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Open Access

Peer-reviewed

Research Article

The empowerment of elderly patients with chronic obstructive pulmonary illness: Managing life with the disease

• Zahra Fotokian,
• Farahnaz Mohammadi Shahboulaghi,
• Masoud Fallahi-Khoshknab,
• Ali Pourhabib

ten

• Published: Apr 3, 2017
• https://doi.org/10.1371/periodical.pone.0174028

Figures

Abstract

Chronic obstructive pulmonary illness (COPD) is a serious wellness problem that has significant effects on the life status of elderly persons. Use of the empowerment approach is necessary for health promotion in older people with COPD, only little attention has and then far been paid to all the dimensions of empowerment in the management of COPD, which would provide useful noesis regarding elders with COPD. This article reports on a study exploring people's experiences of the empowerment of older people with COPD. This written report adopted an exploratory qualitative design and was carried out using grounded theory methodology. Grounded theory was considered advisable for this study because of its focus on how people respond to and act on the issues that they encounter. We collected data past conducting in-depth semi-structured interviews and taking field notes. Twenty-four participants were selected through purposive sampling.

The results showed that in encountering the complexity of disease and in response to difficulties induced by COPD, iii strategies were applied. Elderly persons with COPD, their family caregivers, and professional person squad members engaged in "managing life with COPD," "striving to keep abreast of life," "preparing for battle with illness," and "helping to stabilize the elder's life." The event of these strategies was "co-beingness with disease." The potential of "managing life with COPD" was influenced past the following factors: "co-existence with ageing," "personal potential," "a challenged wellness organization," and "weak social support." "Managing life with COPD" enables the elderberry to feel in command and alive optimally. This is a fragile balance, however, and the unpredictability of COPD can tip the elder into "self-efficacy." Agreement the experiences of the empowerment process of older people with COPD can aid wellness professionals provide more focused elderly intendance.

Citation: Fotokian Z, Mohammadi Shahboulaghi F, Fallahi-Khoshknab M, Pourhabib A (2017) The empowerment of elderly patients with chronic obstructive pulmonary disease: Managing life with the disease. PLoS I 12(4): e0174028. https://doi.org/10.1371/journal.pone.0174028

Editor: Christophe Leroyer, Universite de Bretagne Occidentale, France

Received: October 15, 2016; Accepted: March ii, 2017; Published: April 3, 2017

Copyright: © 2017 Fotokian et al. This is an open access commodity distributed under the terms of the Creative Commons Attribution License, which permits unrestricted utilize, distribution, and reproduction in any medium, provided the original author and source are credited.

Information Availability: The information cannot be made publically bachelor as the participants did non consent to their information being made available and due to restrictions imposed by the Ethical Committee of Social Welfare and Rehabilitation Sciences University. Requests for the data should be directed to both the corresponding author and Research Deputy of Social Welfare and Rehabilitation Sciences University (Accost: Kodakyar Ave., Daneshjo Blvd., Evin, Post code: 1985713834, Tel: (98) - 21 –222180008 Fax: (98) - 21 – 22180121).

Funding: This work was funded by a grant to Zahra Fotokian and Farahnaz Mohammadi Shahboulaghi, Welfare and Rehabilitation Academy, no: 500271.

Competing interests: The authors accept declared that no competing interests exist.

Introduction

Chronic obstructive pulmonary disease (COPD) is condign an increasingly prevalent health problem globally, accounting for massive healthcare expenditure [ane]. By 2020, this affliction is expected to cause 7% of all deaths worldwide (iv–5 million people annually). The prevalence of COPD increases with age, with a v-fold increased risk reported for those aged over 65 years, compared with patients anile less than 40 years [2]. The status affects the well-being of an affected older person and the caste to which this subgroup tin be 'physically active' and participate in social relations [3, 4]. Predominant symptoms include fatigue-induced hypoxia and restrictions in daily living activities [5]. These limitations increase physical inability and elders' dependence on other people [6]. Although COPD results in problems in elders' ability to maintain control over the illness and their lives, studies have shown that empowerment programs institute recommended non-pharmacological treatment for COPD, with considerable testify of benefits to older patients. This demonstrates that empowerment programs are central to reducing the severity or frequency of exacerbations, preventing hospitalization, and improving health-related quality of life [vii].

COPD is a serious health problem that has significant effects on healthcare services and the life condition of older persons. Employ of the empowerment approach is necessary for health promotion and for enabling the efficacy required by elderly persons with COPD to take command over the disease. Nevertheless, previous results take revealed that many older people were unaware of strategies that tin be used to manage COPD. This is supported by Hyland (2005), who found that patients with COPD need to be involved in the development of patient information resource. The results of Robinson's (2010) written report showed that thirty% of elderly patients with COPD are not aware of management practices and control measures over their condition, and not enlightened of control measures over their status', and identified feelings of powerlessness and poor illness direction [8]. This points to a need to empower older people with COPD, to enable better cocky-management and behavioral changes aimed at improving efficacy and quality of life, and reducing disability and healthcare costs [nine]. Empowerment will enable elderly patients to actively participate in their own treatment and plan, access vital data, and make decisions [10].

In spite of the importance and utilise of the empowerment concept, piddling attention has and so far been paid to all the dimensions of empowerment in the management of diseases such every bit COPD. This study aimed to explore the process of empowerment among older persons with COPD. Despite the importance and application of the concept of empowerment, lack of sufficient cognition all aspects in the management of chronic diseases, peculiarly COPD. In the bulk of studies in the field of chronic illness, implementation of an educational programme was considered equal to empowerment. These interventions, in which quantitative methods were employed, were used to impart elderly patient education [11]. Withal, quantitative studies cannot capture the essence of the empowerment concept. While patient education is one aspect of empowerment process, and one of the tasks of the professional team members in empowerment procedure is education. More studies in relation to empowerment interventions accept been conducted as elderly patient education by using a quantitative method in social and cultural context of quondam people with chronic affliction [10].

There is an abundance of vague definitions of the empowerment concept by nurses and healthcare providers; this shows that knowledge regarding the empowerment of Iranian due eastlders with COPD is not well developed. Because the consequences of empowerment (i.e., self-efficacy, well-existence, and QOL promotion) for older people with COPD, it is important to understand the meaning of COPD, peculiarly to elderly Iranian persons with COPD, as well every bit how they respond to the disease. The aim of this study was to illuminate the experiences of empowerment among elderly patients with COPD, their family caregivers, and healthcare providers in the Iranian context. This can be understood by studying the interactions of older people with their families, healthcare providers, and society.

Methods

This study adopted an exploratory qualitative design and was carried out using Grounded theory methodology, which is mainly based on Corbin and Strauss'due south paradigmatic model; its focus is on how people reply to and act towards problems that they encounter. Goal of a grounded theory study is to observe the participants' main concern and how they continually endeavour to resolve information technology. The questions the researcher repeatedly asks in grounded theory are "What'due south going on?" and "What is the main problem of the participants, and how are they trying to solve it?" These questions will be answered past the core variable and its sub-cores and properties in due class [12]. Empowerment concept is an extensive concept [10]. Prevalent definitions of empowerment are therefore mainly based on the view that autonomy is recognized in people'south cocky-determination, and that empowerment is a procedural procedure of giving (provider to patient) and taking (patient from provider) ability. Patient empowerment needs to be seen equally a dynamic and creative process that is shaped past the individual's own activity and yet acknowledges the individual's dependence on others [xiii]. This concept is an interactional concept, and in the procedure of empowerment, the elder with COPD, family unit and professional person team members respond to and act towards problems that they encounter [13]. Therefore the exploring of empowerment process with grounded theory (it explores the procedure of empowerment) in the elders with COPD tin assist to place factors facilitating empowerment and the model of employing the process in the elderly with COPD. Then the exploring the existing process via grounded theory can help to Healthcare providers, and wellness policymakers in obstacles removal and reinforcement facilitators of the process of empowerment.

We nerveless data by conducting in-depth semi-structured interviews and making field notes. Criterion-based and purposive sampling was employed [12]. The following four criteria were used to select participants: (i) Persons with COPD aged sixty years or older (in Iran, >lx years is considered old age); (two) Persons with COPD take an interest in and the ability to explain own experiences, (iii) accept a minimum of five years' experience in caring for patients with COPD (for healthcare providers), (iv) be a family unit caregiver for elderly relatives with COPD (for family caregivers). Study participants (n = 24) were recruited from an academic hospital nether the direction of the National Research Institute of Tuberculosis and Lung Diseases (NRITLD) in Tehran and two district hospitals in the n of Iran. Considering that empowerment is an interactional phenomenon [12], interviews were conducted with older people with chronic diseases and with their family caregivers and healthcare providers. We nerveless information through in-depth semi-structured interviews and field notes. Twenty-four participants were selected using purposive sampling. Purposive sampling was superseded by theoretical sampling once data analysis commenced [12]. Therefore, 24 in-depth interviews were conducted with 15 elderly persons with COPD, 5 healthcare providers, and 4 family caregivers (Tabular array 1). Nosotros tried to include participants with unlike experiences of empowerment, based on historic period, sex, marital status, instruction, socio-economic condition, employment status, and elapsing and severity of affliction, to ensure theoretical saturation. The Abbreviated Mental Exam, which yields a score of 6 or more, was used to screen people for cognitive impairment. The master participants (elders with COPD) could invite someone to back up them while attention the interview and could stop the interview if they became breathless or did not desire to continue. Data were collected from March 2012 to February 2014. The interview venues were called past the participants, for their convenience. In the case of interviews performed past the first author, the participants were interviewed at their homes (northward = 8), the infirmary (northward = viii), the rehabilitation clinic (due north = 4), or their workplace (n = iv). The interviews lasted 30–100 minutes, based on the participants' tolerance and interest. The initial questions were broad, to encourage participants to speak freely and recount their personal experiences in relation to the objective of the written report. Examples of the questions asked are, "What would empower you?" and "What are your experiences of empowerment?" Then, the participants' answers during the interviews were coded and analyzed, followed by more follow-up questions to the participants. Information collection and analysis occurred concurrently. Data were analyzed based on Corbin and Strauss's (2008) arroyo. For data analysis, we also used analytical tools such as asking questions, constant comparison, theoretical comparing, and considering the unlike meanings of a given give-and-take. The abiding comparative technique was used to analyze the data. Analysis began with the repeated reading of the transcript, to facilitate immersion in the information. Open codes were initially fastened to experiences, actions, thoughts, feelings, and events related to empowerment, as experienced by elders with COPD. After extracting the codes and subcategories, the primary categories (or themes) were extracted. Following the generation of concepts, synthesis of the structures, and determining their relationships, the relevant theory was generated and explained. In this study, we carefully selected cases and conducted triangulation and external checks to ensure research rigor. Linking open codes resulted in the emergence of tentative categories. Coding became progressively more than conceptual, as analysis progressed. Memos and diagrams were used to assist reveal the relationships between categories. This facilitated the emergence of the core category.

Steps were taken to ensure the credibility, auditability, and fittingness of this study. Methodological rigor was enhanced by the rigorous application of the grounded theory methodology and techniques. The consistency of coding was monitored throughout the analysis. The researchers discussed, questioned, and agreed on emerging category labels and definitions at all stages of analysis. To evaluate consistency, we individually coded each interview. To strengthen the credibility of the study, the findings were presented to experts in the field, including elders with COPD, their family caregivers, and professional team members, all of whom agreed that the theory was both "recognizable" and "fit" with their experiences [12].

The study was approved by the Research Ethics Committee at the Welfare and Rehabilitation Sciences Academy in Iran (Ethical code: USWR.REC.1393.231). The participants were informed about the study verbally and were assured of confidentiality and anonymity. They were informed that they could withdraw from the report at any fourth dimension. The participants provided written informed consent before the interviews.

Results

The results showed that in encountering the complexity of the disease and in response to difficulties induced past COPD, the post-obit three strategies were practical in "managing life with COPD" by the elderly persons with COPD, their family caregivers, and professional squad members, respectively (Table ane): "striving to keep abreast of life," "preparing for battle with illness," and "helping to stabilize the elderberry's life." The effect of these strategies was "co-existence with illness" (Fig 1). The potential of "managing life with COPD" was influenced by mediating factors, namely, "co-beingness with ageing," "personal potential," "a challenged health system," and "weak social back up." In this process, the mediator of "personal potential" led to some people reaching "controlled co-being" and some elders, "strained co-existence," because of barriers such as "a challenged health system" and "weak social support."

The theory of "Managing life with COPD": The empowerment process for elderly patients with COPD suggests that COPD and aging crusade progressive disability among this subgroup. They have to learn to live with the affliction and do so with three main strategies, namely, "striving to continue abreast of life," "preparing for battle with disease," and "helping to stabilize the elder's life." In relation to the core variable, a participant uses a metaphor to describe himself equally a mechanic who tin can larn most the correct positions of bolts and nuts over time:

"Information technology is like a mechanic who learns virtually bolts and basics over time, considering yous take to manage your life with these drugs." (Participant 4, a threescore-yr-old homo)

Striving to keep abreast of life

Sometimes, elderly patients with COPD might face pregnant losses as a result of developing COPD-induced inability and other conditions that are common among the elderly. Facing loss of capacities and deterioration due to ageing tin also be very enervating. All these hardships tin evoke suffering for the elderly and necessitate a response against a threat to oneself or one'southward being or existence. This requires them to seek a remedy. So at first, all resources are mobilized, and so elderly patients can learn how to live with the disease. The doctor will effort to prescribe medication and provide general information, whereas the nurse, physiotherapist, and the dietician can assistance the elderly "learn to live with the disease." To facilitate "participation in the process of care," the elderly patients must trust healthcare providers. Amidst these, physicians are almost the almost trusted. The chief nurse said:

"The patient arbitrarily agrees with the doctor and ever the dr.'s side and ever accepts what he/she says, compared to nurses. It does not thing that nurses are too literate." (Participant 17, a nurse)

Striving to keep beside of life consisted of five sub-categories, namely, information seeking, 'learning to atomic number 82 a life with COPD', participation in intendance, independence seeking, and promoting socio-psychological capacities (Fig 1).

Data seeking.

Forth with the efforts of healthcare providers, elderly persons or their families seek information to see their needs. They sought the required data from diverse sources, including "professional and non-professional person resources," and "the mass media," which includes television, satellite, and the Internet. Illiterate participants used the radio as an information source. Some participants obtained the data from the nurses. However, in many cases, the participants used hands accessible not-professionals and peers who, in some cases, can give misleading data to the elderly patient. In this regard, 1 participant said:

"When I spoke with friends and relatives and told them that I had this problem, they taught me a lot and have increased my cognition." (Participant 1, a 70-year-old human)

An elderly smoker said:

"My friends say that I should not suddenly quit smoking, or it will be problematic." (Participant 2, a 71-year-sometime human being)

They also used "their experiences" in "continuing with normal life." In some cases, due to the long history of the disease, the elderly persons had gained valuable experiences in self-direction. In response to questions such as, "How did yous get the data that you lot required?," participants responded, "I know!" This indicated that the information was obtained through personal experiences. Another elderly homo believed that he could preclude flu with cocky-care and without vaccination, and said:

"I was conscientious non to catch a common cold or non to exercise too much piece of work, and then on, or I smoked less … Well, I do not leave home, to avoid catching a cold; I am always at home. I have taken care of myself. I have never had a vaccination and I never caught a cold." (Participant 11, a 73-year-old man)

Participation in care.

Participants started participating in the procedure of care once they trusted healthcare providers. Despite the fact that knowledge about ane's condition is necessary, so as to appoint in cocky-intendance, in most cases, participants did not accept sufficient knowledge about the disease. Moreover, teams of healthcare providers believed that, in guild to control the disease, noesis alone is non sufficient and that information technology is necessary for elderly persons to apply their self-intendance knowledge. These teams were trying to help the elderly people manage their lives. The elderly people need to use drugs, oxygen, and Bi-PAP at home. Still, they can only run across their needs:

"If they experience breathless, they could use the devices for initial treatment at home. … When experiencing breathlessness, I use oxygen, spray myself." (Participant vii, an 80-twelvemonth-old woman)

Yet, in some cases, the participants did not follow the recommended lifestyle due to some other reasons. An example of this was the disability by all participants to quit smoking, due to psychological dependence and other deterrent factors. These factors included lack of knowledge, impatience, inability, dementia, drug shortages in the market, and financial problems. There is also a common form of self-treatment past elderly patients that is detrimental to affliction control:

"Self-treatment is very common amongst many of their patients. For example, there was a patient who used dexamethasone several times and took the corticosteroid. He was later on faced with a horrible situation." (Participant 15, a nurse)

"Frequent hospitalization" and the disability to control disease shows lack of cocky-direction power.

"I just started taking l mm of corticosteroids, likewise equally the antibiotics that I got in that location, and and then I decreased the corticosteroid dose, based on my recovery. I was successful twice, just not the third time." (Participant 4, a 60-year-old man)

Independence seeking.

Another subset extracted was, "Independence seeking," which includes the subcategories, "efforts to reduce dependency" and "insistence on abilities." In many cases, dependency may make the family relinquish all responsibilities of handling and intendance of the elderly patient. Even so, less power largely induced aging and disease. Living alone was too stated as a problem. Despite receiving substantial back up from her children, an elderly woman said:

"When ane of my children lived with me, it was easier and more comfortable." (Participant v, a 77-year-old adult female)

Ane of the bug mentioned by some older patients who lived alone was "dependency upon discharge from hospital":

"Nosotros tell them to leave because it may crusade some kind of dependency. They know that you lot will come every day to remind them to use the spray, merely they would not have such a thing at habitation." (Participant 17, a nurse)

In other instances, the elderly patients simply wanted to live lone and felt more than comfortable doing so; an elderly woman said:

"I feel comfortable in my own home. If I go to my son's abode, I cannot stay for more than a day. I go home the next solar day." (Participant 6, an eighty-year-quondam adult female)

"I do all my own piece of work. I practise not need other people and I am not dependent. I am not bedridden and do not need my married woman or kids to exercise things for me because of my affliction." (Participant 1, a 70-year-old man)

Participants believed that independence was possible, as shown by "an insistence on their abilities."

"When a man knows that his body can take care of itself, and then he should be careful not to eat or utilize the things that are harmful for his body. For example, I now know that smoking is bad for me; for the sake of my status, I hate it and will not smoke anymore." (Participant 1, a 70-year-old human)

They fabricated the decisions based on their beliefs and knowledge regarding their own care and handling. In some instances, the decisions were useful and reasonable. In other instances, they attempted to make decisions that were contrary to their empowerment, that resulted in poor affliction control:

"This time, the doctor told me to buy the device (BiPAP) for home use, but I am not in a bad mood. I think that the device is for those who are in a very bad mood." (Participant 1, a 70-year-old man)

Promoting socio-psychological chapters.

Additionally, participants tried to improve their socio-psychological capacity through "advice," "having fun," and "adaptation," to improve their psychosocial capacities.

"That is right; the illness has been bothering her for months, but I will do my best to brand her well, to alive with her happily like in the past. Well, we used to go to the park every morning time before Nov; we did it to boost my mom's morale…." (Participant half dozen, a family caregiver)

Preparing for boxing with disease

Preparing for boxing with illness consisted of 3 sub-categories, namely, "using effective preparation techniques," "accepting the role of the elder family member in treatment," and "evolution of knowledge and professional person skills" (Fig ii).

Using effective training techniques.

In the empowerment process, healthcare providers' efforts to involve elderly people in the treatment entailed utilize of strategies such as "giving information," "striving to reduce dependency," and "participation in disease direction." This ensures that healthcare providers, especially physicians, utilize dissimilar means to inform ill elderly patients almost the disease, handling, diagnosis, physiotherapy and pulmonary rehabilitation, oxygen therapy, how to utilise Bi-PAP, and cocky-care. In some cases, data was provided at the fourth dimension of diagnosis. In this regard, one of the participants said:

"I asked about what I can eat; should I follow a diet for my disease? The doc told me 'no, you can swallow everything, you do non need whatever nutrition.'" (Participant v, a 77-year-old woman)

The healthcare providers know that, during training, they are faced with an aging audience that may detect the teaching material difficult. Use of "techniques for addressing the crumbling audition" is one of the ways in which healthcare providers can provide effective training. In this regard, the physiotherapist said:

"… Every mean solar day we get through the exercises that we taught them the twenty-four hours before, and we ask their family members whether the exercises were completed or non; we teach the elderly patient how to do these exercises once more and try to cheque if they practice them correctly." (Participant 18, a physiotherapist)

Yet, the healthcare providers know that the various training techniques taught should be based on the status of the elderly person. Even then, in some cases, unlike the professional person team'southward merits, client status was non considered. In this regard, one of the elders said:

"A physiotherapist in one case came to our room and I was taking a lot of medication and if 'I felt weak. He/she told me how to breathe, only I actually was not in a good mood. The physiotherapist does non understand your state of affairs." (Participant iv, a 60-twelvemonth-onetime man)

The healthcare providers used different ways to ensure that the elderly were learning. "The nurse and physiotherapist control the patient's learning" is a way in which squad members ensure that elderly patients with COPD acquire. The healthcare providers used educational aids for improved agreement of the material being taught. So, the format and language used in the instructional pamphlets used in field observations were like shooting fish in a barrel to follow; these detailed how to apply the spray and home-oxygen therapy. Moreover, the learning material was comprehensive, education both elderly persons and their families; the presence of families is necessary during all the educational processes:

"Initially, during the first 15–20 minutes, we simply check what they learned the previous time or whether they learned anything or no, and besides examine if they perform activities correctly. Then, we ask questions to see how much they are learning. After ascertaining almost their learning, we decide what to exercise for their physical therapy … because of their conscious fluctuations, 1 twenty-four hours they are sensible and the other twenty-four hour period they are confused; this is why we have to teach their families, as well." (Participant eighteen, a physiotherapist)

In rare cases, medications were provided with training. In this regard, an elderly patient said:

"The doctor gave me a pill and told me to put it in the rice-cooker and switch power on, then take a sheet on information technology and sniff the steam." (Participant seven, an lxxx-year-old adult female)

Accepting the part of the elder family member in treatment.

Other than information by healthcare providers, who are trying to reduce dependency, participation of the elderly and their families is also required in handling. Notwithstanding, the elderly and even family members do non play a role in treatment decisions. This served as a reminder to ask questions well-nigh the participation of the elderly or their families in handling decisions. In this regard, i participant said:

"We are providing training on tobacco cessation, no exposure to very cold or hot environments, no disposal of stimulants, [and] drug use, and they cooperate with us." (Participant xvi, pulmonologist)

Evolution of knowledge and professional skills.

The strengthening of ethical and professional obligations resulted in some people receiving treatment, despite their lack of ability, and working hard to educate and empower seniors for their own benefit and the benefit of elderly sacrifice.

"In that location are two physiotherapists in the hospital, only they are responsible for the 'whole hospital… like' or 'there is staff shortage', but they endeavour to work with all patients." (Participant xv, head nurse)

Help to stabilize the elderberry's life

In the fight against COPD, the family and the elderly cooperate to overcome the affliction, as if the disease has become the most important concern of the family and has affected family unit members' lives. The family makes various efforts towards the elderly person'south well-being, such every bit cooperation with professional person team members, support provision to the elderly, and improved patient intendance skills. Family unit caregivers of elderly people tried to stabilize the lives of the elderly through "cooperation with the team," "support for the elderly," and "improved patient intendance skills" (Fig ii).

Cooperation with professional team members.

Given the importance of families in the procedure of empowerment, participants require families and professional person teams to work together. Family members participating in the procedure of empowerment to ensure the effectiveness of the professional team were aware of this duty to cooperate:

"Elders who have good family back up get better answers than those who live alone; not a hundred pct, just information technology is less probable. In addition, an elderly who may not see or hear well does non have a good relationship with the outside earth." (Participant 16, pulmonologist)

Support for the elderly.

Faced with a complex disease in old age, elderly people were more dependent than at any other fourth dimension. In addition to helping older family members with the process of striving in the form of life, another of import arroyo was "helping to stabilize whose life," and then as to improve the lives of the older people receiving help. In order to raise elderly persons' psychosocial capacity while they are striving in the course of life and searching for information, families seek to heighten the elders' psychosocial capacity. In the struggle with COPD, elderly people and their families have to cope with and overcome the disease, due to the illness beingness the most important concern of the family and affecting the lives of family members. Various attempts are made to ensure the well-existence of elderly patients, to provide them with concrete, emotional, and financial back up, and to ensure that their living conditions are comfy. Taking care of elderly family members brings satisfaction to family members and the elderly are likewise happy to pay more. Although dependent elderly family members have delegated many responsibilities to the family unit members, well-nigh of them had no complaints in this regard and made the utmost efforts to be expedient. They exerted efforts in caring for elderly persons, were satisfied, and considered it a approval. They also seek to ensure the welfare of elderly persons by providing them with invaluable physical, emotional, and financial support.

"People who receive adept family unit support and care from their children get better answers are meliorate off than those who alive alone; not a hundred percent, but 'information technology' is less probable. In addition, an elderly who may not see or hear well is not in a good relationship with the exterior world." (Participant 16, pulmonologist)

Improved patient care skills.

Cooperation with families in treatment and their role as providers of family unit support necessitate that family caregivers meliorate their skills in patient care. Therefore, it is also of import that through either self-study or applied awarding, family members obtain the knowledge and skills required to improve patient intendance to elderly people living with the disease to the elderly living with the disease as well.

"When I saw my mother'due south disease progress day by day, I followed upward with the doctor. I know a lot about my female parent's disease, about drugs, respiratory aid devices. As the saying goes, I am an 'expert."(Participant 12, a family unit caregiver)

Discussion

The theory of "Managing life with COPD" explains elders' struggle with self-regulation and the strategies that they utilise to manage their affliction. A difficult illness shapes their lives and governs their capacity to engage in activities of living. This is consistent with the findings of other researchers, who found that 'elderly persons' experiences with COPD warrants the latter'southward definition as a "hard disease elderly with COPD's experience" [5, 14, 15]. Striving for self-regulation dictated every aspect of the elderly persons' lives, including self- care, social life, autonomy, and family. Similar to the other studies, participants in this report spoke near their attempts to control their symptoms [16]. The written report showed that older people's daily lives were strongly influenced past the bear on of the illness and ageing. They used various strategies to control their symptoms. The importance of "knowing what works" [fourteen] for them personally was key to how they managed their illness. The likelihood of elderly persons with COPD maintaining and sustaining "autonomy" is greater if they know what to practise, when, and how. Even so, the results showed that many elderly people did not know their right diagnosis and the name and nature of their illness. This is considering professional team members, peculiarly physicians, used common words to enable meliorate understanding by the elderly patient, leading to many elderly people thinking that they have asthma, instead of COPD. This result is harmonious with the results of Boots' study, which showed that patients did not know their correct diagnosis [17].

The participants described knowledge acquisition as essential for their empowerment, a finding supported by previous researchers [eighteen, nineteen]. They sought information from literature, the Internet, mass media programs, and peers, and by talking to healthcare providers. Patients have previously described seeking information outside healthcare encounters, and then as to acquire an understanding of the illness [19]. Previous findings take underlined the demand for healthcare providers to support patients past providing relevant knowledge that is of import to them [10, 20].

Besides family members' support to older people, health professionals were besides reported as important resources in the elder's ability to cope with COPD. The characteristics of healthcare providers that elderly people perceived as empowering included delivering skilful information and applying unlike educational strategies to elderly patients and their families. From the healthcare professionals' perspective, they empowered elderly people and their family members by taking time to talk to them, answering questions, and offer helpful information. Furthermore, according to previous research, it is important that family members become the same information equally the elder, to facilitate their understanding of the elder'due south situation [19]. Healthcare providers have a responsibleness to help elders with COPD and their families learn how to better control the erstwhile's affliction, as opposed to letting information technology command them. Empowerment programs that focus on teaching the elderly with COPD (eastward.g., the inhaler technique, working with the oxygen motorcar, and Bi-PAP) strategies to manage breathlessness (e.g., rehabilitation) and how to brand lifestyle changes (east.g., exercising) prove encouraging results. This result is consistent with those of other studies [21, 22].

Presumably, the elder's self-regulation is a effect of family support and the professional squad's efforts, which help motivate older people with COPD to exercise autonomy regarding their healthcare problems. These deportment aim at a variety of issues, namely, coping (both problem-focused and from an emotion perspective) with and living with the illness, taking medication on fourth dimension, managing medication side effects, and keeping oneself safe (including preventing or controlling the disease). This finding is harmonious with that in the study conducted by Sohanpal [23]. In this written report, trust in the medical team, especially the physician, was constitute to be of import to older people with COPD and their family unit members. This also had an bear upon on "adherence to treatment regimens" and the perceived quality of care. In this regard, although some elderly persons had succeeded in quitting smoking spontaneously on the communication of a md, others had made repeated unsuccessful attempts to quit without the do good of a smoking cessation service. There is some evidence to suggest that, in general, older smokers are less likely to make a abeyance attempt than are younger smokers; in one case they do, they are likely to be able to quit for three months or more [24, 25].

The elderly people with COPD in this study were striving for health related quality of life(HRQOL) past trying to control different types of symptoms in unlike ways of living with COPD, such as getting involved in treatment, maintaining independence, collaboration with the professional team, participating "in the process of care," and the promotion of psychosocial chapters. The importance of maintaining independence was reiterated throughout the interviews. This finding is consistent with that in the study reported past Fonseca (2010) in relation to the lives of the elderly, with emphasis on the elderly person exercising his/her functional chapters by engaging in daily activities [26]. This seemed to be true for the participants in this study, equally they struggled with many bodily problems. Their ill and ageing bodies certainly set limits for their lives. This result is the same as that in Hallberg's study, wherein women with vertebral fractures were striving to maintain their independence by trying to manage different types of symptoms in different ways [27].

The nature of COPD ways that control is forever in flux; for example, an acute exacerbation could temporarily shift the person from having "self-efficacy" to "dependence on intendance."

The results of this study showed that demographic, familial, and social factors have important roles in the procedure of empowering elderly persons with COPD. These factors occasionally facilitate the empowerment care process and sometimes get in difficult [28]. By understanding these factors, healthcare providers can support elderly persons with COPD in managing to maintain independence in self-care and controlled co-existence with affliction. Reducing the number of admissions, referral of elders with COPD to medical centers and clinics, and the fiscal burden of the disease, as well as increasing life satisfaction can be a issue of empowerment interventions [29]. The results of this written report tin can also exist used in the formulation of policy and setting the standards of care in our land, equally they illuminate important concepts and provide basic knowledge of the process of empowerment among elderly persons with COPD.

Conclusions

"Cocky-regulation" enables the elder to feel in control and alive optimally. This is a fragile residuum, however, and the unpredictability of COPD can tip the elderberry into "self-efficacy."

Relevance to clinical practice

Nurses and other healthcare staff need knowledge and agreement of the pregnant of empowerment in care, in relation to the power of elders with COPD to meet their needs. Understanding the experiences of the empowerment process of elderly persons with COPD tin can assistance health professionals provide more focused elderly care.

Supporting information

Acknowledgments

The cooperation of all participants in the accomplishment of this research is highly appreciated.

Writer Contributions

1. Conceptualization: ZF FMS MFK APH.
2. Data curation: ZF APH.
3. Formal assay: ZF FMS.
4. Funding acquisition: ZF.
5. Investigation: ZF FMS APH.
6. Methodology: ZF FMS MFK.
7. Software: ZF APH.
8. Supervision: ZF.
9. Validation: ZF FMS MFK.
10. Visualization: ZF FMS APH.
11. Writing – original draft: ZF FMS.

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