Nominal Group Technique consultation of a Pulmonary Rehabilitation Programme

Objective: The purpose of the study was to determine what patients, professionals and significant others regarded as the most important positive- and challenging aspects of Pulmonary Rehabilitation Programmes for patients with Chronic Obstructive Pulmonary Disease (COPD) and to gain insight into how such programmes could be developed and improved. Method: A modified Nominal Group Technique method was used in three consultation workshops (one with COPD patients who had recently undertaken a Pulmonary Rehabilitation Programme; one with ‘significant others’ of the same patients; one with secondary care professionals who deliver the Pulmonary Rehabilitation Programme). Results: Each of three workshops resulted in the production of approximately ten positive- and ten challenging aspects related to Pulmonary Rehabilitation Programmes. These were further developed by a process of thematisation into seven broad themes. The most important was ‘ the patient’, followed by ‘ physical health’; jointly ranked as third were: ‘ mental health’ and ‘ knowledge and education’. ‘ The programme’ and ‘ professional characteristics’ were jointly ranked as fifth, with ‘ the future’ being ranked as the least important theme. Conclusions: The modified Nominal Group Technique method allowed the development of a ranked thematic list that illustrated the important positive- and challenging aspects of Pulmonary Rehabilitation Programmes for patients with COPD. These themes should be core to planning future Pulmonary Rehabilitation Programmes, particularly if patients and carer views are to be considered.

Chronic Obstructive Pulmonary Disease (COPD) is a progressively disabling condition characterised by impaired respiratory function associated with physical limitations and psychological co-morbidity 1 . COPD results in a reduced capacity for functional activities and performance of daily activities with a corresponding impairment in Health Related Quality of Life 2 . Current figures show 900,000 people have been diagnosed with and are receiving treatment for COPD within the United Kingdom 3 . However, due to under reporting or under diagnosis, the actual number of those suffering with COPD is estimated to be as high as 3 million 4 . 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 exacerbations 5 .
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 resources 6-8 . 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 age 6-9 . Pulmonary Rehabilitation Programmes are also being effectively applied to non-COPD causes of pulmonary impairment 10 .
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 assessment 7,8 . 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 experience 11,12 and barriers to participation in Pulmonary Rehabilitation Programmes or other self-management programmes 13,14 . There has been some exploration of the effectiveness of self-management programmes from the patient perspective 15-17 . 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 patients 15,17,18 .
Consensus methods are techniques used 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-existent 19  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 previously 22 , we aimed to provide a picture of the perceived benefits and challenges of Pulmonary Rehabilitation Programmes for COPD patients. Here we report the quantitative analysis of the Nominal Group Technique activities.

Methods
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.

Participants
We recruited across the South West Wales Regional Health Board, 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. 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 also approached to participate in the study. All 20 participants (8 patients, 8 professionals and 4 significant others) provided written informed consent.

Study design
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.

Consultation workshops
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 workshops 23 .
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 work 22 .
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.

Generation of themes
Following the consultation workshops we adapted the Nominal Group Technique method as previously described 22 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 techniques 24-26 . 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.

Thematic consensus
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.
Thematic template generation 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 themes 27,28 . 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 ambiguities 29 . 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.

Consultation workshops
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.

Generation of themes
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).

Thematic consensus
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).

Thematic template generation
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. Year of diagnosis 1 SO M Significant other n/a n/a n/a 2 SO F Significant other n/a n/a n/a 3 SO F Significant other n/a n/a n/a 4 SO F Significant other n/a n/a n/a 5 PROF M Consultant respiratory physician n/a n/a n/a 6 PROF M Consultant respiratory physician n/a n/a n/a 7 PROF M Pharmacist n/a n/a n/a 8 PROF F Occupational therapist n/a n/a n/a 9 PROF F Specialist respiratory nurse n/a n/a n/a 10 PROF F Physiotherapist n/a n/a n/a 11 PROF F Administrator n/a n/a n/a 12 PROF F Dietician n/a n/a n/a  The positive and challenging aspects within each workshop group list represent the ranked lists ordered by the individuals in each group. The aspects generated are based on direct quotes from the individuals attending the workshops.

Discussion
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.
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 Programmes 13,17 . The positive and challenging aspects encompassed within each theme are based on direct quotes from the individuals attending the workshops.
the methods in a range of community and primary care settings 22,30 , 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.

Consent
All participants provided written informed consent.
Author contributions 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.

Competing interests
No competing interests were disclosed. The study sponsor has had no involvement in the study design, collection, analysis or interpretation of data.

Grant information
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.
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. All participants recognised that they were unsure what the future would bring in terms of longterm 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 breathe properly and 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 studies 16 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 multidisciplinary 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 confidence 15,17,18 .
This study was carried out within one geographical location in South-West Wales, United Kingdom, and employed only three consultation workshops. Whilst we are confident that the methods adopted are transferable, in line with our extensive engagement with The article gives a clear introduction to the concept of Pulmonary Rehabilitation (PR) acknowledging the evidence supporting the intervention and the positive impact that is has on participants lives post programme. Most importantly, it seeks to gather the opinions of "significant others" and professionals within the clinical team, something that is often overlooked but that could be a key component in service development.
There is a clear introduction to the use of the Nominal Group Technique and its usefulness in facilitating all participants' views to be gathered and the aim of providing a rank of perceived benefits and challenges in pulmonary rehabilitation is clearly stated.
The authors have used the Nominal Group Technique successfully to provide a useful ranking of themes and challenges from the perspectives of patients, professionals and significant others. These are useful to challenge current assumptions within Pulmonary Rehabilitation Programmes, but the study would benefit from consideration of the socio-demographics of the group as these also impact on health related outcomes. The small sample size also makes it difficult to generalise to a wider population, something which the authors themselves acknowledge. There is also a strong male bias in the sample group, what affect did this have on the results?
The data and techniques used are clearly described and well presented and are representative and reflective of findings in the clinical setting.
In conclusion, going forwards further research is required to establish whether the rankings are concurrent across the country, and if so do they have a role in guiding PR and assisting patients and significant others in overcoming the perceived barriers. Many of the themes and issues identified are already known to those working within the clinical setting and are addressed through education and management within PR in the UK already. There are also assumptions in practice that patients "Learn" as is stated on page 6 in the Thematic Template generation. How is this evidenced? One finding that the authors also highlight is that significant others have more time for themselves as patients become more independent therefore supporting the self management of PR; this would benefit from further exploration.
I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
No competing interests were disclosed.

Competing Interests:
and appears to focus on the benefits of the pulmonary rehabilitation program, but the challenges are not clearly articulated.

DISCUSSION
The conclusions are generally balanced and justified, although special emphasis is placed on the qualitative findings. Some of the discussion would be better suited to the results. The main benefits and challenges of pulmonary rehabilitation for patients, carers, and professionals as presented in the themes are not specific enough to be of use for making recommendations for improving the pulmonary rehabilitation program.
We have read this submission. We believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above.
Pat Camp is a member of the Canadian Thoracic Society COPD Clinical Competing Interests: Assembly and is involved in the development of guidelines for use in COPD. This is an interesting and useful article that explores the implications and lived experience of people dealing with the challenges of a debilitating chronic disease (COPD). This is not a "sexy" area of health care research but it is an important one as COPD substantially limits life in both quantity and quality. As such it is a worthy area of investigation, as the aim of this article is to identify how to improve the delivery of service for a sometimes overlooked patient group.

Kate Bullen
The article is well presented and reflects a high level of attention to detail in design and analysis. The research team has identified an appropriate method of investigation which is sufficiently novel to generate new knowledge that will potentially inform clinical practice. Details of the data collection and analysis processes are well presented and the data are discussed comprehensively. The research team acknowledges that there are limitations in the study in terms of the level of participants, and the level of geographical specificity of the study. Whilst this is a sensible approach such caveats should not detract from the potential value of the study for practitioners who deliver such programmers. Finally, the conclusions are well balanced and insightful with a clear pathway to future research identified.
I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
No competing interests were disclosed. Competing Interests: