Table 3.

Phase 1: mapping of barriers and enablers for referral to TDF domains

TDF domain (construct mapping frequency)	Content mapping (n)	Key	Evidence supporting
1. Social and Professional role (A coherent set of behaviours and displayed personal qualities of an individual in a social or work setting)	289	Referral was considered everyone’s role, however it was considered best undertaken by the PHCP during disease stability and at annual review. It was often considered to be the practice nurses’ role, but also respiratory-interested others. Most PHCPs considered it their duty of care to motivate patients. Only 1 of 19 PHCPs described implementing practice leadership to improve PR awareness and/or referral.	It is largely the nurses’ job to see stable COPD patients at an annual review and that is the most appropriate time to refer to pulmonary rehabilitation, not during an acute exacerbation. GP5 No, I think it’s everybody’s role, I mean I’m not sure about my non-respiratory colleagues. PN2 So we've put forward a proper business case for it (Local PR service). GP4
2. Knowledge (An awareness of the existence of something)	256	17 of 19 PHCPs knew of the existence of PR and a generalised understanding of its purpose. PR Knowledge was reported to be gained through post qualification education and networking events. Local PR knowledge such as programme timing, waiting list (if any), and availability of patient transport, was often unknown and were described as inhibitors to referral discussions. The referral criteria Medical Research Council (MRC) dyspnoea score ≥3 was frequently cited as a referral prompt, although some PHCPs wanted to refer patients with MRC scores of 2 and felt unable to.	I think it’s a fundamental treatment and I think it’s better than drugs. PN7 Do you currently refer to PR? P -I wouldn’t know where. GP2 I don’t know how to describe pulmonary rehab to a patient. GP3 I just feel that we don’t know enough about the program to confidently hand on your heart sell it. PN1 We’ve also got the barrier of we can only refer if their MRC is 3 or 4 or 5. PN5
3. Environment (Any circumstance of a person’s situation or environment that discourages or encourages the development of skills and abilities, independence, social competence and adaptive behaviour)	195	PR referral was often considered inappropriate in non-COPD focused consultations or when a patient was consulting for an acute exacerbation. Clinical time constraints were often described as inhibiting referral, although annual review considered appropriate time because of its clinical focus, template design and longer consultation time. PHCPs often stated little PR promotional material was available in practice for patients or staff; there were however mixed views on the potential value of this. Three practices had initiated an in-practice 12 weekly, 1 hour generic exercise group, this appeared to be seen as equivalent to PR by 1 PN.	I think in our role when you’re treating potentially acutely unwell people in a really limited time span then it’s, it is realistically going to be hard to cover everything, really hard. ANP2 On the annual review well I follow the template and when I get to the pulmonary rehab I mention it then and I say, ‘Would you like to go?’ PN3 It would be useful for our local organisation I think to give us some little leaflets about what they do so we can give that to patients about the local service. ANP4 I’m not against a leaflet but have you seen how many posters and leaflets we have on our walls? GP2
4. Belief about capabilities (Acceptance of the truth, reality, or validity about an ability, talent, or facility that a person can put to constructive use)	141	Individual PHCP PR referral confidence varied, with particular uncertainty expressed in how to best ‘sell PR’ and how to motivate unmotivated patients. Although most were confident in reassuring patients that PR would improve breathlessness. PHCPs with positive non-pharmacological and exercise beliefs appeared to have greater confidence in PR benefit and patients’ abilities. A number of PHCPs described patients with COPD as uninterested in improving their health and some PHCPs emphasised patients needed to be committed to PR. While some PHCPs described ‘knowing’ which patients would accept referral, others described undertaking subjective patient assessment and expressed concerns about patients’ exercise capability in the presence of breathlessness. For patients receiving oxygen therapy there was much uncertainty of the benefit of PR and an assumption that oxygen/secondary care teams would have previously offered this. Most PHCPs considered key environmental factors such as session timing, venue accessibility, patient financial hardship, as barriers for most patients. Patients in work, or those able to take the dog for a walk/wearing walking boots were considered ‘too well’ for PR.	I would need to feel confident, before I speak to this patient about it. ANP4 I quite like…Non-medicinal treatment…think if you're excited by it then it’s easier for patients to get excited by it as well. GP4 They are also very very clear that there not going to take anyone on their course unless there is 100% commitment at the beginning that they are going to complete the course. ANP1 You look at the ones that you think would more likely go. ANP4 It’s really basically where I see a need, where I see they can benefit. ANP1 If the patients already on oxygen therapy, then it’s likely that they’ve already been seen by them. HCA The main stumbling block is that you come across is I’m not going every week for x number of weeks, I can't afford it, I haven't got that much time, how do you expect me to get there….not a huge number of our patients drive. GP4 There’s some patients that I would like to refer but they can’t go because of work commitments. PN3 It’s quite surprising that some patients are still working at odd jobs and things like that and keep them very active. So, for those patients it’s not so important. PN3
5. Memory (Inc: decision-making) (The ability to retain information, focus selectively on aspects of the environment and choose between two or more alternatives)	118	Some PHCPs reported forgetting to refer patients to PR, however, embedded system reminders often found in COPD review templates or on-screen prompts were cited as important for most PHCPs. Patient behaviour and clinical presentation altered decision-making processes for some PHCPs for example not referring current smokers, or remembering PR in light of increasing COPD symptom burden and disease deterioration, while earlier concerns for patient capability and commitment became less apparent.	I do need a reminders because my head’s full, so as I say, I don’t want to tick boxes but I do need a prompt. PN7 That’s something that we do, so we have a prompt that pops up saying has this patient been referred to pulmonary rehab. GP5 I think I go through phases, I’ll do it really well for a while and somebody has motivated me and then I’ll forget that and do something else. PN7 Breathlessness and exacerbations, I think, would be the key factors. GP3
6. Optimism (The confidence that things will happen for the best or that desired goals will be attained)	110	PHCPs frequently reported that patients did not want to attend PR, citing disease stigma and lack of activation as underlying reasons. Negative patient responses appeared to dampen PHCPs optimism and reduce subsequent referral offers. Positive patient experience however had the opposite effect. Positive and negative perceptions of PR providers were also reported on the basis of service quality and frequency of referral acceptance, this appeared to influence referral behaviour.	The first thing you think, Are they going to do it? ANP4 Patients don’t want it. PN5 Even if you then said what the evidence was and how you could improve, it’s – I think that group of people are really difficult to engage.GP3 If they’re negative anyway everything you suggest they sort of have an answer, Oh no that won’t work. PN4 The longer the wait time, the less likely they are to turn up. HCA I don’t think it’s the greatest service, it does have an impact because I’m not going to tell my patients to go. PN7
7. Belief about consequences (Acceptance of the truth, reality, or validity about outcomes of a behaviour in a given situation)	107	There was a general sense that PR is positive with many health and psychological benefits, but beliefs captured in other domains impacted on PHCP belief about consequences of referral offer. A small number of PHCPs expressed concern that PR might worsen patient’s depression and/or anxiety, particularly for those socially isolated.	I’ve seen patients that have been… their lives have been transformed in the first year. PN7 Might have prevented the exacerbation if they’d gone PN5 I will say that when I’m talking to patients, say it’s better than drugs, but I still get a closed reaction. PN7 If we can improve patient’s breathing they’re less likely to get anxious, that makes them less likely to dial 999 or likely to do something about it. And perhaps use their rescue packs more appropriately. ANP4 I wouldn’t want to mention it if it ended up being that I’m saying there’s this really good helpful programme but actually if she’s so effected by her disease that she doesn’t leave the house then I wouldn’t want to have mentioned it and then not for her not to be able to go. ANP2
8. Social influences (Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviours)	84	Out of practice engagement from PR providers and PR advocates were important in increasing overall awareness and positively influencing referral behaviour. Almost all PHCPs described little to no engagement from providers themselves, and described not knowing what had happened to completed referrals. PHCPs also reported that positive patient PR experiences positively influenced PHCPs referral behaviour and that family can be influential, yet patients rarely ask for PR. PHCPs described a need to increase PR’s profile publicly and for it to be marketed similarly to pharmacological treatments. The name PR itself was considered by some PHCPs to be a negative influence as ‘rehab’ was deemed to have undesirable connotations.	Our referral rate has gone up a lot since the respiratory MDT’s because every single one of those patients has subsequently had a referral. GP4 At the moment I wouldn’t know how many people we refer, is that referral going up, Nobodies giving us feedback from the rehab team about how we are doing as a surgery. PN1 If patients that have been to it you know express a positive experience that is something you can share with other people that you are trying to refer. GP1 I asked him to talk to his wife, because I knew she’d want him to go, because I know her through a different channel, and erm… he’s come back and said ‘Ooo I’ll give it a shot. PN5 Nobody has picked up a leaflet and walked in with it and said can you refer me, nobody has. ANP1
9. Skills (An ability or proficiency acquired through practice)	79	The physical act of referring patients to PR were described as largely straightforward by most PHCPs, although there was no standardised process across the two regions. Most undertook this action independently, although there were descriptions of practice administrators helping. However, frequency of referral to PR when described in interviews, was far lower than that which was documented on the returned research interest form.	Do you currently refer people to pulmonary rehab? Some, some. PN7 I’ve been at this practice for nearly three years now and it’s sort of something that falls really far down on your list of things that you do on your COPD review, so it’s always the last thing that you come to. GP4 It’s very easy. It’s a form erm it’s a just a single sheet. PN2 Quicker, easier referral, much easier referral method. PN7
10. Reinforcement (Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus)	59	There appeared to be no direct sanctions for non-referral of patients, although practice financial rewards in one region appeared to enhance awareness and referral. Outside of these practices there was a suggestion that financial incentives would be advantageous, additionally calculating health cost benefit for PR attendance was suggested as potential enabler. Additionally reinforcements such as those offered by social influences and patients were also described to be valuable.	We’ve got this thing called A** that we’re doing for, you know it was the QOF before, so like A** has taken over that so I think because of the A** the doctor who is the lead A** leader he discusses that a lot because of course you get points, you still get the points for it like QoF. So the more we refer is the more points we get so there’s an incentive there for the practice. PN6 Yeah if they did something on the BBC or something they might all be in the next day saying, ‘Oh I wanna do that’. PN4 If you spent 5 minutes with somebody then at the end of that they agreed to go and then they attended, then you would be motivated to do it again. GP5
11. Goals (Mental representations of outcomes or ‘end states’ that an individual wants to achieve)	47	Referral to PR was a low-level goal for most PHCPs, but one that varied by consultation type and was not considered during an acute exacerbation review. However, referral appeared to become a goal in the presence of worsening patient symptoms. Some PHCPs described wanting to refer more patients and learning strategies to improve patient acceptance, but described frequent discord between PHCP and patient goals which PHCPs found challenging. No PHCPs discussed set practice PR referral targets although one GP reported plans to set up a programme geographically closer to practice (captured as leadership in the domain social and professional).	As a practice, when we do the acute exacerbation we're pretty much focus on the acute exacerbation. GP4 I refer a few to pulmonary rehab but I don’t do as many as I feel I should. PN7 She was more receptive because she’d had a few flares up, not after the first one but because she’s had a few. And I think that makes them more receptive to doing that sort of thing. ANP4 One hand I’m wanting them to engage with the disease process so that actually they’ve got more skills to self-manage and that’s going to actually keep them much better for the rest if their whole of their life, on the other hand they don’t want to be classified as ill. ANP1 It would help me in trying to find out why she didn’t go because I would challenge her on it and try and get her to go again and give it another go and that would help me in. ANP4
12. Intentions (A conscious decision to perform a behaviour or a resolve to act in a certain way)	39	Some PHCPs have described adopting patient-aimed strategies that included persistence and warnings against over-reliance and/or possible reduced effectiveness of pharmacological treatments in an effort to move patients to a state ready for PR referral. There also appeared to be an understanding that acceptance for many patients takes time.	I said you know you’ve used those rescue packs a lot you know if we could get your breathing a bit better, perhaps you wouldn’t be so bad…., and she said, alright then I’ll see, do the referral. ANP4 How would you feel about something that’s not medicine based but will probably help you as much as the inhalers that we’ve put you on, she was suddenly very interested in. GP4 I look for that chink of interest and then I’ll try and worm my way in then. PN7 He was very adamant that he didn’t want to go, then I gave him the booklet. PN5
13. Emotion (A complex reaction pattern, involving experiential, behavioural, and physiological elements, by which the individual attempts to deal with a personally significant matter or event)	6	PHCPs emotion was rarely discussed although some said they felt annoyed with providers if a referral had been rejected. There were high levels of empathy towards patients particularly among nurses; a small number described not wanting to offer the hope of PR to patients and for PR providers to reject referral, this appeared to be a particular concern for patients with high disease burden.	Most of our patients are reasonably trusting and say well you seem quite excited by it so shall we give it a try. GP4 They’re gonna meet all these people they don’t know and be told to lift this walk here, do that and they’re frightened, its…I’d be terrified. PN5 I just don’t want to raise–if you raise patients’ hopes and say – and offer it, then it can make them–you know, if they’re already depressed because of the COPD, it could just make the depression worse you know, so I don’t want to impact on their mental wellbeing. ANP1
14. Behavioural regulation (Anything aimed at managing or changing objectively observed or measured actions)	4	Some PHCPs saw events such as hospital admissions/out-patient appointments as good opportunities for patients to change behaviours but for staff in those settings to instigate referral. PHCP personal behavioural regulation was low, many did not know how any they had referred or what, post referral, the patient’s journey had become. One participant described the research interview as helpful in allowing them to consider how to change their referral approach, but most PHCPs did not vocalise intentions to change or modify current or future PR referral behaviours.	I don’t know how much is done in secondary care, but very often when stuff, when you’ve been in anywhere near secondary care people really its often quite a sit up moment, gosh this is serious enough for me to have to go to hospital, even if it an outpatient appointment. ANP1 This is one of your treatment choices’ and perhaps I need to change, thinking about it, my approach in–er, how I word it. ANP4 It’s trying to make it a priority. ANP4

ANP, advanced nurse practitioner; COPD, chronic obstructive pulmonary disease; GP, general practitioner; HCA, healthcare assistant; PHCP, primary healthcare practitioner; PN, practice nurse; PR, pulmonary rehabilitation; QoF, quaility outcomes framework.