Participant characteristics
Thirty participants, including 15 nurses and HCAs who delivered PRIMROSE (from 31 approached) and 15 patients with SMI who received it (from 30 approached), took part in the current study. Six patients did not give a reason for not wanting to take part, however other reasons included inability to gain contact (n=3) and not feeling well enough to take part (n=2) Nine staff did not respond to the invitation to take part and reasons for non-participation included: not interested (n=3), lack of time (n=2) and not yet finished delivering the intervention (n=2)
The characteristics of staff are presented in Table 2 compared to the characteristics of the staff delivering PRIMROSE. The sample comprised of both practice nurses and HCAs of different age ranges (25-65 years) with varying degrees of professional experience (from 1 to 30 years). Staff were all White British ethnicity and female. Most staff were previously not involved in research. The sample in the present qualitative sample were mostly comparable to the rest of the staff delivering PRIMROSE in terms of age, length of experience and previous research experience, but did not capture the perspectives of the few ethnic minority groups, male participants, those delivering 0-1 or 26-35 PRIMROSE intervention appointments or the only GP delivering PRIMROSE.
Table 2. Staff characteristics in the qualitative sample compared to the characteristics of staff delivering PRIMROSE
Characteristics
|
Qualitative Staff sample
(n=15)
|
All PRIMROSE Staff
(n=41)
|
Age group
<25
25-35
36-45
46-55
56-65
|
-
3
1
7
4
|
1
8
9
15
8
|
Gender
Female
Male
|
15
-
|
39
2
|
Ethnicity
White British
White Other
Asian Other
|
15
-
-
|
36
3
2
|
Provider role
Healthcare Assistant
Practice Nurse
Research Nurse
GP
|
6
7
2
-
|
22
15
3
1
|
Length of experience
as a nurse/HCA
(years, months)
<1 year
1 to 2 years
3 to 5 years
6 to 10 years
11 to 15
16 to 20
21 to 30
Unknown
|
-
1
3
4
2
1
4
-
|
1
4
9
10
5
6
5
1
|
Previous experience
of research
Yes
No
|
6
9
|
16
25
|
Number of PRIMROSE intervention appointments delivered
0-1
2-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
|
-
1
1
2
2
3
-
-
1
3
1
1
|
2
3
6
5
8
4
1
2
1
4
1
2
|
The characteristics of the patient sample are in Table 3 compared to the characteristics of the rest of the intervention patients. The sample comprised of participants who were diagnosed with either bipolar disorder or schizophrenia. The age of patients ranged from 30 to 70 years. Patients were mostly male and White ethnicity. The characteristics of the patient sample were similar to those in the overall sample in terms of gender, age group and diagnosis. However, the sample did not capture the perspectives of the few ethnic minority groups in PRIMROSE, the minority of those that were separated, divorced or widowed as well as those that received either 0 or 1 PRIMROSE intervention appointment.
Table 3. Patient characteristics compared to the characteristics of the patient intervention sample
Characteristics
|
Qualitative patient
Sample
(n=15)
|
All patients allocated to the PRIMROSE intervention
(n=155)
|
Gender
Male
Female
|
9
6
|
67
88
|
Age group
30-39
40-49
50-59
60-69
70+
|
2
4
3
4
2
|
25
48
38
31
12
|
Marital Status
Single
Married or cohabiting
Separated or divorced
Widowed
|
8
7
-
-
|
66
59
25
4
|
Ethnicity
White
Black
Asian
Other
|
13
-
2
-
|
134
11
5
4
|
Diagnosis
Schizophrenia/ schizo-affective disorder
Bipolar affective disorder
Other Psychosis
|
6
7
2
|
54
71
30
|
Number of PRIMROSE intervention
appointments attended
(over 6 months)
0
1
2-5
6+
|
-
-
3
12
|
32
15
36
72
|
Findings
The themes derived from the data are provided in Table 4. These are presented alongside the NPT constructs that themes were mapped to. The themes were discussed with specific reference to, and organised by, the NPT constructs in the written presentation of findings. Some themes mapped on to more than one NPT construct. In these instances, the relevance of the theme regarding different NPT constructs were discussed within each NPT heading. When comparing themes across staff and patients, it was apparent that in some cases themes arose in both staff and patient interviews but in other cases may have arisen only in staff or patient interviews.
Table 4. Inductively derived themes mapped to NPT constructs
Themes identified in the raw data
|
Broad theme/NPT constructs
|
Clarity of purpose
|
Coherence
|
Value of intervention
|
Coherence
|
Mental health stigma
|
Cognitive participation
|
Confidence to engage
|
Skill-set workability (Collective action)
|
Motivation to engage
|
Cognitive participation
|
Compatibility with existing practice
|
Cognitive participation
Interactional workability
|
Accessibility of intervention
|
Interactional workability
|
Engagement with intervention
|
Interactional workability (Collective action)
|
Intervention materials
|
Interactional workability (Collective action
|
Resource availability and benefits
|
Contextual integration (Collective action)
Reflexive monitoring
|
The level of ‘in-house’ support
|
Relational integration (Collective action)
|
Patient – staff alliance
|
Relational integration (Collective action)
|
Knowledge
|
Skill-set workability (Collective action)
|
Training
|
Skill-set workability (Collective action)
|
Skills
|
Skill-set workability (Collective action)
|
Modifiability through accessibility
|
Reflexive monitoring
|
1. Coherence
The intervention was mostly perceived by patients as coherent in terms of the aim of the intervention. Both staff and patients reported a shared understanding of the benefits of the intervention.
1a. Clarity of purpose
A common theme among patients was a clear understanding of the purpose of the intervention, acknowledging the focus on health improvement in people with SMI to reduce CVD risk. Patients reported that their understanding was facilitated by staff who provided relevant information sheets and explained the purpose.
“…I thought it was to get an insight into how I was going from time to time, seeing people you know, getting weighed, taking blood pressure and things like that …I got the original pamphlet and I read that and that kind of told me everything I wanted to know.” (Patient 12, female, 70’s)
An atypical view among patients was confusion regarding the purpose of the intervention. One patient believed that the intervention was designed to improve mental health outcomes rather than physical health. The lack of understanding appeared to be caused by the GP’s description of the intervention.
“As I understood it, it was basically, with early intervention, or regular intervention, by your local GP practice, the nurse, normally, then it can offer stability and assistance so people like myself don’t relapse... I was approached by the GP practice, basically saying, would I be happy to take part in a project related to mental health.” (Patient 81, male, 60’s)
1b. Value of intervention
The intervention was perceived as valuable by patients and staff. Staff reported that they understood the intervention could prevent patients from experiencing later health problems and increase quality of life, as well as reduce financial burden for future health services.
“I think it would benefit people. Because it's a positive thing, and it's working towards improving people's health and their lifestyles.” (Staff 8, Nurse, 50’s)
A common theme among patients was that the intervention would provide an opportunity to make changes and improvements to their health.
“I thought it would be a good idea to just look at my healthcare and try and make some necessary adjustments so that my health can be improved…” (Patient 112, female, 50’s)
2. Cognitive participation
Although most staff and patients understood the purpose and value of the intervention (i.e. coherence), the extent to which staff were cognitively willing to participate, engage and commit to the intervention varied. Stigma surrounding perceptions of people with SMI in some cases resulted in negative perceptions among staff of their ability to implement the intervention. In some cases, an understanding (i.e. coherence) of the value of the intervention in terms of helping patients become healthier, motivated staff to deliver the intervention. In other cases, difficulties arising from the contextual environment (collective action/contextual integration) affected cognitive participation.
2a. Mental health stigma
Staff held different views regarding their preconceptions of mental health. There were some prior concerns regarding working with people with SMI. Some staff anticipated problems around the impact of mental health symptoms on attendance and engagement difficulties.
“We can deal with somebody with diabetes and all of that, and we can tell them this, that and the other, but somebody with mental health, when they’ve got that problem they may not have that understanding. They may not engage for a long period of time. It’s really very difficult… I prefer people who can engage with me.” (Staff 5, Nurse, 40’s)
However, other staff felt positive about working with patients with SMI and in some cases prior experience within nursing roles enabled staff to feel open toward delivering the intervention.
“I think you have to be open-minded, as a nurse, to be a good nurse. So I wasn’t intimidated at all, initially” (Staff 4, HCA, 50’s)
2b. Motivation to engage
Despite some negative attitudes towards mental illness in some individuals, it was clear that most staff had the motivation and desire to help patients achieve their goals and therefore engage with the intervention. This appeared to stem from the understanding of the its purpose and potential benefits (i.e. coherence).
“I think probably knowing that you could be a part of helping them, I think that probably influenced us as well, and knowing that if you just gave them that little bit of help then they could improve. I think that’s probably the motivation in that.” (Staff 15, Nurse, 60’s)
2c. Compatibility with existing practice
Some issues related to cognitive participation were also underpinned by difficulties related to contextual integration (discussed later). Some staff questioned the applicability of the intervention to real-world contexts (cognitive participation) and suggested that the intervention would not fit in within a busy GP practice which subsequently affected their willingness to deliver the intervention going forward.
“I'm not sure how it would fit in easily in a surgery that's already quite packed. We've got ever-growing lists, so whether it could be done in more of a mental health environment, it may be more appropriate…” (Staff 13, Nurse, 30’s)
3. Collective action
Several barriers surrounding the work that was needed to facilitate delivery of the intervention were identified. There were some problems related to interactional workability, contextual integration, skill-set workability and, in some cases, relational integration.
3.1 Interactional workability
A typical theme was that staff made substantial efforts to encourage patient engagement by facilitating accessibility to the intervention. This finding was also reported by patients, and staff arranged appointments to suit their preferences. However, staff faced barriers regarding patient engagement. Additionally, both staff and patients found some of the intervention written materials including the use of written health plans, difficult and time-consuming to implement. However, patients expressed mixed views about the use of health plans. It was also difficult to operationalise the intervention into routine practice due to the need for adequate time to facilitate engagement and accessibility.
3.1a. Accessibility of intervention
Staff acknowledged that intervention appointments would sometimes take longer than the time they had available. Difficulties were centred mainly on fitting appointments around additional responsibilities. Despite these difficulties however, staff demonstrated flexibility and scheduled appointments accordingly to increase accessibility.
“Something, finding slots when we’re so busy, that, that would be a thing as well, so sometimes you think to yourself, well, you know, this patient needs extra time, but actually we haven’t got a slot…to fit her in” (Staff 1, HCA, 40’s)
The flexibility in scheduling appointments was also reported by patients who suggested that staff would arrange appointments when it would suit them and were understanding even if patients did not attend.
“She suggested dates on the telephone, and sometimes I would phone and say, I’m not available on that day, so an alternative appointment was made, so it had to be mutually convenient for both of us. Obviously, she has other jobs... in the surgery to do as well, so it had to be convenient for her as well.” (Patient 112, female, 50’s)
3.1b. Engagement with intervention
Despite attempts to make the intervention accessible to patients through flexible appointment scheduling, staff reported difficulties related to patient attendance. Staff commonly reported being disappointed when patients were disengaged from the intervention given the time invested to facilitate accessibility.
“…it was the patients that didn’t come. You just get frustrated; you put all of this time and effort into the first appointment and then you never saw them again.” (Staff 10, Nurse, 40’s)
3.1c. Intervention materials
Staff reported that the materials designed for the intervention including the health plans, in some cases acted as barriers to providing the intervention. Some staff reported that patients sometimes struggled in terms of understanding and completing the required documentation and reported it was time-consuming and negatively impacted on the consultation process.
“I think using the book for something like that, you do need a lot of time to go through it with them…I think maybe the book made it feel too formulized… I don’t find that book a very easy layout so I think that was almost a stumbling block. Maybe I didn’t understand the book particularly and the patients didn’t particularly find it helpful” (Staff 11, Nurse, 60’s)
Patients’ views regarding the value of health plans were mixed. Some patients reported that they were sometimes problematic to use in practice. It was suggested that documents were repetitive and were sometimes difficult to fill in. Conversely, others reported that the health plans helped them keep track of the changes they had made.
“That was okay. A bit repetitive at times because, you know, you were... obviously, the food for four weeks, you tended to be writing a little bit of the same thing…” (Patient 9, female, 50’s)
“... That booklet or a personal diary would help, because sometimes you can’t remember exactly what have you done a week ago, two weeks ago, so it’s good to write down some notes. But it’s difficult sometimes. One of the difficulties, I found it’s difficult to do it on the day sometimes.” (Patient 112, female, 50’s)
3.1d. Compatibility with existing practice
A typical theme among staff was that they were concerned about patient engagement issues with intervention appointment attendance. As a result, they suggested that the practicalities of getting patients with SMI to engage within a GP practice would be difficult. They also suggested there would be a need for additional nurse time to facilitate engagement and accessibility. However, the availability of additional nurse time was questionable.
“I think if we were going to deliver that care in that format and at that intensity, I think it would be quite difficult. Not so much the face-to-face time, but certainly the getting people in... Ringing them once wasn’t a problem, just ringing them again and again…if that was going to be part of how we would deliver the care, that could provide difficulties if it was down to me” (Staff 10, Nurse, 40’s)
The difference between GP and intervention appointments was further highlighted by patients. Patients expressed that more time was available in intervention appointments with care that felt holistic compared to GP appointments. However, this perception may have been influenced by the fact that patients were aware that the care they were receiving were part of an intervention and not usual care.
“This was totally different. This is very patient-centred… From my view is that it’s very much based on a holistic approach of the patient. So it’s patient-centric and in looking at everything whereas a normal GP appointment is five minutes and it’s transactional…” (Patient 17, male, 40’s)
One staff member questioned the structured nature of the intervention and reported that it sometimes felt unnatural.
“…we need to follow these questions and we need to do it this way, but that’s not real life and that’s not how we would speak to our ordinary patients that don’t have a mental health illness… you had to follow this stream of questioning, and that didn’t work…It wasn’t comfortable because that’s not the normal of working….” (Staff 5, Nurse, 40’s)
3.2 Relational integration
Relationships between practice staff and staff delivering the intervention and patients were considered as important in the implementation of the intervention. The availability of team support within some practices facilitated intervention delivery, whilst the lack of availability hindered progress. A positive relationship between patient and staff members encouraged confidence and trust in staff members to deliver the intervention.
3.2a.The level of ‘in-house’ support
Staff suggested that they required support from team members within practices to deliver the intervention. There was a need for access to health advice for difficult cases when staff were unsure. However, there was a variation between the level of teamwork within different practices to facilitate intervention delivery. This sometimes acted as a barrier to providing the intervention, particularly in cases where permission was required for prescribing medications and senior staff members were unavailable.
“I did feel as if I was on my own a little bit in the surgery… There was just not support as in, I’m worried about this patient, but it was maybe just reading consultation notes, that sort of thing.” (Staff 10, Nurse, 40’s)
The differences between team working across different practices were apparent when other staff reported that senior members within their practice were willing to provide advice regarding patients, which facilitated intervention delivery.
“I’ve always got backup. I wouldn’t have hesitation in asking any of the senior and the qualified staff. I think that we’ve got the backup here to do a really good job” (Staff 14, Nurse, 50’s)
3.2b. Patient – staff alliance
It was apparent that some patients and staff had formed close therapeutic relationships. Staff were aware that in order to ensure that patients felt comfortable engaging with the intervention, and instil confidence in their ability of providing it, it was important to establish connections with patients.
“Making them feel comfortable by making a relationship with them to start with… And that is making a relationship with them to come back and encouraging them in their own way.” (Staff 11, Nurse, 60’s)
As a result of the relationships patients had formed with staff, most patients felt positive about interacting with staff and found that this increased their willingness to engage with the intervention.
“…we had quite a good relationship, she’s very supportive and I think she understood about me personally, obviously having my medical record, that it was the medication that stopped me losing weight ....” (Patient 12, female, 70’s)
3.3 Skill set workability
Staff knowledge regarding mental health were both barriers and facilitators to intervention delivery. Most staff appeared knowledgeable regarding physical health. Once staff had received the PRIMROSE study intervention training, it was clear that they developed valuable skills that aided intervention delivery.
3.3a. Knowledge
A common theme was that staff reported a lack of experience working with patients with mental health problems resulting in a lack of knowledge in this area. As a result, they felt anxious about delivering the intervention. One staff member suggested that the intervention was not in keeping with her knowledge and therefore it would be more appropriate that patients were seen in mental health settings.
“I just think better in a mental health environment, with the nurses that already have that knowledge of conditions. Because they were very limited on what knowledge we do know about mental health.” (Staff 13, Nurse, 30’s).
This theme was atypical among patients but demonstrated that patients had noticed that staff appeared to be lacking in confidence providing the intervention.
“… she was kind of paddling in the dark to some degree… the impression I got is that, you know, she was just given a pile of information and she had to do her best to interpret…” (Patient 81, male, 60’s)
In contrast, staff with prior experience with mental health patients were more knowledgeable about interacting with people with mental health and less anxious delivering the intervention. In some cases, this prior experience facilitated their knowledge on delivering the intervention to this population.
“Maybe I was using the tools and the skills I used for really poorly mentally ill patients that were having to be put on a ward for their own safety.” (Staff 14, Nurse, 50’s)
Whilst there was a mixture of staff that had knowledge of mental health, it was clear that most staff had some form of knowledge of physical health as a result of their prior experience.
“… I do the NHS health checks here, if their risk is high and their total cholesterol is high or their ratio is high, I will actually go and initiate a start on the total statin 20mg…if the patient was coming to me wanting to lower their cholesterol or lower their blood pressure, then I have the tools that I can, advise them on that” (Staff 14, Nurse, 50’s)
3.3b. Training
A common theme reported among staff was that the training delivered prior to the intervention was essential in increasing their knowledge of how the intervention could be delivered. In most cases staff reported that the training increased their confidence and prepared them in terms of how to engage with people with SMI.
“…the training you gave us was amazing, very helpful, I wouldn’t have been able to do it without it, just as a background of the different illnesses and going back to basics for us…And also we had some training on communication and body language and things like that, which was a good refresher, because you forget.” (Staff 2, HCA, 50’s)
However, not all patients believed that staff had been trained adequately. One patient felt that HCAs had less training and were consequently unable to deliver the intervention and staff commonly suggested further training would be beneficial
“We had to use Health Care Assistants, who maybe didn’t have quite as much training…” (Patient 17, male, 40’s).
“… it seemed to sort of suit what we had to do but, like you say, perhaps something in the interim would be good” (Staff 12, HCA, 30’s)
3.3c. Skills
Patients reported on the skills that staff members used when delivering the intervention. It was evident that staff provided advice when necessary, displayed patience when interacting with patients, were clear, encouraging and positive.
“…sometimes I wasn’t sure, but then <practice nurse> would kind of give me a bit of hand with ideas, and then we’d kind of come up with it together…it was good….” (Patient 6, female, 30’s)
This in some cases was reinforced by staff who commonly reported attempts to make appointments engaging by interacting with patients and providing guidance when required.
“…when a patient comes in, I try to make it as much fun as possible as well, because doing that... it makes it more comfortable for the patient, I think.” (Staff 1, HCA, 40’s)
3.4 Contextual integration
The integration of the intervention into practice contexts contained challenges., Resources including time were required to successfully implement the intervention and the availability and time taken to identify this in some cases acted as a barrier to delivering the intervention.
3.4a. Resource availability and benefits
Staff described that one of the main intervention functions involved searching for available local services that patients could be referred to for additional support in reducing physical health problems. However, one of the barriers to implementing the intervention was finding the time required to look for such resources as well as the lack of availability of local services.
“…part of the Primrose it was to look what was available in the area, and to be perfectly honest I didn’t have time. We did some of it but you just don’t… you haven’t always got time to sit and read through a directory of things and see what’s around in the city.” (Staff 5, Nurse, 40’s)
The need for external resources to implement the intervention was highlighted where staff had successfully located resources. They suggested that this facilitated easier access to resources which appeared to help patients achieve specific health goals.
“Another person was referred to a dietician. As I said, that was in regard to his cholesterol, and he was referred to a specialist, as well. And I think that probably happened a bit more quickly than it might have done… I think we’re quite lucky, out here, that you can refer people on different groups, clubs…” (Staff 4, HCA, 50’s)
4. Reflexive monitoring
). When evaluating ways to adapt the intervention, it was suggested that there was a need for a PRIMROSE designated clinic within future practices and technology to make the intervention more workable.
4a. Modifiability through accessibility
As apparent in interactional workability (accessibility), staff made necessary adjustments to fit intervention appointments into routine practice in settings where time was limited. Some staff suggested that a designated timeslot could be developed for patients within GP surgeries to better integrate the intervention and allow more time for appointments.
“…rather than have the appointments scattered, have an actual little clinic for it, and then let, let people know what day that you’re running and to come in…” (Staff 1, HCA, 40’s)
4b. Resource availability and benefits
Some patients suggested that there was a need for current digital technology in order to track their progress during the intervention. However, the intervention did not facilitate access to these types of tools, and GP practices in routine settings do not have access to such facilities.
“I have an apple iPhone and I track my weight and my BMI and my measurements on my phone. And I would have liked something like that could have tracked it, not necessarily that it was always on paper.” (Patient 17, male, 40’s)