A total of 9 focus groups were conducted, 4 at hospital #1 and 5 at hospital #2. Forty-nine clinicians participated in total (22 at hospital #1 and 27 at hospital #2), with numbers in each focus group ranging between 4 and 7. Samples from both hospitals included nurses, doctors and allied health professionals. Participants at hospital #1 were generally more likely to recommend the fan to ‘all/nearly all’ patients than those at hospital #2 (8/22 versus 2/27 respectively), but the proportions recommending to ‘most’ patients were similar (7/22 and 10/27 respectively). Focus groups lasted between 19 and 37 min. Further participant characteristics are summarized in Table 1.

Table 1 Characteristics of 49 clinicians from specialist respiratory care who participated in 9 focus groups exploring barriers and facilitators to implementing the battery-operated hand-held fan for chronic breathlessness in patients with COPD

Nearly all line-by-line codes could be mapped to the IBM framework. Findings relating to each of the framework’s constructs are summarized in Table 2 and described in more detail as follows.

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]

Attitudes

Instrumental attitude

Knowledge and beliefs about fan-related benefits and harms

The most influential factor determining clinicians’ willingness to recommend the fan appeared to be their ‘instrumental attitude’—in particular, the degree to which they believed that patient benefit outweighed any disadvantages or harms.

When asked about barriers to implementing the fan, some participants highlighted a “lack of knowledge or a lack of awareness of how a fan can help” (Hospital 1, Pulmonary rehabilitation), with doctors indicating they hadn’t learned about fans in medical school or post-graduate training. Only a few participants appeared familiar with research evidence for the effectiveness of the fan, which they had heard about through related training. Even these participants identified clinical experience as a more important driver.

“She [a trainer] told us about some research that had been done in England about the fan how it can help people with their breathlessness. So, I read up about it, started recommending to patients, and found that it does really help them with their breathlessness.” Hospital 1, Nurse

Most participants reported learning about the fan through patients’ endorsement, and perceived that patients usually learned through the same source.

“Patients who are already using the fan encourage other people to use the fan.” Hospital 1, Nurse

Participants perceived patients to have reaped a range of benefits from using the fan. For some, this included a patient perception that the fan had relieved breathlessness intensity.

“My patients that I’ve had, they’ve reported that they feel a lot less breathless with the fan on and they tend to self-initiate the hand held fan when they do start feeling breathless, as well.” Hospital 1, Advanced trainee

Participants in four focus groups also reported observing psychological benefits from the fan, including reductions in anxiety and feelings of panic.

“Yeah, and in saying that, I’ve had patients say it eases anxiety when they’re really short of breath; rave about it.” Hospital 1, Nurse

The fan was also perceived to increase patients’ confidence, allowing them to extend their activities of daily living.

“The patients have said that it makes them feel less breathless and more confident in managing attacks of breathlessness. So they feel more confident leaving the house, for example. Yeah. That’s probably the main things they’ve said.” Hospital 1, Advanced trainee

One participant also described the benefit of patients using the fan during exercise.

“I also found that during the exercise program, patients cope better doing their exercises if they are holding a fan while they’re exercising.” Hospital 1, Nurse

None of the participants considered there to be serious harms associated with using the fan. Potential harms that were raised by participants but dismissed as minimal included risk of injury from the blades (“that stuff [the blades are made of] is soft” Hospital 1, Advanced trainee) and fire from batteries (“lithium batteries burn hot and durably, I thinkHospital 2, Physician). The lack of perceived harms encouraged participants to take a “why not try it?” (Hospital 1, Nurse) approach to recommending the fan, even when they were uncertain whether a given patient might benefit.

“If I was worried that it would do the patient harm, yes, I would have more questions and reservations about it, but I just don’t feel that way about hand held fans.” Hospital 1, Advanced trainee

Participants were more divided on the risk of transmitting COVID-19, with those at hospital #2 expressing more concern than those at hospital #1. At hospital #2, management had prohibited the use of all fans on inpatient wards alongside other restrictions while Sydney was subject to public health orders. Participants at hospital #1 were surprised to learn that fans had been banned at hospital #2, and were generally dismissive of any risk.

“Advanced trainee 5: I’m not sure how aerosolizing a hand held fan can necessarily be.

Advanced trainee 2: I don’t think there is a significant risk.” (Hospital 1)

The only disadvantage that appeared to dissuade anyone from recommending the fan was a belief that some patients could become overly reliant on the fan, expressed by an allied health professional and nurse in two different focus groups at hospital #2. These clinicians were concerned that patients might become anxious and debilitated if placed in a situation where the fan was not available to them.

“I can find some patients get very over-reliance on the fan as well. They won’t move or do anything without having the fan with them. But obviously, yeah, like [participant’s name], I would explore other techniques first before giving them a fan.” Hospital 1, Allied health

Some participants also perceived there to be belief-related barriers among some patients to the fan, including a concern that the fan might worsen a pollen allergy, a cultural belief that drafts could cause colds, and an image issue for some men.

“[Patients say that] ‘when a draft blows through, then I got a cold’ kind of perspective. So, I definitely have had some patients – and sometimes it’s from certain cultural backgrounds – that absolutely do not want any wind blowing on their face.” Hospital 1, Advanced trainee

[Unlike women] A lot of men don’t carry a bag around, and they’re a bit more reluctant to carry the fan with them when they go out.” Hospital 1, Pulmonary rehabilitation

Knowledge and beliefs about the fan’s mechanism

Perceptions regarding the fan’s mechanism seemed less important than benefit in determining whether participants recommended the fan, but did determine which sub-groups of patients they chose to offer it. In particular, participants who believed the fan’s mechanism to be primarily psychological recommended it predominantly to patients presenting with comorbid anxiety.

“We also get panic attacks very frequently, like anxious patients. We can recommend [the fan].” Hospital 2, Inpatient nurse

Perceived psychological mechanisms were variously described in terms of a “placebo effect” (Hospital 1, Inpatient nurse), “calming” (Hospital 2, Inpatient nurse), mindfulness (“just focus on their breathing when they’ve got the airflow on them” Hospital 2, Inpatient nurse) and distraction (“looking at the fan does give them something different to think about” Hospital 1, Inpatient nurse).

Clinicians in three focus groups also reported reserving the fan for patients in the “palliative” or “end-stage” (Hospital 2, Inpatient nurses) phase of disease after other interventions had failed.

“I don’t bring it up for those individuals who are not quite accepting of their situation, in terms of their diagnosis and how breathless they are, or who lack insight into that. Because then moving on to a strategy to fix that isn’t successful. But I wouldn’t say it’s my last… It’s not my last resort. It’s in combination with several other non-pharmacological strategies.” Hospital 2, Advanced trainee

However, one participant raised a concern that patients with end-stage disease were sometimes “too weak” (Hospital 2, Inpatient nurse) to hold the fan, requiring a desktop or pedestal fan instead.

Several participants from the inpatient setting also prioritized other management interventions during an acute exacerbation, considering the fan suitable only for everyday management.

“Yeah. If there’s an acute deterioration and their respiratory rate is very high they’ve dropped their sats [oxygen saturation] I’m not going to be recommending a fan. I’m worried about other things going on, like they’re septic or something like that. But, long term … [that’s when the fan might be useful].” Hospital 2, Inpatient nurse

Of participants who thought the fan had a physiological mechanism, the majority had a general understanding that this involved airflow, but only a minority were able to describe this in more detail. Where explanations were offered for how airflow affected the sensation of breathlessness, these included reference to “pushing air in” (Hospital 2, Inpatient nurse) and “reducing the work of breathing” (Hospital 1, Advanced trainee), as well as neurological pathways involving various kinds of “receptors”.

“So there are lots of inputs that cause dyspnea, and they might be mechanoreceptors, nociceptors, and the like, which feed back centrally to give a perception that someone’s not getting enough air. And I suspect, in some patients with chronic lung disease, that those receptors, those mechanisms, might be upregulated. Or they’ve just got barriers or end-stage disease such that those nociceptors are always turned on. And so then other receptors would dampen down those nociceptive pathways, such as a feeling of air, a sensory feeling of air coming across the face. And I think those relieve those sensations by triggering those nerve receptors and those nociceptors to get that feeling that the person’s finally getting air.” Hospital 2, Consultant

Only three participants identified involvement of the trigeminal nerve, two of whom were medical staff and one a physiotherapist.

“It stimulates trigeminal nerve and you have inputs through the central respiratory systems that tend to suppress those highest inputs, the sensation of breathlessness and respiratory drive. But yeah, that was my vague understanding…” Hospital 1, Advanced trainee

Several participants likened the fan’s airflow mechanism to fresh air, wind, home oxygen or, in one case, a menthol nasal inhaler, all of which were also perceived to moderate the sensation of breathlessness. One doctor reported advising patients who perceived benefit from home oxygen but did not meet hypoxic criteria to use the fan as an alternative intervention.

“Triggering receptors in the nose and over the face – that’d give you a sensation of air moving across. And that’s why I told them [patients] if they’re funding their own oxygen even when they don’t meet criteria and they’ve got normal oxygen levels, it’s probably the air going over their nose that gives them the relief, not the oxygen itself.” Hospital 2, Consultant

Other participants focused on the cooling effect of the fan either as the sole mechanism or in combination with airflow.

“Usually they [patients] said the cool feeling on their face kind of ‘just helps them breathe better’, in their own quotes.” Hospital 1, Inpatient nurse

In the case of some participants, it wasn’t clear whether they believed airflow and cooling from the fan reduced breathlessness or just made patients more comfortable by compensating for the stuffiness of the inpatient ward or warming effects of equipment.

“So the BiPAPs and the high flows generally blow hot air onto them, or it’s humid, so the cool air of the fan just blowing, helps to make them a bit more comfortable while they are on BiPAP or high flow, or whatnot.” Hospital 2, Inpatient nurse

Experiential attitude

By comparison, participants’ ‘experiential attitude’ (i.e. how they felt emotionally about recommending the fan) seemed less important than their ‘instrumental attitude’ in determining their fan-related practice. When asked whether they had concerns about the fan appearing too ‘cheap’ or ‘plasticky’, none of the participants agreed this was of concern either for themselves or colleagues (“If it works, go for itHospital 1, Advanced trainee). Indeed, the only emotional disposition expressed towards the fan concerned the empathy that participants felt for patients with chronic breathlessness and commensurate relief at being able to offer them interventions that might be of benefit.

“Having a fan, or knowing that there’s one handy somewhere …you can’t find anything, and then you tell the patient, “sorry, I can’t find anything” – it’s a bit frustrating to them. Somehow, you found something, and then you give it [the fan] to them, you can feel their relief for even a little.” Hospital 2, Inpatient nurse

Normative beliefs

Descriptive norms

While patient-reported benefit was the most common reason that participants gave for starting to recommend the fan, a smaller number reported learning about it from other clinicians. Participants reported learning about the fan from both respiratory clinicians (either superiors or other disciplines) and colleagues from specialist palliative care.

“Well I had my bosses suggest it.” Hospital 1, Advanced trainee

“I think the palliative care usually provides some of the handheld fans.” Hospital 1, Inpatient nurse

No participants reported hearing other clinicians criticising the fan or otherwise dissuading others from recommending it and, indeed, expressed incredulity that this would be likely.

“Advanced trainee 2: I don’t know why anyone [clinicians] would resist it.

Advanced trainee 3: Yes, it’s just a fan.

Advanced trainee 4: It seems, like, such a weird pet peeve to have, like, anti-fan.” Hospital 1

Subjective norms

Compared with descriptive norms, participants’ fan-related practice appeared to be more influenced by beliefs and attitudes they held regarding what was expected of them as a clinician. First and foremost, participants perceived their role to centre on patient care, obliging them to support the fan if they believed patients would derive benefits (see ‘Instrumental attitude’ above).

“Anything that will help the patient feel some relief, they [clinicians] won’t say anything that they’re not happy with it. It’s very patient-centred. As long as it’s beneficial for the patient…make them happy…” Hospital 2, Inpatient nurse

However, determining whose role it was to implement the fan faced a lack of clarity at each of the levels of setting, specialty, discipline and clinician. At the setting level, some inpatient clinicians felt that community or outpatient care was better-placed to teach patients how to use the fan at a time when they were not acutely unwell, or at least to reinforce its use if first introduced in the inpatient setting.

“I think it all needs to happen really in the community when they’re not in a crisis situation … here [there’s] just not being enough time to actually reinforce it before they’re out the door.” Hospital 2, Advanced trainee

“… putting them in place in an inpatient setting then reinforcing them when they follow up in the outpatient setting.” Hospital 1, Inpatient nurse

At a specialty level, some participants deferred to specialist palliative care to recommend the fan and other non-pharmacological interventions, especially those who felt these should be reserved for people with end-stage disease.

“My experience was always thinking previously that it was something that usually palliative care would end up recommending” Hospital 1, Advanced trainee

At the level of discipline, there was an assumption among some nurses and allied health professionals that doctors were more concerned with medical care and thus less likely to consider non-pharmacological management.

“But that’s because, I think, doctors are more focused on maybe this blood test or maybe this medication or ‘we need to wean them off oxygen’. Not so much about the long term strategies that people can use when they’re not sick.” Hospital 1, Inpatient nurse

However, most doctors reported recommending the fan among other non-pharmacological and pharmacological interventions, and even those who weren’t felt that they should be taking a holistic approach that included this.

Consultant: The patients are coming to us for help; we should give them all the help that we can. So that’s why I’m castigating myself slightly for not really having remembered this [i.e. to recommend the fan or other non-pharmacological management strategies]. I don’t think that we can put ourselves in little pigeonholes and say, “Oh, that’s not my job.” I think that historically we could when we had very short waiting times for pulmonary rehab. But even so, we can’t count on other clinicians talking about things like that.” Hospital 2

At the individual clinician level, participants generally agreed that any clinician could talk to patients about the fan but, in practice, there was a lack of organisation about who would actually perform this role.

“I think sometimes they can get stuck with “I do this and you do that”. Sometimes, I think in an inpatient setting particularly, everyone assumes someone else has given the education, then no one’s given the education. So, I wonder if that’s a barrier as well, that some professions think that other professions should be giving that recommendations when it should be all of us?” Hospital 1, Inpatient nurse

Personal agency

Perceived behavioural control

Participants expressed a high level of ‘perceived behavioural control’ or autonomy over recommending the fan. This extended across disciplines, posing less of a barrier to implementation than the normative beliefs outlined above, although this was influenced by ‘environmental factors’, as discussed below.

“You don’t have to wait for doctors … you can give it to the patient, and they can use it.” Hospital 1, Inpatient nurse

Self-efficacy

In contrast to perceived behavioural control, clinicians’ ‘self-efficacy’ was more variable, especially concerning which type of fan to recommend and how to train patients to use it optimally. Fan characteristics that participants highlighted as important included the batteries not being especially likely to “fall out” (Hospital 1, Inpatient nurse) or “run out” (Hospital 2, Inpatient nurse) and the airflow being “strong enough” (Hospital 1, Inpatient nurse). However, most participants expressed uncertainty about which fan to recommend. One nurse felt that recommending a fan sold and branded by Lung Foundation Australia lent “credibility” (Hospital 1, Inpatient nurse) that might persuade patients to try it, even though they would also advise the patient that they could get a similar fan cheaper elsewhere.

Participants’ beliefs varied regarding the extent of training and support needed for patients to use the fan optimally, and their confidence in the best approach. Reported approaches varied from minimal (“I tell them where to buy the fan, tell them where to point it” Hospital 1, Advanced trainee) to more in-depth explanations about mechanism and situations in which to use the fan, tailoring to each individual patient’s needs. Some participants emphasized the importance of taking time to properly explain the fan and train patients in its use, while others perceived a lack of clinician time to be a key barrier to fan implementation. At one of the hospitals, a doctor reported that a video tutorial was available for patients, but nurses seemed unaware of this.

Participants also varied in the degree to which they combined the fan with other non-pharmacological interventions, and their confidence in doing so. Some participants had never considered using the fan with other interventions, while one allied health professional reported never recommending it alone.

“From a physio perspective, with all our other breathing strategies as well, it works well, positioning, timing, pacing activities. So, it’s never on its own … It’s an adjunct to what we would normally do.” Hospital 2, Allied health

Environmental factors

Environmental factors were unique among IBM constructs in impinging on participants’ ‘perceived behavioural control’ to recommend the fan, especially the limited availability of fans in the hospital setting and assumption that costs would be prohibitive in making them widely available. The lack of hand-held fans on the ward meant that participants who worked in this setting relied on using desktop fans. The number of these often failed to meet demand. Also, desktop fans could not be taken home on discharge for portable use during activities of daily living. When asked about resourcing hand-held fans, participants at both hospitals assumed that any funding would be short-lived and run out, with one doctor resorting to buying fans at his own expense. While participants perceived that patients could reasonably expected to buy their own fans when back in the community, limited mobility was sometimes considered a barrier to access.

“These individuals, sometimes … aren’t capable of going to the shop themselves to go get it.” Hospital 2, Advanced trainee

Salience and habit

The poor availability of fans in the inpatient setting was perceived to impede implementation not only due to access but also because it reduced the ‘salience’ of fans and meant that nurses were not in the ‘habit’ of recommending them. Nurses reported care on the wards to be time pressured and often procedurally-driven, with the result that any aspect of care not included in protocols was unlikely to be implemented.

“You get that sort of tunnel vision, not necessarily task-oriented, but it’s not part of your protocol. If we knew we had heaps of them there, I think we’d see an increase in people offering them because you’ve got them to offer.” Hospital 2, Inpatient nurse

In the absence of fans being embedded into ward routine, nurses reported that only patients who brought a fan with them or explicitly requested one tended to receive an opportunity to use one.

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