Received: 31 July 2019

| Revised: 14 November 2019

| Accepted: 20 November 2019

DOI: 10.1111/crj.13112

ORIGINAL ARTICLE

The effect of a nurse-led self-management program on outcomes

of patients with chronic obstructive pulmonary disease

Lian Hong Wang1,2 | Yan Zhao2 | Ling Yun Chen2 | Li Zhang1 | Yong Mei Zhang2

1
Nursing department of Affiliated Hospital
of Zunyi Medical University, ZunYi, China
Abstract
2
Nursing department of ZunYi Medical Purpose: To examine the effectiveness of a nurse-led self-management program on
University, ZunYi, China outcomes of patients with chronic obstructive pulmonary disease (COPD).
Design: A randomized controlled, single-blind trial, carried out from October 2017
Correspondence
Lian Hong Wang, Nursing department to December 2018, included 154 participants admitted with COPD to the Affiliated
of Affiliated Hospital of Zunyi Medical Hospital of Zunyi Medical University in Guizhou, (randomized into intervention
University, ZunYi, China.
(n = 77) and control groups (n = 77)).
Email: [email protected]
Materials and Methods: Participants in the intervention group underwent a nurse-
Funding information
led self-management program in addition to routine care, and participants of the
The work described in this paper was
supported by a grant from the Education control group received only routine care. The main outcome measures were COPD-
Department of Guizhou Province, China related readmission and emergency department visits, the 6-minute walk distance
(Grant No. Qian Jiao He KY [2016] 205).
(6MWD) test for measurement of exercise capacity, the St George Respiratory
Questionnaire (SGRQ) for measurement of health-related quality of life, and the
COPD Transitional Care Patient Satisfaction Questionnaire (CTCPSQ) for measure-
ment of satisfaction. Data collection was conducted at baseline (T1) and after 3 (T2),
6 (T3) and 12 mo (T4).
Findings
Compared to the control group, participants in the intervention group showed sig-
nificantly fewer COPD-related hospital admissions (P = 0.03) and emergency de-
partment visits (P = 0.001) and higher total CTCPSQ scores (P = 0.001) at 12 mo.
Meanwhile, analysis of variance showed a significantly greater improvement in ex-
ercise capacity and health status over time in the nurse-led program group than in the
control group, P < 0.001.
Conclusions: This study demonstrated that the nurse-led self-management program
was effective in decreasing hospital readmissions and emergency department visits
and improving exercise capacity, health-related quality of life and satisfaction for
patients with COPD.

KEYWORDS
chronic obstructive pulmonary disease, randomized control trial, self-management

148 | © 2019 John Wiley & Sons Ltd wileyonlinelibrary.com/journal/crj Clin Respir J. 2020;14:148–157.
WANG et al.   
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1 | IN T RO D U C T IO N a randomized clinical trial of COPD patients who had been

hospitalized for acute exacerbation to evaluate the impact of a
Chronic obstructive pulmonary disease (COPD), a chronic nurse-led self-management program on COPD-related hospital
progressive disease that admissions and emergency department visits, exercise capacity,
health-related quality of life and satisfaction.
leads to considerable loss of quality of life (QoL)
and early mortality, is the third leading cause of
2 | M ATERIAL S AND M ETHOD S
mortality worldwide at present.1 The prevalence rates of COPD
are 4.96% and 8.2% in the USA and China, respectively.2,3 2.1 | Design
Because of the aging population, it is expected that the num-
ber of COPD patients will increase by 38% between 2005 and This study was designed as a single-center, single-blind,
2025.4 COPD patients have high rates of emergency depart- randomized controlled trial. Following hospitalization for
ment visits and hospital admissions, which are the main ex- an acute COPD exacerbation, participants were randomized
penses for health-care resources.5-7 According to the reported to receive either usual care or a self-management program
statistics, hospitalization costs account for 65% of all COPD initiated within 1 wk of hospital discharge. After providing
costs and up to 90% of the disease-related expenses of those written consent, participants in the intervention and control
with more severe disease.7 Some risk factors are related to hos- groups were guided by the research assistants, who were
pital admissions because of COPD exacerbations, such as poor blinded to the intervention allocation, to complete the same
adherence to pharmacological treatment and long-term oxygen set of outcome measures at baseline (T1) and after 3 (T2), 6
therapy.8 (T3) and 12 mo (T4). The study was conducted from October
Self-management is a term applied to educational pro- 2017 to December 2018.
grams aimed at the teaching skills that need to carry out med-
ical regimens specific to the disease, guide health behavior
changes, and provide emotional support for patients to control 2.2 | Study setting and participants
their disease and live functional lives.9 Thus, better self-man-
agement has the potential to improve the health-related QoL The study was carried out at the Affiliated Hospital of Zunyi
for patients with chronic conditions.10 Self-management ed- Medical University. This hospital is located in Zunyi, a west-
ucation programs are often carried out by nurses.11 Several ern city in mainland China. It is a general hospital with 3,000
studies on the efficacy of nurse-led self-management educa- beds and mainly provides health care for the residents in this
tion for COPD have been published. However, in these studies, district. On average, 150-200 COPD patients are hospitalized
the effects of such programs showed considerable variation. and discharged every month. The inclusion criteria were as
One early Cochrane review12 reported that a self-manage- follows: (1) aged 40 years or older; (2) diagnosis of Global
ment program had not improved the patients’ QoL, psycho- Initiative for Chronic Obstructive Lung Disease (GOLD) stage
logical wellbeing, disability or pulmonary function, and the II, III or IV COPD documented by pulmonary function testing;
evidence on whether the interventions reduced hospital read- (3) patients hospitalized for acute exacerbation of COPD; and
missions was equivocal. In 2014, another Cochrane review13 (4) willingness to sign an informed consent form. The exclu-
showed that the program had improved patients’ QoL and sion criteria included (1) severe sensory or cognitive impair-
led to a reduction in respiratory-related hospitalization. One ment or symptomatic ischemic heart disease; (2) a coexisting
recent systematic review14 suggested that the evidence was respiratory condition (eg, asthma or lung cancer); (3) inability
insufficient to form recommendations on the clinical effec- to be contacted by phone/mobile phone; and (4) participation
tiveness of nurse-led self-management programs for patients in another research program or inability to provide informed
with COPD. Furthermore, in most of the previous studies, the consent. A participant’s eligibility for inclusion in the trial was
patients were in a stable state. COPD exacerbations result in determined by two respiratory physicians who were involved
marked increases in both physical and emotional distress for in neither in the intervention nor in data analysis of the study.
patients, requiring several weeks for recovery.15 Therefore,
interventions that are effective in a stable state may not be ap-
propriate after patients have recently experienced an exacer- 2.3 | Nurses
bation. Furthermore, approximately 30% of patients admitted
to the hospital for an exacerbation of COPD are readmitted The intervention was administered by advanced respiratory
within 3 mo following discharge.16 nurses who had at least 10 y of respiratory clinical nursing
To address the limited evidence on the efficacy of nurse-led experience. In addition to clinical experience, the nurses
self-management programs for COPD patients, we conducted attended a one-week training session that included (1)
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comprehensive assessment of each patient’s general COPD (the mode and intensity of exercise); and (5) setting the next
and physical activity self-management needs; (2) clini- step goal and care plan. By talking and communicating with
cal communication skills with patients; (3) management of the participants, we identified the barriers to implementing
COPD; and (4) psychological intervention skills. Every self-management for participants and then provided targeted
month, the principal investigator held case conferences, last- interventions. Each phone follow-up lasted of approximately
ing 30 min, to discuss the intervention issues with the nurses. 10-15 min. For home visits, the two nurses undertook the fol-
lowing tasks: (1) assessing the environmental risk factors of
the participants; (2) encouraging participants to have a posi-
2.4 | Interventions tive attitude toward COPD and health behavior modification;
(3) reinforcing the knowledge and skills necessary to engage
2.4.1 | Interventions: intervention group in COPD self-management and home-based rehabilitation;
and (4) furthering family members’ understanding of the im-
The nurse-led self-management program is based on ex- portance of family support in improving participants’ health
perience with the Self-Management Program.17-19 In this status. Each home visit lasted approximately 45-60 min.
study, the program was divided into two phases. In the
first phase (approximately 6 to 7 d before discharge),
each participant’s general COPD and physical activity 2.4.2 | Interventions: control group
self-management needs were assessed using open-ended
questions, including concerns and fears, learning needs, Participants in the control group only received usual care.
previous experiences, social support, barriers to self-man- The participants were provided with health education for
agement, identification of enjoyable physical activities, COPD by a respiratory nurse before discharge from the hos-
perceived barriers to physical activity and social support pital. During follow-up, participants had normal access to
for physical activity, by four advanced respiratory nurses. their physician and respiratory nurse.
Following the comprehensive assessment, every partici-
pant received five to six face-to-face, individually tailored
education sessions before discharge. Each session lasted 2.5 | Outcome measures
45 min, was offered every day and was facilitated by the
advanced respiratory nurses. The topics covered in the ses- 2.5.1 | Primary outcomes
sions included (1) what is COPD and what is its impact;
(2) respiratory muscle training (pursed lip breathing and COPD-related hospital admissions and emergency
abdominal breathing); (3) medication and appropriate use department visits
of inhalation devices; (4) coughing techniques; (5) non- Data on the number of hospitalizations, length of stay and emer-
pharmacologic strategies for controlling symptoms; (6) un- gency department visits were obtained from the hospital records
derstanding the importance of physical activities for COPD through the hospital information system and were reconciled
and how to choose the right type of exercise; (7) smok- with patient follow-up records and participant self-reports.
ing cessation (if needed); and (8) long-term home oxygen
therapy (if needed). The above topics were adapted from
Living Well with COPD20 and the Global Strategy for the 2.5.2 | Secondary outcomes
Diagnosis, Management and Prevention of COPD.21 The
self-management education contents were also summarized Exercise tolerance
in a booklet and given to the participants. The discharge Exercise tolerance was measured using the 6-min walk test
planning for each participant was established according to (6MWT) (American Thoracic Society).22 The 6MWT was
specific needs of the participant at the last session. conducted according to the protocol recommended by the
In the second phase, a three-month follow-up intervention American Thoracic Society (ATS) guidelines to measure
was administered by two advanced respiratory nurses that in- functional exercise capacity. This test measures the self-
cluded phone calls every week and three home visits (within paced distance that a patient can quickly walk on a flat, hard
72 h of hospital discharge and then at month 2 and 3 post-dis- surface during a period of 6 min.23 Two tests were performed
charge). For telephone follow-ups, the main topics included and the longest distance was recorded.24
(1) checking whether the participant was complying with
the self-management care plan; (2) providing encourage- Health-related quality of life
ment and reinforcement to participants regarding their prog- The St George Respiratory Questionnaire (SGRQ) is used
ress; (3) checking for symptoms and signs, complications to measure health-related quality of life (HRQoL) in COPD
or new symptoms in participants; (4) exercise assessment patients. The SGRQ includes 56 items and has been found
WANG et al.   
| 151

to be a valid, sensitive and reliable instrument that can be 2017/06-8. All eligible participants signed written informed
used to assess HRQoL in Western and Chinese people with consent forms and had the right to withdraw at any point
COPD.25,26 A difference of greater than 4 points is consid- without any adverse effects on clinical care.
ered to be clinically important.27

Participant satisfaction 2.9 | Statistical analysis

Participant satisfaction was evaluated using the COPD
Transitional Care Patient Satisfaction Questionnaire Data were analyzed using SPSS version 20.0. An unpaired
(CTCPSQ)17 to determine patients’ satisfaction with the independent samples t test was used to analyze the differ-
nurse-led self-management program and usual care. The ences in the demographic characteristics and the COPD-
CTCPSQ is a disease-specific self-reported satisfaction ques- related hospitalizations and emergency room visits for acute
tionnaire. It comprises 14 items in two domains: service sat- exacerbations during 6 and 12 mo of follow-up between the
isfaction (6 items) and education satisfaction (8 items). Each intervention and control groups. Repeated measures analy-
item is rated on a 5-point Likert-type scale with the following sis of variance (RANOVA) was used to determine whether
response options: 1 = very dissatisfied, 2 = dissatisfied, 3 = the effect of the intervention was statistically significant
neutral, 4 = satisfied, 5 = very satisfied. The raw score of within and between groups according to the exercise capac-
each item ranges from 1-5. Higher scores represent higher ity (6MWT) and HRQoL (SGRQ). The Mann-Whitney U test
levels of satisfaction. The CTCPSQ has good internal con- was performed to evaluate whether the mean ranks for the
sistency reliability with a Cronbach’s alpha of 0.93. two groups differed significantly from each other regarding
CTCPSQ scores. An intention-to-treat principle was applied
to all analyses.
2.6 | Sample size calculation

A final sample size of 154 was calculated, consisting of 77 3 | RESULTS

patients for each group. This number was calculated by a
power analysis using PASS software. One intervention group 3.1 | Participant characteristics
and one control group of equal size and two-tailed hypoth-
esis testing were assumed. The power was set at >0.8, and Of the 479 participants screened for eligibility from October
α was 0.05. According to a study, the self-management pro- 2017 to December 2018, 203 were deemed eligible. After
gram was independently associated with the readmission rate the nurses obtained informed consent, 154 participants were
of COPD patients.18 The calculated sample size was 67 for enrolled, among whom, 143 completed the 12-month study
each group. To account for an attrition rate of 10%, the final program. The attrition rate was 7.14%. These data are sum-
sample size was 154. marized in the consort diagram in Figure 1.
The demographic characteristics included gender, age,
smoking habits, lung function and previous health service
2.7 | Randomization and blinding utilization. The mean age was 68.9 y, with a range of 56-75 y.
There were more male than female participants, 78.6% and
Participants were randomly assigned to groups after consent 21.4%, respectively. Approximately 42.9% of the participants
was obtained and baseline data were collected. The allocation were current smokers. There were no significant differences
sequence was generated and released to the interventionist in demographic and clinical data between the two groups at
on a case-by-case basis by an independent department that baseline (Table 1).
specialized in supplying randomly generated sequences for
research. The randomization sequence was recorded.
To minimize researcher bias, the interventionists who 3.2 | Primary outcomes
provided care were blinded to the participants’ baseline and
allocation sequence. The statistician was blinded to the par- Table 2 describes the number and duration of hospitaliza-
ticipants’ results during the trial. tions and emergency room visits for acute exacerbations at
6 and 12 mo. Compared to the control group, the interven-
tion group had far fewer visits to the emergency room at
2.8 | Ethical considerations both at 6 mo (P = 0.02) and 12 mo (P = 0.001). Regarding
the number and duration of hospitalizations, significant dif-
The study was approved by the institutional review board ferences were observed between the two groups (P = 0.03,
(IRB) of the hospital. The code for ethical approval was P = 0.03) at 12 mo.
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FIGURE 1 Flow diagram of the

progress

TABLE 1 Baseline characteristics of

Intervention Control group
2 participants (n = 154)
Measured parameter group (n = 77) (n = 77) X /t P-value
a
Gender −0.514 0.607
Male (%) 59 (76.6) 62 (80.5)
Female (%) 18 (23.4) 15 (19.5)
Age (years)b 68.7 ± 6.2 69.2 ± 6.1 −0.025 0.872
a
Currently Smoking (%) 34 (44.2) 32 (41.6) −0.446 0.986
Pack-years smokingb 69.9 ± 5.1 62.2 ± 7.3 −1.446 0.158
b
FEV1, % predicted 58.4 ± 17.3 59.2 ± 18.2 −1.526 0.162
FEV1/FVCb 55.2 ± 18.2 56.7 ± 16.9 −1.396 0.173
a
Stage of COPD 0.742 0.241
Mild (%) 1 (1.3) 0 (0)
Moderate (%) 12 (15.6) 14 (18.2)
Severe (%) 43 (55.8) 45 (58.4)
Very severe (%) 21 (27.3) 18 (23.4)
Hospitalizations in past 12 2.1 ± 0.9 2.1 ± 0.8 2.547 0.924
monthsb
Days spent in hospital in past 18.2 ± 10.6 18.3 ± 10.4 3.253 0.982
12 monthsb
Visits to emergency room in 2.8 ± 0.6 2.6 ± 0.8 2.889 0.784
past 12 monthsb
a
for Chi-square test.
b
Stands for t-test.

3.3 | Secondary outcomes T4 time points (t = 5.437; P < 0.001) between the interven-
tion and control groups. The results also showed a signifi-
3.3.1 | Exercise capacity cant difference in the overall means between the two groups
across time for the 6MWT (F = 47.54, P < .001). However,
The results of the 6MWT showed significant differences at no significant changes were noted in the control group during
the T2 (t = 5.124; P < 0.01), T3 (t = 4.768; P < 0.001) and the study period from T1 to T4 (Table 3).
WANG et al.   
| 153

TABLE 2 Healthcare utilization

Intervention Control group
for patients participate in nurse-led self-
Measured parameter Group (n = 77) (n = 77) t P-value
management program versus usual care
6 months
Hospitalizations 0.8 ± 0.5 0.9 ± 1.3 −2.263 0.35
Days spent in hospital 7.6 ± 8.4 8.7 ± 10.5 −2.183 0.21
Visits to emergency room 1.2 ± 1.3 2.1 ± 1.7 −3.659 0.02*
12 months
Hospitalizations 1.3 ± 0.4 2.2 ± 1.2 −3.263 0.03*
Days spent in hospital 12.4 ± 9.6 19.6 ± 11.4 −2.873 0.03*
Visits to emergency room 1.6 ± 0.8 3.4 ± 1.5 −3.784 0.001*
*P < 0.05 for t-test.

TABLE 3 Comparison of 6MWT and HRQoL at baseline, 3rd month, 6th and 12 month

Time × Group
Measured parameter T1 T2 T3 T4 F-value P-value
6MWD, m 47.542 0.000**
Intervention Group (n = 77) 342.7 ± 107.5 457.9 ± 60.5 477.3 ± 54.6 497.3 ± 85.5
Control Group (n = 77) 351.2 ± 97.6 405.3 ± 49.2 394.8 ± 63.7 408.3 ± 76.6
t-value 2.023 5.124 4.768 5.473
P-value 0.425 0.004 0.000 0.000
Total SGRQ 7.854 0.001**
Intervention Group (n = 77) 46.3 ± 16.2 37.4 ± 14.8 37.7 ± 15.1 35.5 ± 11.2
Control Group (n = 77) 44.8 ± 14.3 44.9 ± 16.5 46.3 ± 16.9 47.5 ± 15.8
t-value 6.79 5.72 6.48 7.23
P-value 0.81 0.002 0.002 0.002
Symptoms 7.742 0.017*
Intervention Group (n = 77) 52.2±19.8 47.3 ±14.8 42.2 ±15.7 43.7 ±14.6
Control Group (n = 77) 51.6 ±14.3 52.5 ± 20.1 53.7 ±16.9 50.5 ±14.9
t-value 8.79 8.57 7.77 7.54
P-value 0.57 0.018 0.015 0.018
Activity 4.735 0.024*
Intervention Group (n = 77) 57.2 ± 13.5 50.8 ± 18.1 50.3 ± 14.6 48.5 ± 16.7
Control Group (n = 77) 59.2 ± 18.8 59.3 ± 16.8 60.5 ± 12.7 61.6 ± 15.4
t-value −1.32 −1.55 −1.85 −1.63
P-value 0.79 0.003 0.002 0.001
Impact 7.741 0.001**
Intervention Group (n = 77) 35.3 ± 19.8 26.7 ± 15.2 25.8 ± 14.3 24.3 ± 16.1
Control Group (n = 77) 37.1 ± 13.5 37.6 ± 17.9 38.8 ± 16.1 37.9 ± 20.4
t-value 1.68 2.04 1.85 1.73
P-value 0.88 0.002 0.001 0.001
T1 = at baseline; T2 = 3rd month; T3 = 6th month; T4 = 12th month.
*P < 0.05.
**P < 0.01 for test of repeated measures ANCOVA.

3.3.2 | Health-related quality of life in the control group. Significant group-by-time interac-
tion effects revealed group differences across time, with
Improvements were shown in all domains of the SGRQ in the intervention group showing significant improvement in
the intervention group, whereas deteriorations were noted the total SGRQ score (F = 7.854, P = 0.001), symptom
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domain (F = 7.741, P = 0.017), activity domain (F = 4.735, 4.1 | Effectiveness of the intervention
P = 0.024) and impact domain (F = 7.265, P = 0.001) across on COPD-related hospital admissions and
the 12-month study period compared to the control group. emergency department visits
Improvements in the total score by 8.8 units, self-perceived
symptom score by 8.5 units, activity score by 8.7 units and The current study describes the number and duration of hos-
impact score by 11 units were observed in the interven- pitalizations and emergency room visits for a nurse-led self-
tion group over the 12-month study period. Worsening management program during 6 and 12 mo of follow-up in
health status was found for all aspects in the control group. COPD patients. The nurse-led self-management program sig-
Declines were indicated by increases in the total score nificantly reduced emergency department visits at both 6 and
by 2.7 units, self-perceived symptom score by 1.1 unit, 12 mo compared to the control group. This result is consist-
activity score by 2.4 units and impact score by 0.8 units ent with a recent systematic review report.15 The results of
(Table 3). the current study may be explained by the self-management
program improving participants’ knowledge and skills, which
provided the participants with the capacity to manage their con-
3.3.3 | Participant satisfaction dition, while exacerbations tended to be milder. The present
study found that the numbers and duration of COPD-related
Table 4 describes the participant satisfaction with the pro- hospitalizations were unaltered at 6 mo, while at 12 mo, they
gram at 6 and 12 mo. The table, shows that the intervention were significantly reduced compared to the control group. This
group had a higher median score than the control group for finding was comparable with the results reported in studies by
the total CTCPSQ score (p < 0.05) and service satisfaction Bourbeau et al29 and Wakabayashi et al30 but in contrast to one
(p < 0.05) and education satisfaction (p < 0.05) domains at comparable nurse-led self-management study31. These conflict-
both 6 and 12 mo. ing results may be explained by the variable follow-up times; as
in our study, Bourbeau et al29 and Wakabayashi et al30 followed
up patients for 12 mon, while the Sridhar et al31 study the fol-
4 | D IS C U S S ION lowed up patients for 24 mo. In the present study, nurse-led self-
management intervention was performed, including a patient
In recent years, many studies have examined the effects of self- education program aimed at the teaching skills needed to man-
management interventions delivered by nurses for patients with age medication, symptoms and psychological consequences.
COPD, but this is one of the few studies that has fully described Weekly telephone calls and three home visits with follow-up
the interventions, usual care and professional background of interviews were performed, all of which were aimed to guide
the nurses delivering the interventions. Moreover, the study changes in health behavior. Although the health behavior of the
adopted an intention-to-treat analysis, which can be considered participants may have changed to some degree after 6 mo of
more appropriate for gaining a realistic view of the effective- the self-management intervention, a longer time was needed to
ness of an intervention because poorly adhering patients will facilitate the knowledge and skills. Furthermore, the formation
always be present in real-life situations.28 of motivation for behavioral change is also a long-term process.

TABLE 4 Satisfaction for patients

Intervention Control group
participate in nurse-led self-management
Measured parameter group (n = 77) (n = 77) U P-value
program versus usual care
6 months
Total CTCPSQ 60.5 ± 11.7 33.2 ± 19.6 69.45 0.002*
Service satisfaction 26.1 ± 3.2 17.1 ± 9.3 42.63 0.001*
Education satisfaction 36.5 ± 15.6 15.1 ± 9.4 49.26 0.001*
12 months
Total CTCPSQ 64.3 ± 16.2 34.1 ± 15.2 72.36 0.001*
Service satisfaction 27.4 ± 5.3 16.3 ± 8.6 48.77 0.001*
Education satisfaction 38.6 ± 13.4 16.3 ± 8.6 51.23 0.001*
*P < 0.05 for Mann-Whitney U test.
WANG et al.   
| 155

Thus, this could explain why, in our study, the number and attributable to exercise, given the strong association between
duration of COPD-related hospitalization was unaltered at 6 QoL and physical activity in COPD patients.41
mo but significantly reduced at 12 mo compared to the control
group. A study by Sridhar et al31 found no difference in hospital
admission rates between the intervention and control groups at 4.4 | Effectiveness of the intervention on
24 mo. Although 24 mo may be sufficient for participants to de- patient satisfaction
velop the knowledge and skills to manage their condition, their
motivation for behavioral change gradually decreases over this In contrast to a recent systematic review, and consistent with
time. It is not easy for individuals to maintain motivation for be- a previous report, the present study showed that the self-man-
havioral change for a long time. Therefore, a bimodal time ef- agement program improved participants’ satisfaction. There
fect on behavioral change is observed among patients. Further are many reasons for this difference. First, the participants
research is needed to determine how to maintain motivation for with COPD who participated in the self-management pro-
behavioral change, especially in the long term. gram reported that it made them feel ‘much safer’; therefore,
this may have improved the satisfaction in the self-manage-
ment group. Second, in our study, a number of control group
4.2 | Effectiveness of the intervention on participants also wanted to participate in the same interven-
exercise tolerance tion as provided to the intervention group, and this may have
influenced the satisfaction of the control group.
This study showed a significant improvement in the 6MWT
from T1 to T4 in the self-management group, and the total in-
crease at 6 mo was 155 m, which represented a clinically signif- 5 | LIM ITATIONS
icant improvement.32 Several previous papers investigated the
effect of a self-management program on the exercise capacity Our study had several limitations. First, this was a single-
of COPD patients, but showed inconsistent observations. For center study, which makes generalization difficult. Second,
example, Helen et al (2014) reported the mean increase in the adherence to the self-management intervention was reported
6-minute walk distance (6MWD) achieved by the intervention by the participants but not monitored by the nurses. Third, the
and control group. The results showed that the mean distance in patients’ reactions to the research and to the assigned inter-
the 6MWD test was reduced in both groups.33 The inconsisten- vention may have contributed to the difference in satisfaction.
cies between the present findings and those of previous studies
could be explained because the intervention in the present study
was designed to teach patients skills and techniques known to 6 | CONCLUSIONS
increase the likelihood of physical activity. In addition, patients
were also provided home visits and telephone follow-up post- This study showed that COPD patients in a nurse-led self-
discharge. This correspondence method was modeled after management program had significantly fewer emergency
other trials and was intended to facilitate learning and behav- room visits, better exercise capacity and health-related QoL,
ioral activation.34-37 Therefore, the acquisition of knowledge, and higher satisfaction than those who received usual care
skill and motivation for physical activities may cause patients only. This approach should be part of standard care, with spe-
to continue to exercise. cial attention given to COPD patients with impaired health
and frequent exacerbations.

4.3 | Effectiveness of the intervention

on HRQoL 7 | CLINICAL RESOURCES

Many comparable self-management studies have also shown a Chronic obstructive pulmonary disease in over 16s: diagnosis
clinically significant improvement in HRQoL measured by the and management: https​://www.nice.org.uk/guida​nce/ng115​/
SGRQ, such as the study by Billington et al.38 However, other chapt​er/Recom​menda​tions​
previous studies also failed to show positive effects on HRQoL Managing Chronic Obstructive Pulmonary Disease
in the intervention group.39,40 These inconsistencies in results (COPD): https​://www.cdc.gov/learn​moref​eelbe​tter/progr​ams/
could be explained as follows. Unlike the current study and the copd.htm
other four studies, in studies39 and,40 the intervention consisted
of a patient brochure and action plan only, and no exercise com- CONFLICT OF INTEREST
ponent was included. It could be hypothesized that this effect is All authors declare that they have no conflict of interest.
156
|    WANG et al.

AUTHOR CONTRIBUTIONS 13. Zwerink M, Brusse-Keizer M, van der Valk PDLPM, et al. Self
Conception and Design: Wang, Zhang and Zhang management for patients with chronic obstructive pulmonary dis-
ease. Cochrane Database Syst Rev. 2014;3(3):CD002990.
Analysis and Interpretation of Data: Wang
14. Baker E, Fatoye F. Clinical and cost effectiveness of nurse-led
Drafting the Manuscript: Wang, Hu and Qiu self-management interventions for patients with copd in primary
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