Applied Nursing Research 33 (2016) 85–92 X

Contents lists available at ScienceDirectX

Applied Nursing Research

journa l homepage: www . elsevier . com/locate/apnrX

Nurses' perspectives of a new individualized nursing care intervention for

COPD patients in primary care settings: A mixed method study

a, a
Saskia WM Weldam, Msc, RN , Jan-Willem J Lammers, PhD, MD ,X

a b
Marieke Zwakman, Msc, RN , Marieke J Schuurmans, PhD, RN

Department of Respiratory Diseases, Division Heart & Lungs, University Medical Center Utrecht, PO Box85500, 3508 GA Utrecht, The Netherlands
Department of Rehabilitation, Nursing Science & Sports, University Medical Center Utrecht, PO Box85500, 3508 GA Utrecht, The Netherlands
Keywords:

Background: The major challenges in Chronic

Chronic Obstructive Pulmonary Disease (COPD) care are
article info Obstructive guiding a patient in daily living with the
Pulmonary Disease consequences of the disease, reducing the impact of
(COPD) Clinical symptoms and improving Health Relat-ed Quality of
Article history: nursing research Life (HRQoL). The new nurse-led COPD-Guidance,
Research on an Illness Perception (COPD-GRIP)
Received 19 June 2015 Patient care intervention translates the evidence concerning illness
management perceptions and Health Related Quality of Life
Patient centered (HRQoL) into a practice nurse intervention.
Revised 25 October 2016 nursing Primary
care nursing
The aim is to explore the nurses' experiences with
Accepted 26 October 2016 applying the new COPD-GRIP intervention.

Available online xxxx abstract Method: An explanatory mixed-method study nested

in a cluster randomized trial in primary care was
conduct-ed. Pre-intervention questionnaires were sent to all than the nurses lower social economic status, in patients with a lower
participating nurses (N = 24) to identify expectations. Post- initially expected. health literacy and in patients with other cultural
intervention questionnaires identified experiences after applying the The intervention backgrounds than the Dutch background.
intervention followed by two focus groups to further extend enables to provide
exploration of findings. Questionnaires were analyzed by descriptive patient-centered
analyses. To identify themes the audio-taped and transcribed focus care and to Conclusion: Nurses perceived the COPD-GRIP
groups were independently coded by two researchers. address patient intervention as a feasible, individualized tool.
needs. Barriers According to the nurses, the intervention is a valuable
were encountered, improvement in the care for COPD patients.
Results: The nurses described the intervention as a useful, structured especially in
and individualized tool to guide COPD pa-tients in living with the patients with a
consequences of COPD. Applying the intervention took less time © 2016 Elsevier Inc. All rights reserved.
Disler et address:
a substantial Quality of Life
al., S.Weldam@umcutrecht.nl (S.W.M.contribution to the (HRQoL) ( Fletcher
2014; long-term care of
Fletcher Weldam).X COPD patients
& Dahl, 2013;
GOLD, 2015).
& Dahl, because of their
1. Introduction Evidence show that
2013; unique position:
illness perceptions
Schroed nurses are involved
http://dx.doi.org/10.1016/j.apnr.20 in all stages of the are associated with
Chronic Obstructive Pulmonary l et al., 16.10.010 0897-1897/© 2016 HRQoL in COPD
Disease (COPD) is a progressive Elsevier Inc. All rights reserved. disease, from
2014). patients (
chronic disease characterized by prevention to end-of
persistent airflow limitation resulting X life-care ( Fletcher Bonsaksen,
in breathlessness, limitations in daily Haukeland-Parker,
& Dahl, 2013). Lerdal, &
activities and reduced quality of life (
Moreover their Fagermoen, 2014;
GOLD, 2015). It is estimated that 328 Treatment and care for contribution is
million people worldwide have COPD COPD patients has Fischer et al., 2012;
Correspon characterized by
( Vos et al., 2015) and the prevalence ding increasingly moved from Kaptein et al., 2008;
hospitals to primary care continuity of care ( Scharloo et al.,
of the physical, social and economic author at:
burden that results from this disease University during the last decade in the Fletcher & Dahl, 2007; Weldam,
Medical Netherlands as well as in 2013; Freund et al.,
continues to in-crease ( Decramer et Center
Lammers, Heijmans,
Utrecht, many other countries ( 2015; Griffiths, & Schuurmans,
al., 2011). COPD patients experience
HP Schermer et al., 2008). Maben, & Murrells, 2014; Weldam,
several unmet health needs, such as E03.511,
General practi-tioners, 2011). The major Lammers, Decates,
the need of a better understanding of PO
practice nurses and challenges in COPD
the sustained symptom burden, Box85500 & Schuurmans,
physical limitations, and , 3508 GA respiratory nurses play a key care are guiding a 2013). These illness
Utrecht, role in the care for COPD patient in daily perceptions guide
psychological im-pact of COPD ( The living with the
Netherlan patients in primary care ( individ-uals' efforts
Disler et al., 2014; Schroedl et al., consequences of the
ds. Freund et al., 2015; to cope with COPD.
2014). These develop-ments highlight disease, reducing the
Despite their
the importance to develop new Schermer et al., 2008). impact of symptoms importance,
interventions in COPD management (
E-mail
Particularly nurses can make and improving
Health Related patients'X
86 S.W.M. Weldam et al. / Applied Nursing Research 33 (2016) 85–92
COPD-GRIP inter-vention
was written. The COPD-
illness perceptions are rarely discussed in The COPD-GRIP
GRIP intervention is
consultations with general practitioners and intervention has been applied
currently being tested on its'
nurses ( Miravitlles, Ferrer, Baró, Lleonart, effectiveness in terms of within the COPD-GRIP trial
in primary care in context of
& Galera, 2013; Petrie & Weinman, 2006). health status, quality of life regular contacts between the
and daily activities with a
Although several COPD disease man- COPD patient and the
nine month follow-up period
agement programs ( Kruis et al., 2014; participating nurses at the
in a cluster random-ized trial
primary care-office or at the
Zwerink et al., 2014) and nurse-led in primary care in the
patient's home. The
interventions ( Bischoff et al., 2012; Netherlands. This COPD-
participating nurses were
GRIP trial in-cludes 37
Jonsdottir et al., 2015; Walters et al., 2013; participating nurses from practice nurses who mainly
contacted the patients in the
Zakrisson et al., 2011) have been primary care practices and
primary care office, or
developed, specific guide-lines for nurses 221 COPD patients (COPD-
respira-tory nurses who
how to discuss illness perceptions with GRIP trial, Netherlands Trial
mainly visited the patients at
COPD patients are lacking. Therefore we Registry (NTR) 3945).X
home. All nurses of the 19
have developed a new nursing intervention
participating practices were
that translates the evidence concerning
trained in an educational
illness perceptions into a prac-tical guide
session which was developed
that nurses can use in clinical care.
by a health psychologist and
According to the Medical Research Council
a researcher/nurse (SW).
(MRC) for developing and evaluating 1.2. COPD-GRIP
During this session the
complex inter-ventions it is important to intervention
above-mentioned stages of
evaluate the experiences of the providers of
the intervention were
new interventions in order to improve the
The COPD-GRIP explained and discussed step
intervention and to enable implementation
intervention is an by step. Moreover the content
in practice ( Conn, 2012; Craig & individualized tailor-made of the booklet in which the
Petticrew, 2013; Möhler, Bartoszek, inter-vention. It starts with COPD-GRIP intervention is
assessing and discussing described, was discussed and
Köpke, & Meyer, 2012; Moore et al.,
illness perceptions with the a short animation movie was
2015). There-fore, the purpose of the study
Brief Illness Perception used to explain the content of
is to evaluate the nurses' experiences with
Questionnaire (B-IPQ) ( the booklet. This movie can
this new intervention.X
be found on our website
Broadbent, Petrie, Main, &
www.
Weinman, 2006) as a guide
umcutrecht.nl/griponderzoek
for tailoring the intervention.
1.1. Background It is subsequently followed X
by improving patient's
understanding of the
The COPD-Guidance Research on Illness
relationship between their
Perception (COPD-GRIP) in-tervention ( perceptions and their 2. The study
Weldam, Lammers, & Schuurmans, 2015) behavior, by challeng-ing
is based on the Leventhal's Common Sense them to draw up an
2.1. Aim
model (CSM) of self-regulation of health individualized care plan and
and illnesses ( Leventhal, Brissette, & finally, by evaluat-ing the
action they have taken to The aim of this study was to
Leventhal, 2003). The CSM sug-gests that
change their perceptions and explore facilitators and
people have personal beliefs about their
behavior. The COPD-GRIP barriers in ap-plying the
illness which deter-mine to a large extent
intervention consists of three COPD-GRIP intervention
how people respond to their illness ( face-to face consultations, from the perspective of the
Leventhal et al., 2003). Based on this each lasting approximately nurses.
half an hour. Because of the
CSM and the existing evidence on the rela-
sequential struc-ture and
tionship between illness perceptions and 2.2. Study design
content of the intervention
HRQoL ( Fischer et al., 2012; Petrie, the consultations are planned
Cameron, Ellis, Buick, & Weinman, 2002; with an interval of three An explanatory mixed-
Scharloo et al., 2007; Weldam et al., 2014; weeks.X method study on nurses'
perceptions of facil-itators
Weldam et al., 2013), a first draft of the
and barriers of the COPD-
interven-tion was written. The structure
The intervention is entirely GRIP intervention, nested in
developed by Petrie et al. ( Petrie et al., a cluster randomized trial in
described in a booklet (
2002) of identifying, discussing and primary care was conducted.
evaluating illness perceptions was taken as Weldam et al., 2015). It has As can be seen in Fig. 1
a starting point in developing the an equivalent structure for all
quantitative and qualitative
intervention, followed by a description of patients. The specific content
research methods were used.
specific building blocks which can be used is individualized, based on
The study design was guided
by nurses to guide COPD patients in the patients' responses on the
by the proposed Criteria for
primary care. Subsequently, the face B-IPQ, and based on the
Reporting the Develop-ment
validity of this first draft of the COPD- needs of the patient. An
and Evaluation of Complex
GRIP intervention was assessed in a team English version of the
Interventions in health care;
of experts (4 respiratory nurses, an expert booklet can be found on our
in health psychology, a pul-monologist the CReDECI guidelines (
website:
(JWL), a nursing scientist (MS) and a Möhler et al., 2012).X
www.umcutrecht.nl/griponde
general practitioner). Based on their
comments an adjusted version of the rzoek.X
 Facilitators and barriers with structured list of barriers and
respect to the COPD-GRIP facilitating factors ( Peters,
2.3. Study sample
intervention were explored
by a pre-intervention and a Harmsen, Laurant, &
The study sample consisted of 24 nurses of post-intervention question- Wensing, 2003). The content
19 practices in primary care who naire. The nurses filled in the validity was assessed by a
participated in the COPD-GRIP trial. The pre-intervention group of experts ( van Eijken
primary care practices were situated all questionnaire directly after
et al., 2008) and formerly
around the Netherlands. the educational session and
used in two other studies
before they started to carry
evaluat-ing new interventions
out the COPD-GRIP
2.4. Data collection for practice nurses in primary
intervention. The post-
intervention questionnaire care ( Bleijenberg et al.,
Quantitative data of the nurses' perceptions was filled in after carrying 2013; van Eijken et al.,
of facilitators and bar-riers related to the out the COPD-GRIP 2008). The questionnaire
COPD-GRIP intervention were collected byintervention at least one time included items with respect to
a ques-tionnaire at two moments in time in all patients, which means expectations and experiences
and the qualitative data concerning three consultations in every concerning knowledge,
facilitators and barriers were collected by patient ( Fig. 1). The organizational context,
two focus group meetings with the nurses performing the intervention,
questionnaire was adapted
(see Fig. 1).X time, patient char-acteristics
from van Eijken et al. ( van and nurse perspectives. The
Eijken, Melis, Wensing, response options range from
2.5. Questionnaires 5 (strongly agree) to 1
Rikkert, & van Achterberg,
2008) and based on a (strongly disagree).X
S.W.M. Weldam et al. / Applied Nursing Research 33 (2016) 85–92
87
Fig. 1. Study profile and data collection.
Descriptive analyses of the and MZ. The data were
quantitative data derived with analyzed in a systematic and
2.6. Focus group meetings
the ques-tionnaires were transparent way by using
performed with the Statistical triangulation, segmenting and
A more extended exploration of facilitators Package of the Social Sci- reassembling ( Boeije,
and barriers was obtain-ed by two focus ences (SPSS version 20.0).
group meetings with the nurses who carried The data of the continues 2009).X
out the COPD-GRIP intervention at least outcome measures
one time in all patients, which means three
The data were studied in a
consultations in every patient. The first
were presented as means with transparent and systematic
author (SW) wrote the protocol and
the corresponding standard way using tri-angulation,
selected topics for discussion concerning
deviations. Categorical data segmenting, and
facilitators and barriers. She also observed
were presented as numbers reassembling ( Boeije, 2009).
the process and took notes during the focus
with the corresponding
groups. The moderator (MZ) introduced the The quantita-tive and
percentages who agreed and
groups, led the dis-cussion and ensured that qualitative results were used
strongly agreed with an item
all predefined topics were discussed. A in the interpretation of the
on the questionnaire.
study nurse observed the discussion and results to increase validity.X
took notes. The two focus group meetings
took place in June 2014 at the University To allow for systematic data-
Medical Center Utrecht in the Netherlands analyses the qualitative data The data were studied in a
and lasted one and a half hours each. The from the focus group transparent and systematic
nurses who were not able to participate in meetings were audio taped, way using tri-angulation,
the focus group meetings were asked by transcribed verbatim and ana- segmenting, and
mail to fill in some open questions in the lyzed anonymously ( reassembling ( Boeije, 2009).
post-intervention questionnaire concerning
Krueger & Casey, 2009). The The quantita-tive and
facilitators and barriers of the COPD-GRIP
transcripts were stud-ied qualitative results were used
intervention.
repeatedly and independently in the interpretation of the
by two researchers (MZ and results to increase validity.X
SW). Subsequently open
coding analyses, performed
2.7. Ethical considerations
independently by the same 3. Results
researchers, were used to
This study is nested in a cluster randomized discover important themes
3.1. Results from the pre-
trial assessed and ap-proved by the Medical concerning facilitators and
intervention and post-
Ethics Review Committee (MERC) of the barriers of the COPD-GRIP
intervention questionnaires
Univer-sity Medical Center Utrecht intervention. The results from
(UMCU) with protocol ID 13-026/C. The the open answers from the
questionnaires were analyzed anonymously post-intervention All the nurses from the 19
and audio-recorded verbal consent was questionnaire were participating practices (N =
acquired at the beginning of each focus incorporated in this analysis. 24) filled in the pre-
group. Subsequently the themes that intervention questionnaire.
turned out to be important During the study four nurses
were further analyzed, of
2.8. Data analyses
described and discussed in
con-sensus meetings by SW
88 S.W.M. Weldam et al. / Applied Nursing Research 33 (2016) 85–92
multiple prob-lems (20.8 and … Provides enough freedom to
40%, respectively). incorporate
two practices have withdrawn from the 24 (100)
study without including any pa-tient. 15 (100)
patients' wishes
Therefore the post-intervention
questionnaire was sent to 20 nurses of the
3.2. Results from the focus
remaining 17 participating practices. 15
group meetings
nurses (75%) completed and returned the
questionnaire.
Prior to completing the post-
intervention questionnaires
All the nurses were women, the mean age …is a good start of my self-study
all the 20 nurses were invited 20 (83.3)
was 45.5 years (standard deviation (SD)
to participate in a focus group 11 (73.3)
9.8) and their mean work experience in
meeting to share their …s' lay out makes it feasible to
COPD care was 9.1 years (SD 10.8). work with
experiences of working with
23 (95.9)
the COPD-GRIP 12 (80)
3.1.1. Facilitators intervention. From these 20 I did not read the intervention
nurses 10 nurses were willing enough or I
and able to participate in one 2
Multiple facilitators were identified by the (8.3)
of the two focus group 0
nurses. As can be seen in Table 1 the meetings. The nurses who (0)
nurses indicated in the pre-intervention were not able to par-ticipate did not remember the intervention
questionnaire that they had sufficient in the focus group (N = 10)
knowledge and training to provide the were asked to fill in four
COPD-GRIP intervention. They also additional open questions
mentioned that the lay-out of the concerning their experiences
intervention enabled them to use it in their of facilitators and barriers of
daily practice (95.9%). However, after the COPD-GRIP
working with the COPD-GRIP intervention intervention. From the 10 I need to know more about the
a lower percentage of the nurses, but still nurses, seven nurses filled in intervention
1
80% indicated that the lay-out is easy these open questions. (4.2)
applicable.X 4
(26.7)
The mean age of the nurses before I decide to use it
who participated in the focus
Another facilitator that is described by the
group was 47.4 (SD 10.01)
nurses is the good fit of the intervention
and their mean working
into their work style (91.7% and 97.3%,
experience was 10 years
respectively). Moreover, a high percentage
(5.98).
of the nurses expected, and even a higher
percentage experienced after working with
Table 1 I think that several parts of the
the intervention, that the intervention intervention
improves patient satisfaction (70.9% and 0
93.4%, respective-ly), improves quality of Experiences of the nurses: results (0)
life of the patient (70.9% and 93.4%, from the pre-intervention and post- 0
intervention questionnaire. (0)
respective-ly), and changes the perception are wrong
of the patient (67.7% and 73.4%,
respectively).
Pre-intervention
Although 33.4% of the nurses estimated in Post-intervention
the pre-intervention questionnaire that Domains
N = 24 (%)
performing the intervention will take much N = 15 (%)
time, after actually working with the I′m not trained to accomplish this
0
intervention a lower percentage (20%) (0)
indicated that the intervention is time 0
consuming. (0)
intervention

3.1.2. Barriers

Several barriers were identified. Some Knowledge. The COPD-GRIP

intervention
nurses described that they ex-perienced
more barriers after applying the
I′m not involved in
intervention than they esti-mated in the pre-
developing/spread out
questionnaire. Before using the intervention 2
4.2% estimated they need to have more (8.3)
information before they decide to use the 1
intervention. However, after working with … Provides enough freedom to (6.7)
this intervention
the intervention, a higher percentage make my
(26.7%) indicated they want to know more 22 (91.7)
about the intervention before they decide to 15 (100)
use it. Other barriers were en-countered in own decisions
patients with another cultural background
than the Dutch background (16.6% in the
pre-questionnaire and 60% in the post Organizational
questionnaire, respectively), in patients
with a lower social economic status (29.2
and 60%, respectively), and in patients with
 Patient characteristics

…on male patients

1
(4.2)
1
Colleagues do not work with this (6.7)
4 …on patients with multimorbidity
(16.6) 5
1 Patients do not cooperate in
(20.8)
(6.7) performing this
6
intervention 0
(40)
(0)
…on patients who are willing to
1
change
(6.7)
1
intervention
(4.2)
1
(6.7)
Nurse perspective
The GP does not work with this intervention
4
(16.6)
4
(28.5) It is difficult to perform the COPD-
Supervisor do not cooperate in this GRIP
4
(16.6) The intervention does not fit with
3 my work
(20.3) 2
intervention (8.3)
1
(6.7)
intervention: style or style in my practice

Performing the COPD-GRIP intervention is difficult,

because

…on patients with a different I have difficulties with changing my

cultural “old
16 (16.6) 2
…there is insufficient supporting personnel
9 (8.3)
1
(60) 0
(4.2)
background (0)
1
(6.7) routines”
…there is a lack of several instruments
1
(4.2)
0
(0)
…the time at which the intervention is
0 …on patients who are mainly
(0) healthy In general I experience resistance in
1 8 1
(6.7) (33.3) (4.2)
performed is impractical 6 0
(40) (0)
…on patients with a low social working with guidelines
economic
7
(29.2)
9
(60)
status
…the spaces are insufficient
2
(8.3) This intervention
1
(6.7)
Time

…on older patients

2
(8.3)
…requires a financial compensation
0
14 (58.3)
(0)
8
…on patients who visit the practice
Performing this intervention will take a lot (53.4)
not
8 …improves patient satisfaction
9
(33.4) 17 (70.9)
(37.5)
3 14 (93.4)
6
(20) …improves quality of life of the
(40)
of time patient
regularly
17 (70.9)
14 (93.4)
…changes the perception of the
patient
16 (67.7)
11 (73.4)

As shown in Table 2 several COPD-GRIP

interven-tion
3.2.1. Facilitators facilitators of the
emerged from the data of nursing care. experienced as individualized con-cluded that
analyses of the focus The B-IPQ aX care, to discuss the COPD-GRIP
groups. The interven-tion questionnaire at many topics in intervention is an
is experienced as a good the start of the more de-tail, and important added
structured method to start a intervention to accomplish a value in their
dialogue with a COPD provides a situation of work as a nurse
clear handhold.
patient. It enables to focused way to openness and because of the
The COPD-GRIP
provide patient-centered ask the patient sincerity, which structured way of
intervention
care and to ad-dress the questions. The was experienced providing in-
appeared to be a
patient needs. Moreover, booklet in which as the starting dividualized care.
valuable tool to
the nurses experienced the the intervention point of nursing
provide
interven-tion as the essenceis described was care. The nurses
S.W.M. Weldam et al. / Applied Nursing Research 33 (2016) 85–92
89

Education in
Nurses would like to be more
Table 2 Intervention is helpful in asking trained in applying the intervention
accurate questions. By future
in the future.
Facilitators and barriers that emerged from the focus
group analyses. applying this intervention the nurses
are able to accomplish a

Themes
Facilitators situation of openness and sincerity,
which is the starting point

3.2.2. Barriers
of nursing care. The nurse
Dialogue appreciated working in a structured
A good and structured method to start a dialogue with Although the nurses were
the
way by asking questions, formulate very positive, they
goals and care plans based experienced also some
patient which enables the nurses to provide
individualized, barriers ( Table 2). Even
on shared decision making. though it was feasible to
Themes accommodate the fre-quency
patient centered care which addresses the perceptions Barriers
and of three consultations for
each individual patient within
Time and financial Within the six week in the context of
needs of the patient. It is the essence of the nursing context of normal practice it will be
profession.
participating in the cluster
difficult to
Start of the randomized trial, the nurses
The Brief-Illness Perception Questionnaire provides a explained that they
focused models questioned if they could
intervention accommodate the frequency of three
arrange this in the context of
way to ask questions to the patient. The questions consultations for each
goes beyond their daily practice because of
their busy workload and other
patient within six weeks. Applying work obligations. However,
the topics the nurses normally discuss about the COPD-GRIP
complaints and
under the condition that the
general practitioner authorize
intervention means that the first them and that payment
giving the advice of quit smoking. Some patients consultation-hour took 30 to models will be devel-oped,
interpret the
they highly recommend to
60 min which is longer than within enroll the COPD-GRIP-
questions in diverse or wrong ways. The questions regular care. Financial intervention in daily practice.
elicited the
Finally, the nurses
models need to be developed and the experienced some barriers in
patient to answer the questions and to think about the general practitioner applying the COPD-GRIP
topics. intervention in patients with a
The booklet
The booklet is clear and structured and a good should authorize the nurses to apply lower health literacy, es-
handhold in the intervention. pecially in filling in the B-
Specific patients IPQ questionnaire and
Applying the COPD-GRIP drawing up an individ-
applying the intervention because it guides the nurse intervention is difficult in patients
through ualized care plan. These
barriers were solved by
with a with a lower health literacy taking more time to fill in the
the intervention, step by step with clear examples of and in patients with lower questionnaire together and by
the
taking more time to discuss
social economic status. possi-ble actions within the
questions which they can ask the patient. Themes care plan. The nurses
Added value Recommendations
A useful, structured and individualized tool to get to
experienced also barriers in
know the patients with a lower social
economic status. They
observe more and more that
patient and to learn what is important for a patient. It Digital system
gives the The nurses would like to integrate low financial resources of the
the intervention in the digital patients complicate their
COPD management.
tools to discuss many topics in more detail, enhancing Financial costs can be, for
patient general practitioner system in order
to use it on a computer or a example an obstacle for a
healthy lifestyle. The nurses
knowledge, enhancing understanding and awareness. mentioned that a growing
mobile device.
number of patients could not afford to visit specific patient groups. the results the current
fitness clubs to enlarge their physi-cal Furthermore the nurses evaluationX
activities and a growing number of patients described that if the COPD-
could not pay their medication because of GRIP intervention will be
the own contribution within their health implemented in the future,
assurance.X extra attention should be paid Table 3
to the development of
financial and au-thorization
3.2.3. Recommendations models. Summary of the facilitators and
barriers of the COPD-GRIP
intervention.
The nurses gave some recommendations
for the future. Firstly, in order to make the Facilitators
The key strength of the
COPD-GRIP intervention more feasible, Barriers
present study is that we used
the nurses recommended to integrate the
a mixed-method procedure to
COPD-GRIP intervention into the digital
obtain an in-depth
general practitioner system so they can use
exploration and Sufficient knowledge to provide
it on the computer or mobile device.
understanding of the nurses' Lack of time and financial models to
Secondly, to apply the intervention in the
experiences with the intervention within the trial.
future the nurses would like to receive accommodate three consultations
intervention in order to
more training and education.
identify fa-cilitators and
barriers in applying the within six weeks within normal
3.3. Summary COPD-GRIP intervention in
clinical nursing practice. practice.
Took less time than expected.
A summary of the facilitators and barriers In patients with a different cultural
as described in the questionnaires and in Another strength is that this
the focus groups is provided in Table 3.X study was nested within a background.
cluster-randomized trial.
Structured tool to provide
Although comprehensive In patients with lower social
4. Discussion process evaluations along- economic
side randomized trials are individualized patient-centered care.
status.
In this study we evaluated the nurses' increasingly carried out ( Good method to address perceptions
experiences with the new COPD-GRIP Bleijenberg et al., 2013;
In patients with lower health
intervention. To our knowledge this is the literacy.
Fairbrother et al., 2013; and needs of the patient. Essence of
first nursing in-tervention that translates the
Langer et al., 2014) it
evidence concerning illness perceptions
remains a relatively
into a practical guide that nurses can use in nursing profession.
uncommon procedure in
clinical care. The study re-vealed that the
trials of complex
COPD-GRIP intervention is experienced as Booklet is clear handhold.
a worthwhile tool that provides structured, interventions in general (
individualized and patient centered care to Craig & Petticrew, 2013;
Intervention is a tool to discuss
guide the patient with the COPD. Several Moore et al., 2015) and many
facilitating factors were identified. Firstly, specific in studies concerning
according to almost all nurses in this study, illness perceptions
the COPD-GRIP intervention is a good interventions in other chronic topics in more detail, enhancing
method to address perceptions and the disease patients ( Broadbent,
needs of COPD patients. Secondly, patient knowledge, enhancing
Ellis, Thomas, Gamble, &
applying the COPD-GRIP inter-vention
took less time than they expected. Thirdly, Petrie, 2009; Davies et al., understanding and awareness.
the COPD-GRIP in-tervention as a valuable 2008; Jansen, Heijmans,
tool to discuss many topics in detail and to Rijken, & Kaptein, 2011;
improve the care for COPD patients. Petrie et al., 2002). To
Barriers were encountered, espe-cially in
prevent bias in interpreting
90 S.W.M. Weldam et al. / Applied Nursing Research 33 (2016) 85–92
The finding that nurses in our Nutbeam, 2008). These
study experienced barriers in patients could experience
study should be conducted before the
patients with another cultural problems which dominate the
results of the trial are known. The findings
background than the Dutch health problems. Therefore, it
of this study will provide nurses, other
background, in pa-tients with remains veryX
health care profes-sionals and policy
a lower social economic
makers with vital information about how
status and in patients with a
the new COPD-GRIP intervention can be
low health literacy is not important to explore their
implemented and used in daily practice.
surprising. Chronic illness situation and identify their
case management in these problems in daily life. Hence,
Although the questionnaires and focus patient groups require high we need to adjust the COPD-
groups provided a great deal of rich data, level competencies ( Hibbard GRIP intervention by de-
the study has some limitations. One scribing simple supportive
limitation is that we have not measured & Gilburt; Smolowitz et al., interventions as to ask “What
treatment fidelity. Although all nurses 2015). Although the basic concerns do you have in your
received the same educational session by assumption of the COPD- daily life” or “Are there issues
the same researcher we could not pro-vide GRIP intervention is to you like to discuss with me?”,
information on how the nurses applied the explore the perceptions and or to use a question prompt
intervention during their consultations. needs of the patient, the list. A recent study shows that
Secondly, we did not collect data intervention does not low literate patients
concerning the ex-periences of the nurses describes in detail how to use themselves feel less confident
with the educational sessions. Evaluating the in-tervention in these and perceive more obstacles
these sessions might have provided us with specific patients. Even though in the communication in
recommendations to develop the the Common Sense model medical consultations as well
educational sessions in the future. and self-regulation theory ( ( Henselmans, Heijmans,
Leventhal et al., 2003) takes Rademakers, & van Dulmen,
Some identified barriers of applying the the social context into 2014). Therefore, it is
COPD-GRIP intervention in this study are account, this approach to important to pay extra
in line with barriers described in other health and illness is predomi- attention that patients feel
studies. The iden-tified barrier of financial nantly a Western world confident within the
and authorization models in the future, is approach ( Baumann, consultations ( Henselmans
also described as a barrier in a study where
et al., 2014; Smolowitz et al.,
primary care nurses applied a telephone- 2003). The cultural setting
delivered health monitoring in COPD defines explicit features of 2015).X
patients ( Walters et al., 2013) and in a illness perceptions (
study focussing on nursing interventions Baumann, 2003). To ex-plore 5. Implications for nursing
for frail elderly people in primary care ( these features the COPD- practice
GRIP intervention might be
Bleijenberg et al., 2013). Other studies
helpful. However, to apply
show that not only financial models are To enhance implementation
this intervention in patients
important to implement chron-ic care of the COPD-GRIP
with different cultural
management in primary care, but intervention, we have defined
backgrounds and to detect
organizational priorities could hinder a three recommendations based
cultural variations,
successful collaborative patient-practitioner on the results of this study.
adjustments should be made
relationship ( Kennedy et al., 2014; Young by adding a cultural First, the nurse should be
well educated and trained in
et al., 2015).X assessment as described by
applying the COPD-GRIP
Clark ( Clark, 1996) and intervention. Second, models
Bauman ( Baumann, 2003). for financial compensation
Other barriers in the current study are in
and authorization need to be
line with the barriers re-ported in two This means that in order to
developed. Third,
studies in which a new intervention in un-derstand cultural
adjustments in applying this
primary care was evaluated ( Bleijenberg et variations in illness intervention in specific
perceptions, it should be
al., 2013; van Eijken et al., 2008). Al- patient groups need to be
empha-sized that the context,
though these studies evaluated nursing made.
the underlying premises
interventions that focuses on frail elderly
(such as causes of a disease)
patients, we can compare the barriers at the
of behavior and the meaning 6. Conclusion
level of the nurses, because the studies used
of specific behaviors should
the same questionnaire based on a
be ex-plored in more detail ( The current study meets the
structural list of barriers and facilitators (
Baumann, 2003; Clark, emerging need for research
Peters et al., 2003). Bleijenberg and
1996).X regarding development and
colleagues ( Bleijenberg et al., 2013) evaluation of nursing
indicate that in line with our re-sults, interventions in COPD care
barriers were encountered in patients with In patients with a lower that addresses patient unmet
multimorbidity, in pa-tients with different social economic status and a needs and takes illness
cultural backgrounds, in patients with a lower health literacy it is perceptions into account.
lower social economic status. In the study likewise important to Although adjustments in
by van Eijken ( van Eijken et al., 2008) as understand the context and applying the intervention in
needs of an individual patient specific patients groups
well as in the study by Bleijenberg ( by asking which problems should be made and financial
Bleijenberg et al., 2013) the same barriers patients encounter in daily and authorization models
concerning time and financial compensation life before starting to assess should be developed, the
were identified.X the illness perceptions ( outcomes in this study show
that a nursing in-tervention
Hibbard & Gilburt; which takes illness
perceptions into account is a valuable im- analysis, reviewing, and final following experts for their
provement in providing individualized editing of the manuscript. participation in the expert
COPD care. MZ con-tributed to the data group and their valuable
collection, data analysis and contribution to the
reviewing of the man-uscript. development of the COPD-
Funding
MS contributed to the study GRIP intervention: Carien
concept and design, Roos (respiratory nurse),
This study is funded by Partners in Care providing input on the data Larissa Verweij (respiratory
Solutions for COPD (PICAS-SO). analysis, reviewing, and final nurse), Caroline Veelers-de
PICASSO had no role in the design, editing of the manu-script. Bruin (respiratory nurse),
collection, analysis and interpre-tation of All authors read and Marjorie de Man (clinical
data; in the writing of the report; and in the approved the final nurse specialist), Ad Kaptein
decision to submit the article for manuscript. (profes-sor Health
publication. Psychology), Alfred Sachs
(general practitioner).
Author contributions
Conflicts of interests
We would like to thank all
the nurses within the COPD-
SW contributed to the study concept and
The authors report no GRIP trial who gave their
design, data collection, data analysis, and
conflicts of interest. time to participate in this
writing of the manuscript and takes full
study. We would like to thank
responsibility for the integrity of the data
Simone Sluis (study nurse)
and the accuracy of the data analysis. JWL Acknowledgements
for here valuable help in the
contributed to the study concept and
organiza-tion of the focus
design, providing input on the data
We would like to thank the groups.
S.W.M. Weldam et al. / Applied Nursing Research 33 (2016) 85–92
91

Petrie, K. J. (2009). Can an illness

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