TDF domain | Theme (Barrier [B], Enabler [E], Mixed [M]) | Quote |
---|---|---|
Stroke prevention | ||
Social professional role and identity | HCP did/ did not perceive prescribing stroke prevention their role (M) | “I: Do you see that as part of your role as well, around the stroke prevention, diet and exercise? IV: Totally. So, in terms of stroke prevention, we do lots of education with our patients that come through to ESD.” [H14, AHP, 17 Years of experience] “I think for TIAs it would be more kind of about prevention, wouldn’t it, really. Lifestyle and education and prevention, which wouldn’t really be our role.” [H5, AHP, 16 Years of experience] |
Belief about capabilities | Confident/ not confident in prescribing stroke prevention medication (M) | “…But certainly, blood pressure always worries me, I don’t think we treat blood pressure well. I don’t treat it, I don’t manage it because I’m a Neurologist by training. So, I think I lack expertise…” [H20, Neurologist, 22 Years of experience] |
Environmental context and resources | Lack of time to address lifestyle change (B) | “So, we talk about stopping smoking and healthy diet and exercise but it’s a fairly brief discussion and don’t really feel I have time in the clinic to do that in great depth.” [H20, consultant, 22 Years of experience] |
Information leaflets used to address lifestyle change (E) | “Again, we use a lot of the Stroke Association’s resources, like leaflets about exercise after stroke, prevention and risk of stroke which we tend to give out to patients.” [H1, AHP, 5 Years of experience] | |
Intentions | GPs actively reviewed patients’ medication vs issuing repeat prescriptions from secondary care (M) | “Usually what would happen is we get a letter from the specialist and we add the medication that they’ve suggested onto the person’s repeat medications.” [H13, GP, 13 Years of experience] “…personally I quite like to see patients particularly when patients have been started on a whole bunch of new tablets… So, I like to get them to come and see me.” [H11, GP, 18 Years of experience] |
Lifestyle change not meaningfully addressed or actively supported (B) | “Diet maybe we could improve, I don’t talk a lot about diet I’ll just say generally healthy diet and that’s all I’ll say. Smoking, I’ll tell people to stop smoking but I won’t talk about medication for that…” [H20, consultant, 22 Years of experience] | |
Goal | Stroke prevention was/ was not considered a goal of HCPs’ follow-up (M) | “The whole point [of a TIA clinic] is that they’re at increased risk early, so the whole point to come and see them early is to get treatment started early.” [H21, consultant, 24 Years of experience] |
Beliefs about consequences | Lifestyle change considered important for stroke prevention (E) | “I’m very passionate about how lifestyle can change your life or has an effect on your life.” [H17, consultant, 8 Years of experience] |
Residual impairments | ||
Knowledge | Knowledge/ lack of knowledge of residual impairments (M) | “I don’t think there is an awareness that there are these long-term sequalae... So there’s probably a bit of a lack of, well speaking personally, I don’t know what my colleagues would say, but there might be a lack of education, medical education about the, yeah, the long-term consequences really.” [H13, GP, 13 Years of experience] “But actually, from our experience, we see a lot of patients who have had a TIA and you know, they may only have had symptoms for 10 min but actually, there are a lot of other, what we call sort of hidden effects that I think are missed.” [H22, nurse, 13 Years of experience] |
Beliefs about capabilities | Confidence/ lack of confidence in addressing residual problems (M) | “I don’t think I will bring back somebody to manage their mood and fatigue because I don’t feel competent in doing that and probably I’m not.” [H17, consultant, 8 Years of experience] “Yeah, I feel confident being able to then draw from that whether they needed directing to further psychology referral or whether it’s maybe just providing that sort of information with regards to prevention or what they’ve actually been through. I’d feel quite confident being able to do that, from having talked to them.” [H1, AHP, 5 Years of experience] |
Intentions | Stroke prevention prioritised over residual problems (B) | “I guess I prioritise things which I think are extremely important, so smoking advice, cessation advice, exercise, restrictions into what they can do... The things which are absolutely mandatory to make sure that they completely understand the importance of their medication and why they’re taking it and what side effects they may get, that sort of thing; things which are commonly going to arise. I guess I probably don’t spend so much time, unless they specifically ask, about the slightly more quality of life activities of living questions that they may have.” [H24, consultant, 12 Years of experience] |
Skill | Some AHPs/nurses had the skills to actively addressed residual needs (E) | “As an OT, obviously we’re dual trained in physical and mental health. So, we do have a certain basic training in terms of anxiety management skills, anger management, those types of things.” [H14, AHP, 17 Years of experience] |
Beliefs about consequences | AHPs/ nurses believed in the value of a “supportive chat” which involved active listening, acknowledging patients’ needs and reassurance (E) | “But then a lot of the time spent with them doing the supportive chat will be reassurance wouldn’t it you know. I think a lot of people I think supportive chat and reassurances is a big thing that people perhaps require and then if they don’t have that that’s when things build up and the stress levels and stuff are worse.” [H4, nurse, 37 Years of experience] |
Education about diagnosis, stroke risk and medication | ||
Intentions | HCP provided/ did not provide education (M) | “Rightly or wrongly I think we have to really make the assumption that the patient has been counselled adequately about that medication and why they’re being put on it in secondary care, yes, because otherwise it’s duplication of work” [H13, GP, 13 Years of experience] “We do a lot of education on exercise and basically, the benefits of keeping active, diet, alcohol and smoking.” [H1, AHP, 5 Years of experience] |
Beliefs about consequences | Belief that it is difficult for patients to retain information provided at the acute stage (M) | “in the acute phase when patients are seen [patients get] an awful lot of information ... And so the amount of information that they absorb is tricky...” [H11, GP, 18 Years of experience] |
Use of support services and resources | ||
Environmental context and resources | HCPs used/ did not use support services (M) | “Smoking cessation I have to say I don’t often refer them to a smoking cessation clinic. I’m guilty of not doing that…” [H24, consultant, 12 Years of experience] “The main ones that we do refer to tend to be the Stroke Association... There’s a Recover group, I think, for alcohol and drug substance misuse. We’ve got referral forms for quite a different few and various links for different reasons and we would refer if necessary.” [H1, AHP, 5 Years of experience] |
Lack of support services (B) | “The other side of the problem is that there is very little to refer to.” [H3, AHP, 23 Years of experience] | |
Barriers to accessing support services, including long wait times, referral processes, transport issues and geographical boundaries (B) | “I mean at the moment, again, it’s the waiting times, a lot of people complaining, that I’ve been told, I’ve rung them, but they see they can’t see me for eight weeks, ten weeks, something like that.” [H7, consultant, 20 Years of experience] “I always feel like there are big geographical gaps. [H3, AHP, 23 Years of experience] “I think transport is a huge issue.” [H3, AHP, 23 Years of experience] | |
Directories used to facilitate identification of support services (E); however, these were often outdated (B). Successful directories had someone delegated to update them (E) | “We have our own directory … and basically what people do, what’s the name, how do you refer and how do you access. We already have an inhouse directory... We have an admin person that manages that directory, any new updates, any new differences to the referral pathway, any different forms, that is updated by our admin staff…” [H9, GP, 6 Years of experience] “…but I must admit in the past when I’ve been sent little directories of support services, they are useful but it suddenly becomes limited after about six or twelve months because a lot of these organisations are they don’t sustain… they just change or they move or whatever…” [H8, GP, 17 Years of experience] | |
In primary care, access to social prescribers or community champions facilitated identification of support service (E) | “…locally we’ve got something called Community Information Champions and I think a couple of our staff are trained, so a couple of receptionists, our healthcare assistant, they get additional training and normally it’s about accessing services, it’s our healthcare assistant she’s really good at that…” [H8, GP, 17 Years of experience] | |
Knowledge | Knowledge/ lack of knowledge of support services (M) | “I’d say good knowledge of what’s available but it’s probably not a very in-depth knowledge of what the service, potentially, will always offer.” [H1, AHP, 5 Years of experience] “I don’t have knowledge of what services are there.” [H20, consultant, 22 Years of experience] |
Memory, attention and decision processes | AHPs proactively searched for services to meet specific patient needs (E) | “…the other day I saw a patient who might benefit from maybe like a befriending type scheme. So, I’m going to look into that for her… if I feel that there’s something a patient would benefit from, just come away and do my own kind of internet searching.” [H16, AHP, 4 Years of experience] |
Patient factors | ||
Social influences | Patients refusing referral to support services, denial, low education, IT illiteracy and comorbidities were barrier to addressing needs (B) | “I think some people, not all, but they don’t really want that ongoing support. Cause obviously that’s a barrier in itself. Cause sometimes there’s patients where you feel that they would benefit more from it but if they’re not consenting then there’s nothing you can do.” [H16, AHP, 4 Years of experience] |
Family members often supported patients to access services or online resources, and relayed/ repeated information (E) | “Family are usually very good at helping. If family are available and around, they usually can be really good with directing or helping patients to work out what they need to access.” [H1, AHP, 5 Years of experience] |