Theme | Subtheme | Codes |
1. Training and experience | Limited feature in undergraduate education. | Little formal medical school exposure to OA. |
Focus on other occupational or exposure-related aspects of respiratory disease. | ||
Limited feature in formal postgraduate education. | Not a formal part of GP vocational training. | |
Little focus on OA in asthma-related CPD. | ||
Little formal training on asthma management for practice nurses. | ||
Likely only to do asthma-related CPD if in a respiratory role. | ||
Limited feature of experiential (‘on-the-job’) learning. | OA a feature of experiential learning. | |
OA not a feature of experiential learning. | ||
Exposure to specific disease areas varies between individuals during formative experiences. | ||
Personal experiences have influenced practice more than any experiential learning. | ||
Primary care asthma diagnosis and management have become a more specialised task. | Some GPs take on the responsibility for management of respiratory diseases within the practice. | |
Some GPs have become deskilled at asthma management. | ||
Some GPs see individuals with asthma only in certain circumstances. | ||
Increased GP workload has resulted in practice nurses taking on more asthma management. | ||
Some practice nurses are the respiratory experts within practices. | ||
Individuals with asthma receive chronic disease management in specialised clinics, primarily delivered by practice nurses and nurse practitioners. | ||
2. Perceptions and beliefs | Variation in subject knowledge. | Appreciation of factors in the clinical presentation suggestive of OA. |
GPs lack knowledge about OA. | ||
OA perceived to be a specialist subject. | ||
Unable to relate learnt enquiry about exposures (eg, birds, chemicals) to OA. | ||
Variation in understanding of high-risk exposures for OA. | ||
Beliefs about the occurrence of OA. | Different ideas about the impact of OA on individuals and collectively. | |
Work-related symptoms are trivial. | ||
Work exposures trigger, not cause, asthma in susceptible individuals. | ||
Onset of asthma in adult life is not unusual. | ||
OA is not prevalent in the local patient population. | ||
OA is underestimated in primary care. | ||
OA is a historical problem. | ||
Perceived risks and benefits of making a diagnosis of OA. | Jeopardy for patients’ jobs and income if investigated further. | |
Potential health and employment benefits for affected patients. | ||
Specialist care adds value in diagnosing and managing OA. | Complex and challenging diagnostic process for OA. | |
Workplace management requires specialist knowledge. | ||
Central coordination of cases is important in identifying outbreaks of OA or novel causes. | ||
Beliefs about the role of primary care in diagnosing OA. | Responsibilities for diagnosis and management of OA lie outside the NHS. | |
Shared responsibilities between primary and specialist care. | ||
Certain level of knowledge should be attained in primary care. | ||
3. Systems constraints | Lack of continuity of care. | Patients are looking for a quick fix. |
Less opportunity to explore social aspects of health. | ||
Poor continuity of HCPs between consultations. | ||
Time pressure and workload. | Priority is to make a diagnosis of asthma. | |
Lack time for detailed enquiry and diagnosis of OA. | ||
Use of guidelines. | No OA-specific guidelines used. | |
Use of asthma guidelines varies between individuals and practices. | ||
Clinic templates do not focus on OA. | ||
External targets. | Practice driven by essential requirements only. | |
Focus on diagnosis and drug management of asthma. | ||
Perceived as a tick-box exercise. | ||
Referral pressures. | Perceived restrictions on referrals. | |
Diagnosis and management of OA would be an ‘acceptable’ reason to refer to a specialist. | ||
Feel a pressure to reduce unnecessary referrals. | ||
4. Variation in individual practice | Variation in clinical enquiry about work and OA. | Enquire about work-related asthma symptoms or not. |
Enquire about occupation and nature of work or not. | ||
Would not revisit the cause if diagnosis of asthma already made. | ||
Different thresholds or referral to a specialist. | Would refer on suggestive history for OA alone. | |
Would not refer on suggestive history for OA alone. | ||
Referral preferences. | Would refer to local secondary care physicians. | |
Perceived difficulty in accessing occupational lung disease services. |
CPD, continuous professional development; GP, general practitioner; HCP, healthcare professional; NHS, National Health Service; OA, occupational asthma.