Expanding nurse practice in COPD: is it key to providing high quality, effective and safe patient care?

Study on the impact of comprehensive geriatric assessment on anxiety and depression in chronic obstructive pulmonary disease patients

BACKGROUND

Psychological factors such as anxiety and depression will not only aggravate the symptoms of chronic obstructive pulmonary disease (COPD) patients and reduce the quality of life of patients, but also affect the treatment effect and long-term prognosis. Therefore, it is of great significance to explore the clinical application of senile comprehensive assessment in the treatment of COPD and its influence on psychological factors such as anxiety and depression.

AIM

To explore the clinical application of comprehensive geriatric assessment in COPD care and its impact on anxiety and depression in elderly patents.

METHODS

In this retrospective study, 60 patients with COPD who were hospitalized in our hospital from 2019 to 2020 were randomly divided into two groups with 30 patients in each group. The control group was given routine nursing, and the observation group was given comprehensive assessment. Clinical symptoms, quality of life [COPD assessment test (CAT) score], anxiety and depression Hamilton Anxiety Rating Scale (HAMA) and Hamilton Depression Rating Scale (HAMD) were compared between the two groups.

RESULTS

CAT scores in the observation group decreased from an average of 24.5 points at admission to an average of 18.3 points at discharge, and in the control group from an average of 24.7 points at admission to an average of 18.3 points at discharge. The average score was 22.1 (P < 0.05). In the observation group, HAMA scores decreased from 14.2 points at admission to 8.6 points at discharge, and HAMD scores decreased from 13.8 points at admission to 7.4 points at discharge. The mean HAMD scores in the control group decreased from an average of 14.5 at admission to an average of 12.3 at discharge, and from an average of 14.1 at admission to an average of 11.8 at discharge.

CONCLUSION

The application of comprehensive geriatric assessment in COPD care has a significant effect on improving patients' clinical symptoms and quality of life, and can effectively reduce patients' anxiety and depression.

Breathing better: A tech-monitored study of positive expiratory pressure and reading aloud for chronic obstructive pulmonary disease

BACKGROUND

Breathing exercises, such as diaphragmatic breathing and positive expiratory pressure (PEP), relieve breathlessness in people with chronic obstructive pulmonary disease (COPD).

AIM

This study aimed to investigate the effects of breathing exercises with PEP and reading aloud on vital signs, fatigue level, severity of dyspnoea and respiratory function parameters in patients with COPD.

DESIGN

The study followed a randomized controlled trial of COPD patients from a single hospital in eastern Turkey.

METHODS

The study included 103 patients who were randomly assigned to receive pre-reading exercises, breathing exercises with a PEP device or no intervention for 8 weeks.

RESULTS

The use of a PEP device improved oxygen saturation, forced expiratory volume in 1 s (FEV1 ) and FEV1 /forced vital capacity (FVC) values and reduced fatigue and dyspnoea severity. Reading aloud lowered the mean arterial pressure and reduced fatigue and dyspnoea severity.

CONCLUSION

The study concludes that PEP devices and reading aloud can improve respiratory function in patients with COPD. Additionally, reading aloud is an accessible, easy-to-implement and economically feasible method for treating COPD symptoms.

Efficiency of an Online Intervention in the Knowledge Concerning COPD in Nursing Students

Background

Chronic obstructive pulmonary disease (COPD) is a progressive and debilitating respiratory disorder. Nurses play a major role in managing the disease. This study aimed to test the effect of a brief online intervention in increasing the knowledge of COPD in a sample of nursing students in Greece.

Materials and Methods

The intervention entailed a combination of two ½ hour lectures focusing on the treatment and care of patients with COPD according to existing guidelines. Data were collected with a structured questionnaire specially designed for this study including questions regarding information on sociodemographic characteristics of the participants, and the Bristol COPD Knowledge Questionnaire (BCKQ) which is designed to assess the knowledge of 13 COPD-specific topics. The questionnaire was distributed three times and the one-way ANOVA test of repeated measures was applied to investigate the effect of the educational intervention by examining the periods before, immediately after, and one month after the intervention.

Results

125 nursing students participated in this study of which 13.6% were men (n=17) and 86.4% were women. According to the results of the repeated measures ANOVA test, there was a statistically significant improvement in gained knowledge about COPD.

Conclusions

Short educational interventions can be effective in acquiring and cultivating nursing students concerning COPD. These short online tutorials seem to be cost-effective as they can be organized easily and with minimal financial resources.

Empowering Self-Efficacy by Using Patient Empowerment among Chronic Obstructive Pulmonary Disease: Pre-Post-Test Study

Patient empowerment is increasingly acknowledged as a milestone of high-quality patient-centered care. This study was conducted using COPD Self-Efficacy Scale to determine the effectiveness of the patient empowerment intervention program among chronic obstructive pulmonary disease patients on self-efficacy. We employed an interventional design with a pre-test and post-test. Sixty COPD patients comprised the final sample of the study. The current study revealed significant improvement in overall self-efficacy factors among most participants. Statistically significant positive correlations were found between the total self-efficacy post-empower intervention model scores concerning age, sex, work, educational level, and marital status. The study's findings revealed that the patient empowerment intervention program positively affected COPD patients' self-efficacy.

The Effect of Progressive Relaxation Exercises on Dyspnea and Anxiety Levels in Individuals With COPD: A Randomized Controlled Trial

Dyspnea is a common symptom and anxiety is a common comorbidity of chronic obstructive pulmonary disease (COPD). They affect individuals with COPD in a multifaceted way, causing many disabilities. Progressive relaxation exercises (PREs) are an important intervention in reducing symptoms and comorbidity. The aim of this study was to determine the effects of PREs on dyspnea and anxiety levels in individuals with COPD. A pretest-posttest randomized controlled trial was conducted at the chest diseases clinic of a university hospital in Turkey. Forty-four patients with COPD who met the inclusion criteria for participation in the study were assigned either to an intervention or a control group, with 22 patients in each group. In the intervention group, the patients performed PREs once a day for 4 weeks in addition to the standard treatment. The patients in the control group received the standard treatment. In the data collection stage of the study, questionnaire forms, namely, the Modified Borg Scale (MBS), Modified British Medical Research Council Dyspnea Scale, COPD Assessment Test (CAT), and Beck Anxiety Inventory (BAI), were used. Data were collected before (the first follow-up) and after the intervention (the second follow-up). In the second follow-up, the MBS, BAI, and CAT scores decreased significantly in the intervention group (P < .05) but showed no significant changes in the control group (P > .05). This study demonstrates that PREs can reduce dyspnea and anxiety levels in individuals with COPD.

COPD - do the right thing

A gap exists between guidelines and real-world clinical practice for the management and treatment of chronic obstructive pulmonary disease (COPD). Although this has narrowed in the last decade, there is room for improvement in detection rates, treatment choices and disease monitoring. In practical terms, primary care practitioners need to become aware of the huge impact of COPD on patients, have non-judgemental views of smoking and of COPD as a chronic disease, use a holistic consultation approach and actively motivate patients to adhere to treatment.This article is based on discussions at a virtual meeting of leading Nordic experts in COPD (the authors) who were developing an educational programme for COPD primary care in the Nordic region. The article aims to describe the diagnosis and lifelong management cycle of COPD, with a strong focus on providing a hands-on, practical approach for medical professionals to optimise patient outcomes in COPD primary care.

Renaming COPD exacerbations: the UK respiratory nursing perspective

BACKGROUND

Patients with COPD experience acute worsenings, termed 'exacerbations'. While other terms to describe these events have been proposed there is no consensus on terminology which has led to multiple terms being used across the UK. Respiratory nurses are part of a multi-disciplinary team managing COPD patients, however, the nursing perspective on the term 'exacerbation' is unknown.

METHODS

An anonymised survey of 17 questions was sent to respiratory nurses through an email invitation link. The survey link was open for one month. The aim was to understand the nurse perspective on 'exacerbation'. Alternative terms used in the UK were compared versus the term 'exacerbation'.

RESULTS

Responses were received from 113 nurses. The majority (88%) were female. There was no consensus on preference or meaning for the term 'exacerbation' between nurses. Less than 5% of nurses thought that patients with COPD would understand the term 'exacerbation'. In ranked order, the nurses preferred the following terms: 'flare-up', 'lung attack', 'crisis', 'exacerbation' and 'chest infection'. The term 'crisis', although new, was considered to be the term that most resonated with clinical practice.

CONCLUSION

Respiratory nurses in the UK report that the term 'exacerbation' is not fit for purpose for patients, and alternatives should be sought.

The Effect of Nursing Care Applied to Patients with Chronic Obstructive Pulmonary Disease on Their Sexual Experiences and Quality of Life

This study was conducted for the aim of assessing the effect of nursing care applied to patients with chronic obstructive pulmonary disease on their sexual experiences and quality of life. The sample of the study was determined via power analysis, patients were assigned groups using a simple random sampling method. The data were collected between December 2019-June 2020. The researcher applied the nursing care to patients in the experimental group in their home three times. There was a statistically significant difference between posttest mean scores of the Short Form-36 Health-Related Quality of Life Questionnaire subscales and Arizona Sexual Experiences Scale of the patients in the experimental and control groups (p < 0.05). In this study, it was determined that there was an increase in the Health-Related Quality of Life Questionnaire mean score of patients with COPD after the nursing care; whereas, there was a slight decrease in the Arizona Sexual Experiences Scale mean score.

Closing the gap: The effect of an evidence-based intervention in increasing COPD nurses' knowledge

BACKGROUND

Chronic obstructive pulmonary diseases (COPD) is the leading cause of respiratory failure and is associated with high morbidity and mortality rates. Nurses play a vital role in ensuring effective, safe, and person-centered care in COPD.

AIM

To assess the effect of an evidence-based intervention in increasing the COPD knowledge in a sample of care nurses, staffing public primary, and secondary healthcare services infrastructures and hospitals.

METHODS

An intervention that entailed a combination of an educational program and the use of an educational algorithm based on the Global Strategy for the Diagnosis, Management, and Prevention of COPD was performed.

RESULTS

At the baseline, the mean total percentage of correct answers was very low (52.74%) as opposed to the other time intervals in which there was a huge increase after the session that was maintained 3 and 6 months later. The highest effect in the total knowledge score was attributed to the educational session followed by the use of the educational algorithm.

CONCLUSION

The effect of the intervention on the mean score of correct answers was very strong, which is confirmed by the consistency of the high performance of nurses after 3 and 6 months, respectively.

Do we need tailored training and development plans for European Union respiratory nurses?

Nurses are critical players in healthcare and should be the next profession to standardise levels of education, preparing them for an active partnership with other healthcare professionals prepared to tackle the chronic disease problem in Europe https://bit.ly/3bMR76b.

Effect of training provided to patients with chronic obstructive pulmonary disease on drug management

AIM

Wrong use of an inhaler arising from a lack of knowledge can negatively affect treatment management. Therefore, this study was performed with the aim of determining the effects on treatment management of inhaler training carried out under the leadership of a nurse in individuals with medium and advanced stage chronic obstructive pulmonary disease (COPD).

METHODS

This was an experimentally designed pre-test post-test study with a control group. Participants were interviewed four times in 1 year. The experimental group performed inhaler training. A Patient Description and Follow-Up Form, an Inhaler Drug Use Skill Chart, the Morisky eight-item Medication Adherence Scale, the COPD Assessment Test, and the St. George Respiration Questionnaire were used to collect data. Data analysis was performed by SPSS, using nonparametric tests.

RESULTS

Although there was no significant difference between the groups, a reduction in hospital visits and admissions because of attacks was seen in the experimental group (p = .239, p = .492). It was found there was a greater increase in the correct use of the inhaler in the experimental group than in the control group, and that correct use of the handihaler increased significantly (p = .008). Also, the increases in adherence to treatment (p = .006) and quality of life (p = .010) in the experimental group were significantly different from the control group. In the control group, the annual decline in forced expiratory volume in 1 s increased significantly (p = .016).

CONCLUSIONS

It was seen that long-term inhaler training given by nurses at regular intervals made a significant contribution to treatment management.

Training needs for Ugandan primary care health workers in management of respiratory diseases: a cross sectional survey

Background

Respiratory diseases are among the leading causes of morbidity and mortality in Uganda, but there is little attention and capacity for management of chronic respiratory diseases in the health programmes. This survey assessed gaps in knowledge and skills among healthcare workers in managing respiratory illnesses.

Methods

A cross sectional study was conducted among primary care health workers, specialist physicians and healthcare planners to assess gaps in knowledge and skills and, training needs in managing respiratory illnesses. The perspectives of patients with respiratory diseases were also sought. Data were collected using questionnaires, patient panel discussions and review of pre-service training curricula for clinicians and nurses. Survey Monkey was used to collect data and descriptive statistical analysis was undertaken for quantitative data, while thematic content analysis techniques were utilized to analyze qualitative data.

Results

A total of 104 respondents participated in the survey and of these, 76.9% (80/104) were primary care health workers, 16.3% (17/104) specialist clinicians and 6.7% (7/104) healthcare planners. Over 90% of the respondents indicated that more than half of the patients in their clinics presented with respiratory symptoms. More than half (52%) of the primary care health workers were not comfortable in managing chronic respiratory diseases like asthma and COPD. Only 4% of them were comfortable performing procedures like pulse oximetry, nebulization, and interpreting x-rays. Majority (75%) of the primary care health workers had received in-service training but only 4% of the sessions focused on respiratory diseases. The pre-service training curricula included a wide scope of respiratory diseases, but the actual training had not sufficiently prepared health workers to manage respiratory diseases. The patients were unsatisfied with the care in primary care and reported that they were often treated for the wrong illnesses.

Conclusions

Respiratory illnesses contribute significantly to the burden of diseases in primary care facilities in Uganda. Management of patients with respiratory diseases remains a challenge partially because of inadequate knowledge and skills of the primary care health workers. A training programme to improve the competences of health workers in respiratory medicine is highly recommended.

Effectiveness of a community health worker (CHW) training in monitoring and care of patients with chronic obstructive pulmonary disease (COPD) in rural Gujarat, India

Context:

Chronic obstructive pulmonary disease (COPD) is the second leading contributor to the disease burden of India. The current COPD burden cannot be managed effectively just through a physician-based approach. In a primary care setting, community health workers (CHWs) can play an effective role in making COPD care accessible and effective.

Aim:

Findings of an assessment of a training program for CHWs on COPD have been reported here. Methods: 90 CHWs working as a part of a noncommunicable disease prevention and care program in a rural primary care setting were exposed to a series of five training sessions. The sessions were designed and administered jointly by a team of public health experts and physiotherapists in the year 2017–18. Topics covered were basic clinical aspects of COPD, monitoring a patient with COPD, and basic aspects of pulmonary rehabilitation. The assessment comprised 12 MCQs and short questions, 7 video exercises, 2 case vignettes, and 5 skill assessments through objectively structured clinical examination (OSCE).

Statistical Analysis:

Mean percentage scores were calculated for each domain of assessment to make it comparable.

Results:

70 CHWs with a mean age of 42.2 years completed all the training and underwent the assessment. Mean percentage score (SD) for knowledge was 62% (16.3). In OSCE assessment, scores were best in sputum clearance technique demonstration (92.1%) and the least in dyspnea relieving positions (59.2%). The CHWs had difficulties in identifying signs of respiratory distress (score - 55.1%). No statistically significant association was observed between performance scores and their sociodemographic profile.

Conclusion:

The results were encouraging and the program may be pilot tested in a government setting particularly using the health and wellness centers (HWC) platform.

"Looking for Deviations": Nurses' Observations of Older Patients With COPD in Home Nursing Care

Nurses working in home care play a significant role in observing and identifying changes in the health status of patient with chronic obstructive pulmonary disease (COPD). The aim of this study was to explore and describe nurses' observations of older patients with COPD when providing home nursing care. In this qualitative explorative study, data were collected through observations of 17 home care visits using the think-aloud technique, followed up with individual interviews with the nurses. Qualitative content analysis was used to analyze the data. The findings showed that the nurses' observations (focus, methods, and interpretation) were characterized by their search for deviations from what they judged to be the patient's habitual state. The nurses did not use any tool or guidelines, nor did they follow a standard procedure. Instead, when observing and interpreting, they performed a complex process guided by their experience and knowledge of the patient, and the patient's individual and contextual circumstances. This knowledge contributes to warranted reflection on nurses' practice in this context to secure COPD patients' safety and quality of life.

Patients' perspectives on the COPD-GRIP intervention, a new nursing care intervention for COPD

BACKGROUND

The nurse-led chronic obstructive pulmonary disease-Guidance Research on Illness Perception (COPD-GRIP) intervention was developed to incorporate illness perceptions into COPD care with the intention to improve the health-related quality of life of COPD patients. This individualized intervention focuses on identifying, discussing and evaluating illness perceptions and consists of three consultations with a practice nurse. The aim of this study is to explore patients' experiences regarding the COPD-GRIP intervention.

METHODS

A qualitative interview study nested in a cluster randomized trial in primary care. One-time semi-structured individual interviews with COPD patients who were guided with the COPD-GRIP intervention were conducted. During data collection, the constant comparative approach was used. All interviews were recorded, transcribed, anonymized and uploaded to MAXQDA. To identify themes, the transcripts were independently coded by two researchers.

RESULTS

Sixteen patients were interviewed. All patients were positive and experienced an additional value of the COPD-GRIP intervention in different areas. Three main themes were identified and show that taking part in this intervention made the patients feel 'listened to and acknowledged', improved their awareness of the disease and its management and helped them to make lifestyle changes. Some patients suggested that the individualized care plan could be improved and to start the intervention immediately after being informed of the COPD diagnosis. All patients recommended this intervention.

CONCLUSION

The results of this study indicate that patients acknowledge that the COPD-GRIP intervention is a useful and promising tool for providing individualized COPD care.

Sex and intimacy in people with severe asthma: a qualitative study

Introduction

People with severe asthma experience unpredictable daily symptoms requiring an intense treatment regimen impacting on health-related quality of life (QoL). Sexuality contributes to this, yet there is a dearth of research exploring intimacy in people with severe asthma. We aimed to explore the patient's perception of the impact of severe asthma on intimacy, establish their information needs and their perceived role of the healthcare practitioner.

Methods

We have performed a qualitative study guided by Interpretive Phenomenological Analysis. We interviewed patients diagnosed with severe asthma recruited from a dedicated clinic using purposive sampling. Interviews were audio recorded and transcribed verbatim. Using thematic analysis, the data were analysed for emergent themes.

Results

The nine interviews provided unique and detailed insights into their perspectives on how living with severe asthma impinges on sexual intimacy. Four superordinate themes emerged: (1) 'Physical intimacy': including disclosure of physical limitations of severe asthma on intimacy; (2) 'Emotional intimacy': the cyclical impact of the often-negative emotional struggle of living with severe asthma on relationships; (3) 'The role of the healthcare professional': a perceived failure of healthcare professionals (HCPs) to tackle sexual intimacy in consultations and (4) 'Image of self': the reported struggle to deal with negative body image and confusion regarding changing relationship roles.

Discussion

This study is the first to explore the impact of severe asthma on intimacy. We suggest an emphasis on education to raise awareness and help HCPs to address this sensitive topic in this cohort and adopt positive strategies to help improve QoL.

Effectiveness of nursing interventions for breathlessness in people with chronic obstructive pulmonary disease: A systematic review and meta-analysis

AIM

To critically review and synthesize the findings of studies that evaluated the effectiveness of nursing interventions for improving breathlessness in adults with chronic obstructive pulmonary disease.

BACKGROUND

Systematic reviews of nursing interventions for breathlessness in people with chronic obstructive pulmonary disease have not been specifically addressed.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

A systematic search of Medline, CINAHL, PsycINFO and Embase was performed for studies published between January 2000 and June 2017.

REVIEW METHODS

Risk of bias, data extraction and meta-analysis were conducted using Cochrane methodology. The quality of evidence was assessed using the GRADE approach.

RESULTS

Twenty papers were included. A meta-analysis of interventions performed at home, including two trials, showed a significant effect in favour of experimental groups for the symptom score of the St. George Respiratory Questionnaire compared with controls. A meta-analysis of interventions performed in clinics with home follow-up showed a significant effect in favour of experimental groups for the mastery and fatigue scores of the Chronic Respiratory Questionnaire compared with controls. In this category of intervention, an additional meta-analysis showed a significant effect in favour of experimental groups for the symptom, activity and total scores of the St. George Respiratory Questionnaire compared with controls. The quality of evidence was assessed to be very low to moderate.

CONCLUSION

The results are equivocal as to whether nursing interventions performed at home and nursing interventions performed in hospital with follow-up improve breathlessness in people with chronic obstructive pulmonary disease.

Nurse-led versus doctor-led care for bronchiectasis

BACKGROUND

Specialist nursing roles to manage stable disease populations are being used to meet the needs of both patients and health services. With increasing cost pressures on health departments, alternative models such as nurse-led care are gaining momentum as a substitute for traditional doctor-led care. This review evaluates the safety, effectiveness, and health outcomes of nurses practising in autonomous roles while using advanced practice skills, within the context of bronchiectasis management in subacute, ambulatory, and/or community care.

OBJECTIVES

To compare the effectiveness of nurse-led care versus doctor-led care in the management of stable bronchiectasis.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register and bibliographies of selected papers in addition to grey literature such as electronic clinical trials registries. Searches were current as of March 2018.

SELECTION CRITERIA

Randomised controlled trials were eligible for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted and entered data from included studies. Primary outcomes were numbers of exacerbations requiring treatment with antibiotics, hospital admissions, and emergency department attendances.

MAIN RESULTS

We included one United Kingdom (UK) study in the review. In this randomised controlled trial, a total of 80 participants, with a mean age of 58 years, were treated for 12 months by a specialist nurse or doctor, then were crossed over to the other clinician for the next 12 months. Two participants died during the study period. Six participants failed to cross over to nurse-led care because of unstable bronchiectasis. Overall, the level of study completion was high.Data show no difference in the numbers of exacerbations requiring treatment with antibiotics (rate ratio 1.09, 95% confidence interval (CI) 0.91 to 1.30, 80 participants, moderate-certainty evidence). Investigators reported more hospital admissions in the nurse-led care group (rate ratio 1.52, 95% CI 1.04 to 2.23, 80 participants, moderate-certainty evidence) and did not report emergency department attendance.For secondary outcomes, participants in the nurse-led care group used more healthcare resources during the first year of the trial. Increased admissions and greater use of resources made treatment costs for nurse-led groups' higher. Total costs for both years of the study were £8,464 and £5,228 for nurse-led care compared with doctor-led care. However, by the second year, treatment costs were almost equitable between the two groups, which may reflect the nurses' learning of how to better treat people with bronchiectasis. No statistically significant changes were observed in quality of life, exercise capacity, mortality, or lung function. Wide confidence intervals led to uncertainty regarding these results. Adverse events were not an outcome for this review.

AUTHORS' CONCLUSIONS

This update of the review shows that only one trial met review criteria. Review authors were unable to demonstrate effectiveness of nurse-led care compared with doctor-led care on the basis of findings of a single study. The included study reported no significant differences, but limited evidence means that differences in clinical outcomes between nurse-led care and usual care within the setting of a specialist clinic remain unclear. Further research is required to determine whether nurse-led care is cost-effective, if guidelines and protocols for bronchiectasis management are followed does this increases costs and how effective nurse-led management of bronchiectasis is in other clinical settings such as inpatient and outreach.

Education and non-pharmacological approaches for gout

The objectives of this review are as follows: to highlight the gaps in patient and physician knowledge of gout and how this might impede optimal disease management; to provide recommended core knowledge points that should be conveyed to people with gout; and to review non-pharmacological interventions that can be used in gout management. MeSH terms were used to identify eligible studies examining patients' and health-care professionals' knowledge about gout and its management. A narrative review of non-pharmacological management of gout is provided. Many health-care professionals have significant gaps in their knowledge about gout that have the potential to impede optimal management. Likewise, people with gout and the general population lack knowledge about causes, consequences and treatment of this condition. Full explanation about gout, including the potential benefits of urate-lowering treatment (ULT), motivates people with gout to want to start such treatment, and there is evidence, albeit limited, that educational interventions can improve uptake and adherence to ULT. Additionally, several non-pharmacological approaches, such as rest and topical ice application for acute attacks, avoidance of risk factors that can trigger acute attacks, and dietary interventions that may reduce gout attack frequency (e.g. cherry or cherry juice extract, skimmed milk powder or omega-3 fatty acid intake) or lower serum uric acid (e.g. vitamin C), can be used as adjuncts to ULT. There is a pressing need to educate health-care professionals, people with gout and society at large to remove the negative stereotypes associated with gout, which serve as barriers to optimal gout management, and to perceive gout as a significant medical condition. Moreover, there is a paucity of high-quality trial evidence on whether certain simple individual dietary and lifestyle factors can reduce the risk of recurrent gout attacks, and further studies are required in this field.

Research priorities for respiratory nursing: a UK-wide Delphi study

Respiratory nurses make a significant contribution to the delivery of respiratory healthcare, but there is a dearth of nurse-led, practice-focused, published research.

Using a modified three-round Delphi, this study sought to identify research priorities for respiratory nursing to inform a national research strategy. Study information and the survey link were sent electronically to members of UK professional respiratory organisations. Round 1 had 78 items across 16 topics, informed by a systematic literature review. Respondents suggested additional items which were content analysed to inform Round 2. Respondents rated all items and ranked the topics in all rounds. To ensure rigour, rounds had an explicit focus with pre-determined criteria for consensus (70%).

In total, 363 responses were received across Rounds 1, 2 and 3 (n=183, 95 and 85, respectively). The top five research priorities were: 1) “Patient understanding of asthma control”; 2) “The clinical and cost-effectiveness of respiratory nurse interventions”; 3) “The impact of nurse-led clinics on patient care”; 4) “Inhaler technique”; and 5) two topics jointly scored: “Prevention of exacerbations” and “Symptom management”.

With potential international significance, this is the first UK study to identify research priorities for respiratory nursing, providing direction for those planning or undertaking research.

UK-wide Delphi survey identifies nursing research priorities to enhance respiratory care for patients and carershttp://ow.ly/ekGt30iXYXt

An intervention for pulmonary rehabilitators to develop a social identity for patients attending exercise rehabilitation: a feasibility and pilot randomised control trial protocol

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a degenerative condition that can impair health-related quality of life (HRQoL). A number of self-management interventions, employing a variety of behavioural change techniques (BCTs), have been adopted to improve HRQoL for COPD patients. However, a lack of attention has been given to group management interventions with an emphasis on incorporating BCTs into rehabilitators' practice. This study aims to pilot and feasibly explore a social identity group management intervention, delivered by COPD rehabilitation staff to patients attending exercise pulmonary rehabilitation. Doing so will help inform the plausibility of the intervention before conducting a full trial to evaluate its effectiveness to improve HRQoL.

METHODS

This is a two-centre, randomised cross-over controlled trial. Two pulmonary rehabilitation centres based in the UK will be randomly allocated to two treatment arms (standard care and intervention). Outcome measurements relating to HRQoL and social identity will be completed pre- and post-exercise rehabilitation. Focus group interviews will be conducted at the end of exercise rehabilitation to capture participants' contextualised experiences of the intervention. COPD rehabilitators will undertake semi-structured interviews at the end of the trial to garner their holistic perspectives of intervention fidelity and implementation.

DISCUSSION

This is the first study to adopt a social identity approach to develop a rehabilitator-led, group management intervention for COPD patients attending exercise pulmonary rehabilitation. The results of this study will provide evidence for the feasibility and sample size requirements to inform a larger study, which can ascertain the intervention's effectiveness for improving HRQoL for COPD patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02288039. Date 31 October 2014.

Managing chronic obstructive pulmonary disease in the community setting

Chronic obstructive pulmonary disease (COPD) is an umbrella term used to describe respiratory diseases characterised by airway obstruction. COPD is now an established and significant chronic disease, killing over 30 000 people in the UK every year. According to the World Health Organization, COPD will become the third biggest killer in the world by 2020. The financial and human cost of the disease is huge. To appreciate the pathophysiology of obstructive pulmonary diseases, it is first necessary to understand a number of important lung concepts. This article discusses the pathophysiology of COPD, highlighting the main mechanisms involved, provides an outline of the associated signs, symptoms and treatment of COPD and explore how health care professionals in the community/residential care settings can help manage and improve the quality of life for patients with COPD.

The effectiveness of a nurse-led illness perception intervention in COPD patients: a cluster randomised trial in primary care

The new COPD-GRIP (Chronic Obstructive Pulmonary Disease - Guidance, Research on Illness Perception) intervention translates evidence regarding illness perceptions and health-related quality of life (HRQoL) into a nurse intervention to guide COPD patients and to improve health outcomes. It describes how to assess and discuss illness perceptions in a structured way. This study aimed to assess the effectiveness of the intervention in primary care. A cluster randomised controlled trial was conducted within 30 general practices and five home-care centres, including 204 COPD patients. 103 patients were randomly assigned to the intervention group and 101 patients to the usual-care group. To assess differences, repeated multilevel linear mixed modelling analyses were used. Primary outcome was change in health status on the Clinical COPD Questionnaire (CCQ) at 9 months. Secondary outcomes were HRQoL, daily activities, health education impact and changes in illness perceptions. There was no significant difference between the groups in the CCQ at 9 months. We found a significant increase in health-directed behaviour at 6 weeks (p=0.024) and in personal control (p=0.005) at 9 months in favour of the intervention group. The COPD-GRIP intervention, practised by nurses, did not improve health status in COPD patients in primary care. However, the intervention has benefits in improving the ability to control the disease and health-related behaviours in the short term. Therefore, taking illness perceptions into account when stimulating healthy behaviours in COPD patients should be considered. Further study on influencing the health status and HRQoL is needed.

Evaluation of the current landscape of respiratory nurse specialists in the UK: planning for the future needs of patients

INTRODUCTION

The National Health Service currently faces significant challenges and must optimise effective workforce planning and management. There are increasing concerns regarding poor workforce planning for respiratory medicine; a greater understanding of the role of respiratory nurse specialists will inform better workforce planning and management.

METHODS

This was a survey study. Two surveys were administered: an organisational-level survey and an individual respiratory nurse survey.

RESULTS

There were 148 and 457 respondents to the organisational and individual nurse survey, respectively. Four main themes are presented: (1) breadth of service provided; (2) patient care; (3) work environment; and (4) succession planning. The majority of work conducted by respiratory nurse specialists relates to patient care outside the secondary care setting including supporting self-management in the home, supporting patients on home oxygen, providing hospital-at-home services and facilitating early discharge from acute care environments. Yet, most respiratory nursing teams are employed by secondary care trusts and located within acute environments. There was evidence of multidisciplinary working, although integrated care was not prominent in the free-text responses. High workload was reported with one-quarter of nursing teams short-staffed. Respiratory nurses reported working unpaid extra hours and a lack of administrative support that often took them away from providing direct patient care. Nearly half of the present sample either plan to retire or are eligible for retirement within 10 years.

CONCLUSIONS

This survey report provides a current snapshot of the respiratory nurse specialist workforce in the UK. This workforce is an ageing population; the results from this survey can be used to inform succession planning and to ensure a viable respiratory nurse specialist workforce in future.

How do general practitioners implement decision-making regarding COPD patients with exacerbations? An international focus group study

PURPOSE

To explore the decision-making of general practitioners (GPs) concerning treatment with antibiotics and/or oral corticosteroids and hospitalization for COPD patients with exacerbations.

METHODS

Thematic analysis of seven focus groups with 53 GPs from urban and rural areas in Norway, Germany, Wales, Poland, Russia, the Netherlands, and Hong Kong.

RESULTS

Four main themes were identified. 1) Dealing with medical uncertainty: the GPs aimed to make clear medical decisions and avoid unnecessary prescriptions and hospitalizations, yet this was challenged by uncertainty regarding the severity of the exacerbations and concerns about overlooking comorbidities. 2) Knowing the patient: contextual knowledge about the individual patient provided a supplementary framework to biomedical knowledge, allowing for more differentiated decision-making. 3) Balancing the patients' perspective: the GPs considered patients' experiential knowledge about their own body and illness as valuable in assisting their decision-making, yet felt that dealing with disagreements between their own and their patients' perceptions concerning the need for treatment or hospitalization could be difficult. 4) Outpatient support and collaboration: both formal and informal caregivers and organizational aspects of the health systems influenced the decision-making, particularly in terms of mitigating potentially severe consequences of "wrong decisions" and concerning the negotiation of responsibilities.

CONCLUSION

Fear of overlooking severe comorbidity and of further deteriorating symptoms emerged as a main driver of GPs' management decisions. GPs consider a holistic understanding of illness and the patients' own judgment crucial to making reasonable decisions under medical uncertainty. Moreover, GPs' decisions depend on the availability and reliability of other formal and informal carers, and the health care systems' organizational and cultural code of conduct. Strengthening the collaboration between GPs, other outpatient care facilities and the patients' social network can ensure ongoing monitoring and prompt intervention if necessary and may help to improve primary care for COPD patients with exacerbations.

Nurses' perspectives of a new individualized nursing care intervention for COPD patients in primary care settings: A mixed method study

BACKGROUND

The major challenges in Chronic Obstructive Pulmonary Disease (COPD) care are guiding a patient in daily living with the consequences of the disease, reducing the impact of symptoms and improving Health Related Quality of Life (HRQoL). The new nurse-led COPD-Guidance, Research on an Illness Perception (COPD-GRIP) intervention translates the evidence concerning illness perceptions and Health Related Quality of Life (HRQoL) into a practice nurse intervention. The aim is to explore the nurses' experiences with applying the new COPD-GRIP intervention.

METHOD

An explanatory mixed-method study nested in a cluster randomized trial in primary care was conducted. Pre-intervention questionnaires were sent to all participating nurses (N=24) to identify expectations. Post-intervention questionnaires identified experiences after applying the intervention followed by two focus groups to further extend exploration of findings. Questionnaires were analyzed by descriptive analyses. To identify themes the audio-taped and transcribed focus groups were independently coded by two researchers.

RESULTS

The nurses described the intervention as a useful, structured and individualized tool to guide COPD patients in living with the consequences of COPD. Applying the intervention took less time than the nurses initially expected. The intervention enables to provide patient-centered care and to address patient needs. Barriers were encountered, especially in patients with a lower social economic status, in patients with a lower health literacy and in patients with other cultural backgrounds than the Dutch background.

CONCLUSION

Nurses perceived the COPD-GRIP intervention as a feasible, individualized tool. According to the nurses, the intervention is a valuable improvement in the care for COPD patients.

Recent updates in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD), characterized by chronic airways inflammation and progressive airflow limitation, is a common, preventable and treatable disease. Worldwide, COPD is a major cause of morbidity and mortality; smoking tobacco is the most important risk factor. This translational review of recent updates in COPD care for the primary care audience, includes recommendations from the 2015 Global Initiative for chronic obstructive lung disease (GOLD) report on diagnosis, pharmacological and non-pharmacological treatment, prevalence of comorbidities, management of exacerbations and the asthma and COPD overlap syndrome, with a focus on the importance and benefit of physical activity and exercise in COPD patients. Exacerbations and comorbidities contribute to the overall severity of COPD in individual patients. Management of exacerbations includes reducing the impact of the current exacerbation and preventing development of subsequent episodes. Healthcare professionals need to be alert to comorbidities, such as cardiovascular disease, anxiety/depression, lung cancer, infections and diabetes, which are common in COPD patients and can have a significant impact on HRQoL and prognosis. Pulmonary rehabilitation is recommended by a number of guidelines for all symptomatic COPD patients, regardless of severity, and involves exercise training, patient education, nutritional advice and psychosocial support. At all stages of COPD, regular physical activity and exercise can aid symptom control, improve HRQoL, reduce rates of hospitalization, and improve morbidity and respiratory mortality. Healthcare professionals play a pivotal role in improving HRQoL and health-related outcomes in COPD patients to meet their specific needs and in providing appropriate diagnosis, management and advice on smoking cessation.

Managing uncertainty in advanced liver disease: a qualitative, multiperspective, serial interview study

OBJECTIVE

To understand the experiences and support needs of people with advanced liver disease and those of their lay and professional carers to inform improvements in the supportive and palliative care of this rapidly growing but currently neglected patient group.

DESIGN

Multiperspective, serial interviews. We conducted up to three qualitative in-depth interviews with each patient and lay carer over 12 months and single interviews with case-linked healthcare professionals. Data were analysed using grounded theory techniques.

PARTICIPANTS

Patients with advanced liver disease of diverse aetiologies recruited from an inpatient hepatology ward, and their lay carers and case-linked healthcare professionals nominated by the patients.

SETTING

Primary and secondary care in South-East Scotland.

RESULTS

37 participants (15 patients, 11 lay and 11 professional carers) completed 51 individual and 13 joint patient-carer interviews. Nine patients died during the study. Uncertainty dominated experiences throughout the course of the illness, across patients' considerable physical, psychological, social and existential needs and affected patients, lay carers and professionals. This related to the nature of the condition, the unpredictability of physical deterioration and prognosis, poor communication and information-sharing, and complexities of care. The pervasive uncertainty also shaped patients' and lay carers' strategies for coping and impeded care planning. While patients' acute medical care was usually well coordinated, their ongoing care lacked structure and focus.

CONCLUSIONS

Living, dying and caring in advanced liver disease is dominated by pervasive, enduring and universally shared uncertainty. In the face of high levels of multidimensional patient distress, professionals must acknowledge this uncertainty in constructive ways that value its contribution to the person's coping approach. Pervasive uncertainty makes anticipatory care planning in advanced liver disease challenging, but planning 'just in case' is vital to ensure that patients receive timely and appropriate supportive and palliative care alongside effective management of this unpredictable illness.

[Perceptions of patients and health professionals about the quality of care provided to chronic obstructive pulmonary disease patients]

OBJECTIVE

To explore the understanding and knowledge of patients and health professionals about factors that influence the quality of care provided in Primary Care to people with Chronic Obstructive Pulmonary Disease (COPD).

DESIGN

Qualitative study performed between February and March 2010.

LOCATION

Primary Care Centers.

PARTICIPANTS

Medical and nursing professionals and patients with COPD.

METHODS

Non-probabilistic intentional sampling with representation criterion of the discourse. Two group (focus group) and 6 individual interviews were performed. The interviews were recorded, literally transcribed and interpreted by social discourse analysis.

RESULTS

Patients neither identify properly the symptomatology nor they assume the COPD importance until advanced states. The lacks of knowledge about the evolution of the disease and the impact on quality of life hinders the necessary changes. Professionals reports problems with performing spirometry. Among doctors, scepticism regarding to the effectiveness of the interventions aimed at change of behaviour is identified. The existence of Clinical Guides, the improvement of the coordination between professionals and the alignment of priorities between managers and professionals stand out as organizational factors.

CONCLUSIONS

The identified factors suggest the possibility of improving the health care through improved communication to motivate them to take the recommended changes and to increase the adherence to treatments. To this effect, the awareness and training of professionals, the healthcare coordination, the implementation of Clinical Guides and the use of indicators in a process of quality assessment.

Effectiveness of community-based integrated care in frail COPD patients: a randomised controlled trial

Background:

Chronic obstructive pulmonary disease (COPD) generates a high burden on health care, and hospital admissions represent a substantial proportion of the overall costs of the disease. Integrated care (IC) has shown efficacy to reduce hospitalisations in COPD patients at a pilot level. Deployment strategies for IC services require assessment of effectiveness at the health care system level.

Aims:

The aim of this study was to explore the effectiveness of a community-based IC service in preventing hospitalisations and emergency department (ED) visits in stable frail COPD patients.

Methods:

From April to December 2005, 155 frail community-dwelling COPD patients were randomly allocated either to IC (n=76, age 73 (8) years, forced expiratory volume during the first second, FEV₁ 41(19) % predicted) or usual care (n=84, age 75(9) years, FEV₁ 44 (20) % predicted) and followed up for 12 months. The IC intervention consisted of the following: (a) patient’s empowerment for self-management; (b) an individualised care plan; (c) access to a call centre; and (d) coordination between the levels of care. Thereafter, hospital admissions, ED visits and mortality were monitored for 6 years.

Results:

IC enhanced self-management (P=0.02), reduced anxiety–depression (P=0.001) and improved health-related quality of life (P=0.02). IC reduced both ED visits (P=0.02) and mortality (P=0.03) but not hospital admission. No differences between the two groups were seen after 6 years.

Conclusion:

The intervention improved clinical outcomes including survival and decreased the ED visits, but it did not reduce hospital admissions. The study facilitated the identification of two key requirements for adoption of IC services in the community: appropriate risk stratification of patients, and preparation of the community-based work force.

Management of stable chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a common condition. There are an estimated 3 million cases in the UK. Of these, 2 million have not got a formal diagnosis. Community nurses meet patients with COPD frequently, although COPD may not be the primary reason for the encounter, or the COPD may be present but undiagnosed. The number of patients with COPD is believed to be increasing and, with increased awareness of the condition and an emphasis on improving diagnosis, the number of cases is expected to rise. Community nurses are well placed to raise concerns that a patient in their care may have undiagnosed COPD; if the condition is subsequently diagnosed and appropriate treatment is given, outcomes will improve for that individual. Community nurses can also support patients and their families to manage the condition through all stages of the disease trajectory, from diagnosis to the end-of-life phase.

Quality of Life in Chronic Obstructive Pulmonary Disease: An Evolutionary Concept Analysis

AIM

To explore the concept of quality of life (QoL) of people with chronic obstructive pulmonary disease (COPD) in the nursing context.

BACKGROUND

The issue of QoL takes on a leading role in the COPD field because it is an incurable pathology. Despite its relevance, this concept is quite ambiguous, and there is no consensus of opinion in the literature regarding its definition.

DESIGN AND METHODS

Rodgers' method of evolutionary concept analysis was employed to delineate and clarify the concept of QoL in COPD. An electronic review was made on scientific databases from 2008 to 2013. The 75 selected articles were analyzed in order to highlight the main themes related to QoL concept.

RESULTS

The QoL appears as a dynamic and multidimensional concept that evolves with the progression of the pathology and the impairment of health status. It has both subjective and objective characteristics, intrinsic and extrinsic elements.

CONCLUSIONS

This analysis provides an overview of the QoL concept related to COPD patients that is useful as a guide to research into nursing care and for clinical practice.

Symptom burden in stable COPD patients with moderate or severe airflow limitation

OBJECTIVES

To describe a multidimensional symptom profile in patients with stable chronic obstructive pulmonary disease (COPD) and determine whether symptom experience differed between patients with moderate or severe airflow limitations.

BACKGROUND

Patients with severe airflow limitation experience numerous symptoms, but little is known regarding patients with moderate airflow limitation.

METHODS

A multidimensional symptom profile (Memorial Symptom Assessment Scale) was assessed in 42 outpatients with moderate and 49 with severe airflow limitations.

RESULTS

The mean number of symptoms in the total sample was 7.9 (±4.3) with no difference between patients with moderate and severe airflow limitations. The most prevalent symptoms with the highest MSAS symptom burden scores were shortness of breath, dry mouth, cough, sleep problems, and lack of energy in both groups.

CONCLUSIONS

Patients with moderate or severe airflow limitations experience multiple symptoms with high severity and distress. An assessment of their multidimensional symptom profile might contribute to better symptom management.

Accuracy of diagnosis and classification of COPD in primary and specialist nurse-led respiratory care in Rotherham, UK: a cross-sectional study

BACKGROUND

Studies have suggested that chronic obstructive pulmonary disease (COPD) is commonly misdiagnosed and misclassified in primary care, but less is known about the quality of diagnosis in specialist respiratory care.

AIMS

To measure the accuracy of COPD diagnosis and classification of airway obstruction in primary care and at a specialist respiratory centre, and to explore associations between misdiagnosis and misclassification and a range of explanatory factors.

METHODS

Data were obtained for 1,205 referrals to a specialist respiratory centre between 2007 and 2010. Standard analysis methods were used.

RESULTS

The majority of patients were referred for pulmonary rehabilitation (676/1,205, 56%). Of 1,044 patients with a primary care diagnosis of COPD, 211 (20%) had spirometry inconsistent with COPD. In comparison, of 993 specialist centre diagnoses, 65 (6.5%) had inconsistent spirometry. There was poor agreement between the airflow obstruction grade recorded on the referral and that based on spirometry (kappa=0.26, n=448), whereas agreement between the respiratory centre assessment of airflow obstruction and spirometry was good (kappa=0.88, n=1,016). Referral by practice nurse was associated with accuracy of airflow obstruction classification in primary care (OR 1.85, 95% CI 1.33 to 2.57). Males were more likely than females to have an accurate specialist care classification of airway obstruction (OR 1.40, 95% CI 1.01 to 1.93). Grade of airway obstruction changed between referral and assessment in 56% of cases.

CONCLUSIONS

In primary care, a proportion of patients diagnosed with COPD do not have COPD, and misclassification of grade of airflow obstruction is common. Misdiagnosis and misclassification is less common in the specialist care setting of BreathingSpace.