FEATURE

Effects of a 6-Month Nurse-Led Self-Management Programon Comprehensive Pulmonary Rehabilitation for Patientswith COPD Receiving Home Oxygen Therapy
Michiko Moriyama1, PhD, RN, Yae Takeshita2, PHN, MSN, RN, Yoshinori Haruta1, MD,
Noboru Hattori1, MD & Chidum E.Ezenwaka3, PhD, MPhil
1 Institute of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
2 Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
3 Faculty of Medical Sciences, The University of the West Indies, St Augustine, Trinidad and Tobago

Keywords

Abstract

ADL; COPD; home oxygen therapy; QOL;
self-management.
Correspondence
Michiko Moriyama, RN PhD, Institute of
Biomedical & Health Sciences, Hiroshima
University, Kasumi 1-2-3, Minami-ku,
Hiroshima-shi, Hiroshima 734-8553, Japan.
E-mail: morimich@hiroshima-u.ac.jp
Accepted June 03, 2013.
doi: 10.1002/rnj.119

Purpose: This study was to examine the effectiveness of a nurse-led 6-monthcomprehensive pulmonary rehabilitation program for stage IV chronic obstructive pulmonary disease patients receiving home oxygen therapy.
Design: A controlled clinical study was performed.
Methods: Face-to-face and telephone interviews were conducted with the intervention group, whereas conventional education was given to the control group.
Findings: Fifteen participants were analyzed in each group. There were no
improvements in physiological outcomes; however, the severity of dyspnea,
social activity, and walking distance significantly improved in the intervention
group, and consequently quality of life was improved. Three patients in theintervention group received treatment for cold-like-symptoms but did not
require hospitalization. However, five patients in the control group received
treatment for cold-like-symptoms and two required hospitalization.
Conclusions: The findings demonstrate that our program contributes topatients’ learning of self-management skills and significantly improves dyspnea,
social activity level, walking distance, and overall quality of life.

Introduction
A comprehensive pulmonary rehabilitation program isrequired to manage chronic obstructive pulmonary disease (COPD) so as to relieve symptoms, prevent diseaseprogression, improve exercise tolerance and health status,
prevent and treat complications and exacerbations andreduce mortality (Global Initiative for Chronic Obstructive Lung Disease, 2010). Nurses play central roles in promoting and implementing pulmonary rehabilitation
program in the community (Akinci & Olgun, 2011;
Sridhar, Taylar, Dawson, Roberts, & Partridge, 2008;
Zakrisson et al., 2011). It has been suggested that a successful pulmonary rehabilitation program should aim to provide a patient education which promotes self-management© 2013 Association of Rehabilitation Nurses
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(Carriei-Kohlman et al., 2005; Chavannes et al., 2009;
Tiep & Barnett, 2008); and subsequently prevent complications and exacerbations.
Review of the literature
It is important to note that the results of self-management education differ from study to study, and theefficacy of such education has not been well established.
For instance, there are several reports on self-management
programs that have resulted in reduced exacerbations
and hospitalizations of patients (Bourbeau et al., 2003;
Gadoury et al., 2005), improvement in patients’ qualityof life (Bourbeau et al., 2003; Koff, Jones, Cashman,
Voelkel, & Vandivier, 2009) and potential economic

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A Self-Management Program for COPD

benefits (Bourbeau et al., 2006). Arguably, these studies
have produced mixed results for pulmonary function
outcomes, long-term physiological effects, and mortality.
Indeed, systematic evaluation reviews have shown that
self-management education can potentially modify lifestyle, reduce symptoms, and improve healthcare utilization among COPD patients with no improvement inpulmonary function and varied effects on quality of lifeand hospitalization (Blackstock & Webster, 2007; Taylor
et al., 2005). A previous study using proactive integrated
care (PIC) and St George’s Respiratory Questionnaire(SGRQ) has demonstrated that the self-management educational intervention can improve early detection andtreatment of exacerbations in COPD patients (Koff et al.,2009). Additionally, a recent UK study which assessed
the effectiveness measured by quality of life (QOL) andcost effectiveness of a layperson-led theoretically driven
COPD self-management support program reported theprogram’s potential to meet the UK health criteria forcost effectiveness (Taylor et al., 2012). Thus, it is important in different populations to provide self-management
education for COPD patients using the SGRQ that is
becoming a reliable tool for measuring patient’s QOL(Al-Shair et al., 2012).
Therefore, this study aimed to improve overall QOL ofthe patients by reducing exacerbations and hospitalizationand improve pulmonary function and dyspnea using a
carefully designed nurse-led educational program developed and implemented for stage IV severe COPD patientson home oxygen therapy (HOT).
Development of self-management education program for
COPD patients
Self-management education is operationally defined inthis study, based on the works of Funnell et al. (2007)
and Moriyama et al. (2009), as an approach for supporting a process involving a patient’s understanding of
his/her disease through the establishment of a partnership between the patient and healthcare professionals.
Self-management education also includes provision of
support by healthcare professionals and the patients’families, provision of relevant information to thepatients, patients understanding of the basics of decision
making and the treatment regimen, appropriate management of a patient’s lifestyle and emotions, and thepatients’ sustenance of health management activities.
This study, which is based on the review of literatureand operational definition, aimed to improve overall

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QOL and strengthen the weak points of self-management, through reducing exacerbations and hospitalizations and improving pulmonary function and dyspnea
using a carefully designed nurse-led educational program
developed and implemented for stage IV, severe COPD
patients on HOT.
The study was based on the ethnographical researchmethod to identify when and how patients fail to acquireself-management skills and lose adherence before the program development. Through this research, we found thatpatients practiced incorrect breathing methods during
their activities of daily life (ADL). We learned thatpatients’ fear, shame, and hesitation in the use of oxygen
during activities such as bathing, sleeping, and activities
outside the home was due to a lack of knowledge, causing
a vicious cycle of inactivity resulting in social isolation,
altered mood status, muscle weakness, weight loss due tolack of appetite, and decreased pulmonary function.
Moreover, patients with stable condition visited non-specialist clinics, where no pulmonary rehabilitation/exercise
education was provided; therefore, patients did not practice at home.
In this study, other issues are addressed. In Japan,
although a Lung Information Needs Questionnaire program, a self-complete questionnaire that measures theinformation needs of patients with COPD, has beenreported (Watanabe et al., 2011), there is no report of acomprehensive COPD patient education program. Obstacles to the establishment of a COPD educational program include the following: (1) lack of an establishedstructure and process of patient education to enhanceself-management; therefore, there are no nurses with adequate and appropriate training; and (2) an ineffective
and fractured healthcare delivery system. Because many
patients visit non-specialists, there is little recognition for
the importance of patient education. Moreover, patient
education on COPD self-management is not included innational health insurance reimbursement program warranting that some physicians are reluctant to provide
education.
Therefore, to implement this research study, we set up
a disease management center for nurses to provide patient
education outside hospitals settings. A nurse-led self-management program involving the application of comprehensive
pulmonary rehabilitation by the participants themselves
was used, and goals for physiological outcomes were set.
This article examined the effectiveness of the nurse-led
program in terms of the acquisition of self-management
skills, physiological outcomes, and overall QOL.
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A Self-Management Program for COPD

Methods
Framework of the self-management educational programfor COPD patients
An outline of the educational program, the outcome indicators, and nurses’ collaboration with patients are shownin Figure 1. The focus of this program was the acquisition of self-management skills for the period of 6 months
using a predesigned interactive workbook, learning materials, and a daily journal for self-monitoring. Each patient
worked with a nurse and used the workbook to analyze
his/her own physiological data to understand his/her own
condition and to set long-term (purpose of life) andshort-term (lifestyle and behavior change) goals. The
patient also learned the basics in the management of signs
and symptoms such as dyspnea, color of sputum, andedema and self-management of skills and behavior as
listed in Figure 1. Subsequently, the patient practiced pulmonary rehabilitation, gargling and hand washing, effective coughing (sputum elimination techniques), andexercise training on a daily basis and recorded them inthe daily journal. Self-monitoring was performed forpulse rate, SpO2 (resting and during exercise), bodyweight, symptoms of common cold, shortness of breath,color of sputum, cigarette smoking, amount of exercise,number of steps taken/day, duration of oxygen use (inhour), and amount of social activity. These data were also
recorded in the daily journal. The patients set behavioral
step-by-step goals, such as “a walk to the mailbox athome everyday” for the first month, then “a walk aroundhis/her house everyday” for the second month. For pulmonary rehabilitation activities such as diet, effective
coughing, and smoking cessation were reported to thenurse on a monthly basis. The physician and nurse
checked the journal monthly and provided positive reinforcement and education as necessary.
Two nurses who participated in this program weretrained on self-management education and motivational
interviewing techniques for 2 weeks. All processes of the
program were led by the nurses, who taught basic knowledge and skills to patients, set monthly goals, evaluatedthe results with patients, and provided feedback topatients.
The primary endpoint of the study was an improvement in overall QOL. The program began with thepatient learning self-management skills. Thereafter, thepatient would execute the required treatment regimen
every day and record his or her activities, and we
hypothesized that this action would result in an increasein practical adherence behavior, improve in dyspnea
and physiological outcomes, and then improve ADL

Program Ɵtle "Program for Improving Shortness-of-Breath"<1st & 2nd Ɵme> Face-to-face educaƟon
ParƟcipant establishes partnerships with his/her nurseParƟcipant learns how to use supports (ex.family)ParƟcipant analyzes his/her behavior and set goals
࡮Analyzes laboratory data & physical condiƟons
࡮Sets long-term (purpose of life) and short-term (6 months)
goals
࡮Starts learning process using a workbook & materials
࡮Learns how to carry out self-monitoring & record data inthe daily journal

㧨Monthly㧪ParƟcipants report their data by mail or telephone,and nurses evaluate them and advise them
Indicator evaluaƟon by the nurse
feedback‫࡮ޓ‬Physiological data : Weight, Blood pressure, Pulse rate‫࡮ޓ‬Accomplishment & performance level‫࡮ޓ‬Observa on of compliance of scheduled physician's visits,
number of emergency visits/unscheduled hospital visits/
hospitaliza on

Contents in the workbook
EducaƟonal contents
Understanding COPD, symptom management, self-analysis of physical condi on (understanding oflaboratory data), comprehensive pulmonary rehabilita on (oxygen therapy, breathing, strategies in dailyliving to prevent shortness of breath, exercise, eﬀec ve coughing , diet, infec on control, cessa on ofsmoking), remaking of daily schedule, learning countermeasures for emergencies & disasters (including
panic control, ming of consulta on with the physician).
Learning materials㧦Pulse oximeter, pedometer, flu er (sputum elimina on & pulmonary training device),rubber band for exercise, medicine case for weekly dose, straw for pulmonary training, mask.
࡮Learning decision-making and problem-solving skills
EducaƟonal contents for Family.
Need for collabora on, countermeasures for emergencies & disaster, ming of consulta on with thephysician, support of eﬀec ve coughing
Self-monitoring : ParƟcipant completes the daily journal, his/her physician & nurse evaluate it࡮Monthly goal se ngs by par cipants㧔Pulmonary rehabilita on, diet, tabaco use㧕
࡮Daily monitoring㧔pulse rate, SpO2 (res ng and during exercise), body weight, symptoms of common
cold, shortness of breath, color of sputum, cigare e smoking, amount of exercise, number of steps
taken/day, hours of oxygen use, amount of social ac vity)࡮Report performance rates to his/her nurse & physician, receive posi ve feedback
࡮Set new goals
࡮Discuss about obstacles to a ain goals, experss feelings

Improvement of monthly implementaƟon rate
Improvement of dyspnea and physiological data
Improvement of acƟvity of daily living and social acƟvity
Improvement of quality of life

Figure 1 Conceptual framework of this study: an outline of the program and the outcome indicators.

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A Self-Management Program for COPD

and social activities with a resultant enhancement of
QOL.
Study period
The participants were enrolled from May to December
2008, and the program was implemented from May 2008
to June 2009.
Participants
The participants were stage IV COPD outpatients undergoing HOT, who had no physical or cognitive impairment that would interfere with their participation in the
program. All participants provided informed consent.
Participants were eligible for the study regardless of age,sex or treatment other than HOT, although those withcongestive heart failure (CHF) with New York Heart
Association functional classification Class II to IV were
excluded as exercise for those patients often was not
appropriate and it is difficult to distinguish whether
symptoms were produced by CHF or COPD.
Study design
The study was a nonrandomized controlled trial. As randomization was not considered an appropriate approach,participants in the control group were recruited from different medical facilities than those in the intervention
group.
Procedure
After a voluntary consent was obtained, evaluation questionnaires were administered and physiological data werecollected from the participants. Data for assessment were
subsequently collected at the scheduled times.
Intervention GroupThe nurse made a home visit twice in the enrolled
month for a face-to-face individualized educational demonstration using our research devices tailored forcomprehensive pulmonary rehabilitation activity practices. The daily journal is received monthly by mail fromthe second month. The nurse evaluated the data andmade a telephone call once every month to provide
advice for better practice. The participant was allowed tocall the nurse if they have any questions, concerns orchallenges.

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M. Moriyama et al.

Control GroupThe participants were asked to visit physician’s clinics
monthly as required for consultation. Self-reported data
were collected on the enrollment day (baseline) and at
3 and 6 months consultation days after starting thestudy. Physiological data were obtained from thepatients’ medical records. All participants in this group
had received education on pulmonary rehabilitation
once by medical staff at the clinics when they started
HOT; however, no further education was received afterthat.
Evaluation indicators and points
Indicators for QOL (St. George’s Respiratory Questionnaire; SGRQ) (Jones, Quirk, Baveystock, & Littlejohns,
1992), ADL (Nagasaki University Respiratory ADL Questionnaire; NRADL) (Matsumoto, Tanaka, Matsuki, Kitagawa, & Senjyu, 2006; Matsumoto et al., 2008), andseverity of breathlessness (British Medical Research Council; MRC) (Bestall et al., 1999; Global Initiative for
Chronic Obstructive Lung Disease, 2010) were evaluated.
NRADL is the activities of daily living evaluation scale
developed specifically for chronic respiratory disease
patients with 10 enlisted activities such as eating, toileting, grooming, bathing, dressing, movement in a room/
floor/house/stairs, and going out/shopping. These are
evaluated from 0 to 3 points from three aspects of speedof movement, shortness of breath, and oxygen flow rate;and cumulative walking distance from 0 to 10 points areadded. The score ranged from 0 to 100 in ascendingorder of improvement.
Social activity was evaluated in terms of range (howfar they go out) and frequency (times of going out fromhome per week). Goal attainment rate was measured bothsubjectively by the participant and objectively from thedaily journal data. Physiological data were obtained forbody weight, blood pressure (systolic and diastolic), pulse
rate, SpO2 level and 24-h SpO2 (under oxygen therapy),
respiratory function (forced expiratory volume in 1 s[FEV1]), FEV1 percent (FEV1%), and blood gas analysis(PaO2 and PaCO2 under oxygen therapy). The 6-minwalk test (6MWT) could not be practiced because of a lackof space at clinics and hospitals. For all these items, data
were collected at baseline and at 3 and 6 months of theintervention. Health economic data regarding the numberof times each participant made an emergency/unscheduled
hospital visit and the number of hospitalizations were alsocollected.
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Statistical analysis
Baseline data for the intervention and control groups
were compared by v2 test, t-test, or Mann–Whitney
U-test after normality was verified. For evaluation of
the indicators, two-way repeated-measures ANOVA wasused for the physiological data and the respective scales
for chronological comparison after verification of datanormality. One-way repeated-measures ANOVA was
conducted for chronological comparison of data in theintervention group. Friedman’s test was also performed
for the chronological comparison of each group for datathat was not normally distributed. Two-tailed p values
were used and the significance level was set at < 5%.
Ethical considerations
The study was approved by the Ethical Committee of the
University. The intent of the study was explained in detailto each participant and informed voluntary consent was
obtained.
Results
Participation and baseline characteristics and thecomparison between the two groups
Three of 18 participants in the intervention group andtwo of 17 participants in the control group withdrew
from the study. In the intervention group, one participant
had difficulty completing the journal, one died of an aortic aneurysm rupture, and one was admitted to hospitalfor treatment of drug-induced acute heart failure. In thecontrol group, two withdrew due to failure to complete
the journal. Therefore, 15 patients in each group were
included in the analysis. The program completion rate
was 83.0% in the intervention group.
There were no significant differences in the baselinecharacteristics of the intervention and control groups(Table 1). SGRQ scores showed no significant difference
between the groups (Table 2). NRADL scores indicated asignificant difference only in shortness of breath at baseline (p = .01), with milder symptoms in the control
group than in the intervention group (Table 3 a and b).
The range and frequency of social activities did not differ
between the groups. For physiological data, the 24-h
SpO2 value (p = .05) and FEV1% (p = .05) were lower in
the intervention group than in the control group, butthere were no other significant differences (Table 4).

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Table 1 Baseline characteristics of the participants and acomparison between the two groups
Intervention
Group (n = 15)

ControlGroup (n = 15)

p-value

74.7  9.8

72.0  8.3

0.42a

12/3

12/3

1.00b

0.3  0.60

0

0.10a

14/1

15/0

1.00b

3/12

5/10

0.68b

Age (years)
Mean  SD
Sex(Male/Female)Emergency/unscheduled
hospital visit(times)Hospitalization(None/Yes)
Smoking(Yes/No)t-test.
Fisher’s exact test.

ab

Self-management behavior of participants
The performance in self-management behavior definedin the program was calculated for the intervention
group based on the daily journal using the formula:(number of days with good behavioral practice/numberof days in the month) 9 100. The number of cigarettes
smoked per day was examined to obtain the monthly
average. All behaviors except cigarette use significantly
increased after the intervention. During the program,the average (SD) rates of performance of behavior
were 96.2  8.7% for pulmonary exercise, 96.0  14.9%
for gargling and hand washing, 65.9  41.6% foreffective coughing, 64.8  25.4% for exercise training,
99.6  1.5% for weight measuring, and 99.4  2.3%
for medication intake. The rates for performance ofeach behavior at the end of the program (6 months
from start) were 97.3  6.9%, 99.8  0.8%, 73.5 
40.4%, 68.7  26.1%, 99.8  0.8%, and 98.8  4.7%,
respectively.
Four participants did not perform effective coughing
as they had no sputum, leading to a large deviation in
the data. Variation in exercise training was observed
depending on the severity of dyspnea and co-morbidities.
Three participants in the intervention group and five inthe control group used tobacco at baseline, and one in
the intervention group and four in the control group
stopped smoking after the start of the study. Only twoparticipants in the intervention group and one in the5A Self-Management Program for COPD

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Table 2 Chronological changes in QOL (St. George’s Respiratory Questionnaire: SGRQ) Scores between two groups

Intervention Group (n = 15)

Control Group (n = 15)

Two-way repeated-measures
ANOVA(upper: F-value; lower: p-value)

Baseline

3 months

6 months

Baseline

3 months

6 months

Interaction

BetweenGroupsWithinGroupsTotal

54.2 (12.4)

44.9 (14.3)

50.9 (13.1)

56.3 (12.8)

55.7 (12.4)

55.3 (14.3)

Symptoms

51.7 (21.4)

48.9 (19.9)

49.1 (21.6)

53.4 (15.5)

57.9 (21.6)

55.6 (20.3)

Activity

76.8 (7.4)

73.8 (9.2)

73.3 (12.0)

75.3 (13.1)

75.5 (11.9)

78.1 (14.1)

Impacts

43.5 (19.5)

36.0 (16.8)

38.9 (19.3)

46.3 (15.5)

43.7 (14.4)

42.2 (16.1)

2.095
0.133
0.625
0.539
1.187
0.313
0.765
0.432

1.929
0.176
0.835
0.369
0.227
0.637
0.643
0.429

2.533
0.088
0.055
0.947
0.271
0.764
3.103
0.071

SGRQ

Values denote mean (SD).
Baseline comparison between two groups: total p = .66, symptoms p = .81, activity p = .72, impacts p = .68.
The lower the score, the higher the QOL.

Table 3(a) Chronological comparison of ADL (The Nagasaki University Respiratory ADL Questionnaire: NRADL) Scores between
two groups

Intervention Group (n = 15)

Control Group (n = 14)

Two-way repeated-measures
ANOVA(upper: F-value; lower: p-value)

Baseline

3 months

6 months

Baseline

3 months

6 months

Interaction

BetweenGroupsWithinGroupsTotal

51.7 (14.0)

54.1 (17.7)

56.2 (21.6)

56.2 (23.2)

59.6 (20.8)

60.7 (22.2)

Speed ofmovement
Oxygen flow

17.3 (3.1)

17.4 (4.6)

19.0 (5.7)

18.9 (6.6)

20.4 (5.9)

20.2 (6.4)

18.6 (10.0)

16.9 (11.5)

16.4 (12.2)

17.3 (11.5)

17.9 (12.2)

19.6 (11.8)

0.033
0.968
0.657
0.523
2.843
0.089

0.466
0.501
1.154
0.292
0.052
0.821

2.294
0.111
1.597
0.212
0.274
0.675

ADL

Values denote mean (SD).
Baseline comparison: total p = .54, Speed of Movement p = .44, Oxygen Flow p = .74.
The higher the score, the higher the ADL.
The higher the score, the lower the oxygen flow.

control group continued smoking after the program. It
would appear that some of the patients in the control
group made extraordinary effort to stop smoking evenwhen they had no intervention.
QOL and ADL
There were no significant changes in SGRQ scores overtime or between the groups. The average total score and all

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subscales scores were reduced (improved QOL) in theintervention group. In contrast, there were no changes inthese scores in the control group (Table 2). Similarly, there
were no significant changes in total NRADL score and thescore for speed of movement over time or between thegroups (Table 3a). There was no significant difference inoxygen flow rate between the groups; however, the score
decreased (increased flow rate) in the intervention groupand increased (decreased flow rate) in the control group.
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Table 3(b) Chronological changes in the ADL (NRADL)
Intervention Group

Shortness of breath
Cumulative walking distanceControl GroupnBaseline

3 months

6 months

p-valuenBaseline

3 months

6 months

p-value15
15

13.3(4.1)
2.0(0.7)

16.1(4.4)
2.7(1.0)

15.6(5.4)
3.2(1.0)

0.230<0.00114

19.5(5.8)
2.1(1.2)

20.1(5.1)
1.9(0.8)

19.4(5.8)
2.0(1.0)

0.923
0.861

Values denote mean (SD).
Shortness of breath: One-way repeated ANOVA, as baseline difference was significant p = .01, the higher the score, the lighter
the shortness of breath.
Cumulative walking distance: Friedman’s test. Baseline comparison p = .65.
Multiple comparison (Bonferroni correction): BL-3M (p = .005), BL-6M (p = .002), 3M-6M (p = .052).
Cumurative walking distance (curriculated by not score but by rank): 1 = within 50 m, 2 = 50–200 m, 3 = 200–500 m,
4 = 500 m–1 km, 5 = more than 1 km.

These results suggest that participants in the intervention
group who did not follow the treatment regimen for oxygen use came to comply with it and that the nurses
reported the status of the patients accurately to physicians,
with a resultant increase in oxygen flow rate.
Severity of shortness of breath (Table 3b) was significantly higher in the intervention group at baseline(p = .01) which improved after our intervention. On theother hand no such changes were observed in the control
group. Cumulative walking distance (Table 3b) significantly increased in the intervention group (p < .001). In
contrast, no changes were observed in the control group.
As significant difference was observed in intervention
group, multiple comparison using Bonferroni correction
was conducted between three points. The result showedthat the average walking distance increased significantly
from baseline to 3 months (p = .005) and to 6 months(p = .002) after the start of the program.
Social activities
The frequency and range of social activities were significantly extended only in the intervention group (p = .011
and p = .041, respectively; Figure 2a,b). A remarkable
improvement was noticeable in the intervention groupwith an increase in the frequency and range of social
activities in this group despite the greater severity ofshortness of breath at baseline compared with the control
group. Multiple comparison of time-course data for thefrequency and range of social activities showed a significant increase only in the intervention group after the startof the program relative to baseline with a significant difference in frequency (v2 = 13.5 > 5.991) and range(v2 = 9.6 > 5.991) of social activities after 3 and6 months, respectively.
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Severity of shortness of breath
Changes in the self-reported severity of dyspnea (MRC)
are shown in Figure 3. These data significantly improved
over time in the intervention group (p = .011), whereas
participants in the control group complained serious subjective symptoms of dyspnea throughout the study. Multiple comparison showed improved severity of dyspnea in
the intervention group after 3 months (v2 = 7.756 >
5.991) and 6 months (v2 = 17.566 > 5.991) relative tobaseline.
Physiological data
There was a trend toward decrease in systolic blood pressure in the intervention group, but not in the control
group (p = .061, Table 4). There was no significant
change in pulse rate, but a slight decrease in the intervention group and a slight increase in the control group weredetected at the end of the study. The 24-h oxygen saturation measurement showed accelerated stabilization ofpulse rate after exercise in the intervention group as compared with the control group. Vital capacity (FEV1,
FEV1%) were only measured in a few participants, asmany participants in both groups were reluctant toundergo the pulmonary function test due to pain. For
this reason, the number of participants in the control
group was insufficient to compare PaO2 and PaCO2.
Consultation and prevention of exacerbations
Participants in both groups received regular consultationfrom a physician (hospital visits) throughout the study.
Influenza vaccination was completed in 86.7% of theintervention group and 62.5% of the control group by7

8

68.6 (10.9)
90.9 (14.2)

15

15

15

12

15

15

15

SpO2 (%)

24-h mean
SpO2

Vital capacity (L)

FEV1

FEV1.0%---92.5 (3.9)

96.3 (1.4)

85.6 (15.7)

70.6 (11.7)

125.4 (19.3)

51.5 (12.1)

3 months

42.00 (12.53)

0.79 (0.38)

2.16 (0.85)

93.3 (3.0)

95.9 (1.6)

86.7 (14.4)

70.1 (9.8)

120.3 (21.1)

51.4 (11.7)

6 months

6

6

6

14

15

14

13

13

12

n

61.25 (20.51)

0.79 (0.31)

1.78 (0.84)

95.8 (2.0)

96.5 (2.0)

86.9 (17.7)

71.1 (12.2)

122.5 (14.7)

48.3 (9.4)

Baseline---

96.0 (1.8)

96.2 (1.7)

87.3 (15.2)

71.4 (10.4)

127.9 (18.3)

49.1 (10.3)

3 months

Control Group

56.47 (10.91)

0.92 (0.62)

1.87 (0.87)

95.1 (3.6)

95.3 (3.4)

87.2 (14.1)

73.2 (10.6)

129.9 (12.4)

49.5 (10.4)

6 months

BetweenGroupsWithinGroups

1.796
0.305
3.315
0.185
0.586
0.057
2.958
0.150
0.156
0.061
0.702
0.856
0.146
0.441
0.327
0.865
0.513
0.723
0.824
0.015
0.591
0.444
0.903
0.557
2.067
0.518
0.683
0.154
0.478
0.455
Intervention
group(repeated
ANOVA) p = .404
Control group(repeated ANOVA)
p = .536
0.234
0.672
0.190
0.634
0.423
0.668
2.106
0.089
1.464
0.163
0.769
0.241
Intervention
group(t-test)p = .21
Control group (t-test) p = .44

Interaction

Two-way repeated-measures
ANOVA(upper: F-value; lower: P-value)

Values denote mean (SD).
FEV1.0%: forced expiratory volume 1.0(s) %.
Data were taken by physicians on the visit day.
Baseline comparison: Body weight p = .50, Systolic blood pressure p = .39, Diastolic blood pressure p = .58, Pulse rate p = .51, SpO2 p = .09, 24-h SpO2 p = .05, Vital
Capacity p = .38, FEV1 p = .91. FEV1.0% p = .05.
24-h SpO2: significant difference was observed in baseline, One-way repeated ANOVA was calculated in each group.
FEV1.0%: significant difference was observed in baseline, t-test was calculated in each group
PaO2 & PaCO2 were taken only in two participants, therefore, it is not listed above.

46.74 (10.74)

0.81 (0.36)

2.16 (0.90)

93.4 (3.6)

94.7 (3.4)

128.0 (17.7)

15

Systolic bloodpressure (mmHg)
Diastolic bloodpressure (mmHg)
Pulse rate (times/min)

51.2 (12.0)

15

Baseline

Body weight (kg)nIntervention Group

Table 4 Chronological changes in the physiological indicators between two groups

A Self-Management Program for COPD
M. Moriyama et al.

© 2013 Association of Rehabilitation Nurses
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M. Moriyama et al.

A Self-Management Program for COPD

the control group received treatment for pneumonia,
dyspnea, and acute aggravation eight times during thestudy, and two required hospitalization for treatment of
acutely exacerbated pneumonia.

Key Practice Points
 Self-management education for COPD patients improves
patients’ perception of dyspnea, social functioning, andoverall QOL.
 Self-management education for COPD patients prevents
their hospitalization.

Discussion

 It is important for rehabilitation nurses to acquire a self-

Effectiveness of the program

management education skill.
 Self-management education should be included in the

The objectives of our management program for COPD
patients were to support comprehensive pulmonary rehabilitation at home, to encourage the acquisition of selfmanagement skills and modification of lifestyle behavior,and to prevent deterioration of pulmonary function withthe aim of improving the QOL. The results did not show
significant improvement in physiological data, except systolic blood pressure, but it did show an improvement in
the severity of dyspnea, a significant increase in the frequency and range of social activities, and a significant

comprehensive pulmonary rehabilitation program.

the end of the program. Symptoms of common cold wereobserved in both groups with no significant differences in
the rates of these symptoms between the groups. Threeparticipants in the intervention group made eight
unscheduled hospital visits for the treatment of common
cold associated with COPD during the study period, but
none were hospitalized. However, all five participants in
(a)

16

14

14

12
(# of par cipants)

Friedman's test p=0.867

Friedman's test p=0.011

16

8

2

6

3

10

16

6
2

4

4

2

2

2

0
Baseline

10
3 month1
0
6 month0

Friedman's test p=0.041

1
1

2

Baseline

3 month12(# of par cipants)

baseline comparison p=0.53

10

10
13

14

6

1
6 monthFriedman's test p=0.956

16

12

n=14
8

8

10
went out by transporta on

8went out a li le far on foot

6

4

2

4

2

2
1
Baseline

2

0

2

3

Control Group (n=15)

14

8

3

went out almost everyday
went out 4-5 mes a week
went out 2-3 mes a week
went out once a week
do not go out at all

1

2

3
2

14

10

8

8

Intervention Group (n=15)
(b)

8

10

2

4

0

8
10

10

2

12

6

2
3 month1
6 monthIntervention Group (n=15)

0

6

1

4

3
1

2

1

Baseline

3 month

6 monthwent shopping near bygardening levelbaseline comparison p=0.46

Control Group (n=15)

Figure 2 (a) Range of social activity: chronological change. (b) Frequency of social activity: chronological change.

© 2013 Association of Rehabilitation Nurses
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9

A Self-Management Program for COPD

161(# of participants)

12

5

Baseline

12

7

8
6

2

3 months

6

3
3

6
4

2
3

14
6

10

4

4

0

1

11

6

2

1

6

10
8

Control Group (n=15)Intervention Group (n=15)

16
14

M. Moriyama et al.

2

2

1

0

6 months

Friedman's test p=0.011

3

6

2

4

4

5
4
3
2
1
0

Baseline comparison p=0.27

1

Baseline 3 months 6 months
Friedman's test p=1.000

Figure 3 Severity of shortness of breath (MRC score): chronological change.

increase in total walking distance in ADL in those who
participated in the program. These participants showed ahigh rate of adherence to the treatment regimen andlearned breathing methods based on respiratory training.
This led to an increase in SGRQ score and an improvement in QOL at the overall living level. One significant
success of this program is that two participants in thecontrol group were admitted to the hospital for treatmentof pneumonia, whereas no participants in the intervention group were hospitalized during the winter season
even though three had common colds. In addition to
respiratory training, development of self-management
behavior for prevention of infections, such as effective
coughing, gargling and hand washing contributed tobetter outcomes.
Although a previous study suggested that a nurse-led
educational intervention had less effect on pulmonary
function as compared to physiotherapy and medicationbased intervention (Taylor et al., 2005), the findings ofour study showed that the program can assist in preventing patients from withdrawing from the society, improving subjective symptoms, and reduce patients
hospitalization and exacerbations of symptoms in COPD
patients at stage IV. The results of 24-h oxygen saturation
measurements as an indicator of physiological improvement showed a trend toward restoration of the pulse rates
of patients in the program after exercise regimen. This
trend in pulse rate restoration is likely to be significant ina study with larger sample size.
Several participants provided positive comments during the study, including “I found that my life was worth
living through this program,” and “I was glad that thenurse checked and assessed my outcomes.” These positive
feelings may be due to increased self-confidence through10

the acquisition of knowledge, improved achievement andextension of social activities. Thus, the goals of ourprogram were attained in terms of overall QOL. To
observe physiological effects, more participants, a longer
observation period and more pulmonary function test
results are needed, but as discussed in the limitations, themedical care system in Japan is not sufficiently equipped
for this purpose.
Significance of this program
For stage IV COPD patients, pulmonary function recovery
is difficult and treatment goals shift over time to palliativecare. In this situation, improvement and expansion ofsocial activity, finding a meaning to life and a sense of selfworth are important. When the study began, the daily
activities of many patients were limited to their homes. The
program subsequently encouraged them to walk to theiroutside mailboxes to collect newspapers and letters, to walkin the garden and to walk around their houses. These specific activities gradually increased their overall activity levels. Consequently, some participants found greater
meaning to their life, such as escorting schoolchildren for
traffic safety. Additionally, using the study workbook, theimportance of oxygen use especially during activity andsleeping were reinforced. Thus, the patients were relievedof their perceived social stigma and misconception regarding the use of oxygen. In our experience, the approach
employed in the current program was effective for the participants given that social stigma is an important issue anda major challenge for patients with chronic illness (Saylor,
Yoder, & Mann, 2002). Indeed, in this study, nurses’ support to relief the patients of this perceived stigma helped
them to make a tremendous progress.
© 2013 Association of Rehabilitation Nurses
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M. Moriyama et al.

Limitations and future suggestions: feasibility of
program implementation
COPD patients often visit various medical facilities andthe number of COPD patients per medical facility isoften insufficient to conduct a study, which makes
recruitment of participants difficult. Therefore, conducting a randomized trial was not feasible. In the future, ahome-visiting nursing system may be available to provide this program with personnel from the HOT devicecompanies. Given that in Japan there is the policy, inwhich the companies should inspect HOT devices periodically, our program will be of assistance in continuing
the service within the range of available medical service
fees.
Pulmonary function could not be assessed at many
clinics because a spirometer or oxygen saturation instrument was not available, space was insufficient to conduct
the 6MWT, and many patients with dyspnea refused the
spirometry test. Thus, the use of alternative indicators
including QOL assessment of social activities, 24-h oxygen saturation level in daily life, and the rate of development of complications was required. To conduct clinical
trials in Japan, these obstacles have to be overcome.

Implications for rehabilitation nursing
Self-management education for COPD patients improves
patients’ perception of dyspnea, social functioning, overall
QOL, and prevents hospitalization. Therefore, it is important for rehabilitation nurses to acquire this skill. Also,
self-management education should be included in thecomprehensive pulmonary rehabilitation program.

Acknowledgments
This study was funded by TechnoView Ltd. and ADIC
Co. Ltd. The author greatly appreciates the kind cooperation of the disease management nurses, Mrs. Hidemi Daikoku, RN, and Mrs. Sachiyo Hirai, RN, and is indebted
to the patients, the physicians who supported and participated in this study and to the Respirology medical teamof Hiroshima University.

References
Akinci, A.C., & Olgun, N. (2011). The effectiveness of nurseled, home-based pulmonary rehabilitation in patients with
COPD in Turkey. Rehabilitation Nursing, 36, 159–165.
© 2013 Association of Rehabilitation Nurses
Rehabilitation Nursing 2013, 0, 1–12

A Self-Management Program for COPD

Al-Shair, K., Atherton, G.T., Kennedy, D., Powell, G.,
Denning, D.W., & Caress, A. (2012). Validity and reliabilityof the St. George’s Respiratory Questionnaire in assessing
health status in patients with chronic pulmonary
aspergillosis. Chest, doi: 10.1378/chest.12-0014. [Epub aheadof print].
Bestall, J.C., Paul, E.A., Garrod, R., Garnham, R., Jones, P.W.,& Wedzicha, J.A. (1999). Usefulness of the Medical ResearchCouncil (MRC) dyspnea scale as a measure of disability inpatients with chronic obstructive pulmonary disease.
Thorax, 54, 5816.
Blackstock, F., & Webster, K.E. (2007). Disease-specifichealth education for COPD: a systematic review ofchanges in health outcomes. Health Education Research,
22, 703–717.
Bourbeau, J., Collet, J.P., Schwartzman, K., Ducruet, T., Nault,
D., & Bradley, C. (2006). Economic benefits of selfmanagement education in COPD. Chest, 130, 1704–1711.
Bourbeau, J., Julien, M., Maltais, F., Rouleau, M., Beaupre, A.,
Begin, R., et al. (2003). Reduction of hospital utilization inpatients with chronic obstructive pulmonary disease: adisease-specific self-management intervention. Archives ofInternal Medicine, 163, 585–591.
Carriei-Kohlman, V., Nguyen, H.Q., Donesky-Cuenco, D.,
Demir-Deviren, S., Neuhaus, J., & Stulbarg, M.S. (2005).
Impact of brief or extended exercise training on the benefitof a dyspnea self-management program in COPD. Journal of
Cardiopulmonary Rehabilitation, 25, 286–287.
Chavannes, N.H., Grijsen, M., van den Akker, M., Schepers,
H., Nijdam, M., Tiep, B., et al. (2009). Integrated disease
management improves one-year quality of life in primarycare COPD patients: a controlled clinical trial. Primary Care
Respiratory Journal, 18, 171–176.
Funnell, M.M., Brown, T.L., Childs, B.P., Haas, L.B., Hosey,
G.M., Jensen, B., et al. (2007). National standards fordiabetes self-management education. The Diabetes Educator,
33, 599–614.
Gadoury, M.A., Schwartzman, K., Rouleau, M., Maltais, F.,
Julien, M., Beaupre, A., et al. (2005). Self-management
reduces both short- and long-term hospitalization in COPD.
European Respiratory Journal, 26, 853–857.
Global Initiative for Chronic Obstructive Lung Disease. (2010).
Global Strategy for the Diagnosis, Management, andPrevention of Chronic Obstructive Lung Disease. RetrievedApril 15, 2011, from http://www.goldcopd.org/uploads/
users/files/GOLDReport_April112011.pdf.
Jones, P.W., Quirk, F.H., Baveystock, C.M., & Littlejohns, P.
(1992). A self-complete measure of health status for chronic
airflow limitation: the St. George’s Respiratory
Questionnaire. American Review of Respiratory Disease, 145,
1321–1327.

11

A Self-Management Program for COPD

Koff, P.B., Jones, R.H., Cashman, J.M., Voelkel, N.F., &Vandivier, R.W. (2009). Proactive integrated care improves
quality of life in patients with COPD. European Respiratory
Journal, 33, 1031–1038.
Matsumoto, T., Tanaka, T., Matsuki, Y., Kinoshita, M.,
Sumimoto, K., & Senjyu, H. (2008). The Nagasaki
University Respiratory ADL questionnaire: NRADL no
hannousei no kentou. [The Nagasaki University Respiratory
ADL questionnaire: discussion on responsibility of NRADL.]
Journal of Japan Society for Respiratory Care, 18, 227–230.
Matsumoto, T., Tanaka, T., Matsuki, Y., Kitagawa, C., &Senjyu, H. (2006). Senjyura no ADL hyoukahyou ni taisuru
shinraisei no kentou. [Discussion on reliability of Senjyu’s
Respiratory ADL questionnaire.] Journal of Japan Society for
Respiratory Care, 15, 612–616.
Moriyama, M., Nakano, M., Kuroe, Y., Nin, K., Niitani, M.,& Nakaya, T. (2009). Efficacy of a self-management
education program for people with type 2 diabetes: resultsof a 12 month trial. Japan Journal of Nursing Science, 6,
51–63.
Saylor, C., Yoder, M., & Mann, R.J. (2002). Stigma. In I.M.
Lubkin, & P.D. Larsen (Eds.), Chronic illness: impact andinterventions 5th ed. (pp. 53–76). Boston: Jones andBartlett.
Sridhar, M., Taylar, R., Dawson, S., Roberts, N.J., & Partridge,
M.R. (2008). A nurse led intermediate care package inpatients who have been hospitalized with an acute12

M. Moriyama et al.

exacerbation of chronic obstructive pulmonary disease.
Thorax, 63, 194–200.
Taylor, S.J.C., Candy, B., Bryar, R.M., Ramsay, J., Vrijhoef,
H.J., Esmond, G., et al. (2005). Effectiveness of innovations
in nurse led chronic disease management for patients withchronic obstructive pulmonary disease: systematic review of
evidence. BMJ, 331, 485. doi:10.1136/bmj.38512.664167.8F.
Taylor, S.J., Sohanpal, R., Bremner, S.A., Devine, A., McDaid,
D., Fernandez, J.L., et al. (2012). Self-management support
for moderate-to-severe chronic obstructive pulmonary
disease: a pilot randomised controlled trial. British Journal of
General Practice. 2012;62(603):687–695. doi: 10.3399/
bjgp12X656829.
Tiep, B.L., & Barnett, M.C. (2008). Disease management forchronic obstructive pulmonary disease: a clinical strategy.
Disease Management and Health Outcomes, 16, 305–313.
Watanabe, R., Motegi, T., Yamada, K., Yamada, K., Ishii, T.,
Jones, R.C.M., et al. (2011). Efficient integrated educationfor older patients with chronic obstructive pulmonary
disease using the Lung Information Needs Questionnaire.
Geriatrics and Gerontology International, 11, 422–430.
Zakrisson, A.B., Engfeldt, P., Hagglund, D., Odencrants, S.,
Hasselgren, M., Arne, M., et al. (2011). Nurse-led
multidisciplinary programme for patients with COPD in
primary health care: a controlled trial. Primary Care
Respiratory Journal, 20, 427–433.

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Rehabilitation Nursing 2013, 0, 1–12