clinical focus

An exploration of self-efficacy and

self-management in COPD patients
Edwina Simpson and Martyn Jones

governments and healthcare providers are

Abstract engaged in initiatives to develop new ways
Aim: This study examined if self-efficacy in managing chronic obstructive of supporting patients living with long-term
pulmonary disease is associated with better mood, less breathlessness and fewer conditions such as COPD to manage their own
exacerbations; what helps or hinders patients in managing their chronic obstructive health (Rijken et al, 2008).
pulmonary disease (COPD); and patients’ suggestions to improve the self- Research suggests that improving self-efficacy
management support they receive. Background: COPD is the fifth leading cause (SE) and promoting self-management could
of death in the UK, and it has been suggested that supporting self-efficacy and reduce some of the burden on the NHS. Many
self-management could improve patient outcomes and reduce demands for NHS theorists including Monninkhof (Harris et al,
resources. Methods: An exploratory, descriptive survey involving the collection of 2008) believe that patients’ SE—their sense of
both quantitative and semistructured qualitative data was chosen. Participants were confidence in their competence to manage
randomly selected from four GP practices across the north east of Scotland. Results: their condition—has been established as the
Higher levels of self-efficacy were associated with lower levels of breathlessness, lower route to better outcomes such as a reduction
levels of anxiety and lower levels of depression in COPD patients. There was no in exacerbations. According to this approach,
association between high self-efficacy and exacerbation rates. Conclusion: Increasing increasing patients’ SE is likely to support them
self-efficacy and reducing anxiety and depression in patients living with COPD are in changing their behaviour and lead to more
important focus points for self-management support. effective self-management.
Empowering patients to manage their long-
Key words: Chronic obstructive pulmonary disease ■ COPD ■ Self-efficacy
term conditions is likely to involve a major
■ Self-management
change to the working practices of some health

A
n estimated 3  million people are
affected by chronic obstructive
pulmonary disease (COPD) in the
UK. About 900 000 have been
diagnosed with the condition and an estimated
2  million people are undiagnosed (National
Institute for Health and Care Excellence
(NICE), 2010).
NICE states:‘Chronic obstructive pulmonary
disease (COPD) is characterised by airflow
obstruction. The airflow obstruction is usually
progressive, not fully reversible and does not
change markedly over several months. The
disease is predominantly caused by smoking.
There is no single diagnostic test for COPD.
Making a diagnosis relies on clinical judgement
based on a combination of history, physical
examination and confirmation of the presence
of airflow obstruction using spirometry’
(NICE, 2010).
Edwina Simpson is COPD Specialist Nurse, Primary
Care, NHS Tayside, Dundee and Martyn C Jones is
© 2013 MA Healthcare Ltd
Most GP practices have access to a spirometer.
This equipment measures the volume and flow
rate of breathing. In healthy people, more than
70% of forced vital capacity (FVC) is exhaled in
the first second; obstruction or airflow limitation
is defined as FEV1/FVC<70% (Kelly, 2009). In
COPD, severity is graded according to FEV1%
predicted—the volume of air exhaled in the
first second of the FVC.
The main symptoms associated with COPD
are a chronic productive cough, breathlessness
and wheeze. Anxiety, depression and acute
exacerbations feature predominantly in the
natural history of COPD (Kelly, 2009).
Exacerbations are defined by NICE (2010) as ‘a
sustained worsening of the patient’s symptoms
from their usual, stable state, which is greater
than the day-to-day variations and is acute on
onset’ (NICE, 2010). Exacerbations carry a high
mortality; within 90 days of admission for an
exacerbation, 33% of patients with COPD are
readmitted and almost 14% have died (Scullion,
2009). The average cost of treating a COPD
patient in Scotland is estimated to be £1 036
professionals (Health Foundation, 2012). The
idea of self-management support implies there
will be a change in the role of the health
professional from an authoritarian position
in delivering education and information
to supporting patients to help them build
confidence and make choices that lead to better
self-management and outcomes (Coleman and
Newton, 2005).
This study also set out to discover what
patients thought would help them to manage
their COPD. Identifying where COPD patients
commonly have low self-efficacy is likely to
assist COPD nurses in identifying strategies
to support patients to increase their SE and
consequently improve their self-management.
Improved patient self-management has the
potential to reduce rates of exacerbation and
hospital admission (Scullion, 2009).
Rationale for study
The evidence from studies including Cochrane
reviews (Monninkhoff, 2003; Effing et al,
2009) suggests that further research is needed
before firm conclusions can be drawn on what

Personal Chair of Healthcare, Research School of

Nursing and Midwifery, University of Dundee per patient per year (Long Term Conditions constitutes successful self-management support
Collaborative, 2009). in COPD. Research in this area has not focused
Accepted for publication: October 2013 With an increasingly ageing population and on SE and does not seem to have sought patients’
predicted reductions in the NHS workforce, views on how they self-manage their condition.

British Journal of Nursing, 2013, Vol 22, No 19 1105

 This study attempted to identify the barriers
faced by patients when self-managing their
COPD and what patients thought health
professionals could do to assist them to self-
manage COPD. The use of SE, mood and
symptom questionnaires and scales can help
identify situations where COPD patients
commonly experience low SE. The study
focused on measuring patients’ levels of self-
efficacy in relation to:
■■ Anxiety/depression
■■ Exacerbation rates
■■ Breathlessness.
This study gained patients’ views on self-
management using a cross-sectional patient
self-report survey. We are not aware of any
other studies using the same combination of
assessment methods; these involved measuring
breathlessness with the Medical Research
Council (MRC) dyspnoea scale (Bestall et
al, 1999; Ozalevli and Ucan, 2006), mood
using the hospital anxiety and depression
(HAD) scale (Zigmond and Snaith, 1983),
and exacerbation rates using the COPD self-
efficacy scale (Wigal, 1991).
Full ethical approval was granted by both
the local research and ethics committee and
the Caldicott guardian.
Data search
Four databases were chosen and searched
for evidence in the literature of effective
self-management/SE in the care of COPD
patients: MEDLINE, CINAHL Plus, OVID
Online and the Cochrane Library (Figure 1).
Two separate searches were undertaken. The
search terms entered were:
■■ Self-management in COPD
■■ Self-efficacy in COPD.
Thirty-four studies meeting the criteria
were found; some of these are cited in this
paper. Excluded studies included those that
mentioned SE or self-management in their
text but were rejected as their abstracts and
conclusions showed they mentioned the topics
only briefly. Studies that focused completely
on pulmonary rehabilitation were rejected
as their focus was more on the benefits
of exercise.
The study focused on Cochrane reviews
and randomised controlled trials (RCTs) as
they are regarded as producing the most robust
evidence (Education for Health, 2008).
Literature review
Monninkhof ’s (2003) Cochrane review
aimed to clarify the effectiveness of self-
management programmes in COPD. This
systematic review of eight RCTs and one
1106
Self-efficacy and self-
management searched;
Ovid Online, Cinahl
Plus, Medline and the
Cochrane Library
Number of
articles found and
Number of articles
excluded: 81
screened: 115
Number of articles Excluded articles:
with full text pulmonary: 10;
discussing either
foreign language: 8;
self-efficacy or
>10 yrs old: 15;
self-management
meeting the triplicates: 20;
criteria: 34 not suitable: 28
Figure 1. Results of data search
controlled clinical trial assessed the efficacy of
self-management education in patients with
COPD. The self-management programmes
reviewed used various methods of education
including group and individualised sessions
and providing written material. The education
components targeted smoking cessation,
managing exacerbations and improving
exercise or nutrition.
The review showed that self-management
education had no effect on hospital admissions,
emergency unit visits, days lost from work and
lung function but led to an increased use
of courses of antibiotics and oral steroids.
Study limitations included participants
having different diagnostic criteria and the
educational components being of varying
duration. In addition, a wide variation in
outcome measures meant that insufficient data
were obtained to make recommendations.
The outcomes measured also varied in
appropriateness. Days lost from work may not
be relevant as many COPD patients are over
retirement age. COPD patients are also prone
to anxiety/depression and may not retain
educational information. As COPD is a less
variable disease than asthma, it can be more
difficult to show positive results.
A Cochrane review by Effing et al (2009)
built on the results of Monninkhof ’s (2003)
Cochrane review by assessing the settings,
methods and efficacy of COPD self-
management education programmes on health
outcomes and use of healthcare services.
The method was a systematic review of 15
group comparisons drawn from 14 RCTs.
A total of 2  239 patients were recruited for
the trials, of whom 1  924 participated. The
various RCTs followed up patients from
periods of 8 weeks to 12 months. The studies
reviewed examined a broad spectrum of
self-management interventions, including
individualised education on COPD, breathing
and coughing techniques, relaxation exercises,
energy conservation and adapting a healthy
lifestyle as well as action plans to identify
and treat exacerbations. The self-management
education included smoking cessation, self-
treatment of exacerbations and improving
exercise and nutrition.
A significant reduction was seen in the
probability of at least one hospital admission
for about 36% for patients receiving self-
management education compared with
those receiving usual care, combined with an
improvement in their health-related quality
of life. However, because of the heterogeneity
in interventions, study populations, follow-up
time and outcome measures, the data were
insufficient to be used to formulate clear
recommendations regarding specific facets of
self-management education programmes in
COPD. Effing et al (2009) recognised the
limitations of their study and recommended
further research with larger RCTs and a longer-
term follow-up before conclusions could be
drawn. They added that it may be useful to
choose only studies that measure the same
variables, thereby reducing the heterogeneity.
Similar conclusions were drawn by Bourbeau
and van der Palen (2009), who suggested
that further research was needed to increase
our understanding of the effectiveness of
the specific components of self-management
programmes and how best to support COPD
patients in self-management. This Cochrane
review discussed the increase in the use
of antibiotics and steroids, and suggested
that self-management education with the
addition of action plans resulted in patients
recognising their exacerbations and treating
them promptly, which resulted in less severe
exacerbations. However, in the first author’s
experience, this is not suitable for all patients
as some will take them inappropriately, despite
having written guidance.
Wood-Baker et al (2006) examined the
efficacy of the components of action plans
in the self-management of COPD. This
longitudinal RCT prospective parallel group
study compared written action plans to usual
practice. All patients received an information
© 2013 MA Healthcare Ltd
booklet on COPD and an individual
educational session with a respiratory nurse.
Topics included smoking cessation, exercise,
sputum clearance, nutrition, stress management,
British Journal of Nursing, 2013, Vol 22, No 19
 clinical focus

inhaler use and support services. Intervention
group members also received a written self-
management plan and were encouraged to
contact their GP during the early stages of an
exacerbation. Patients were followed up every
three months for a year.
Intervention group members were more
likely to have had treatment with antibiotics;
there were no differences between the
groups in numbers of GP visits and hospital
admissions. These findings are similar to those
of Monninkhof et al’s (2003) review.
Wood-Baker et al’s (2006) study had several
limitations including a lack of blinding; the
use of self-reporting, which is open to error
as some participants cannot recall events
accurately; and insufficient power to determine
differences between interventions. In addition,
many patients only received one educational
session, which may limit the amount of
information they retained. The majority of
patients had stopped smoking at the time they
enrolled onto this study. The results may have
differed had more smokers been included.
Research questions
This study was designed to answer the
following questions:
■■ Is self-efficacy in managing COPD
associated with improved mood, reduced
breathlessness and reduced exacerbations in
patients?
■■ What helps or hinders patients in managing
their COPD?
■■ What suggestions do patients with COPD
have to improve the self-management
support that they receive?
Study inclusion criteria
All patients included in this study:
■■ Had a definite diagnosis of COPD
■■ Were aged 50–90 years
■■ Had an FEV1/FVC <70%
■■ Had an Fev1% predicted value of 20–79%.
So that participants would be representative
of patients seen at COPD clinics, both smokers
and non-smokers were included.
Methodology
A descriptive survey involving the collection of
quantitative and qualitative data was chosen to
best answer the research questions. This survey
comprised a questionnaire with validated
scales and semistructured questions.
Study participants received an information
© 2013 MA Healthcare Ltd
closed questions to maintain their interest.The
COPD questionnaire included:
■■ Visual analogue scales measuring confidence
in both recognising and treating an
exacerbation. The scales for each had a
0–100 range, with 0=‘Not at all confident’
and 100=‘Very confident’. The patients
marked an X on the line to determine how
confident they were.
■■ The Wigal COPD self-efficacy scale. This
measures how confident patients are in
managing their breathlessness in certain
situations. It lists 47 specific situations. This
scale has proven acceptability, reliability and
validity (Wigal et al, 1991).
■■ The MRC dyspnoea scale. This is on a scale
of 1–5, with 1 representing no breathlessness
except on strenuous exercise and 5
representing being too breathless to leave
the house or being breathless when dressing
or undressing. A higher score suggests more
advanced disease. This breathlessness scale
is commonly used in COPD as it has been
proven to be acceptable, reliable and valid
(Bestall et al, 1999: Ozalevli and Ucan, 2006).
■■ HAD scale. This is a 14-item self-report
instrument for the detection of anxiety and
depression in patients. It has two domains,
each with seven statements on emotions or
emotional situations. Patients express their
agreement with the statements on a scale of
0–3, which leads to a maximal score of 21
points for each domain. Scores of 8–11 per
domain suggest the presence of the mood
disorder; scores >11 indicate a probable
presence (Trappenburg et al, 2009). The
HAD has proven acceptability, reliability and
validity (Zigmond and Snaith, 1983).
The first researcher measured self-efficacy
Table 1. Study population characteristics
Disease severity Moderate COPD FEV1 50–79%
Disease severity Severe COPD FEV1 20–49%
Total
Sex Male
Female
Total
Smoking Non-smoker
Smoker
Total
MRC dyspnoea scale score MRC 1 6
MRC 2 14
MRC 3 11
using the COPD self-efficacy scale and the
two visual analogue scales in confidence in
recognising and confidence in treating an
exacerbation separately.
Data analysis
Pearson’s r correlation and independent sample
t-test was chosen as the most appropriate
statistical test for the numerical data meeting
assumptions of normality. Spearman’s rho
non-parametric test was used for the nominal/
ordinal data. Qualitative data were analysed by
content analysis, which is a process of analysing
qualitative material for recurring themes
and patterns (Polit et al, 2001). Correlation,
according to Education for Health (2008),
shows the relationship between the data of
two continuous study variables.
The data were analysed using the SPSS  18
statistical analysis package.
Results
Study population
Two hundred and fifty patients were contacted,
with 48 completing the study, giving a 19.2%
response rate. Table 1 shows the characteristics
of the study population. Participants were aged
53–86 years, and the mean age was 69 years.
The majority of patients were still smoking.
There were equal numbers of men and
women.The majority of patients had moderate
COPD with FEV1=50–79% predicted. The
most common score on the MRC dyspnoea
scale was 3; people with this score walk more
slowly than their contemporaries on level
ground because of breathlessness, or have
to stop to take a breath when walking at
their own pace. Exacerbation rates were also
recorded (Table 4).
Frequency Percentage
31 64.6
17 35.4
48 100
24 50
24 50
48 100
19 39.6
29 60.4
48 100
12.5
29.2
22.9

sheet, a consent form and a COPD MRC 4 7 14.6

questionnaire. The questionnaire had 10 MRC 5 7 14.6
Total 45 93.8
questions; these included open questions
to allow patients to express themselves and Total 48 100

British Journal of Nursing, 2013, Vol 22, No 19 1107

 Table 2. Correlation between self-efficacy scales and anxiety and depression
Pearson’s r bivariate was used to examine relationships between variables that were normally distributed
Mean SD n COPD Depression Anxiety VAS confidence in VAS confidence in
self-efficacy ability to recognise ability to treat an
scale score an exacerbation exacerbation
COPD self-efficacy scale 109.932 34.491 47 1
Missing scores replaced
Depression 5.96 4.232 48 –0.612** 1
Anxiety 6.27 4.574 48 –0.579** 0.805** 1
VAS confidence in ability to 67.05 25.204 44 0.539** –0.486** 0.501** 1
recognise an exacerbation
Vas confidence in ability to 66.14 22.947 44 0.562** –0.615** –0.599** 0.804** 1
treat an exacerbation
P*<0.05, **<0.01, ***<0.001; VAS: visual analogue scale

Table 3. Correlation between self-efficacy scales and the MRC dyspnoea scale
Spearman’s rho non-parametric test was used as the variable was ordinal
Mean SD n COPD self-efficacy VAS confidence in VAS confidence in MRC dyspnoea
scale score ability to recognise ability to treat an scale score 1–5
an exacerbation exacerbation
COPD self-efficacy scale 109.932 34.491 47 1

VAS confidence in ability to 67.05 25.204 44 0.544** 1

recognise an exacerbation
VAS confidence in ability to 66.14 22.947 44 0.578** 0.829** 1
treat an exacerbation
MRC dyspnoea scale 1–5 2.89 1.283 45 –0.562** –0.500** -0.439** 1
P*<0.05, **<0.01,***<0.001; VAS: visual analogue scale

Table 4. Means of the exacerbation rate and anxiety/depression for patients who have visited confidence in recognising and confidence
GP in last 6 months with an exacerbation in treating an exacerbation, the dyspnoea
Have you had an n Mean SD Standard scale and the COPD self-efficacy scale are
appointment in the error mean all positively correlated. This suggests that
last 6 months for an people who have higher self-efficacy have less
exacerbation? breathlessness—they scored less on the MRC
Anxiety total No 20 5.65 4.069 0.910 dyspnoea scale.
Yes 18 6.61 4.937 1.164 There were no significant differences in
Depression total No 20 5.55 4.236 0.947 anxiety (t-test result) and depression (t-test
Yes 18 6.50 4.541 1.070 result) for patients who had had an appointment
for an exacerbation in the last 6 months.

Research question: correlation
The study’s first question was: is self-efficacy
in managing COPD associated with improved
mood, reduced breathlessness and reduced
exacerbation?
In testing the normality of the variables, all
variables were normally distributed using the
Kolmogorov-Smirnov test.
Table 2 shows there were positive correlations
between high visual analogue scale scores in
confidence in recognising and treating an
exacerbation, high confidence in the COPD
self-efficacy scale and lower levels of anxiety
treating an exacerbation and more confident
at controlling their breathlessness have less
anxiety and depression. The COPD self-
efficacy scale measures the control of managing
breathlessness in certain situations and the two
visual analogue scales measure confidence
in recognising and confidence in treating an
exacerbation. To establish if higher levels of
self-efficacy reduced breathlessness, it was
also necessary to see if there was a positive
correlation between the two visual analogue
scales, the COPD self-efficacy scale and the
MRC dyspnoea scale; a non-parametric test
Qualitative data
The qualitative data were collected from the
COPD questionnaire.
The study’s second question was: what
helps or hinders patients in managing their
COPD? The data suggested that patients
were aware that smoking and weight gain
increased breathlessness. They also commented
that taking their medication as prescribed
and pacing themselves helped control their
breathlessness.
The study’s third question was: what
suggestions do patients with COPD have to
© 2013 MA Healthcare Ltd

and depression. was used for the MRC scale as the variable improve the self-management support that
The p value is <0.05 in all of the variables, level is ordinal (Table 3). they receive? The data suggested that keeping
which suggests that COPD patients who The P values are all <0.05, which suggests patients up to date with new medications,
are more confident in recognising and that the visual analogue scales scores of being there when they needed advice, offering

1108 British Journal of Nursing, 2013, Vol 22, No 19


Key points
nA
 nxiety, depression and acute exacerbations feature predominantly in the natural history of
chronic obstructive pulmonary disease (COPD)
nG
 overnments and healthcare providers are engaged in initiatives to develop new ways of
supporting patients living with long-term conditions such as COPD to manage their own
health
n Increasing self-efficacy is likely to lead to behaviour change and more effective self-
management
nP
 eople with long-term conditions may need self-management support to cope more
effectively with the psychological effects of their illness
a written progress chart annually and believing
them when they said they were having an
exacerbation would all be helpful.
Discussion and conclusion
Although the response rate was poor, the
patient sample was randomly selected and
robust processes were in place to reduce
selection bias. The first researcher was blind
to the random selection and the participants’
identifiable information. The study population
was a true sample of COPD patients across four
GP practices in north east Scotland including
men and women, smokers, non-smokers and
those with moderate or severe COPD.
This study looked to see if there was
an association between self-efficacy, mood,
breathlessness and exacerbations. The results
show there is an association between higher
levels of self-efficacy, reduced breathlessness
(Table 3) and lower levels of anxiety and
depression (Table 2). Patients who had high
scores on the COPD self-efficacy scale—
which concerns their ability to control their
breathlessness in certain situations—had lower
anxiety and depression levels. Those who said
they were more confident at recognising an
exacerbation and treating one had less anxiety/
depression and breathlessness. However,
© 2013 MA Healthcare Ltd
British Journal of Nursing, 2013, Vol 22, No 19
exacerbation rates were the same for people
with high and low self-efficacy levels.
We should therefore focus on increasing
self-efficacy and reducing anxiety and
depression in patients living with COPD
(Effing et al, 2009).The COPD team of nurses
in this NHS setting have received training in
health behaviour change. These skills, used
in combination with this study’s findings,
will enable us to assist patients with problem
solving, achieving their goals and enhancing
behaviour change.
Future research
Further research is needed, using a larger
sample, preferably over a prolonged period
of time. The outcome measures should focus
on behaviour change, the attainment of goals
and/or self-efficacy scores, as opposed to
exacerbation rates or GP visits (Bourbeau and
van der Palen, 2009). Past studies have focused
mainly on exacerbations; acute exacerbations
feature predominantly in the natural history of
COPD (Kelly, 2009) so it may not always be
possible to prevent them.  BJN
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