Table 2 Summary of the enablers and barriers to delivering the PA Intervention; recommendations for future studies
Enablers identified by nurses | Barriers identified by nurses | Recommendations from the research team: | |
|---|---|---|---|
Pre – trial | |||
Training | • Comprehensive initial training day & follow up • Training delivered by ‘credible professionals’ • Clear instructions on what has to be carried out at each consultation | • Last minute cancellations by nurses due to work commitments | • Aim to recruit practices and nurses who are interested/committed to research (via PCRN’s) • Pre- trial preparation and training on all aspects of the trial by appropriately trained professionals is essential • Ensure a mix of both theory based and group role play sessions to allow nurses to rehearse difficult scenarios and to allow for reflection & discussion in a supportive environment • Importance of training and ongoing support should not be underestimated and care taken not to neglect the more ‘mundane’ elements of training (e.g. use of the computer) • Consider consulting potential trial nurses at protocol conception stage to gather their opinions on the intervention, recruitment of appropriate participants etc. |
Specific training in behaviour change techniques | • Clear instruction by experienced trainer • Role play scenarios • Protocol guidance clear | • BCT terminology/ jargon sometimes not clear • Some role play scenarios too early as nurses had not seen participants yet | • Make sure any new terms and BCT jargon are clearly explained to the nurses and understanding is checked. • Role play, especially difficult scenarios is essential, However, time it appropriately in training |
Support (from the research team and other practice nurses) | • Ongoing support • Accessible team members • Nurse group supervision • Communication | • Establish a good communication and support network/system, not only with the research team but also between the nurses in the trial but. • Communicate effectively with practices to enable nurses to attend training sessions etc. • Before a practice agrees to being involved, ensure protected time is negotiated for group/individual supervision | |
Delivering the intervention | |||
Timing between visits and length of consultations | • Length of appointments and timing between appointments just right | • Annual holidays and Statutory holidays delayed intervention timings (no appts available at surgery near Christmas) | • Consider whether the trial will take place over holiday periods. If so, have alternative strategies. |
Seasonal variations & weather conditions | • Summer months & sunny weather | • Winter (due to darker evenings, snow and rain!) | • Consider timing of study • Use as a potential relapse/barrier & try to work with participants to find a solution to maintaining walking in poor conditions. |
Feedback on performance during the intervention | • Being audio recorded and provided with constructive verbal and written feedback | • Felt self-conscious being recorded • Feedback not always timely | • Audio recordings of consultations a good way of ensuring quality and consistency across consultations • Ensure feedback is timely so that any changes can be made to consultations quickly • Ensure feedback is given both verbally and in writing |
Following the trial protocol | • Clear protocols and guidance to follow at each consultation • Ability within protocol to individualise activity plans | • Religious observance (e.g. Ramadan) • Wording on some of the handouts patronising to some participants and nurses | • Consider the population area that you are recruiting from in terms of ethnicity and socio-economic groups • Allow some flexibility within the protocol to personalise the consultation to the participant without compromising fidelity • Consider the possibility that you may have to ‘relax’ the protocol in order to retain participants • Ensure nurses are aware of which elements of the protocol are essential for fidelity and which can be adapted – empower nurses to make ‘patient-centred’ changes where appropriate, to maximise trial retention and success |
Use of equipment | • Pedometer • Accelerometer | • Pedometer not always accurate with participants who are obese, have unusual gaits or disabilities • Not able to wear pedometer easily with a dress • Differences in readings (especially couples) • Computer programme to extract accelerometer data too complicated and time consuming within consultation • Accelerometer belt uncomfortable to wear | • Be aware that certain participant characteristics may affect intervention • Consider admin staff time to support nurses to ensure quality of consultation • Explain that different people will record different step counts on the same walk, due to differences in stride length etc. • Consider use of equipment not worn on a belt, such as accelerometers within smartphones etc. |
Use of materials -Handbook, handouts and diaries | • Patients enthusiastic about step count diary • Freedom to individualise goal setting targets within consultation | • Terminology and content of some of the handouts & handbook off-putting • Handouts too general | • Ensure that all materials are piloted with appropriate groups before trial starts • Allow flexibility on use of materials if individuals do not find them helpful |
Participant engagement | • Motivated participants | • Some participants considered too active • Patients not committed to long term change • Patients ‘complying’ to ‘help the nurses out’ | • If possible, involve nurses in participant selection & recruitment and if not possible, then ensure nurses are fully aware of inclusion/exclusion criteria so they are reassured that the correct patients are recruited • Consider appropriate exclusions, particularly for PA trials |
Spousal couples | Often couples motivated each other to walk more | • Difficulties dealing with couples requires additional training | • If considering an intervention aimed at couples, the nurses will require more training & support to build confidence as this is a novel way of working and has complexities not dealt with simply by giving more time within the consultation |