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Table 4 Quotes illustrative of refined CMOs

From: Implementing pelvic floor muscle training for women with pelvic organ prolapse: a realist evaluation of different delivery models

Facilitators Barriers
Refined CMO 1a explaining the impact of PROPEL on access to PFMT
‘I think although I did have the advantage of being a physio over perhaps my nursing colleagues, who I know felt a bit overwhelmed with the whole process of doing it, so, yeah, I felt sort of in the middle where obviously, at the time, I hadn’t had much experience, that was the first time I’d actually treated anybody with a prolapse. But, yeah, I’ve gone on to treat more and I think the training was great, it was good, but what helped me more was the confidence of having worked alongside a specialist. H011 (MSK Physiotherapist with special interest in women’s health) [Rd 4 Intv 2] ‘I do remember feeling very uncomfortable [at the training session]. I don’t know why. I just think...I think I felt uncomfortable mainly because anybody else that was there probably had some kind of experience doing [internal] examinations and things […] but I had never, ever, done anything like that.’ H006 (Community Nurse & Link Nurse for continence) [Rd 3 Intv] 2 [Withdrew from study]
Refined CMO 1b explaining the impact of PROPEL on access to PFMT
‘Certainly the GPs are more aware and I suppose where they used to just send patients to me who just wanted incontinence pads, well now they send them for other continence issues as well, kind of thing. But they send them more for treatment rather than for just management, if you know what I mean.’ H007 (District Nurse, including Continence Link Nurse) [Rd 3 Intv 2] ‘I’ve noticed that my caseload has been particularly quiet this year. I’m not quite sure of it definitely but I’m thinking {PFMT service] it’s maybe just not known as much. I’ve sent out emails. I sent one out to the GPs about a year ago to try and flag up that I was participating in the study and just to try and get some referrals coming in. The ones I’ve had since I have noticed that some of them have been referred straight to gynaecologists, and gynaecologists have referred them back to physio. So, I don’t know if there’s a bit of GPs just not sure of the service.’ H020 (Community Physiotherapist, MSK & women’s health) [Rd 4 Intv 2]
Refined CMO 2 explaining the impact of PROPEL on women’s health
‘Oh, I’d be 100 % a positive experience, and I’m glad that I had that experience. I’m not glad that I’ve got a prolapse, but I’m glad I’ve had the experience of discussing it with the physios, and being shown how to do the exercises probably better than I would have done them without any intervention by physios. So my experience is a very positive one.’ H019 [Rd 4 Intv 2]
It was excellent, because the benefits I’ve reaped from it. […] the prolapse is not cured 100 %. But I have, I feel I have quality of life back, I have control over it.’ G012 [Rd 4 Intv 2]
‘We’d forgotten the training by the time we started to […] see the patients, and that’s why we started to [deliver PFMT] together […] Because we felt more confident the two of us doing it […]. L015 (Gynaecology ward nurse) [Rd 3 Intv 1]
‘But we were concerned that, Were we doing it right?, Were we good enough?. […] We were a little bit concerned.’ L015 (Gynaecology ward Nurse) [Rd 3 Intv 1]
Refined CMO 3 explaining the impact of PROPEL on service delivery
‘I think it fits in really well with my workload; it doesn’t impact it at all.’ Med 005 (MSK Physiotherapist) [Rd 4 Intv 1]
‘I think in terms of a clinical research team, the admin team, the physios, everybody is proactive about what they are doing and also nudge each other in doing what they are doing. […] So, kind of, being proactive about what you are doing and having the general set-up and pathways, I think leads to that, and good managers who actually do allow you to be available for such kind of research that is going to enhance the service, I think is what’s needed. […] So yes, a good manager and a good team. M003 (Manager/Service Lead, Physiotherapy team) [Rd 3 Intv 1]
‘Well, we both work as staff nurses on the gynae ward, and then we’ve been trying to sort of carry out the PROPEL study within that role, which, in itself, we feel has been quite difficult. Because you’re sort of on the ward one minute and you’re in charge of the ward, or in charge of the patients, and then we’re having to switch off of that and go over and do a PROPEL’s lady, which can be quite difficult, can’t it?’ L015 (Gynaecology ward nurses) [Rd 3 Intv 1]
Refined CMO 4 explaining the impact of PROPEL on implementation plans
‘Well, I suppose I’ve not really spoken to...apart from with people who are the physios and nurses. And I think their response to that is quite positive about it being...because we live in a remote and rural area I think we’re far more open to services being delivered more widely because patients have such long journeys to travel to get treatment. So as you know we have some specialist physios up here who have already trained people throughout NHS Highland to be able to deliver it in other remote and rural areas, because otherwise we were only seeing just such a small number of people that actually were needing to be seen. So I feel that that’s why we’re thinking this is quite good if we can get some nurses on board and trained up as well’. H (Senior AHP 002), [Rd 1, Intv 1]
‘Well, particularly for places like [place name] where we don’t have a specialist physio I think it would be useful, and because I know also the physios are understaffed, so I don’t think it matters. As long as we’ve got somebody who’s got the training, whether that’s the physio or a community nurse, as long as it’s available to the patients then I think that would be beneficial’. H (District nurse 002), [Rd 2, Intv 1]
‘Well, the obvious one (barrier) appears to be role protection. It seems to me it’s a bit unfair to say that but I got the distinct impression that there was reluctance to train people of a lower deemed banding or skill mix to do something that was more skilled’ L01 (Service manager) [Rd 1, Intv 1]
And, you know, again, for someone who’s just had the basic training, yes, they might be able to treat someone who’s very basic … you know, like a stress incontinence patient, or someone who’s very, you know, straightforward. But not, you don’t get many people like that, from my experience. Most of my patients with prolapse symptoms will have, you know, maybe overactive bladder symptoms, or stress incontinence, they might have sexual dysfunction. So you might find that there’s a lot more there, that if someone has only done a brief training course, that that’s way more advanced for them, you know, and having bowel incontinence issues. And again, it’s, I think it’s difficult to train someone up, unless you’re a specialist physio within, you know, pelvic, obstetric, and gynaecology physiotherapy. G006 (Specialist physiotherapist) [Rd 4 Intv 2]