Keywords

1 Introduction

COPD is a preventable and treatable respiratory disease characterized by persistent and progressive airway limitation and is associated with an inflammatory response of the respiratory tree resulting from the inhalation of harmful substances, which may evolve into chronic bronchitis, obstructive bronchiolitis and pulmonary emphysema [1]. There are several risk factors that condition the appearance of the pathology, as well as its exacerbation. The use of tobacco is the main factor, having a smoker 80 to 90% probability of developing the disease. Air pollution, gender, age, repetitive respiratory infections and bronchial hyperreactivity are also factors to be taken into account for the appearance of COPD [2]. In Portugal, according to the National Health Service (NHS) records, COPD has no less impact compared to the world panorama. In 2017 136 958 cases of this pathology were registered in our country, thus having a high prevalence rate, being responsible for 19% of deaths and one of the main causes of hospitalization. It is estimated that in 2020 the number will increase, being worldwide one of the respiratory diseases that cause the highest number of deaths and with an expected rise to 12 million deaths worldwide [5]. However, Portugal is the OECD country with the lowest number of hospitalizations for COPD. These admissions can be avoided based on preventive measures adopted, use of therapy and follow-up by Primary Health Care, these measures being an incentive focus based on Health Policies [6]. COPD is a pathology with great implications at several levels, which compromises the person in his/her well-being and at the level of self-care, as well as has an incapacitating character in the participation of social life. In the person with COPD, the progression of the pathology implies the appearance of physiological deficits such as airflow limitation and hyperinflation, leading to episodes of dyspnea and in turn to fatigue, intolerance to physical exertion, impairment in ADL and alteration of physical condition [3]. Therefore, this change in physical condition, directly related to stress tolerance, accompanies the decrease in the ability to perform most of the daily activities, thus leaving the person with COPD committed to the ADL and with a greater degree of vulnerability to the changes that the pathology conditions [7, 8]. It is therefore necessary that the person with COPD receives support in order to restructure their entire routine, especially in self-care, reducing the conflict that the disease itself brings, because it is a cause of change/transition, sometimes drastic, spontaneous, generating insecurity, stress and instability.

The nurse is a health professional trained to anticipate, evaluate, diagnose and help the person to deal with these changes [8]. It is up to the nurse to promote the maximum autonomy and well-being of the person, so that he/she adopts behaviors and holds a notion of self-meaning in his/her family and social context, being able to accomplish this “transition”. According to the same author and according to her “Theory of Transition” this process requires the person to use resources and mechanisms that support the adaptation to this new status/crisis. This context reinforces the importance of teaching in the change of behaviors, regarding autonomy and self-determination. It is essential to monitor and guide in order to enable adaptation to the new reality, ensuring self-care and independence [9]. In COPD the person suffers this transition, thus having their daily habits affected, not only by the alteration of its functionality, but also by the limitations that are felt in basic and instrumental activities. This transition-generating status can affect more than the self-care of the person with COPD, but it also influences a whole family dynamic and/or life of the caregiver [4]. In this perspective, the intervention of the rehabilitation nurse should meet a care approach concordant with a theoretical model that provides the fundamental basis for the practice of care. Thus, it is imperative to approach the theory of self-care of Dorothea Orem, which advocates the concept of nursing care in a relationship between the capabilities of action of the person in the face of the requirements of self-care. “The promotion of health through educational interventions of the nurse, which enhances the individual and/or population groups self-care (…) related to the advancement of chronic conditions of illness and the needs of particular care (…) as ways of caring for oneself.” [10] (p. 2).

This theory guides the nursing care provision according to the patient’s needs in relation to his self-care, becoming of great use for a good practice. Since it allows the elaboration of functional and educational intervention plans, outlining goals together with the patient, empowering the person and promoting support and education strategies by providing capabilities and tools to deal with the self-care deficit. The nurse provides care in order to lead the patient to independence, fostering his or her involvement in his or her well-being and state of health-disease [9]. Orem’s theory is the basis to reach the conditions and limitations of the action that the person can reach with the contribution of nursing, being very important that there is a point of balance between what is really necessary and what is excess, all this so that the person can achieve self-care [11]. Thus, the provision of specialized nursing rehabilitation care to the person with COPD should focus on implementing and evaluating specialized plans for quality of life, training and promotion for self-care, always based on a reintegration into society and sharing in their usual habits of life [12]. The nursing intervention is then necessary when the person has needs greater than the capacities of accomplishment of the self-care, occurring an alternation in the intervention of the nurse in the compensation (total or partial) or in the educational intervention. COPD, as a chronic and progressive disease, implies difficulties in the achievement of self-care. The National Program for Respiratory Diseases aims at maximizing the health gains of people with COPD, with the intervention of all social sectors in the application of strategies based on citizenship, equity of access to specialized care and health policies. Also in this context, the DGS has prepared the “Health Literacy Action Plan” for the triennium 2019–2021, in which it contemplates an approach throughout the entire life cycle “(…) promoting the informed choices of citizens” [13] (p.n.p.). This plan emphasizes the importance of developing, defining and implementing strategies among professionals and populations that aim to achieve objectives that promote health literacy and thus boost new opportunities to encourage the adoption of healthy behaviors, with a view to informed self-management and better health outcomes in the population.

Within the scope of respiratory rehabilitation, there are three important pillars for rehabilitation of the person with COPD: respiratory functional re-education, airway permeability and energy conservation techniques [7]. In functional re-education, it is based on relaxation techniques, breathing techniques and global exercises that the rehabilitation nurse achieves health gains from the point of view of controlling dyspnea, being the symptom that brings more disability for the realization of ADL and its independence, always having the attention to educate the person in order to acquire skills that allow him/her to be autonomous in a crisis situation. Thus, the rehabilitation nurse should challenge the person with COPD to be the manager of his health condition [14]. If the informal person/caregiver demonstrates aptitude for self-management, it will be crucial to develop strategies based on knowledge and instrumental skills, the result of skills education, that can contribute to effective management of COPD. These skills associated with “facilitating awareness of the “changes” in daily life can add confidence and sustain effective self-care over time”. [14] (p. 38). It is through health education that rehabilitation nursing is a facilitator in empowering and promoting the autonomy of the person/family, through the development of capabilities inherent to self-care, acquisition of behaviors adapted to the health condition and through the provision of information [6]. This educational aspect enables the person/family to be the self-manager of their disease and in a certain way enables them to prevent complications.

2 Methodology

In this SLR, the main objective is to know the strategies and gains of self-care management of the person with COPD and the research question is what are the strategies and gains of self-care management in the person with COPD. To build it, we followed the guidelines of the Joanna Briggs Institute (JBI) [15] Based on the PICO method (P - Participants; I - Intervention; C - Context/Control; O - Outcomes), we selected studies to be included in this literature review, using the same method to define the inclusion and exclusion criteria, as follows (Table 1).

Table 1. Definition of criteria for selection of studies
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The following descriptors were selected for the research: MeSH (Medical Subject Heading), COPD; patient; self-management; nursing care; empowerment, using the Bolean AND; and, to meet the inclusion criteria, using the Bolean NOT, acute disease.

The electronic database PubMED (US National Library of Medicine and National Institutes of Health) was searched, and the Discovery Service of the Polytechnic Institute of Beja was used, based on EBSCO Host and accessing the CINAHL Complete, MEDLINE Complete and MedicLatina databases, using the keywords above. The research was limited to the years 2014–2019, peer-reviewed, published in academic journals and providing access to the full text. The languages of the articles used in the research were English and Portuguese, the search words were used in English. In total, 280 studies were found in the databases (PubMed and EBSCOhost), of which, after removal by duplication of results, there were 171 records for analysis, which was carried out through the title of the study and whenever the analysis of the abstract was justified. According to the reading of the titles/summaries presented, 154 records were excluded for revealing little interest and/or not presenting thematic criteria that fit the theme of our work, resulting in 17 studies of interest. After reading and full analysis of the text, 11 articles were removed because they did not fit the inclusion criteria. In total 6 articles were selected for detailed analysis and used for systematic literature review. The researches were carried out between December 2019 and January 2020. In a syntactic way, we describe the methodology through the diagram below:

Prisma Statement

See Fig. 1.

Fig. 1.
figure 1

Research Methodology Diagram, PRISMA type [16]

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3 Results and Discussion

See Tables 2, 3 and 4.

Table 2. JBI critical appraisal checklist (results)
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Table 3. Levels of evidence and recommendation
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Table 4. Extraction of results from articles
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The analysis of the results of this work is based on three assumptions, the symptoms and barriers felt by the person with COPD, the strategies used in the promotion of self-care management to overcome these barriers/difficulties and the gains/outcomes obtained after the implementation of these same measures. In order to obtain a more detailed knowledge of the daily reality experienced by the person with COPD, a standard outpatient pulmonary rehabilitation program was implemented [20], which allows to verify the presence of dyspnea, other comorbidities and the feeling of despair, which determined the influence of the participation of people with COPD in the respiratory rehabilitation program. It also referred to barrier factors such as aging, lack of physical capacity, physical comorbidities, forgetfulness, difficulties inherent to the disease, complex treatments, low economic status, fears and hope, cultural values and beliefs and weak health system, literacy, symptoms and professional and economic issues [21, 22]. Thus, the evolution of COPD leads to episodes of dyspnea, fatigue, intolerance to physical exertion that seriously compromises your physical condition [3]. The alteration of the physical condition, implies the decrease of the capacity in the realization of ADL’s, increasing their degree of vulnerability and dependence [7, 8].

After the diagnosis of the situation, strategies were outlined, which allowed the promotion of self-management and self-care of the person with COPD. The organization of care, the development of standards, the nursing records, the decision making, are fundamental measures that promote the continuous improvement of the quality of health services, thus allowing, as this author recommends, to transform a model of care focused on treatment, in a concept and model of nursing care planning that focuses on the development of individual management skills in people with COPD [17], based on the Theory of transition [8]. Thus, the transmission of information through the help of health professionals using medication, oxygen, ventilotherapy and respiratory techniques, the promotion of socio-psychological capacity, the involvement of family members and professionals and the application of the Theory of “Life Management with COPD”, are determinant in the success of the improvement of the quality of life of the person [19]. Monitoring (via pulse oximetry) was used as a guide in the control and decision making of the person, allowing him/her to assume a prominent role in taking responsibility for his/her self-management in order to reduce the dependence on health professionals [18]. This service called “Light Touch” has also become a teaching tool for people to use their daily readings to understand their state of health. As previously mentioned, the nurse is defended as a health professional trained to anticipate, evaluate, diagnose and help the person to deal with these changes, so that the person acquires concepts and capacity of autonomy in their family and social context, in order to achieve this “transition” [8]. This transition influences not only the person with this respiratory deficiency but also the whole family dynamic and/or life of the informal caregiver [4].

The implementation of a self-management program in health, through the figure of the “coach” nurse, via telephone, with total availability, transmitting feelings of trust and encouragement to the expression of emotions, clarification of doubts [22], can be a facilitating factor, since it is considered as facilitating factors the encouragement, confidence in health care providers, the learning capacity of the elderly and their level of experience [21]. Faced with the complexity of the disease, in response to imposed difficulties and structured strategies, the results show that the use of the strategies mentioned above, allows for gains in self-care and self-management of the person with COPD. Thus, there was an increase not only in the safety and quality of nursing care, but also a preservation of self-management, autonomy and quality of life of people with COPD through the provision and learning of specific contents important for the control of the disease [17] in treatment, in a concept and model of nursing care planning that bets on the development of the individual capacity of management of COPD. The optimization of information exchange between professionals and health services, the changes in nursing records that allowed to define indicators that prove the achievement of results for each patient and optimization of health resource management without increasing costs. Changes were also made in outpatient consultations, reinforcing and facilitating access to health care for people with COPD, allowing doubts to be dispelled and necessary information to be obtained. The use of continuous telemonitoring encouraged people with COPD to invest in emergency medication courses after they were able to relate symptoms to the readings obtained [18]. This study has become a guide for the well-being of the person, giving immediate indication of their state of health, reducing the level of depression, stress and anxiety, thus improving the quality of life, since it gives the patient confidence to act in accordance with his plan of self-management, having an educational role, giving rise to less dependence on health professionals, making people more able to recognize standard symptoms associated with the disease. We consider that the effectiveness of nursing interventions were fundamental to the person’s rehabilitation process, as it was demonstrated in the telemonitoring, evaluation and consequent improvement of SPO2 parameters, allowing to demonstrate that telerehabilitation is central to the patient’s empowerment, self-management and autonomy. The results obtained [18], are in line with the outcomes obtained [19], since they defend health education as a promoter of people’s independence in the development of knowledge and skills, through exercises and management of therapeutic regimes implemented by health professionals, food care, respiratory techniques and physical activity, in order to promote their training, self-responsibility, empowerment and autonomy, allowing people to accept and live better with their condition or illness, living happier, consequently increasing their level of satisfaction with life. These results are also defended by the DGS, which states that it is through health education that rehabilitation nursing enables to empower and promote the autonomy of the person/family, developing adapted self-care capabilities, enabling the person/family to be the self-manager of their disease [6]. Increased well-being, confidence and hope were noted, although without success in all participants [17,18,19,20,21,22].

The analysis of these articles is supported by functional re-education with interventions implemented by the rehabilitation nurse, who achieves health gains through the control of dyspnea, always aiming at the education of the person in the acquisition of skills that enable him/her to become autonomous in a crisis situation [7]. Facing this perspective, Dorothea Orem’s theory of self-care, which bases the concept of nursing care on a relationship between the capabilities of action of the person in the face of the demands of self-care, becoming one of the main foundations in the intervention of the concept of self-care, where it advocates the conditions and limitations of action that the person can achieve with the contribution of nursing, in order to find the balance between what is really necessary and what the person wants or desires, so that the person feels independent and satisfied in their self-care [11]. The DGS suggests that it is through health education that rehabilitation nursing empowers and promotes the autonomy of the person/family, through the development of capabilities inherent to self-care, acquisition of behaviors adapted to the health condition [6]. This educational aspect enables the person/family to be the self-manager of his/her illness and in a certain way enables him/her to self-care and prevent complications.

Thus, it can be seen that in all the articles analyzed, literacy, although not mentioned directly in the articles analyzed, is implicitly associated with competence learning processes and that it underlies a model of empowerment, because it is through cognitive skills implemented by therapeutic education strategies, which must be extremely interactive, motivating and adapted to needs [18,19,20, 22], in order to instill a positive attitude in the person’s daily life, as it also underpins the Action Plan for Health Literacy [13]. In this context, the rehabilitation nurse plays a crucial role, providing the necessary tools for the person with COPD to be able to manage his or her own illness, thus promoting the person’s self-management and decision-making capacity, supported by the principle of responsibility, From our point of view, this is the right way to promote the independence and self-care of the person, in which the rehabilitation nurse, through his interventions, is an agent of change, orienting his praxis to the provision of knowledge and empowerment of the person and family, so that they adopt behaviors that go from finding favorable and expectable results: Self-management and Self-care [9].

4 Study Limitations

The fact that this RSL presents only qualitative studies is a limitation, since, in this type of investigation, each reality depends on the individual perceptions and beliefs. The questions have an exploratory nature and aim to discover, explore, describe and understand the problems that exist in a given context and the way in which each person experiences this experience. Since age, literacy, the severity of symptoms, professional conditions and socioeconomic conditions will influence how each person develops capacities to self-manage their illness.

5 Contributions to Nursing

The realization of this scientifically based synopsis allowed to explain the knowledge of the strategies and the management gains of self-care of the person with COPD, highlighting the vital need to incorporate the rehabilitation nursing legis artis in this process and the assertion that in view of the complexity of this disease it is essential to outline and implement strategies that converge in the empowerment and self-management of the person due to their disease, enhancing the improvement of their autonomy and quality of life.

Following the studies analyzed in this Systematic Literature Review, the support for the success of these programs is the presence of the specialist nurse in rehabilitation, who with his body of specialized scientific technical knowledge is a motivating agent for change, allocating behaviors that culminate in the results expectable: Self-management and Self-care, justified by the measured results that were demonstrative of the improvement in the continuity and safety of health care, less dependence on health professionals as a consequence of training and self-management of the disease and, at the same time, the presence of nurses as the motivating element, trust and encouragement. We admit that the need for scientific evidence is crucial through randomized experimental studies, which corroborate the benefits and the vital role of rehabilitation nursing intervention in programs developed in the area of self-care management, thus guaranteeing the scientific quality and reliability of the results obtained.

6 Conclusion

COPD is a disease that has a great impact on the lives of people who have it. Among the various symptoms, it is the dyspnea that has the most impact on ADL, as well as all the associated comorbidities, fatigue, the feeling of disability, intolerance to effort that compromise the entire condition of the person’s experiences. The increase in the degree of dependence and inability to carry out the basic and instrumental tasks that a person usually performs in daily life leads to an increase in the degree of vulnerability, dependence on self-care and dissatisfaction with life. The delineation of strategies with the objective of promoting the self-management of the pathology and self-care of the person with COPD emerges as an imperative base of a nursing action with a view to autonomy and functionality. The improvement of the quality of life of these people, the continuous improvement of health services, the use and guidance of therapy, the promotion of socio-psychological capacity and the involvement of informal caregivers/family enable desirable and expected outcomes for the person, resulting in their satisfaction and greater independence in the use of health services.

Rehabilitation nursing assumes a central role in all this dynamic of promoting self-care, self-management and functionality of the person with COPD. It is certain that there are always phenomena as barriers and facilitators of this nursing intervention. However, structured strategies and specialized care of quality are propellants of the security of the person, autonomy and of consequent quality of life. To define indicators to obtain results, in view of the individuality of each person it makes possible the optimization of the self-management of resources in health in an efficient way, possibility gained at the level of the health of the person and of economic resources. The educational role of rehabilitation nursing, literacy and functional re-education, have as objectives the development of skills and abilities, promoting not only the training of the person in self-management of the therapeutic regimen but also becomes a reducer of anxiety, stress and lack of confidence. The implementation of strategies that promote empowerment and self-management consequently brings a better and greater degree of autonomy and satisfaction of the person with COPD.