Managing Chronic Obstructive Pulmonary Disease (COPD)

Introduction

Chronic Obstructive pulmonary disease or COPD is an inflammatory pulmonary illness in which the inner wall of airways becomes inflamed thereby narrowing the inner space for passing air inside it (Maddocks et al. 2017). People with COPD experience different symptoms such as breathlessness, chest tightness, breathing difficulties, chest pain, wheezing, heavy cough and episodic shortness of breath. In the case of COPD patients, breathing difficulty occurs due to limited oxygen supply through the airways due to the narrowing in the inner diameter of bronchioles which leads to supply less than the normal amount of oxygen to the lung thereby supplying the limited oxygen to the different body parts from the lung. Due to the scarcity of a sufficient amount of oxygen to different parts of the body it cannot perform regular functions. COPD poses severe adverse impacts on the psychological, physical and emotional wellbeing of people thereby interfere with their activities of daily livings (ADLs).

A recent World Health Organisation (WHO) report shows that in the UK recently more than 1.2 billion people live with COPD. More than 850,000 cases of COPD have been registered by DoH (Department of Health, UK) in 2016. The PHE (2018) data shows that 1 in every 5 people in the UK develops COPD and asthma which pose severe economic burden on that NHS, UK. COPD is responsible for more than 700,000 hospital admission in the UK, out of which nearly 34% people suffers from exacerbation of COPD condition [WHO, 2019]. The overburden of disease and increasing morbidity pose an economic burden of £3.8 billion on NHS, England, in 2017. More than 25% of the people suffering from COPD are obliged to leave their jobs due to their poor physical and mental condition which pose adverse impacts on the overall economy of the UK [PHE, 2019].

For managing the ever-increasing number of COPD in the UK, government has taken several effective health and social care initiatives such as NHS Long Term Plan (2019) has been developed to promote the earlier diagnosis and risk assessment of COPD [NHS, 2019]. This plan assists health professionals and nursing professionals to use the modernised and effective risk assessment and disease management process to reduce the cases of COPD exacerbation. NICE (2019), sets guidelines for effective management of COPD by using the appropriate pharmacological intervention, vaccination, nutrition regimen and lifestyle changes in COPD patients [NICE, 2019]. PHE (2019) recommend that nurses and healthcare practitioners must use effective care regimen for treating the COPD condition in which they can provide the physical, emotional and psychological support to the patients to improve their quality of living.

This essay will discuss a case study of a patient who suffers from COPD [PHE, 2019]. Here the essay will introduce the biography, demographic data, personal and professional life of the patient. Then the study will discuss the pathophysiology of COPD by discussing the cause and health implications of this chronic illness. Then the essay will discuss the social, physical and emotional impacts of COPD on patients. Finally, the essay will demonstrate the care plan, integrated care, health education and patient empowerment in relation to managing the symptoms of COPD in the UK.

Confidentiality statement:

In this assignment, the real names and identity of the patient has been changed in order to protect the rights of patients to confidentiality and privacy of their personal and health care data. In this study the Data Protection Act 1998 has been followed in terms of maintaining the confidentiality of all the personal and professional data of patient [NHD, 2018]. Here patient’s autonomy and dignity have been respected throughout the care (NHS, 2018). This assignment will discuss the NMC (2018) codes and the safeguarding guidelines of NICE (2018) in relation to demonstrate the effective implementation of all these guidelines into the care delivery to the patients in the case study [NMC, 2018].

Case study:

Morris, the 62 years old gentleman had been admitted in the emergency ward with episodic shortness of breath, chest tightness and chest pain. He is a pensioner and lives with his wife which is diagnosed with dementia. They have no children, therefore, are dependent on each other. Morris has a 10 years history of COPD. He manages that cost of his and his wife’s livelihood by his pension which is sufficient to live a healthy life. Morris belongs to a lower socioeconomic condition which poses adverse impacts on his physical and mental wellbeing. He is a regular smoker and drinker. Apart from COPD he also suffers from other psychological condition such as depression; loneliness and anxiety. After that diagnosis of his wife with dementia 2-year ago, he has to take care of medicines, foods and cleansing f his wife. There is no one in the home to take care of Morris and his wife, therefore Morris has to manage all the household works as his wife is unable to do regular activities. In these aspects, Morris is unable to have a healthy lifestyle such as he forgets to take a COPD inhaler, skips meals, cannot manage time to prepare nutritional and healthy foods for him and his wife and skips regular exercise. All this contribute to the deterioration of Morris’s physical and mental health. For the last four days, he suffers from breathing issues and chest pain and on the last night, the condition exacerbates. One of the neighbours brings Morris to the local hospital in which he is immediately shifted to the emergency ward.

The assessment of the medical history of Morris shows that sling with COPD he has another physical health condition, obesity. His weight is 85 kg which is more than the normal range based on his height. The medical assessment shows that he does not have any genetic history of COPD. From the pre-medical history and the genetic data, it is clear that smoking and obesity can be two potential causes of COPD in the case of Morris. From evaluating the physical assessment report health care professionals recommend that Morris needs to provide palliative care (end of life support), in which it is important to take a holistic approach in term of providing physical, emotional and spiritual support to Morris.

Pathophysiology:

While it comes to provide palliative care to a COPD patient the care professionals need to have the clear knowledge of the pathophysiology of this health condition. In normal people air first enters into the mouth and then passes through the nasal cavity, pharynx, larynx, trachea and then bronchiole (Bringsvor et al. 2018). The end of each bronchus enters into the lungs. Inside the lung, bronchi are divided into many bronchioles which form the air sac or alveoli at its end. After air enters into the lungs the gaseous exchange takes place insides the alveoli. Blood vessels are surrounding the outer wall of alveoli (Jenkins et al. 2017). While air enters into alveoli, oxygen inside the alveoli enters into the surrounding blood vessels by the diffusion process and the carbon dioxides enter from the blood vessels into the alveoli which then exhaled from the body. This is the normal pathway of respiration that take places in each normal person thereby supplying sufficient oxygen to each body cell to perform regular functions.

In the case of a patient with COPD there is severe inflammation inside the inner wall of the airways which pose restriction on the sufficient oxygen supply inside the airways (Jolly et al. 2018). On the inner walls of the airways, some many hair-like structures or projections are called cilia. Cilia are associated with taking an active part in blocking the entry of any debris or foreign particles along with the air inside the airways thereby allowing fresh air to pass through the airways. On the other hand, cilia are also associated with sweeping away mucous from the inner walls thereby restricting the accumulation of mucous insides in the inner walls which allows proper oxygen supply to the lung and then to the different body parts. In the case of COPD patients the heavy smoking, excessive exposure to the non-ventilated room or fume, lead to damages of cilia inside the airways as a result there is excessive mucous production in the wall which is then accumulated inside the wall thereby narrowing the inner diameter of the airways (Jenkins et al. 2017). On the other hand, the damaged cilia cause no restriction on the entry of debris and foreign particles inside airways which then stored inside the wall thereby restricting the entry of a sufficient amount of oxygen through the inner side of the airways. This is why there is reduced oxygen supply to the lungs and the different body parts in case of patients with COPD which cause severe breathlessness and chest pain.

COPD is associated with two chronic lung condition such as chronic bronchitis and emphysema. As argued by Hillebregt et al. (2017), it is not necessary that a person who suffers from COPD will develop both the condition, rather the patients also can develop only one condition. Emphysema is the condition, in which the alveoli inside the lung become highly inflamed which cause reduced oxygen supply to the surrounding blood vessels thereby reducing the oxygen supply to all the body system. On the other hand, chronic bronchitis is a long-term condition in which the bronchi are affected adversely with severe inflammation on the inner wall which poses restriction on the oxygen supply inside the airways thereby supplying limited oxygen to body cells that cause episodic breathlessness.

In the case of Morris, he is highly vulnerable to the risk of these above-mentioned two health condition, (emphysema and chronic bronchitis) (Sandelowsky et al. 2018). Smoking is strongly associated with developing COPD in people. While smoking, nicotine and other substances enter into the bronchi and cause severe structural and functional changes of lung and bronchioles. In case of Morris, the structural change that occurs inside the bronchiole is damaging the cilia that causes severe inflammation of the inner wall that leads to accumulation of excess mucus on the inner walls of the airways. On the other hand, smoking also causes severe damages to the air sacs inside the lungs thereby reducing the oxygen supply to the surrounding blood vessels. This is why Morris suffers from severe breathing issues as his body gets limited oxygen that is unable to perform all the body functions

Physical, social and psychological challenges:

COPD affects people in several ways such as physically, psychologically, and socioeconomically.

The common impact of COPD is poor lung functions and inflammation on the inner wall in the airways which cause shortness of breath. Evidence suggests that COPD reduces the ability of people in performing activities of daily living (ADLs) (Van der Molen et al. (2017). In the case of Morris, COPD pose adverse impacts on his ability to perform regular activities, this is because he feels breathlessness and chest pain after doing some work. As Morris is obese and aged, COPD may lead to reduce his mobility which deteriorates his quality of living. Evidence suggests that people with COPD face difficulties in running or walking as their body cannot get sufficient oxygen to do so. As mentioned by Sigurgeirsdottir et al. (2019), for performing the normal function body needs enough oxygen. In case of a COPD patient like Morris, the person cannot perform so many works in a day due to the lack of oxygen supply to body cells.

Evidence also suggests that COPD is associated with adverse structural and functional changes in the lung and airways which reduce the oxygen supply to the body cells (Sandelowsky et al. 2018). In case of Morris there is severe accumulation of nicotine and mucous inside the wall of bronchiole and air sacs (alveoli) that cause narrowing of the inner diameter of the airways. On the other hand, as cilia are damaged inside the airways in the COPD patients like Morris, the autoimmune system is actives permanently which cause the cytokines wit moves towards the airways and gets accumulated into the inner wall thereby causing further narrowing of the diameter. These structural changes inside the airways cause limited oxygen supply to lung and the entire body.

COPD is associated with the lung hyperinflation, in which there is decreased elasticity of the parenchyma wall the which then cause restriction on supplying sufficient amount of oxygen to the lung alveoli.

COPD poses adverse impact on the emotional and psychological status of people. It adversely impacts how people think, feels and decide things. Evidence suggests that tree is a strong relation with COPD and mental condition such as depression, anxiety, frustration and low self-esteem (Hillebregt et al. 2017). In case of Morris, he suffers from severe depression due to his poor physical condition. He is unable to walk more than a mile and unable to manage household work systematically due to the breathing issues which make him feel sad, helpless and anxious. PHE (2019), mentioned that, in the UK, the majority of the aged people who suffer from COPD are diagnosed with more than one mental condition such as depression, dementia and lack of self-confidence. In the case study as Morris is unable to perform the activities of daily living he develops feeling of lack of self -esteem and reduced self-confidence. As mentioned by Ogunbayo et al. (2017) patients with COPD are more likely to suffers from lack of right decision-making skill, problem solving ability and analysing skill. This is because they feel underestimated and helpless to take any decision on the personal and professional life. On the other hand the inability of COPD patients in forcing any work to develop a feeling of inactiveness in them, which is due to their reduce self-confidences and lack of self-esteem.

NHS (2018) mentioned that majority of the COPD patients in the UK suffers from lack of judgement skill and analysing ability. They are unable to analyse the outcomes and reason of any things that happen to their life due to that poor health condition (Khan et al. 2017). NMC (2018) mentioned that care professionals must take palliative care approach for the COPD patient empower them in developing effective self-management sill. The 10 years history of COPD in case of Morris is associated with his lack of self-management and reduced stress mange met skill that not only impacts adversely on his overall decision making but also impacts on his positive thoughts and well-being. COPD pose adverse impacts of patient’s soft feeling and positive thoughts, thereby developing a feeling of helplessness and loss inside them (Sandelowsky et al. 2018).

COPD affects the social lives of people by affecting the way they interact and communicate with the surrounding people (Jenkins et al. 2017). People with COPD feel shy to attend any social functions because of their breathing difficulties and heavy cough. People with COPD cannot take part in the morning walk and other social activities with their neighbours as they get easily exhausted and suffer from severe breathing issues. In the case study, Morris may be unable to maintain effective interaction with his neighbours and other society members due to his poor physical health. He may feel embarrassed in front of neighbours while suffering from heavy cough with sputum and wheezing sound as he feels that his physical health condition can be a matter of irritation to the society people. COPD also affects the communication and interactive ability of people (Hillebregt et al. 2017). In case of Morris, due to COPD he feels difficulties in speaking or discussing something for a long time as he needs more oxygen to breathe which is not possible in his case. In addition to this, as compared to the normal people, Morris speaks slowly which can be potential reason for society people will avoid talking and interacting with him as it can kill their time.

COPD is strongly associated with socio-economic condition of patients. Evidence suggests that patients with COPD must have proper socioeconomic resource to afford the lifestyle that is needed to manage the symptoms of this illness. For example, in case of Morris, due to his lower economic condition he is unable to manage healthy and nutritional foods every day, regular exercise, proper vaccination and systematic lifestyle which exacerbate his breathing condition. People with lack of jobs and housing facilities are unable to afford the good quality life which impacts their physical and emotional wellbeing (Hillebregt et al. 2017). Although COPD is the lunge term condition, its symptoms can be managed if the patients follow a systematic and regular lifestyle such as no skipping meals, intake healthy foods each time, taking homemade foods and fruits, take regular medicines and stay in the hygienic and fresh room environment. In case of Morris his low socioeconomic condition makes him unable to afford all these facilities which cause deterioration of COPD condition

Nursing and medical care:

Effective nursing and medical care are important for managing COPD by providing the immediate clinical, emotional, physical and psychological support to the patient. In case of Morris, a person-centred approach has been taken which are as follows:

First physical assessment has been performed by nursing professionals to determines the physical status of Morris. In this context nurses use ABCDE [airways, breathing, circulation, disability and exposure] assessment framework (Guimarães et al. 2018). For checking the airways condition of Morris spirometry, HRCT (high resolution computed tomography) test and PFT test have been performed, which shows that he has highly inflamed airways and lung.

HRCT test shows that breathing rate is more than 25 breaths per minute. With an oxygen saturation level 87% (normal is 95-99 in COPD patient). NEWS score for Morris’s breathing condition is 2 which shows that he is under high risk of further deterioration of the lung condition.

An ECG is done to check circulation of Morris which shows normal range. Therefore, it is assessed that Morris does not have any heart disease. Disability test has been performed in case of Morris which shows that although he is not immobile, as compared to normal people he has reduced mobility which pose adverse impacts on his ability if performing regular functions.

The assessment also shows that Morris is highly exposed to smoking and friendly which contribute to deterioration of the lung's ability to perform normal function.

Psychological assessment is another important part of the clinical intervention through which carte professionals determine the psychological illness of COPD patients (Patel, 2015). In case of Morris, nurses use empathetic communication with him to maintain trustworthy and friendly relationship with Morris. Through using the regular empathetic and friendly communication, nurses can be able determine what Morris thinks about his health condition, what impacts COPD poses on his overall psychology and what is his current perspectives regarding taking the hospital care. Additionally, nurses also follow the behaviour and attitudes of Morris to detect whether there is any change in his behaviour and activity due to the COPD.

The next step in the nursing and medical care is planning of the treatment and effective care process. Here nurses have use the APIE model to plan the effective care regimen for Morris (Tregoning, 2015). Under this care plan Morris is referred to a multidisciplinary team for providing his with the holistic as well as integrated care. This multidisciplinary team consist of occupational therapist, psychotherapist, general physicians, nurses, health and social care staffs, pulmonologists and nutritionist. This team will work on different health of Morris such as his emotional, physical, psychological, spiritual and social needs. The multidisciplinary team will perform different functions such as conducting regular observation of Morris’s physical health, examines his behaviour and activities, maintaining effective communication with him to know his pain and needs, provide him with psychotherapies and physiotherapies and empower him by providing emotional and spiritual support (Lasley, 2017).

The next stage of this nursing care is the implementation in which nurses will implement the three 6C, competence, courage and commitment (NMC, 2010). Nurses who work with Morris must be highly skilled and well-trained in implementing the care plan effectively. Under NMC (2010), nurses must work under their level of competence and professional skill in relation to provide safe and high-quality care to service users. In case of Morris, nurses will ensure that they provide the good standard of the evidence-based care to him in terms of promoting his holistic needs (Mirhaghi et al. 2017). Nurses must be countable and committed to their responsibilities towards Morris

In relation to ensure that appropriate care and support is provided to Morris. In implementation of care plan nurse would ensure that they promote the effective lifestyle changes in Morris such as developing healthy eating habits in him and motivating him to do regular exercise (Riggall, 2016). Additionally, nurses also help Morris to develop positive and optimistic thoughts which will empower him to develop self-confidence to cope up with his illness (COPD).

The next stage is the evaluation stage, in which nurses will evaluate the usefulness of the care plan that is implemented in case of Morris. In this context nurses will analyse the reviews of the care staffs and feedback of Morris in relation to determines whether there is any improvement in his oxygen saturation, breathing condition and lung condition of Morris after implementation of the care plan.

Integrated care:

Integrated care is the coordinated care in which all the health and social care professionals work collaboratively on patient needs to ensure promoting positive health and wellbeing of COPD patients (Rehman et al. 2017). Integrated care plan or ICP is the systematic pathway that assists nurses and care professionals to implement a person-centred approach to determine and meet all needs of patients thereby promoting their holistic wellbeing. Under NMC (2010), nurses must implement the 6C into their practices to ensure that they work in collaboration with all t others health care professional to provides high quality care to patients. These 6Cs are care, compassion, communication, competence, courage and commitment.

In case of Morris, nurses use the three of the 6Cs, care, communication and compassion to implement the person-centred approach into the care plan. Here nurses would ensure that, they develop a regular empathetic and friendly communicating with Morris that will enable them to get updates on the current physical and psychological communication of Morris. Nurses will also ensure that they provide the compassionate care to Morris that will not only improve his breathing condition and lung condition but also provide him with health information regarding self-management of COPD. Through following ICP nurses and care professionals are able to develop strong health literacy in Morris that enables him to understand his breathing condition, check his oxygen saturation himself and manage his breathing condition by following a healthy and systematic lifestyle.

Education, health promotion and empowerment:

Health education and effective health promotion are crucial to empower patients with COPD (Feldstein Ewing et al. 2016). In case of Morris, nurses can improve his knowledge on the cause, health implication ad effective management of COPD. Nurses can develop effective self-management skill in Morris by guiding him regarding his diet and; lifestyle. For example, Morris can be advised to do aerobic exercise daily which will improve his breathing condition and lung capacity to receive oxygen from bronchi. On the other hand, nurses can guide Morris in terms of taking the foods that are appropriate to his COPD conduction such as he must avoid such foods that can cause allergic reaction such as cold drinks, junk foods, prawn and packaged foods. On the other hand, nurses would promote positive mental health in Morris by reinforcing optimistic thoughts and positive thinking in him which will empower him to cope with the health implications of COPD.

Through providing stress management training to Morris, nurses can assist him to reduce his stress regarding his breathing condition and lung capacity. Nurses must show supportive and empathetic attitude towards Morris to enhance his self-confidence and self-esteem.

Conclusion:

From the overall discission, it can be concluded that, effective care plan is crucial for providing the holistic care to patients with COPD. Through using APIE model nurses can assess health condition of patients, plan the effective care regimen for them, implement effective care plan and evaluate the usefulness of the careplan. Through using integrated care pathway, nurses can promote holistic wellbeing of patients with COPD by meeting all health needs. Additionally, health education, empowerment and health promotion are associated with enhancing psychological and physical strength f COPD patients that help them to cope up with their health condition.

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Reference list:

Bringsvor, H.B., Langeland, E., Oftedal, B.F., Skaug, K., Assmus, J. and Bentsen, S.B., 2018. Effects of a COPD self-management support intervention: a randomized controlled trial. International journal of chronic obstructive pulmonary disease, 13, p.3677.

Feldstein Ewing, S.W., Apodaca, T.R. and Gaume, J., 2016. Ambivalence: Prerequisite for success in motivational interviewing with adolescents?. Addiction, 111(11), pp.1900-1907.

Glauser, A.S. and Bozarth, J.D., 2001. Person‐centered counseling: The culture within. Journal of Counseling & Development, 79(2), pp.142-147.

Hillebregt, C.F., Vlonk, A.J., Bruijnzeels, M.A., van Schayck, O.C. and Chavannes, N.H., 2017. Barriers and facilitators influencing self-management among COPD patients: a mixed methods exploration in primary and affiliated specialist care. International journal of chronic obstructive pulmonary disease, 12, p.123.

Jenkins, C.R., Chapman, K.R., Donohue, J.F., Roche, N., Tsiligianni, I. and Han, M.K., 2017. Improving the management of COPD in women. Chest, 151(3), pp.686-696.

Jolly, K., Sidhu, M.S., Bates, E., Majothi, S., Sitch, A., Bayliss, S., Kim, H.S. and Jordan, R.E., 2018. Systematic review of the effectiveness of community-based self-management interventions among primary care COPD patients. NPJ primary care respiratory medicine, 28(1), pp.1-8.

Jolly, K., Sidhu, M.S., Hewitt, C.A., Coventry, P.A., Daley, A., Jordan, R., Heneghan, C., Singh, S., Ives, N., Adab, P. and Jowett, S., 2018. Self management of patients with mild COPD in primary care: randomised controlled trial. bmj, 361.

Kessler, R., Casan-Clara, P., Koehler, D., Tognella, S., Viejo, J.L., Dal Negro, R.W., Díaz-Lobato, S., Reissig, K., González-Moro, J.M.R., Devouassoux, G. and Chavaillon, J.M., 2018. COMET: a multicomponent home-based disease-management programme versus routine care in severe COPD. European Respiratory Journal, 51(1).

Khan, A., Dickens, A.P., Adab, P. and Jordan, R.E., 2017. Self-management behaviour and support among primary care COPD patients: cross-sectional analysis of data from the Birmingham Chronic Obstructive Pulmonary Disease Cohort. NPJ primary care respiratory medicine, 27(1), pp.1-10.

Lasley, J., 2017. Developing Empathic Communication Skills Through Service Learning: A Qualitative Case Study. Radiation Therapist, 26(2).

Miller, W.R. and Moyers, T.B., 2017. Motivational interviewing and the clinical science of Carl Rogers. Journal of Consulting and Clinical Psychology, 85(8), p.757.

Mirhaghi, A., Sharafi, S., Bazzi, A. and Hasanzadeh, F., 2017. Therapeutic relationship: Is it still heart of nursing?. Nursing Reports, 7(1), pp.4-9.

Mullin, D.J., Saver, B., Savageau, J.A., Forsberg, L. and Forsberg, L., 2016. Evaluation of online and in-person motivational interviewing training for healthcare providers. Families, Systems, & Health, 34(4), p.357.

Ogunbayo, O.J., Russell, S., Newham, J.J., Heslop-Marshall, K., Netts, P., Hanratty, B. and Kaner, E., 2017. Understanding the factors affecting self-management of COPD from the perspectives of healthcare practitioners: a qualitative study. NPJ primary care respiratory medicine, 27(1), pp.1-9.

Patel, B., 2015. Communicating across cultures: proceedings of a workshop to assess health literacy and cross‐cultural communication skills. Journal of Pharmacy Practice and Research, 45(1), pp.49-56.

Plaza, V., Álvarez, F., Calle, M., Casanova, C., Cosío, B.G., López-Viña, A., de Llano, L.P., Quirce, S., Román-Rodríguez, M., Soler-Cataluña, J.J. and Miravitlles, M., 2017. Consensus on the Asthma–COPD Overlap (ACO) Between the Spanish COPD Guidelines (GesEPOC) and the Spanish Guidelines on the Management of Asthma (GEMA). Archivos de Bronconeumología (English Edition), 53(8), pp.443-449.

Rehman, H., Karpman, C., Douglas, K.V. and Benzo, R.P., 2017. Effect of a motivational interviewing-based health coaching on quality of life in subjects with COPD. Respiratory care, 62(8), pp.1043-1048.

Riddell, M.C., Gallen, I.W., Smart, C.E., Taplin, C.E., Adolfsson, P., Lumb, A.N., Kowalski, A., Rabasa-Lhoret, R., McCrimmon, R.J., Hume, C. and Annan, F., 2017. Exercise management in type 1 diabetes: a consensus statement. The lancet Diabetes & endocrinology, 5(5), pp.377-390.

Riggall, S., 2016. The sustainability of Egan’s Skilled Helper Model in students’ social work practice. Journal of Social Work Practice, 30(1), pp.81-93.

Sandelowsky, H., Natalishvili, N., Krakau, I., Modin, S., Ställberg, B. and Nager, A., 2018. COPD management by Swedish general practitioners–baseline results of the PRIMAIR study. Scandinavian journal of primary health care, 36(1), pp.5-13.

Sigurgeirsdottir, J., Halldorsdottir, S., Arnardottir, R.H., Gudmundsson, G. and Bjornsson, E.H., 2019. COPD patients’ experiences, self-reported needs, and needs-driven strategies to cope with self-management. International journal of chronic obstructive pulmonary disease, 14, p.1033.

Tregoning, C., 2015. Communication skills and enhancing clinical practice through reflective learning: a case study. British Journal of Healthcare Assistants, 9(2), pp.66-69.

van der Molen, T., van Boven, J.F., Maguire, T., Goyal, P. and Altman, P., 2017. Optimizing identification and management of COPD patients–reviewing the role of the community pharmacist. British journal of clinical pharmacology, 83(1), pp.192-201.