Self-Management In Chronic Obstructive Pulmonary Disease (COPD)

Effectiveness of Nurse-Centred Approaches in Self-Management of COPD

Discuss about the Guided Review of Nominated Qualitative Literature.

Williams and his team address the issue of “self-management in chronic obstructive pulmonary disease (COPD)” (2014). Effective self-management in COPD is vital to the sustainable reduction of hospital admissions and enhanced patient outcomes (Kaptein, Fischer, & Scharloo, 2014). Interventions for self-management in COPD patients have primarily been associated with nurse-centred approaches that focus on teaching the patient how to use written instructions exacerbation events and determining the outcomes such as mortality and clinical admissions. Evidence on the effectiveness of this approach is contradictory showing mixed and negative results as well as excess amounts of mortality stimulating healthcare researchers to reconsider broadening the concept of self-management in COPD.

Patients are the first people to notice changes at the onset of a health concern. Therefore, it is important for patients to understand the composition of exacerbation, and understand the signs of deterioration and react accordingly.  Zwerink, Brusse-Keizer, Van der Valk, Zielhuis, Monninkhof, Van der Palen, et al. (2014) conducted a recent review on self-management intervention in Cochrane and suggested the removal of the term “education” replacing it with “training.  The authors argue that education alone not be sufficient in achieving behavioural change.

The results of the review indicate that self-management training in COPD patients is essential to improving the overall quality of life, declined related hospitalisations, as well dyspnea enhancement. According to Fletcher and Dahl (2013) improvement of nursing education and support is key to addressing the issues and barriers to the recognition of nurse roles in the survival of persons with chronic illnesses like COPD. The classic argument asserts that people with chronic disorders have several tasks in self-management including behavioural and health management, emotional management, and life-role management (Kaptein et al., 2014; Simpson & Jones, 2013).  As such, patients should gather medical personal medical information, manage symptoms and medication, maintain a healthy lifestyle, and communicate effectively to achieve sustained efficient self-management of exacerbation in COPD.  

Although there is significant amount of published research regarding the hospital assessment of exacerbation and, there is limited knowledge on how patients identify and manage exacerbation in COPD (Williams et al., 2014). The study by Williams and his colleagues helps to stakeholders in the management of chronic illness. Medical professionals can use the findings of the research to inform their training on patients with COPD. Policy formulators can also use the findings of the article to inform policies on nursing education and practice. Moreover, patients can use the article to improve how they identify and manage COPD. Further, researchers in the field of chronic illness can use the article as a reference to their studies.

The Need for Patient Self-Management Training in COPD

This section addresses the aim of the research and the research design.

There is need to expand the knowledge of nurses through education (Fletcher & Dahl, 2013). At the same time, patient education is shallow resulting in many adverse outcomes (Zwerink, et al., 2014). However, no research explains how patients identify and manage exacerbation in COPD at home; indicating a gap in the study. Following the need to fill the gap in research, the article embarked on qualitative research to determine how people identify and self-manage exacerbation at home. As such the article aimed “to explore patient’s current understanding and experience of managing and identifying COPD exacerbations at home” Williams et al. (2014).

The research design should be appropriately chosen about the research topic and the developing questions. The research design is the framework of the study and includes the strategies and procedures for sampling, data collection and analysis (Holloway & Galvin, 2016). The article uses a qualitative research approach (Williams et al., 2014). Qualitative research design which is critical in the collection of descriptive data from survey interviews regarding healthcare processes, systems and settings (Holloway & Galvin, 2016). The design allows the researchers to collect primary information concerning the respondents’ demographics length of diagnosis, number and frequency of exacerbation. The data was used to determine how COPD patients notice and control exacerbations at home.

The study sampled patients with different backgrounds “from hospital admission records, pulmonary rehabilitation programmes and general practice” Williams et al., (2014, p. 1). The criteria for eligibility are illustrated in table 1 below. The criteria for eligibility allowed the researcher to determine whom to include and whom to exclude from the research. The sample collected using the criteria allowed the researchers to collect data from the appropriate sample to inform the topic and achieve the aim of the study. Consequently, data were collected for patients of the right age (>40 years) across both sexes allowing the researchers to classify the information collected into themes for coding, analysis, and interpretation of data.

Sampling decision is usually made early in the project. Sampling is complex and is informed by the research questions, topic, aim, theoretical and practical considerations, and the ethical principles and concepts (Holloway & Galvin, 2016). The article used a purposive sampling technique to identify the sample respondents. Purposive sampling allows the researcher to select the sample carefully to achieve the aim of the research and is popularly known as “criterion-based sampling” (Holloway & Galvin, 2016, p. 141). Specific criteria are implemented allowing the research to select the sample accordingly.

Research Design and Sampling Methodology

Researchers need data to test the hypothesis and to inform the study which is helpful in decision making. Healthcare researchers collect data using standard methods, primarily through interviewing and observation (Holloway & Galvin, 2016). William and his colleague’s utilised in-depth interviews conducted the homes of patients. Semi-structured interview questions were used with questions focusing on the patients’ experience in identifying and managing exacerbation at their place of residence. Each interview lasted between half an to onw hour during which important notes were taken to provide the content of the interviews and aid in data analysis (Williams, Hardinge, Ryan, & Farmer, 2014). The interviews were guided by the research questions and the aim of the study. The instrument allowed the researchers to collect appropriate data from the responds which would inform the conclusion of the study (Holloway & Galvin, 2016).  

Respondents in the interview were required to sign a consent letter agreeing to participate in the interview voluntarily and can leave willingly at any point of the research. The research observed ethical principles by assuring the participants’ of privacy and confidentiality of the information they share.  “The interviews were conducted with the approval of the South Central Berkshire Research Ethics Committee (ref 12/SC/0437) and research governance was granted by Oxford Health NHS Foundation Trust and Oxford University Hospitals NHS Trust” Williams et al. (2014, p. 1). The study collected data on several variables including patient demographics to identify the patient’s background.

Research interviews are unlike ordinary conversations because the interviewer sets to elicit information from the interviewee. Interviews are meant to discover the respondent’s thoughts, perceptions and feelings. Holloway and Galvin (2016) state that interviews seek the past, present and the personal experience of the informant. Interviews allow researchers to collect information that may not be collectable through other methods such as observation and questionnaire and can either be formal or informal taking place face-to-face or electronically. An informal conversation with the participants often generates exciting ideas for the study. The researcher formulates the questions as the chat continues and implying that the next interview would be different as the interview does not ask predetermined questions. The participants also have control over the agenda. Although the wording and structure may be different, researchers find distinct patterns that are common often during analysis. However, this type of interview requires extensive planning for researchers to be able to uncover the patterns during data analysis. Williams et al. (2014) in their article do not mention whether a formal or informal interview was used. The article does not also tell us whether the interviews were conducted face-to-face (such as individual or group interview) or through electronic media (such as email and telephone).   

Data Collection Techniques

Qualitative interviews do not need pilot studies as the research in developmental; starting with relatively unstructured questions to give the participant minimal guidance. The initial outcomes of the interview typically guide subsequent questions. As the interview proceeds, questions start to take a structure pattern focusing on particular concerns that are important to the informant. Most qualitative interviews not only focus on commonalities and pattern discovery but also describe the experiences of the respondents, especially in face-to-face interviews which are the most common (Holloway & Galvin, 2016).

There are advantages and disadvantages in interviewing. Shared norms and language can be a strength or a limitation  (Holloway & Galvin, 2016). They can give the researchers the advantage of quickly understanding the culture and concept of the informant. Alternatively, the research may interpret values and beliefs leading to misunderstandings. Therefore, researchers should not make unwarranted assumptions and should instead act naïve, asking the respondent to clarify their statements.

In many qualitative interviews, the participant and the respondent are all equal, and the researcher is not anonymous or distant. The closeness is essential to the study as it gives the interviewee the confidence to speak openly and trust the researcher. On the contrary, there is the danger of over-involvement.

Therefore, researchers should choose their interviewees prudently to minimise challenges and problematic issues such as unexpected respondent or researcher behaviour, constructing and phrasing questions about sensitive matters. For example, some participants may be less articulated than expected; bringing out their in-depth experience becomes hard. A particular skill is required to be able to ask sensitive questions without creating an awkward atmosphere. In nursing, the researcher must first create a rapport with the patient to obtain the richest sets of data, being able to communicate empathy without being judgmental. The nurse should also be able to deal with emotional situations (Holloway & Galvin, 2016).

Williams et al. (2014) could also have used alternative data collection methods such as questionnaires and observations. Interviews, questionnaires and observations can be used separately or in combinations. However, each method is used to produce a different kind of data set depending on the research questions.

Data in the article was audio-recorded and transcribed verbatim before being imported to NVIVO 10 where it is appropriately stored, organized and analyzed. The grounded theory approach was used for data analysis. Data was imported into NVIVO for coding where the respondents answers were grouped into themes using open coding, axial coding and selective coding to uncover the patterns and shared concepts in data (Williams et al., 2014).

It is crucial to select applicable methods of data analysis in qualitative research  (Holloway & Galvin, 2016). Data analysis begins at the onset of data collection during in the interviews and observations and is progressively clear. The researcher revisits the aim and objectives of the study during data analysis. If an appropriate method of data analysis is not used, the results obtained may not be reliable, valid, and trustworthy implying that the findings may not be generalizable.

Williams et al. (2014) indicate that the study coded two interviews using an experienced external qualitative researcher to ascertain the accuracy and quality of the coding activity. The researchers also met often to analyze and interpret data. Both echniques were crucial in ensuring transparency and credibility of the results.

The findings of the study indicate that patients can identify exacerbation from visible and invisible symptoms based on experience. For self-management of exacerbation in COPD, patients employed techniques “such as pacing and breathing techniques, self-administered antibiotics and steroids…” William et al. (2014, p. 4). Additionally, patients consulted medical professional whenever they felt that their condition was not improving. However, some cases were reported later leading to admission to emergency wards.

References

Alshenqeeti, H. (2014). Interviewing as a data collection method: critical review. English Linguistics Research, 3(1), 35-45.

Bryman, A., & Bell, E. (2015). Business research methods. USA: Oxford University Press.

Fletcher, M. J., & Dahl, B. H. (2013). Expanding nurse practice in COPD: is it key to providing high quality, effective and safe patient care? Primary Care Respiratory Journal(22), 230-233.

Holloway, I., & Galvin, K. (2016). Qualitative Research in Nursing and Healthcare. New Jersey: Wiley Publishers.

Kaptein, A. A., Fischer, M. J., & Scharloo, M. (2014). Self-management in patients with COPD: theoretical context, content, outcomes, and integration into clinical care. International Journal of Chronic Obstructive Pulmonary Disease, 9, 907-917.

Simpson, E., & Jones, M. C. (2013). An exploration of self-efficacy and self-management in COP patients. British Journal of Nursing, 22(19).

Williams, V., Hardinge, M., Ryan, S., & Farmer, A. (2014). Patients’ experience of identifying and managing exacerbation in COPD: a qualitative study. NPJ Primary Care Respiratory Medicine, 24(14062), 3-6.

Zwerink, M., Brusse-Keizer, M., Van der Valk, P., Zielhuis, G. A., Monninkhof, E. M., Van der Palen, J., Frith, P. A., & Effing, T. (2014). Self-management for patients with chronic obstructive pulmonary disease (Review). Cochrane Database of Systemic Review(3).