An estimated 3 million people are

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1 clinical focus An exploration of self-efficacy and self-management in COPD patients Edwina Simpson and Martyn Jones Abstract Aim: This study examined if self-efficacy in managing chronic obstructive pulmonary disease is associated with better mood, less breathlessness and fewer exacerbations; what helps or hinders patients in managing their chronic obstructive pulmonary disease (COPD); and patients suggestions to improve the selfmanagement support they receive. Background: COPD is the fifth leading cause of death in the UK, and it has been suggested that supporting self-efficacy and self-management could improve patient outcomes and reduce demands for NHS resources. Methods: An exploratory, descriptive survey involving the collection of both quantitative and semistructured qualitative data was chosen. Participants were randomly selected from four GP practices across the north east of Scotland. Results: Higher levels of self-efficacy were associated with lower levels of breathlessness, lower levels of anxiety and lower levels of depression in COPD patients. There was no association between high self-efficacy and exacerbation rates. Conclusion: Increasing self-efficacy and reducing anxiety and depression in patients living with COPD are important focus points for self-management support. Key words: Chronic obstructive pulmonary disease COPD Self-efficacy Self-management An estimated 3 million people are affected by chronic obstructive pulmonary disease (COPD) in the UK. About have been diagnosed with the condition and an estimated 2 million people are undiagnosed (National Institute for Health and Care Excellence (NICE), 2010). NICE states: Chronic obstructive pulmonary disease (COPD) is characterised by airflow obstruction. The airflow obstruction is usually progressive, not fully reversible and does not change markedly over several months. The disease is predominantly caused by smoking. There is no single diagnostic test for COPD. Making a diagnosis relies on clinical judgement based on a combination of history, physical examination and confirmation of the presence of airflow obstruction using spirometry (NICE, 2010). Edwina Simpson is COPD Specialist Nurse, Primary Care, NHS Tayside, Dundee and Martyn C Jones is Personal Chair of Healthcare, Research School of Nursing and Midwifery, University of Dundee Accepted for publication: October 2013 Most GP practices have access to a spirometer. This equipment measures the volume and flow rate of breathing. In healthy people, more than 70% of forced vital capacity (FVC) is exhaled in the first second; obstruction or airflow limitation is defined as FEV1/FVC<70% (Kelly, 2009). In COPD, severity is graded according to FEV1% predicted the volume of air exhaled in the first second of the FVC. The main symptoms associated with COPD are a chronic productive cough, breathlessness and wheeze. Anxiety, depression and acute exacerbations feature predominantly in the natural history of COPD (Kelly, 2009). Exacerbations are defined by NICE (2010) as a sustained worsening of the patient s symptoms from their usual, stable state, which is greater than the day-to-day variations and is acute on onset (NICE, 2010). Exacerbations carry a high mortality; within 90 days of admission for an exacerbation, 33% of patients with COPD are readmitted and almost 14% have died (Scullion, 2009). The average cost of treating a COPD patient in Scotland is estimated to be per patient per year (Long Term Conditions Collaborative, 2009). With an increasingly ageing population and predicted reductions in the NHS workforce, governments and healthcare providers are engaged in initiatives to develop new ways of supporting patients living with long-term conditions such as COPD to manage their own health (Rijken et al, 2008). Research suggests that improving self-efficacy (SE) and promoting self-management could reduce some of the burden on the NHS. Many theorists including Monninkhof (Harris et al, 2008) believe that patients SE their sense of confidence in their competence to manage their condition has been established as the route to better outcomes such as a reduction in exacerbations. According to this approach, increasing patients SE is likely to support them in changing their behaviour and lead to more effective self-management. Empowering patients to manage their longterm conditions is likely to involve a major change to the working practices of some health professionals (Health Foundation, 2012). The idea of self-management support implies there will be a change in the role of the health professional from an authoritarian position in delivering education and information to supporting patients to help them build confidence and make choices that lead to better self-management and outcomes (Coleman and Newton, 2005). This study also set out to discover what patients thought would help them to manage their COPD. Identifying where COPD patients commonly have low self-efficacy is likely to assist COPD nurses in identifying strategies to support patients to increase their SE and consequently improve their self-management. Improved patient self-management has the potential to reduce rates of exacerbation and hospital admission (Scullion, 2009). Rationale for study The evidence from studies including Cochrane reviews (Monninkhoff, 2003; Effing et al, 2009) suggests that further research is needed before firm conclusions can be drawn on what constitutes successful self-management support in COPD. Research in this area has not focused on SE and does not seem to have sought patients views on how they self-manage their condition. British Journal of Nursing, 2013, Vol 22, No

2 This study attempted to identify the barriers faced by patients when self-managing their COPD and what patients thought health professionals could do to assist them to selfmanage COPD. The use of SE, mood and symptom questionnaires and scales can help identify situations where COPD patients commonly experience low SE. The study focused on measuring patients levels of selfefficacy in relation to: Anxiety/depression Exacerbation rates Breathlessness. This study gained patients views on selfmanagement using a cross-sectional patient self-report survey. We are not aware of any other studies using the same combination of assessment methods; these involved measuring breathlessness with the Medical Research Council (MRC) dyspnoea scale (Bestall et al, 1999; Ozalevli and Ucan, 2006), mood using the hospital anxiety and depression (HAD) scale (Zigmond and Snaith, 1983), and exacerbation rates using the COPD selfefficacy scale (Wigal, 1991). Full ethical approval was granted by both the local research and ethics committee and the Caldicott guardian. Data search Four databases were chosen and searched for evidence in the literature of effective self-management/se in the care of COPD patients: MEDLINE, CINAHL Plus, OVID Online and the Cochrane Library (Figure 1). Two separate searches were undertaken. The search terms entered were: Self-management in COPD Self-efficacy in COPD. Thirty-four studies meeting the criteria were found; some of these are cited in this paper. Excluded studies included those that mentioned SE or self-management in their text but were rejected as their abstracts and conclusions showed they mentioned the topics only briefly. Studies that focused completely on pulmonary rehabilitation were rejected as their focus was more on the benefits of exercise. The study focused on Cochrane reviews and randomised controlled trials (RCTs) as they are regarded as producing the most robust evidence (Education for Health, 2008). Literature review Monninkhof s (2003) Cochrane review aimed to clarify the effectiveness of selfmanagement programmes in COPD. This systematic review of eight RCTs and one Self-efficacy and selfmanagement searched; Ovid Online, Cinahl Plus, Medline and the Cochrane Library Number of articles found and screened: 115 Number of articles with full text discussing either self-efficacy or self-management meeting the criteria: 34 Figure 1. Results of data search Number of articles excluded: 81 Excluded articles: pulmonary: 10; foreign language: 8; >10 yrs old: 15; triplicates: 20; not suitable: 28 controlled clinical trial assessed the efficacy of self-management education in patients with COPD. The self-management programmes reviewed used various methods of education including group and individualised sessions and providing written material. The education components targeted smoking cessation, managing exacerbations and improving exercise or nutrition. The review showed that self-management education had no effect on hospital admissions, emergency unit visits, days lost from work and lung function but led to an increased use of courses of antibiotics and oral steroids. Study limitations included participants having different diagnostic criteria and the educational components being of varying duration. In addition, a wide variation in outcome measures meant that insufficient data were obtained to make recommendations. The outcomes measured also varied in appropriateness. Days lost from work may not be relevant as many COPD patients are over retirement age. COPD patients are also prone to anxiety/depression and may not retain educational information. As COPD is a less variable disease than asthma, it can be more difficult to show positive results. A Cochrane review by Effing et al (2009) built on the results of Monninkhof s (2003) Cochrane review by assessing the settings, methods and efficacy of COPD selfmanagement education programmes on health outcomes and use of healthcare services. The method was a systematic review of 15 group comparisons drawn from 14 RCTs. A total of patients were recruited for the trials, of whom participated. The various RCTs followed up patients from periods of 8 weeks to 12 months. The studies reviewed examined a broad spectrum of self-management interventions, including individualised education on COPD, breathing and coughing techniques, relaxation exercises, energy conservation and adapting a healthy lifestyle as well as action plans to identify and treat exacerbations. The self-management education included smoking cessation, selftreatment of exacerbations and improving exercise and nutrition. A significant reduction was seen in the probability of at least one hospital admission for about 36% for patients receiving selfmanagement education compared with those receiving usual care, combined with an improvement in their health-related quality of life. However, because of the heterogeneity in interventions, study populations, follow-up time and outcome measures, the data were insufficient to be used to formulate clear recommendations regarding specific facets of self-management education programmes in COPD. Effing et al (2009) recognised the limitations of their study and recommended further research with larger RCTs and a longerterm follow-up before conclusions could be drawn. They added that it may be useful to choose only studies that measure the same variables, thereby reducing the heterogeneity. Similar conclusions were drawn by Bourbeau and van der Palen (2009), who suggested that further research was needed to increase our understanding of the effectiveness of the specific components of self-management programmes and how best to support COPD patients in self-management. This Cochrane review discussed the increase in the use of antibiotics and steroids, and suggested that self-management education with the addition of action plans resulted in patients recognising their exacerbations and treating them promptly, which resulted in less severe exacerbations. However, in the first author s experience, this is not suitable for all patients as some will take them inappropriately, despite having written guidance. Wood-Baker et al (2006) examined the efficacy of the components of action plans in the self-management of COPD. This longitudinal RCT prospective parallel group study compared written action plans to usual practice. All patients received an information booklet on COPD and an individual educational session with a respiratory nurse. Topics included smoking cessation, exercise, sputum clearance, nutrition, stress management, 1106 British Journal of Nursing, 2013, Vol 22, No 19

3 clinical focus inhaler use and support services. Intervention group members also received a written selfmanagement plan and were encouraged to contact their GP during the early stages of an exacerbation. Patients were followed up every three months for a year. Intervention group members were more likely to have had treatment with antibiotics; there were no differences between the groups in numbers of GP visits and hospital admissions. These findings are similar to those of Monninkhof et al s (2003) review. Wood-Baker et al s (2006) study had several limitations including a lack of blinding; the use of self-reporting, which is open to error as some participants cannot recall events accurately; and insufficient power to determine differences between interventions. In addition, many patients only received one educational session, which may limit the amount of information they retained. The majority of patients had stopped smoking at the time they enrolled onto this study. The results may have differed had more smokers been included. Research questions This study was designed to answer the following questions: Is self-efficacy in managing COPD associated with improved mood, reduced breathlessness and reduced exacerbations in patients? What helps or hinders patients in managing their COPD? What suggestions do patients with COPD have to improve the self-management support that they receive? Study inclusion criteria All patients included in this study: Had a definite diagnosis of COPD Were aged years Had an FEV1/FVC <70% Had an Fev1% predicted value of 20 79%. So that participants would be representative of patients seen at COPD clinics, both smokers and non-smokers were included. Methodology A descriptive survey involving the collection of quantitative and qualitative data was chosen to best answer the research questions. This survey comprised a questionnaire with validated scales and semistructured questions. Study participants received an information sheet, a consent form and a COPD questionnaire. The questionnaire had 10 questions; these included open questions to allow patients to express themselves and closed questions to maintain their interest. The COPD questionnaire included: Visual analogue scales measuring confidence in both recognising and treating an exacerbation. The scales for each had a range, with 0= Not at all confident and 100= Very confident. The patients marked an X on the line to determine how confident they were. The Wigal COPD self-efficacy scale. This measures how confident patients are in managing their breathlessness in certain situations. It lists 47 specific situations. This scale has proven acceptability, reliability and validity (Wigal et al, 1991). The MRC dyspnoea scale. This is on a scale of 1 5, with 1 representing no breathlessness except on strenuous exercise and 5 representing being too breathless to leave the house or being breathless when dressing or undressing. A higher score suggests more advanced disease. This breathlessness scale is commonly used in COPD as it has been proven to be acceptable, reliable and valid (Bestall et al, 1999: Ozalevli and Ucan, 2006). HAD scale. This is a 14-item self-report instrument for the detection of anxiety and depression in patients. It has two domains, each with seven statements on emotions or emotional situations. Patients express their agreement with the statements on a scale of 0 3, which leads to a maximal score of 21 points for each domain. Scores of 8 11 per domain suggest the presence of the mood disorder; scores >11 indicate a probable presence (Trappenburg et al, 2009). The HAD has proven acceptability, reliability and validity (Zigmond and Snaith, 1983). The first researcher measured self-efficacy using the COPD self-efficacy scale and the two visual analogue scales in confidence in recognising and confidence in treating an exacerbation separately. Data analysis Pearson s r correlation and independent sample t-test was chosen as the most appropriate statistical test for the numerical data meeting assumptions of normality. Spearman s rho non-parametric test was used for the nominal/ ordinal data. Qualitative data were analysed by content analysis, which is a process of analysing qualitative material for recurring themes and patterns (Polit et al, 2001). Correlation, according to Education for Health (2008), shows the relationship between the data of two continuous study variables. The data were analysed using the SPSS 18 statistical analysis package. Results Study population Two hundred and fifty patients were contacted, with 48 completing the study, giving a 19.2% response rate. Table 1 shows the characteristics of the study population. Participants were aged years, and the mean age was 69 years. The majority of patients were still smoking. There were equal numbers of men and women. The majority of patients had moderate COPD with FEV1=50 79% predicted. The most common score on the MRC dyspnoea scale was 3; people with this score walk more slowly than their contemporaries on level ground because of breathlessness, or have to stop to take a breath when walking at their own pace. Exacerbation rates were also recorded (Table 4). Table 1. Study population characteristics Frequency Percentage Disease severity Moderate COPD FEV % Disease severity Severe COPD FEV % Sex Male Female Smoking Non-smoker Smoker MRC dyspnoea scale score MRC 1 MRC 2 MRC 3 MRC 4 MRC British Journal of Nursing, 2013, Vol 22, No

4 Table 2. Correlation between self-efficacy scales and anxiety and depression Pearson s r bivariate was used to examine relationships between variables that were normally distributed COPD self-efficacy scale Missing scores replaced Mean SD n COPD self-efficacy scale score Depression Anxiety VAS confidence in ability to recognise an exacerbation Depression ** 1 Anxiety ** 0.805** 1 VAS confidence in ability to ** 0.486** 0.501** 1 recognise an exacerbation Vas confidence in ability to treat an exacerbation ** 0.615** 0.599** 0.804** 1 P*<0.05, **<0.01, ***<0.001; VAS: visual analogue scale VAS confidence in ability to treat an exacerbation Table 3. Correlation between self-efficacy scales and the MRC dyspnoea scale Spearman s rho non-parametric test was used as the variable was ordinal Mean SD n COPD self-efficacy scale score VAS confidence in ability to recognise an exacerbation VAS confidence in ability to treat an exacerbation MRC dyspnoea scale score 1 5 COPD self-efficacy scale VAS confidence in ability to ** 1 recognise an exacerbation VAS confidence in ability to ** 0.829** 1 treat an exacerbation MRC dyspnoea scale ** 0.500** ** 1 P*<0.05, **<0.01,***<0.001; VAS: visual analogue scale Table 4. Means of the exacerbation rate and anxiety/depression for patients who have visited GP in last 6 months with an exacerbation Have you had an appointment in the last 6 months for an exacerbation? n Mean SD Standard error mean Anxiety total No Yes Depression total No Yes confidence in recognising and confidence in treating an exacerbation, the dyspnoea scale and the COPD self-efficacy scale are all positively correlated. This suggests that people who have higher self-efficacy have less breathlessness they scored less on the MRC dyspnoea scale. There were no significant differences in anxiety (t-test result) and depression (t-test result) for patients who had had an appointment for an exacerbation in the last 6 months. Research question: correlation The study s first question was: is self-efficacy in managing COPD associated with improved mood, reduced breathlessness and reduced exacerbation? In testing the normality of the variables, all variables were normally distributed using the Kolmogorov-Smirnov test. Table 2 shows there were positive correlations between high visual analogue scale scores in confidence in recognising and treating an exacerbation, high confidence in the COPD self-efficacy scale and lower levels of anxiety and depression. The p value is <0.05 in all of the variables, which suggests that COPD patients who are more confident in recognising and treating an exacerbation and more confident at controlling their breathlessness have less anxiety and depression. The COPD selfefficacy scale measures the control of managing breathlessness in certain situations and the two visual analogue scales measure confidence in recognising and confidence in treating an exacerbation. To establish if higher levels of self-efficacy reduced breathlessness, it was also necessary to see if there was a positive correlation between the two visual analogue scales, the COPD self-efficacy scale and the MRC dyspnoea scale; a non-parametric test was used for the MRC scale as the variable level is ordinal (Table 3). The P values are all <0.05, which suggests that the visual analogue scales scores of Qualitative data The qualitative data were collected from the COPD questionnaire. The study s second question was: what helps or hinders patients in managing their COPD? The data suggested that patients were aware that smoking and weight gain increased breathlessness. They also commented that taking their medication as prescribed and pacing themselves helped control their breathlessness. The study s third question was: what suggestions do patients with COPD have to improve the self-management support that they receive? The data suggested that keeping patients up to date with new medications, being there when they needed advice, offering 1108 British Journal of Nursing, 2013, Vol 22, No 19

5 clinical focus Key points Anxiety, depression and acute exacerbations feature predominantly in the natural history of chronic obstructive pulmonary disease (COPD) Governments and healthcare providers are engaged in initiatives to develop new ways of supporting patients living with long-term conditions such as COPD to manage their own health increasing self-efficacy is likely to lead to behaviour change and more effective selfmanagement People with long-term conditions may need self-management support to cope more effectively with the psychological effects of their illness a written progress chart annually and believing them when they said they were having an exacerbation would all be helpful. Discussion and conclusion Although the response rate was poor, the patient sample was randomly selected and robust processes were in place to reduce selection bias. The first researcher was blind to the random selection and the participants identifiable information. The study population was a true sample of COPD patients across four GP practices in north east Scotland including men and women, smokers, non-smokers and those with moderate or severe COPD. This study looked to see if there was an association between self-efficacy, mood, breathlessness and exacerbations. The results show there is an association between higher levels of self-efficacy, reduced breathlessness (Table 3) and lower levels of anxiety and depression (Table 2). Patients who had high scores on the COPD self-efficacy scale which concerns their ability to control their breathlessness in certain situations had lower anxiety and depression levels. Those who said they were more confident at recognising an exacerbation and treating one had less anxiety/ depression and breathlessness. However, exacerbation rates were the same for people with high and low self-efficacy levels. We should therefore focus on increasing self-efficacy and reducing anxiety and depression in patients living with COPD (Effing et al, 2009).The COPD team of nurses in this NHS setting have received training in health behaviour change. These skills, used in combination with this study s findings, will enable us to assist patients with problem solving, achieving their goals and enhancing behaviour change. Future research Further research is needed, using a larger sample, preferably over a prolonged period of time. The outcome measures should focus on behaviour change, the attainment of goals and/or self-efficacy scores, as opposed to exacerbation rates or GP visits (Bourbeau and van der Palen, 2009). Past studies have focused mainly on exacerbations; acute exacerbations feature predominantly in the natural history of COPD (Kelly, 2009) so it may not always be possible to prevent them. BJN Conflict of interest: none. 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BMC Pulm Med 9: 52 Wigal JK, Creer TL, Kotses H (1991) The COPD self-efficacy scale. Chest 99(5): Wood-Baker R, McGlone S, Venn A, Walters EH (2006) Written action plans in chronic obstructive pulmonary disease increase appropriate treatment for acute exacerbations. Respirology 11(5): Zigmond AS, Snaith RP (1983) The hospital anxiety and depression scale. Acta Psychiatr Scand 67(6): British Journal of Nursing, 2013, Vol 22, No

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