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The UNIVERSITY OF HONG KONG
LI KA SHING FACULTY OF MEDICINE
SCHOOL OF NURSING
MASTER OF NURSING
Course Title : Dissertation
Assignment Title : Final Dissertation Report
Student Name : Choy Kwan Yee, Jenny
Student Number : 2006106789
Year of Intake : 2012
Year of Study : 2
Teaching Staff : Dr. Athena Hong
Submission Date : 31-7-2014
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Abstract of dissertation entitled
‘An evidence-based self-care management education program for elders with
COPD’
Submitted by
CHOY KWAN YEE, JENNY
for the Degree of Master of Nursing
at The University of Hong Kong
in July 2014
Chronic Obstructive Pulmonary Disease (COPD) is one of the most common
chronic disabling diseases. Approximately one-fourth of the old-age population in
Hong Kong is expected to be affected by COPD. Symptoms such as exacerbation
attack not only affect patients’ physical health, but also restrict their daily activities,
affecting their quality of life. This causes heavy financial and social burden to the
society.
Studies indicated that COPD self-care management education program is
effective in improving patients’ health-related quality of life and reducing their health
service utilization. However, such intervention in Hong Kong is lacking. There is a
need to develop an evidence-based guideline for the COPD elderlies in order to
improve their health outcomes.
The objectives of this dissertation are (1) to systematically evaluate the
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evidences from the literature on the effectiveness of the self-care management
education program for COPD patients in improving their health-related quality of life
and reducing their health service utilization; (2) to establish an evidence-based
guideline of the program; and (3) to develop implementation and evaluation plans for
the proposed program.
Four individual education sessions are proposed to be held by nurses in this
program. The target audience is elderlies aged 65 years old or above and are
diagnosed with mild-to-moderate stage of COPD. The target setting is one of the local
public elderly health centers. Evidence and related information are obtained from six
high quality studies. The implementation potential of the proposed program is
assessed according to the cost-benefit ratio, the transferability and feasibility of the
findings of the selected studies. An evidence-based guideline of the proposed program
is developed based on the obtained findings. The implementation plan and the
evaluation plan of the proposed program are established.
This evidence-based guideline is established to improve old-age COPD
patients’ health-related quality of life and reduce their health service use. It is
recommended to implement this program in all local elderly health centers so as to
enhance their health outcomes.
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An evidence-based self-care management education program for elders with
COPD
by
CHOY KWAN YEE, JENNY
BNurs(Hons) H.K.U, R.N.
A dissertation submitted in partial fulfillment of requirements for
the Degree of Master of Nursing
at The University of Hong Kong
July 2014
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Declaration
I declare that this dissertation represents my own work, except where due
acknowledgement is made, and that it has not been previously included in a thesis,
dissertation or report submitted to this University or to any other institution for a
degree, diploma or other qualifications.
Signed ______________________________________
CHOY KWAN YEE, JENNY
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Acknowledgements
I would like to express my sincere gratitude to my dissertation supervisor, Dr.
Athena Hong from the School of Nursing of The University of Hong Kong, for her
generous guidance and enthusiastic support during my master study.
Also, I am heartily thankful to the teaching team in the School of Nursing, The
University of Hong Kong, for their assistance and teaching over the past two years.
Besides, I would like to express my heart-felt thanks to the Public Health
Division and the Elderly Health Service of the Department of Health for providing all
kinds of support and assistance throughout the master program.
Moreover, I would like to present my sincere thanks to Dr. Clifford Attkisson
for his generosity in granting the permission of using the Client Satisfaction
Questionnaire (CSQ-8) in my dissertation.
Furthermore, I would like to take this opportunity to express my deepest
gratitude to Dr. P.W. Jones from the St. George’s University of London for the use of
St. George’s Respiratory Questionnaire (SGRQ) in this dissertation.
Last but not the least, I express my warmest thanks to my family and my love
for the encouragement and unfailing support throughout this master program.
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Contents
Declaration ...................................................................................................................... i
Acknowledgements ........................................................................................................ ii
Table of Contents .......................................................................................................... iii
List of Appendices ...................................................................................................... viii
Abbreviations ................................................................................................................ ix
Chapter 1 Introduction ................................................................................................ 1
1.1 Background .......................................................................................................... 2
1.1.1 Definition of COPD and its related clinical terms ......................................... 2
1.1.2 Magnitude of the problem ............................................................................. 3
1.2 Affirming the needs .............................................................................................. 4
1.2.1 Increased demand in standard COPD education ........................................... 4
1.2.2 Common misconception and poor inhalation techniques .............................. 5
1.2.3 Impaired quality of life .................................................................................. 5
1.2.4 Heavy burden on society ............................................................................... 6
1.2.5 Limitation of current COPD education ......................................................... 6
1.3 Research Question, Hypothesis, Objectives and Study Significance ................... 7
1.3.1 Research Question ......................................................................................... 7
1.3.2 Hypothesis ..................................................................................................... 8
1.3.3 Objectives ...................................................................................................... 8
1.3.4 Significance ................................................................................................... 9
Chapter 2 Critical appraisal ..................................................................................... 11
2.1 Searching strategies ............................................................................................ 11
2.1.1 Searching methodology ............................................................................... 11
2.1.2 Keywords ..................................................................................................... 11
2.1.3 Selection criteria .......................................................................................... 12
2.1.4 Results of the search .................................................................................... 13
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2.2 Appraisal strategies ............................................................................................ 14
2.3 Appraisal results ................................................................................................. 14
2.3.1 Overview of selected studies ....................................................................... 14
2.3.2 Research questions ...................................................................................... 15
2.3.3 Randomization ............................................................................................. 15
2.3.4 Binding Process ........................................................................................... 16
2.3.5 Treatment group and control group ............................................................. 16
2.3.6 Outcome measures and precision of results ................................................ 17
2.3.7 Applicability to the local setting.................................................................. 18
2.3.8 Summary of quality assessment of selected studies .................................... 19
2.4 Summary and synthesis of data .......................................................................... 19
2.4.1 Patient characteristics .................................................................................. 19
2.4.2 Intervention.................................................................................................. 20
2.4.2.1 The components of the self-management education program ............. 20
2.4.2.2 Training mode ...................................................................................... 21
2.4.2.3 Time-frame ........................................................................................... 22
2.4.3 Assessment and outcome measures ............................................................. 23
2.4.4 The effect of the self-management education program ............................... 24
2.5 Implication ......................................................................................................... 25
Chapter 3 Innovation ................................................................................................. 28
3.1 Name of the educational program ...................................................................... 28
3.2 Target audience .................................................................................................. 28
3.3 Target setting ...................................................................................................... 29
3.4 Target staff ......................................................................................................... 29
3.5 Length of follow-up ........................................................................................... 29
3.6 Patient education tools ....................................................................................... 29
3.7 Activities schedule ............................................................................................. 30
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3.8 Conclusion .......................................................................................................... 31
Chapter 4 Translation and Application ................................................................... 32
4.1 Implementation potential .................................................................................... 32
4.1.1 Target audience and setting ......................................................................... 32
4.1.1.1 Target audience .................................................................................... 32
4.1.1.2 Target setting ........................................................................................ 33
4.1.2 Transferability of the findings ..................................................................... 33
4.1.2.1 Similarity of target audience and setting .............................................. 34
4.1.2.1.1 Basic characteristics of the target audience .................................. 34
4.1.2.1.2 Fitness of the setting ..................................................................... 34
4.1.2.1.3 Gender difference ......................................................................... 34
4.1.2.1.4 Country of implementation .......................................................... 35
4.1.2.2 Philosophy of care ................................................................................ 35
4.1.2.3 Clients benefit from the innovation ..................................................... 35
4.1.2.4 Time-frame ........................................................................................... 36
4.1.3 Feasibility .................................................................................................... 36
4.1.3.1 Administrative support ......................................................................... 36
4.1.3.2 Consensus among staff and anticipated resistance .............................. 37
4.1.3.3 Co-operation among departments ........................................................ 38
4.1.3.4 Required skills and training ................................................................. 38
4.1.3.5 Availability of resources ...................................................................... 39
4.1.3.6 Measuring tools for the evaluation ....................................................... 39
4.1.4 Cost-benefit ratio of innovation................................................................... 40
4.1.4.1 Patients’ potential risks and costs ........................................................ 40
4.1.4.2 Potential benefits towards staff and clinic ........................................... 40
4.1.4.3 Potential risks of maintaining current practice .................................... 41
4.1.4.4 Potential material cost and non-material cost ...................................... 41
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Chapter 5 Developing an Evidence-Based Practice Guideline .............................. 43
5.1 Background ........................................................................................................ 43
5.2 Guideline title ..................................................................................................... 44
5.3 Target population ............................................................................................... 44
5.4 Intended users ..................................................................................................... 44
5.5 Aim of guideline ................................................................................................. 44
5.6 Objectives of guideline ....................................................................................... 45
5.7 Practice recommendations .................................................................................. 45
Chapter 6 Implementation Plan ............................................................................... 50
6.1 Communication plan .......................................................................................... 50
6.1.1 Identification of the stakeholders ................................................................ 50
6.1.2 Process of communication plan ................................................................... 52
6.1.2.1 Initiation stage ...................................................................................... 52
6.1.2.2 Guiding stage ....................................................................................... 53
6.1.2.3 Sustaining stage .................................................................................... 55
6.2 Pilot study plan ................................................................................................... 55
6.2.1 Objectives .................................................................................................... 55
6.2.2 Setting and recruitment................................................................................ 56
6.2.3 Time frame .................................................................................................. 56
6.2.4 Method ......................................................................................................... 57
6.2.5 Pilot review .................................................................................................. 58
Chapter 7 Evaluation Plan ........................................................................................ 59
7.1 Identification of outcomes .................................................................................. 59
7.1.1 Patient outcomes .......................................................................................... 59
7.1.2 Healthcare provider outcomes ..................................................................... 60
7.1.3 System outcome........................................................................................... 61
7.2 Nature and number of patients involved ............................................................ 61
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7.3 Timing and frequency of data collection .......................................................... 62
7.4 Data analyses ...................................................................................................... 63
7.5 Basis for an effective change of practice............................................................ 63
Chapter 8 Conclusion ................................................................................................ 65
Appendices .................................................................................................................. 67
References ................................................................................................................. 106
viii
List of Appendices
A Classification of severity of airflow limitation in COPD…………… 67
B Systematic Search…………………………………………………… 68
C Tables of Evidence………………………………………………….. 71
D Quality Assessment of Selected Studies……………………………. 74
E Similarity between proposed setting and literature reviewed………. 86
F Recommendations for the COPD education program……………… 87
G Time frame for Communication Plan & Pilot Study Plan…………. 89
H St. George’s Respiratory Questionnaire (SGRQ) – English Version. 90
I St. George’s Respiratory Questionnaire (SGRQ) – Chinese Version. 96
J Evaluation Questionnaire of Satisfaction level of nurses…………. 102
K Client Satisfaction Questionnaire -8 (CSQ-8)- English Version….. 103
L Client Satisfaction Questionnaire -8 (CSQ-8)- Chinese Version……. 104
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Abbreviations
Abbreviation Full text
CG Control Group
CHEU Central Health Education Unit
CNE Continuous Nursing Education
COPD Chronic Obstructive Pulmonary Disease
COS Chief of Service
CRQ Chronic Respiratory Questionnaire
CSQ-8 Client Satisfaction Questionnaire-8
CWC Communication Working Committee
DH Department of Health
EBP Evidence-based Practice
EHC Elderly Health Center
EHS Elderly Health Service
ePR Electronic Patient Record
FEV1/FVC Tiffeneau-Pinelli Index
GOLD Global Initiative for Chronic Obstructive Lung Disease
HEA Health Education Activity
HK Hong Kong
HRQoL Health-related Quality of Life
IG Intervention Group
MO Medical Officer
N Number
NO Nursing Officer
p Significance Level
QoL Quality of Life
RCT Randomized Controlled Trial
RN Registered Nurse
SD Standard Deviation
SGRQ St. George’s Respiratory Questionnaire
SIGN Scottish Intercollegiate Guidelines Network
x
Abbreviation Full text
SNO Senior Nursing Officer
SPSS Statistical Package for the Social Sciences
SQ Satisfaction Questionnaire
WHO World Health Organization
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Chapter 1
Introduction
In recent years, the number of people with chronic illnesses is increasing
worldwide due to the aging population (Chau et al., 2011). This rising trend will bring
a heavy burden to the society, leading to a severe consequence on the healthcare
service (Chau et al., 2011; Global Initiative for Chronic Obstructive Lung Disease,
2013). Chronic diseases are of significant concerns locally and globally. Chronic
obstructive pulmonary disease (COPD) is one of the most common chronic disabling
diseases which are usually managed in the primary care settings. According to the
Global Initiative for Chronic Obstructive Lung Disease (GOLD, 2013), COPD often
develops at the middle age and worsens with advancing age. It is a progressive
deteriorating disease and its disease state is irreversible. Symptoms of COPD such as
exacerbation attacks restrict the daily activities of the patients, affecting their quality
of life (QoL) (Elkington et al., 2005; Logne et al., 2010; Borge, Wahl & Moun, 2011).
Also, the increasing demand for healthcare services such as hospitalization may be
resulted due to an acute exacerbation. In this regard, COPD causes serious burdens,
including impaired QoL and heavy financial costs.
The main goal of COPD management is to reduce the frequency of
exacerbation attacks (GOLD, 2013). Research has found that COPD self-management
education intervention can help improving health-related quality of life (HRQoL) and
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reducing healthcare service use (Bourbeau, 2003). After the education program,
COPD patients can have a better QoL and less healthcare service is required.
Moreover, COPD education is not implemented in the Elderly Health Service (EHS)
of the Department of Health (DH) in Hong Kong (HK). It is essential to translate the
evidence from the literature into practice so as to improve patients’ HRQoL and
reduce their healthcare service utilization, enhancing their coping capability.
1.1 Background
1.1.1 Definition of COPD and its related clinical terms
According to the GOLD (2013), COPD is a progressive inflammatory lung
disease. It is defined as the ratio of Tiffeneau-Pinelli Index (FEV1/FVC) < 0.7, which
is measured by the persistent limitation of airflow by spirometer (Appendix A). Also,
the main characteristics of COPD are a chronic airflow limitation and pathological
changes in the lung. It can lead to various morbid conditions such as exacerbations.
The severity of COPD is categorized into four stages consisting of mild, moderate,
severe and very severe (Appendix A).
An exacerbation is an acute event and is characterized by a deterioration of the
patient’s respiratory system such as shortness of breath, chronic cough and sputum
production (GOLD, 2013). Under exacerbation attacks, patients experience different
levels of breathlessness and inability to resume usual activities, leading to social life
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restriction and a poor QoL (Rodriguez, Picabia, & Gregorio, 2002). When the disease
progresses, the impact of exacerbations become more magnificent, resulting in an
increased need for healthcare service utilization such as hospitalizations and a reduced
lung function. Hence, the risk of dying heightened (GOLD, 2013).
Although COPD is a life-threatening and incurable disease, COPD
exacerbations are preventable. In fact, the GOLD guidelines suggested that
knowledge of treatment, including inhalation technique and treatment with
long-acting inhaled bronchodilators, can reduce the number of exacerbations and
hospitalizations (GOLD, 2013). Also, more than 80% of exacerbation can be managed
in primary care clinics with pharmacologic therapy (Celli, Thomas & Anderson, 2008;
Hurst et al., 2010; GOLD, 2013). In order to optimize the chronic care of the COPD
patients, good compliance to the treatment regime is of great significance (GOLD,
2013).
1.1.2 Magnitude of the problem
In 2007, 210 million people are estimated to have COPD worldwide (Centre for
Health Promotion, 2010). In HK, although the exact prevalence of COPD is unknown
due to the difficulty in defining cases (Chau et al., 2011), the prevalence of COPD
elder patients is estimated to be 10.9%-25.9% (Ko et al., 2006; Ko et al., 2008).
The consequences of COPD can be serious. The World Health Organization
4
(WHO) estimated that COPD is the third leading cause of death and the fifth leading
cause of global burden of disease globally by 2030 (WHO, 2008). Also, COPD will
cause nearly 52 million disability-adjusted life years worldwide by 2030. Globally,
over 3 million people died of COPD in 2005, accounting for 5% of all deaths (Centre
for Health Promotion, 2010). The above data reflects the seriousness of COPD locally
and globally.
1.2 Affirming the needs
1.2.1 Increased demand in standard COPD education
Being a primary care nurse working in the Elderly Health Center (EHC) of the
DH, my work setting is similar to the out-patient clinics. All my clients are old-age
adults aged 65 years old or above. Among all my cases, around 200 elders have
COPD. Though the number of cases is not as large as the other chronic diseases, it is
noted that many of them are referred to nurses for health education such as inhalation
techniques and symptoms of exacerbation. Based on my own observation, the
frequency of the COPD education referral is around four times a week. However, over
half of the patients are not able to perform inhalation techniques properly and they do
not recognize the symptoms of exacerbation correctly.
5
1.2.2 Common misconception and poor inhalation techniques
Many COPD patients have poor and incorrect inhalation techniques. As
inhaled medication is the main treatment for COPD (Suzanne & Hodder, 2012), they
are usually in the form of pressurized metered dose inhaler. A proper inhalation
technique is essential for delivering the right dosage of medication to the lung (Fink &
Rubin, 2005). However, a study has shown that 98% of the COPD participants
claimed that they knew how to use an inhalation device but only 8.3% of them could
perform every step correctly (Souza et al., 2009). Besides, a systematic review
demonstrated that up to 94% of the COPD patients used their inhaler wrongly
(Lavorini et al., 2008).
Also, based on my daily observation, many of my COPD clients not only
confuse about the inhalation techniques, they also unsure the correct sequence in
taking the inhaled medication.
1.2.3 Impaired quality of life
Repeated exacerbation attacks will affect the psychological and social
functioning of COPD patients (Ferrer et al., 1997; Seemungal et al., 1998). According
to the DH, 15% of the COPD old-age patients display depressive symptoms (Chau et
al., 2011). Studies have demonstrated that poor inhalation technique is associated with
poor disease and symptom control, leading to a poor QoL (Restrepo et al., 2008).
6
1.2.4 Heavy burden on society
Most of the healthcare costs are from hospital admissions due to an acute
exacerbation (Chau et al, 2011). In HK, hospitalization is one of the major direct
costs of COPD. According to the Hospital Authority (2008), the proportion of hospital
admission due to COPD from the old-age adults rose from 64% in 2003 to 80% in
2006. Also, the length of stay for COPD old-age patients was 7.6 days per episode in
2006 and a total of 17.8 days in 2006. The medical cost due to COPD was enormous.
Around HK$844 million was spent on COPD hospitalization in HK in 2006 (Chau et
al., 2011). On average, the annual cost of hospitalization for each COPD old-age
patient was around HK$66000 in public hospitals in 2006 (Chau et al., 2011). The
healthcare and economic consequences of COPD is serious and results in enormous
healthcare expenditure.
1.2.5 Limitation of current COPD education
Although public hospitals and some non-governmental organizations will
organize pulmonary rehabilitation programs (Center for Health Promotion, 2010),
only a small proportion of these patients receive education about COPD and inhaler
techniques. A local study has shown that only 18 % of study participants with COPD
had ever received COPD education. Also, inhaler techniques were taught among 20 %
of COPD participants within the previous 6 months (Yu et al., 2011).
7
Pharmacotherapy with the proper use of inhaled medication is an important therapy
for COPD patients to decrease the distressing symptoms and related complications.
In spite of the need of this kind of education program, there is no existing
evidence-based protocol or guideline regarding the health education for COPD elders
in EHS of the DH in HK.
Due to the need of preventing the repeated exacerbations among the COPD
patients, the knowledge of self-management has to be strengthened. Nurses play an
important and essential role in promoting health education. There is a need to develop
a standard and well-organized guideline for an education program to enhance their
skills and knowledge of self -management and inhaler techniques, hoping to
improving their HRQoL and reducing the health service use.
1.3 Research Question, Hypothesis, Objectives and Study Significance
1.3.1 Research Question
The research question is developed according to the “PICO” principle.
(Sackett, Richardson, Rosenberg & Haynes, 1997) PICO is a way to form a research
question by identifying the population (P), intervention (I), comparison (C) and
outcome (O). In this dissertation, the “PICO” is as follows:
P : Elderlies aged 65 years old or above and are diagnosed with COPD living in
the community
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I : Self-care management education program
C : One of the Elderly Health Centers under the Department of Health
O : A reduction of health service utilization and improvement of their HRQoL
And the research question is ‘Among patients with chronic obstructive
pulmonary disease aged 65 years old or above residing in the community, how does
an evidence-based nurse-led self-care management education program improve their
health-related quality of life and reduce the health service utilization in the primary
care clinics in Hong Kong?’.
1.3.2 Hypothesis
Elderlies with COPD who receive the proposed education program will have a
better health-related quality of life and reduced health service utilization than those
who do not receive it in 12-month time.
1.3.3 Objectives
To review the current literature systematically on the effectiveness of a nurse-led
self-care management education program among COPD patients living in the
community.
1. To perform a quality critical appraisal of the selected studies in educational
interventions for elders with COPD in order to improve their HRQoL and
reduce their healthcare service utilization.
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2. To determine the feasibility and transferability of a nurse-led self-care
management education program for COPD patients in one of the EHCs
under the DH in HK
3. To develop an evidence-based self-care management education program
guideline for delivering the best quality of care to COPD patients living in
the community.
1.3.4 Significance
COPD is a fatal disease which imposes heavy burden to the society. An
evidence-based guideline for COPD education is profitable for COPD patients, health
care professions, the EHS as well as the healthcare system.
For COPD patients, they can have better knowledge about the COPD care through
the education program. Also, they can achieve a better control of their symptoms and
hence improving their QoL. As their needs of healthcare service such as
hospitalization and emergency department visit may reduce due to the program, the
healthcare service utilization may be reduced. Thus, the costs of the healthcare
expenditures may decrease, relieving the heavy financial burden on the healthcare
system.
For healthcare professions, as a standard guideline for COPD education is
developed, nurses in EHS can follow the guidelines and deliver the education
10
program. Thus, a better quality of care can be delivered through evidence-based
practice since the quality of an education program is ensured due to the
standardization. Also, rapport between nurses and COPD patients can be developed
through the education program. A good nurse-client relationship can be established.
Besides, since better quality of care can be delivered by the evidence-based
practice, the reputation of the EHS can be built up and enhanced.
11
Chapter 2
Critical appraisal
2.1 Searching strategies
2.1.1 Searching methodology
From 11 February to 22 August, 2013, a systematic search for relevant studies
relating to the self-management education program for COPD patients was carried out
in 17 electronic databases, including PubMed (1997-2013), ProQuest Health &
Medicine Databases (1994-2013) consisting of 16 searching engines, which were the
British Nursing Index, ComDisDome, COS Conference Papers Index, ebrary®
e-books, GenderWatch, Health & Safety Science Abstracts, MEDLINE® , PILOTS:
Published International Literature On Traumatic Stress, ProQuest Dissertations &
Theses: UK & Ireland: Health & Medicine, ProQuest Dissertations & Theses A&I:
Health & Medicine, ProQuest Medical Library, ProQuest Research Library: Health &
Medicine, PsycARTICLES, PsycBOOKS, PsycINFO, TOXLINE. All reference lists
of the identified articles were screened manually for additional articles.
2.1.2 Keywords
The initial search consisted of five keywords, which are ‘chronic obstructive
pulmonary disease’, ‘self-management’, ‘education program’, ‘nurse-led’ and ‘health
12
service utilization’. To identify additional relevant studies, similar keywords were
used in subsequent search. These keywords are ‘copd lung’, ‘copd pulmonary’,
‘disease management’, ‘self- care’, ‘educational interventions’, ‘educational program’,
‘health education’, ‘patient education’, ‘nurse-led care’, ‘nurse-led interventions’.
Details of the database and the search are listed in the tables in Appendix B.
2.1.3. Selection criteria
The selection criteria were chosen based on four major aspects, including target
participants, the design of study, intervention and outcome measures.
For target participants, patients who are diagnosed with mild, moderate, severe
or very severe COPD based on the GOLD criteria were included (GOLD, 2013).
However, hospitalized or institutionalized COPD patients, which are expected to have
better control of exacerbation and inhalation, were excluded. Also, patients diagnosed
with severe mental and psychiatric diseases (e.g. schizophrenia) or cognitive
dysfunctions (e.g. dementia) were also excluded as their learning ability is relatively
weak.
Randomized controlled trials (RCTs) were included and is regarded as a high
level of evidence.
13
For the intervention component, studies involving self-management education
program for COPD patients were included. However, studies were excluded if the
program was web-based since it is not feasible in the proposed setting.
The included studies focused on main outcome measures − healthcare service
utilization and HRQoL. Health care service utilization due to exacerbation-related
diseases among COPD patients included accident and emergency department visits,
hospital admissions, and unscheduled primary care centre visits (outpatient
department).
2.1.4 Results of the search
10173 studies were retrieved by using the mentioned keywords in the 17
electronic databases. Judging according to the selection criteria, 56 studies remained
in the review. Then, 35 studies were retained after removing the duplicates. After
screening the titles and the abstracts of the remaining papers, 13 potential studies were
yielded. Finally, 6 articles were yielded after checking the full text.
14
2.2 Appraisal strategies
The data extracted from the six chosen studies were presented in the tables of
evidence according to the Scottish Intercollegiate Guidelines Network (SIGN) (2008).
The tables of evidence summarized the type of study, level of evidence, patient
characteristics, interventions, comparison, length of follow-up, outcome measures and
the effect size of the selected papers. The details of the tables of evidence of the six
selected studies are shown in Appendix C.
In addition, the quality of six selected papers was critically assessed by the
updated version of the ‘Methodology checklist 2: Controlled trials’ of the SIGN
(2013). Since all of the selected studies were RCTs, all of them were criticized by the
same checklist in this dissertation. The detailed appraisal is shown in Appendix D.
2.3 Appraisal results
2.3.1 Overview of selected studies
All of the six selected papers were RCTs. They were published from 1999 to
2008. Among six studies, two of them were conducted in Norway (Gallefoss, Bakke
& Kjaersgaard, 1999; Gallefoss & Bakke, 2000), two in Canada (Bourbeau et al.,
2003; Gadoury et al., 2005), one in London (Sridhar et al., 2008) and one in Sweden
(Efraimsson, Hillervik, & Ehrenberg, 2008). No local study was found. Studies were
15
conducted from 1994 to 2005. Ethical approval was noted in all studies. The source of
funding was reported in five studies (Gallefoss, Bakke & Kjaersgaard, 1999;
Bourbeau et al., 2003; Gadoury et al., 2005; Efraimsson, Hillervik & Ehrenberg, 2008;
Sridhar et al., 2008).
2.3.2 Research Question
All studies provided clear background information about COPD and stated the
research questions, objectives and aims regarding the self-management education
program for COPD patients.
2.3.3 Randomization
The study participants were assigned to either intervention group or control
group randomly in all selected studies. All of them clearly described the
randomization method (i.e. use of random numbers). However, only three studies
used central computerized allocation for concealment (Bourbeau et al., 2003; Gadoury
et al., 2005) and drawing for allocation by an independent person (Efraimsson,
Hillervik & Ehrenberg, 2008).
16
2.3.4 Blinding Process
Due to the nature of education intervention, blinding is not possible. Specifically,
all study participants and the researchers would need to be informed about the
education program and to deliver the education respectively. On the other hand, two
studies blinded the independent process evaluator (Bourbeau et al., 2003; Gadoury et
al., 2005).
2.3.5 Treatment group and control group
All studies provided the baseline characteristics of the study participants in both
control and intervention group. The demographic information such as sex, age, lung
function was compared. Most of the characteristics were similar and comparable at
the study commencement.
Across all studies, participants in the control group received usual care without
any additional treatment and those in the intervention group only received COPD
self-management program. The only difference between two groups was the
education program in all studies.
All studies clearly stated the dropout rates. The dropout rates of the intervention
groups ranged from 5.2% to 12.9% and the respective rates for the control groups
17
were from 11.6% to 19.7%. One study only stated out the overall dropout rate which
was 19.2% (Efraimsson, Hillervik & Ehrenberg, 2008).
2.3.6 Outcome measures and precision of results
All studies clearly stated the outcomes and these outcomes were measured by
valid and reliable tools. For health care service utilization, the data was collected
through hospital records, records of general practitioners or health insurance
databases in four studies (Gallefoss & Bakke, 2000; Bourbeau et al., 2003; Gadoury et
al., 2005; Sridhar et al., 2008). For HRQoL, it was measured by St. George
Respiratory Questionnaire (SGRQ) (Gallefoss, Bakke & Kjaersgaard, 1999; Bourbeau
et al., 2003; Efraimsson, Hillervik & Ehrenberg, 2008) and Chronic Respiratory
Questionnaire (CRQ) (Sridhar et al., 2008). Both of the two questionnaires were valid
and sensitive in determining the quality of life (Chan et al., 2002; Meng, Chen, Lo &
Cheng, 2011).
The outcomes were compared by various tests and analyses. Four studies used
Mann -Whitney U Test to compare the difference between the intervention group and
the control group (Gallefoss & Bakke, 2000; Efraimsson, Hillervik, & Ehrenberg,
2008; Sridhar et al., 2008). The Fisher exact test and independent or paired T-tests
were used in three studies (Bourbeau et al., 2003; Gadoury et al., 2005; Efraimsson,
18
Hillervik & Ehrenberg, 2008). The Chi square test was used in four studies (Gallefoss,
Bakke & Kjaersgaard, 1999; Gallefoss & Bakke, 2000; Bourbeau et al., 2003; Sridhar
et al., 2008). All studies defined p-value at the five percent level as statistically
significant.
The intention to treat analysis was performed in two studies (Bourbeau et al.,
2003; Gadoury et al., 2005). The other four papers did not clearly state their
treatments for the dropout (Gallefoss, Bakke & Kjaersgaard, 1999; Gallefoss & Bakke,
2000; Efraimsson, Hillervik & Ehrenberg, 2008; Sridhar et al., 2008).
Three of the six studies were conducted in one site only (Gallefoss, Bakke &
Kjaersgaard, 1999; Gallefoss & Bakke, 2000; Efraimsson, Hillervik, & Ehrenberg,
2008) while the other three were carried out in multiple centers (Bourbeau et al., 2003;
Gadoury et al., 2005; Sridhar et al., 2008). However, none of the studies with multiple
centers compared the results across the centers as the differences of the centers could
not be determined.
2.3.7 Applicability to the local setting
The results of the five studies are applicable to the local setting as the
characteristics of these studies were similar to that of the proposed guideline. Also,
these studies are of moderate-to-high quality of methodology. However, one study
19
may not be applicable to the proposed setting since it is of poor methodology quality
(Sridhar et al., 2008).
2.3.8 Summary of quality assessment of selected studies
Using the SIGN checklist, two studies were rated as 1++ as they had covered
most of the criteria in the checklist, indicating a high level of evidence (Bourbeau et
al., 2003; Gadoury et al., 2005). Three of the studies were rated as 1+, which were of
the medium level of evidence (Gallefoss, Bakke & Kjaersgaard, 1999; Gallefoss &
Bakke, 2000; Efraimsson, Hillervik & Ehrenberg, 2008). One study was considered as
having poor methodological quality (Sridhar et al., 2008). It did not mention the
concealment method. The intention to treat was not done as well. Also, the dropout
rate of the control group was relatively high (19.7%) and the results were not
compared across multiple research sites. These may lead to bias and affect the quality
of evidence.
2.4. Summary and synthesis of data
2.4.1 Patient characteristics
The study participants of the six selected studies were all diagnosed with COPD
with various severities. Their mean age ranged from 57 to 69.7 years old. The sample
size of these studies varied from 52 to 191. Around 19.7% to 39% of the study
20
participants were smokers at the baseline. The study participants were recruited from
1994 to 2004. For the site of intervention, two studies were conducted in outpatient
chest clinics (Gallefoss, Bakke & Kjaersgaard, 1999; Gallefoss & Bakke, 2000), one
in a primary health care clinic (Efraimsson, Hillervik & Ehrenberg, 2008), two in
health centers of hospitals (Bourbeau et al., 2003; Gadoury et al., 2005) and one in the
community and hospital (Sridhar et al., 2008).
2.4.2 Intervention
2.4.2.1 The component of the self-management education program
For intervention, all studies involved self-management education program.
Moreover, the components and content of the self-care management education
program in these six studies varied. The common education components were
inhalation techniques, early symptoms of exacerbation and its management, smoking
cessation advice, use of a personalized action plan for acute exacerbation. Two studies
involved a compulsory physical training program (Efraimsson, Hillervik & Ehrenberg,
2008; Sridhar et al., 2008) while the other two consisted of an optional exercise
program (Bourbeau et al., 2003; Gadoury et al., 2005). Also, written materials such as
workbooks, brochures were given to study participants in all studies.
21
2.4.2.2 Training mode
The delivery time varied across these six studies. Three studies divided education
programs into seven to eight sessions with an interval of one week (Bourbeau et al.,
2003; Gadoury et al., 2005; Sridhar et al., 2008). Two of them divided the program
into 4 sessions (Gallefoss, Bakke & Kjaersgaard, 1999; Gallefoss & Bakke, 2000)
while one delivered the education program into two visits (Efraimsson, Hillervik &
Ehrenberg, 2008).
For the duration of the education session, three studies delivered each session for
one hour (Bourbeau et al., 2003; Gadoury et al., 2005; Efraimsson, Hillervik &
Ehrenberg, 2008). One had each session lasting for two hours for each session
(Sridhar et al., 2008). The remaining two studies gave education to patients for a
combination of two sessions with forty minutes and two sessions with two hours
(Gallefoss, Bakke & Kjaersgaard, 1999; Gallefoss & Bakke, 2000).
For the training mode, three studies were in individual education (Bourbeau et al.,
2003; Gadoury et al., 2005; Efraimsson, Hillervik, & Ehrenberg, 2008). Three of them
combined group and individual education in different sessions (Gallefoss, Bakke &
Kjaersgaard, 1999; Gallefoss & Bakke, 2000; Sridhar et al., 2008).
22
Among all six studies, three of them involved telephone calls for follow-up
during and after the education period (Bourbeau et al., 2003; Gadoury et al., 2005;
Sridhar et al., 2008).
Nurses were the one who delivered the education program in all studies. Other
disciplines such as physiotherapists, dietitians and respiratory therapists were
involved in the education program in five studies (Gallefoss, Bakke & Kjaersgaard,
1999; Gallefoss & Bakke, 2000; Bourbeau et al., 2003; Gadoury et al., 2005;
Efraimsson, Hillervik & Ehrenberg, 2008).
2.4.2.3 Time-frame
The length of follow-up varied from 4 to 24 months. Three studies followed
cases after 12 months of intervention (Gallefoss, Bakke & Kjaersgaard, 1999;
Gallefoss & Bakke, 2000; Bourbeau et al., 2003) while two of them investigated cases
for 24 months after the education program (Gadoury et al., 2005; Sridhar et al., 2008).
Only one of them followed cases for 4 months after the program (Efraimsson,
Hillervik & Ehrenberg, 2008). Since some studies emphasized on the long term
effects of the education program and some focused on the short term effects, the
length of follow up of these studies varied.
23
2.4.3. Assessment and outcome measures
Different outcomes were investigated among these six studies, including HRQoL
(Gallefoss, Bakke & Kjaersgaard, 1999; Bourbeau et al., 2003; Efraimsson, Hillervik
& Ehrenberg, 2008; Sridhar et al., 2008), healthcare service utilization (Gallefoss &
Bakke, 2000; Bourbeau et al., 2003; Gadoury et al., 2005; Sridhar et al., 2008),
smoking cessation rate (Efraimsson, Hillervik & Ehrenberg, 2008), Knowledge about
COPD (Efraimsson, Hillervik & Ehrenberg, 2008), the death rate of COPD (Sridhar et
al., 2008), the number of absence from work (Gallefoss & Bakke, 2000) and the
number of acute exacerbation (Bourbeau et al., 2003). In this dissertation, HRQoL
and healthcare service utilization are the main focus as they are the major burdens and
concerns to COPD patients.
For HRQoL, three of them used SGRQ as measurement of quality of life
(Gallefoss, Bakke & Kjaersgaard, 1999; Bourbeau et al., 2003; Efraimsson, Hillervik
& Ehrenberg, 2008) while one study adopted CRQ to measure QoL (Sridhar et al.,
2008). Both measurements are widely used in nowadays and are valid and reliable for
assessing the HRQoL among COPD patients (Rutten-van, Roos & Van Noord, 1999).
Also, for healthcare service utilization, four studies investigated the number of
unscheduled primary care visits, emergency department visits, hospital admissions
24
and general practitioner visits as the outcome measures (Gallefoss & Bakke, 2000;
Bourbeau et al., 2003; Gadoury et al., 2005; Sridhar et al., 2008).
2.4.4 The effect of the self-management education program
After reviewing the studies regarding self-management education program, the
intervention group in two studies had a significant improvement in HRQoL
(Bourbean et al., 2003; Efraimsson et al., 2008). However, two studies showed
statistically insignificant improvement in QoL (Gallefoss, Bakke & Kjaersgaard, 1999;
Sridhar et al., 2008). A possible reason for the study of Sridhar et al (2008) may be
due to the poor quality of methodology, which may affect the results. And a likely
explanation for the study of Gallefoss, Bakke & Kjaersgaard (1999) was that the
participants were not investigated with SGRQ before the trial. They used four simple
HRQoL questions which are translated from Omnibus interviews before the
intervention and examined with SGRQ at the follow-up period. Hence, changes of pre
and post education could not be examined. This could lead to a variation of the real
effect of the education program.
Healthcare service utilization was used in four studies as outcomes. Among the
four studies, statistically significant reduced needs of healthcare service utilization
after 12-24 months of intervention were noted in three studies (Gallfoss & Bakke,
25
2000; Bourbeau et al., 2003; Efraimsson, Hillervik & Ehrenberg, 2008). However,
one study demonstrated an insignificant result in healthcare service utilization
(Sridhar et al., 2008). A likely explanation is that around 30% of study participants
were oxygen dependent at home, which was relatively high when comparing with
other studies. As the participants’ general respiratory condition was bad, the need of
healthcare service such as hospitalization maybe more common for this group of
patients.
2.5 Implication
Overall speaking, there is sufficient evidence to show that the self-care
management education program can help COPD clients to improve their HRQoL and
reduce healthcare service utilization. The proposed setting of this self-care
management education program is one of the EHCs under DH.
The components of this program included inhalation techniques, early
symptoms of exacerbation and its management. However, smoking cessation will not
be included in the program since EHS has held support groups and health talks about
smoking cessation regularly. Also, physical exercise will not be involved as many of
the COPD clients are having physiotherapy counseling in EHS regularly. A
26
personalized action plan for acute exacerbation is suggested to involve in the program
so as to promote self-care for the symptoms monitoring in their daily lives.
Clear written materials with visual instructions will be provided so as to
facilitate their learning.
For the training mode, individual health education is recommended as a
personalized action plan has to be established during the program. One-to-one
education can allow nurses to elaborate the content according to the needs and
concerns of the clients and it is more feasible in the primary care clinic setting.
The number of education sessions varied from two to eight in total. Most of
them can show significant result in improvement of health outcomes and quality of
life. Four sessions were appropriate and feasible in the clinic setting. As suggested by
three studies (Bourbean et al., 2003; Gadoury et al., 2005; Sridhar et al, 2008), weekly
one-hour education session is recommended. The follow-up internal is suggested to be
three months so as to match the day of their chronic follow-up, saving transportation
fee and time. Since this dissertation focuses on the short term effects of the
self-management education program, the length of the follow- up is suggested to be
12 months (Gallefoss, Bakke & Kjaersgaard, 1999; Gallefoss & Bakke, 2000;
Bourbeau et al., 2003). In this way, four sessions of the self-management education
27
program will be carried out weekly for one hour, the follow-up period is 3-month and
12-month.
28
Chapter 3
Innovation
The critical appraisal of the reviewed literature performed in the previous
chapters showed that a nurse-led self-care management education program is
beneficial to COPD patients by improving patients’ HRQoL and reducing their needs
of health service. It is important to translate the evidence into an innovation in the
local setting.
3.1 Name of the educational program
An evidence-based self-care management education program for elders with COPD
3.2 Target audience
Patients aged 65 or above and are diagnosed with mild-to-moderate stage of
COPD by spirometer according to GOLD (2013) are the target audience (Appendix
A). Patients who are hospitalized or institutionalized or with severe mental diseases or
cognitive dysfunction or terminal diseases will be excluded. Also, patients who are
participating similar program in other settings are excluded as well. All eligible
participants will be recruited by convenience sampling.
29
3.3 Target setting
An Elderly Health Center (EHC) under EHS of the DH will be chosen as the
pilot clinic.
3.4 Target staff
One Nursing Officer (NO) and two registered nurses (RNs) who work in the
pilot clinic are the target staff.
3.5 Length of follow-up
The length of follow-up of this intervention will last for one year. According to
the informal statistics in the unit, there are around 200 patients with COPD receiving
chronic care in the selected setting in 2013. These patients visited the clinic regularly,
mostly every 3 months, for follow-up and medication for COPD. The number of
COPD cases is estimated to grow at around 20% annually based on the previous
record. As there are only three nurses in the selected clinic, it is estimated that around
100 cases will be recruited in a year.
3.6 Patient education tools
Clearly written pamphlets with visual instructions will be provided to
participants during the education sessions to facilitate their learning. The detailed
30
information about inhaler use, COPD exacerbation management will be covered in the
pamphlets.
3.7 Activities schedule
Before the implementation of innovation, nurses will receive training. Two half
day training courses will be provided to each nurse during working hours in the
selected setting.
The target audience will be recruited according to the inclusion criteria. Nurses
will invite eligible patients to participate in the program. After obtaining verbal
consent, the schedule of the education sessions will be given to patients. Phone calls
will be given to patients one day before the education sessions for gentle reminder.
There are four individual education sessions in total, each session will last for
around 1 hour. Four weekly sessions will be held. Then the follow-up will be made 3
months and 12-month after the first session of the program. The date of the first
session and the follow-ups will be arranged on the same day of their follow-up. This
program consists of several parts such as inhalation techniques, early signs of
exacerbation and its management. Return demonstration is needed so as to ensure the
correct techniques are performed. Also, a personalized action plan will be developed
with each patient during the education sessions. Baseline assessment including the
31
SGRQ and the past health service usage within the past 12 months will be performed
at the beginning and at the end of the education sessions. During the program, the
regimes of patients remain unchanged. If participants do not return to the clinic on the
day of education session, phone calls for rescheduling will be made. If they miss more
than two sessions, they will be counted as drop out.
3.8 Conclusion
This program is designed to improve patients’ health outcome and enhance their
quality of care. If the pilot program runs successfully, all the remaining 17 EHCs will
implement this program so as to maximize its benefit.
32
Chapter 4
Translation and Application
4.1 Implementation Potential
In order to develop evidence-based guideline for this COPD education program,
it is essential to assess the implementation potential of this new innovation. The
implementation potential of this program will be discussed in terms of transferability,
feasibility and the cost-benefit ratio according to the criteria developed by Polit &
Beck (2008).
4.1.1 Target audience and setting
4.1.1.1 Target audience
The target participants are elders aged 65 or above and are diagnosed with
mild-to-moderate COPD according to the GOLD criteria (2013).They are also
receiving chronic care under the selected EHC. They can be new or old cases. They
have to be able to communicate with fluent Cantonese or Mandarin or English.
However, patients diagnosed with any severe psychiatric diseases or cognitive
dysfunction or terminal diseases will be excluded. Also, patients who are participating
similar program in other settings are excluded as well.
33
4.1.1.2 Target setting
The COPD education program will be implemented in an EHC under EHS of the
DH in HK. The target setting provides health assessment, curative treatment and
health education to elderlies (Elderly Health Service, 2012). Five staff are responsible
for running the clinic, including two Medical Officers (MOs), one NO and two RNs in
the target setting. There are around 50 attendances every day. Among the 50
attendances, around one tenth are COPD cases. In EHS, patients visit the clinic by
making appointments for chronic cases or walk in for curative cases. During the
medical consultation, MOs will prescribe medication if necessary. Some patients will
be referred to nurses for brief health advice if necessary. Currently, there is no
dedicated education for COPD patients and the health education is not standardized.
Also, not all COPD patients will be provided with health education.
4.1.2 Transferability of the findings
In order to transfer the evidence into practice, it is essential to assess whether the
findings from the selected studies are transferable to the target setting. Four areas will
be considered for the fitness of the intervention, including similarity of target
audience and setting, philosophy of care, clients benefit from the innovation and
time-frame.
34
4.1.2.1 Similarity of target audience and setting
4.1.2.1.1 Basic characteristics of the target audience
The basic characteristics of the patients and the setting between the proposed and
literature are compared and listed in appendix E. It can be seen that the proposed
innovation and literature shared similar characteristics in terms of population, severity
of disease and intervention.
4.1.2.1.2 Fitness of the setting
According to the selected studies, five studies delivered the education program in
outpatient clinics while the proposed innovation will be implemented in the EHC.
They shared a similar nature of setting. Also, nurses will be responsible for delivering
the program in the proposed setting while nurses are the main educator in most
selected studies.
4.1.2.1.3 Gender difference
The men-to-women ratio of the identified studies was around 1-to-1 while in the
EHC is around 3-to-1. Both male and female elderlies will be recruited for the
program and the gender disparity is not expected to substantially influence to the
innovation.
35
4.1.2.1.4 Country of implementation
All studies were carried out in western developed countries while the proposed
innovation will be implemented in HK Chinese society. Although there may be
cultural difference, it is not expected to influence the intervention.
4.1.2.2 Philosophy of care
Philosophy of care is another essential determinant in assessing the
transferability of innovation. The aim of this program is to enhance the knowledge of
the COPD patients and hence improving their HRQoL and reducing healthcare
service utilization. Also, it aims to provide evidence-based guideline, delivering a
better quality of nursing care. The objectives of the chosen literature are similar to
that of the proposed innovation. And this program is coherent with the philosophy of
care of EHS. The mission of EHS is to provide quality primary healthcare services for
promoting the health of the elderly population with client-oriented approach (Elderly
Health Service, 2012). This program matches the emphasis of a holistic care in EHS.
4.1.2.3 Clients benefit from the innovation
As EHS emphasizes on the continuity of care, this program will target on the
COPD patients who are under chronic care. Around 100 patients will be benefited
from the program annually. If more than 100 patients are recruited, the first 100
36
recruited patients will be the participants and the others will join the program next
year.
4.1.2.4 Time-frame
It is estimated that the implementation and evaluation of the innovation will take
around one year. The education sessions will be arranged in the following time frame:
the baseline, the second visit, the third visit, last-visit, 3-month, and 12-month
follow-up. The time frame is similar to that of literature.
4.1.3 Feasibility
Six aspects of the feasibility have to be considered for a smooth program in the
clinical setting. They are the administrative support, consensus among staff and
anticipated resistance, co-operation among departments, required skills and training,
availability of resources and measuring tools for evaluation.
4.1.3.1 Administrative support
It is essential to communicate well with the Senior Nursing Officer (SNO) so as
to gain support. Generally, the target setting provides a supportive and positive
climate to research. DH encourages evidence-based practices (EBPs) in clinical
setting. EHS has put much effort in the development of evidence-based nursing
guidelines. Besides, nurses have the autonomy to introduce a new innovation in the
37
selected setting after obtaining approval from the administrators. All the
administrators support EBPs.
Since the overall organization culture is conducive to research utilization and the
innovation is beneficial to patients, the administrative level is likely to support this
innovation.
4.1.3.2 Consensus among staff and anticipated resistance
As all nursing staffs have to work on the new innovation, consensus among staff
is important in running the program. Both the nursing and the administrative staff
have a consensus about the benefits of evidence-based practices. Yet, some nurses
may be reluctant to change to a new practice as they may think that it will increase
their workload.
To increase the motivation, the COPD education program will be recommended
to count as a health education activity (HEA). As every nurse in EHC has to perform
5 HEAs every month as set by the EHS, counting it into a HEA indicates that running
this program is not an extra work. In this way, this innovation will not affect their
daily work. Besides, it is essential to show them the supportive evidence of this
program and provide sufficient time for them to prepare and practice.
The other healthcare professionals such as MOs are likely to support this
38
innovation as it does not involve any changes in their existing practice and it is
beneficial to patients.
4.1.3.3 Co-operation among departments
It is important to co-operate with other departments so as to implement the
program smoothly. Since this innovation is new, existing pamphlets have to be
revised and reprinted. As the Central Health Education Unit (CHEU) is responsible
for the printing of the written materials, co-operation with CHEU is needed for
developing the pamphlets. This may need the support from the administrators.
4.1.3.4 Required skills and training
All of the three nurses in the target setting will deliver the education program. As
they hold health talks and support groups every week, they have good communication
skills in the delivery of health education. Besides, all of them are bachelor holders,
who have basic knowledge about COPD management. However, since there is no
existing standard COPD education program in EHS, nurses should receive related
training in order to obtain updated knowledge. The content of the training consists of
several elements, including updated management of COPD exacerbation, the usage of
the assessment tools and proper communication skills. Since the training is within the
working hours, no extra time is required. Nurses can obtain Continuous Nursing
39
Education (CNE) points after completing the training so as to boost their learning
motivation.
4.1.3.5 Availability of resources
As HEAs are held regularly in the target setting, equipment such as interview
rooms, computers, projector and microphones are readily available, no extra
preparation is needed. However, existing pamphlets have to be revised to meet the
theme of self-care of this innovation.
4.1.3.6 Measuring tools for the evaluation
According to the selected studies, SGRQ is an important measuring tool for
assessing HRQoL among the COPD patients (Gallefoss, Bakke & Kjaersgaard, 1999;
Bourbeau et al., 2003; Efraimsson, Hillervik & Ehrenberg, 2008). It is commonly
used for the COPD patients in recent years (Rhazi et al., 2006; Xu et al., 2008).
Also, for the usage of the healthcare service, the number of unscheduled primary
care visits, accident and emergency visits, hospitalizations are used for assessing
healthcare service utilization (Gallefoss & Bakke, 2000; Bourbeau et al., 2003;
Gadoury et al., 2005; Sridhar et al., 2008).
40
4.1.4 Cost-benefit ratio of innovation
4.1.4.1 Patients’ potential risks and costs
This innovation has no harms to patients as their existing regime remains
unchanged. The participants are still under the expert care of MOs. Also, this program
is free of charge. The only cost to patients is the time for education. However, it can
improve their health outcomes and thus it is worthy to spend time on this program.
4.1.4.2 Potential benefits towards staff and clinic
Different parties will have benefits after the implementation of the program,
including patients, nurses, and EHS.
For COPD patients, they can have better knowledge about the COPD
management, clarifying misconceptions on inhaler use. Hence, they have better
disease control. This can reduce the rate of exacerbation attacks, improving their
HRQoL and reducing healthcare needs.
For nurses, they can acquire new knowledge about the COPD management
through the preparation of this program. Also, systematic and standardized guideline
can help to ensure the quality of education. This can raise their job satisfaction and
staff morale. Also, a good nurse-client relationship can be developed through this
41
innovation.
For EHS, as this program can help the COPD patients to improve their health
outcomes and HRQoL, they will feel more satisfied with the service, leading to an
enhanced reputation for the EHS.
4.1.4.3 Potential risks of maintaining current practice
Without implementation of this education program, the patients may have higher
risk of mortality. As many of them have misconceptions on inhaler use and COPD
management as mentioned in Chapter 1, poor disease control will easily lead to
exacerbation, resulting in poor HRQoL and a higher risk of death (GOLD, 2013). If
the current practice is kept, frequent exacerbation attacks and high hospitalization rate
will remain and also causes heavy financial burden to the society.
4.1.4.4 Potential material cost and non-material cost
For the material cost, the main expense is the printing cost of the written
materials, which is around HK$300. The other materials such as education models,
computers and audiovisual equipment are currently available in the selected setting. A
photocopying machine is currently available in the target setting. In this way, the
material cost of the innovation is minimal when comparing with the enormous
healthcare expenditures.
42
For non-material cost, the extra time for preparation of the program is the major
source of non-material cost. Stress and anxiety may arise among nurses as the
innovation is new. They have to pay effort to adapt to the new practice. This may
lower the staff morale. Therefore, a flexible pace for the innovation adoption is
suggested in order to provide adequate time for the preparation.
In conclusion, this innovation is transferrable, feasible and cost-effective in the
local setting. It can be implemented successfully.
43
Chapter 5
Developing an Evidence-Based Practice Guideline
After determining the transferability, feasibility and cost-effectiveness of this
new innovation in the target setting, an evidence-based practice guideline is
developed. Ten practice recommendations are synthesized from the selected studies.
The level of evidence and the grades of recommendations are determined by the
criteria developed by SIGN (2011). Tables of the detailed grades of recommendations
are listed in Appendix F.
5.1 Background
COPD exacerbation is an important and serious public health issue which causes
enormous social and financial burden to the society in recent years. Many research
studies demonstrated that self-care management education program can help COPD
patients to improve their HRQoL and decrease their needs for healthcare service.
However, there is no existing COPD self- management education program in HK.
There is a great urge to implement such program in HK to meet the needs of COPD
patients.
44
5.2 Guideline title
An evidence-based self-care management education program for elders with COPD
5.3 Target population
Patients attending EHC with the following criteria:
Aged 65 or above
Diagnosed with mild-to-moderate COPD according to the GOLD criteria
(GOLD, 2013)
Currently receiving chronic care under EHC
No severe psychiatric diseases or cognitive dysfunction or terminal diseases
Able to communicate with Cantonese, Mandarin or English
Not hospitalized or institutionalized
Not participating similar program in other settings
5.4 Intended users
This guideline is intended to develop for nurses who work in EHS of the DH.
5.5 Aim of guideline
The aim of guideline is to provide evidence-based recommendations for nurses
to follow and standardize the health education for COPD patients.
45
5.6 Objectives of guideline
To summarize the clinical evidence for self-care management education
program for COPD patients
To synthesize clinical practice recommendations for the health education
for COPD patients based on the best available evidence
To standardize the health education for COPD patients in EHS so as to
assist nurses to deliver a structured COPD education
To promote the education program for COPD patients in order to improve
their HRQoL and reduce their needs of healthcare service
5.7 Practice Recommendations
Recommendation 1: New Innovation
Recommendation 1.1: A self-care management education program can help COPD
elderlies to improve their HRQoL and reduce the healthcare service utilization (Grade
A).
Self-care management education program is found to be an effective way for
COPD management in improving HRQoL (Bourbeau et al., 2003) (1++); (Efraimsson,
Hillervik & Ehrenberg, 2008) (1+) and reducing healthcare needs (Bourbeau et al.,
2003; Gadoury et al., 2005) (1++); (Gallefoss & Bakke, 2000) (1+). These studies can
provide supportive evidence for these two aspects.
46
Recommendation 2: Mode of Education
Recommendation 2.1: Nurses are responsible for delivering the education program
(Grade A).
Nurses are the major health educator and therefore the education program should
be provided by nurses (Bourbeau et al., 2003; Gadoury et al., 2005) (1++); (Gallefoss,
Bakke & Kjaersgaard, 1999; Gallefoss & Bakke, 2000; Efraimsson, Hillervik &
Ehrenberg, 2008) (1+); (Sridhar et al., 2008) (1- ).
The trusting relationship between nurses and patients is an important element to
enhance the positive outcomes of the innovation.
Recommendation 2.2: The education program is held in individual sessions (Grade
A).
Nurses can address the needs of each client during the individual sessions
(Bourbeau et al., 2003; Gadoury et al., 2005) (1++); (Efraimsson, Hillervik &
Ehrenberg, 2008) (1+). Since this program is in a client-oriented approach, individual
sessions can help nurses to deliver a tailor-made education.
Recommendation 2.3: The duration of each education session is around 1 hour
(Grade A).
47
The length of each education session is around 1 hour (Bourbeau et al., 2003;
Gadoury et al., 2005) (1++); (Efraimsson, Hillervik & Ehrenberg, 2008) (1+). If the
length of each session is too long, it is not feasible in the busy EHC. On the other
hand, short education session is not sufficient for nurses to provide suitable and
appropriate education.
Recommendation 3: Components of the education program
Recommendation 3.1: The education topics include inhalation techniques, signs of
exacerbation and its management (Grade A).
As proper inhalation technique can help COPD patients to receive optimal
dosage of medication, it is essential for the daily care of the disease control (Bourbeau
et al., 2003; Gadoury et al., 2005) (1++); (Gallefoss, Bakke & Kjaersgaard, 1999;
Gallefoss & Bakke, 2000; Efraimsson, Hillervik & Ehrenberg, 2008) (1+); (Sridhar et
al., 2008) (1-).
Also, understanding the signs of exacerbation and its management can help
patients to recognize the early signs of attacks and thus facilitate appropriate
responses to the emergency conditions. Hence, it will reduce their needs of healthcare
service and prevent even mortality (Bourbeau et al., 2003; Gadoury et al., 2005) (1++);
(Gallefoss, Bakke & Kjaersgaard, 1999; Gallefoss & Bakke, 2000; Efraimsson,
48
Hillervik & Ehrenberg, 2008) (1+); (Sridhar et al., 2008) (1- ).
Recommendation 3.2: Self-management action plan is developed with patients
(Grade A).
As the condition of each client is different, self-management action plan is
personalized and customized according to their personal needs. This plan can guide
patients to tackle their exacerbation by prompt and appropriate therapeutic actions
(Bourbeau et al., 2003; Gadoury et al., 2005) (1++); (Gallefoss, Bakke & Kjaersgaard,
1999; Gallefoss & Bakke, 2000; Efraimsson, Hillervik & Ehrenberg, 2008) (1+);
(Sridhar et al., 2008) (1- ).
Recommendation 4: Written materials
Recommendation 4.1: Written materials such as pamphlets should be provided to
patients (Grade A).
Pamphlets about COPD management should be given to the patients to eradicate
misconception. They can revise the content about COPD care anytime when they
want (Bourbeau et al., 2003; Gadoury et al., 2005) (1++); (Gallefoss, Bakke &
Kjaersgaard, 1999; Gallefoss & Bakke, 2000) (1+).
Recommendation 4.2: The written information should be written in clear and simple
language, with visual instructions (Grade A).
49
The materials should be user-friendly and clearly written in simple language
with graphics (Bourbeau et al., 2003; Gadoury et al., 2005) (1++). Since the target
participants are elderlies, pamphlets which are easily understood can facilitate them to
follow the concepts.
Recommendation 5: Evaluation
Recommendation 5.1: One of the outcomes (HRQoL) can be measured by St.
George’s Respiratory Questionnaire (SGRQ) (Grade A).
SGRQ is a well-known tool for measuring the quality of life for COPD patients
(Rhazi et al., 2006; Xu et al., 2008). It can reflect the impact of respiratory symptoms
on overall health (Bourbeau et al., 2003) (1++); (Gallefoss, Bakke & Kjaersgaard,
1999; Efraimsson, Hillervik & Ehrenberg, 2008) (1+).
Recommendation 5.2: The other outcome (healthcare service utilization) can be
evaluated by electronic hospital and medical records (Grade A).
The healthcare service uses include accident and emergency department visits,
hospital admissions and unscheduled primary care clinic visits. It is essential to
evaluate patients’ healthcare service usage by accessing their electronic medical
records (Gadoury et al., 2005) (1++); (Gallefoss & Bakke, 2000) (1+).
50
Chapter 6
Implementation Plan
After affirming the potential of the program, the evidence-based guideline is
developed. It is essential to develop a comprehensive implementation plan in order to
ensure the success of the program. The implementation plan includes communication
plan and pilot study plan. It aims at evaluating the effectiveness of the program. They
will be discussed in detail in this chapter.
6.1 Communication plan
Effective communication between various stakeholders is needed for a smooth
implementation. A good communication plan is important to facilitate communication
with different stakeholders. Also, it is essential to gain their support by demonstrating
the needs of the innovation, the potential benefits towards target patients and staff,
and the potential risks of maintaining existing practice. In this way, obstacles can be
removed during the implementation process.
6.1.1 Identification of the stakeholders
Since effective communication with stakeholders is the key of success, it is
essential to identify stakeholders in this program. There are 3 main groups of
51
stakeholders. They are:
1. Administrators in the EHS of the DH including the Chief of Service (COS),
the SNO and the NO.
2. Two clinic MOs
3. Two clinic RNs
The administrators in the EHS are the key stakeholders as the implementation of
this innovation would need their approval. They can allocate human and capital
resources to support the program.
Besides, two clinic MOs are the stakeholders. Although this innovation does not
involve any changes in their practice, their support is significant to this program as
they can help to refer suitable patients to participate in the program.
Also, two frontline RNs are important stakeholders of this program. As they are
the main users of the proposed guidelines and the educators of this program, they play
an important role in delivering health education to the target patients. To obtain their
support and co-operation, the reasons leading to the changes of the existing practice
will be clearly explained and that will ensure the program efficiency.
52
6.1.2 Process of communication plan
The process of communication is vital in gaining support from various parties. It
should be planned comprehensively. There are three stages in the process of
communication, which are initiation, guiding and sustaining stage. The time frame for
communication plan is illustrated in Appendix G.
6.1.2.1 Initiation stage
In order to initiate the new innovation, it is necessary to seek approval from the
decision makers including NO, SNO and COS of the EHS. The administrators will be
the first to be approached.
At first, the new innovation will be introduced to the NO and SNO by email.
Explanation about reasons of the change, its potential benefits, risks and costs will be
described clearly. A detailed proposal with evidence from the literature will be
attached in the email for reference. Also, the proposal will be presented during the NO
meeting if permission is granted. Detailed explanation on the innovation will be
presented clearly, including evidence from the studies, the proposed guideline, the
cost-effectiveness, feasibility and transferability of the program, implementation and
evaluation plans. Enquires can be answered directly after the presentation.
After gaining support from the SNO and NO, the COS will then be
53
approached. As the COS is the decision maker of the EHS, her support can help to
promote the innovation. An email and a formal letter will be sent to COS via SNO for
introducing the education program. Formal presentation will be carried out if
permission is obtained. During the presentation, it should be emphasized that it does
not involve any changes of the practice of MOs.
After seeking approval from the administrators, the next concern is the frontline
staff. Clinic nurses will be reached for support during the monthly staff meeting.
Detailed proposed guideline will be explained. Since nurses are the main educators in
the program, their feedbacks are valuable for amending the innovation.
Finally, the MOs will be approached for their support. Though this innovation
will not influence their practice and workload, it is necessary to get their support for
the implementation. An oral presentation will be given during the monthly meeting to
introduce the new innovation.
6.1.2.2 Guiding stage
After gaining support from the stakeholders, a communication working
committee (CWC) will be set up for developing the innovation. One NO, one senior
nurse and the proposer, who is the author of this study will be the core members of
CWC. CWC is in charge of the initiation, guiding and sustaining stage of the
54
innovation. They will be responsible for training staff, preparing educational
pamphlets and materials, monitoring implementation progress within the designated
time frame, solving problems and evaluating the innovation.
Two half-day training courses will be provided to each nurse to enrich and
standardize their knowledge regarding the updated COPD management and the use of
SGRQ. The training courses will be held by the NO during the working hours. As
there are only 3 nurses in the clinic, nurses will receive training sessions on separate
days in order to maintain the daily work of the clinic. Written materials will be
provided during the training courses. Also, Continuing Nurse Education (CNE) points
will be awarded to nurses to motivate their learning. The training courses for nurses
will last for four weeks.
Furthermore, if one of the nurses is on leave, the other frontline nurses will help
to deliver the education program. Besides, a manual of the guideline will be prepared
by CWC and will be kept in the nursing treatment room. Nurses can have a quick
reference if necessary. Also, CWC is responsible for monitoring the working progress.
Six weeks are expected for seeking approval from different parties. Then, after a
4-week training program for nursing staff, a pilot study will be conducted to assess
the feasibility of the program. They will be discussed in the following part.
55
6.1.2.3 Sustaining stage
During sustaining stage, audit will be held by CWC regularly to assess the
standard of the program and the compliance of the nurses. Besides, CWC is
responsible for monitoring patients’ outcomes and reporting to the administrators
regularly. Furthermore, updated journals about COPD will be circulated to staff to
enrich their knowledge. Also, all new staff should complete training program before
carrying out this innovation to ensure a high quality of education program.
6.2 Pilot study plan
A pilot study will be carried out for 3 months in the selected clinic before a
full-scale implementation. It can help to identify possible problems and limitations as
well as make appropriate modification and revision for the guideline.
6.2.1 Objectives
The objectives of the pilot study are:
1. To determine the feasibility and cost-effectiveness of the implementing
COPD educational intervention guideline in the actual clinic setting
2. To identify potential barriers encountered during the pilot study.
3. To assess the satisfaction level of nurses and patients.
56
4. To evaluate the guideline and make appropriate modification.
6.2.2 Setting and recruitment
The inclusion criteria of the target participants and setting of the pilot study are
the same as the proposed guideline mentioned in Chapter 4. The pilot study will be
conducted in a local EHC. The target participants are elders aged 65 or above and are
diagnosed with mild-to-moderate stage of COPD by using spirometer. They should be
able to communicate with Cantonese or English or Mandarin. All participants will be
recruited by convenience sampling. The sample size of the pilot study is around 20 so
each nurse can practice for at least 6 clients before the actual implementation.
6.2.3 Time frame
The pilot study will last for 3 months. The detailed time frame is demonstrated in
Appendix G. Preparation of the pilot study will last for 2 months, including the
training for nursing staff and the preparation of the education materials. Each task will
take a month.
The recruitment will begin after obtaining the ethical approval. The recruitment
period will be around 2 weeks. The pilot will then be carried out in the next 2 months.
After the completion of the pilot study, CWC will evaluate and revise the
guideline in the fifth month. Modification of the guideline will be made before the
57
actual implementation of the program.
6.2.4 Method
The program will be delivered according to the evidence-based guideline in
Chapter 5. The method is same as mentioned in Chapter 3. Nurses will invite eligible
patients to participate in the program. After obtaining verbal consent from the
participants, they will complete the SGRQ with the help from the nurses as the
baseline assessment (Appendix H & I; Jones, Quirk & Baveystock, 1991; Jones,
Quirk, Baveystock & Littlejohns, 1992). Also, nurses will collect the medical history
of their healthcare service utilization within the past 12 months through the Electronic
Patient Record (ePR).
After the baseline assessment, nurse will start the individual education session.
As mentioned in Chapter 2, there are four education sessions in total. Each session
will last around one hour. The sessions will be held weekly. The program will include
inhalation techniques, early symptoms of exacerbation and its management. Also, a
personalized tailor-made action plan will be developed for the patients.
Participants will complete the same set of questionnaire and Client Satisfaction
Questionnaire-8 (CSQ-8) in the last session for comparison (Appendix K & L;
Attkisson, Larson, Hargreaves & Nguyen, 1979).
58
6.2.5 Pilot review
At the end of the pilot study, CWC will evaluate the program regarding the
feasibility and cost-effectiveness of the guideline, satisfaction level of nurses and
patients.
By exploring possible barriers of the innovation, it helps to improve the program
for the actual implementation. The comments from nurses and patients will be
collected and assessed by the Satisfaction Questionnaire (SQ) (Appendix J) and
CSQ-8 respectively. They are encouraged to voice their difficulties and give
constructive suggestions. This can help modifying the program.
Besides, the effectiveness of the program will be evaluated by the changes of the
SGRQ scores and the healthcare service utilization.
After completion of the pilot analysis, the result of the pilot study and the revised
guideline will be sent to the administrators for seeking approval. If they approve and
support this program, a full-scale implementation of the program will take place in the
selected clinic.
59
Chapter 7
Evaluation Plan
After the implementation of the innovation, evaluation plays an important role in
assessing the effectiveness of the innovation. In this chapter, the evaluation plan,
which includes identifying different outcomes, evaluation of the data collection and
analysis of the program, will be discussed in details.
7.1 Identification of outcomes
Three major outcomes should be considered in evaluating the program. They are
outcomes for patients, nurses and healthcare system. The innovation is regarded as
effective if the anticipated outcomes are achieved.
7.1.1 Patient outcome
The primary outcomes of patient outcomes are the improvement of patients’
HRQoL and reduction of their healthcare service utilization.
For HRQoL, the clinical benefits will be assessed by the pre- and
post-measurement of the SGRQ (Jones, Quirk & Baveystock, 1991; Jones, Quirk,
Baveystock & Littlejohns, 1992). It is a well-known tool for measuring QoL for
COPD patients (Rhazi et al., 2006; Xu et al., 2008). The SGRQ consists of 76 items
60
measuring on 3 aspects – the respiratory symptoms, activities and impact. It takes
around 15 minutes to complete the questionnaire (St. George’s University of London,
2000). The score ranges from 0 to 100. A lower score indicates a better quality of life.
For the healthcare service utilization, the electronic medical records and
self-report questionnaire will be used for the evaluation. Measures of the healthcare
service utilization include the frequency of accident and emergency department visit,
hospital admission and unscheduled clinic visit. Nurses will access the ePR for the
data after seeking authorization from the participants. If patients do not attend public
healthcare service, self-report questionnaire will be used to evaluate the use of the
healthcare service.
Besides, the secondary outcome of patient outcomes is the satisfaction level of
participants towards the education program. It will be assessed by the CSQ-8. It
directly measures patients’ experience in primary care and other healthcare services
(Attkisson & Greenfield, 2004). The scores range from 4 to 32. The higher score
indicates greater satisfaction.
7.1.2 Healthcare provider outcomes
Nurses are the main target of the healthcare provider outcomes as they are the
main guideline users. The quality of care can be reflected by the satisfaction level of
61
the nurses towards the new innovation and their competency of using the new
guideline. Since the guideline is new to them, it is important to assess their
satisfaction level by using the SQ.
In addition, regular clinical audit will be performed by the NO to assess the
quality of program.
7.1.3 System outcome
The system outcome will be evaluated by the cost saved in this innovation. The
cost of the program is anticipated to be compensated by the reduced use of the
healthcare service. The material cost of the innovation will be calculated and
compared with the cost of healthcare service use in the follow-up.
Also, the patient satisfaction level towards the program will be determined by the
CSQ-8. A high satisfaction expressed by the patients would imply a good quality of
care delivered by the EHS. High satisfaction from patients also indicates a good
nurse-client relationship and it can enhance the reputation of the EHS.
7.2 Nature and number of patients involved
Eligible participants will be recruited in the selected clinic according to the
inclusion and exclusion criteria of the selected studies. Convenience sampling will be
adopted for the recruitment.
62
The sample size will be calculated by Lenth’s Java Applets (2009). Its
consideration is related to the paired t-test as it will be used for the analyses. The
power will be set at 0.8 while the alpha will be set at 0.05 in the test. Based on the
calculation, 96 participants are needed. The drop-out rate is expected to be around
10% according to the identified studies. As a result, the minimum sample size is
around 105. Currently, there are around 200 COPD patients receiving care under the
EHS. Therefore, the innovation should recruit sufficient number of patients in one
year.
7.3 Timing and frequency of data collection
For short-term evaluation, the patient outcomes will be assessed at baseline and
3-month after the first session of the program by the SGRQ and CSQ-8. For the
healthcare provider outcomes, evaluation of the satisfaction level of the nurses will be
performed at 3-month by the SQ. The clinical audit will be done by the NO in every 3
months throughout the program to ensure the delivery of a high quality of education.
For long-term evaluation, the healthcare service utilization will be evaluated by
accessing the ePR and the self-report questionnaire at baseline, 3-month and
12-month after the first session of the program. The cost-benefit ratio will be
calculated in 12-month after the commencement of the program.
63
7.4 Data analyses
For data analyses, SPSS (version 21.0) will be used for all quantitative data.
Descriptive statistics such as mean, standard deviation, frequency and range will be
used for describing the demographic characteristic of the participants. Their score of
the QoL, their healthcare service utilization records, and the satisfaction level of
nurses and patients will also be described. Paired t-test will be performed to measure
the differences of the scores of the SGRQ and self-report for assessing the
improvement of the QoL and reduction of the healthcare service use before and after
the program. Besides, for the satisfaction level of nurses and patients, the mean score
of the SQ and CSQ-8 will be calculated. The opinions within the open-ended question
in SQ will be analyzed by content analysis.
The results of the above analyses are used for assessing whether the proposed
program can improve the HRQoL of participants and decrease their healthcare service
usage.
7.5 Basis for an effective change of practice
The main objectives of this innovation are to improve the HRQoL of the COPD
patients and reduce their healthcare service usage. The education intervention is
considered to be effective if the SGRQ score of participants are decreased in 1 year.
64
As participants are expected to have better disease control after the program,
improved QoL is anticipated.
Besides, the innovation is also considered to be successful if participants have
less health service utilization rate after receiving the program in 1 year. Since they
should have better COPD management skills, less healthcare service is needed.
The other outcomes are regarded as achievements of enhancing the program.
The program is considered as effective if the satisfaction level of the participants
and nurses is above 60% according to CSQ-8 and the SQ.
Moreover, the program is expected to reduce the use of the healthcare service
among the COPD patients. The cost benefits are expected for an effective innovation.
However, even if the innovation cannot reach these outcomes, limitations will be
evaluated and improvement will be made to achieve these outcomes in the future.
65
Chapter 8
Conclusion
In recent years, COPD becomes an important public health problem locally
and globally due to the aging population. COPD exacerbation attacks not only lead to
a heavy healthcare and financial burden to the society, it also restricts the daily
activities of the patients, worsening their quality of life.
In order to prevent repeated exacerbations, some research studies suggested
that self-care management education program is beneficial for COPD patients by
improving their HRQoL and reducing their usage of healthcare service. Although
there is an urgent need of the education program, there is no existing evidence-based
guideline for COPD patients in EHS of the DH in HK.
In order to implement the innovation into practice, literature review is
performed. Six studies are selected and critically appraised. By determining the
implementation potential of the new innovation, it is found that the program is
transferrable, feasible and beneficial for COPD patients in the local clinic.
An evidence-based practice guideline is established aiming at improving
patients’ HRQoL and reducing their healthcare service utilization. Ten practice
recommendations are synthesized from the selected studies.
After communicating with different stakeholders and gaining their support,
66
Communication Working Committee is formed to initiate, guide and sustain the
program. Pilot study will then be carried out in the designated EHC to determine the
feasibility of the program in the real setting and evaluate changes.
After the pilot study, the guideline will be revised and modified according to
the needs. Then an evaluation plan is established to determine the effectiveness of the
program.
In this study, the guideline is designed to reduce healthcare service utilization
and improve the HRQoL of COPD elderlies. It is suggested to implement this
education program in all EHCs, hence more COPD patients will be benefited from
this program.
67
Appendices
Appendix A – Classification of severity of airflow limitation in COPD
According to Global Initiative for Chronic Obstructive Lung Disease (GOLD)
(2013), the use of spirometry is required in order to make a clinical diagnosis of
COPD.
Spirometry is a common lung function test which measures the amount of air a
person can breathe out and the count of time is needed. The ratio of forced
expiratory volume in 1 second (FEV1)* and forced vital capacity (FVC)** is an
important indicator for diagnosis of COPD. The presence of post-bronchodilator
FEV1/FVC < 0.7 confirms the presence of persistent airflow limitation, which is
COPD.
There are four stages of COPD according to the severity of airflow limitation.
The following table listed out different stages with corresponding FEV1% predicted
(GOLD, 2014). The lower the FEV1% predicted, the worse the prognosis.
Classification of severity of airflow limitation in COPD
(Based on post-bronchodilator FEV1)
Stage Severity FEV1 % Predicted
GOLD 1 Mild ≥80
GOLD 2 Moderate 50 - 79
GOLD 3 Severe 30 - 49
GOLD 4 Very severe <30
*Forced Expired Volume in one second (FEV1): volume expired in the first second of
maximal expiration after a maximal inspiration.
**Forced vital capacity (FVC): maximum volume of air that can be exhaled during a
forced maneuver.
68
Appendix B – Systematic Search
Keywords Pubmed
1. copd patients OR copd exercise OR copd lung OR
copd pulmonary OR chronic obstructive airways
disease OR chronic obstructive airway disease OR
chronic obstructive pulmonary disease exercise OR
chronic obstructive pulmonary diseases OR
pulmonary disease chronic obstructive OR chronic
obstructive lung disease OR chronic obstructive lung
OR chronic obstructive pulmonary disease OR
chronic obstructive pulmonary
62291
2. management OR care management OR case
management OR disease management OR self
management OR self regulation OR self medication
OR self monitoring OR self care OR self
administration
6855679
3. educational programs OR educational interventions
OR educational program OR educational intervention
OR education program OR education OR health
education OR patient education
904824
4. nurse-led care OR nurse-led interventions OR
nurse-led OR nurse care OR role nurse OR nurse
specialist OR care nurses OR health nurse OR
practice nurse OR nurse role OR clinical nurse OR
nurses OR care nurse OR nurse practitioners OR
nurse practitioner OR nurse
318215
5. 1 AND 2 AND 3 AND 4 340
6. 65 + years 94
7. Randomized controlled trial OR Controlled clinical
trial
28
69
Appendix B – Systematic Search
Keywords ProQuest- Health &
Medicine Databases
1. copd patients OR copd exercise OR copd lung OR
copd pulmonary OR chronic obstructive airways
disease OR chronic obstructive airway disease OR
chronic obstructive pulmonary disease exercise OR
chronic obstructive pulmonary diseases OR
pulmonary disease chronic obstructive OR chronic
obstructive lung disease OR chronic obstructive lung
OR chronic obstructive pulmonary disease OR
chronic obstructive pulmonary
123026
2. management OR care management OR case
management OR disease management OR self
management OR self regulation OR self medication
OR self monitoring OR self care OR self
administration
3459264
3. educational programs OR educational interventions
OR educational program OR educational intervention
OR education program OR education OR health
education OR patient education
3616372
4. nurse-led care OR nurse-led interventions OR
nurse-led OR nurse care OR role nurse OR nurse
specialist OR care nurses OR health nurse OR
practice nurse OR nurse role OR clinical nurse OR
nurses OR care nurse OR nurse practitioners OR
nurse practitioner OR nurse
1042245
5. 1 AND 2 AND 3 AND 4 9832
6. Aged, older people 1396
7. Randomized controlled trial OR Controlled clinical
trial
28
70
Appendix B – Systematic Search
Keywords Number of study
1. Pubmed 28
2. ProQuest- Health & Medicine Databases 28
3. 1 AND 2 56
4. After removing duplicated paper 35
5. After screening title and abstract 13
6. After checking full text 6
71
Appendix C – Tables of Evidence Bibliographic citation/ Study type (Evidence Level) Patient characteristics Intervention Comparison
Length of follow-up Outcome measures
Effect size (IG vs CG)
1. Gallfoss, Bakke & Kjaersgaard (1999) RCT (+)
1. COPD patients with FEV1 ≧ 40% and ≦80%
of predicted
2. Mean age (years): IG: 57 (SD= 9) CG: 58 (SD= 10)
3. Sex ratio (Male: Female) IG: 15: 16 (N=31) CG: 16: 15 (N=31) (Total: 62)
Education program 1. Two 2-hour group
sessions, with patient brochure, emphasis on:
Early symptoms of exacerbation
Inhalation technique
Smoking cessation
Treatment plan
2. 2 individual education sessions (40 mins)
3. Usual care
Usual care: Regular follow-up by GP only
12 months
1. Level of lung function (Change in FEV1)
2. HRQoL ( 4Lung-specific QoL questions & SGRQ)
1. 5.6% vs 2.9% (p<0.05) 2. Q1: Feel better 62% vs
41% (p=0.21) Q2: Had COPD symptoms in daytime 15% vs 27% (p=0.25) Q3: Had COPD symptoms in night-time 42% vs 37% (p=0.92) Q4: Restriction on activities 58% vs 56% (p=0.3) SGRQ: 40.0(16) vs 43.1(21)
(p=0.54)
2. Gallefoss& Bakke (2000) RCT (+)
1. COPD patients with FEV1 ≧ 40% and ≦80%
of predicted
2. Mean age (years): IG: 57 (SD= 9) CG: 58 (SD= 10) 3. Sex ratio (Male: Female) IG: 15: 16 (N=31) CG: 16: 15 (N=31) (Total: 62)
Education program 1. Two 2-hour group
sessions, with patient brochure, emphasis on:
Early symptoms of exacerbation
Inhalation technique
Smoking cessation
Treatment plan
2. 2 individual education sessions (40 mins)
3. Usual care
Usual care: Regular follow-up by GP only
12 months
1. No. of GP visits
2. No. of absence from work
3. No. of days in hospital
4. Relationship
between QoL & No. of GP visits
1. Mean (SD) 0.5 (0.9) vs 3.4 (5.5) (p < 0.0001) 2. Mean (SD)
1 (7) vs 18.5 (86) (p = 0.64)
3. Mean (SD) 0.7 (2) vs 2.5 (11) (p=0.74) 4. Spearson coefficient: 0.42 (p < 0.028)
Note: IG: Intervention group; CG: Control group; SD: standard deviation; N: Number; HRQoL: Health-related quality of life; SGRQ: St. George Respiratory Questionnaire, the lower the scores, the better quality of life
72
Appendix C – Tables of Evidence Bibliographic citation/ Study type (Evidence Level) Patient characteristics Intervention Comparison
Length of follow-up Outcome measures
Effect size (IG vs CG)
3. Bourbean et al (2003) RCT (++)
1. COPD patient
2. FEV1 < 70%
3. Mean age (years): IC: 69.4 (SD = 6.5) CG: 69.6 (SD = 7.4)
4. Sex ratio (Male: Female) IG: 50 : 46 ( N= 96) CG: 56 : 49 (N = 95) (Total N = 191)
‘Living Well with COPD’ Skill-oriented teaching, 1 hour/ week, for 7-8 weeks
1. Inhalation techniques
2. Plan of action for exacerbation
3. Adopting healthy lifestyle
4. Leisure activities and traveling
5. Simple home exercise program
Standard Care
12 months
1. No. of hospital admission
2. Scheduled & unscheduled visits to physicians and ED visits
3. HRQoL (SGRQ)
4. No. of acute exacerbation
1. a. For acute exacerbation: -39.8% (p= 0.01)
b. For other health problems: -57.1% (p= 0.01)
c. No. of days per patient: -42.4% (p= 0.01)
2. a. No. of ED visits:
-41% (p= 0.02) b. No. of unscheduled
visits: -58.9% (p= 0.003)
3. -2.0 (95%CI: -5.9-1.8) 4. IG:CG= 299: 362
(p=0.06)
4. Gadoury et al (2005) RCT (++)
1. COPD patient
2. FEV1 < 70% 3. Mean age (years):
IC: 69.4 (SD = 6.5) CG: 69.6 (SD = 7.4)
4. Sex ratio (Male: Female) IG: 50 : 46 ( N= 96) CG: 56 : 49 (N = 95) (Total N = 191)
‘Living Well with COPD’ Skill-oriented teaching, 1 hour/ week, for 7-8 weeks
1. Inhalation techniques 2. Plan of action for
exacerbation 3. Adopting healthy
lifestyle 4. Leisure activities and
traveling 5. Simple home exercise
program
Standard Care
24 months
1. All-cause hospital admissions
2. All-cause emergency visits
1. – 0.44 (-26.9%) (95% CI: -0.68- -0.21)
2. – 0.7 (-21.1%) (95% CI: -0.58- -0.82)
Note: RCT: Randomized controlled trial; COPD: Chronic obstructive pulmonary disease; IG: Intervention group; CG: Control group; SD: standard deviation; N: Number; HRQoL: Health-related quality of life; SGRQ: St. George Respiratory Questionnaire, the lower the scores, the better quality of life
73
Appendix C – Tables of Evidence Bibliographic citation/ Study type (Evidence Level) Patient characteristics Intervention Comparison
Length of follow-up Outcome measures
Effect size (IG vs CG)
5. Efraimsson, Hillervik & Ehrenberg (2008) RCT (+)
1. Mild, moderate, severe or very severe COPD patients based on GOLD criteria
2. Mean age (years): IG: 66 (SD = 9.4) CG: 67 (SD = 10.4)
3. Sex ratio (Male: Female) IG: 13: 13 (N=26) CG: 13: 13 (N=26) (Total N = 52)
1. Conventional care
2. 2 visits for self care education (1 hour each), emphasis on:
Inhalation technique
Individual treatment plan
Management of exacerbation
Smoking cessation
Conventional care only (2 visits with 3-5 months interval. First visit to the nurse and spirometry, the follw-up visit to the physician)
Mean: 4 months
1. QoL (SGRQ)
2. Smoking cessation rate
3. Knowledge about COPD
1. a. QoL -26.8%
(p=0.00030) b. ↓dyspnoea, cough
-52.8% (p=0.00035) 2. + 37.5% vs 0%
(p=0.0185)
3. 73.1% vs 19.0% (p < 0.001)
6. Sridhar et al. (2008) RCT (-)
1. COPD patients
2. Mean age (years): IG: 69.9 (SD= 9.6) CG: 69.7 (SD= 10.4)
3. Sex ratio (Male: Female) IG: 30: 31 (N= 61) CG: 30: 31 (N=61) (Total: 122)
1. Nurse-led intermediate care program: 8 group sessions (2 hours each), 2 sessions/ week, emphasis on general education about COPD & treatment ; individualized physical training program; with personalized action plan
2. Monthly phone calls and home visits every 3 months
Without nurse-led intermediate care program:
24 months
1. Hospital readmission rate
2. No. of unscheduled 1º care consultations
3. QoL (CRQ)
4. Death rate due to COPD
1. 52.7% vs 48.9% (p= 0.361)
2. 171 vs 280 (p < 0.05)
3. Improvement in score: 5% vs 11.1% (p < 0.05)
4. 16.7% vs 66.6% (p=0.015)
Note: RCT: Randomized controlled trial; COPD: Chronic obstructive pulmonary disease; GOLD: Global Initiative Chronic Obstructive Lung Disease; IG: Intervention group; CG: Control group; SD: standard deviation; N: Number; HRQoL: Health-related quality of life; SGRQ: St. George Respiratory Questionnaire, the lower the scores, the better quality of life; CRQ: Chronic Respiratory Questionnaire, the higher the score, the better quality of life.
74
Appendix D – Quality Assessment of Selected Studies
SIGN
Methodology Checklist 2: Controlled Trials
Study identification (Include author, title, year of publication, journal title, pages)
1.Gallefoss, F., Bakke, P.S., & Kjaersgaard, P. (1999). Quality of Life Assessment after
Patient Education in a Randomized Controlled Study on Asthma and Chronic Obstructive
Pulmonary Disease. American journal of respiratory and critical care medicine, 159,
812-817.
SECTION 1: INTERNAL VALIDITY
In a well conducted RCT study… Does this study do it?
1.1 The study addresses an appropriate and
clearly focused question.
Yes. The objective was addressed at
the end of introduction.
1.2 The assignment of subjects to treatment
groups is randomised.
Yes. The randomization method was
the use of random number tables.
1.3 An adequate concealment method is used. No. The concealment method was
not mentioned in the study.
1.4 Subjects and investigators are kept ‘blind’
about treatment allocation.
No. Due to the nature of education,
no blinding was done.
1.5 The treatment and control groups are
similar at the start of the trial.
Yes. The demographic data of two
groups was similar, which was listed
in a table.
1.6 The only difference between groups is the
treatment under investigation.
Yes. No additional treatment was
added for two groups.
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes. SGRQ was a valid tool but it
was assessed during the follow-up
only, no baseline data was collected.
1.8 What percentage of the individuals or
clusters recruited into each treatment arm
of the study dropped out before the study
was completed?
For intervention group: 12.9%
For control group: 10.3%
1.9 All the subjects are analysed in the groups
to which they were randomly allocated
(often referred to as intention to treat
analysis).
No. The intention to treat analysis
was not mentioned in the study.
1.10 Where the study is carried out at more than
one site, results are comparable for all
sites.
Does not apply. The study was
carried out in one site only.
75
Appendix D – Quality Assessment of Selected Studies
SIGN
Methodology Checklist 2: Controlled Trials
Study identification (Include author, title, year of publication, journal title, pages)
1.Gallefoss, F., Bakke, P.S., & Kjaersgaard, P. (1999). Quality of Life Assessment after
Patient Education in a Randomized Controlled Study on Asthma and Chronic Obstructive
Pulmonary Disease. American journal of respiratory and critical care medicine, 159,
812-817.
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to
minimise bias? Acceptable (+)
2.2 Taking into account clinical
considerations, your evaluation of the
methodology used, and the statistical
power of the study, are you certain that
the overall effect is due to the study
intervention?
Yes. The study is in medium level of
quality of methodology.
2.3 Are the results of this study directly
applicable to the patient group targeted
by this guideline?
Yes. The characteristics of the study
participants were similar to that of the
proposed guideline.
2.4 Notes.
This study showed that the education program did not have significant
improvement in health-related quality of life of COPD patients.
76
Appendix D – Quality Assessment of Selected Studies
SIGN
Methodology Checklist 2: Controlled Trials
Study identification (Include author, title, year of publication, journal title, pages)
2.Gallefoss, F., & Bakke, P.S. (2000). Impact of patient education and self-management on
morbidity in asthmatics and patients with chronic obstructive pulmonary disease. Respiratory
Medicine, 94, 279-287.
SECTION 1: INTERNAL VALIDITY
In a well conducted RCT study… Does this study do it?
1.1 The study addresses an appropriate and
clearly focused question.
Yes. The objective was addressed at
the end of introduction.
1.2 The assignment of subjects to treatment
groups is randomised.
Yes. The randomization method
was the use of random number
tables.
1.3 An adequate concealment method is used.
No. The concealment method was
not mentioned in the study.
1.4 Subjects and investigators are kept ‘blind’
about treatment allocation.
No. Due to the nature of education,
no blinding was done.
1.5 The treatment and control groups are similar
at the start of the trial.
Yes. The demographic data of two
groups was similar, which was
listed in a table.
1.6 The only difference between groups is the
treatment under investigation.
Yes. No additional treatment was
added for two groups.
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes.
1.8 What percentage of the individuals or
clusters recruited into each treatment arm of
the study dropped out before the study was
completed?
For intervention group: 12.9%
For control group: 10.3%
1.9 All the subjects are analysed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
No. The intention to treat analysis
was not mentioned in the study.
1.10 Where the study is carried out at more than
one site, results are comparable for all sites.
Does not apply. The study was
carried out in one site only.
77
Appendix D – Quality Assessment of Selected Studies
SIGN
Methodology Checklist 2: Controlled Trials
Study identification (Include author, title, year of publication, journal title, pages)
2.Gallefoss, F., & Bakke, P.S. (2000). Impact of patient education and self-management on
morbidity in asthmatics and patients with chronic obstructive pulmonary disease. Respiratory
Medicine, 94, 279-287.
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to
minimise bias? Acceptable (+)
2.2 Taking into account clinical
considerations, your evaluation of the
methodology used, and the statistical
power of the study, are you certain that
the overall effect is due to the study
intervention?
Yes. The study is in medium level of
quality of methodology.
2.3 Are the results of this study directly
applicable to the patient group targeted
by this guideline?
Yes. The characteristics of the study
participants were similar to that of the
proposed guideline.
2.4 Notes.
Patient education in COPD patients reduced GP visits and kept a greater proportion
of patients independent of their GPs. Increasing number of GP visits was
correlated with decreased health-related quality of life for COPD patients.
78
Appendix D – Quality Assessment of Selected Studies
SIGN
Methodology Checklist 2: Controlled Trials
Study identification (Include author, title, year of publication, journal title, pages)
3.Bourbeau, J., Julien, M., Maltais, F., Rouleau, M., Beaupre, A., Begin, R., Renzi, P., Nault,
D., Borycki, E., Schwartzman, K., Singh, R., & Collet, J.P. (2003). Reduction of Hospital
Utilization in Patients With Chronic Obstructive Pulmonary Disease. Archives of Internal
Medicine, 163, 585-591.
SECTION 1: INTERNAL VALIDITY
In a well conducted RCT study… Does this study do it?
1.1 The study addresses an appropriate and
clearly focused question.
Yes. The objective was addressed at
the end of introduction.
1.2 The assignment of subjects to treatment
groups is randomised.
Yes. The randomization method
was the use of random numbers.
1.3 An adequate concealment method is used. Yes. The concealment method was
the use of central computer.
1.4 Subjects and investigators are kept ‘blind’
about treatment allocation.
No. Due to the nature of education,
no blinding was done. But the
independent evaluator was blinded.
1.5 The treatment and control groups are similar
at the start of the trial.
Yes. The demographic data of two
groups was similar, which was
listed in a table.
1.6 The only difference between groups is the
treatment under investigation.
Yes. No additional treatment was
added for two groups.
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes.
1.8 What percentage of the individuals or
clusters recruited into each treatment arm of
the study dropped out before the study was
completed?
For intervention group: 10.5%
For control group: 16.8%
1.9 All the subjects are analysed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
Yes. Intention to treat analysis was
performed in the study.
1.10 Where the study is carried out at more than
one site, results are comparable for all sites.
No. The results were not compared
across different sites.
79
Appendix D – Quality Assessment of Selected Studies
SIGN
Methodology Checklist 2: Controlled Trials
Study identification (Include author, title, year of publication, journal title, pages)
3.Bourbeau, J., Julien, M., Maltais, F., Rouleau, M., Beaupre, A., Begin, R., Renzi, P., Nault,
D., Borycki, E., Schwartzman, K., Singh, R., & Collet, J.P. (2003). Reduction of Hospital
Utilization in Patients With Chronic Obstructive Pulmonary Disease. Archives of Internal
Medicine, 163, 585-591.
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to
minimise bias? High quality (++)
2.2 Taking into account clinical
considerations, your evaluation of the
methodology used, and the statistical
power of the study, are you certain that
the overall effect is due to the study
intervention?
Yes. The study has well covered most
criteria in the checklist except the
blinding method.
2.3 Are the results of this study directly
applicable to the patient group targeted
by this guideline?
Yes. The characteristics of the study
participants were similar to that of the
proposed guideline.
2.4 Notes.
Self management program for COPD patients can reduce the health care service
utilization and improve their health status.
80
Appendix D – Quality Assessment of Selected Studies
SIGN
Methodology Checklist 2: Controlled Trials
Study identification (Include author, title, year of publication, journal title, pages)
4.Gadoury, M.A., Schwartzman, K., Rouleau, M., Maltais, F., Julien, M., Beaupre, A., Renzi,
P., Begin, R., Nault, D., & Bourbeau, J. (2005). Self-management reduces both short- and
long-term hospitalisation in COPD. European Respiratory Journal, 26, 853-857.
SECTION 1: INTERNAL VALIDITY
In a well conducted RCT study… Does this study do it?
1.1 The study addresses an appropriate and
clearly focused question.
Yes. The objective was addressed at
the end of introduction.
1.2 The assignment of subjects to treatment
groups is randomised.
Yes. The randomization method
was the use of random numbers.
1.3 An adequate concealment method is used. Yes. The concealment method was
the use of central computer.
1.4 Subjects and investigators are kept ‘blind’
about treatment allocation.
No. Due to the nature of education,
no blinding was done. But the
independent evaluator was blinded.
1.5 The treatment and control groups are similar
at the start of the trial.
Yes. The demographic data of two
groups was similar, which was
listed in a table.
1.6 The only difference between groups is the
treatment under investigation.
Yes. No additional treatment was
added for two groups.
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes.
1.8 What percentage of the individuals or
clusters recruited into each treatment arm of
the study dropped out before the study was
completed?
For intervention group: 5.2%
For control group: 11.6%
1.9 All the subjects are analysed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
Yes. Intention to treat analysis was
performed in the study.
1.10 Where the study is carried out at more than
one site, results are comparable for all sites.
No. The results were not compared
across multiple sites.
81
Appendix D – Quality Assessment of Selected Studies
SIGN
Methodology Checklist 2: Controlled Trials
Study identification (Include author, title, year of publication, journal title, pages)
4.Gadoury, M.A., Schwartzman, K., Rouleau, M., Maltais, F., Julien, M., Beaupre, A., Renzi,
P., Begin, R., Nault, D., & Bourbeau, J. (2005). Self-management reduces both short- and
long-term hospitalisation in COPD. European Respiratory Journal, 26, 853-857.
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to
minimise bias? High quality (++)
2.2 Taking into account clinical
considerations, your evaluation of the
methodology used, and the statistical
power of the study, are you certain that
the overall effect is due to the study
intervention?
Yes. The study has well covered most
criteria in the checklist except the
blinding method. It is of strong
methodology quality.
2.3 Are the results of this study directly
applicable to the patient group targeted
by this guideline?
Yes. The characteristics of the study
participants were similar to that of the
proposed guideline.
82
Appendix D – Quality Assessment of Selected Studies
Methodology Checklist 2: Controlled Trials
Study identification (Include author, title, year of publication, journal title, pages)
5.Efraimsson E.O., Hillervik C., & Ehrenberg A. (2008). Effects of COPD self-care
management education at a nurse-led primary health care clinic. Scandinavian Journal of
Caring Science, 22, 178-185.
SECTION 1: INTERNAL VALIDITY
In a well conducted RCT study… Does this study do it?
The study addresses an appropriate and clearly
focused question.
Yes. The objective was stated at
the end of introduction.
The assignment of subjects to treatment groups
is randomised.
Yes. The randomization method was the use
of random numbers.
An adequate concealment method is used.
Yes. The concealment method was drawing
lots for allocation to either intervention
group or control group by an independent
person.
Subjects and investigators are kept ‘blind’
about treatment allocation.
No. Due to the nature of education, no
blinding was done.
The treatment and control groups are similar at
the start of the trial.
Yes. The demographic data of two groups
was similar, which was listed in a table.
The only difference between groups is the
treatment under investigation.
Yes. No additional treatment was added
for two groups.
All relevant outcomes are measured in a
standard, valid and reliable way.
Yes.
What percentage of the individuals or clusters
recruited into each treatment arm of the study
dropped out before the study was completed?
Overall: 19.2%
All the subjects are analysed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
No. The intention to treat analysis was not
mentioned in the study.
Where the study is carried out at more than
one site, results are comparable for all sites.
Does not apply. The study was carried out
in one site only.
83
Appendix D – Quality Assessment of Selected Studies
Methodology Checklist 2: Controlled Trials
Study identification (Include author, title, year of publication, journal title, pages)
5.Efraimsson E.O., Hillervik C., & Ehrenberg A. (2008). Effects of COPD self-care
management education at a nurse-led primary health care clinic. Scandinavian Journal of
Caring Science, 22, 178-185.
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
How well was the study done to minimise bias? Acceptable (+)
Taking into account clinical considerations,
your evaluation of the methodology used, and
the statistical power of the study, are you
certain that the overall effect is due to the
study intervention?
Yes. The study is in medium level of
quality of methodology.
Are the results of this study directly applicable
to the patient group targeted by this guideline?
Yes. The characteristics of the study
participants were similar to that of the
proposed guideline.
84
Appendix D – Quality Assessment of Selected Studies
SIGN
Methodology Checklist 2: Controlled Trials
Study identification (Include author, title, year of publication, journal title, pages)
6. Sridhar.M., Taylor, R., Dawson, S., Roberts, N.J., & Partridge, M.R. (2008). A nurse led
intermediate care package in patients who have been hospitalized with an acute exacerbation
of chronic obstructive pulmonary disease. Thorax, 63, 194-200.
SECTION 1: INTERNAL VALIDITY
In a well conducted RCT study… Does this study do it?
1.1 The study addresses an appropriate and
clearly focused question.
Yes. The objective was addressed at
the end of introduction.
1.2 The assignment of subjects to treatment
groups is randomised.
Yes. The randomization method
was the use of random numbers.
1.3 An adequate concealment method is used. No. The concealment method was
not mentioned in the study.
1.4 Subjects and investigators are kept ‘blind’
about treatment allocation.
No. Due to the nature of education,
no blinding was done.
1.5 The treatment and control groups are
similar at the start of the trial.
Yes. The demographic data of two
groups was similar, which was
listed in a table.
1.6 The only difference between groups is the
treatment under investigation.
Yes. No additional treatment was
added for two groups.
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes. Reliable tools such as Chronic
Respiratory Questionnaire were
used.
1.8 What percentage of the individuals or
clusters recruited into each treatment arm
of the study dropped out before the study
was completed?
For intervention group: 9.83%
For control group: 19.7%
1.9 All the subjects are analysed in the groups
to which they were randomly allocated
(often referred to as intention to treat
analysis).
No. The intention to treat analysis
was not mentioned in the study.
1.10 Where the study is carried out at more than
one site, results are comparable for all
sites.
No. The results were not compared
across different sites.
85
Appendix D – Quality Assessment of Selected Studies
SIGN
Methodology Checklist 2: Controlled Trials
Study identification (Include author, title, year of publication, journal title, pages)
6.Sridhar.M., Taylor, R., Dawson, S., Roberts, N.J., & Partridge, M.R. (2008). A nurse led
intermediate care package in patients who have been hospitalized with an acute exacerbation
of chronic obstructive pulmonary disease. Thorax, 63, 194-200.
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to
minimise bias? Unacceptable – reject 0
2.2 Taking into account clinical
considerations, your evaluation of the
methodology used, and the statistical
power of the study, are you certain that
the overall effect is due to the study
intervention?
No. Bias may arise as no concealment
method and intention to treat analysis
were mentioned in study.
2.3 Are the results of this study directly
applicable to the patient group targeted
by this guideline?
No. The study was of poor quality of
methodology.
86
Appendix E – Similarity between proposed setting and literature reviewed
Characteristics Proposed setting/ Target
population
Literature reviewed
1. Target population COPD patients aged 65 and
above
COPD patients with mean age of
57-69.9 years old
2. Gender Ratio Male : Female 3: 1
Recruited both females and
males
Male : Female 1: 1
3. Severity of COPD Mild to moderate COPD Mild to moderate COPD
4. Setting Elderly health center Outpatient chest clinics/ Primary
health care clinics/ Health centers
of hospitals/ Hospitals
5. Country/ Region Hong Kong Norway/ Canada/ Sweden/ London
6. Intervention Self-care management
education program
Self management education
program
7. Educator Nurses Mainly nurses, some involved
physiotherapists, respiratory
therapists
87
Appendix F – Recommendations for the COPD education program
Recommendation Grade Evidence (Level of evidence)
Recommendation 1: New innovation
1.1 A self-care management education program
can help COPD patients to improve their
HRQoL and decrease the healthcare service
needs.
A Bourbeau et al., 2003; Gadoury
et al., 2005 (1++)
Efraimsson, Hillervik &
Ehrenberg, 2008; Gallefoss &
Bakke, 2000 (1+)
Recommendation 2: Mode of education
2.1 Nurses are responsible for delivering the
education program.
A Bourbeau et al., 2003; Gadoury
et al., 2005 (1++)
Gallefoss, Bakke, &
Kjaersgaard, 1999; Gallefoss &
Bakke, 2000; Efraimsson,
Hillervik & Ehrenberg, 2008
(1+)
Sridhar et al., 2008 (1-)
2.2 The education program is held in individual
sessions.
A Bourbeau et al., 2003; Gadoury
et al., 2005 (1++)
Efraimsson, Hillervik &
Ehrenberg, 2008 (1+)
2.3 The duration of each education session is
around 1 hour.
A Bourbeau et al., 2003; Gadoury
et al., 2005 (1++)
Efraimsson, Hillervik &
Ehrenberg, 2008 (1+)
Recommendation 3: Components of the
program
3.1 The education topics include inhalation
techniques, signs of exacerbation and COPD
management.
A Bourbeau et al., 2003; Gadoury
et al., 2005 (1++)
Gallefoss, Gallefoss, Bakke, &
Kjaersgaard, 1999; Gallefoss &
Bakke, 2000; Efraimsson,
Hillervik & Ehrenberg, 2008
(1+)
Sridhar et al., 2008 (1-)
88
Recommendation Grade Evidence (Level of evidence)
3.2 Self-management action plan is developed
with patients during education session.
A Bourbeau et al., 2003; Gadoury
et al., 2005 (1++)
Gallefoss, Gallefoss, Bakke, &
Kjaersgaard, 1999; Gallefoss &
Bakke, 2000; Efraimsson,
Hillervik & Ehrenberg, 2008
(1+)
Sridhar et al., 2008 (1-)
Recommendation 4: Written materials
4.1 Written materials such as pamphlets should
be provided to patients.
A Bourbeau et al., 2003; Gadoury
et al., 2005) (1++)
Gallefoss, Gallefoss, Bakke, &
Kjaersgaard, 1999; Gallefoss &
Bakke, 2000 (1+)
4.2 The written information should be clear and
with simple language and visual instructions.
A Bourbeau et al., 2003; Gadoury
et al., 2005 (1++)
Recommendation 5: Evaluation
5.1 One of the outcomes (HRQoL) can be
measured by St. George’s Respiratory
Questionnaire.
A Bourbeau et al., 2003 (1++)
Gallefoss, Bakke, &
Kjaersgaard, 1999; Efraimsson,
Hillervik & Ehrenberg, 2008
(1+)
5.2 The other outcome (healthcare service
utilization) can be measured by electronic
hospital and medical records.
A Gadoury et al., 2005 (1++);
Gallefoss & Bakke, 2000 (1+)
89
Appendix G – Time frame for communication plan & pilot study plan
Time Staff/Activity Content
Week 1-3 1 NO & 1 SNO
(Gain support & approval)
Email & formal presentation during NO
meeting:
-Needs for change
-Details of the new innovation with evidence
-Potential benefits, risks & cost
-Evidence-based guideline with time frame
-Implementation and evaluation plan
Week 3-4 COS
(Gain support & approval)
Email & formal presentation:
-Details of the new innovation with evidence
-Potential benefits, risks & cost
-Implementation and evaluation plan
-No change in current practice of MOs
Week 4-5 2 RNs
(Gain support &
co-operation)
Sharing during monthly staff meeting:
-Details of the new innovation with evidence
-Potential benefits, risks & cost
-Explain training program
Week 6 2 MOs
(Gain support)
Oral presentation:
-Details of the new innovation with evidence
-No change in current practice & no extra
workload
Week 7 Formation of
Communication Working
Committee (CWC)
Core members :1 NO, 1 senior nurse &
coordinator
-Organize training program
-Prepare educational materials
-Monitor & report the implementation progress
-Evaluate the program
Week 8-11 Training program During working hours:
-Standardize COPD management
-Updated information about COPD care
-The use of SGRQ
Week
12-15
Preparation period -Prepare relevant educational pamphlets,
relevant tools and written materials
Week
16-17
Recruitment period -Recruit eligible patients to be participants
Week
18-25
Pilot study period -Recruit eligible patients to join the program
-Pilot study trial run
Week
26-29
Evaluation of the pilot study -Evaluate the feasibility & cost-effectiveness of
the guideline, potential barriers and acceptance
from nurses
-Make appropriate modification
90
Appendix H - St. George’s Respiratory Questionnaire (SGRQ) - English Version
ST. GEORGE’S RESPIRATORY QUESTIONNAIRE (SGRQ)
This questionnaire is designed to help us learn much more about how your
breathing is troubling you and how it affects your life. We are using it to find out
which aspects of your illness cause you most problems, rather than what the
doctors and nurses think your problems are.
Please read the instructions carefully and ask if you do not understand anything.
Do not spend too long deciding about your answers
Before completing the rest of the questionnaire
Please tick one box to show how you describe
your current health:
Very good Good Fair Poor Very poor
□ □ □ □ □
Copyright reserved
P.W. Jones, PhD FRCP
Professor of Respiratory Medicine,
St. George’s University of London,
Jenner Wing,
Cranmer Terrace,
London SW17 ORE, UK.
Tel. +44 (0) 20 8725 5371
Fax +44 (0) 20 8725 5955
Hong Kong/ English version continued…
91
St. George’s Respiratory Questionnaire
PART 1
Questions about how much chest trouble you have had over the past 4 weeks.
Please tick one box for each question
most
days
a week
several
days
a week
a few
days
a month
only with
chest
infections
not
at
all
1. Over the past 4 weeks, I have coughed: □ □ □ □ □
2. Over the past 4 weeks, I have brought up
phlegm (sputum): □ □ □ □ □
3. Over the past 4 weeks, I have had shortness
of breath: □ □ □ □ □
4. Over the past 4 weeks, I have had attacks of
wheezing: □ □ □ □ □
5. During the past 4 weeks how many severe or very
unpleasant attacks of chest trouble have you had?
Please tick one
more than 3 attacks □
3 attacks □
2 attacks □
1 attack □
no attacks □
6. How long did the worst attack of chest trouble last?
(Go to question 7 if you had no severe attacks)
Please tick one:
a week or more □
3 or more days □
1 or 2 days □
less than a day □
7. Over the past 4 weeks, in an average week, how many good days
with little chest trouble) have you had?
Please tick one:
No good days □
1 or 2 good days □
3 or 4 good days □
nearly every day is good □
every day is good □
8. If you have a wheeze, is it worse in the morning? Please tick one:
No □
Yes □
Hong Kong/ English version continued…
92
St. George’s Respiratory Questionnaire
PART 2
Section 1
How would you describe your chest condition?
Please tick one
The most important problem I have □
Causes me quite a lot of problems □
Causes me a few problems □
Causes no problem □
If you have ever had paid employment.
Please tick one:
My chest trouble made me stop work altogether □
My chest trouble interferes with my work or made me change my work □
My chest trouble does not affect my work □
Section 2
Questions about what activities usually make you feel breathless these days.
Please tick each box that
applies to you these days:
True False
Sitting or lying still □ □
Getting washed or dressed □ □
Walking around the home □ □
Walking outside on the level □ □
Walking up a flight of stairs □ □
Walking up hills □ □
Playing sports or games □ □
Hong Kong/ English version continued…
93
St. George’s Respiratory Questionnaire
PART 2
Section 3
Some more questions about your cough and breathlessness these days.
Please tick each box that
applies to you these days:
True False
My cough hurts □ □
My cough makes me tired □ □
I am breathless when I talk □ □
I am breathless when I bend over □ □
My cough or breathing disturbs my sleep □ □
I get exhausted easily □ □
Section 4
Questions about other effects that your chest trouble may have on you these days.
Please tick each box that
applies to you these days:
True False
My cough or breathing is embarrassing in public □ □
My chest trouble is a nuisance to my family, friends or neighbours □ □
I get afraid or panic when I cannot get my breath □ □
I feel that I am not in control of my chest problem □ □
I do not expect my chest to get any better □ □
I have become frail or an invalid because of my chest □ □
Exercise is not safe for me □ □
Everything seems too much of an effort □ □
Section 5
Questions about your medication, if you are receiving no medication go straight to section 6.
Please tick each box that
applies to you these days:
True False
My medication does not help me very much □ □
I get embarrassed using my medication in public □ □
I have unpleasant side effects from my medication □ □
My medication interferes with my life a lot □ □
Hong Kong/ English version continued…
94
St. George’s Respiratory Questionnaire
PART 2
Section 6
These are questions about how your activities might be affected by your breathing.
Please tick each box that applies to you
because of your breathing:
True False
I take a long time to get washed or dressed □ □
I cannot take a bath or shower, or I take a long time □ □
I walk slower than other people, or I stop for rests □ □
Jobs such as housework take a long time, or I have to stop for rests □ □
If I walk up one flight of stairs, I have to go slowly or stop □ □
If I hurry or walk fast, I have to stop or slow down □ □
My breathing makes it difficult to do things such as walk up hills
carrying things up stairs, dance, play bowls or play golf □ □
My breathing makes it difficult to do things such as carry heavy loads,
jog or walk at 5 miles per hour, play tennis or swim □ □
My breathing makes it difficult to do things such as very heavy manual
work, run, cycle, swim fast or play competitive sports □ □
Section 7
We would like to know how your chest usually affects your daily life.
Please tick each box that applies to you
because of your chest trouble:
True False
I cannot play sports or games □ □
I cannot go out for entertainment or recreation □ □
I cannot go outside my home to do shopping □ □
I cannot do housework □ □
I cannot move far from my bed or chair □ □
Hong Kong/ English version continued…
95
St. George’s Respiratory Questionnaire
Here is a list of other activities that your chest trouble may prevent you doing. (You do not have
to tick these, they are just to remind you of ways in which your breathlessness may affect you):
Going for walks or walking the dog
Doing things at home or in the garden
Sexual intercourse
Going out to church, pub, club or place of entertainment
Going out in bad weather or into smoky rooms
Visiting family or friends or playing with children
Please write in any other important activities that your chest trouble may stop you doing:
Please tick one box which you think best describes how your chest affects you:
It does not stop me doing anything I would like to do □
It stops me doing one or two things I would like to do □
It stops me doing most of the things I would like to do □
It stops me doing everything I would like to do □
Thank you for filling in this questionnaire.
Before you finish would you please check to see that you have answered all the questions.
This dissertation uses SGRQ HK/English and HK/ Chinese version with the permission of Dr. P.W.
Jones from St George’s, University of London (St George’s Hospital Medical School).
This must not be copied without the permission of the authors.
96
Appendix I - St. George’s Respiratory Questionnaire (SGRQ) - Chinese Version
聖佐治醫院呼吸問卷(SGRQ)
這份問卷是設計來幫助我們了解你的呼吸問題如何影響你的生活。
我們想用此找出你的疾病在那些方面為你帶來最多問題
(並不是醫生與護士所認為的問題)。
請小心閱讀指示，如有不明白請發問。
但不要用太長時間去決定你的答案。
在完成問卷的其餘部份之前：
請“”一個可形容你現在的健康的方格： 很好 好 一般 差 很差
□ □ □ □ □
Copyright reserved
P.W. Jones, PhD FRCP
Professor of Respiratory Medicine,
St. George’s University of London,
Jenner Wing,
Cranmer Terrace,
London SW17 ORE, UK.
Tel. +44 (0) 20 8725 5371
Fax +44 (0) 20 8725 5955
Hong Kong / Chinese version 轉下頁…
97
聖佐治醫院呼吸問卷
第一部分
這些問題是有關你在過去四星期內出現呼吸問題的次數。
每題請“”一個方格：
一周內
幾乎每
天
一周
有幾天
一個月
有幾天
只有呼
吸道受
感染時
完全
沒有
1 在過去四星期內，我有咳嗽： □ □ □ □ □
2 在過去四星期內，我有咳痰： □ □ □ □ □
3 在過去四星期內，我有氣促： □ □ □ □ □
4 在過去四星期內，我有氣喘發作： □ □ □ □ □
5
.
在過去四星期內，你曾有多少次很不舒服
或嚴重的呼吸問題發作？
請“”
一個方格：
超過三次發作 □
三次發作 □
二次發作 □
一次發作 □
從未發作 □
6
.
最嚴重的一次呼吸問題發作持續了多久？
(如果沒有嚴重發作，直接答第7 題）
請“”
一個方格：
一周或以上 □
3 天或以上 □
1 或 2 天 □
少於一天 □
7
.
在過去四星期內，在一個平常的星期裏你有幾多天安好
(有很少呼吸症狀)？
請“”
一個方格：
每天都有症狀 □
1 或 2 天無症狀 □
3 或 4 天無症狀 □
幾乎每天都無症狀 □
每天都無症狀 □
8
.
假如你有氣喘，是否在早上起床時最嚴重？ 請“”
一個方格：
不是 □
是 □
Hong Kong / Chinese version 轉下頁…
98
聖佐治醫院呼吸問卷
第二部分
第 1 節
你會怎樣形容你的呼吸情況？ 請“”
一個方格：
是我最重要的問題 □
給我造成很多問題 □
給我造成一些問題 □
無造成問題 □
假如你曾有一份有入息的工作。 請“”
一個方格：
我的呼吸問題使我完全停止工作 □
我的呼吸問題影響我的工作或使我更換工作 □
我的呼吸問題並不影響我的工作 □
第 2 節
這些問題是有關最近通常會使你感到氣促的活動。
在每一項中，請就你最近
的情況“”一個方格：
對 錯
坐着或躺着 □ □
梳洗或穿衣 □ □
在家中行走 □ □
在戶外平路行走 □ □
行上一層樓梯 □ □
行上山 □ □
做運動或戶外活動 □ □
Hong Kong / Chinese version 轉下頁…
99
聖佐治醫院呼吸問卷
第二部分
第 3 節
這是更多有關你最近咳嗽和氣促的問題。
在每一項中，請就你最近
的情況“”一個方格：
對 錯
我的咳嗽使我痛楚 □ □
我的咳嗽使我疲倦 □ □
我說話時氣促 □ □
我彎腰時氣促 □ □
我的咳嗽或呼吸打擾我的睡眠 □ □
我很容易會極之疲倦 □ □
第 4 節
這些問題是有關最近你的呼吸問題可能對你的其它影響。
在每一項中，請就你最近
的情況“”一個方格：
對 錯
我的咳嗽或呼吸令我在公眾場所感到難為情 □ □
我的呼吸問題對我的家人、朋友或鄰居是一個騷擾 □ □
當我上氣唔接下氣時，我感到害怕或驚慌 □ □
我感到無法控制我的呼吸問題 □ □
我不預期自己的呼吸問題會有改善 □ □
我的呼吸問題使我變得虛弱或無能力 □ □
運動對我不安全 □ □
所有事對我來說都好像很吃力 □ □
第 5 節
這是有關你的葯物的問題，如果你沒有用葯，請直接回答第 6 節。
在每一項中，請就你最近
的情況“”一個方格：
對 錯
我的葯物幫唔到我很多 □ □
在公眾場所用葯使我感到難為情 □ □
我有葯物引起的不舒服副作用 □ □
我的葯物十分妨礙我的生活 □ □
Hong Kong / Chinese version 轉下頁…
100
聖佐治醫院呼吸問卷
第二部分
第 6 節
以下問題是有關你的呼吸問題如何妨礙你的活動。
請就你的呼吸問題於
每一項“”一個方格：
對 錯
我要用長時間去梳洗或穿衣 □ □
我不能或需用較長時間去洗澡或淋浴 □ □
我行路比其他人慢，或需要停下來休息 □ □
我要用長時間去做家務，或需停下來休息 □ □
如我行上一層樓梯，我要慢慢行或要停低 □ □
如我匆忙或行快一點，我要停低或減慢 □ □
我的呼吸問題使我做事有困難例如行上山、提物上樓梯、做園藝例如
除草、跳舞、打保齡球或打高爾夫球 □ □
我的呼吸問題使我做事有困難例如提取重物、在花園挖土、
緩步跑或以每小時八公里急步行、打網球或游泳 □ □
我的呼吸問題使我做事有困難例如做粗重的工作、跑步、踄單車、
快速游泳或做劇烈運動 □ □
第 7 節
我們希望知道你的呼吸問題通常怎樣影響你的日常生活。
請就你的呼吸問題於
每一項“”一個方格：
對 錯
我不能做運動或戶外活動 □ □
我不能外出娛樂或消遣 □ □
我不能離家外出購物 □ □
我不能做家務 □ □
我不能離開床或椅太遠 □ □
Hong Kong / Chinese version 轉下頁…
101
聖佐治醫院呼吸問卷
這是一些可能是由於你的呼吸問題而使你不能做的其它活動。(你不需要選答，這只是提醒你氣促問題可能
怎樣影響你)：
散步或帶狗行街
打理家裡或花園中的事務
性交
去教堂/寺廟或娛樂場所
在壞天氣裏外出或進入有煙味的房
探訪親人或朋友或與小孩玩耍
請寫下任何其它因為你的呼吸問題而使你不能做的重要活動：
現在請你只 “”一個最能夠形容你的呼吸問題對你的影響的方格
它不影響我想做的任何事 □
它使我不能做 1 或 2 件我想做的事 □
它使我不能做大部分我想做的事 □
它使我不能做所有我想做的事 □
多謝你填寫問卷。在你完成之前，請檢查你是否已回答所有問題。
This dissertation uses SGRQ HK/English and HK/ Chinese version with the permission
of Dr. P.W. Jones from St George’s, University of London (St George’s Hospital Medical
School). This must not be copied without the permission of the author.
102
Appendix J – Evaluation Questionnaire for Satisfaction level of nurses
Evaluation Questionnaire
This questionnaire has been prepared to collect your views on the program. Please
give your response to the listed items by circling the appropriate number, and make
comments or suggestions, if any.
Strongly
Disagree
1
Disagree
2
Agree
3
Strongly
Agree
4
1. This program is clear and easy for
delivery. 1 2 3 4
2. The workload of this program is
appropriate and affordable. 1 2 3 4
3. The manpower, resources and
support from Communication
Working Committee (CWC) are
adequate for me.
1 2 3 4
4. The training sessions are sufficient
and useful for providing education
program to COPD patients.
1 2 3 4
5. I am confident and competent in
delivery of this education program. 1 2 3 4
6. I am able to establish personalized
action plan for COPD patients. 1 2 3 4
7. Overall speaking, I am satisfied with
this program. 1 2 3 4
8. Which part(s) of the program you find difficult or need further elaboration?
9. Any ways in which the program can be improved in future?
10. Other comments:
103
Appendix K – Client Satisfaction Questionnaire – 8 (CSQ-8) – English Version
CSQ-8 UK English
CLIENT SATISFACTION QUESTIONNAIRE
CSQ-8
Please help us improve our service by answering some questions about the help that you have received. We are interested in your honest opinions, whether they are positive or negative. Please answer all of the questions. We also welcome your comments and suggestions. Thank you very much. We appreciate your help.
CIRCLE YOUR ANSWERS
1. How would you rate the quality of service you received?
4 Excellent 3 Good 2 Fair 1 Poor
2. Did you get the kind of service your wanted?
1 No, definitely not 2 No, not really 3 Yes, generally 4 Yes, definitely
3. To what extent has our service met your needs?
4 Almost all of my needs have been met
3 Most of my needs have been met
2 Only a few of my needs have been met
1 None of my needs have been met
4. If a friend were in need of similar help, would you recommend our service to him or her?
1 No, definitely not 2 No, I don’t think so 3 Yes, I think so 4 Yes, definitely
5. How satisfied are you with the amount of help you received?
1 Quite dissatisfied 2 Indifferent or mildly dissatisfied
3 Mostly satisfied 4 Very satisfied
6. How the services you received helped you to deal more effectively with your problems?
4 Yes, they helped a great deal
3 Yes, they helped somewhat
2 No, they really didn’t help
1 No, they seemed to make things worse
7. In an overall, general sense, how satisfied are you with the service you received?
4 Very satisfied 3 Mostly satisfied 2 Indifferent or
mildly dissatisfied 1 Quite dissatisfied
8. If you were to seek help again, would you come back to our service?
1 No, definitely not 2 No, I don’t think so 3 Yes, I think so 4 Yes, definitely
WRITE ANY COMMENTS OVERLEAF
Distributed by Tamalpais Matrix Systems, LLC [email protected] www.CSQscales.com
Copyright © 1979, 1989, 1990, 2013 Clifford Attkisson, Ph.D. Use, transfer, copying, reproduction, merger, translation, modification, or enhancement
(in any format including electronic), in whole or in part is forbidden without written permission.
TMS.180S
This dissertation uses the CSQ-8 UK English and Chinese Traditional Characters items and Item responses by permission of the
copyright holder. “Copyright © 2014 Clifford Attkisson, Ph.D. Use, transfer, copying, reproduction, merger, translation, modification,
or enhancement (in any version, format, and/or media including electronic), in whole or in part, is forbidden without written permission
by Dr. Attkisson.” Contact: [email protected]
104
Appendix L – Client Satisfaction Questionnaire – 8 (CSQ-8) – Chinese Version
CSQ-8 UK Chinese Mandarin
CLIENT SATISFACTION QUESTIONNAIRE
CSQ-8 滿意程度量表
請幫助我們改善我們的治療方案。針對有關于您所得到的服務回答下列問題。我們非常關切您真實的意見，不論是正
面的或負面的。 請回答所有的問題。 我們也歡迎您的批評與建議。 謝謝您。 非常感激您的協助。
圈選您的答案
1. 您會說您所得到的服務品質是?
4 極優良 3 好 2 普通 1 很差
2. 您是否得到您所期望的服務？
1 當然沒有 2 不盡然 3 大致上是有 4 當然有
3. 我們的治療方案滿足到您的需要的程度是？
4 幾乎全部滿足到 3 大部分滿足到 2 只少部分滿足到 1 完全沒有滿足到
4. 若您的朋友需要類似的協助，您會推薦我們的治療給他/她嗎？
1 一定不會 2 應該不會 3 應該會 4 一定會
5. 您對所得到的幫助的滿意程度是?
1 相當不滿意 2 不在意/有點不滿意 3 大部分滿意 4 似乎使問題變得更糟
6. 您所得到的服務是否幫助您更有效地處理您的問題?
4 有很大的幫助 3 有些幫助 2 實際上沒有什麽幫助 1 似乎使問題變得更糟
7. 大體上而言, 您對所得到的服務的滿意程度是?
4 非常滿意 3 大部分滿意 2 不在意/有點不滿意 1 相當不滿意
8. 如果您將來再尋求幫助, 您還會選擇我們的治療方案嗎?
1 一定不會 2 應該不會 3 應該會 4 一定會
Distributed by Tamalpais Matrix Systems, LLC [email protected] www.CSQscales.com
版 权 © 1979, 1989, 1990. 2013 Clifford Attkisson, Ph.D.
未經書面授權 禁止使用。無論是正體或部份，任何形式之利用, 調動, 複製, 再生產，合併，翻譯，修改，或改進,
在沒有 Clifford Attkisson, Ph.D. 的書面授權下均被禁止。
TMS.120S
This dissertation uses the CSQ-8 UK English and Chinese Traditional Characters items and Item responses by permission of the
copyright holder. “Copyright © 2014 Clifford Attkisson, Ph.D. Use, transfer, copying, reproduction, merger, translation,
modification, or enhancement (in any version, format, and/or media including electronic), in whole or in part, is forbidden
without written permission by Dr. Attkisson.” Contact: [email protected]
105
CLIENT SATISFACTION QUESTIONNAIRE
Various forms of the CSQ are available to serve a range of program evaluation and research
applications within health, human services, public benefit, and governmental service programs.
Choose a version of the CSQ that best fits your specific application:
CSQ-8 CSQ-3 CSQ-4 CSQ-18A CSQ-18B CSQ-31
Assistance in making your choice can be found at www.CSQscales.com.
The CSQ-8 is available in over 35 languages. The CSQ-3 and CSQ-18B are also available in
selected languages. The CSQ-8 is available in “Big Print” format in English and Spanish
The CSQ is copyrighted (Attkisson, 1979, 1989, 1990, 2013). Any use of the CSQ Scales requires
express written permission and payment of use fees.
Every effort is made to respond rapidly to requests for information about use of the CSQ Scales.
Permission is never given for any modification of the text or format of the scales. Such changes
violate copyright and invalidate findings from research regarding the validity and reliability of
the scales.
For additional information: Clifford Attkisson, Ph.D. Tamalpais Matrix Systems, LLC 660 Amaranth Boulevard Mill Valley, California 94941-2605
(415) 310-5396
Distributed by Tamalpais Matrix Systems, LLC [email protected] www.CSQscales.com
Copyright © 1979, 1989, 1990, 2013 Clifford Attkisson, Ph.D. Use, transfer, copying, reproduction, merger, translation, modification, or enhancement
(in any format including electronic), in whole or in part is forbidden without written permission. This dissertation uses the CSQ-8 UK English and Chinese Traditional Characters items and Item responses by permission of the
copyright holder. “Copyright © 2014 Clifford Attkisson, Ph.D. Use, transfer, copying, reproduction, merger, translation, modification,
or enhancement (in any version, format, and/or media including electronic), in whole or in part, is forbidden without written permission
by Dr. Attkisson.” Contact: [email protected]
106
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