has examined the reasons for non-attendance on Pulmonary Rehabilitation Programmes13,17. Interestingly, the significant others focused on the social elements, with friendships made, caring staff and individual care contributing to the patients’ gaining confidence and learning about how to manage their condition. The significant others also highlighted the knock-on-effect of allowing them to have more time for themselves and not be so protective of the patients. The benefits of this increased patient independence on their partners and carers warrants further investigation. All participants recognised that they were unsure what the future would bring in terms of long-term health and health-care support, but were keen for continued contact with professionals, Pulmonary Rehabilitation Programmes refresher courses and for the Pulmonary Rehabilitation Programmes to be recognised as beneficial for others, and thus maintained.
The final outcome of the Nominal Group Technique exercise was a ranked list of seven themes (Table 3), with ‘the patient’ ranked as the most important theme, followed by ‘physical health’. Overall, the main positive benefits of Pulmonary Rehabilitation Programmes were that they instilled confidence, enabled patients to ‘learn’ to breathe properly which subsequently allowed them to manage their health more efficiently, encouraged the patient to be more self-sufficient and in control, and were enjoyable. The challenges to participation were that Pulmonary Rehabilitation Programmes were daunting, physically challenging, and required motivation. Interestingly, many of these challenges have been highlighted in previous qualitative studies16 with COPD patients as important reasons why patients decline entry or withdraw from Pulmonary Rehabilitation Programmes. Patient beliefs about Pulmonary Rehabilitation Programmes can comprise positive aspects (e.g. that they will lead to improvement, safe and multi-disciplinary setting, and motivation) as well as negative aspects (they lead to disruption of normal routine, being tired, transport issues and limited privacy)13. It has been shown that attending a Pulmonary Rehabilitation Programme is associated with better management of breathlessness, which in turn has a positive impact on physical and social activity, coping strategies and patient confidence15,17,18.
This study was carried out within one geographical location in South-West Wales, United Kingdom, and employed only three consultation workshops. In addition, we had a greater proportion of male patients in our population (mostly likely due to the former industrialised nature of the geographical location). We only received responses from 60% of the original participants and, as these were anonymised, we were unable to compare the demographic characteristics of the respondents from the non-respondents, which may have influenced the ranking process. Whilst we are confident that the methods adopted are transferable, in line with our extensive engagement with the methods in a range of community and primary care settings22,30, a larger study, employing more consultation workshops conducted over a larger geographical area is necessary to consider whether all the important aspects of Pulmonary Rehabilitation Programmes have been revealed, and whether the themes we identified within this study are generalisable.
The adapted Nominal Group Technique exercise was a mechanism for distilling the important aspects of Pulmonary Rehabilitation Programmes in a mixed group of individuals, which allowed the views of all the participating groups to be considered as equal. The process of qualitative elaboration of these themes in terms of what they meant to patients, professionals and significant others, provided a more comprehensive picture than other studies have derived. Moreover, combining qualitative with quantitative assessments provides more information, and these approaches could be used to make recommendations to improve and develop Pulmonary Rehabilitation Programmes across health-care contexts.
Figshare: Nominal Group Technique consultation of a Pulmonary Rehabilitation Programme Data Set, doi: 10.6084/m9.figshare.92854031
All participants provided written informed consent.
HH, FR, MD and SW developed the research proposal and applied for funding. HH and FR were joint principal investigators on the project. HH, FR, MD and SW were involved in the study consultation workshops. All authors were involved in the analysis and presentation of the study data. HH led on writing the manuscript. FR, MD, CC and SW provided input to and reviewed all drafts of the manuscript.
No competing interests were disclosed. The study sponsor has had no involvement in the study design, collection, analysis or interpretation of data.
This work was supported by a grant from the Hywel Dda Local Health Board Research and Development Committee (Project R&D reference HD/12/004) and was awarded to Dr Hayley Hutchings and Professor Frances Rapport as joint principal investigators.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
We would like thank all of the study participants for giving their time and attending the workshops. We would also like to thank Carol-Anne Davies for her help in recruiting COPD patients and significant others, and Vicky Davies for her administrative support.
Views | Downloads | |
---|---|---|
F1000Research | - | - |
PubMed Central
Data from PMC are received and updated monthly.
|
- | - |
Competing Interests: No competing interests were disclosed.
Competing Interests: No competing interests were disclosed.
Competing Interests: No competing interests were disclosed.
Competing Interests: Pat Camp is a member of the Canadian Thoracic Society COPD Clinical Assembly and is involved in the development of guidelines for use in COPD.
Competing Interests: No competing interests were disclosed.
Alongside their report, reviewers assign a status to the article:
Invited Reviewers | |||
---|---|---|---|
1 | 2 | 3 | |
Version 2 (revision) 06 Aug 14 |
read | read | |
Version 1 13 Feb 14 |
read | read | read |
Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list:
Sign up for content alerts and receive a weekly or monthly email with all newly published articles
Already registered? Sign in
The email address should be the one you originally registered with F1000.
You registered with F1000 via Google, so we cannot reset your password.
To sign in, please click here.
If you still need help with your Google account password, please click here.
You registered with F1000 via Facebook, so we cannot reset your password.
To sign in, please click here.
If you still need help with your Facebook account password, please click here.
If your email address is registered with us, we will email you instructions to reset your password.
If you think you should have received this email but it has not arrived, please check your spam filters and/or contact for further assistance.
Comments on this article Comments (0)