Chronic condition self-management support within a respiratory nursing service

Abstract

Aim. The aim of this study was to report the steps taken by health professionals in practice to embed an innovative chronic condition self-management support programme. Within a small Australian Respiratory Nursing Service in Australia between 2008–2010. Background. Chronic obstructive pulmonary disease (COPD) encompasses chronic obstructive lung conditions such as emphysema and chronic bronchitis. These debilitating chronic conditions require a coordinated service response by health professionals across the spectrum of inpatient and community care services to support patients’ to effective management their heath and prevent exacerbations. Conclusions. By recognising the importance of the different phases of change involving diagnostic, planning, implementation, ongoing monitoring and review, but also the supporting tools for data collection, the readiness of staff for change, the mapping of barriers and enablers and planning for short- and long-term impacts, this Respiratory Service was able to embed effectively into practice a more coordinated service for patients with COPD across the inpatient/community continuum. Relevance to clinical practice. This change process was undertaken by respiratory nurses in the field using the Chronic Care Model and associated tools to guide implementation and sustainability of the change. Guided by identification of enablers and gaps of most relevance to these health professionals and those they serve, effective service improvement was achieved. The description of how these health professionals achieved change holds lessons potentially for others attempting to improve support for chronic condition self-management across other areas of health.