Patients and families realising their future with chronic obstructive pulmonary disease-A qualitative study

Facilitators and barriers to self-management in Iranian men with chronic obstructive pulmonary disease: a qualitative study

INTRODUCTION

Self-management, as the most common method of chronic obstructive pulmonary disease (COPD) management, is not an isolated behaviour, but a set of physical, social, cultural, psychological and existential factors affecting it.

AIM

This study aimed to explore the facilitators and barriers to self-management in men with COPD in the unique social, cultural, political and economic context of Iran.

METHODS

This paper reports part of the findings of a qualitative grounded theory study aimed at exploring the process of self-management in Iranian men with COPD, which was conducted in Iran from January 2019 to July 2023. Participants included men with COPD, their family members and pulmonologists. The selection of participants in this research began with the purposeful sampling method. Data was collected using semistructured interviews. Data collection continued until the data saturation was achieved. A total of 15 interviews were conducted with nine patients, three family members of patients and three pulmonologists. The data was analysed using the constant comparative analysis method.

RESULTS

The findings of this study showed that knowledge, education, experience, family involvement and financial support are the factors that facilitate self-management. Factors related to deficits include lack of education, lack of treatment support, family cooperation deficit, financial problems, medication obtaining problems and factors related to disease impacts include specific nature of the disease, residual effect, comorbidity and factors related to negative patients characteristics include false beliefs, poor self-efficacy, feeling shame and non-adherence are barriers to self-management in men with COPD.

CONCLUSION

Based on results of this study, healthcare providers and health planners can strengthen the factors that facilitate self-management and weaken or remove the barriers to self-management, so that these patients use self-management strategies with maximum capacity to control the disease.

Partnership-based nursing practice framework for patients with advanced chronic obstructive pulmonary disease and their families-A discursive paper

AIM

The increase in the number of people with chronic obstructive pulmonary disease (COPD) and the disease burden, has prompted concerted efforts to improve healthcare, particularly outpatient services. In line with these attempts the Partnership-Based Nursing Practice Theoretical Framework for People with COPD was developed to guide outpatient nursing care. The principal approach of the framework is a 'Dialogue' with the patients, which has four components: 'Establishing family involvement', 'Assisting living with symptoms' and 'Facilitating access to healthcare', with the primary goal being 'Enhancement of the health experience'. With new knowledge, research on the framework, and extensive experience in using it, a need arose to modify the framework to maximize its clinical utility.

DESIGN

Discursive paper.

METHODS

A narrative review and critical reflection was conducted to revise the nursing practice framework via selected literature search from 2012 to 2022, research on the framework, and the authors' reflections on the clinical experience of using the framework.

RESULTS

The nursing practice framework highlights capacities and possibilities that lie in the nurse-patient relationship. The overarching dialogue in the revised framework includes both patients and families. The action-related component 'Assisting living with the disease' was added to the framework to underscore the significance of attempting to understand what may lie ahead for patients and families. The other action-related components are as follows: 'Assisting living with symptoms' and 'Facilitating access to healthcare'. The primary goal remains unchanged: enhancing the 'Health experience'.

CONCLUSION

Using the revised nursing practice framework in outpatient care may help to enhance the lives of people with COPD and their families, particularly at advanced stages of the disease. It may have transferability to other groups of people living with progressive diseases dealing with complicated health problems, and to reduce the usage of costly healthcare resources such as hospital care.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The partnership-based nursing practice framework assumes an extension of conventional specialized respiratory service and embraces a comprehensive account for that which may influence the patient's health problems. This guidance, which holistically attends to patient-family needs of living with complicated and progressive health predicaments, is fundamental. It contributes to strengthening the disciplinary focus of nursing, interdisciplinary collaboration, person-family-centred quality nursing care and inspires research initiatives. Critical reflections and updates on nursing practice frameworks, such as this revision, are essential to advance nursing and healthcare.

PATIENT OR PUBLIC CONTRIBUTION

There is no direct patient- or public contribution.

Case-Finding and Treatment Effects in COPD: Secondary Analysis of an Interdisciplinary Intervention Trial

Background

US Preventive Services Taskforce recommends against screening for COPD in asymptomatic adults due to limited evidence on the efficacy of treatments for this population. However, global and Australian guidelines recommend a case-finding approach where those with symptoms and/or risk factors, including smoking, are screened. This study aims to explore patient characteristics by time of COPD diagnosis and the effectiveness of early treatment in those with or without symptoms.

Methods

Secondary analysis of a randomised controlled trial that included those with a pre-existing (n=130) or new diagnosis (n=142) of COPD. Those randomised to the intervention arm received an interdisciplinary intervention of smoking cessation support, home medicines review and home-based pulmonary rehabilitation, while controls received usual care. The primary outcome was health-related quality of life (HR-QoL) measured using St George's Respiratory Questionnaire. To estimate the impact of early treatment, we compared the effectiveness of treatment versus control at 6- and 12-months for the new versus pre-existing diagnosis groups, and those symptomatic versus asymptomatic or minimally symptomatic based on COPD Assessment Test score.

Results

Approximately half of those newly diagnosed with COPD were already symptomatic. Early treatment in those diagnosed via case-finding had a positive non-significant impact on HR-QoL. The size of the treatment effects generally favoured the pre-existing diagnosis group when compared to case-finding and favoured those symptomatic when compared to those asymptomatic.

Conclusion

Despite useful insights into the impacts of case-finding and early treatments, this study, like most others, was not sufficiently powered. Further larger studies or combining sub-groups across studies are required.

"Dignity as a Small Candle Flame That Doesn't Go Out!": An Interpretative Phenomenological Study with Patients Living with Advanced Chronic Obstructive Pulmonary Disease

Long-term illness, such as chronic obstructive pulmonary disease (COPD), can expose people to existential suffering that threatens their dignity. This qualitative study explored the lived experiences of patients with advanced COPD in relation to dignity. An interpretative phenomenological approach based on lifeworld existentials was conducted to explore and understand the world of the lived experience. Twenty individuals with advanced COPD (GOLD [Global Initiative for Chronic Obstructive Lung Disease] stages III and IV) were selected using a purposive sampling strategy. In-depth interviews were used to collect data, which were then analysed using Van Manen's phenomenology of practice. The existential experience of dignity was understood, in essence, as "a small candle flame that doesn't go out!". Four intertwined constituents illuminated the phenomenon: "Lived body-balancing between sick body and willingness to continue"; "Lived relations-balancing between self-control and belongingness"; "Lived Time-balancing between past, present and a limited future"; and "Lived space-balancing between safe places and non-compassionate places". This study explains how existential life phenomena are experienced during the final phases of the COPD trajectory and provides ethical awareness of how dignity is lived. More research is needed to investigate innovative approaches to manage complex care in advanced COPD, in order to assist patients in discovering their inner resources to develop and promote dignity.

Micro-phenomenological approach to explore the patient experience during an initial spirometry examination to diagnose COPD in general practice in France

OBJECTIVES

To explore the patient experience of a spirometry test used to confirm chronic obstructive pulmonary disease (COPD) diagnosis in patients with suspected smoking-related COPD.

DESIGN

This is a qualitative study, performed with open interviews in adults following a routine spirometry test to confirm COPD diagnosis. Data were analysed with a phenomenological-inspired micro-phenomenology approach.

PARTICIPANTS

Eligible patients were recruited through their general practitioner, 10 were interviewed.

SETTING

Primary care in Centre-Val-De-Loire area, France, in 2018.

RESULTS

Participants reported the spirometry test experience as being unfamiliar but gave meaning to the symptoms they experience. Participants expressed a desire to perform the test well and a willingness to confront their state of health. After the spirometry had been completed and the results announced, participants moved through stages of grief from their pre-spirometry self and symptom perception to a state of acceptance. Overall, participants expressed a narrative of an evolving cognitive and corporeal awareness during this spirometry experience. The verbatim quotes describe a cognitive rupture with their chronic illness usually considered as a 'way of life'.

CONCLUSIONS

A spirometry test goes beyond a diagnostic value, providing patients with an opportunity to gain awareness of their own state of health, reframe their breathlessness-related limitations and thus begin to accept the disease. These awareness gains may be considered as small steps towards health behavioural change. Spirometry may have educative potential and support lifestyle changes.

Stigma Experiences in People with Chronic Obstructive Pulmonary Disease: An Integrative Review

Background

People with chronic obstructive pulmonary disease (COPD) are stigmatized by smoking history. Although little is known about COPD-related stigma, it can adversely affect self-management and quality of life.

Objective

To synthesize relevant scientific literature exploring stigma experiences and their impacts on people with COPD.

Methods

CINAHL/PsycINFO/PubMed/Scopus were searched for relevant studies. Findings were organized using Major et al’s conceptual model.

Results

Fifteen studies documented COPD-related stigma processes: enacted, felt, internalized, and anticipated. Moderating factors included visibility, origin, and illness perception. Individual-level stigma responses included emotional distress, limited social interactions, and negative effects on medication adherence and help-seeking. Social/community-level stigma experiences included healthcare provider and employer behaviors. Smoking is interwoven throughout all domains of stigma processes and responses to stigma.

Conclusion

Substantial evidence documents processes, moderating factors, and individual and social/community responses to the complex phenomenon of COPD-related stigma; however, prevalence of COPD-related stigma and its health effects are unclear.

Mirror of shame: Patients experiences of late-stage COPD. A qualitative study

AIMS AND OBJECTIVES

This study aims to shed light on patients with late-stage COPD and their experiences of shame.

BACKGROUND

Patients with COPD often experience shame for bringing the disease into their lives due to smoking. Knowledge about patients with COPD and their feelings of shame is crucial, but limited, however.

DESIGN

The study has a qualitative and explorative design. We interviewed twelve patients with late-stage COPD. The data were analysed using Kvale and Brinkmann's three interpretative contexts. The COREQ checklist was used.

RESULTS

Three main themes were defined; the body as a mirror of shame; a sense of being unworthy, invisible and powerless; and that sharing the burden is too difficult. The participants experienced that the disease defined their value as human beings and that made them feel vulnerable, ashamed and more socially isolated.

CONCLUSIONS

The participants experienced feelings of shame, guilt and self-blame due to their own perceptions of themselves. They were in doubt about whether they were worthy to receive care and comfort from both health professionals and, their family and friends. The participants seemed to have internalised the moral norms of contemporary society and the understanding that the disease, and especially a 'self-inflicted' disease, is a personal weakness.

RELEVANCE FOR CLINICAL PRACTICE

Findings from this study show that patients struggle with feelings such as shame and misery. The nurses who work bedside are in continuous contact with the patients and have an opportunity to gain knowledge of these feelings in order to meet the patients' needs for comfort and care. They have an obligation to ask patients about their feelings and meet them with empathy and respect. Moreover, it is necessary to have interdisciplinary fora in clinical practice where health professionals reflect, discuss and challenge themselves according to attitudes towards patients with so-called 'self-inflicted' diseases.

The information needs of people with COPD-The holistic approach with special reference to gender and time since diagnosis

Aims

The aim of this study was to determine what kinds of unmet information needs people with COPD have and whether there are differences in information needs between genders or based on the time since COPD diagnosis.

Design

A descriptive cross‐sectional study.

Methods

Data on people with COPD (N = 169) were collected from a two‐part questionnaire distributed via website. On the first part, information needs concerning the medical aspects of self‐management were measured by the Lung Information Needs Questionnaire (LINQ). On the second part, which was developed specifically for this study, a more holistic view of self‐management counselling was sought. Statistical methods were used to analyse the data.

Results

The respondents had wide‐ranging information needs in many areas of COPD self‐management. The most often reported areas of unmet information needs included exacerbations, diet, fatigue, stress and anxiety, palliative care and sexual life. The information needs varied by gender and time since COPD diagnosis.

Family members' experiences and expectations of self-management counseling while caring for a person with chronic obstructive pulmonary disease: a systematic review of qualitative evidence

OBJECTIVE

The objective of this review was to identify and synthesize existing evidence on the experiences and expectations of self-management counseling of adult family members who are informal caregivers of a person with chronic obstructive pulmonary disease (COPD) in the context of inpatient or outpatient care.

INTRODUCTION

Chronic obstructive pulmonary disease is the fourth leading cause of mortality and morbidity worldwide. It is a progressive, lifelong and unpredictable disease. As the disease progresses, both the people with COPD and their family members require information and practical skills to manage the disease. The role of family members is particularly important at the advanced stage of COPD. This systematic review examined family members' experiences and expectations of self-management counseling.

INCLUSION CRITERIA

This review considered qualitative studies that investigated adult (older than18 years) family members' experiences or expectations of COPD self-management counseling in the context of inpatient or outpatient care. "Family member" refers to a person who is an informal caregiver because of his or her relationship to the person with COPD.

METHODS

A three-step search strategy was utilized in this review. The search strategy aimed to find published and unpublished studies in English and Finnish. The databases MEDLINE, CINAHL, PsycINFO, Scopus and the Finnish medical bibliographic database, Medic, were searched. The search was conducted in December 2015 and updated in September 2018. Titles and abstracts were screened by two independent reviewers for the review's inclusion criteria. Eligible studies were then critically appraised by two independent reviewers for methodological quality. The findings and illustrations of the findings were extracted and assigned a level of credibility. The qualitative research findings were pooled using the JBI method of meta-aggregation.

RESULTS

Ten papers were selected for inclusion in this review. These studies were published from 2002 to 2017. The quality of all included studies was at least moderate. Each study had a total score between 7 and 10 on the JBI Critical Appraisal Checklist for Qualitative Research. The following four synthesized findings were aggregated from nine categories and 39 study findings: i) Family members' experiences with unresponsive behavior from health professionals, ii) Family members' experiences of unmet needs in self-management counseling, iii) Family members' information needs concerning COPD management, and iv) Family members' information needs concerning coping strategies.

CONCLUSIONS

The synthesized findings indicate that family members are frustrated by the shortcomings of self-management counseling. They also feel unprepared for and uncertain about their caring role. They need more information about COPD and coping strategies for COPD. Counseling is essential to high-quality care and should be offered to family members caring for a loved one at any stage of COPD.

Improving access to community-based pulmonary rehabilitation: 3R protocol for real-world settings with cost-benefit analysis

Background

Pulmonary rehabilitation (PR) has demonstrated patients’ physiological and psychosocial improvements, symptoms reduction and health-economic benefits whilst enhances the ability of the whole family to adjust to illness. However, PR remains highly inaccessible due to lack of awareness of its benefits, poor referral and availability mostly in hospitals. Novel models of PR delivery are needed to enhance its implementation while maintaining cost-efficiency. We aim to implement an innovative community-based PR programme and assess its cost-benefit.

Methods

A 12-week community-based PR will be implemented in primary healthcare centres where programmes are not available. Healthcare professionals will be trained. 73 patients with CRD and their caregivers (dyads patient-caregivers) will compose the experimental group. The control group will include dyads age- and disease-matched willing to collaborate in data collection but not in PR. Patients/family-centred outcomes will be dyspnoea (modified Medical Research Council Questionnaire), fatigue (Checklist of individual strength and Functional assessment of chronic illness therapy – fatigue), cough and sputum (Leicester cough questionnaire and Cough and sputum assessment questionnaire), impact of the disease (COPD Assessment Test), emotional state (The Hospital Anxiety and Depression Scale), number of exacerbations, healthcare utilisation, health-related quality of life and family adaptability/cohesion (Family Adaptation and Cohesion Scale). Other clinical outcomes will be peripheral (biceps and quadriceps-hand held dynamometer, 1 or 10 repetition-maximum) and respiratory (maximal inspiratory and expiratory pressures) muscle strength, muscle thickness and cross sectional area (biceps brachialis, rectus femoris and diaphragm-ultrasound imaging), exercise capacity (six-minute walk test and one-minute sit to stand test), balance (brief-balance evaluation systems test) and physical activity (accelerometer). Data will be collected at baseline, at 12 weeks, at 3- and 6-months post-PR.

Changes in the outcome measures will be compared between groups, after multivariate adjustment for possible confounders, and effect sizes will be calculated. A cost-benefit analysis will be conducted.

Discussion

This study will enhance patients access to PR, by training healthcare professionals in the local primary healthcare centres to conduct such programmes and actively involving caregivers. The cost-benefit analysis of this intervention will provide an evidence-based insight into the economic benefit of community-based PR in chronic respiratory diseases.

Trial registration

The trial was registered in the ClinicalTrials.gov U.S. National Library of Medicine, on 10th January, 2019 (registration number: NCT03799666).

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7045-1) contains supplementary material, which is available to authorized users.

Reluctance of patients with chronic obstructive pulmonary disease in its early stages and their families to participate in a partnership-based self-management trial: A search for explanation

Recruitment, the process of accessing, screening, selecting and retaining participants for research remains a challenge. In a randomized controlled trial, partnership-based self-management intervention for patients who have chronic obstructive pulmonary disease (COPD) in its initial stages, and their families, a theoretical framework developed for patients with an advanced COPD and their families was modified and implemented in a primary care context. In contrast to recruitment to the original study where 4% decline participation, in this study 25% of the potential patients declined participation. Although participants were encouraged to bring a family member, only 25% of them did so. The main reason for not being accompanied by a family member was that patients did not want anybody accompany them. Those who had quit smoking were more often accompanied by a family member compared to those who smoked. Reviewing the literature, the most compelling explanations for non-participation are shame and self-blame due to smoking, and that potential participants may not have envisioned any benefits from participating since they might not have realized that they had COPD. An alternative recruitment process needs to embrace the situation that potential participants find themselves in and which takes account of the issues at stake.