Chronic condition self-management support within a respiratory nursing service

Abstract

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.