Steven

							The role of patients, nurses and
general practitioners in asthma
management: participants’ goals

Steven K, Sullivan FM, Williams B, Hoskins G.

University of Dundee

Funding: CSO Research Training Fellowship
• Background
• Aim
• Sample
• Findings:
  – Patients’ goals for the health
    professional / patient relationship
  – health professionals’ goals for the health
    professional / patient relationship
• Discussion
• Future of the project
                              Background

  May be differences between patients’
  goals and health professionals goals for
  asthma management:
• poor rate of patient compliance with
  asthma drugs
• differences between patient goals and the
  goals in the British Thoracic Society (BTS)
  guidelines
                                       Aim

To help health professionals to elicit
patients’ disease related goals in order to
make management more patient-centred
and to help patients to self-care
                       Outline of project
• Qualitative study to describe the asthma
  management goals of people with asthma
  and primary care health professionals

• Development of an instrument to improve
  asthma nurse’ ability to elicit patients’
  asthma goals

• RCT of instrument
                                 Method

• One to one interviews with each
  participant
• Interview based on a topic guide
• Interviews recorded and transcribed
  verbatim
• Transcripts analysed using Framework
                        Method: sample

• a purposive sample of Tayside general
  practices

• each practice was asked to invite 4-6
  patients who wanted to change their
  asthma management or who ought to
  change their asthma management.
                   Practice Characteristics
• Location               - 5 urban
                         - 4 rural

• Number of GP partners - 2 single-handed
                        - 2 with 2-4 partners
                        - 5 with 5+ partners

• Asthma nurse training
   – 1 with no asthma nurse
   – 2 with a nurse without an asthma diploma
   – 6 with a nurse with an asthma diploma

• Deprivation payments   - 2 receive deprivation
  payments
                 Patient Characteristics

• Gender -3 male, 12 female

• Age     16-19: 2 participants
          20-29: 0 participants
          30-39: 4 participants
          40-47: 3 participants
          50-59: 3 participants
          60+ : 3 participants
          Patient Characteristics cont.

• Social Class   I:        1 participant
                 II:       5 participants
                 IIINM:    2 participants
                 IIIM:     2 participants
                 IV:       0 participants
                 V:        5 participants

• Time since diagnosis of asthma: 2 – 58 years

• Smoking status: 2 current smokers
                                    Findings

  All of the participants had goals related to
  their perceived role in asthma
  management and the role they expected
  of the others:
• Patients’ goals
• Health professionals’ goals
     The health professional/ patient
         relationship: patients’ goals
• Requesting treatment from the health
  professional

• Responding to health professional advice
                   Requesting treatment

Some of the participating patients had
 unmet preferences for their asthma

  – Some patients asked the health professional
    to meet their needs

  – Some patients with similar preferences did not
                   Requesting treatment

Patients 7a and 9b wanted to try a new drug
 for their asthma:

  – Patient 7a requested the drug

  – Patient 9b did not because she’d ‘never ever
    been offered it.’
                  Responding to advice

• Two patients had the goal of following
  ‘doctor’s orders’.
• Thirteen patients’ goal was to consider the
  health professional’s view alongside their
  own views and sometimes:
  – reached a compromise position (13 patients)
  – rejected the health professional’s views (5
    patients)
              Following ‘doctor’s orders’
Patient 2: If the doctor says I've t' take it
  [medication], I take it, mean?...You've gotta dae
  what your doctor tells yeh. Ken what I mean. If
  em no gonna tak the medication, well em no
  gonna get any better, am eh?

I: Yeah. So you feel that he's, he's tellin' you the
   right thing? [pause]

Patient 2: Gotta lot o' faith in Dr X. An I like Dr X.
                   Reaching a compromise
Patient 7a:   [My GP] always said t' me t' get rid o' my dogs
              but like that we'd had them for years an you
              just dinna get rid o' [pause] pets like that. But
              when we, we lost them naturally we thought
              we'll give it a year an see if my asthma
              improves without the dogs. An if it doesna
              improve then we reckon we're gonna have
              another one…

I:            And then you wouldn't ha' got rid o' the dog
              on account of your asthma?

Patient 7a:   Um, I think I would've had t' be at death's
              door afore I…we'd had them for years, we'd
              had them since they were pups. T' me that's
              like givin' one o' your kids away
                            Rejecting advice
Patient 5c: I think my doctors would like it if I could
  [avoid the outdoors to avoid pollens etc.] but I'm
  the sort of person, I say, well I've got this an' its
  my choice if I go out, whatever happens it’s my
  choice you know, I don't want to wrap myself in
  cotton wool and sit at home in a plastic bubble
  with oxygen piped through it you know, I'm sorry
  it’s like, no, if my life comes to that please just
  terminate me now you know, I don't want that, I
  want to be able to go and have my life you know.
        The health professional/ patient
relationship: health professionals’ goals


 All but one of the health professionals
 believed that they were the experts on
 asthma management and had the goal of
 getting patients to manage their asthma
 ‘properly’.
                   The patient is the expert

GP 2: We're talking about people who have had asthma –
  some of them for many, many years – some of them
  from childhood. And em they are very well aware of of
  their disability and how the medication affects them and
  and whatever- they might get thrush if they take too
  much of the steroid. Um and they come to a
  compromise between treatment and effect. And that
  compromise is often less an optimal treatment…
        The patient is the expert cont.
…Well to put it in its bluntest terms, if I'm so prescriptive
and demanding and and and hectoring about their
asthma, they may not come and see me about
something else. And that may be, you know, I I I em I've
been in practice as I say 30 years this summer. Many of
the families have been with me all of that time – now well
into 3rd generations of many of them. Um and I have a
responsibility to the whole of the family. You know.
Whatever it may be and mostly we're talking about um
other kinds of problems, like family problems and drug
addiction and abuse and god knows what, and the
relationship between the patient and the GP is very, very
important for that and a domineering attitude about
asthma isn't going to help it.
    The health professional is the expert
   but…insisting on the best may be the
                     enemy of the good
Nurse 4: It’s not necessarily going to be [to] aim for
 the best way by teaching them all that it should
 be regular steroid dose and how to manage their
 asthma but if that's not happening then we take
 the next best line rather than trying to resist
 them and perhaps alienate them by insisting that
 they do it our way and then they are not wanting
 to come to the clinic and em and not following
 any advice.
      The health professional is the expert
      but…patients decide for themselves
GP4: I honestly can't remember saying ever to saying somebody they'd
  have to get rid of the dog. Eh obviously I can't tell the patients, I can
  suggest to them that a dog's maybe not the best thing for their
  asthma and perhaps if you could keep the dog in a kennel outside
  the house, you can still have your pet but eh restrict the contact you
  have with the dog, cut them out of allergens that are knocking
  around the house if you can em

I: But you don't feel it’s your job to say look

GP 4: Well no that doesn't work, you just point out the facts to people
  and they have to make up their own minds. I think gone are the days
  when people eh listen to what you have to say em, you know I
  certainly feel that over the years people are less receptive of what
  you have to say nowadays, they are always looking for something
  better em and that can be a bit awkward at times.
      The health professional is the expert
                   but…there are no buts!
R: You actually get [patients] coming in and saying, I've never had to
   use [my inhaler] but checking their peak flows gives you a
   reasonable idea, checking if they've got a night cough. I've caught a
   couple [of patients] out just recently that again they haven't been
   using [their inhalers], not fine and you just go on and you know sort
   of pop that in, do you cough at night or you know in the morning …
   I've been wakened a couple of times you know with this persistent
   cough I can't get rid of it so then you find out that they haven't
   actually been taking their [inhalers]

I: And what do you say next?

R: That they, I actually say to them, look I want you to take it, two
   puffs, three times a day of your reliever and take your steroid twice,
   em, two puffs in the morning, two puffs at night and I want you to do
   that em, until your cough disappears and I'll see you back again in
   say six weeks and that way they do what they are told because they
   know they are coming back to you in six weeks
            Strengths & Weaknesses

• In-depth interviews
• Range of participants
• No direct observation of asthma
  consultations
                                   Discussion

Barriers to eliciting and using patients’ asthma
  goals to improve asthma care:
   – Sometimes patients do not expect to have to
     voice their asthma goals to the health
     professional
   – Some patients expect to ‘follow doctors’
     orders’
   – Some health professionals disregard patients’
     expertise in asthma
                  The future of the project

    We have devised an instrument to help patients
    to formulate goals and to increase asthma
    nurses’ awareness of patients’ goals:
•   3 life goals
•   Does asthma stop you achieving your goals?
•   3 asthma goals
•   Can you achieve your asthma goals?