Chapter 1

Introduction

Background of the Study

The threat of chronic obstructive pulmonary disease (COPD) in developed countries, particularly

in the West, has been observed to be on the rise (Barnes, 2002; Kaminsky, Marcy and Barchand,

2005). The more severe cases often end in death, and even if this is not the case, one’s quality of

life is sure to suffer (Petty, 1998). That it comes with airflow obstruction, observable by how the

lungs empty more slowly, mean that COPD is often lumped together with similar diseases such

as bronchitis and emphysema. While these symptoms remain mostly constant over a period of

time, these also show the progressive nature of lung impairments (Goodrich, Lawson, Duggleby,

Marciniuk, Rennie and Stang, 2008).

There has already been some research on COPD rates in both developed and developing nations,

and in fact it was the top 6th cause of death in the past decade, having claimed the lives of 2.2

million (Buist, McBurnie and Vollmer, 2007). There is an especially high risk that it will claim

the top 3rd spot by 2020 and that the mortality rate will balloon to 3.5 million. And even those

lucky enough to have nonlethal cases of COPD were not much better off (Seemungal,

Harrinarine and Rios 2008). More than anything, cigarette smoking and secondhand smoke were

found to have caused most cases of this disease, not to mention biomass fuels in the developing

countries (Varkey, 2004). It affects 1-2 out of 20 males and females, though this may vary in
some nations such as Australia and the United Kingdom (Varkey, 2004). Overall, the prevalence

of this disease is only bound to go up in the coming decade.

One’s current and previous medical history need to be assessed if COPD is to be treated properly

(Soriano, Maier and Egger, 2000). It is through these procedures that healthcare providers will be

able to determine how best to intervene, specifically whether to use oxygen therapy or surgery,

among other methods (Calverley, 2000). Of course, patients also need to do their part by eating

right, proper exercise and in general, taking care of themselves. Treatment of COPD is primarily

aimed at strengthening one’s lungs against secondary complications in order to improve one’s

quality of life (Han, Postma and Mannino, 2007) .

In the treatment of COPD, community-based management planning and care is necessary.

Specifically, support from healthcare professionals is a major factor in determining the success

of such treatment (Seemungal, Donaldson, Bhowmik, Jeffries, and Wedzicha, 2000). Healthcare

professionals need to be properly trained and informed as to how to manage COPD, if prevention

and treatment drives are to succeed. Aside from this, they also need to be able to operate

diagnostic equipment and to examine test results; as can be observed by research, the lack of

professional training and development can sometimes have deadly consequences. It should be

perfectly plain, then, that healthcare professionals need to be better trained to combat this disease

(Suissa, 2008). And in general, demands for rehabilitation services further necessitate their

involvement in such activities in order to improve the quality of life of COPD patients.
Research Aims

This research firstly aims to recognize the skills carers need to render the best services to COPD

patients, as well as the challenges they face in doing so. The outcomes and effectiveness of such

healthcare shall also be assessed. And lastly, the necessary content shall be determined for

COPD-related training programs.

Significance of the Study

Much research has attested to how lack of training and development can have highly unpleasant,

sometimes even lethal consequences. And by the same token, those who have undergone

superior, specialized training programs have been found to be more successful in their treatment

of COPD. This research could further ascertain the factors that affect training and development

programs for healthcare professionals focusing on COPD, as well as the challenges facing them

and how these can be overcome. It would also help improve healthcare strategies on the

management of COPD patients if the outcomes of COPD care were to be examined. And of

course, it would help healthcare professionals to address the top priorities of COPD care if they

were to be given more effective training programs. These programs should also go a long way in

reinforcing the concepts and practices they should have mastered but somehow have not.

Overview of the Dissertation

A background shall be given for the study and its main objectives discussed. The second chapter,

meanwhile, serves as a literature review focusing specifically on factors such as 1) the main
concepts of such research; 2) difficulties encountered by carers with regard to COPD; and 3)

how training programs have helped to address the treatment of this as well as other similar

diseases. Chapter 3, meanwhile, concerns itself with how to gather valid, usable data, the results

of which will in turn be discussed in greater detail in Chapter 4. Finally, the 5th chapter contains

conclusions and recommendations derived from the overall research.

Chapter 2

Review of Related Literature

Introduction

Caring has its impact on the physical and mental health not only of the patients, but of the carers

themselves (Arksey and Glendinning, 2008). The longer one works as a carer, the more his

health suffers, and the more urgently support must be given to him (Department of Health,

2008). When it comes to the effects of these care-giving experiences, gender also suffers –

specifically, females are said to experience greater levels of anxiety and stress. It should also be

noted that these psychological consequences are most apparent during the first and last days of

caring (Hirst, 2005). Still, though, the caregiving profession is not without its own extensive,

multidimensional benefits for those working there (Nolan, Keady, Grant and Lundh, 2003). At

the same time, this should not suggest that caregiving exchanges and relationships are easy
(Forbat, 2005). According to research, those with COPD are neglected compared to those

afflicted with more ‘lethal’ diseases such as cancer, especially where healthcare and palliative

care are concerned. It could then be inferred, and not without cause, that COPD patients often

have to put up with insufficient and sometimes even substandard care. It has been said by the

Global Initiative for Obstructive Lung Disease (GOLD) that the growing prevalence of COPD

now constitutes a public health threat to the larger community. But even then, governments and

those in the healthcare community have yet to rectify the situation, and those afflicted with

COPD continue to suffer as they have yet to receive proper care (GOLD, 2001).

Overview of COPD and its Effects on Patients

According to the World Health Organization (WHO), even the world’s most developed countries

need to become wary as chronic obstructive pulmonary disease (COPD) is fast becoming a

leading cause of death, which some even say spreads faster than even lung cancer, to say nothing

of other, more common lung diseases. And yet, in spite of the situation, over 75% of all

Europeans suffering from COPD have yet to be given the healthcare and treatment they deserve,

all the while languishing as their lungs continue to deteriorate in function and capacity (Feenstra,

Genugten and Hoogenveen, 2001). The most apparent symptoms of this are long-term coughing

problems, constantly spitting, shortness of breath and tightness of the chest. While none of these

are immediately life-threatening, if at all, these are still highly troublesome and are a major

source of stress for those afflicted with COPD. They cannot handle daily life as well as they used

to (Feenstra et al, 2001; Price, Tinkleman and Halbert, 2006).

More than anything else, cigarette smoking has been determined to be the factor that most

aggravates cases of COPD. In fact, 8-9 out of the risk factors associated to COPD all result from

smoking. And also because of this, more and more people become afflicted and even die from

COPD (GOLD, 2001). On average, someone who smokes over 20 cigarettes for a year, on a

daily basis, has an increased chance of developing COPD within 20-25 years (Halbert, Isonaka

and George, 2003). Neither cigarette smoking nor the high levels of pollution that characterize

most cities in developing countries help the stem the development of COPD, already worsened

by harmful and detrimental airborne particles and genetic factors1 (European Respiratory

Society, 2002). And while it is generally believed that males are at greater risk for COPD,

women should still not become careless as the rising frequency of smoking among females

means that they are also at substantial risk of developing COPD (European Respiratory Society,

2002). Due to how common COPD currently is, it along with other lung ailments constitutes a

major socio-economic problem for communities everywhere. It develops as patients suffer from

increasingly severe symptoms such as wheezing, coughing, chest pains and shortness. Ways for

them to overcome their condition range from a doctor’s advice to emergency aid and in the most

extreme cases, hospitalization (Sullivan, Ramsey and Lee, 2000).

Understandably, it is the patients themselves who suffer most from COPD, the effects of which

plague them as they struggle to live their daily lives (Petty, 1998). Most of them commonly

suffer sleeping disturbances and shortness of breath, both of which cause high levels of fatigue

that may make more strenuous, physical activities more ill-advised. In addition, those afflicted

with COPD often find that their economic and social activities also suffer (Elkington, White,

Higgs and Pettinari, 2001). And of course, the symptoms of this condition also takes its toll on
one’s psych as he becomes increasingly plagued by anxiety, doubt and depression. Due to the

recurring nature of COPD and its associated symptoms, COPD carers are hard-pressed when it

comes to caring for others, as they need to be especially careful (Sexton and Munro, 1988).

Concept of Caring

In a nutshell, caring entails that one provide care for another person who is plagued by

unhealthful conditions (Leininger, 1988). Thus, caregivers and other healthcare professionals

need to be sufficiently skilled if they hope to give sufficient care to their patients, taking care of

them as appropriate and as best they can (Brunton, 2005). The possession of both professional

and humanistic knowledge allows caregivers to better understand the patients under their care,

which should then allow them to take better care of these patients. As noted by Roach (1985), the

5 Cs – compassion, competence, confidence conscience and commitment – are key character

traits that none in the healthcare profession, especially nurses, should be caught dead without. In

a study of Lee-Hsieh and Fang (2000) as well as Hsieh, Fang and Chiang (1998) with regards to

the concept of caring, it was found out that caring involves a psychosocial domain that includes

different components such as respect, empathy, sincerity, unconditional acceptance, and treating

patients as family members, and a caring action domain that includes professional behavior such

as providing an appropriate and comfortable environment and being sensitive with touching,

listening, tones and facial expressions.

Professional caring requires that one possess substantial levels of scientific knowledge,

competence and compassion. More than just ordinary, everyday care, caregivers should also

keep professional morals, practices and ethics in mind when ministering to the needs of their
patients (Gerard, 1995). In caring, says Scotto (2003), one offers himself, integrating his

physical, mental and spiritual aspects in order to achieve his goals. Paterson and Crawford

(1994) as well as Watson (1990) have all emphasized the importance of giving students guidance

and instruction as to how to care for others. More importantly, it is said that caregivers and

healthcare professionals must themselves have received sufficient levels of care in their

education and training in order to care for others effectively (Bernick, 2004). Without havin g

experienced care, caregivers cannot reasonably be expected to provide it adequately themselves

(Beck 1991). Thus, healthy interaction between students and instructions helps a lot in seeing

that this goal is achieve. According to Grams, Kosowski and Wilson (1997), instructors should

exercise equality and empathy in order to help their students grow both professionally and

personally.

Many research disagree with the notion that caring can be taught. For a start, the studies of both

Patterson and Crawford (1994) and Tanner (1990) attest to how caregivers can be best trained to

care for others if their training takes place in a caring environment, and under the tutelage of a

supporting instructor. However, this is in turn contested by Yang and Lu (1998) who point out

that while their caring knowledge is increased, this does not necessarily follow for their caring

behaviors. A compromise between these two views is adopted by Lebold and Douglas (1998),

who note that aspiring caregivers can learn the concept of caring in the classroom, even if not

completely. And according to Beck (1992), teachers need to be proper role models if their

students are to learn to care for others. Also according to Beck (1993), those students who share

their professional caring experience with their peers stand to gain deeper understanding and
familiarity with it, in effect allowing them to become each other’s role models. And according to

Lee-Hsieh (2003), this kind of role modeling is often readily apparent.

Carers: Their Needs and Experiences

According to the 1990 General Household Survey, roughly 6.8 million - 10% of the UK’s

population - is comprised of carers, while 15% of all adults have at least some caring

responsibilities (Sprung, Carmel and Sjokvist, 2007). While most of these adults call themselves

‘helpers’, approximately 1.6 million of them provide care for 20 hours a week and can thus be

considered caregivers. A handful of them provide over 100 hours every week and/or work as

personal carers, which could stem from high dependency (Twigg, Atkin and Perring, 1990). A

fifth of all households had been found to require a carer, and a fifth of all carers have cared for

one patient for over 10 years. Also, most of these carers are female. But regardless of their

gender, all carers strive to take care of people who are physically or mentally handicapped

(Stalker, 2003).

Studies, however, have been showing the increasingly distressing experiences of carers in their

day job. An example of these experiences is related by Caress et al (2009), who note that the

anxiety, depression and negativism experienced by COPD sufferers also takes its toll on their

caregivers (Caress, Lukers, Chalmer and Salmon, 2009). Complications associated with medical

technology, treatments and regimens likewise cannot be ignored, as each carer finds it

increasingly difficult to provide effective care to their patients. Other fields in which carers are

similarly challenged includes psychiatric care, especially if the patient in question happens to be
suffering from psychotic disorders. According to Helzen, Asplund, Sandman and Norberg

(1999), their study on Swedish caregivers in such an institution noted the difficulties they endure

everyday in the form of unpredictability and sometimes even violence. The carers also become

more doubtful of their future, and become frustrated as they struggle to understand the disturbing

behavior of their patients. Carers also experience difficulty in caring for the elderly, especially

when they have suffered extensive levels of cognitive impairment (Morris, Morris and Briton,

1988), and this can take its toll on them whether financially, socially or psychologically (Fadden,

Bebbington and Kuipers, 1987). It is admirable, then, that carers still find it in themselves to care

for the elderly despite these challenges. Thus, formal services need to take their needs into

account, not only to retain them but also to make it easier for them. All in all, social workers

need to have wider vision and greater support (Sharkey, 1989).

The needs of carers have also been overlooked in the previous decades; however, more recently,

psycho-oncology has recognized the possibility of psychological distress levels among carers

(Grant, Keady and Nolan, 1996). Studies have been conducted with regards to their needs of

further information and training from health professionals as well as the likelihood of coping and

other psychological interventions (Katz, Boesch and Herzog, 1998). Carers are mainly involved

in the entire process of caring for patients with certain conditions; therefore, their needs should

be addressed and their experiences be satisfying (Rogers, Karlsen and Addington-Hall, 2000).

Significant needs refer to the needs that are considered to be of great importance to the carer; it

only becomes an unmet need if it is believed to be not satisfied. The nature of the carers’

dilemma has been understood by researchers and clinicians to come from stress, pressure or their
coping strategies. The research conducted by Gilleard, Gilleard, Gledhill and Whittick (1984)

conducted an interview among 129 carers and focused on the forms of stressful experiences that

they went through, the formal and informal support they received, as well as their sense of strain.

The need for regular monitoring of the patient as well as their uncontrollable behavior was

regarded as the greatest stressors. The amount of support did not signficantly contribute to the

level of stress experienced by the carers. Morris, Morris and Britton (1988), in their study,

emphasized the importance of personal coping strategies of carers which play a significant role

in moderating the impact of stressors, such as the carers’ way of thinking towards a difficult

situation and the available resources as well as how they respond to it. Voluntary or informal

support was also shown to be linked to a decrease in demands when it comes to formal services.

Morris et al (1988) encouraged researchers and practitioners to carefully consider these factors in

order to enhance services to caregivers.

The concept of coping primarily includes personal coping strategies and ‘social support’ (Moore,

Vosvick and Amey, 2006). Social support is characterized by informal help for emotional

problems including emotional, practical and informational support. Meanwhile, personal coping

strategies range from cognitive and behavioral approaches to avoidance strategies towards

dilemmas (Pierce, Singer and Prigerson, 2006). A survey in the United Kingdom among 1,000

individuals showed that the respondents were often kept busy through a range of activities

(behavioral strategy) and by developing ways with which the problem can be solved (cognitive

strategy) (Bledin, MacCarthy, Kuipers, and Woods, 1990). Avoidance strategies such as

drinking or smoking were not common. With regards to social support, it has been shown that

majority of the respondents sought the aid of non-professional helpers, such as a family member
(68%), close friend (48%) or mental health workers (16%) (Bledin et al, 1990). Mental health

workers have played a great role in assisting and helping carers when it comes to coping even

during the previous decades with which Zarit, Anthony and Bontselis (1987) provided support

for carers through family counseling, Cantley and Smith (1983) provided a relatives support

group, and Brodaty and Gresham (1989) was able to develop a coping training package for

carers, all of which have shown how carers have their own needs when assuming the caring role.

Training Needs and Content for COPD Carers

Lack of knowledge, information and understanding when it comes to COPD may lead to failure

in identifying the needs of those patients who suffer this disease (Kasikci and Alberto, 2007).

Therefore, there is a need to promote the standards of quality and life as well as the care

provided for individuals who are living with this condition along with their families and

caregivers (Mays, Pope and Popay, 2005). Aside from using campaigns to raise awareness for

COPD prevention and as well as to promote equal access to education, information, treatment

and rehabilitation of COPD patients, there is also a need to make use of training and education

programs that will provide the necessary information for effectively managing individuals who

are living with COPD. Education materials and support networks should be utilized in training

programs and seminars to enhance the management and rehabilitation of COPD patients both at

home and in the hospital.

COPD and its Progression

Because COPD is one of the major causes of death when it comes to lung diseases (Fauzi, 2003),

it is necessary that health care professionals and carers of COPD patients should be completely

aware of its symptoms and exacerbations along with the appropriate measures and procedures in

dealing with such conditions. Training education programs should include the risk factors of

COPD associated with one’s lifestyle and surrounding environment. Widespread educational

campaigns that can help in increasing awareness of risk factors including tobacco smoke and air

pollution will help inform and encourage those at risk for the disease to make use of more

healthful steps. Meanwhile, for carers of COPD patients, it is best that regular education

programs are provided for them to completely understand how the disease goes about, its

outcomes on the patients, and the ways with which it can be effectively managed. Fully knowing

and recognizing COPD will allow carers to undergo the necessary preparations; moreover, they

will be able to send timely and correct reports to their doctors.

Disease Management

Due to the increasing occurrence of COPD and its debilitating conditions (Mannino, Buist, Petty,

Enright and Redd, 2003), strategies for an early and accurate diagnosis along with effective

management should be implemented by all health care providers who have the ability and

resources to do such procedures such as physicians and specialized doctors. Training programs

for these individuals should encompass diagnostic strategies that will target patients in the early

stages of any disease. The use of spirometry should also be integrated into the program in order

to have an early confirmation of any diagnosis, thereby, improving disease management. All
forms of care, from primary care up to specialized health care, should be carefully discussed

particularly in giving the safest and most favorable care in any level.

Providing information on disease management will allow carers to further understand and out

into practice a number of treatments, necessary medications, and safety measures to avoid

unnecessary hospitalizations or emergency care. For instance, being trained to assess the

patients’ respirations, pulse rate, lung sounds, and cough will help determine the level of severity

of the disease. Being informed with the available treatment and medications as well as the proper

diet, exercise, breathing techniques, and various daily activities for COPD patients will improve

the carers’ management of their patients’ conditions. Daily reports are also advised in order to

monitor the progress, changes, improvements, and concerns of the patients’ conditions for their

doctors to come up with timely and appropriate measures.

The Role of Caregivers

Carers normally assume the role of improving their patients’ quality of life (Hirst, 2005). They

can accomplish their primary goal by guiding their patients towards healthful actions. One of the

most important interventions for COPD patients is smoking cessation with which they

immediately stop smoking. Both carers and their patients can attend smoking cessation programs

for both sides to understand the effects of tobacco smoke on the lungs. Training carers how to

accomplish pursed-lip and diaphragmatic breathing will aid them in teaching their patients how

to do these breathing techniques which may help improve their quality of breathing. Because

patients can develop fullness when eating, being informed with the proper nutrition and fluid

therapy is essential for those who provide care for COPD patients. Caregivers should be able to
encourage their patients to eat nutritious and healthy meals at the same time recognize the

benefits offered by daily water therapy. Moreover, carers should also be taught how to develop a

plan of activities for their patients. Despite the fact that COPD patients may experience a low

tolerance of energy during certain periods of the day, it is important that they still be involved in

structured activities such as gentle exercises. Training programs for caregivers should also

include information on other health conditions such as the colds and pneumonia to name a few so

that the carers could encourage their patients to take the annual vaccine shots to avoid the flu and

other conditions that may aggravate their state. When caregivers are taught about their

responsibilities and tasks for their patients, they will further be capable of educating their

patients on how to decrease or avoid the risks associated with COPD, limit or prevent recurrent

exacerbations, maintain good health, and eventually improve quality of life.

End-of-Life Issues and Advanced Plans

Care utilization during the older adults’ last year of life is very important, though only a small

number of studies have given emphasis on this subject. Most often, research conducted for this

subject take on a political and economical point of view, focusing on the costs involved. In other

words, the last year of life is more expensive when it comes to care utilization compared to the

earlier years of life (Serup-Hansen, Wickstrom and Kristiansen, 2002). Aside from costs,

knowing the types and determining the appropriate health care utilization during the last year of

life is very important. Health conditions and the utilization of health care during the end of life is

normally complex (Bickel, 1998); however, identifying these factors will significantly aid in

facilitating the proper allocation and management of health care for individuals who are
considered to be in their last year of life. This will then create a significant impact on the patients

themselves as well their carers including physical, psychological, social and financial effects.

Caregivers should then be trained to anticipate and assess the end-of-life needs of their patients.

As COPD progresses and symptoms worsen, families and carers of patients tend to move away

from lifesaving support and on to comfort care. It should be recommended to caregivers that they

write instructions regarding the preferences of their patients with regards to medical care at the

end of life. This is ideal especially when they are still capable of communicating their desires.

Combining these advanced directives with their medical charts and reports will allow carers to

become aware of the necessary actions to be done in any situation or emergency. Focusing on

comfort and care is sometimes more favorable than life extensions as excessive medications and

treatment may worsen the pain that is suffered by the patient. Training programs may suggest to

caregivers that comfort care and pain management be provided to their patients especially during

the last year of life when they are no longer capable of clearly communicating or have developed

further severe health complications.

Living Well with the Disease

Coping well with COPD requires that patients incorporate healthful actions in their daily living.

Therefore, it is necessary that carers be trained and educated with regards to their patients’ diet,

the situations that have to be avoided, proper medication-taking habits, and the suitable activities.

It is a must that carers should provide enough support for the eating habits for their patients, the

foods that should be included in the meals, the foods to avoid, the number of times their patients

should take their meals, and so on. Guiding their patients to avoid crowded places during the
cough and colds season, frequently clean their hands and used things, or decrease exposure to

irritants such as dust and other pollutants may generally help in improving the patients’ COPD

conditions. It is also necessary that education programs inform their caregivers about the

appropriate treatment for them to accurately know which medications should be taken at which

time as well as their effects on their patients. Moreover, carers being trained to perform gentle

activities, such as gardening or dancing, with patients will be more advantageous.

Stress Management

Numerous studies have shown how assuming a caring role will give carers more stress and

pressure rather than personal satisfaction, particularly depending on the severity of their patients’

conditions, their behaviors, their frequency of demands, and so on (Ramirez, Addington-Hall and

Richard, 1998). Most often, carers experience a level of fear and uncertainty when dealing with

the concerns of their patients, especially when caring for a family member. Financial pressures

are also a consideration while little time alone for oneself may further increase levels of stress.

Constant care and demand to attend to their patients may also be a great burden to these carers.

Therefore, it is a great need that training programs incorporate stress management practices for

caregivers as these individuals should be able to care for themselves as well. Staying informed

about a patient’s condition is essential so carers will know what to expect. Attending seminars

and education programs should be recommended so caregivers will have as much information as

they can to completely understand the effects of COPD and its consequences. Being aware will

somehow reduce their level of stress. Being able to physically, mentally and emotionally take

care of themselves is also necessary for these people to effectively manage their caretaking role.
Carers should be encouraged to take up a hobby that will accommodate their interests outside the

role of a caregiver and at the same time maintain their social interaction with others as well.

Outside training programs that provide practical information, it is also recommended that

religious programs are carried out for caregivers as a number of studies have shown how religion

and spirituality can help reduce stress and improve satisfaction. A spiritual community will aid in

strengthening a caregiver’s capability of providing unconditional care for his or her patient.

Empirical Studies for COPD Care

Chronic obstructive pulmonary disease (COPD) has been reported to be one of the major causes

of death both in developed and developing nations. Although many COPD patients are provided

with optimum therapy, the relief that they experience is often temporary as recurrent symptoms

exist which result to a significant reduction in one’s quality of life (Au, Edris, Fihn, McDonnell

and Curtis, 2008). Reports have also showed how many patients receive insufficient palliative

care which may be caused by a number of reasons such as poor communication between patients

and physicians when it comes to palliative and end-of-life care (Gore, Brophy and Greenstone,

2000). The difficulty in predicting the future situations of COPD patients is also a contributing

factor in the inaccurate diagnosis and inadequate treatment of these individuals. Furthermore,

such patients, their families and caregivers do not always know how severe COPD can

permanently affect quality of life. The study of Curtis (2008) focused on the palliative and end-

of-life care for COPD patients and through a qualitative review of related literature, findings

showed that people who are suffering from COPD may be provided with poor quality palliative

care due to the fact that many patients and their physicians do not discuss end-of-life care with
each other, what should be done, what is preferred, and so on. Whenever communication about

this subject occurs, it usually happens during late illness, as Curtis, Engelberg, Nielsen, Au and

Patrick (2004) assert. Moreover, there is a lack of training programs for physicians when it

comes to communicating with their patients with regards to end-of-life (Block, 2005). Therefore,

understanding these factors that negatively affect patient-physician communication may help

improve this form of information exchange. Palliative care for COPD patients should also

require the recognition of the effects of anxiety and depression in order to come up with

strategies that will combat these negative emotions. Findings have also suggested that advanced

directives and good advance care planning provide an opportunity to enhance the quality of

palliative care obtained by COPD patients. It is also critical for clinicians and all other health

care providers to find ways with which they can fully utilize hospital and palliative care services

to improve the end-of-life care for individuals suffering from severe COPD (Curtis, 2008).

In another study by Roberts, Sieger, Buckingham and Stone (2008) with its main focus on the

end-of-life care for COPD patients, the research was carried out with the aid of the National

Chronic Obstructive Pulmonary Disease Resources and Outcomes Project (NCROP) which is a

4-year program that has been conducted in the United Kingdom. This project aimed to evaluate

the COPD services available in UK hospitals. As part of the said program, a survey was

conducted in 2007 among 100 hospitals to evaluate palliative care services they offer COPD

patients as well as to raise health care standards regarding care for COPD patients. Outcomes of

the survey showed that 42% of the hospitals that were surveyed made use of formal palliative

care services for their patients who suffer COPD; meanwhile, 59% planned to make further

arrangements for their COPD care services to be further enhanced (Roberts et al, 2008). By
analyzing the data collected, four examples of good practice were identified- teams that consist

of specialized members and undergo adequate training; care pathways that include formal

policies and communication with patients; service components which refer to the general and

specialist services and resources provided to patients; and linkages that exist across departments

in secondary care as well as between the acute and community settings. Being able to identify

examples of good COPD care practices may help contribute further information to the

development of standards in terms of palliative care for patients who are suffering severe COPD

(Roberts et al 2008).

Yawn and Wollan (2008) also conducted their own study on COPD care, particularly on the

primary care that is provided by physicians on COPD patients. Primary care physicians provide

at least 80% of health care for over 20 million American patients with both recognized and

unrecognized COPD as noted by Mannino (2002). It has been reported by GOLD (2007) that

current management does not go well with the recommended care for patients with recognized

COPD. Meanwhile, for individuals with unrecognized COPD, opportunities to prevent

exacerbations and enhance quality of life are not provided due to the failure to recognize and

diagnose the disease (Lindberg, Eriksson and Larsson, 2006). A number of barriers exist that

may hinder the implementation of COPD management such as unclear recommendations for

COPD screening as well as the lack of primary care guidelines for managing patients with

diagnosed COPD (Hansen-Flaschen, 2007). The research carried out by Yawn and Wollan

(2008) made use of a survey that was carried out among attendees of 3 CME programs in 3

different US states with which participants were asked to complete a survey before a 70-minute

talk on COPD diagnosis and management. The researchers therefore believe that the information
provided by the participants was based on their prior knowledge regarding COPD, and not on

their knowledge that will be obtained during the lecture. Only a small percentage of the

respondents reported that they knew or made use of COPD guidelines. Barriers to COPD

recognition and diagnosis that were reported included the failure of patients to report their COPD

symptoms, the common morbidities among many COPD patients, and the inadequate knowledge

and training when it comes to COPD diagnosis, management and treatment. Only a few of the

participating physicians reported that they perceived COPD treatment to be useful in providing

relief (3%), improving conditions (15%), and reducing exacerbations (3%). Nonetheless, 13%

stated that they perceived COPD treatment as a satisfactory means of extending the lives of

COPD patients. Therefore, Yawn and Wollan (2008) suggest that due to a lack of understanding

and use of COPD guidelines as well as a lack of awareness of the importance of COPD

treatment, significant improvement in COPD diagnosis and management will only be

accomplished when such issues are addressed.

The study conducted by Barr et al (2009) focused on how COPD symptoms has been given

treatment as numerous reports have shown how COPD can also lead to other conditions such as

osteoporosis or hypertension. COPD is often left under-treated while the overlapping conditions

can, on the other hand, be provided with adequate treatment. The researchers assessed the

prevalence of such ‘comorbid’ conditions as well as the knowledge, diagnosis, management, and

treatment of COPD conditions. Through the use of a survey among 1,003 patients suffering from

COPD, 41% of them reported being hospitalized before being diagnosed with COPD while 61%

reported that they experienced moderate to severe dyspnea (shortness of breath).55% reported

that they experienced hypertension as a co-morbid condition, 52% with hypercholesterolemia,

37% for depression, 31% with cataracts, and 28% with osteoporosis. 72% of the participants

reported that they were taking medications to reduce exacerbations and improve COPD

conditions, often using a short-acting bronchodilator. 87% of COPD patients with hypertension

took antihypertensive medications while those suffering from both COPD and

hypercholesterolemia (72%) were taking a statin. However, despite these treatments and

hospitalizations for COPD patients, a low level of COPD self-knowledge was evident and COPD

was untreated compared to less morbid conditions such as osteoporosis or hypertension (Barr et

al, 2009).

Empirical Studies for Training Effectiveness

Training programs intended to help carers manage stress have been one of the strategies

implemented to improve the performance of these individuals who have assumed the caregiving

role. The study of Brodaty and Gresham (1989) has focused on collecting information to reduce

the psychological stress as well as to enhance the coping skills of carers who provide care and

support for relatives who have dementia. Research had been conducted in a psychiatry unit

located in a Sydney teaching hospital wherein patients were not more than 80 years old, suffered

mild to moderate dementia, and lived at home with a carer. Out of all the 96 patient-carer pairs

that were used as a sample, 33 were included in the dementia carers’ program group, 31 for the

memory retraining group, and 32 in the wait list group. In the dementia carers’ program, the

carers had been provided with training with regards to dealing with the challenges of managing

patients with dementia (Brodaty and Gresham, 1989). Meanwhile, the carers under the memory

retraining program received 10 days of vacation from their work. In the wait list group, carers
had to wait for six months for them to undergo any carers’ program. Findings showed that the

follow-up conducted after 12 months reported that those who were included in the carers’

program had a reduced level of psychological stress compared to those in the memory retraining

program (Brodaty and Gresham, 1989). The level of stress experienced by those who were in the

wait list group was stable as there were no changes.

This suggests that the intervention program implemented for carers of patients suffering from

dementia can benefit from a training program that included reminiscence therapy, environmental

reality orientation, general ward activities and memory retraining. Assessments of their physical

and psychological states were carried out. The difficulties that they experienced in being a carer

for a dementia patient were discussed such as lack of support, psychological distress, inadequate

information regarding diagnosis, treatment and management of dementia patients, legal and

financial matters, safety at home, as well as poor coping skills. To address these issues, the

training program made use of group therapy, training for management skills and assertiveness,

discussion of what their roles should be comprised of, basic principles for behavior modification,

and other use of activities. The study of Brodaty and Gresham (1989) imply that when carers are

provided with a comprehensive training especially for managing problems and coping with

stressful events, their psychological stress will be significantly reduced and the possibility of

placing their patients in an institution will be less likely to happen.

Informal carers of cancer patients were also found to have an implication on restructuring

training programs for these care givers. The study conducted by Soothill et al (2001) aimed to

assess the previous training received by caregivers who worked with cancer patients and further
identify their training needs. Such needs of the carers of cancer patients have been recognized as

an increasing concern in health care policies though only limited research exists to address this

issue. A descriptive cross-sectional survey was conducted among 195 carers with which

psychosocial factors had also been analyzed. 43% of the respondents showed that they were not

satisfied with the training that had been provided for them because they had been experiencing

various challenges in their caring roles (Soothill et al, 2001). Carers who had low levels of

satisfaction in their experience were shown to be in poor health as well. Many of the respondents

desired for training programs and other opportunities that will allow them to establish good

relationships with other healthcare professionals as well as obtain adequate and accurate

information. They also believed that training programs should always include ways with which

carers can manage their daily lives along with their emotions and social identity (Soothill et al,

2001).

Kalra et al (2004) also focused on evaluating the effectiveness of the training that is offered to

carers who provide informal care support to disabled stroke patients. It has been estimated that

25-74% of patients who have survived stroke are in great need of help with their regular

activities from caregivers, most often their own family members (Anderson, Linto and Stewart-

Wynne, 1995). Care giving can often generate physical, psychological, social, financial and

emotional benefits; however, the needs of carers in terms of stroke patient management have

often been overlooked. Due to advances made in stroke rehabilitation, the level of severe

disability and hospitalization among stroke survivors has significantly been reduced, thereby

increasing the number of stroke patients living at home with their carers. However, Kerr and

Smith (2001) assert that many of them have been living with carers who are incapable of
providing superior care due to a lack of adequate training and information, as well as a lack of

support after patient discharge. To examine these issues, Kalra et al (2004) conducted a study

among 300 carers for stroke patients using a single, randomized controlled trial. Through this

procedure it has been demonstrated that caregivers who received more training experienced less

anxiety, depression and caregiving burden. Rather, they experienced a higher level of quality of

life. Providing carers with sufficient training for moving and handling, facilitating activities on a

daily basis, and nursing tasks can significantly reduce their burden of care and enhance quality of

life not just in the caregivers but in the patients as well. Moreover, through training, education

and family support, the emotional health of caregivers can also be improved to reduce the costs

of stroke care and improve the patients’ quality of life as well (Kalra et al, 2004).

Research carried out by Kamiru, Ross, Bartholomew, McCurdy and Kline (2009) also focused

on evaluating the effectiveness of a training program provided for health care providers in sub-

Saharan Africa. The assessment of any training program is necessary in order to identify the

components that are in need of improvement. The study aimed to evaluate the Baylor

International Pediatric AIDS Initiative’s (BIPAI) HCP training program. 101 health care

providers were used as a sample and data was collected through a pretest-posttest survey along

with semi-structured interviews with 7 trainers from a particular college of medicine and 16

other health care local providers. By analyzing the gathered information, it has been proven that

the training had a satisfactory coverage, a successful deliver, and brought about improvements in

work. The training program helped increase the health care providers’ information regarding

HIV/AIDS; it also enhanced their effectiveness as well as their attitudes towards AIDS patients.

Therefore, the study of Kamiru et al (2009) showed the effective delivery of the BIPAI training
program in Swaziland particularly in providing information about health care facilities,

increasing HCP skills and improving attitudes towards AIDS patients.