Patient and provider perspectives of a self-management program for COPD in the context of multimorbidity: a qualitative study

Abstract

Background

Chronic obstructive pulmonary disease (COPD) is often associated with comorbidities, which further complicates the impact of the disease. However, most self-management support for COPD do not account for patients’ comorbidities. This study is the qualitative evaluation of a novel self-management program for people with COPD in the context of multimorbidity, delivered by practice nurses (PNs) in collaboration with general practitioners (GPs) in Sydney, Australia.

Methods

Semi-structured interviews were conducted with 12 patients, 10 PNs, and seven GPs. The interviews were thematically analysed using a constructivist approach, and further interpreted through the Normalisation Process Theory.

Results

Most patients accepted the program and perceived it as beneficial. Facilitators towards better activation were personalised care and the PNs’ counselling approach during the program. Barriers to better health behaviour included personal challenges and comorbidities. Overall, the PNs and GPs found the program to be feasible and beneficial for participating patients. The PNs felt upskilled about COPD, and confident for delivering self-management support, following participation in the study. The main challenge faced by them were managing their existing workload alongside the education sessions.

Conclusions

The findings emphasise the need for tailored, self-management support for people with COPD and comorbidities, and upskilling of the PN’s role in general practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-025-03077-5.

Background

Chronic obstructive pulmonary disease (COPD) was the fourth leading cause of death globally in 2021 [1], and the fifth leading cause of death in Australia in 2023 [2]. COPD frequently occurs in the context of multimorbidity contributing to increased mortality, healthcare utilisation, and reduced quality of life [3, 4]. Furthermore, people with COPD and comorbidities often have difficulty recognising the importance of the disease and its implications [5]. Prior research has shown self-management support to improve quality of life and self-efficacy in people with COPD, highlighting the need for a biopsychosocial perspective to such interventions [6]. However, effective management of the disease by primary care providers has always been a challenge due to psychological barriers including stigma and fear of judgement [7].

Effective self-management is challenged by patient-level factors including individual context, and COPD knowledge and understanding [8]. Self-management support for COPD are substantially heterogenous; there has been limited insight into the perspectives of patients receiving, and healthcare providers delivering, such programs, with a key feature of these interventions being nurse involvement [9]. In Australia, practice nurses (PNs) are increasingly contributing to chronic disease management and care coordination of patients with COPD in primary care, which could lead to significant uptake of pulmonary rehabilitation and other relevant healthcare services [10]. There is a lack of effective self-management support for COPD in primary care that specifically recognise the implications of comorbidities and patient’s motivation and skills in a psychosocial context.

The authors (SA, HH, SD and NZ) developed, implemented and evaluated a global-first, PN-delivered, tailored, self-management program for COPD in the context of patients’ multimorbidity [11]. The complex program comprised multiple components including COPD knowledge; self-management strategies such as COPD Action Plan, referral to pulmonary rehabilitation, inhaler device technique, medication adherence and vaccination; strategies to cope with multimorbidity and smoking cessation. The PNs were trained to deliver the program in three one-to-one health coaching sessions followed by monthly follow-up calls for six months. The single-arm pilot trial, titled the Activating Primary Care COPD Patients with Multimorbidity (APCOM) study, was conducted in general practices across Sydney, Australia. The quantitative findings of the study can be found elsewhere; in brief, there were significant improvements in patient activation, COPD knowledge, COPD-related quality of life and accuracy of inhaler device technique at six months’ follow-up following the self-management program [12].

This paper describes the qualitative evaluation of the APCOM Program through post-study interviews conducted with participating patients, PNs and general practitioners (GPs). The aim of these semi-structured interviews was to gain their perspectives on the acceptability, feasibility and sustainability of the program.

Methods

The study was approved by the Human Research Ethics Committee of UNSW Sydney (HREC14139). Written informed consent was obtained from the participants prior to each interview, and their permission was sought before commencement of the audio recordings.

Participant recruitment

All PNs who actively participated in the APCOM study were invited by email to participate in the interviews; GPs were also invited for the interviews given their supportive role in delivery of the self-management program. Patient participants were recruited from among the patients who completed six months’ follow-up data collection; recruitment continued until data saturation was achieved. Maximum variation type of purposeful sampling [13] was performed based on patients’ age, sex, general practice, social support, employment status, level of education, number of health coaching sessions completed, comorbidity count and change in their Patient Activation Measure [14] (PAM) score between baseline and six months’ follow-up.

Data collection

Participating PNs and GPs were interviewed face-to-face by SA at their general practice as it was most convenient for them. Participating patients were interviewed by MK via telephone at a mutually convenient time; this method of data collection was more suitable for patient interviews due to their widespread location across the Sydney region. The interviews were conversational in nature and guided by semi-structured interview guides (Supplements 1, 2 and 3). SA and MK were not involved in healthcare delivery to the participating patients, nor did they work with any of the participating healthcare providers. Since development of the APCOM Program was based on the Health Belief Model (HBM) [15], and its implementation was in accordance with the Normalisation Process Theory (NPT) [16], tenets of the HBM and NPT were incorporated into the interview guides for patients and providers, respectively.

Data analysis

All interview recordings were professionally transcribed, and interview transcripts were cross checked against the audio recordings by SA to ensure accuracy and consistency of the data. The transcripts were managed and coded using NVivo version 11.0. After familiarisation with the interviews, coding of the transcripts was undertaken. The coding was initially descriptive and became more analytical as themes were identified. Following iterative coding, the data was analysed using a constructivist approach [17], in order to understand and interpret the findings beyond what was reported by the participants including relating to their demographics.

Although the resulting themes reflected the questions in the semi-structured interview guide, the data was not fitted into a preconceived coding framework; the interviews were coded line by line and assigned to appropriate themes and sub-themes as they were induced [18]. The parent codes were broken down into four sub-categories. After completion of the coding process, investigator triangulation [19] was done between SA, HH, SD and NZ to arrive at a consensus on the initial set of themes, following which the data was revisited many times by SA. The thematic framework was modified and eventually narrowed down to converge into the main themes from the interviews. Feedback on analyses and reporting of the provider interviews was sought from a qualitative research expert at the University of New South Wales.

Results

Patient interviews

A total of 12 patient participants were interviewed. Data from these interviews was considered to be sufficient, as it was evident after listening to the interview recordings that saturation had been attained by the 11th interview. The participants’ demographic characteristics have been summarised in Table 1.

Table 1.

Demographics of patient participants

No.	Gender	Age	Living status	Employment status	Level of education	Time since COPD diagnosis	GOLD stage	Pulmonary Rehabilitation attendance	Smoking status	Number of comorbidities	Sessions attended with PN	Change in PAM score at 6 months’ follow-up
1	Male	64	Lives alone	Retired	Attended some high school	2 years 11 months	2	No	Ex-smoker	1	3	No change within stage 2
2	Female	63	Lives alone	Employed part-time	Tertiary educated	9 years 6 months	3	Yes	Ex-smoker	7	3	Increased within stage 4
3	Female	66	Lives alone	Retired	Tertiary educated	1 year 11 months	1	No	Quit during program	8	3	Increased from stage 1 to 4
4	Male	80	Lives alone	Employed part-time	Vocational training	8 years 10 months	1	Yes	Resumed during program	13	3	Decreased from stage 3 to 2
5	Male	60	Lives with partner	Unemployed	Attended some high school	1 year 8 months	Unknown	Yes	Ex-smoker	10	0	Decreased from stage 4 to 3
6	Female	70	Lives with partner	Retired	Vocational training	5 years 9 months	Unknown	Yes	Ex-smoker	6	3	Increased from stage 2 to 4
7	Male	57	Lives alone	Employed full-time	Tertiary educated	5 years 7 months	1	No	Ex-smoker	9	3	Increased from stage 2 to 3
8	Female	58	Lives alone	Carer	Attended some high school	10 years 1 month	1	No	Ex-smoker	5	3	Increased within stage 4
9	Male	77	Lives alone	Retired	Completed high school	4 years 10 months	1	No	Ex-smoker	1	3	Increased from stage 1 to 2
10	Female	76	Lives alone	Retired	Attended some high school	1 year 3 months	2	No	Ex-smoker	5	3	No change within stage 2
11	Male	67	Lives with partner	Retired	Tertiary educated	1 year 1 month	2	Yes	Ex-smoker	13	3	Increased within stage 4
12	Male	68	Lives with children	Retired	Attended some high school	11 years 6 months	1	No	Ex-smoker	9	3	Increased from stage 3 to 4

Fourteen sub-themes were induced from the interviews, which were categorised under five core themes (Table 2).

Table 2.

Themes from patient interviews

Core theme	Sub-themes
1. Change in overall health behaviour	i) Medication adherence ii) Perception of COPD iii) Lifestyle modification iv) Self-efficacy
2. Factors influencing patient activation	i) Comorbidities ii) Personal stressors iii) Resistance to change
3. Experience of the program	i) Personalised care ii) Motivational interviewing
4. Feedback on the program	i) Educational resources ii) Cues to action iii) Suggestions
5. Feasibility and sustainability of the program	i) Alternate venue and educator ii) Recommendation to others

1. Change in overall health behaviour

• i)Medication adherence: The program improved patient compliance with their prescribed inhaler and medication regime and made them recognise that they had not been performing their inhaler technique properly. They found that the correct technique led to less inconvenience caused by DPIs (dry-powder inhalers).
• ii)Perception of COPD: The program enhanced patients’ awareness about COPD and its impact upon their health, leading to lesser breathlessness and exacerbations due to improved health behaviour. They felt that they learnt more about the nature and implications of COPD during the education sessions.
• iii)Lifestyle modification: Some patients had an improvement in their lifestyle following the program, including increased physical activity, reduced alcohol intake, being more mindful about their diet, and becoming aware of potential environmental triggers that could exacerbate their COPD.
• iv)Self-efficacy: Most patients became more mindful about continuing their improved health behaviour. Two patients reported improved coping with mental health concerns. One patient was able to return to their medication and diet regime despite major surgery following completion of the program, as a result of increased confidence to keep up health behaviours. For two patients who were ex-smokers, the program reinforced the benefits of smoking cessation and validated their decision.

I’ve got to see my GP about it and take the medication correctly and use the puffer correctly, because if I don’t, then it’s going to affect my health. So yes, it did instil in me how serious it (COPD) is – P11.

2. Factors influencing patient activation

• i)Comorbidities: The presence of comorbidities, including depression and anxiety, was an important factor that affected patients’ engagement with the program’s sessions and its components, and their self-efficacy. Three patients mentioned that another chronic condition was dominant in their daily lives, with one patient finding the program not beneficial as their comorbidities affected their life more than COPD, and one patient not attending any sessions due to their comorbidities.

I’ve got bigger problems, much bigger problems than breathing problems…they’re permanent problems, I’m not going to get rid of them – P10.

• ii)Personal stressors: Challenges faced in their personal life had varied implications towards activation for different patients. One patient resumed cigarette smoking during the program after a relationship separation. However, being the main carer for their child encouraged one patient to take their PN’s advice and commence pulmonary rehabilitation. Another patient who was a carer for their child relied on faith, positive thinking and exercise to aid with coping of their multiple chronic conditions.
• iii)Resistance to change: A patient who was an ex-smoker was frustrated when their PN talked about smoking being the main cause of their COPD as they considered prolonged exposure to asbestos earlier in life and being obese affecting their lung disease and breathlessness. Another patient felt that the education sessions, although interesting, did not give them new knowledge about COPD as they considered their lived experience provided them good awareness. Underlying resistance to change might have deterred one patient from attending any of the education sessions with their PN.

3. Experience of the program

• i)Personalised care: The patients were receptive to the tailored information provided by their PNs during the program, commending their PN’s demeanour and supportive nature. Three patients with long-term diagnoses of COPD, reported the program provided new information on COPD. The patients appreciated the individual attention and care beyond routine consultations during the one-to-one sessions with their PN. Both male and female patients thought their PN being female was a positive factor.
• ii)Motivational interviewing: Some patients appreciated the counselling style of their PNs during the sessions which promoted collaborative decision-making. One patient, despite struggling for many years, quit smoking at the end of the program with the PN’s motivation and increased understanding of the threat of COPD.

They (the PN) just basically eased me into how to do things…They were using all positive thoughts; they weren’t using any negatives – P3.

4. Feedback on the program

• i)Educational resources: Most patients found the pictures and videos of the program to be very useful, particularly the videos on proper inhaler device technique. Patients with lower levels of education and computer literacy had lesser utilisation of the educational resources. One patient mentioned that the resources helped refresh knowledge gained from the sessions with their PN. Some patients felt that although being guided to the educational resources by their PN was helpful, they did not need further information, mainly because of the information provided during the health coaching sessions.
• ii)Cues to action: Patients had mixed opinions as to whether the motivational fridge magnet acted as a helpful prompt for changing health behaviour. Most completed the daily reflection logs in between sessions with their PNs and found them to be good reminders of the program but one patient found it difficult to complete them due to their repetitive nature. In contrast, another patient felt that the repetition made them more conscious about taking their prescribed medicine. Patients appreciated the monthly phone calls from their PNs, where the positive reinforcement about their health behaviour through the phone calls and the continuity of care improved their self-efficacy.

  I think the good thing about it (the program) is that it keeps you aware and it makes you not get too complacent. - P6.

• iii)Suggestions: Three patients felt that there was too much paperwork for completing the study questionnaires at baseline and post-test, and one patient felt frustrated with the repetitive nature of some questions. Suggestions included more telephone communication during the program to reduce in-person visits, and group sessions with PNs for similar conditions.

5. Feasibility and sustainability of the program

• i)Alternate venue and educator: Eleven patients attended all three education sessions of the program with their PN. All felt it was convenient to attend the education sessions at their general practice, possibly because they were familiar with the location. Five patients lived within a walkable distance, four used public transport and three drove to their practice. When asked if they would have attended the program at alternate venues, as compared to the practice, seven patients answered affirmatively. Two were unsure and three would not have attended due to inaccessibility and unfamiliarity. Most patients were amenable to the program being delivered by a different educator.
• ii)Recommendation to others: Irrespective of their own uptake of the program, the patients were positive about recommending it to others who might benefit from it. One patient shared some of the knowledge gained from the program with a friend who had COPD.

Absolutely − 100% - because there are people worse than me that have no idea…They definitely should go through this program because this program is not wasted, this is something very, very necessary for people - P9.

PN interviews

Ten PNs from 10 general practices, who were involved in delivery of the APCOM Program, participated in the post-study interviews. Demographics of the PNs, all female, are presented in Table 3. Following analysis of the interviews, 14 sub-themes were induced, which were categorised under five core themes (Table 4).

Table 3.

PN demographics

No.	Age (years)	Time in general practice (years)	Number of patients managed during the study	Number of patients who attended the program	Work pattern at the practice	Prior participation in research	Practice type
1	29	1	7	5	Part-time	No	Solo
2	45	3.5	6	3	Part-time	Yes	Solo
3	57	26	5	4	Full-time	Yes	Solo
4	45	5	5	5	Full-time	No	Solo
5	45	1	6	5	Part-time	No	Group
6	27	2.5	6	5	Full-time	Yes	Group
7	39	6	6	5	Part-time	No	Solo
8	64	6	4	4	Full-time	Yes	Group
9	49	9	2	2	Part-time	Yes	Group
10	50	6	3	3	Part-time	No	Group

Table 4.

Themes from PN interviews

Core theme	Sub-themes
1. PN’s experience of the program	i) Enhanced professional skills and satisfaction ii) Better rapport with patients and GPs iii) Value of self-management support sessions
2. Barriers to delivering the program	i) Time constraints ii) Influence of comorbidities iii) Lack of support from GPs iv) Logistics of program delivery
3. Facilitators to delivering the program	i) Support from practice staff ii) Support from research facilitator iii) Patients’ enthusiasm
4. Feasibility and sustainability of the program	i) Incorporation of the program into existing practice ii) Delivery of health education by PNs
5. Feedback on the program	i) Structure and content ii) Suggestions for refining the program

1. PNs’ experience of the program

• i)Enhancing professional skills and satisfaction: The PNs found that participating in the study enhanced their awareness and skills in care of COPD, irrespective of prior experience. They perceived their involvement in the study to be worthwhile and were satisfied about achieving better health outcomes for some participating patients, particularly PNs who participated in research for the first time.
• ii)Better rapport with patients and GPs: Some PNs felt that delivering the program improved their communication and rapport with patients, and they became better equipped at discussing their patients’ COPD and other health conditions.
• iii)Value of self-management support sessions: Delivering the program made PNs appreciate the importance of personalised self-management support and the intricacies of chronic disease management.

Looking at not just COPD but their other chronic illnesses, and how they link together to actually work best for the patients, and with their GPs and have them put on their action plans so they know what to do when they get sick, and so we can assist them to prevent them going to hospital – PN4.

2. Barriers to delivering the program

• i)Time constraints: The main challenge for the PNs was to schedule appointments with patients and to incorporate the education sessions into their existing work regime, with PNs becoming overwhelmed by the workload at some points.
• ii)Influence of comorbidities: Patients’ comorbidities hampered progress made during the study and affected their attendance of the program, which they reported to their PNs. Three PNs felt frustrated due to lack of progress by some patients because of the burden of their multimorbidity.
• iii)Lack of support from GPs: Some PNs felt that they did not receive support from the GPs in their practice, in signing off the patients’ COPD Action Plan and recruiting eligible patients and conducting the self-management support sessions.
• iv)Logistics of program delivery: Some practices did not have speakers on their computers, which hindered some elements of program delivery, such as inhaler device technique videos.

Time is the biggest factor and you probably get that with everything, time is always an issue – PN7.

3. Facilitators to delivering the program

• i)Support from practice staff: All PNs believed that their practice provided adequate organisational support for delivering the program including access to a consultation room for patient education sessions, irrespective of how busy the practice was at a given time. Most PNs felt that support from the GPs was particularly important, for collaboratively drawing up COPD Action Plans and reviewing the patients’ medication.

Everyone was very supportive. With our appointments, we were able just to basically block off an appointment for that particular patient and just fit it in with our day – PN9.

• ii)Support from research facilitator: The PNs felt that ongoing guidance from the study coordinator (SA) throughout the program was helpful, especially at the onset of the education sessions. They also found the guidelines provided for program delivery beneficial.
• iii)Patients’ enthusiasm: For some PNs, the patients’ enthusiasm and willingness to learn was an incentive towards completing the program, especially when it was evident that there was improvement in the patient’s activation as the sessions progressed.

4. Feasibility and sustainability of the program

• i)Incorporation of the program into existing practice: Irrespective of the type of practice (solo or group), or the nature of their work pattern (full or part-time), all PNs successfully implemented and delivered the program to participating patients. Although the eventual number of patients managed by a PN was determined by their workload and patients’ interest in the study, the expected number of five patients per PN seemed feasible. As outlined in Table 3, seven PNs managed at least five patients and five of them delivered the program to five patients. When sessions did not take place as scheduled, PNs were mostly able to successfully reschedule sessions. All PNs were enthusiastic about continuing the program beyond the study and were confident that they could incorporate the program into their existing work schedule.

We (PNs) can give more time, unlike with a GP that they’re too busy seeing so many patients…we can go into details of what’s really going on with the patient and…prioritise which to address first – PN1.

Most PNs had transferred some program elements, such as inhaler technique and the COPD Action Plan, towards the care of other patients in their practice. They felt that self-management support was essential for chronic disease and should commence for patients shortly after confirmation of a COPD diagnosis.

• ii)Delivery of health education by PNs: The PNs felt that health education was part of their role in general practice, especially given the time pressures on GPs. They affirmed that, with initial training and the provision of guidelines, the program could be implemented sustainably in general practice.

5. Feedback on the program

• i)Structure and content: The PNs felt that the program was mostly simple, well-structured and organised, and understandable by them and the patients. They all benefited from the initial training and educational resources provided, which equipped them with confidence and direction for tailoring and delivering the program to patients.

While all PNs found the COPD Action Plan very useful, one PN felt that patients with advanced COPD would benefit more from it. Assessing and correcting patients’ inhaler device technique was considered vital by all. PNs with less experience felt that educating patients about their inhalers improved their own awareness about COPD medication.

• ii)Suggestions for refining the program: Some PNs felt that the assessment and planning template, used during the education sessions interfered with the motivational interviewing, due to the need to take notes. One PN suggested a checklist would be more convenient. Some PNs thought that the daily reflection logs, although a good point of reference for each session, were cumbersome.

The PNs thought that patient follow-up after sessions, while important, did not have to be communicated via telephone and could be in person, especially for patients who visited the practice regularly. A PN felt that the duration between follow-up phone calls should be dependent on individual patient health status and level of activation. Another PN felt that there should be more education sessions for the patients, as well as ongoing training for the PNs.

PNs’ suggestions for program content included providing patient handouts containing visual cues, having the research facilitator with them during the first patient education session, and training GPs to be actively involved in such programs. Developing such programs for other chronic diseases was also recommended.

I think there is an increase in chronic conditions generally and something has to be done to keep it all under control…If they (patients) can manage it first, then they’re going to prevent any sort of crisis situations – PN10.

One PN felt that the program would be more sustainable if there was allocation of government funding to practices for PN-delivered education.

GP interviews

Of the seven GPs representing the 12 practices that took part in the study, six participated in the post-study interviews. One GP could not be interviewed as they were on leave at the time of data collection. The GPs’ demographics are presented in Table 5. Ten sub-themes induced from analysis of the GP interviews were categorised under the following five core themes (Table 6).

Table 5.

GP demographics

No.	Sex	Age (years)	Time in general practice (years)	Practice type
1	F	51	21	Solo
2	M	33	3.5	Solo
3	M	61	30	Solo
4	M	61	30	Group
5	M	62	32	Group
6	M	52	24	Solo
7	F	64	30	Group

Table 6.

Themes from GP interviews

Core theme	Sub-themes
1. Recognition of the program	i) Perception of benefits ii) Significance of COPD in general practice
2. Improving quality of patient care	i) Interest in research and quality improvement ii) Self-management support
3. Role of the practice nurse	i) Upskilling of the PN ii) GP-PN collaboration
4. Feasibility and sustainability of the program	i) Practice organisation ii) Remuneration
5. Recommendations for the future	i) Upscaling of the program ii) Suggestions for practice

1. Recognition of the program

• i)Perception of benefits: All GPs felt that the program was well devised and highlighted the importance of tailored, individual education for COPD. They perceived that the study enhanced patient-provider communication and led to most participating patients having better health outcomes, awareness and coping skills for COPD, including one patient having considerably fewer COPD-related presentations since having participated in the study.
• ii)Significance of COPD in general practice: For most GPs, the study raised awareness of the need to monitor COPD and deliver preventative care to avert patients’ hospital admission or emergency department attendance.

If they (patients) don’t have acute attack you forget that they suffer from this chronic disease…you forget, you just forget – GP5.

2. Improving quality of patient care

• i)Interest in research and quality improvement: The GPs were keen about their practices being part of the program. They felt being involved in research, and resultant upskilling of the PNs, added to holistic care and better outcomes for their patients.

I think we all share an interest in doing good systematic care… how we can engage with patients to do things that they wouldn’t normally be offered that are beneficial to their health – GP3.

• ii)Self-management support: The importance of tailoring chronic disease management and education according to individual patient needs was recognised by most GPs. They also acknowledged that the patients’ comorbidities were a barrier to optimal management and prioritisation of COPD during their consultations, rendered more challenging by lack of time.

3. Role of the practice nurse

• i)Upskilling of PNs: Most GPs felt that it was important to upskill PNs to better support patients’ self-management of chronic disease by equipping them with knowledge and skills for delivering patient care, beyond routine clinical duties. They thought that the PNs in their practice were competent in supporting patients in chronic disease education and maintaining care plans, and that it was important to work as a team towards self-management of chronic disease.
• ii)GP-PN collaboration: In practices where the PN’s role in management of stable COPD was already established, GPs felt that the PNs had an important role in enhancing the patients’ care through improving disease knowledge, ensuring correct inhaler technique, making referrals to pulmonary rehabilitation and encouraging lifestyle modifications.

I think that sort of division of labour into nurses being able to do COPD-specific things and get across the messages, that I will probably get mixed up as I try and do everything else at the same time, which is something…quite helpful and quite effective – GP2.

4. Feasibility and sustainability of the program

• i)Practice organisation: GPs perceived the program as feasible mainly because their practice employed PNs, who were able to manage their clinical workload, and the logistics of organising patients’ appointments and consultations spaces. They considered the PNs to be better suited than GPs for having long consultations to provide tailored self-management support but that the PNs needed ongoing support from a facilitator, to sustain the program.
• ii)Renumeration: In practices prioritising research participation and GP-PN collaboration for chronic disease management, the principal GPs were supportive of incorporating tailored self-management support without PN reimbursement. However, they felt that the PNs’ time away for the workshop and education sessions would have been expensive for the practice, had they not been remunerated for participating in the study.

It’s time occupying, now that’s on the one hand a good and a bad thing, so it’s a good thing in terms of patients. Because it was delivered by our nurses, it meant that those nurses were spending a huge amount of time on those patients to the detriment of other people because we’ve only got nurses there for a certain time – GP7.

5. Recommendations for the future

• i)Upscaling of the program: There was a consensus among all GPs that the program should be tested as a larger trial. Although they were not as involved in the study as the PNs, most had ideas for refining the program. GP suggestions to improve feasibility included having shorter educational sessions, receiving collaborative training alongside PNs and ongoing access to educational resources, and handouts for patients with program content.

GPs who were familiar with the content of the program felt that action plans were beneficial for patients with any chronic disease since personalised, written instructions are helpful especially in emergencies. GP suggestions to improve program content included developing audio action plans to improve accessibility and personalisation of patient materials, extending the follow-up period more than six months to assist patients with maintaining new health behaviours and monitoring patients’ COPD-related hospital admissions when implementing the study as a larger trial.

• ii)Suggestions for practice: A GP suggested that self-management support for COPD should be delivered on a regular basis as a consultation clinic at the practice, with a dedicated PN for the clinic. Another GP considered self-management support for COPD to be more effective if delivered seasonally, such as at the onset of the flu season, especially for patients who are not on care plans for their chronic conditions.

Maybe it would be a good idea to have a video on COPD which the doctors can play in their practice or maybe a CD which we can put on at times in the waiting room where patients can watch it – GP4.

The GPs of patients who withdrew from the study due to resistance to change suggested that, for self-management support to be effective, patients’ willingness towards changing their health behaviour should be considered. A GP suggested that chronic disease education could be delivered to patients by other health professionals, such as trained personnel from healthcare NGOs (non-governmental organisations) or medical students.

Discussion

Most patients perceived the program as a positive experience, appreciated the personalised care and education provided by the PNs. Overall, PNs and GPs found the program to be acceptable and beneficial for participating patients. The PNs felt more skilled in care of COPD, confident in delivering self-management support and were able to incorporate delivery of the program into their routine clinical practice. The GPs considered PNs to be better suited than themselves for delivering self-management support for chronic disease, and also that the program was feasible in the longer term.

The consensus of acceptance is an important determinant for the sustainability of a program in the longer term [20, 21]. Patients’ reception of the self-management support provided by their PNs could be attributed to recognition of the PN’s role in Australia [22] and the USA [23]. The patients’ perception of being cared for by their PNs during the program enhanced their sense of wellbeing, which was also seen in prior research [22, 24, 25]. Uptake of the program depended on patients’ socio-economic status and interplay of comorbidities, as seen in a prior complex intervention for multimorbidity in British general practice [26]. Patients’ existing level of motivation, willingness to change and enthusiasm were determinants of their performance in the program. This is in line with the Trans Theoretical Model, which advocates that a person’s readiness to change is crucial for changing health behaviour [27] and has been observed in a prior study of self-management in the context of multimorbidity [28].

The biopsychosocial aspects of the APCOM Program, which entailed consideration of patients’ individual needs, preferences and values, were well received by the patients. Patients’ appreciation of phone calls and motivational interviewing from their PNs was also seen in prior feasibility and interventional studies [29–31]. Completion of the reflection logs by the patients in between sessions with their PNs was a good mode of reflecting upon and improvising their health behaviour, seen previously in a lifestyle intervention for diabetes [31]. Ongoing guidance, provided by the PNs during the follow-up period and well received by the patients, is important for the success of self-management support for COPD [32]. PNs found that the motivational interviewing approach and follow-up phone calls assisted in improving patient wellbeing by reducing anxiety; suggesting that the approach of the study was feasible and acceptable.

Co-existing anxiety and depression, as already known [33–35], were barriers to improving self-efficacy for most patients. The patients’ comorbidity count, although important in determining the multimorbidity burden [36], did not seem to determine their performance in the program, including attending the sessions with PNs and increased health outcomes. Type, rather than number, of comorbidities impacted their participation in the program. Patients’ comorbidities being a barrier towards effectiveness of the program underlines the importance of incorporating a multimorbidity perspective in interventions for patients with COPD [37, 38]. Although the APCOM Program encouraged PNs to consider comorbidities, COPD self-management was the main focus of the study given that it is the index disease. Although older age has been cited as a barrier for self-management [29], increasing age was not a deterrent to better health behaviour in this study. Recent diagnosis of COPD was also a barrier to patient self-efficacy, with duration since diagnosis of COPD being a known determinant of self-efficacy [39]. A patient’s reluctance to accept cigarette smoking as the cause of their COPD could be a reluctance towards taking responsibility for disease causation, especially as it co-existed with the risk factor of occupational lung diseases [40, 41].

The main challenges for PNs were managing their existing workload alongside the self-management support sessions, sometimes influenced by a lack of support from GPs. PNs were enthusiastic about providing self-management support in the longer term, with some incorporating components of the program into their routine practice. The frustration expressed by some PNs related to patients’ lack of progress during the program may be explained by psychological distress experienced by nurses when dealing with the burden of chronic disease [25, 42]. Most GPs were supportive of upskilling PNs for providing tailored education for COPD and considered PNs to be suitable for delivering self-management support for chronic disease in general practice, consistent with patient perceptions.

Patient suggestions for group education sessions and more telephone interactions should be considered given their prior success in self-management of COPD [29, 43–45]. GPs had many suggestions for modifying the program for evaluation in a larger trial, with most expressing an interest in being more actively involved. The initial training and ongoing support provided to PNs during the program was seen as vital to successfully delivery of the program, highlighting the need for ongoing nurse education in general practice [46–51]. However, concerns about associated time and costs for the practice in upskilling of PNs, voiced by multiple providers, has been a longstanding barrier to expansion of the PN’s role in the Australian context [52–55]. This is understandable given that the national Practice Nurse Incentive Program [56] does not reimburse general practices for PNs’ participation in health education and financial renumeration was a theme raised in the interviews. Given the recent update to the Workforce Incentive Program – Practice Stream, this could change in the future [57]. Workload pressures were also a barrier to delivering self-management support for chronic disease, as seen in other studies [24, 58, 59].

In Australia, relevant organisations including Primary Health Networks, Lung Foundation Australia, Australian Primary Health Care Nurses Association and the Royal Australian College of General Practitioners should consider facilitating delivery of self-management support programs for COPD in primary care. The current study’s findings show that the global-first APCOM Program is acceptable, feasible and beneficial from a patient and primary healthcare provider perspective. These findings provide a nuanced understanding of the experience of participants in the program, therefore enriching the study’s quantitative findings which have been previously described [12].

Limitations and strengths

Duration of the PN and GP interviews, which averaged 15 and 13 min each respectively, were shorter than typical interviews in health services research [60]. This was mainly because the interviews were conducted during their work time at the general practices; despite pre-arranged appointments, there were frequently delays in commencing the interviews and occasionally interruptions during the interviews. Regardless of the relatively short duration of the interviews, sufficient data covering all topics in the semi-structured interview guide was collected for the purpose of program evaluation. The interview guide and focused questions appropriately allowed for ‘rich’ data collection and subsequent, robust analyses of the perspectives provided by all stakeholders.

To further understand the findings from the interviews, they were interpreted through the tenets of the Normalisation Process Theory (NPT) [16], as seen in Tables 7 and 8; theoretical triangulation of the findings enhance their transferability [19]. Review of the analyses and findings by SA, HH, SD and NZ provided confirmation of the findings and added breadth to the interpretation, thereby achieving investigator triangulation [19].

Table 7.

Interpretation of patient interviews through normalisation process theory

NPT tenet	Points to ponder	Relevance of the interview findings
1. Coherence	Was the program clear, distinct and feasible to the participants? Did they perceive and value its benefits?	All patients understood the reason the study was being conducted and why they were invited to participate in it by their PNs. Most patients appreciated the benefits brought about by the program, in terms of their awareness and skills for coping with COPD in the context of multimorbidity. This was reflected through improved medication adherence and inhaler device technique, as well as lifestyle changes such as smoking cessation, increased physical activity and environmental modification.
2. Cognitive participation	Were the participants willing to invest time and effort? Did they easily see the point of the program?	All 12 patients completed six months’ follow-up. Although the patients appreciated that the program intended to improve their health status, uptake and perceived benefits of the program varied depending on their individual demographics and circumstances. In the case of one patient who attended pulmonary rehabilitation following referral by their PN, it was difficult to discern whether the feedback was on pulmonary rehabilitation or the program as such.
3. Collective action	What effect did the program have on patient consultations? How compatible was it with their healthcare regime?	The patients visited their practice five times across a span of eight months during the study. When a GP consultation was needed to review medication or draw up a COPD Action Plan, routine appointments were made. These mostly coincided with an education session with their PN or a regular visit to the practice. None of the patients felt that they had to go out of the way to participate in the program in spite of each education session lasting about 45 min, which is more than double the duration of a standard GP appointment. Attending the baseline and post-test visits was not considered inconvenient either. The monthly follow-up calls from their PNs were appreciated by the patients.
4. Reflexive monitoring	How did the participants perceive the program? Were they able to contribute feedback on the program? Did they view the program as being sustainable?	Eleven of the 12 patients attended all three education sessions of the program with their PN, in spite of personal and professional commitments. Successful completion of the sessions, with most patients being able to maintain new health behaviours, demonstrates their perceived utility of the program. All patients enthusiastically offered their perspectives on the program and its components, with some of them contributing suggestions for improvement.

Table 8.

Interpretation of provider interviews through normalisation process theory

NPT tenet	Points to ponder	Relevance of the interview findings
1. Coherence	Was the program clear, distinct and feasible to the participants? Did they perceive and value its benefits? Did the program fit into the practice organisation?	All PNs understood the content of the program, and knew how to deliver it to participating patients. They attributed simplicity and structure of the program, the initial training and ongoing guidance as contributing factors towards this. The GPs did not have a working knowledge of the program, but seemed to recognise its significance in terms of better health outcomes for participating patients. All PNs saw the program through to completion. They were able to arrange long appointments for the education sessions and book consultation rooms. Two PNs faced barriers towards recruiting patients and conducting the education sessions, due to resistance from some GPs within the practice. This indicates that support of all GPs in a practice, and not just the principal GP who endorsed the PN’s participation in the study, is important for smooth implementation of the program.
2. Cognitive participation	Were the participants willing to invest time and effort? Did they easily see the point of the program?	Participating in the study required an average time of about 30 h from each PN, over a span of 8 months. They consented to participating in the study understanding the time commitment required; the principal GPs were also aware of this and supported the PNs’ participation in the research. At the onset of the study, all PNs and GPs were able to see the significance of the program, with its potential for empowering patients and upskilling the PNs.
3. Collective action	How did the program affect the work of the PNs? What effect did the program have on GP consultations?	The PNs were able to incorporate the education sessions into their existing schedule. Booking the education sessions meant having to make prior appointments, which sometimes needed to be changed. This was not a barrier for the PNs, as they were used to dealing with such issues in clinical practice. One PN felt that the sessions were much longer than routine clinical consultations. Some PNs felt that the monthly follow-up calls were cumbersome when patients could not be contacted. All PNs were required to attend a one-day training workshop, which provided them with knowledge and understanding of the program. This meant that they had to be away from the practice for the day. Although it was not possible for all PNs to attend the workshop on the same day, they managed to attend the training. Overall, the PNs did not feel overwhelmed by their participation in the study. This could be attributed to the prolonged and individual support provided to them by the researcher, thus facilitating the collective action towards implementation of the program. The GPs’ involvement in the program was mainly required for signing the COPD Action Plans and when patients’ medication had to be revised.
4. Reflexive monitoring	How did the participants perceive the program? Were they able to contribute feedback on the program? Did they view the program as being sustainable?	All PNs felt upskilled in regard to COPD knowledge, and some reported increased confidence in their interactions with GPs and patients. For some GPs, the program enhanced the prioritisation of COPD during patient consultations. Most PNs and GPs made enthusiastic suggestions towards refining and upscaling the program. Except for one GP, who considered PNs to be unsuitable for delivering chronic disease self-management support, all felt that the program could be carried on in day-to-day general practice.

Conclusions

The APCOM Program demonstrated that an approach to self-management support in COPD which considers patient context and a multimorbidity perspective is feasible and acceptable and should be implemented in routine general practice. The benefit is maximised when all practice staff, including PNs and GPs, support program delivery and are aware of its significance. However, for this program to become integrated into routine general practice, financial incentivisation is recommended for PN education and to GPs to provide self-management support to patients with awareness of comorbidities. Funding is a significant barrier to care of COPD and similar chronic conditions and should be addressed by national government standards. To support implementation of this program, standards should be established for training PNs in chronic disease management and education.

Abbreviations

Abbreviation

Definition

COPD

Chronic obstructive pulmonary disease

PN

Practice nurse

APCOM

Activating Primary Care COPD Patients with Multimorbidity

GP

General practitioner

PAM

Patient Activation Measure

HBM

Health Belief Model

NPT

Normalisation Process Theory

DPI

Dry powdered inhaler

Authors’ contributions

SA, HH, SD and NZ conceptualised the study. SA and MK conducted data collection. SA coordinated the study, performed data coding and analysis. The manuscript was drafted and edited by SA, TS, ST and NZ. All authors critically reviewed the manuscript and approved the final draft. SA and TS revised the manuscript following peer review.

Funding

The study was funded by an Investigator Sponsored Studies grant awarded to SA, HH, SD and NZ by GlaxoSmithKline Australia (Study number 204950), and recognised by the Australian National Health and Medical Research Council through a PhD Scholarship awarded to SA (GNT1093032).

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request, subject to the completion of a data sharing agreement.

Declarations

Ethics approval and consent to participate

The study was approved by the Human Research Ethics Committee of UNSW Sydney (HREC14139). Written informed consent was obtained from the participants prior to each interview, and their permission was sought before commencement of the audio recordings. This research study was conducted in adherence with the Declaration of Helsinki.

Consent for publication

Consent for publication was obtained from the participants at the time of providing written informed consent.

Competing interests

The authors declare no competing interests.