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Table 3 Thematic Analysis of Primary Care data

From: Referral of patients to diabetes prevention programmes from community campaigns and general practices: mixed-method evaluation using the RE-AIM framework and Normalisation Process Theory

Topic Exemplar Data Initial interpretation & analysis Interpretation with NPT Constructs
1. Adoption: engagement of providers    
1a) Coherence: consensus, agreement and congruence around shared purpose GPs [General Practitioners] are interested in health promotion and disease prevention, but actually they’ve already got a load of stuff to do with people who are already ill.” Primary focus group 1 “I think we’re very restricted time-wise because of staffing to sit down with patients to impart that information and utilising the services that are setup.” Primary 3 Value of prevention recognised but accompanied by perception that practices themselves are under- resourced to deal with this. High coherence, with all participants agreeing on the need for a prevention programme with patients at risk of diabetes, and agreement that existing practice resource was insufficient.
1b) Cognitive participation: roles and relationships “You need to be a healthcare professional, yeah … You’ve got to interpret the blood results, look at the patient records to see if they’re suitable.” Lead 5 “Having somebody that knew about diabetes … and able to make decisions at a higher level. You need that gravitas of someone who’s clinically trained. The patients respect that more.” Primary focus group 1 “I put together flowcharts for our surgery about what to do around blood sugar, I adapted the stuff that the nurse facilitator had originally sent me and I did a flowchart for staff on how to refer so I’ve done quite a lot of work … It’s taken months of implementing.” Primary 3 The support of the NF (Nurse Facilitator) was viewed by practices as providing additional full capacity to co-ordinate and deliver referrals (as opposed to supporting the practices to do this themselves). Perceived as essential that the role was for a Nurse, who could interact with the clinical systems and with patients in a clinical capacity. Practices which did not receive full support reflect on complexity and burden of referral process. Cognitive participation was straight-forward given that consensus was that the NF needed to act independently rather than requiring additional work by the practice staff. There was also agreement that the nurse facilitator was the appropriate role, as the person offering support needed to be clinically trained. In those practices where the full support of the NF was not provided, practices instead reflected on the burden created by referral, again demonstrating that cognitive participation for these participants centred around the difficulty of practices themselves trying to do the work and therefore needing full support.
2. Implementation and barriers to implementation    
2a) Collective action: relationships and confidence in each other A lot of [GPs] felt that the education they already gave them [patients] was adequate … so their question was why should we refer in?... But when you then explain how you go into things in great detail [in the telephone service] and what we actually do, they could see what’s going on.” Lead 5 The NF role as part of the telephone service increased understanding of the service. The model of NF was simple to implement in comparison to the community route given that a need for collective action was largely avoided – the role of the NF in conducting the work in practices and liaising directly into the telephone service meant the interactions were simplified. The NF’s dual role as part of the telephone service itself further embedded trust in the process by being able to directly communicate value to GPs.
2b) Reflexive monitoring: extent to which there is a shared understanding about the intervention. “It’s certainly built up relationships. I still get emails now from doctors in different practices and practice nurses, so they’re now aware of the service which before they may not have been... … they now know that they’ve got somebody to contact if they need the help … I think once you’ve got that link they will be more receptive to referring in and the services and helping the patients.” Lead 5 “I’d refer to our Health Care Assistant [HCA] … they’d get a face-to-face with a HCA. I could understand if I was getting some diabetic input … If it’s just for a chat on the phone then I wouldn’t refer. If it was just to a health care person then I’d do that in-house.” Primary focus group 1 Participants again reflected on the value of the NF being integrated with the telephone service itself, which provided reassurance and an accessible way to clarify issues regarding referral and the service. Possible changes to the telephone service intervention itself (removing a first contact with a Diabetes Specialist Nurse) may threaten the evaluation of the service as useful, and consequently the need for referral. Reflexive monitoring was supported by the NF being the person performing the referrals and also part of the telephone service itself, providing a clear means for staff to understand the value of the service. However, this may be undermined if primary care staff felt that patients would not benefit from additional specialist input, demonstrating how congruence (perceived value) can be reflectively reassessed and may decrease cognitive participation and collective action.