Table 2 Barriers and facilitators to implementing the hand-held fan for breathlessness in specialist respiratory care as identified by clinician focus groups and classified using the Integrated Behavioural Model (IBM) [35]
IBM construct | Â | Barriers | Facilitators |
|---|---|---|---|
Instrumental attitude | Knowledge and beliefs about fan-related benefits and harms | Most participants lacked a knowledge of the fan’s evidence-base A small number of participants were concerned that patients might become over-reliant on the fan | Clinician awareness of evidence for the fan might benefit from greater inclusion in clinical practice guidelines None of the participants believed the fan posed a serious risk of harm so were more prepared to ‘try it’ even if unaware of evidence for benefit |
|  | Knowledge and beliefs about the fan’s mechanism | Participants who believed the fan’s mechanism to be mostly psychological recommended it only to anxious patients Most participants reserved the fan for ‘end stage’ disease None of the participants considered the fan suitable during an exacerbation | Educational efforts should focus on persuading clinicians to recommend the fan to any patient with COPD for whom breathlessness impacts on daily life, regardless of anxiety and disease stage Use of the fan during exacerbations should be promoted in line with ATS guidance for breathlessness ‘crises’ [9] |
Experiential attitude |  | Participants were much more motivated by the fan’s benefit/harm profile than whether it appeared ‘cheap’ or ‘plasticky’ | None relevant |
Normative beliefs | Descriptive norms | Participants’ views were relatively unaffected by colleagues, being much more influenced by patient reports regarding efficacy | Patient advocacy has been a key facilitator to date Clinical champions may have potential but are as yet untested |
| Â | Subjective norms | At a setting level, participants tended to consider outpatient and community services more appropriately placed to implement the fan than inpatients, where patients were acutely unwell At a specialty level, some participants expected specialist palliative care to recommend the fan rather than respiratory care At a discipline level, some nurses and allied health professionals considered doctors to be more focused on pharmacological than non-pharmacological management, but doctors refuted this At a clinician level, participants agreed that anyone could recommend the fan but were unclear whose role this should be | Allocate the fan within the scope of practice for respiratory care within each setting and discipline for all or selected roles |
Personal agency | Perceived behavioural control | Participants expressed a high level of autonomy with regard to the fan, rendering this no barrier to implementation | None relevant |
| Â | Self-efficacy | Most participants were uncertain which type of fan to recommend and how to train patients to use it optimally | Promote types of fan supported by emerging evidence [59] Further research is required to identify the optimal approach to training patients in using the fan |
Environmental factors | Â | A lack of hand-held fans in the inpatient setting posed a significant barrier | Establish locally-contextualised models for ensuring fans are available to patients in the inpatient setting |
Salience and habit | Â | In a time-pressured procedurally-driven inpatient setting, implementation was perceived to be hindered by the fan not being part of a standard protocol | Include the fan in ward protocols |