Patients’ experience of identifying and managing exacerbations in COPD: a qualitative study

This article reviews a qualitative study on how patients identify and manage exacerbations in COPD. The study aimed to explore patient’s current understanding and experience of managing and identifying COPD exacerbations at home. The article covers the background of the study, research design, sampling technique, data collection and analysis, and research results.

Running head: REVIEW OF QUALITATIVE ARTICLE
1
Guided Review of Nominated Qualitative Literature
Name:
Institution:

REVIEW OF QUALITATIVE ARTICLE 2
Guided Review of Nominated Qualitative Literature
This paper is a review of the qualitative article: “Patients’ experience of identifying
and managing exacerbations in COPD: a qualitative study” (Williams, Hardinge, Ryan, &
Farmer, 2014). The paper covers the background of the study, the research design, sampling
technique, data collection and analysis, and research results.
Background of the Study
Williams and his team address the issue of “self-management in chronic obstructive
pulmonary disease (COPD)” (2014). Effective self-management in COPD is vital to the
sustainable reduction of hospital admissions and enhanced patient outcomes (Kaptein,
Fischer, & Scharloo, 2014). Interventions for self-management in COPD patients have
primarily been associated with nurse-centred approaches that focus on teaching the patient
how to use written instructions exacerbation events and determining the outcomes such as
mortality and clinical admissions. Evidence on the effectiveness of this approach is
contradictory showing mixed and negative results as well as excess amounts of mortality
stimulating healthcare researchers to reconsider broadening the concept of self-management
in COPD.
Literature Review
Patients are the first people to notice changes at the onset of a health concern.
Therefore, it is important for patients to understand the composition of exacerbation, and
understand the signs of deterioration and react accordingly. Zwerink, Brusse-Keizer, Van der
Valk, Zielhuis, Monninkhof, Van der Palen, et al. (2014) conducted a recent review on self-
management intervention in Cochrane and suggested the removal of the term “education”
replacing it with “training. The authors argue that education alone not be sufficient in
achieving behavioural change.

REVIEW OF QUALITATIVE ARTICLE 3
The results of the review indicate that self-management training in COPD patients is
essential to improving the overall quality of life, declined related hospitalisations, as well
dyspnea enhancement. According to Fletcher and Dahl (2013) improvement of nursing
education and support is key to addressing the issues and barriers to the recognition of nurse
roles in the survival of persons with chronic illnesses like COPD. The classic argument
asserts that people with chronic disorders have several tasks in self-management including
behavioural and health management, emotional management, and life-role management
(Kaptein et al., 2014; Simpson & Jones, 2013). As such, patients should gather medical
personal medical information, manage symptoms and medication, maintain a healthy
lifestyle, and communicate effectively to achieve sustained efficient self-management of
exacerbation in COPD.
The Significance of the Study
Although there is significant amount of published research regarding the hospital
assessment of exacerbation and, there is limited knowledge on how patients identify and
manage exacerbation in COPD (Williams et al., 2014). The study by Williams and his
colleagues helps to stakeholders in the management of chronic illness. Medical professionals
can use the findings of the research to inform their training on patients with COPD. Policy
formulators can also use the findings of the article to inform policies on nursing education
and practice. Moreover, patients can use the article to improve how they identify and manage
COPD. Further, researchers in the field of chronic illness can use the article as a reference to
their studies.
Overview of Research Design
This section addresses the aim of the research and the research design.

REVIEW OF QUALITATIVE ARTICLE 4
The Aim of the Research
There is need to expand the knowledge of nurses through education (Fletcher & Dahl,
2013). At the same time, patient education is shallow resulting in many adverse outcomes
(Zwerink, et al., 2014). However, no research explains how patients identify and manage
exacerbation in COPD at home; indicating a gap in the study. Following the need to fill the
gap in research, the article embarked on qualitative research to determine how people identify
and self-manage exacerbation at home. As such the article aimed “to explore patient’s current
understanding and experience of managing and identifying COPD exacerbations at home”
Williams et al. (2014).
Overview of Research Design
The research design should be appropriately chosen about the research topic and the
developing questions. The research design is the framework of the study and includes the
strategies and procedures for sampling, data collection and analysis (Holloway & Galvin,
2016). The article uses a qualitative research approach (Williams et al., 2014). Qualitative
research design which is critical in the collection of descriptive data from survey interviews
regarding healthcare processes, systems and settings (Holloway & Galvin, 2016). The design
allows the researchers to collect primary information concerning the respondents’
demographics length of diagnosis, number and frequency of exacerbation. The data was used
to determine how COPD patients notice and control exacerbations at home.
Sampling
The study sampled patients with different backgrounds “from hospital admission
records, pulmonary rehabilitation programmes and general practice” Williams et al., (2014, p.
1). The criteria for eligibility are illustrated in table 1 below. The criteria for eligibility
allowed the researcher to determine whom to include and whom to exclude from the research.

REVIEW OF QUALITATIVE ARTICLE 5
The sample collected using the criteria allowed the researchers to collect data from the
appropriate sample to inform the topic and achieve the aim of the study. Consequently, data
were collected for patients of the right age (>40 years) across both sexes allowing the
researchers to classify the information collected into themes for coding, analysis, and
interpretation of data.
Figure 1: Criteria for participant eligibility (Williams et al., 2014)
Sampling decision is usually made early in the project. Sampling is complex and is
informed by the research questions, topic, aim, theoretical and practical considerations, and
the ethical principles and concepts (Holloway & Galvin, 2016). The article used a purposive
sampling technique to identify the sample respondents. Purposive sampling allows the
researcher to select the sample carefully to achieve the aim of the research and is popularly
known as “criterion-based sampling” (Holloway & Galvin, 2016, p. 141). Specific criteria are
implemented allowing the research to select the sample accordingly.

REVIEW OF QUALITATIVE ARTICLE 6
Data Collection
Researchers need data to test the hypothesis and to inform the study which is helpful
in decision making. Healthcare researchers collect data using standard methods, primarily
through interviewing and observation (Holloway & Galvin, 2016). William and his
colleague's utilised in-depth interviews conducted the homes of patients. Semi-structured
interview questions were used with questions focusing on the patients’ experience in
identifying and managing exacerbation at their place of residence. Each interview lasted
between half an to onw hour during which important notes were taken to provide the content
of the interviews and aid in data analysis (Williams, Hardinge, Ryan, & Farmer, 2014). The
interviews were guided by the research questions and the aim of the study. The instrument
allowed the researchers to collect appropriate data from the responds which would inform the
conclusion of the study (Holloway & Galvin, 2016).
Respondents in the interview were required to sign a consent letter agreeing to
participate in the interview voluntarily and can leave willingly at any point of the research.
The research observed ethical principles by assuring the participants’ of privacy and
confidentiality of the information they share. “The interviews were conducted with the
approval of the South Central Berkshire Research Ethics Committee (ref 12/SC/0437) and
research governance was granted by Oxford Health NHS Foundation Trust and Oxford
University Hospitals NHS Trust” Williams et al. (2014, p. 1). The study collected data on
several variables including patient demographics to identify the patient’s background.
Advantages and Disadvantages of Qualitative Interviews
Research interviews are unlike ordinary conversations because the interviewer sets to
elicit information from the interviewee. Interviews are meant to discover the respondent’s
thoughts, perceptions and feelings. Holloway and Galvin (2016) state that interviews seek the
past, present and the personal experience of the informant. Interviews allow researchers to

REVIEW OF QUALITATIVE ARTICLE 7
collect information that may not be collectable through other methods such as observation
and questionnaire and can either be formal or informal taking place face-to-face or
electronically. An informal conversation with the participants often generates exciting ideas
for the study. The researcher formulates the questions as the chat continues and implying that
the next interview would be different as the interview does not ask predetermined questions.
The participants also have control over the agenda. Although the wording and structure may
be different, researchers find distinct patterns that are common often during analysis.
However, this type of interview requires extensive planning for researchers to be able to
uncover the patterns during data analysis. Williams et al. (2014) in their article do not
mention whether a formal or informal interview was used. The article does not also tell us
whether the interviews were conducted face-to-face (such as individual or group interview) or
through electronic media (such as email and telephone).
Qualitative interviews do not need pilot studies as the research in developmental;
starting with relatively unstructured questions to give the participant minimal guidance. The
initial outcomes of the interview typically guide subsequent questions. As the interview
proceeds, questions start to take a structure pattern focusing on particular concerns that are
important to the informant. Most qualitative interviews not only focus on commonalities and
pattern discovery but also describe the experiences of the respondents, especially in face-to-
face interviews which are the most common (Holloway & Galvin, 2016).
There are advantages and disadvantages in interviewing. Shared norms and language
can be a strength or a limitation (Holloway & Galvin, 2016). They can give the researchers
the advantage of quickly understanding the culture and concept of the informant.
Alternatively, the research may interpret values and beliefs leading to misunderstandings.
Therefore, researchers should not make unwarranted assumptions and should instead act
naïve, asking the respondent to clarify their statements.

REVIEW OF QUALITATIVE ARTICLE 8
In many qualitative interviews, the participant and the respondent are all equal, and
the researcher is not anonymous or distant. The closeness is essential to the study as it gives
the interviewee the confidence to speak openly and trust the researcher. On the contrary, there
is the danger of over-involvement.
Therefore, researchers should choose their interviewees prudently to minimise
challenges and problematic issues such as unexpected respondent or researcher behaviour,
constructing and phrasing questions about sensitive matters. For example, some participants
may be less articulated than expected; bringing out their in-depth experience becomes hard. A
particular skill is required to be able to ask sensitive questions without creating an awkward
atmosphere. In nursing, the researcher must first create a rapport with the patient to obtain the
richest sets of data, being able to communicate empathy without being judgmental. The nurse
should also be able to deal with emotional situations (Holloway & Galvin, 2016).
Other advantages and disadvantages of qualitative interviews are highlighted in table
1 below:
Source: (Alshenqeeti, 2014)
Alternative Methods of Data Collection
Williams et al. (2014) could also have used alternative data collection methods such
as questionnaires and observations. Interviews, questionnaires and observations can be used

REVIEW OF QUALITATIVE ARTICLE 9
separately or in combinations. However, each method is used to produce a different kind of
data set depending on the research questions.
Analysis/Results
Data in the article was audio-recorded and transcribed verbatim before being imported
to NVIVO 10 where it is appropriately stored, organized and analyzed. The grounded theory
approach was used for data analysis. Data was imported into NVIVO for coding where the
respondents answers were grouped into themes using open coding, axial coding and selective
coding to uncover the patterns and shared concepts in data (Williams et al., 2014).
It is crucial to select applicable methods of data analysis in qualitative research
(Holloway & Galvin, 2016). Data analysis begins at the onset of data collection during in the
interviews and observations and is progressively clear. The researcher revisits the aim and
objectives of the study during data analysis. If an appropriate method of data analysis is not
used, the results obtained may not be reliable, valid, and trustworthy implying that the
findings may not be generalizable.
Williams et al. (2014) indicate that the study coded two interviews using an
experienced external qualitative researcher to ascertain the accuracy and quality of the coding
activity. The researchers also met often to analyze and interpret data. Both echniques were
crucial in ensuring transparency and credibility of the results.
The findings of the study indicate that patients can identify exacerbation from visible
and invisible symptoms based on experience. For self-management of exacerbation in COPD,
patients employed techniques “such as pacing and breathing techniques, self-administered
antibiotics and steroids…” William et al. (2014, p. 4). Additionally, patients consulted

REVIEW OF QUALITATIVE ARTICLE 10
medical professional whenever they felt that their condition was not improving. However,
some cases were reported later leading to admission to emergency wards.

REVIEW OF QUALITATIVE ARTICLE 11
References
Alshenqeeti, H. (2014). Interviewing as a data collection method: critical review. English
Linguistics Research, 3(1), 35-45.
Bryman, A., & Bell, E. (2015). Business research methods. USA: Oxford University Press.
Fletcher, M. J., & Dahl, B. H. (2013). Expanding nurse practice in COPD: is it key to
providing high quality, effective and safe patient care? Primary Care Respiratory
Journal(22), 230-233.
Holloway, I., & Galvin, K. (2016). Qualitative Research in Nursing and Healthcare. New
Jersey: Wiley Publishers.
Kaptein, A. A., Fischer, M. J., & Scharloo, M. (2014). Self-management in patients with
COPD: theoretical context, content, outcomes, and integration into clinical care.
International Journal of Chronic Obstructive Pulmonary Disease, 9, 907-917.
Simpson, E., & Jones, M. C. (2013). An exploration of self-efficacy and self-management in
COP patients. British Journal of Nursing, 22(19).
Williams, V., Hardinge, M., Ryan, S., & Farmer, A. (2014). Patients’ experience of
identifying and managing exacerbation in COPD: a qualitative study. NPJ Primary
Care Respiratory Medicine, 24(14062), 3-6.
Zwerink, M., Brusse-Keizer, M., Van der Valk, P., Zielhuis, G. A., Monninkhof, E. M., Van
der Palen, J., Frith, P. A., & Effing, T. (2014). Self-management for patients with
chronic obstructive pulmonary disease (Review). Cochrane Database of Systemic
Review(3).

REVIEW OF QUALITATIVE ARTICLE 12