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An in-depth analysis of ten research studies on nursing interventions for COPD patients. The interventions included education, exercise, follow-ups, making individual plans, monitoring, and smoking cessation. The studies were conducted in various countries and recruited patients with acute exacerbations of COPD. The interventions covered a wide range of topics, including disease knowledge, symptom management, relaxation techniques, and self-monitoring. The document also discusses the impact of these interventions on health-related quality of life, hospital admission/readmission rate, exacerbation frequency, and activity level.
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NURSING DEPARTMENT, MEDICINE AND HEALTH COLLEGE
FACULTY OF HEALTH AND OCCUPATIONAL STUDIES Department of Health and Caring Sciences
Supervisor: Zhu Kewen (Keelia) Examiner: Annica Björkman
Student thesis, Bachelor degree, 15 HE Nursing Study Programme in Nursing
Background: Chronic obstructive pulmonary disease (COPD) seriously affect the quality of life (QoL) with poor physical, social and emotional function. So, the authors want to find effective nursing interventions to physical and mental health for patients with COPD. It is important for nurses to give effective interventions to every patient. Therefore, the authors would like to do this descriptive literature review from the nurse’s perspective to uncover any measures that can help the patients to alleviate suffering, improve QoL and promote the recovery of patients.
Aim: To describe how the nurses can support patients with COPD and which intervention is effective for outcomes to improve QoL, and to review the samples used in the articles.
Method: 31 Scientific articles with a quantitative design were searched in the databases Medline, Cinahl. Chosen articles were processed in order to determine whether they were relevant to the study purpose. In the end, 10 articles were used by the authors.
Results: This review tried to sum up the findings about the nursing intervention of COPD during the past decade. This review identified 10 articles associated with COPD. Our findings revealed that education, exercise, follow-ups, making individual plans, monitoring, smoking cessation are significant interventions relating to the QoL of patients with COPD. And the outcomes identified if the intervention was effective for patients, there had outcomes were HRQoL, anxiety and depression level, hospital admission/readmission rate, exacerbation, self-care, activity level, functional capacity and the health belief & self- efficacy.
Conclusions : There were a lot of interventions about education, and together with exercise in common. Smoking cessation was needed in all treatment or recovery procedure. Monitoring conscientiously and follow-ups responsibly contributed to realize the progress of COPD and degree of mitigation. Nursing interventions were indispensable in the procedure of treatment and recovery to COPD patients.
Keywords : Chronic Obstructive Pulmonary Disease, nursing, quality of life
Introduction
1.1 Definitions for COPD and QoL
Chronic obstructive pulmonary disease (COPD) is a disease of chronic potentially fatal, slowly progressive, not fully reversible airflow obstruction, which although preventable, is not curable, is predominantly caused by smoking. (National Collaborating Centre for Chronic Conditions [NCCCC], 2004). This airflow restriction emphasized is persistent and gradual (Global Initiative for Chronic Obstructive Lung Disease 2016). Chronic bronchitis and pulmonary emphysema are subcategories of COPD. Chronic bronchitis is characterized by hypersecretion of mucus followed by a chronic (more than three months in two consecutive years) productive cough. Infection is a major pathogenic factor of chronic bronchitis. Pulmonary emphysema is characterized by enlargement of air spaces distal to the terminal bronchioles where gas-exchange normally takes place. This is usually caused by destruction of the alveolar wall. Pulmonary emphysema can be classified according to the location and distribution of the lesions. (Tabloski 2014)
According to WHO, Quality of life (QoL) refers to individuals’ view in the context of culture and value systems, is relating to the personal position in life. Further, it is related to individual goals, standards, expectations, and concerns. The concept of QoL is broad. It is influenced by physical health, personal psychological state, personal beliefs, the level of independence, social relations and their relationship to the characteristics of their environment.(WHO 1997)
1.1.1 situation of COPD
COPD is associated with progressive respiratory deterioration which is characterized by coughing and expectoration, worsening lung function, dyspnea (Brian et al. 2017). The acute exacerbations of COPD (AECOPD) become more frequent with the severity of COPD and smoking (Hurst et al. 2010). COPD is the third leading cause of death in America since 2008, and is the leading cause of chronic lower respiratory tract disease (Centers for Disease C, Prevention 2011). In recent years, COPD has become a serious public health problem, and it is expected to become the third leading cause of death in the
world by 2030 (Brian et al. 2017). Deterioration affects the morbidity, mortality and QoL of patients with COPD, and the frequency is relating to a rapid decline with pulmonary function (Wedzicha et al. 2013). The diagnosis of COPD requires spirometry. The standard diagnostic measure of the presence of airflow limitation is a ratio of postbronchodilator forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) less than 0.7 (Global Initiative for Chronic Obstructive Lung Disease 2016). The 6-minute walking distance (6MWD) is an useful approach in assessing the functional status of patients with COPD (Redelmeier et al. 1997; Singh et al. 2014). Early diagnosis and treatment can availably prevent the deterioration of pulmonary function and improve the prognosis of patients with COPD (Decramer et al. 2009).
1.1.2 symptoms of COPD
National Institute for Health and Clinical Excellence (NICE 2004) COPD guidelines suggested that medical professionals in primary care should investigate all smokers over the age of 35 years (where resources are available) who have any of the following symptoms: breathlessness on exertion, frequent winter bronchitis, chronic cough, chronic sputum production and wheeze. Different patients may present different kinds of symptoms, but generally the symptom of breathlessness is the most primary, it affects both physical and social activities (Barnett 2005).
In order to exclude other diseases, like bronchiectasis or congestive cardiac failure, some investigations should be used, such as full blood count , a routine chest X-ray and electrocardiogram (Margaret 2008).
Some people may lack physical strength, like one woman said “I walked a few steps and then I had to stop and breathe and pant and I felt ready to cry because I just couldn’t handle it ”; and some may experience meaninglessness, said “I feel awful and at that point I just want to get away from everything, even commit suicide, I feel like there’s just no point” (Kristina Ek & Britt-Marie Ternested, 2008).
theory--physiology can ’ t be satisfied (Maslow 1954). And another example here,
safety needs are personal security, financial security, health and well-being. Safety worrying is the major reason for mental disorders, such as anxiety, fear, depression. So,
what we nurses do is trying our best to decrease patients’ negative emotions through
psychological nursing.(Zheng et al. 2016)
COPD seriously affect the QoL with poor physical, social and emotional functioning (Weingaertner et al. 2014). In recent years, COPD has become a serious public health problem, and it is expected to become the third leading cause of death in the world by 2030 (Brian et al. 2017). So, it is important for nurses to give interventions to every patient. The authors want to describe nursing interventions to support patients with COPD.Therefore, the authors would like to do this descriptive literature review from the nurse’s perspective to uncover any measure that can help the patients to alleviate suffering, improve QoL and promote the recovery of patients.
1.5 Aim and research questions
The aim of the literature review was to describe nursing interventions and outcomes to support patients with COPD, and to review the samples used in the scientific articles,
2.1 Design
The authors have conducted a descriptive literature review (Polit & Beck 2012).
2.2 Search strategy
Articles were searched in the databases of PubMed and Cinahl with certain limits (Humans, Full text, 10 years). The search terms included Pulmonary Disease, Chronic Obstructive, nursing, quality of life, and used different combinations with each other. When combining search terms, the Boolean term AND was used. Indexed search term was fetched from MeSH and Cinahl headings.
The selection of eligible studies through a flowchart is shown in Fig. 1.
Table 1. Results of preliminary database searches.
Database + Date of search
Limits Search terms Number of hits
Potential articles (excluding doubles)
Medline through PubMed 2017 -0 5 - 15
University of Gävle, Humans, Full text, 10 years
"Pulmonary Disease, Chronic Obstructive"[Mesh]
Medline through PubMed 2017 -0 5 - 15
University of Gävle, Humans, Full text, 10 years
"Pulmonary Disease, Chronic Obstructive/nursing"[M esh]
Medline through Pubmed 2017 -0 5 - 15
University of Gävle, Humans, Full text, 10 years
"Pulmonary Disease, Chronic Obstructive/nursing"[M esh] AND quality of life
Exclusion criteria which were articles that were only concerned with physicians’ diagnosis or treatment for COPD, describing the experience of patients with COPD, studying the symptoms or signs of COPD, qualitative studies, or review studies. Inclusion criteria for articles that would be included in the degree project would be that they should be relevant for the aim of the review study (that is, nursing interventions which are effective for outcomes to improve QoL for patients with COPD), empirical scientific articles only using a quantitative approach, the population including nurses and patients with COPD, articles must be written in English and published between 2007-05- 15 and 2017-05-15, and freely avaliable to the University of Gävle, 2.4 Selection process and outcome of potential articles The titles and abstracts of the articles were firstly read in order to decide whether they might be useful to answer the literature review’s research questions, so the authors got 31 articles, see Table 1. Then, the authors removed one duplication, Later, articles were read carefully in order to determine whether they meet the inclusion criteria of this literature review, the authors removed 10 articles. Last, when reading the full articles, 10 articles were found to be irrelevant to the present study’s aim, so the authors got 10 articles finally. The authors carefully illustrated every step of the selection process, see Figure 1.
Full-text articles assessed for eligibility (n=20)
Total documents included in integrative review (n=10)
When reading the full articles, 10 were found to be irrelevant to the present study’s aim (n=10)
2.5 Data analysis
The articles used in the degree project was analysed with the help of one template, so called matrixe. According to Polit and Beck (2012), using a matrix is a good way to organize the information. The template was used to review the chosen 10 articles. The articles were read and carefully processed in order to identify the nursing interventions to support the patients with COPD and review the outcomes which were indicated in 10 articles, and then be structured according to appropriate categories, such as self-care, education, follow-ups and so on, and then presented under the corresponding category. We extracted basic information from 10 articles, for example: country, design and approach of articles, age, sexual distinction, data collection method and data analysis method, then we put these information into appropriate categories of a table, see Table 2.
2.6 Ethical considerations
The articles searched objectively, authors did not change any ethical problems of 10 articles included in this review. The results was presented according to its integrity without being changed due to the authors’ wishes. Thus, the risk of ethical dilemmas in our choice of studies is low, and no plagiarising of material has taken place. So, the degree project was away from cheating. The results and discussion of articles have been analysed and processed objectively by both authors. This is a working method recommended by Polit & Beck (2012).
Results
The characteristics of the included studies are described in Table2 and Table 3. The studies were based in 8 different countries, one article in China(Wang et al. 2013), one article in Korea(Song et al. 2012), one article in Spain(Abad-Corpa et al. 2007), three articles in Sweden(Zakrisson et al. 2011; Zakrisson et al. 2016; Osterlund-Efraimsson et al. 2008), one article in UK(Sridhar et al. 2007), one article in Japan(Moriyama et al.
Efraimsson et al. 2008), energy conservation (Zakrisson et al. 2016; Akinci & Olgun 2011; Moriyama et al. 2013 ), breathing (Moriyama et al. 2013; Akinci & Olgun 2011; Osterlund-Efraimsson et al. 2008), relaxation techniques, airway clearance techniques (Akinci & Olgun 2011; Osterlund-Efraimsson et al. 2008), effective coughing, diet and infection control (Moriyama et al. 2013; Osterlund-Efraimsson et al. 2008).
Moriyama et al. (2013) put some more contents in the education, like physical condition, sign, self-analysis of physical condition (understanding of laboratory data), oxygen therapy, strategies in daily living to prevent shortness of breath, remaking of daily schedule, learning countermeasures for emergencies & disasters (including panic control, timing of consultation with the physician), device and instrument, decision-making and problem-solving skills.
They also had education contents for family: need for collaboration, countermeasures for emergencies and disaster, timing of consultation with the physician, support of effective coughing. ( Moriyama et al. 2013 )
In another study by Osterlund-Efraimsson et al. (2008), their education contents including the effects of COPD, measurement of respiratory function (spirometry), explanation of the outcome to the patient, measurement of oxygen saturation, physical activity, psycho- social counselling and support, individual treatment plan in collaboration with the patients.
In the study by Titova et al. (2017), they repeated the core element of the educational program and reinforced the specific health behaviors and made necessary changes in the
patients’ treatment program.
The approach of how healthcare professionals deliver knowledge to patients is different. Face-to face way was mostly adopted (Song et al. 2012; Wang et al. 2013; Zakrisson et al. 2011; Sridhar et al. 2007; Moriyama et al. 2013; Osterlund-Efraimsson et al. 2008 ). Three articles adopted practicing exercise (Song et al. 2012; Zakrisson et al. 2011; Sridhar et al. 2007), such as participants performed a 10-minute-per-toleration walk on a course 30-m corridor in the unit, they also learned 10 sets of upper and lower extremities stretching with pursed lip breathing (Song et al. 2012). Other articles adopted workbook, materials (Wang et al. 2013 ), daily journal (Moriyama et al. 2013), meetings (Zakrisson
et al. 2016 ), booklet (Akinci & Olgun 2011) and home visits (Akinci & Olgun 2011; Osterlund-Efraimsson et al. 2008).
For the duration of education, mostly one session lasts about 45 minutes to 3 hours (Song et al. 2012; Zakrisson et al. 2011; Sridhar et al. 2007; Osterlund-Efraimsson et al. 2008). In one article, the duration of nursing education is 20 to 30 minutes (Wang et al. 2013 ).
The frequency of carrying out education maybe can influence patients’ patience and acceptance to knowledge, in two articles, patients were educated every week for six weeks (Zakrisson et al. 2011; Zakrisson et al. 2016 ); patients accepted education every 2 days after their disease conditions were stable and the day before discharge in the article by Wang et al. (2013); patients were educated in the day of discharge in the article by Song et al. (2012); patients accepted education two attendances per week for 4 weeks (Sridhar et al. 2007); in article by Moriyama et al. (2013) patients were educated 2 times in the enrolled months; patients went to accept education in 2 times between the first and last visits (Osterlund-Efraimsson et al. 2008) and 2-3 times during the course of pulmonary rehabilitation (Akinci & Olgun 2011).
3.2.2 Exercise
Five articles referred to exercise (Moriyama et al. 2013, Zakrisson et al. 2016; Akinci & Olgun (2011); Zakrisson et al. 2011; Song et al. 2012). Zakrisson et al. (2016) reported that the lower-extremity (walking) and upper-extremity (arm exercises) with pursed lip breathing. The same type of exercise has been reported by Akinci & Olgun (2011) and Song et al. (2012). The effective coughing techniques is mentioned in the study by Moriyama et al. (2013) and Zakrisson et al .(2011). In addition, some of the following exercises are mentioned: breathing (Zakrisson et al. 2016; Akinci & Olgun 2011; Zakrisson et al. 2011; Song et al. 2012), aerobic fitness (Zakrisson et al. 2016; Akinci & Olgun 2011), muscle-strengthening and relaxation techniques (Zakrisson et al. 2016; Zakrisson et al. 2011).
3.2.3 Follow-ups
Five articles used follow-ups as an intervention (Titova et al. 2017; Zakrisson et al. 2016; Osterlund-Efraimsson et al. 2008; Abad-Corpa et al. 2012; Wang et al. 2013). The Titova
rate, cigarette smoking) in the daily journal, the daily journal was received monthly by mail from the second month, and the patients monthly reported data by mail or telephone to nurses and physicians, patients also needed to set monthly goal (Moriyama et al. 2013). Other ways of monitoring can be seen in following articles in the study by Moriyama et al .(2013), nurses evaluated patients’ data. In the study by Abad-Corpa et al. (2012), primary care nursing personnel also were used , they recorded any new needs, problems or events that arose during that time. The nurses measured kinds of tests, like Spirometry and oxygen saturation in Sridhar et al .(2007). The study of Song et al. (2012) only used phone calls to remind and advise patients to continue their exercise therapy and discussed and reinforced the self- management education which had been given. All studies specified the type of nurse delivering the intervention, and all nurses involved had training. These included: specialist respiratory nurses, the research respiratory nurses, nurses with master degree prepared, advanced nurse practitioners, coordinating nurses, primary care nurses and what were described as ‘nurses interventionists’.
3.2.6 Smoking cessation
In our review, eight articles were included (Moriyama et al. 2013; Osterlund-Efraimsson et al. 2008; Zakrisson et al. 2016; Akinci & Olgun 2011; Song et al. 2012; Wang et al. 2013; Zakrisson et al 2011; Sridhar et al. 2007). In addition, Zakrisson et al .(2011) reported 4 of 16 patients stopped smoking in the intervention group and 7 of 23 in the control group. And Osterlund-Efraimsson et al .(2012) reported that in the intervention group 6 of the 16 patients who were smokers had stopped smoking during the intervention phase. In the control group none of the 14 smokers stopped smoking. The difference between the groups was significant.
The reviewed studies examined a total of 10 clinical outcomes using 40 different outcome measures. The same outcome was often measured with several different instruments (i.e.
functional capacity , six different measures) which making comparisons difficult and meta-analysis unfeasible. Outcomes for all studies are outlined in Table 4 using the categories suggested by Polit & Beck (2012).
Eight of the ten articles reported on health-related QoL(Song et al. 2012; Akinci & Olgun 2011; Osterlund-Efraimsson et al. 2008; Moriyama et al. 2013; Titova et al. 2017; Zakrisson et al. 2016; Zakrisson et al. 2011; Sridhar et al. 2007). Mostly, six articles used the the St. George's respiratory questionnaire (SGRQ) to collect data, and two articles used The Clinical COPD Questionnaire (CCQ).
The studies by Song et al .(2012) and Akinci & Olgun (2011) reported the quality-of-life score and its subscale scores in the intervention group were decreased significantly compared to control group. Osterlund-Efraimsson et al. (2008) reported that the participants in the intervention group perceived a reduction in symptoms of cough, phlegm, dyspnea and wheezing, increased activities, and a decreased impact of COPD. The participants in the control group did not report any improvement or no change was observed. So QoL was improved in the intervention group, but no change in the control group. And the difference between the groups was significant and clinically relevant.
However, in other studies, there were no statistically significant differences in the change of the scores in both groups (Moriyama et al. 2013; Titova et al. 2017; Zakrisson et al. 2016; Zakrisson et al. 2011). One article by Zakrisson et al. (2016) reported the CCQ scores improved both in the intervention group and the control group, and Titova et al.( 2017) reported there were reduction of the SGRQ scores in both groups. The article by Sridhar et al .(2007) did not report the total scores or the differences between two groups, and only reported significant worsening in the score about dyspnea in both groups. The mean mastery score improved in the intervention group but this change was not clinically significant.
One of the ten papers reported on anxiety and depression level (Titova et al. 2017). Titova et al .(2017) reported no significant differences between the integrated care group (ICG)
