The asthma/COPD nurses' experience of educating patients with chronic obstructive pulmonary disease in primary health care

Needed competence for registered nurses working at a patient-centred telehealth service aimed to engage and empower people living with COPD: A five-month participatory observational study

BACKGROUND

The global population of older aged 65 and over is increasing, which means an increase in people living with long-term health conditions and multimorbidity. Implementing new digital health technologies enables increased patient empowerment and responsibility, and the ability to respond to changes in their condition themselves, with less involvement of healthcare professionals. Important parameters need to be addressed for this digitally enabled empowerment to be successful, these include increased individual and organizational health literacy, the establishment of joint decision-making activities among patients and healthcare professionals, and efforts that target the individual's ability to manage their condition, which include education to increase skills and providing technology for self-monitoring.

OBJECTIVE

To identify needed competencies of digital healthcare professionals to be able to provide the needed services to service users with chronic obstructive pulmonary disease in a 24/7 digital healthcare service.

METHOD

Five registered nurses' work was observed weekly for five months. In total 13 participatory observations were conducted. Data from the observations was transcribed and analysed through inductive content analysis.

RESULTS

Five main categories were identified in the analysis; 1) tasks, 2) communication, 3) the relationships between the registered nurses, 4) service users, and 5) technology. These categories contain different competencies needed for registered nurses working in a digitalized healthcare system.

CONCLUSIONS

Future digital healthcare professionals will require several competencies, to be able to deliver proper care in a digital health community that goes beyond traditional healthcare competencies, including social, technological, and communication skills.

Analysis of the Current State of COPD Nursing Based on a Bibliometric Approach from the Web of Science

Background and Aim

COPD nursing plays a crucial role in alleviating disease symptoms, prolonging patient survival, and is therefore of paramount importance. However, authoritative research findings, research hotspots, and development trends in the field of COPD are still unclear. This study aimed to examine authoritative research findings, research hotspots, and trends in the field of COPD nursing. Descriptive statistics and bibliometric and visual analyses of the literature were conducted.

Methods

Bibliometric data were obtained from the Web of Science database. Citespace was used to explore publication trends, countries, institutions, journals, authors, keywords, and co-citation characteristics of the included literature in order to summarize the key research in the field of COPD nursing.

Results

In total, 693 articles on COPD nursing were published. 1998-2014 showed a rapid growth period in this research field, which stabilized in 2015-2022. The research content could mostly be summarized into five categories: acute exacerbation, quality of life, risk, evidence-based nursing, and pulmonary rehabilitation. The research hotspots in 1998-2014 included randomized controlled trials, education, elderly patients, nursing home residents, nursing homes, rehabilitation, and prevalence. Research in 2015-2022 focused on impact, palliative care, needs, and predictors. In recent years, research mainly concentrated on symptom management models, cost-effectiveness, and cumulative meta-analysis.

Conclusion

Bibliometric analysis of COPD nursing articles indicates that the focus of COPD nursing research is shifting from tertiary prevention to primary and secondary prevention. Helping patients achieve self-management of symptoms, reducing the financial burden of COPD on healthcare, and summarizing research evidence by meta-analyses will likely remain the focus of future research.

Tailored or adapted interventions for adults with chronic obstructive pulmonary disease and at least one other long-term condition: a mixed methods review

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory condition characterised by shortness of breath, cough and recurrent exacerbations. People with COPD often live with one or more co-existing long-term health conditions (comorbidities). People with more severe COPD often have a higher number of comorbidities, putting them at greater risk of morbidity and mortality.

OBJECTIVES

To assess the effectiveness of any single intervention for COPD adapted or tailored to their comorbidity(s) compared to any other intervention for people with COPD and one or more common comorbidities (quantitative data, RCTs) in terms of the following outcomes: Quality of life, exacerbations, functional status, all-cause and respiratory-related hospital admissions, mortality, pain, and depression and anxiety. To assess the effectiveness of an adapted or tailored single COPD intervention (simple or complex) that is aimed at changing the management of people with COPD and one or more common comorbidities (quantitative data, RCTs) compared to usual care in terms of the following outcomes: Quality of life, exacerbations, functional status, all-cause and respiratory-related hospital admissions, mortality, pain, and depression and anxiety. To identify emerging themes that describe the views and experiences of patients, carers and healthcare professionals when receiving or providing care to manage multimorbidities (qualitative data).

SEARCH METHODS

We searched multiple databases including the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, and CINAHL, to identify relevant randomised and qualitative studies. We also searched trial registries and conducted citation searches. The latest search was conducted in January 2021.

SELECTION CRITERIA

Eligible randomised controlled trials (RCTs) compared a) any single intervention for COPD adapted or tailored to their comorbidity(s) compared to any other intervention, or b) any adapted or tailored single COPD intervention (simple or complex) that is aimed at changing the management of people with COPD and one or more comorbidities, compared to usual care. We included qualitative studies or mixed-methods studies to identify themes.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods for analysis of the RCTs. We used Cochrane's risk of bias tool for the RCTs and the CASP checklist for the qualitative studies. We planned to use the Mixed Methods Appraisal tool (MMAT) to assess the risk of bias in mixed-methods studies, but we found none. We used GRADE and CERQual to assess the quality of the quantitative and qualitative evidence respectively. The primary outcome measures for this review were quality of life and exacerbations.

MAIN RESULTS

Quantitative studies We included seven studies (1197 participants) in the quantitative analyses, with interventions including telemonitoring, pulmonary rehabilitation, treatment optimisation, water-based exercise training and case management. Interventions were either compared with usual care or with an active comparator (such as land-based exercise training). Duration of trials ranged from 4 to 52 weeks. Mean age of participants ranged from 64 to 72 years and COPD severity ranged from mild to very severe. Trials included either people with COPD and a specific comorbidity (including cardiovascular disease, metabolic syndrome, lung cancer, head or neck cancer, and musculoskeletal conditions), or with one or more comorbidities of any type. Overall, we judged the evidence presented to be of moderate to very low certainty (GRADE), mainly due to the methodological quality of included trials and imprecision of effect estimates. Intervention versus usual care Quality of life as measured by the St George's Respiratory Questionnaire (SGRQ) total score may improve with tailored pulmonary rehabilitation compared to usual care at 52 weeks (mean difference (MD) -10.85, 95% confidence interval (CI) -12.66 to -9.04; 1 study, 70 participants; low-certainty evidence). Tailored pulmonary rehabilitation is likely to improve COPD assessment test (CAT) scores compared with usual care at 52 weeks (MD -8.02, 95% CI -9.44 to -6.60; 1 study, 70 participants, moderate-certainty evidence) and with a multicomponent telehealth intervention at 52 weeks (MD -6.90, 95% CI -9.56 to -4.24; moderate-certainty evidence). Evidence is uncertain about effects of pharmacotherapy optimisation or telemonitoring interventions on CAT improvement compared with usual care. There may be little to no difference in the number of people experiencing exacerbations, or mean exacerbations with case management compared with usual care (OR 1.09, 95% CI 0.75 to 1.57; 1 study, 470 participants; very low-certainty evidence). For secondary outcomes, six-minute walk distance (6MWD) may improve with pulmonary rehabilitation, water-based exercise or multicomponent interventions at 38 to 52 weeks (low-certainty evidence). A multicomponent intervention may result in fewer people being admitted to hospital at 17 weeks, although there may be little to no difference in a telemonitoring intervention. There may be little to no difference between intervention and usual care for mortality. Intervention versus active comparator We included one study comparing water-based and land-based exercise (30 participants). We found no evidence for quality of life or exacerbations. There may be little to no difference between water- and land-based exercise for 6MWD (MD 5 metres, 95% CI -22 to 32; 38 participants; very low-certainty evidence). Qualitative studies One nested qualitative study (21 participants) explored perceptions and experiences of people with COPD and long-term conditions, and of researchers and health professionals who were involved in an RCT of telemonitoring equipment. Several themes were identified, including health status, beliefs and concerns, reliability of equipment, self-efficacy, perceived ease of use, factors affecting usefulness and perceived usefulness, attitudes and intention, self-management and changes in healthcare use. We judged the qualitative evidence presented as of very low certainty overall.

AUTHORS' CONCLUSIONS

Owing to a paucity of eligible trials, as well as diversity in the intervention type, comorbidities and the outcome measures reported, we were unable to provide a robust synthesis of data. Pulmonary rehabilitation or multicomponent interventions may improve quality of life and functional status (6MWD), but the evidence is too limited to draw a robust conclusion. The key take-home message from this review is the lack of data from RCTs on treatments for people living with COPD and comorbidities. Given the variation in number and type of comorbidity(s) an individual may have, and severity of COPD, larger studies reporting individual patient data are required to determine these effects.

Factors influencing nurses' provision of self-management support for patients with chronic illnesses: A systematic mixed studies review

BACKGROUND

Self-management support is considered an important task for nurses working in chronic care provision. The complex nature of self-management support makes it necessary to clarify the factors affecting the behaviour of nurses in supporting patients living with chronic illnesses.

OBJECTIVE

The aim of this review is to synthesize the factors influencing the provision of self-management support as perceived by nurses in the care for patients living with a chronic illness.

DESIGN

A systematic mixed studies review.

DATA SOURCE

Studies published in English from 1999 to April 2020 were extracted from five databases: CINAHL, PubMed, Cochrane library, EMBASE, and Web of Science.

REVIEW METHOD

The selection process was guided by PICo (Population, phenomenon of Interest, and Context). Studies that highlighted factors associated with the provision of self-management support among nurses, within the context of the top four non-communicable chronic diseases, were included. The risk of bias was carefully assessed. Using data-based convergent synthesis, the identified factors were synthesized and tabulated. The clusters of factors organized under each theme were approved by all researchers in discussion meetings.

RESULTS

In total, sixteen studies met the inclusion criteria; out of these, seven were qualitative, seven quantitative, and two mixed methods studies. The review identified nurses' perspectives regarding factors influencing self-management support at the patient, nurse, care relationship, education and training, organization and healthcare system, and intra- and inter-professional levels. The review provided evidence that these factors are interdependent in nature.

CONCLUSION

This review proposed considering a framework of interdependent factors influencing self-management support. It highlighted the need to come up with a comprehensive definition of self-management support that takes into account the emotional aspect as well as patient-as-partner approach. The proposed framework can be useful in tailoring multi-faceted interventions to strengthen nurses' supportive role in self-management of chronic care. Future studies should focus on exploring contextually relevant factors impacting nurses' supportive role in self-management.

Effect of an Educational Program on Healthcare Professionals' Readiness to Support Patients with Asthma, Allergies, and Chronic Obstructive Lung Disease for Improved Medication Adherence

PURPOSE

The aim of this study was to strengthen the healthcare professionals' readiness to support patients who have asthma, an allergy, and COPD for better medication adherence.

METHODS

The design was an educational intervention in a study population (n = 70) consisting of 66 nurses and four other allied healthcare professionals working in primary care with patients diagnosed with asthma, allergy, or COPD in a county in southern Sweden. As part of two training days, an educational intervention-consisting of lectures and workshops-was conducted. Both qualitative and quantitative data were collected. The qualitative data were collected during the workshops when the participants worked with fictitious patient cases. They documented in writing how they, based on the theoretical content in the educational intervention in combination with their clinical experiences, reasoned that the fictitious patients could be supported for better adherence. This documentation constituted qualitative data. The quantitative data were collected through questionnaires, which the participants completed before and after the intervention. Data from the questionnaires were statistically analyzed using descriptive statistics and paired t-tests. The qualitative data collected from the workshops were analyzed with content analysis.

RESULTS

The intervention increased the participants' knowledge of adherence (pre mean 3.95 versus post mean 4.18, p=0.001) and how to better support patients' adherence to medication (pre mean 3.71 versus post mean 3.98, p=0.001). Moreover, their knowledge of how to measure patients' adherence behavior (pre mean 3.02 versus post mean 3.54, p=0.001) and how to communicate with patients effectively about adherence was heightened (pre mean 3.92 versus post mean 4.13, p=0.011). Furthermore, participants felt that their readiness to support patients for better adherence had strengthened (pre mean 3.78 versus post mean 4.13, p=0.001). Individual adherence support for three fictitious patients with different adherence issues was developed.

CONCLUSION

An educational intervention focusing on adherence and communication equipped healthcare professionals with tools to support patients with asthma, an allergy, or COPD for better medication adherence.

Psychosocial issues need more attention in COPD self-management education

Objective: To find out how regularly the contents of patient education regarded as essential for COPD patients' self-management are provided by healthcare professionals in specialised healthcare (SHC) and primary healthcare (PHC) in Finland.Design: A cross-sectional study based on an e-questionnaire with 42 items on the content of self-management education of COPD patients.Setting: The study sample included all public SHC units with pulmonary outpatient clinics (n = 29) and nine out of 160 health centres in Finland.Subjects: 83 doctors and 162 nurses.Main outcome measures: The respondents' answers on how regularly they included the contents regarded as essential for COPD patients' self-management in their education of COPD patients.Results: COPD patients were educated regularly on medical issues regarding COPD treatment, such as smoking cessation, exercise and pharmacological treatment. However, issues vital for coping with the disease, such as psychological well-being, stress management or fatigue, were often ignored. Patient education in SHC seemed to be more systematic than education in PHC. The education provided by the asthma/COPD nurses (n = 70) was more systematic than the education provided by the other nurses (n = 84).Conclusion: Healthcare professionals' continuous education should cover not only the medical but also the psychosocial aspects of coping with COPD. The role of doctors and nurses should be considered to ensure that there is no gap in COPD patients' education. Training asthma/COPD nurses and promoting specialised nurse-led asthma/COPD clinics in primary care could be beneficial while improving practices of patient education that enhance patients' ability to cope with the disease.KEY POINTSIssues vital for coping with chronic obstructive pulmonary disease (COPD), such as psychological well-being, stress and fatigue, are irregularly included in self-management education both in primary and specialised healthcare.Patient education provided by asthma/COPD nurses is more regular than patient education provided by other nurses.The distribution of work between doctors and nurses should be considered to ensure that there is no gap in COPD patients' education.

Working with patients suffering from chronic diseases can be a balancing act for health care professionals - a meta-synthesis of qualitative studies

BACKGROUND

The number of patients with long-term chronic diseases is increasing. These patients place a strain on health care systems and health care professionals (HCPs). Presently, we aimed to systematically review the literature on HCPs' experiences working with patients with long-term chronic diseases such as type 2 diabetes, chronic obstructive pulmonary disease (COPD), and chronic kidney disease (CKD).

METHOD

A systematic search of papers published between 2002 and July 2019 was conducted in the Embase, AMED, PsycINFO, MEDLINE, CINAHL, and COCHRANE databases to identify studies reporting qualitative interviews addressing HCPs' experiences working with adults with COPD, CKD or type 2 diabetes. An interdisciplinary research group were involved in all phases of the study. With the help of NVivo, extracts of each paper were coded, and codes were compared across papers and refined using translational analysis. Further codes were clustered in categories that in turn formed overarching themes.

RESULTS

Our comprehensive search identified 4170 citations. Of these, 20 papers met our inclusion criteria. Regarding HCPs' experiences working with patients with COPD, CKD, or type 2 diabetes, we developed 10 sub-categories that formed three overarching main themes of work experiences: 1) individualizing one's professional approach within the clinical encounter; 2) managing one's emotions over time; 3) working to maintain professionalism. Overall these three themes suggest that HCPs' work is a complex balancing act depending on the interaction between patient and professional, reality and professional ideals, and contextual support and managing one's own emotions.

CONCLUSION

Few qualitative studies highlighted HCPs' general working experiences, as they mainly focused on the patients' experiences or HCPs' experiences of using particular clinical procedures. This study brings new insights about the complexity embedded in HCPs' work in terms of weighing different, often contrasting aspects, in order to deliver appropriate practice. Acknowledging, discussing and supporting this complexity can empower HCPs to avoid burning out. Leaders, health organizations, and educational institutions have a particular responsibility to provide HCPs with thorough professional knowledge and systematic support.

TRIAL REGISTRATION

PROSPERO number: CRD42019119052.

COPD patient education and support - Achieving patient-centredness

BACKGROUND

The art of medicine is undergoing a dramatic shift in focus, evolving to focus on patient involvement as partners in care, transforming the traditional, prescriptive, reactive practice of healthcare into a proactive discipline. The personal and societal burden of chronic diseases is burgeoning and unsustainable in current systems, novel approaches are required to address this.

DISCUSSION

Although considerable progress has been made in the development of diagnostics, therapeutics and care guidelines for patients with chronic obstructive pulmonary disease (COPD), questions remain surrounding the implementation of best practice education and support. Current educational programmes, personal limitations and preferences and patient-clinician communication in modification of coping styles and behaviour are discussed. A novel holistic model, the Kaleidoscope Model of Care is proposed to address the barriers to optimal self-care behaviours.

CONCLUSION AND PRACTICE IMPLICATIONS

Holistic approaches are essential for optimal self-management and improved outcomes. Guidance on personalised goals for patients to help meeting their therapy priorities is needed to aid healthcare professionals (HCPs) and funders to minimise healthcare burden and costs. The novel KALMOD approach may optimise patient empowerment, exploring whole-life factors that impact COPD care and improve interactions between patients and HCPs for optimised outcomes.

The nurse's challenge of caring for patients with chronic obstructive pulmonary disease in primary health care

AIM

The aim was to describe asthma and chronic obstructive pulmonary disease nurses' experiences of caring for patients with chronic obstructive pulmonary disease in primary health care.

DESIGN

Descriptive qualitative research.

METHODS

Ten asthma and chronic obstructive pulmonary disease specialized nurses were interviewed. Systematic Text Condensation by Malterud was used to analyse the data.

RESULTS

Two main categories were found: the patient-nurse relationship and available resources. Several challenges emerged when connecting with patients and the nurses found it difficult to individualize care. They struggled with a lack of time and support from other professionals. Being responsible for asthma and chronic obstructive pulmonary disease practice was experienced as positive, but could become overwhelming. The asthma and chronic obstructive pulmonary disease nurses described several challenges and the need for support and resources to provide the best possible care for patients with chronic obstructive pulmonary disease.

Living with breathlessness: a systematic literature review and qualitative synthesis

What is the experience of people living with breathlessness due to medical conditions, those caring for them and those treating them, with regard to quality of life and the nature of clinical interactions?Electronic databases (Ovid MEDLINE, Embase, CINAHL Plus and PsycINFO) were searched (January 1987 to October 2017; English language), for qualitative studies exploring the experience of chronic breathlessness (patients, carers and clinicians). Two independent reviewers screened titles, abstracts and papers retrieved against inclusion criteria. Disagreements were resolved with a third reviewer. Primary qualitative data were extracted and synthesised using thematic synthesis.Inclusion and synthesis of 101 out of 2303 international papers produced four descriptive themes: 1) widespread effects of breathlessness; 2) coping; 3) help-seeking behaviour; and 4) clinicians' responsiveness to the symptom of breathlessness. The themes were combined to form the concept of "breathing space", to show how engaged coping and appropriate help-seeking (patient) and attention to symptom (clinician) helps maximise the patient's quality of living with breathlessness.Breathlessness has widespread impact on both patient and carer and affects breathing space. The degree of breathing space is influenced by interaction between the patient's coping style, their help-seeking behaviour and their clinician's responsiveness to breathlessness itself, in addition to managing the underlying disease.

Qualitative systematic review of barriers and facilitators to self-management of chronic obstructive pulmonary disease: views of patients and healthcare professionals

Self-management interventions for chronic obstructive pulmonary disease (COPD) can improve quality of life, reduce hospital admissions, and improve symptoms. However, many factors impede engagement for patients and practitioners. Qualitative research, with its focus on subjective experience, can provide invaluable insights into such factors. Therefore, a systematic review and synthesis of qualitative evidence on COPD self-management from the perspective of patients, carers, and practitioners was conducted. Following a systematic search and screening, 31 studies were appraised and data extracted for analysis. This review found that patients can adapt to COPD; however, learning to self-manage is often a protracted process. Emotional needs are considerable; frustration, depression, and anxiety are common. In addition, patients can face an assortment of losses and limitations on their lifestyle and social interaction. Over time, COPD can consume their existence, reducing motivation. Support from family can prove vital, yet tinged with ambivalence and burden. Practitioners may not have sufficient time, resources, or appropriate skills or confidence to provide effective self-management support, particularly in regard to patients' psychosocial needs. This can compound patients' capability to engage in self-management. For COPD self-management to be effective, patients' psychosocial needs must be prioritised alongside medication and exacerbation management. In addition, patients' personal beliefs regarding COPD and its management should be reviewed periodically to avoid problematic behaviours and enhance positive adaptions to the disease. Patients with COPD are not a homogenous group and no one intervention will prove effective for all. Finally, practitioners require greater education, training, and support to successfully assist patients.

Understanding the factors affecting self-management of COPD from the perspectives of healthcare practitioners: a qualitative study

Self-management is recognised as an essential criteria for the provision of high quality care for chronic obstructive pulmonary disease (COPD). The management of COPD is usually delivered by a wide range of healthcare practitioners. This study aimed to understand the factors affecting self-management of COPD from the perspectives of the different multidisciplinary healthcare teams involved in COPD care. Semi-structured interviews were conducted with participants from primary care, specialist respiratory and pulmonary rehabilitation (PR) teams. Purposive sampling and snowballing were employed in participant recruitment. All interviews were audio-recorded and transcribed verbatim and data were analysed thematically. A total of 20 participants (eight primary care practitioners, seven respiratory specialists and five PR practitioners) were interviewed until data saturation was reached. Participants identified a range of complex and interrelated factors affecting COPD self-management that were grouped into three broad categories-patient, practitioner and organisational/system-level factors. Patient-level factors were predominantly considered as barriers, with COPD knowledge and understanding, and the individual patients' life circumstances/context being the most prominent issues. Practitioner-level factors identified were practitioners' speciality, interest and experience in respiratory conditions as the overarching factor that influenced how self-management was understood and practiced. A number of organisational/system-level factors were identified by all practitioners, including inconsistency of referral pathways and the wide variations of different self-management planning tools. Factors affecting self-management of COPD across these three levels need to be tackled equally in order to improve the effectiveness of interventions and to embed and integrate self-management support approaches into routine practice.

CHRONIC LUNG DISEASE

A BALANCED APPROACH FOR IMPROVED SELF-MANAGEMENT: Better co-ordination between healthcare services, practitioners and patients may help improve self-management for chronic lung disease. Self-management is crucial for patients with chronic obstructive pulmonary disease (COPD), but it can be difficult for healthcare workers to monitor and support patient progress. Oladapo Ogunbayo at Newcastle University, UK, and co-workers conducted interviews with healthcare practitioners to explore perceived barriers to successful self-management of COPD. Three distinct categories emerged; those at patient level, practitioner level and organisational level, the needs of which should be carefully balanced to improved self-management. Patient knowledge and understanding of COPD, alongside individual life circumstances, were often barriers to effective self-care. Those practitioners with specialist respiratory knowledge took a more holistic approach to self-management than their primary care counterparts. A lack of continuity between services and across self-management planning tools presented further barriers.

Symptom-reducing actions: a concept analysis in the context of chronic obstructive pulmonary disease

Patients with Chronic Obstructive Pulmonary Disease (COPD) have multiple symptoms. Nursing care is based on six core competencies and one of them is person-centred care that includes the aspect of professional symptom relief. The aim was to clarify a meaning of the concept of Symptom-reducing actions in the context of COPD. Databases MEDLINE and CINAHL were searched between 1982 and February 2016 and 26 publications were found. Two dictionaries and three books were investigated. The method of Walker & Avant was followed. The use of the concept of Symptom-reducing actions may be categorized by the sub-concepts of supervision, information, and patient education. Exploration of defining attributes was symptom management, instructions, support, motivation, explanation, advice, teaching, and learning. Antecedent occurrences were related to factors that affect the patient's level of function such as physical performance and cognitive function. Symptom-reducing actions offer a way to support patients with COPD in self-management. Symptom-reducing actions can mediate facts in a purposeful process performed by the nurse to enable the patient to take control over and manage unpleasant symptoms by a person-centred, planned process. The nurse can achieve this via supervision, information, and patient education with an integrated emotional component. Evaluating the outcomes is needed.

We need to talk about purpose: a critical interpretive synthesis of health and social care professionals' approaches to self-management support for people with long-term conditions

BACKGROUND

Health policies internationally advocate 'support for self-management', but it is not clear how the promise of the concept can be fulfilled.

OBJECTIVE

To synthesize research into professional practitioners' perspectives, practices and experiences to help inform a reconceptualization of support for self-management.

DESIGN

Critical interpretive synthesis using systematic searches of literature published 2000-2014.

FINDINGS

We summarized key insights from 164 relevant papers in an annotated bibliography. The literature illustrates striking variations in approaches to support for self-management and interpretations of associated concepts. We focused particularly on the somewhat neglected question of the purpose of support. We suggest that this can illuminate and explain important differences between narrower and broader approaches. Narrower approaches support people to manage their condition(s) well in terms of disease control. This purpose can underpin more hierarchical practitioner-patient communication and more limited views of patient empowerment. It is often associated with experiences of failure and frustration. Broader approaches support people to manage well with their condition(s). They can keep work on disease control in perspective as attention focuses on what matters to people and how they can be supported to shape their own lives. Broader approaches are currently less evident in practice.

DISCUSSION AND CONCLUSION

Broader approaches seem necessary to fulfil the promise of support for self-management, especially for patient empowerment. A commitment to enable people to live well with long-term conditions could provide a coherent basis for the forms and outcomes of support that policies aspire to. The implications of such a commitment need further attention.

Primary and secondary care clinicians' views on self-treatment of COPD exacerbations: a multinational qualitative study

OBJECTIVE

To explore clinicians' views on antibiotic and/or steroid 'rescue packs' used as self-treatment for patients with exacerbations of COPD.

METHODS

21 focus groups conducted in 7 countries--Netherlands, Russia, Norway, China (Hong Kong), Wales, Germany and Poland involving 142 primary care clinicians and pulmonologists.

RESULTS

We found wide variation in reported use of and attitudes to self-treatment among GPs and pulmonologists in the participating countries. Clinicians highlighted the importance of identifying patients who were most likely to benefit (those with more severe disease) and most likely to use the treatment appropriately (demonstrated by previous behaviour), and the importance of adequate patient education and ongoing communication in regard to use of self-treatment packs. Clinicians recognised patient empowerment and facilitating prompt treatment as potential benefits of self-treatment. However, many felt they did not have the time or resources for appropriate patient selection and education.

CONCLUSION

Clinicians do not feel it is appropriate to offer self-treatment rescue packs to all patients routinely without careful consideration of patient understanding of their illness and their capacity for self-management.

PRACTICE IMPLICATIONS

Adequate resources and continuity of patient care are required for clinicians to feel confident in the safe and effective implementation of this strategy.

Nurses’ Patient Education Questionnaire – development and validation process

Conditions for nurses’ daily patient education work are unclear and require clarification. The aim was to develop and validate the Nurses’ Patient Education Questionnaire, a questionnaire that assesses nurses’ perceptions of appropriate conditions for patient education work: what nurses say they actually do and what they think about what they do. The questionnaire was developed from a literature review, resulting in the development of five domains. This was followed by ‘cognitive interviewing’ with 14 nurses and dialogue with 5 pedagogical experts. The five domains were identified as significant for assessing nurses’ beliefs and knowledge; education environment; health care organisation; interdisciplinary cooperation and collegial teamwork; and patient education activities. A content validity index was used for agreement of relevance and consensus of items by nurses ( n = 10). The total number of items in the final questionnaire is 60, consisting of demographic items, what nurses report they do and perceptions about patient education in daily work. The questionnaire can be used by managers and nurses to identify possibilities and barriers to patient education in different care contexts.

The development of an integrated care model for patients with severe or very severe chronic obstructive pulmonary disease (COPD): the COPD-Home model

BACKGROUND

Adherence to guidelines for managing stable chronic obstructive pulmonary disease (COPD) and its exacerbations is inadequate among healthcare workers and patients. An appropriate care model would meet patient needs, enhance their coping with COPD and improve their quality of life (QOL).

AIM

This study aims to present the 'COPD-Home' as an integrated care model for patients with severe or very severe COPD.

MODEL

One principle of the COPD-Home model is that hospital treatment should lead to follow up in the patient's home. The model also includes education, improved coordination of levels of care, improved accessibility and a management plan. One of the main elements of the COPD-Home model is the clear role of the home-care nurse. Model development is based on earlier research and clinical experience. It comprises: (i) education provided through an education programme for patients and involved nurses, (ii) joint visits and telephone checks, (iii) a call centre for support and communication with a general practitioner and (iv) an individualised self-management plan including home monitoring and a plan for pharmacological and nonpharmacological interventions.

CONCLUSION

The COPD-Home model attempts to cultivate competences and behaviours of patients and community nurses that better accord with guidelines for interventions. The next step in its development will be to evaluate its ability to assist both healthcare workers and planners to improve the management of COPD, reduce exacerbations and improve QOL and coping among patients with COPD.

Strategies used by respiratory nurses to stimulate self-management in patients with COPD

AIMS AND OBJECTIVES

To gain an insight into strategies, adopted by Dutch respiratory nurses during clinic sessions, to improve self-management of patients with chronic obstructive pulmonary disease.

BACKGROUND

Chronic obstructive pulmonary disease is highly prevalent and a significant cause of morbidity and mortality, impacting on quality of life and healthcare expenditure. Health promotion is therefore an important consideration. By applying specific strategies, respiratory nurses can play a major role in the promotion of self-management. Research has shown that respiratory nurses, who run clinics, have insufficient knowledge of evidence-based strategies that can be adopted to promote self-management among chronic obstructive pulmonary disease patients. It appears that respiratory nurses adopt their own strategies during clinic sessions.

DESIGN

A qualitative research study was carried out using Grounded Theory method.

METHODS

Data were collected during open interviews conducted by an external researcher with a nursing background. The interviews were analysed through coding after which categories were developed.

RESULTS

Fourteen respiratory nurses were interviewed. The results show that respiratory nurses emphasise quitting smoking during the consult. Attention is also paid to inhalation medication and techniques. Other self-management strategies that respiratory nurses use are: application of specific interviewing techniques, referring to other healthcare professionals and providing tools for coping with the illness in everyday life.

CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE

The main emphasis during the clinic session is directed at quitting smoking. Other self-management strategies such as providing information regarding nutrition and exercise, instilling confidence and becoming an equal discussion partner, gain less attention. During the clinic session, respiratory nurses should also focus on these self-management strategies in addition to quitting smoking. Further research should be directed at self-management strategies used by respiratory nurses in relation to different characteristics of patients. In this way, a more patient-oriented form of consultation could be developed for chronic obstructive pulmonary disease patients.

Consultation performance of general practitioners when supported by an asthma/COPDC-service

Background

General practitioners (GPs) can refer patients to an asthma/COPD service (AC-service) for diagnostic assessment of spirometry and medical history and for asthma or COPD monitoring. The AC-service reports diagnostic results and additional information about disease burden (BORG-score for complaints, MRC-dyspnoea score, exacerbation rate), life style, medication and compliance, to the patient’s GP. This study explores how GPs use this additional information when discussing the patient’s disease burden and how this influences GPs’ information and education provision during consultations with asthma/COPD patients.

Method

Patients with (a suspicion of) asthma or COPD were referred to an AC-service and consulted their GPs after they had received a report from the AC-service. Retrospectively patients answered questions about their GPs’ performance during these consultations. Performances were compared with performances of the same GPs during consultations without support of the AC-service (usual care), earlier that year.

Results

Of consultations not initiated by an AC-service check-up, 91% focussed on complaints, the initial reason for the consultation. In AC-service supported follow-up consultations, GPs explored disease burden when the (BORG-)score for complaints was high - as reported by the AC-service - even when patients themselves thought it was irrelevant. GPs put significantly less effort in exploring disease burden when the Borg-score was low (BORG 3–4: 69%; BORG1-2: 51%, p = 0,01). GPs mostly ignored MRC-dyspnoea scores: attention to dyspnoea was 18% for MRC-score <3 and 25% for MRC-score ≥3 (p = 0,63). GPs encouraged physical fitness in 13% of patients. Smoking behaviour was discussed with 66% of the actual smokers but only 14% remembered a stop smoking advice. Furthermore, pharmacotherapeutic management education in AC-service supported consultations did not differ from performance in usual care according to patient evaluations.

Conclusion

Other than taking into account the severity of complaints, there was no difference between GPs’ performance in AC-service supported and in usual care consultations. AC-service reports are thus not effective by themselves. GPs should be encouraged to use the information better and systematically check all relevant aspects that characterize the disease burden of their patients.