Chronic obstructive pulmonary disease: assisting with health behaviour change

Module overview

Chronic obstructive pulmonary disease (COPD) is common in the UK and causes a significant burden to patients and the NHS. Healthcare provision for COPD is largely focused on biomedical treatment, yet research suggests the complexity of factors contributing to this disease requires a deeper understanding of the patient experience and a more holistic approach to care provision. Smoking cessation is the single most cost-effective and significant way to slow progress of the disease and improve outcomes for patients. However, barriers to smoking cessation are higher in patients with COPD than in other groups, requiring different approaches. This is part one of a two-part module, which focuses on patients with COPD caused by smoking. The second part will focus on non-pharmacological therapy.

Keywords

behaviour change, breathlessness, COPD, chronic obstructive pulmonary disease, dyspnoea, health promotion, lifestyles, lung diseases, public health, respiratory, smoking, smoking cessation

Aims

The aim of this module is to increase knowledge and encourage critical thinking and reflection when managing the treatment of patients with chronic obstructive pulmonary disease (COPD). This first module refers in particular to tackling the barriers to smoking cessation.

Intended learning outcomes

After reading this module and completing the time out activities, you should be able to:

• Explain and provide insights into the importance of effective health promotion and symptom management, within socioeconomic influences, for high quality care and efficient use of resources.
• Develop a holistic approach to care for patients with COPD with extensive and complex health problems, with consideration to social circumstances, attitudes and preferences.
• Analyse the barriers and challenges of smoking cessation for patients with COPD and how these may be addressed to influence health behaviour positively.
• Understand the physical and psychological consequences of breathlessness and its effects on quality of life and the NHS.

Background

COPD is common in the UK, with an estimated three million people living with the disease (Healthcare Commission 2006, National Institute for Health and Care Excellence (NICE) 2010). It is the fifth highest cause of death in the UK, causing around 25,000 deaths each year (Department of Health (DH) 2011), and the incidence of deaths is increasing (NICE 2010).

COPD costs the NHS more than £800 million each year and represents one of the most frequent causes of emergency hospital admission (DH 2010a). The DH strategy for COPD services highlights the potential for community care to engage with patients with COPD, promote health (DH 2010b), and address the cost of avoidable COPD-related hospital admissions as outlined in the document Delivering Care Closer to Home: Meeting the Challenge (DH 2008).

In relation to COPD, it is suggested that healthcare providers often focus on biomedical treatment of the disease (Arnold et al 2005, Bausewein et al 2007). The King’s Fund, however, reviewed research investigating the effectiveness of interventions for reducing avoidable hospital admissions of patients with COPD and found that the complexity of patients’ chronic health problems, home situation, attitudes and preferences rendered a single model of care insufficient (Purdy 2010). To improve service quality and economic accountability, the evidence base for COPD should incorporate both quantitative and qualitative evidence that captures biological, psychological and social influences on health. A deeper understanding of the attitudes, values and beliefs of patients with COPD is also required (Green and Tones 2010, Kumar 2011).Pathophysiology

COPD is characterised by lung airflow obstruction with the presence of breathlessness or cough (NICE 2010). Airflow obstruction occurs as a result of chronic inflammation and damage to the airway and parenchyma, most often caused by tobacco smoke. COPD is an irreversible, progressive disease resulting in subsequent disability, impaired quality of life (NICE 2010) and ultimately death (DH 2011).

Complete time out activity 1

Reflect on any encounter you have had with a patient with COPD. What was the focus of the encounter? Did you explore the attitudes, values, beliefs and preferences of the patient? What areas might you improve on?

Learning Points

1. Chronic obstructive pulmonary disease (COPD) is the fifth most common cause of death in the UK.
2. COPD is characterised by lung airflow obstruction with the presence of breathlessness or cough.
3. COPD is an irreversible, progressive disease resulting in subsequent disability, impaired quality of life and ultimately death.
4. The evidence base for COPD should incorporate both quantitative and qualitative evidence that captures biological, psychological and social influences on health to improve service quality and economic accountability.

Smoking and COPD: extent of the problem

Although not all patients with COPD smoke or have a history of smoking, smoking cessation has been identified as the single most cost-effective and significant way to slow the disease progress (Hersh et al 2004, Willemse et al 2004) and improve outcomes for patients in all stages of COPD (Coakley and Ruston 2001). Barnett (2008) suggests that exacerbations can be reduced by smoking cessation. However, nicotine is highly addictive and people with COPD have been shown to be heavier smokers and more addicted to nicotine than those without COPD (Shahab 2006).

Approximately 19.5% of the UK population smokes, but 53.3% of older people in poor health are smokers (Office for National Statistics 2012). Smoking cessation rates are lower in people with COPD than without (Schiller and Ni 2006, Lundh et al 2012). However, 78% of smokers with COPD had made at least one attempt to quit over their lifetime and 79% had reduced the number of cigarettes smoked (Schofield et al 2007). Schofield et al (2007) suggest that this indicates a major desire to quit.

COPD and smoking rates are much higher in deprived socioeconomic groups (Acheson 1998). The predictive factors associated with unsuccessful smoking cessation attempts, which suggests that these patients require more help to stop smoking (Wagena et al 2004, Lundh et al 2012), are:

• Poverty.
• Feelings of hopelessness (Schiller and Ni 2006).

Complete time out activity 2

Return to the patient with COPD you identified in time out activity 1. What socioeconomic factors influenced the patient? Discuss with your colleagues how any socioeconomic deficits may be addressed.

Learning Points

1. Smoking cessation has been identified as the single most cost-effective and significant way to slow the disease progress and improve outcomes for patients in all stages of COPD.
2. Nicotine is highly addictive and people with COPD have been shown to be heavier smokers and more addicted to nicotine than those without COPD.
3. Predictive factors associated with unsuccessful smoking cessation attempts are poverty and feelings of hopelessness.

Patients’ perceptions of smoking cessation

Hilbernick et al (2006) suggest that most smokers understand the harmfulness of smoking. However, one study of 22 participants with COPD found that only one participant made reference to the benefits of smoking cessation (Schofield et al 2007). Other participants remarked that smoking improved their breathing and was helpful when they were upset because it reduced anxiety. Smoking cessation appeared ‘pointless’ for these participants because damage to their bodies had already been done.

Despite this, most participants wanted to quit, and Hilbernick et al (2006) estimated that 50% of smokers with COPD are amenable to smoking cessation support. Wilson et al (2011) suggest that people with COPD are ambivalent about the advantages and disadvantages of smoking cessation.

Definition

Becker’s (1974) Health Belief Model requires an individual to identify first that they are susceptible to harm, with subsequent behaviour change depending on how the individual weighs up the benefits and costs.

Since smokers with COPD appear to place little emphasis on the benefits of smoking cessation, behaviour change is unlikely, particularly when cigarettes are perceived to provide comfort.

The focus of smoking cessation with patients with COPD should therefore emphasise the benefits of reduced exacerbations and improved lung function, rather than the harm smoking causes.

Complete time out activity 3

Review the following website to determine how you might improve smoking cessation advice: http://www.smokefree.gov. Make a list of your three preferred strategies.

Learning Points

1. The Health Belief Model requires an individual to identify first that they are susceptible to harm, with subsequent behaviour change depending on how the individual weighs up the benefits and costs.
2. Smokers with COPD appear to place little emphasis on the benefits of smoking cessation and behaviour change is unlikely, particularly when cigarettes are perceived to provide comfort.
3. The focus of smoking cessation with patients with COPD should emphasise the benefits of reduced exacerbations and improved lung function, rather than the harmful effects of smoking.

Changing health behaviour

Smoking can provide structure, routine and company throughout the day (Wilson et al 2011). People with COPD may experience greater levels of psychological distress and low self-esteem (Nicolson and Anderson 2003). During smoking cessation, times of grief are often the trigger for relapse (Schofield et al 2007).

The self-inflicted nature of COPD may cause embarrassment and shame for individuals continuing to smoke and they may adapt their behaviour to avoid confrontation and upsetting their family. This can create a cycle of guilt, low self-esteem and low self-worth that compounds the inability to achieve smoking cessation (Wilson et al 2011). Lundh et al (2012) suggest that this can have either a positive or negative effect. In other words, pressure to stop smoking can result in either smoking cessation (or continuation of attempts to stop), or loss of motivation and hope of quitting.

Lundh et al (2012) discuss the transtheoretical model of change and its stages (Figure 1):

• Pre-contemplation – the individual may not be aware of issues with their health behaviour and have no intention of making changes in the foreseeable future.
• Contemplation – the individual starts to realise that the behaviour is an issue and assesses the benefits of and barriers to behaviour change.
• Preparation – there is intention to change the behaviour in the immediate future and the individual prepares for this.
• Action – the individual makes specific modifications and changes to their health behaviour.
• Maintenance – the individual works to prevent relapse and the new health behaviour is sustained.

Figure 1. Transtheoretical model of change

Since the role of the community practitioner involves assisting the individual through the pre-contemplation and contemplation stages, motivational interviewing can be used to help patients who are not ready to change behaviour and to identify reasons for behaviour change. This is especially important when the rationale for smoking cessation requires an emphasis on improved lung function rather than on prevention of ill health.

Complete time out activity 4

Return to your patient with COPD (time out activities 1 and 2). Research the transtheoretical model of change, and identify what stage the patient is in, or was in, according to this model and how this might be addressed.

Learning Points

1. People with COPD may experience greater levels of psychological distress and low self-esteem.
2. The self-inflicted nature of COPD may cause embarrassment and shame for individuals continuing to smoke and they may adapt their behaviour to avoid confrontation and upsetting their family.
3. Pressure to stop smoking can result in either smoking cessation (or continuation of attempts to stop), or loss of motivation and hope of quitting.
4. The stages of the transtheoretical model of change are: pre-contemplation, contemplation, preparation, action and maintenance.
5. Times of grief are often the trigger for relapse after smoking cessation.

Factors leading to change in behaviour

The family

Luker et al (2007) suggest that being married or single have a positive effect on smoking cessation in men, compared with men who are divorced or separated. Further, men whose spouse did not smoke were more likely to quit than those with a spouse who smoked. Those who were successful in quitting reported that their close family was the most important factor in quitting.

Women, however, often cited pressures at home and family members who smoked as reasons for not succeeding in smoking cessation. These findings may reflect limited self-efficacy and external locus of control (where the individual believes the factors influencing their behaviour are uncontrollable) and highlight the need for empowerment techniques and support. Health practitioners should consider the effect of the patient’s family and encourage inclusion of any close family members in the smoking cessation intervention (Luker et al 2007, Schofield et al 2007). This would also promote ethical practice in which the health needs of family members are included (NMC 2015).

Self-efficacy

Counselling and learning coping mechanisms such as stress management, relaxation and exercise can raise self-efficacy (Petty 2000, Schofield et al 2007). These empowerment techniques aim to increase people’s control over their lives, raise self-esteem and change their ‘social reality’ to acquire the skills and confidence necessary to stop smoking (Naidoo and Wills 2009). However, Sarafino (2002)argues that empowering older people may be particularly difficult as a result of their socialisation at a time when attitudes were more paternalistic than today. Loft et al (2003) suggest that the ways older people are regarded also create a barrier for empowerment, because issues associated with old age, such as living alone, deteriorating health and lower income, make them vulnerable and create an assumption that they are less able to care for themselves.

Health professionals

Each smoker, regardless of age, should be offered smoking cessation advice and support at every clinical opportunity (NICE 2010, 2013). However, evidence suggests that health professionals are less likely to engage in smoking cessation advice with older people as they consider success less likely (Maguire et al 2000). Schiller and Ni (2006) found that 22.9% of respondents had not received smoking cessation advice from a health professional in the previous year.

Rice et al’s (2013) systematic review of 35 trials, published between 1987 and 2012 with a total of more than 17,000 participants, revealed that smoking cessation interventions by nurses increase the likelihood of quitting. A high-intensity smoking cessation intervention produced a quit rate of 172 per 1,000, compared with a rate in the control group of 137 per 1,000. A low-intensity smoking cessation intervention produced a quit rate of 64 per 1,000, compared with 51 per 1,000 in the control group. These interventions produced a combined quit rate of 144 per 1,000 for a smoking cessation intervention as opposed to a rate of 115 per 1,000 in the control group.

Schorr et al (2008) found tailored smoking cessation interventions to be more effective than standardised interventions. Stead et al’s(2013) literature review of advice interventions on smoking cessation revealed that even brief advice can raise smoking cessation rates by 1-3%. Schofield et al (2007) reported that smoking cessation attempts are inspired by external sources rather than by increasing disease severity. Participants in another study spoke about previous failed attempts to quit with regret (Wilson et al 2011). However, Petty (2000) acknowledged that smokers may relapse six or seven times before abstinence from smoking is achieved. Therefore, previous quit attempts should be reframed as positive in order to motivate the patient for a further attempt (Wilson et al 2011).

Assessment, advice and support for smoking cessation in patients with COPD may be time consuming; however, the potential patient benefits are well documented. Community practitioners already support, monitor and treat patients with COPD at home, and this presents an efficient opportunity to explore smoking cessation with patients to maximise health outcomes (NICE 2013). It has been suggested that the cost benefits of investing time in effective smoking cessation interventions are favourable, compared with simply treating smoking-related diseases (Parrott et al 1998).

Complete time out activity 5

With your patient and with COPD in mind, formulate a plan for providing effective advice on smoking cessation support. Write down the key steps in your plan.

Learning Points

1. Married or single men were more likely to give up smoking than their divorced or separated counterparts. Men whose spouse did not smoke were more likely to quit than those with a spouse who smoked.
2. Health practitioners should consider the effect of the patient’s family and encourage inclusion of any close family members in the smoking cessation intervention.
3. Factors that lead to change in behaviour are the family, self-efficacy and health professionals.
4. Counselling and learning coping mechanisms such as stress management, relaxation and exercise can raise self-efficacy.
5. These empowerment techniques aim to increase people’s control over their lives, raise self-esteem and change their ‘social reality’, allowing them to acquire the necessary skills and confidence to give up smoking.
6. Each smoker, regardless of their age, should be offered smoking cessation advice and support at every clinical opportunity.
7. Smoking cessation attempts are inspired by external sources rather than by increasing disease severity.
8. Smokers may relapse six or seven times before abstinence from smoking is achieved. Therefore, previous quit attempts should be reframed as positive experiences in order to motivate the patient for a further attempt.
9. Community practitioners who support, monitor and treat patients with COPD at home have a good opportunity to explore smoking cessation with patients and maximise health outcomes.

Assisting with health behaviour change

An initial interview may assess patients for baseline health beliefs, attitudes, values, knowledge, skills, health status, functional ability, confidence and self-efficacy (Corcoran 2013). The health professional may use motivational interviewing.

Motivational interviewing may be used as a brief intervention where the patient’s motivational readiness for behaviour change is identified as deficient; this is well supported in behaviour change management (Miller and Rollnick 1991, National Institute on Drug Abuse 1999) and has been successfully applied to smoking cessation (Taylor et al 1996, Wakefield et al 2004). Interviewing enhances the patient’s internal motivation and thus makes the change more successful. It involves the regular assessment of motivation, assisting the health professional to tailor the approach, duration and resources used with and for the patient.

Motivational interviewing can be used with the stages of the transtheoretical model of change, where the goal is to encourage the patient to move through the stages of change rather than to cease smoking. Therefore motivation to change is determined by the patient, rather than externally imposed by the health professional, and the patient has the responsibility of resolving their ambivalence (Lai et al 2010).

Motivational interviewing is based on four guiding principles (Miller and Rollnick 2002):

• Expressing empathy.
• Developing discrepancy.
• Rolling with resistance.
• Supporting self-efficacy.

Health professional-patient relationship

• The health professional-patient relationship is regarded as one of collaboration and partnership, rather than one of expert and recipient.
• A patient’s resistance and denial are viewed as reactions to the behaviour of the health professional rather than an expression of their personality, and should be addressed through a change of strategy; this can reframe the patient’s thinking and encourage examination of different perspectives.
• The health professional should be non-judgemental, and adopt a sensitive and empathetic approach to understanding the patient’s experience.
• Suggesting externally derived methods or techniques is ineffective; instead, the nurse should be led by the patient’s own means of change.
• Patients should be encouraged to perceive the difference between their present behaviour and the desired change in lifestyle, as this increases their motivation to change when they realise that their current behaviour will not achieve a future goal.
• Self-efficacy should be supported and hope fostered through the celebration of previous efforts.

Assessing a patient’s motivation

A patient’s motivation may be assessed using a motivation or readiness ruler (Figure 2) (Centre for Evidence-Based Practice 2011).

Figure 2. Example of a motivation or ‘readiness’ ruler

Motivation rulers are popular in clinical practice (Kahler et al 2009), are quick to use and can rapidly assess three dimensions of motivation: importance, readiness and confidence.
Subsequent interviews and motivation ruler assessments can assist with evaluating the effect of motivational interviewing on the patient’s cognitive processes as well as on smoking cessation outcomes in terms of physical health and ability (Corcoran 2013).

Learning Points

1. An initial interview may assess patients for baseline health beliefs, attitudes, values, knowledge, skills, health status, functional ability, confidence and self-efficacy.
2. Motivational intervention strategies are employed where the patient’s motivational readiness for behaviour change is identified as deficient, and are used to enhance the patient’s motivation.
3. Motivational interviewing is based on four guiding principles: expressing empathy, developing discrepancy, rolling with resistance and supporting self-efficacy.
4. The health professional-patient relationship is regarded as one of collaboration and partnership, rather than one of expert and recipient.
5. Motivation rulers, which are popular in clinical practice, are quick to use and can rapidly assess three dimensions of motivation: importance, readiness and confidence.

Conclusions

• COPD is a major health burden to both the NHS and the individual, causing poor quality of life.
• Smoking cessation is identified as an important health promotion intervention because of its beneficial impact on physical health, functional ability and mental health.
• The issues affecting the ability of the individual to give up smoking are complex and require a sensitive and empathetic approach.
• Motivational interviewing and assessment using a motivational ruler are useful tools for supporting patients to achieve successful health behaviour change.

Acronyms

COPD: chronic obstructive pulmonary disease

NHS: National Health Service

NICE: National Institute for health and Care Excellence

Author

Donna Jones, District nurse sister, Shropshire Community Health NHS Trust, Shrewsbury, England.

Short description

Update your knowledge and skills in caring for people with chronic obstructive pulmonary disease. This module focuses on how nurses can help patients stop smoking.

Detailed description

Chronic obstructive pulmonary disease (COPD) is common in the UK and causes a significant burden to patients and the NHS. Healthcare provision for COPD is largely focused on biomedical treatment, yet research suggests the complexity of factors contributing to this disease requires a deeper understanding of the patient experience and a more holistic approach to the provision of care. Smoking cessation is the single most cost-effective and significant way to slow the disease progress and improve outcomes for patients. However, barriers to smoking cessation are higher in patients with COPD than in other groups, requiring different approaches. This learning module focuses on patients with COPD caused by smoking.

Glossary

Breathlessness: a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. It is a common and distressing symptom in patients with advanced COPD.

Chronic obstructive pulmonary disease (COPD): a progressive lung disease characterised by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible.

Motivational intervention: an umbrella term for a range of strategies designed to enhance the patient’s motivation to change.

Motivational interviewing: a process of engaging the patient in behaviour change through strategies such as empathetic listening and self-efficacy.

Motivation or readiness ruler: a helpful tool to support the use of motivational interviewing.

Transtheoretical model of change: assesses an individual’s readiness to adopt healthier behaviour and provides strategies to guide the individual through the five stages of change.

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