Yearbook on Journal of the Japan Society of Nursing Research 2016

Process of Attaining Self-care for Chronic Respiratory Failure Patients Receiving Home
Noninvasive Positive Pressure Ventilation Therapy
Makoto Shimoyama1) and Midori Furuse2)
Key Words :Noninvasive positive
pressure ventilation therapy
Chronic respiratory failure
Self-careSemi-structured interview
The modified groundedtheory approach

ABSTRACTThe objective of this study was to investigate how chronic respiratory failure (CRF) patients on noninvasive
positive pressure ventilation (NPPV) therapy attain self-care in order to continue home care following hospital discharge. Participants were 10 CRF patients receiving home NPPV therapy. Semi-structured interviews
were conducted and data were analyzed using the modified grounded theory approach. The results revealed
the following factors in the process of attaining self-care: 1) ‘difficulties associated with NPPV’, 2) ‘facilitationof independent behavior’; 3) ‘independent behavior’; 4) ‘awareness of controlled NPPV use’ where NPPV was
not used during the daytime even when the patient had dyspnea; and 5) ‘awareness of proactive NPPV use’
where NPPV was proactively used. ‘Awareness of controlled NPPV use’ was triggered when “resistance at thestart of NPPV” was prolonged. “Understanding the effectiveness” of NPPV influenced ‘awareness of proactive
NPPV use.’ The study indicated the importance of assisting the patients before discharge to understand theeffectiveness of NPPV in developing motivation of its proactive use.

I. Introduction

after asking the intentions of patients and their family
members. Most of those who started IPPV are compelled tobe bedridden in a hospital, making their prognosis and QOL
poor7). It is, therefore, considered that patients themselves
must avoid acute exacerbation and receive home treatment
for a long period for the success of NPPV therapy8).
Kozu9) revealed everyday-life experiences and thoughts ofpatients with chronic respiratory failure who received homeoxygen therapy and NPPV therapy. Takekawa and others10)
clarified that patients with chronic respiratory failure who
receive NPPV therapy keep their feelings of self-esteem
and vitality by receiving social support from others andlive a life albeit with ambivalent feelings. Thierry Petitjean,et al11). noted that patients with chronic respiratory failure
would suffer respiratory failure in one or two days if they
discontinued NPPV therapy, showing the importance ofcontinuing NPPV for maintaining home care treatment.
However, NPPV complications include mask intolerance12),
dry mouth6), and abdominal distention13), implying that
there is a possibility that these physical distress and thedevelopment of psychological distress caused by wearing amask subconsciously disrupt self-care, making it difficult tomaintain home care treatment.
Self-care refers to the attempt to engage in activities
directed at oneself or his/her environment by himself/herself
in order to regulate one’s own functions and development,
aiming for the maintenance of life, health, and well-being14).
There are some studies focusing on feelings and cognition of
NPPV patients but there is little research on their self-care,
therefore, it remains to be known what kinds of self-care isconducted for preventing deterioration of disease conditions
and how home care treatment is maintained.
This study, therefore, attempts to clarify how patients withchronic respiratory failure who receive NPPV acquire self careafter discharge from hospital in order to maintain home caretreatment.

Noninvasive positive pressure ventilation (NPPV) is amethod of positive pressure ventilation that can be given via
nasal or face masks, which is widely used for patients of typeII respiratory failure caused by alveolar hypoventilation andchronic respiratory failure with hypercapnia1). It is usually
introduced through understanding and cooperation ofpatients themselves below the level of consciousness. Mask
could be removed for making conversation and eating meals,
therefore, patients can perform daily activities as patientswith home oxygen therapy (HOT) do. The introduction of
NPPV has improved the prognosis and especially quality oflife (QOL) of patients1).
Researches on the survival rate of patients with NPPV andthe probability of continuing NPPV have been conducted inmany countries, whose results vary according to a type of
disease2)~4). According to Tsuboi’s report, the probability ofcontinuing NPPV among patients with pulmonary tuberculosis
sequelae was 80% at 3 years and 65% at 5 years, relatively
higher compared with the survival rate among patients with
HOT (74% at 3 years and 58% at 5 years)5). On the other
hand, the probability of continuing NPPV among patients withchronic obstructive pulmonary disease was 54% at 3 years
and 24% at 5 years. This result differs little from the survival
rate among patients with HOT5) but NPPV is still tailored to
be used because clinical improvement is observed on disease
with hypercapnia.
The necessary time required for home NPPV therapy isless than 15 hours for 94% of patients6). Respiratory status
of most patients becomes stable with night use or intermittent
use during the day or night, managing NPPV therapy bythemselves and enjoying a good QOL.
Yet, if their daily life is disrupted by acute exacerbation or
an exacerbation of underlying disease, the transition fromNPPV to invasive positive pressure ventilation (IPPV) which
requires tracheal intubation is considered for their treatment

II. Research Methods

1) School of Nursing, Miyagi University
2) School of Nursing, Faculty of Medicine, Yamagata University

1. Subjects and Extraction of Them
Subjects are 10 patients with chronic respiratory failure
who attended an outpatient department at Hospital A and

Corresponding author. Tel.: +81 22 377 8277; Fax.: +81 22 377 8290.
E-mail address: shimo.ma@myu.ac.jp (M. Shimoyama)

1
This paper was published at “the Japan Society of Nursing Research” Vol.35 No.2 in 2012.

Yearbook on Journal of the Japan Society of Nursing Research 2016

received home NPPV therapy. Those who had communicative
problems due to dementia or others were excluded fromanalysis. Those who satisfied the requirements were introduced
from doctors when they visited the hospital, and only those
who agreed to participate in the research were included as
subjects (see Table 1 on a summary of subjects).
Hospital A has 300 beds and provides secondary medicalcare in the southern part of Prefecture B. Among a total of
3,680 outpatients who visited the Department of Respiratory
Medicine at Hospital A, 13 patients received home NPPV
therapy. The number of chronic respiratory failure patients
who received home NPPV therapy in Prefecture B was about
100.

of interactions with others such as family members, medical
experts, and the providers of NPPV. M-GTA is considered to
be an appropriate research method because it is best suitedfor explaining human behaviors and interactions with others.
M-GTA sets the analytical theme and the analyticallyfocused person. The setting of the analytical theme refers to
the narrowing down of research theme in order to perform
detailed data analysis. Analytical theme of this research was:“What kind of daily activities do you conduct in order not todevelop the disease?” The analytically-focused person was“patients with chronic respiratory failure who receive home
NPPV therapy.”
The analytical procedure is as follows:
The content of interviews recorded in an IC recorder wastranscribed verbatim.
Concepts, the smallest unit of analysis, was generated byfocusing on parts related to the analytical theme fromverbatim transcripts. Analytical sheets were used forwriting down concepts, definitions of concepts, variation,and notes on a theory.
Concepts and definitions were modified, removed, or
generated newly in order to describe their relations withadditional variations accurately.
Constant comparison analysis was conducted by focusing
on the similarities and differences with other interview datain order to avoid arbitrary interpretation. Concepts wereidentified by examining whether interpretation, definitions,and the names of concepts were closely related to data.
Categories were generated through the examination of theinterrelationship between concepts in parallel to the workon the generation of new concepts after about 13 concepts
were generated.
A figure describing “the self-care acquisition process ofchronic respiratory failure patients receiving home caretreatment with NPPV therapy” was created by using concepts
and categories.
In this research subjects were added in the process of data
analysis for attaining theoretical saturation. The attempt to
add subjects was stopped once the analysis of the data of 10
subjects was completed because we judged that new concepts
would not be likely to be generated.

2. Research Period
From May to December 2010.

3. Methods of Collecting Data
We explained the purpose and content of this research to
subjects and conducted semi-structured interviews with those
who agreed to participate in it. The content of an interview
was recorded using an IC recorder with their consent. It
was about what occurred in home care since they received
explanations about NPPV therapy from a doctor. They wereasked to talk specifically about the following two points.

What kinds of problems did you face after starting NPPV
therapy and how did you deal with them?
What kinds of things do you care about in daily activities
where NPPV therapy is conducted.
Each interview was lasted for one hour and was conductedin a room of the hospital where privacy is protected. In cases
where a subject requested, an interview was conducted in
his/her home at an appropriate date and time. Information
on subjects’ disease and treatment process was acquired byreading their medical record.
4. Research Methods
Modified Grounded Theory Approach (M-GTA)15), 16) wasused for the analysis of data.
M-GTA is useful for clarifying human interaction. Somepatients receive home care treatment with NPPV therapy inorder not to worsen respiratory status. There are a variety

Table 1. Outline of Subjects

Case
Number Age
1

78

3

83

2
4

5

85
81

88

6

60

8

70

7

9

10

73

68

88

Sex

Male

Disease

COPD
Pulmonarytuberculosis
FemalesequelaeThoracoplasty forMaleempyemaMale
Sleep apnea syndrome

Duration of
NPPV therapy

Hours for NPPV
prescription

Female Alveolar hypoventilation

1 year
8 years &10 months
2 years &1 month
7 months
5 years &7 months

8 hours at nightMale

10 years &4 months

8 hours at nightMale

Kyphoscoliosis after
tuberculous spondylitis
COPD

tuberculosis
Female Pulmonary
sequelaeFemale Alveolar hypoventilation

tuberculosis
Female Pulmonary
sequelae

2 years

9 months

6 years &1 month
1 year &8 months

Type of amask

8 hours at night

Oral & nasal

8 hours at nightNasal

8 hours at night

Oral & nasal

of Family
The use of Certification
long-term carelivingHOT
needtogether
Yes

No

Yes

No

No

Yes

Yes

8 hours at night

Oral & nasal

Yes

8 hours at night

Nasal

No

8 hours at night

8 hours at night
8 hours at night

Nasal

Oral & nasal

No

Yes

Yes

No

No

Yes

Yes

Yes (level 4)

Yes

No

No

Oral & nasal

Yes

Oral & nasal

Yes

Oral & nasal

No2This paper was published at “the Japan Society of Nursing Research” Vol.35 No.2 in 2012.

No

No

No

Yes

Yes

Yes
Yes

Yearbook on Journal of the Japan Society of Nursing Research 2016

disadvantages in medical care. All obtained data were kept
under lock and key. We also explained to them that data
were not used for purposes other than this research, all therecorded data were erased after the research was completed,and their identities were kept anonymous when we present
our research results in an academic conference or as anarticle.

5. Assurance of Plausibility
There are following methods by which researchers checkand verify plausibility of qualitative research: “searching fornegative case and alternative explanations,” “peer review,” “theaudit or decision trail,” “thick description,” and “reflexivity.”17)
On “searching for negative case and alternative explanations”
constant comparison analysis was conducted with theperspective of the similarities and differences with other datain order not to interpret data arbitrarily.
On “peer review,” we were supervised by a faculty member
in adult nursing who was familiar with M-GTA on the settingof analytical theme, generation of concepts and the making of
figures and storyline.
On “peer review,” “the audit or decision trail,” “thickdescription,” and “reflexivity” we wrote down what we noticed,
questions, and the reasons for modifying concepts while
generating concepts. In addition, we created an analyticalnote, organized our ideas and the meanings of content
taken from what subjects had told, and examined whether
interpretation, definitions, and the names of concepts wereclosely related to data.

III. Results

Categories, concepts, and in-vivo concepts that treats words
and expressions in data as concepts were shown in [ ], < >,and “ ”, respectively. The analysis of interviews with 10 chronic
respiratory failure patients receiving home care treatment
with NPPV therapy generated 5 categories and 13 concepts.
A storyline which verbalized analytical results and a figurethat explained it is shown in Figure 1.
1. Storyline
There were following categories on the process of
attaining self-care among chronic respiratory failure patients
receiving home NPPV therapy: [difficulties associated with
NPPV], [facilitation of independent behavior], [independent
behavior], [awareness of proactive NPPV use], and [awarenessof controlled NPPV use].
There are <intolerance at the time of introduction> and<a feeling of difficulty in wearing a mask> in [difficulties
associated with NPPV]. Patient’s responses changed from
<intolerance at the time of introduction> at the time of
doctor’s explanation on NPPV therapy to <a feeling ofdifficulty in wearing a mask> when he/she put a mask on
his/her face when doing NPPV therapy. At the same time

6. Ethical Considerations
This research was approved by the ethics committee ofFaculty of Medicine, University C. We explained to subjects
the purpose and content of this research in a written form
and verbally and asked those who agreed to participate in
the research to sign the letter of consent. We also explained
to them that participation in the research is voluntary, they
do not have to answer questions they do not want, they candecline to participate in the research at any time, and those
who declined to participate in the research do not suffer any
Anxiety over non-use【Dif�iculties associated with NPPV】“Oxygen only at night”“To do on my own”

Awareness of effectivenessA feeling of dif�iculty inwearing a mask

Category

Denial of mask-wearing despite having dif�iculty【Facilitation of independent behavior】

Intolerance at the timeof introduction

The narrowing of the range of activities【Awareness of controlled NPPV use】

【Independent behavior】
Ingenuity to prevent respiratory
deterioration
Original adjustment ofmask-wearing

Nightly custom of mask-wearing【Awareness of proactive NPPV use】

Possibility of rehospitalization prevention
Concept

Mask-wearing even at a time of dif�iculty

Direction of in�luence

Direction of change

Figure 1. The process of attaining self-care among chronic respiratory failure patients receiving home NPPV therapy

3This paper was published at “the Japan Society of Nursing Research” Vol.35 No.2 in 2012.

Yearbook on Journal of the Japan Society of Nursing Research 2016

patients felt <the narrowing of the range of activities>
associated with the deterioration of respiratory status thanhe/she was before. Due to <a feeling of difficulty in wearing
a mask> and <the narrowing of the range of activities> theyreceived support from their family members but they also
started to recognize the need <“to do on my own”> and findout <original adjustment of mask-wearing> gradually. They
also reassured awareness of <“to do on my own”> througha recognition that NPPV therapy can be done by themselvesfrom an <original adjustment of mask-wearing>. In addition,awareness of <“to do on my own”> affected an <ingenuity toprevent respiratory deterioration>, making a patient engage
in a <habituated preventive behavior> through the trial-anderror process. They raised <awareness of effectiveness> of
NPPV therapy by making an <original adjustment of maskwearing.>[Facilitation of independent behavior], which is composedof <“to do on my own”> and <awareness of effectiveness>,
was awareness of a factor leading to [independent behavior],
which is composed of <ingenuity to prevent respiratory
deterioration>, <original adjustment of mask-wearing>, and<nightly custom of mask-wearing>.
[Awareness of proactive NPPV use] was influenced by<awareness of effectiveness> on NPPV therapy. There
were <possibility of rehospitalization prevention> and<mask-wearing even at a time of difficulty> in [Awarenessof proactive NPPV use]. Patients recognized <possibility ofrehospitalization prevention> by receiving NPPV therapy andtheir awareness changed into <mask-wearing even at a time ofdifficulty> in which NPPV was used even during the daytime.
On the other hand, <the narrowing of the range of activities>
contributed to awareness of <anxiety over non-use> by having<a feeling of difficulty in wearing a mask>.
On [awareness of controlled NPPV use] patients dealt
with <anxiety over non-use>, <intolerance at the time of
introduction>, and <“to do on my own”>, whose awarenessof NPPV therapy changed into <“oxygen only at night”> and<denial of mask-wearing despite having difficulty>. There is<nightly custom of mask-wearing> on the basis of <maskwearing even at a time of difficulty> and <denial of maskwearing despite having difficulty.>

variety of difficulties associated with the use of mask-wearing
in home NPPV therapy.
“Well, let me see it was hard until getting used to it. I was sobad about using it. Well, I had a lot of trouble until I adjusted
myself to it. Yeah, about one month... well, I got a pain on thisplace (the root of nose).” (Case 1)“It hurts. There was a mark for long periods. I tried hard to
give myself a massage but it did not disappear because I was
squeezed so hard.” (Case 2)“Well, it’s somehow difficult. It’s agonizing because this place(around mask) is compressed. It’s difficult. So I sometimes
pulled off a mask because I had difficulty in a dream although
I was not conscious of it at all.” (Case 3)“It’s difficult to breathe when I use it. I had a pain aroundhere (the root of nose) as if I got a hole in my nose.” (Case 7)

b. Category of Facilitation of Independent Behavior[Facilitation of independent behavior] refers to a variety
of awareness seen as promotional factors leading to[independent behavior]. It is compose of two concepts: <“todo on my own”> and <awareness of effectiveness>.
<“To do on my own”> was defined as the life with the feelingthat I have to do on my own as much as possible because
nobody except me can know how to receive NPPV therapy.
“If I told that there was something wrong with the NPPV
equipment, my uncle fixed it anyhow but I did not ask anybody
about how to wear the device. I mean, he thinks that’s his job.”(Case 2)
“Saliva or something... around here... it was around mymouth. Threads go bad. Threads or something strange comeunstuck. So I clean after I use it every day… everyday bymyself. I could do it without any trouble.” (Case 5)“I have to protect my body. Nobody knows it.” (Case 8)<Awareness of effectiveness> was defined as the awarenessthat respiratory status becomes stable by receiving NPPV
therapy and the feeling that it is necessary to do it.
“(Before changing the setting) when I inhaled I felt that thefrontal part was stuck lately, but (after changing the setting)the feeling of being stuck disappeared. I felt a tug toward theequipment. So, I feel it might be good. I feel easy. And as I feelcalm, I could walk a bit faster.” (Case 6)“I’m accustomed to it. At first I felt strange but I became
increasingly accustomed to it and felt well. I felt strange before
doing it. My breathing is also getting well. It starts to fit mybody.” (Case 8)

2. Each Category And Concept

a. Category of Difficulties Associated with NPPVIn [difficulties associated with NPPV] NPPV therapy
is conducted at the stage of the explanation of NPPV
introduction, showing difficulties associated with home care.
It is composed of two concepts: <intolerance at the time of
introduction> and <a feeling of difficulty in wearing a mask>.
<Intolerance at the time of introduction> was defined
as a feeling of unwillingness toward NPPV therapy held at
the stage of doctor’s explanation on NPPV therapy before its
implementation.
“It started about four years ago. (When my doctor told
me about it) I thought I don’t like it, it’s embarrassing andtroublesome.” (Case 2)“When a doctor told me that I had to receive NPPV, I replied,‘I don’t need it.’ But he insisted it...” (Case 3)“They say that I should receive NPPV therapy because it isshorter in use than nose oxygen but I felt scared at using mask
oxygen at first.” (Case 5)<A feeling of difficulty in wearing a mask> was defined as ac. Category of Independent Behavior[Independent Behavior] is a behavior affected by theconcepts of [facilitation of independent behavior] and doing
for patients by themselves in home care. It is composed ofthree concepts: <original adjustment of mask-wearing>,<ingenuity to prevent respiratory deterioration>, and <nightly
custom of mask-wearing>.
<Original adjustment of mask-wearing> is defined as thesituations in which a patient is gradually accustomed to thedifficulty of mask-wearing in NPPV therapy and adjusts thedegree of tightening a mask in his/her own way.
“Well, I have to do it by myself. Other people can’t adjust
the equipment properly. I have to do it by myself. Well, it’sdelicate. It’s difficult to adjust the degree of tightening a mask.
I had others do it but it did not work. It sometimes worked but
there was no way to continue to work.” (Case 1)“Well, yeah, I do it by myself. I got out of the hospital after
4

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Yearbook on Journal of the Japan Society of Nursing Research 2016

so I can do that. So, sometimes I wear the mask for about 30
minutes. Yes, during the day. Then, I somehow feel relaxed.”(Case 6)

I was accustomed to it. Nobody can do it for me. Even nurses
do not know the degree of tightening a mask. I could notknow the place where leaking occurs, so I asked her aboutprocedures and the ways for avoiding leakage. It took about
half a year to be accustomed to it.” (Case 2)<Ingenuity to prevent respiratory deterioration> wasdefined as the objective or subjective realization that one’s
own breathing is good and behaviors for preventing thedeterioration of respiratory status.
“I do abdominal breathing every day. At least 50 times
in the morning. Yes, every morning. Abdominal breathing...
After I do abdominal breathing I do calisthenics at 6:30. Yes,
radio calisthenics. 365 days a year. I never miss a day. I havedone calisthenics without fail for a long time. Oxygen levels
go up after doing calisthenics. They go up to 100. Then, I
raise the level of an oxygen concentrator by 3. Yes, when I do
calisthenics, oxygen levels go up. Well, in this way breathingin and out repeatedly. This raises oxygen levels because thepace of breathing becomes faster.” (Case 1)“I receive vaccine as soon as possible when necessary. I canknow it. I need a dose of vaccine if I catch a cold. Especially,
you know, I need to be careful not to get phlegm in my throat
because it’s very difficult to spit it out. Phlegm is like, let mesee, it becomes like rubber.” (Case 4)<Nightly custom of mask-wearing> was defined as thewearing of a NPPV mask as a daily routine with no pain.
“My doctor tells me to wear it every day but I think nobody
follows his prescription. I wear it when I am in bed without
fail.” (Case 6)“I do not miss it. I always do it punctually. All night. I haven’t
missed it. Every night I do it.” (Case 5)“I’m always on time. It is earlier now... Around 8 or 9PM I
lie down and listen to music until I wear a mask. Then around
9:30PM I put on a mask. Then I wake up in the morning.”(Case 4)e. Category of Awareness of Controlled NPPV Use[Awareness of controlled NPPV use] refers to awarenessthat NPPV is used only at night with the feeling that I use
it as little as possible and not be used when respiratory
symptoms appear. It is composed of two concepts: <“oxygen
only at night”> and <denial of mask-wearing despite having
difficulty>.
<“Oxygen only at night”> is defined as the feeling that apatient can undergo NPPV without lowering the quality oflife if a patient undergoes NPPV only at night.
“I do not like to use it but a doctor say it can be done in ashort time in my case. Well, I do not like to use it all day. I justdo not like it.” (Case 3)“Anyway, oxygen I use (NPPV) is not so terrible. Oxygen justonly at night. Of course, I do not know how it can be serious.
It may be that those who use it even during the day may feel
terrible. But I’m not sure about it.” (Case 5)“I do not use it for long. About nightly mask. Whatever
happens, I use it as usual.” (Case 10)<Denial of mask-wearing despite having difficulty> wasdefined as the awareness that controlling one’s breathing
and keeping quiet, not using NPPV is a way of coping at thetime of dyspnea.
“Well, anyway sleeping is the best. Any place, for instance,
on a veranda and even on tiles of bathroom. Tile floors would
be hard, but I should lie down.” (Case 2)“I do not walk steadily. When I become uncomfortable, I
remain standing for about 3 minutes, then I get a bit better.”(Case 9)f. The Narrowing of the Range of Activities<The narrowing of the range of activities> was defined
as a decline in the amount of activity and the narrowing of
the range of activities due to the deterioration of physicalsymptoms such as shortness of breath and dyspnea althougha patient used to be active.
“I am making efforts to sleep comfortably as much as
possible whenever I have free time. I really sleep so muchtime. There’s nothing easier than sleeping. But I do notundertake physical activity if I always sleep. So, I try to walk
between a living room and a bedroom in the house. It might
be better if I walk outside a little on clear days. It’s good when
I am walking but I wheeze the moment I stopped walking andsat down.” (Case 2)“I get out of breath a bit when I squat on the ground andweed my garden. I also get out of breath when I walk for along time. I could do that but I can’t now. How long do I haveto walk from here? Well, I get fed up with walking for 300m
or 400m. I can’t walk very much now. I think my legs are
weakened, therefore, I get out of breath.” (Case 3)

d. Category of Awareness of Proactive NPPV Use[Awareness of proactive NPPV use] shows awareness that
attempts to keep one’s own respiratory status properly byusing NPPV proactively. It is composed of two concepts:<possibility of rehospitalization prevention> and <maskwearing even at a time of difficulty>.
<Possibility of rehospitalization prevention> was definedas the self-awareness of the effectiveness of NPPV therapy
and the realization that “I do not have to be rehospitalized if
I receive properly” NPPV therapy by myself although in thelight of own experience a patient considers that he/she might
be rehospitalized if his/her conditions get worse.
“Things like that... I have to be hospitalized if symptoms arebad in such a way. But I do not need to be hospitalized because
the symptoms subside if I wear a mask.” (Case 1)“I’m thinking that I would have to go to the hospital if I do
not receive NPPV therapy. I was told that my breathing was
getting normal if I wear a mask.” (Case 8)<Mask-wearing even at a time of difficulty> was defined as
the awareness that I have to wear the NPPV mask for copingwith the appearance of respiratory symptoms.
“Yes, I feel better. When I get out of breath, I rushed to wear
the mask. Then, the symptoms subside in five minutes. Well,it’s very good.” (Case 1)“I do a variety of things depending on circumstances. I
sometimes think I had better wear the mask. I do it in thedaytime when my symptoms are very bad. I employ others,

g. Anxiety over Non-use<Anxiety over non-use> was defined as the hesitancy of
not using NPPV because of the anxiety that symptoms ofrespiratory failure might be worsened if NPPV is not used.
“I worried that what would happen if I do not use NPPV. I
worry that I might get out of breath.” (Case 3)“If I’m not able to use NPPV by myself, if my father is
not able to help me to use NPPV, if nobody can’t put on the5This paper was published at “the Japan Society of Nursing Research” Vol.35 No.2 in 2012.

Yearbook on Journal of the Japan Society of Nursing Research 2016

respiratory equipment, is a hole made in the throat?” (Case 9)

an <ingenuity to prevent respiratory deterioration> from theirown belief that patients must prepare for the possibility ofdeath and prevent respiratory deterioration.
As an <original adjustment of mask-wearing> some patients
talked about an appropriate way of wearing a mask which only
he/she can can know, showing the influence of the awarenessof <“to do on my own”>. As <a feeling of difficulty in wearing amask> they are aware of the things <“to do on my own”> andacquired skills of an <original adjustment of mask-wearing>
through the associations with family members in home care.
<“To do on my own”> is awareness of taking care of one’s
own affairs by oneself because only he/she can know how
to use NPPV properly, which affected <original adjustmentof mask-wearing> and <ingenuity to prevent respiratory
deterioration> in an [independent behavior]. Strengthen theawareness of <“to do on my own”> is considered to be one of[facilitation of independent behavior] because it is expected
to promote an [independent behavior].
On the other hand, on the awareness of <“to do on myown”> patients told that they sometimes did not follow
family members’ opinions on the use of NPPV. It is consideredthat they try to manage things that only the users of NPPV
can know, so that they tend to neglect and refuse to accept
their advice. The results showed that there is a possibility
that patients may rely too much on their own judgment andundergo medical care by their own one-sided interpretation.
Strengthening awareness of <“to do on my own”> promotes
an [independent behavior] but it was suggested that patients
may conduct inappropriate self-care based on an erroneousinterpretation.
Connie M. Dennis notes that one characteristic of self-careis that it might be therapeutic (effective) or nontherapeutic(ineffective). Self-care is conducted by patients themselves,
therefore, their correct understanding of proper way ofcare affects the ways they conduct self-care. Therefore, it issuggested that although awareness of <“to do on my own”>
is indispensable for promoting an [independent behavior],
nurses must make an effort not only to strengthen theirawareness of <“to do on my own”> but also to help them tolisten to family’s opinions and conduct self-care with correctknowledge.
Patients was influenced by an <original adjustment ofmask-wearing> and had an <awareness of effectiveness> of
NPPV therapy. As content of <awareness of effectiveness>patients told that they felt the necessity to undergo NPPV
after being aware that their respiratory status became stableby receiving it. It was found that <awareness of effectiveness>
and an <original adjustment of mask-wearing> influence one
another. It is considered that <awareness of effectiveness>enhances the willingness of an <original adjustment of maskwearing>.
In a <nightly custom of mask-wearing> all patients notedthat the wearing of a NPPV mask was incorporated into daily
activities as a night routine. It was found that patients thought
about wearing it in home care, was influenced by an <originaladjustment of mask-wearing>, wore it by setting aside aregular time within a specified time arranged by doctors.

IV. Discussion

1. About the Category of Difficulties Associated with NPPVIn [difficulties associated with NPPV] <intolerance at thetime of introduction> which a patient held when a doctor
talked about NPPV changed into <a feeling of difficulty inwearing a mask> by actually using NPPV. Takekawa10) andDoi showed a pain associated with the introduction of NPPV
therapy as a category of internal experience. Kouzu9) alsomentions the struggle with the equipment as a categoryof a daily life experience. This research also revealed thatawareness a patient has toward NPPV involves change.
In addition, <a feeling of difficulty in wearing a mask> is apatient’s awareness felt during the period in which he/she
attempts to accept NPPV therapy, a transition from <a feelingof difficulty in wearing a mask>.
Richard S. Lazarus notes that a stressful event is a potential
stressor in stress and coping theory, whose interpretation
determines that it becomes a stressor. This research showedthat doctor’s explanation of NPPV initiation becomes a
stressful event by a patient’s interpretation affected by his/her level of understanding, affecting whether he/she canaccept NPPV therapy.
When it is not explained well, <intolerance at the time of
introduction> is intensified and the use of NPPV therapy isrejected, often resulting in the minimum use of NPPV, that is,<“oxygen only at night”>. It is, therefore, considered that it isimportant to figure out patients’ level of understanding andacceptance after doctor’s explanation and provide explanations
on their worries and questions about <intolerance at thetime of introduction> at an early stage for prompting themto receive NPPV.
<A feeling of difficulty in wearing a mask> strongly showed
problems of masks such as pain at the root of nose, the mask’spressure on the patient’s face, and breathing discrepancy. <A
feeling of difficulty in wearing a mask> is a matter to which
patients want nurses to give much attention. According to
Akiyo Suzuki19) and others, it is important that nurses pay
attention to patient’s complaints of complications, detect
their difficulties accurately, and help them. It is consideredthat nurses must care about <a feeling of difficulty in wearing
a mask> and deal with each patient’s feeling of difficultyin order to make patients acquire skills of an <originaladjustment of mask-wearing> promptly.
2. About the Categories of Independent Behavior andFacilitation of Independent Behavior
Patients had [difficulties associated with NPPV] in thepast but engaged in <ingenuity to prevent respiratory
deterioration>, <original adjustment of mask-wearing>,<nightly custom of mask-wearing> as an [independent
behavior].
They talked about behaviors such as oral rinse to prevent
infection and everyday radio calisthenics as an <ingenuity toprevent respiratory deterioration>. Patients using NPPV is in
respiratory distress with hypercapnia. It is considered that
deterioration of their respiratory status would immediately
bring major challenges to their survival. Respiratory trace
infection is the most popular causes of the acute exacerbationof respiratory failure, which necessitates infection prevention
and early treatment8). It is considered that patients exhibited

3. About the Categories of the Awareness of Controlled NPPVUse and the Awareness of Proactive NPPV Use[Awareness of controlled NPPV use] was composed of<“oxygen only at night”> and the <denial of mask-wearing
despite having difficulty>. <“Oxygen only at night”> is6This paper was published at “the Japan Society of Nursing Research” Vol.35 No.2 in 2012.

Yearbook on Journal of the Japan Society of Nursing Research 2016self-efficacy. Therefore, it is important that medical staffs
check how patients breathe and their change of physicalconditions while listening to their complaints since they arein a hospital whereby they have <awareness of effectiveness>of NPPV therapy, which, in turn, enhances [awareness of
proactive NPPV use].

awareness that the night use of NPPV prescribed by a doctor
does not decrease patient’s quality of life, which is influenced
by <anxiety over non-use>, <intolerance at the time of
introduction> and <“to do on my own”>.
Ruth Wu21) mentioned a non-activity as one form of disease
behavior, resulting from hesitancy to face with the sufferingfrom disease. This research revealed that <intolerance at thetime of introduction> is a factor that dissuade patients fromusing NPPV positively. It is considered that they therefore
decided not to use NPPV during the day as much as possible
and changed their awareness of <“oxygen only at night”> into
<denial of mask-wearing despite having difficulty>. In <denialof mask-wearing despite having difficulty> they say that they
control their breathing and rest in bed without receiving
NPPV when they have breathing problems.
Previous studies also revealed that patients with chronic
respiratory disease conduct breathing control and action
coordination as management of breathing difficulties22).
According to a NPPV guideline8), although home NPPV therapy
is usually used in cases of chronic respiratory failure it is used
to cure breathing difficulties and hypercapnia caused bysleep-disordered breathing, respiratory muscle loading, andrespiratory control disorder. It also mentioned a decrease inrespiratory symptoms and a decrease in the work of breathing
as a short-time goal of NPPV therapy. NPPV patients expect
to improve breathing difficulties immediately after receiving
NPPV. Therefore, it is important for them to engage inactivities that promote the use of NPPV during the hospitalstay, making them have awareness that they can prevent theworsening of respiratory status by themselves under doctor’s
guidance.
Awareness of <“to do on my own”> brings about passive useof NPPV and the neglect of family’s urge to use NPPV leads
to [awareness of controlled NPPV use]. Therefore, we needto advise them to listen to family’s opinions, not just making
own judgment.
On the other hand, there is a possibility that they may
misinterpret doctor’s explanation, so that they have [awarenessof controlled NPPV use] by believing that NPPV can be used
only at night. In this case it is necessary that medical experts
should allay their misunderstanding.
It was found that there is [awareness of proactive NPPVuse] which is distinct from [awareness of controlled NPPVuse] on awareness of NPPV use during dyspnea. <Awarenessof effectiveness> on NPPV therapy is a promotional factorof [awareness of proactive NPPV use]. Kozu9) notes thatawareness of the improvement of physical conditions affects
patient’s recognition that NPPV therapy is needed. Kameda
and others23) also points out that patients who have positive
image of NPPV consider that it is good for their health and use
it without any hesitation.
On the other hand, self-efficacy is named as a component of
supporting the self-management of chronic disease patients24).
This research shows that <awareness of effectiveness> byconducting <original adjustment of mask-wearing> affects[awareness of proactive NPPV use] as self-efficacy. According
to Sato and others25), it is important to enhance patient’s selfefficacy in order to promote their behavioral transformation.
The experience of success and verbal encouragement is
indispensable for achieving that purpose. It is considered thatsymptomatic improvement by using NPPV and its affirmationfrom medical professionals bring about their <awarenessof effectiveness>, which leads to the enhancement of their

4. The Implications of Nursing Practice for Promoting the Useof NPPV
This research revealed that [difficulties associated with
NPPV] is one of a variety of processes in which patients accept
NPPV therapy. <A feeling of difficulty in wearing a mask>shows that nurses must help them wear a mask properly inorder to make them acquire skills of an <original adjustmentof mask-wearing>.
The following self-care awareness on the use of NPPV was
also shown: [awareness of controlled NPPV use] in which
NPPV is not used during the day even if they have breathingdifficulties and [awareness of proactive NPPV use] in which
NPPV is used during the day with no hesitation if they havebreathing difficulties. It was also suggested that it is importantfor nurses to check whether patients breathe properly andtheir changes of physical conditions in order to make them
have <awareness of effectiveness> of NPPV therapy because
it affects their [awareness of proactive NPPV use].
5. The Limitations of This Research and the Tasks Ahead
The explanatory power of this research is limited to selfcare of patients with chronic respiratory failure undergoinghome NPPV therapy. Therefore, the results of this research
can be applied to cases of “care of patients with chronic
respiratory failure undergoing home NPPV therapy.” It mustalso be noted that the length of time of receiving home NPPV
therapy did not affect self-care concepts in the analysis of thisresearch.
This research clarified the awareness and accompanying
behaviors of patients with chronic respiratory failure undergoinghome NPPV therapy, and thereby showed concrete measures togive guidance to them during the hospital stay and in outpatient
visits. Based on insights gained from this research, we must help
patients with chronic respiratory failure undergoing home NPPV
therapy to undergo NPPV therapy properly and induce theirawareness of its effectiveness and analyze its effectiveness.
V. Conclusion

1. There were following categories on the process of
attaining self-care among chronic respiratory failure patients
receiving home NPPV therapy: [difficulties associated with
NPPV], [facilitation of independent behavior], [independent
behavior], [awareness of controlled NPPV use] in which NPPV
is not used during the day even if patients have breathingdifficulties, and [awareness of proactive NPPV use] in which
NPPV is used during the day with no hesitation if they havebreathing difficulties.
2. [Difficulties associated with NPPV] is a process of accepting
NPPV therapy. <Intolerance at the time of introduction>affected [awareness of controlled NPPV use] when NPPV
therapy was not accepted properly.
3. <“To do on my own”> became a trigger to hold [awarenessof controlled NPPV use] while at the same time it affected<original adjustment of mask-wearing>.
4. <Awareness of effectiveness> on NPPV therapy affected
7This paper was published at “the Japan Society of Nursing Research” Vol.35 No.2 in 2012.

Yearbook on Journal of the Japan Society of Nursing Research 2016[awareness of proactive NPPV use].
These findings suggested that patients with chronic
respiratory failure undergoing home NPPV therapy start
to have awareness to use NPPV positively if nurses could
successfully help them to have <awareness of effectiveness>since they were hospitalized.

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Acknowledgements

We thank the subjects and the staff at Hospital A.

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This paper was published at “the Japan Society of Nursing Research” Vol.35 No.2 in 2012.