Where breath meets care: nurses’ perspectives on enabling COPD self-management in polyclinic settings

Abstract

Background

Effective self-management is central to living well with chronic obstructive pulmonary disease (COPD), yet its success depends heavily on how nurses translate guidelines into everyday encounters with patients and families. Evidence from primary care and polyclinic settings, particularly in Middle Eastern contexts, remains limited.

Aim

To explore nurses’ perspectives on how they enable COPD self-management in polyclinic settings, and to illuminate the relational, organizational, and cultural factors that shape this work.

Design

A qualitative interview study using reflexive thematic analysis, informed by attention to nurses’ lived experiences of providing COPD self-management support.

Methods

Semi-structured, in-depth interviews were conducted with nurses providing care for adults with COPD in university-affiliated polyclinics. Participants were purposively sampled to capture variation in experience, role, and clinic type. Interviews were audio-recorded, transcribed verbatim, and analyzed using reflexive thematic analysis. Rigour was enhanced through iterative coding, team discussions, reflexive journaling, and member reflections with a subset of participants.

Results

Eighteen nurses described COPD self-management support as an ongoing negotiation “where breath meets care.” Four interrelated themes were identified: (1) Teaching patients to breathe again—using simple language, demonstrations, and repetition to make complex regimens manageable; (2) Between protocols and people—working around time pressure, fragmented pathways, and limited resources while trying to individualize care; (3) Culture, family, and the silent burden—navigating family gatekeeping, stigma, and culturally embedded health outcomes are predetermined about lung disease; and (4) Building trust, breathing hope—developing long-term, relationship-based care in which small clinical gains (e.g. fewer exacerbations, better inhaler use) signalled meaningful progress.

Conclusions

Nurses’ efforts to enable COPD self-management extend far beyond technical education, encompassing relational work, advocacy, and adaptation to cultural and system constraints.

Implications for nursing practice

Findings highlight the need for protected time, continuity of care, and context-sensitive training that strengthens nurses’ skills in collaborative teaching, family engagement, and navigating structural barriers in COPD self-management support.

Clinical trial number

Not applicable.

Supplementary information

The online version contains supplementary material available at 10.1186/s12912-026-04353-0.

Introduction

Chronic obstructive pulmonary disease (COPD) is a progressive, preventable respiratory condition and a leading cause of morbidity and mortality worldwide [1]. In 2021, COPD accounted for an estimated 3.5 million deaths (≈5% of all global deaths) and disproportionately affected people in low- and middle-income countries, where nearly 90% of COPD deaths under age 70 occur [2]. Beyond mortality, COPD is a major contributor to disability and health-care utilization through persistent symptoms, exacerbations, and multimorbidity, necessitating long-term, person-centred management strategies endorsed by contemporary clinical guidance such as the Global Initiative for Chronic Obstructive Lung Disease (GOLD) [3, 4].

Self-management has emerged as a core pillar of high-quality COPD care. Consensus work defines a COPD self-management intervention as “a structured but personalized and often multi-component approach” that equips people to recognize, treat, and prevent exacerbations; optimize daily symptoms; and adopt health-promoting behaviors in collaboration with clinicians [5, 6]. Conceptually, these programs map to the Practical Reviews in Self-Management Support (PRISMS) taxonomy for long-term conditions, which spans 14 components, including tailored information, skills training (e.g., inhaler technique, breathlessness management), action planning, problem-solving, equipment provision (e.g., oximeters, spacers), social support, and regular feedback loops [7]. In COPD, these elements are typically delivered alongside smoking cessation, vaccination, physical activity, and pulmonary rehabilitation (PR) pathways recommended by GOLD [8].

Accumulating evidence indicates that COPD self-management programs improve patient-important outcomes. Cochrane syntheses and updates report consistent gains in health-related quality of life and reductions in COPD-related hospitalizations when self-management includes individualized action plans for exacerbation recognition and treatment [9]. Landmark trials, such as “Living Well with COPD,” demonstrated declines in healthcare utilization with nurse-supported education and action planning, catalyzing subsequent implementation efforts internationally [9]. In parallel, robust evidence shows PR improves exercise capacity and quality of life, with growing models for in-person, home-based, and hybrid delivery to enhance reach [10]. Taken together, these findings underscore the centrality of supported self-management and PR across the COPD continuum [11, 12].

Nurses are pivotal to making self-management “work” in real clinical contexts. Across primary, community, and hospital settings, nurses provide iterative education; coach inhaler technique and breathing strategies; co-produce written action plans; support smoking cessation and vaccination uptake; triage early deterioration; and coordinate referrals to PR and other services. Qualitative evidence suggests patients value nurse-led and nurse-supported interventions for building confidence, continuity, and relational safety,key precursors to behavior change,while also highlighting the need for consistent structures and training to standardize delivery [13]. Yet, despite policy emphasis, the day-to-day enactment of self-management support remains variable across teams and systems [14, 15].

Several persistent implementation challenges shape whether self-management support achieves its promise. First, inhaled therapy remains foundational in COPD, but critical errors in technique are common and linked to worse outcomes, making hands-on coaching and re-assessment a continuing nursing priority [16]. Second, health literacy constraints, understanding, accessing, and using health information, limit patients’ ability to self-manage, particularly after acute exacerbations; literacy-informed interventions can improve knowledge and engagement but are not routinely embedded [17]. Third, PR is underutilized despite strong evidence, with referral and uptake hampered by service availability, clinician awareness, patient beliefs, transportation, and competing responsibilities, barriers that nurses are often tasked with negotiating at the bedside and in the community [18]. Collectively, these factors illustrate why “supported” self-management, delivered by trained clinicians within clear pathways, matters for equitable outcomes [19].

Despite a mature evidence base for what to deliver, there is comparatively less understanding of how nurses conceptualize and operationalize self-management in routine COPD care, particularly across diverse organizational contexts and resource settings. Prior qualitative work reveals mixed and sometimes conflicting interpretations of “self-management,” tensions between autonomy and safety, and the influence of workload, training, and interprofessional dynamics on delivery fidelity [20]. Capturing nurses’ perspectives is therefore essential to clarify practice-based mechanisms, what enables or constrains effective education, action-planning, inhaler coaching, early deterioration recognition, and PR linkage, and to inform contextually sensitive implementation strategies aligned with GOLD recommendations [21, 22].

Accordingly, this qualitative study explores nurses’ perspectives on supporting self-management among people living with COPD. The objectives are to [1] describe how nurses define and prioritize the components of COPD self-management in everyday practice [2]; examine perceived barriers and enablers (patient-, clinician-, and system-level) to delivering consistent, high-quality support, including PR referral and uptake; and [3] identify pragmatic strategies nurses use to help patients recognize deterioration, optimize inhaler use and breathlessness management, and sustain behavior change after discharge. By centering the opinions and voices of those who teach patients how to breathe again, this study aims to generate actionable insights for strengthening nursing-led self-management support and, ultimately, improving outcomes for people with COPD.

Method

Design

This study used a qualitative design to explore nurses’ experiences of enabling COPD self-management in polyclinic settings. While the study was guided by a phenomenological sensibility—prioritizing how nurses describe and make meaning of their everyday practice—data were analyzed using reflexive thematic analysis to generate interpretive patterns across accounts. This approach was selected because it supports rich, practice-proximal interpretation of experiential data while remaining theoretically flexible and transparent in analytic decision-making [23]. COPD care encompasses more than standardized procedures, as it involves relational engagement, implicit expertise, and ethical discernment as nurses navigate the priorities of safety, autonomy, and cultural considerations over time [24]. Reporting adhered to the Standards for Reporting Qualitative Research (SRQR) to guarantee transparency, reflexivity, and methodological rigor. [25].

Study setting and recruitment

The study was conducted in the polyclinics affiliated with King Faisal University (KFU), Al-Ahsa, Saudi Arabia, multi-specialty ambulatory centers serving diverse urban and peri-urban communities. Services include family medicine, respiratory clinics, pharmacy, and chronic-disease education, with established referral pathways to pulmonary rehabilitation and hospital-based care. Participants in the study were recruited from outpatient respiratory and family medicine clinics, which ensured variation in roles, years of experience, and service lines. The sociocultural context of the participants is characterized by strong family involvement, high value placed on modesty and privacy, and varied multilingual communication needs (Arabic predominates, and English is used in interprofessional exchanges). So this diversity enhances transferability to similar Gulf ambulatory settings where cultural norms and resource variability shape how self-management is delivered. Recruitment occurred via unit liaison nurses who distributed study invitations to eligible staff and posted flyers in staff areas. Interested nurses contacted the research team directly to reduce coercion. Purposive sampling continued until the team judged the dataset to have sufficient informational depth and thematic adequacy across roles and clinic types.

Inclusion and exclusion criteria

Nurses were eligible if they were registered nurses (any rank) providing direct COPD care in KFU polyclinics for at least six months and routinely involved in at least two COPD self-management activities (e.g., inhaler education, breathlessness management such as pursed-lip breathing, exacerbation action planning, smoking cessation or vaccination counselling, referral to pulmonary rehabilitation, or follow-up contact). Participants had to be able to complete a 60–90-minute interview in Arabic or English and provide informed consent. Nurses were excluded if they were on short-term rotation ( < 6 months), worked exclusively in administrative roles, had conditions substantially limiting communication or reflective participation, or were currently under disciplinary proceedings related to patient education (to avoid coercion or distress).

Data collection

Data were collected through in-depth, semi-structured interviews designed to elicit thick descriptions of everyday work, decision points, and contextual contingencies in COPD self-management support. This approach is appropriate for exploring professional practices and sensitive dynamics (e.g., discussing smoking, fear, or stigma) that benefit from privacy and rapport building [26]. Interviews were conducted in quiet staff education rooms within the polyclinics or, when preferred, via secure video conferencing using institutionally approved platforms. The lead researcher,a nurse academic trained in qualitative methods and not part of the participants’ managerial line,conducted all interviews to reduce power imbalances and social desirability. Brief demographic and professional background data were recorded prior to the interview (role, years in practice, COPD caseload, relevant training). Field notes were written immediately after each session to capture contextual details, workflow constraints, and non-verbal cues pertinent to interpretation.

Interview structure and conduct

The interview guide was iteratively developed from COPD self-management literature, local care pathways, and input from two senior clinical educators. The guide was piloted in two pilot interviews with eligible nurses to assess clarity, flow, and cultural appropriateness; pilot participants were not included in the analytic dataset, and minor refinements were made to prompt order and wording. The full semi-structured interview guide, including core questions and probing prompts, is provided in Appendix A.

Recording and transcription

With consent, all interviews were digitally audio-recorded. Files were stored on encrypted, password-protected university devices accessible only to the study team. Recordings were transcribed verbatim by a professional transcriptionist fluent in Arabic and English. Arabic interviews were translated and back-checked by a bilingual team member to preserve idiomatic meaning and clinical terminology. Back-checking” refers to bilingual verification in which a second team member reviewed translated segments against the original audio/transcript to confirm meaning, clinical terminology accuracy, and preservation of idiomatic expressions. All transcripts were verified against audio for accuracy and de-identified; pseudonyms (e.g., N03, N14) replaced names and any potentially identifying details (units, shifts, unique positions) were masked or generalized.

Data analysis

Analysis was conducted reflexively and iteratively by the research team (Fig. 1). Initial coding was led by the primary analyst, with regular analytic meetings used to interrogate interpretations, refine theme boundaries, and strengthen reflexive awareness rather than to calculate agreement. Memos and an audit trail documented analytic decisions across theme development. [27]. Analysis proceeded inductively at the semantic and latent levels, privileging participants’ language while attending to underlying assumptions and contextual influences. Privileging participants’ voices involved grounding analysis in nurses’ own words and meanings, ensuring that themes reflected participants’ perspectives rather than researcher-imposed interpretations. Two analysts independently coded an initial subset (≈25%) to establish a shared codebook; discrepancies were discussed until consensus and the codebook was iteratively refined. Constant comparison across roles and clinics supported attention to variation and common mechanisms. An audit trail documented coding decisions, theme iterations, and reflexive memos. Preliminary themes were sense-checked with a subset of participants for resonance and completeness (member reflections).

Fig. 1.

Braun and clarke’s thematic analysis

Ethical considerations

Ethical approval was obtained from the King Faisal University Institutional Review Board (IRB; KFU-2025-ETHICS3666). Written informed consent was secured before participation; nurses were reminded that participation was voluntary and withdrawal could occur at any point without consequence. Interviews were scheduled outside direct patient-care duties to minimize burden. Confidentiality was ensured through de-identification, secure data storage, and restricted access to recordings and transcripts in line with institutional data governance. No patient information was collected.

Rigour and reflexivity

Trustworthiness followed Lincoln and Guba’s criteria [28].

• Credibility: Prolonged engagement in the clinical setting, triangulation of data with field notes, and member reflections on thematic summaries enhanced interpretive confidence.

• Dependability: A detailed audit trail (versions of the guide, codebook iterations, memo logs) was maintained and is available upon reasonable request.

• Confirmability: Independent peer debriefs by two qualitative scholars external to KFU reviewed coding structures and theme-to-data coherence.

• Transferability: Thick description of organizational workflows, cultural context, and resource pathways (education, pharmacy, PR referral) supports application to similar ambulatory services.

  The lead researcher maintained a reflexive journal throughout, documenting assumptions about “effective education,” preferences for nurse-led coaching, and potential influences of academic–clinical positioning. These entries informed analytic discussions and mitigated bias during interpretation.

Results

Characteristics of participants

Eighteen registered nurses working in the polyclinics affiliated with King Faisal University, Al-Ahsa, Saudi Arabia, participated in this study (Table 1). Participants represented a diverse mix of clinical roles, including staff nurses (n = 10), charge nurses (n = 4), and nurse educators (n = 4). Ages ranged from 27 to 49 years, with a mean age of 36.4 years (SD = 5.8). Years of nursing experience ranged from 4 to 23 years (M = 11.2, SD = 5.3), and all had at least six months of experience providing direct care for patients with chronic respiratory conditions.

Table 1.

Sociodemographic and professional characteristics of participants (n = 18)

Participant ID	Age group (years)	Role	Years of experience	Highest qualification	Clinic assignment	Years in COPD care	COPD-related training	Primary self-management activities*
N01	25–34	Staff Nurse	5	BSc Nursing	Family Medicine	2	Yes	Inhaler teaching, breathing exercise training
N02	25–34	Staff Nurse	8	BSc Nursing	Respiratory Clinic	6	Yes	Smoking cessation counseling, action planning
N03	35–44	Charge Nurse	15	BSc Nursing	Family Medicine	8	No	Inhaler technique review, referral coordination
N04	35–44	Nurse Educator	12	MSc Nursing Education	Clinical Training Unit	10	Yes	Staff training on COPD education
N05	25–34	Staff Nurse	4	Diploma	General OPD	1	No	Basic education and follow-up reminders
N06	35–44	Charge Nurse	20	BSc Nursing	Respiratory Clinic	12	Yes	Inhaler coaching, family education
N07	35–44	Staff Nurse	9	BSc Nursing	Chronic Disease Unit	5	Yes	Pursed-lip breathing, adherence counseling
N08	45–54	Nurse Educator	23	MSc Adult Health	Clinical Education	10	Yes	Policy development, training support
N09	25–34	Staff Nurse	6	BSc Nursing	Family Medicine	3	Yes	Education on trigger avoidance
N10	35–44	Staff Nurse	10	BSc Nursing	Respiratory Clinic	7	No	Smoking cessation and inhaler review
N11	35–44	Charge Nurse	14	BSc Nursing	Family Medicine	9	Yes	Education plan supervision
N12	25–34	Staff Nurse	8	BSc Nursing	General OPD	4	No	Breathlessness coaching
N13	45–54	Charge Nurse	19	BSc Nursing	Chronic Care Unit	11	Yes	Exacerbation action planning
N14	25–34	Staff Nurse	7	BSc Nursing	Family Medicine	3	No	Patient education and referrals
N15	25–34	Staff Nurse	5	Diploma	General OPD	2	No	Basic inhaler teaching
N16	35–44	Nurse Educator	18	MSc Nursing Administration	Education Dept.	10	Yes	Staff mentorship and evaluation
N17	35–44	Staff Nurse	11	BSc Nursing	Respiratory Clinic	6	Yes	Reinforcement of self-care plans
N18	35–44	Charge Nurse	13	BSc Nursing	Chronic Care Unit	8	Yes	COPD review clinic coordination

^*Primary self-management activities refer to the nurses’ most frequent or emphasized educational or supportive interventions as described during interviews

The sample included both Saudi (n = 12) and expatriate (n = 6) nurses, reflecting the multicultural workforce typical of Saudi outpatient clinics. Educational backgrounds ranged from diploma-prepared (n = 4) to bachelor’s degree (n = 10) and postgraduate qualifications (n = 4). Most participants worked in the family medicine or respiratory clinics, where they provided patient education, follow-up counseling, and chronic-disease coordination. Twelve nurses had previously received in-service training on COPD management or inhaler technique, while six learned primarily through peer mentorship or clinical experience.

Participants’ years of involvement in COPD care ranged from 1 to 12 years (M = 6.1, SD = 3.4). Nearly all (n = 16) routinely taught inhaler use and breathing exercises such as pursed-lip and diaphragmatic breathing; thirteen provided smoking-cessation counseling, and ten were involved in pulmonary-rehabilitation referral or education. The majority (n = 14) reported spending at least 20 minutes on initial COPD education sessions and expressed a sense of personal responsibility for empowering patients to “breathe better and live independently.”

Thematic findings

Thematic analysis generated four interrelated themes that collectively illustrate how nurses perceive, interpret, and operationalize self-management support for patients living with chronic obstructive pulmonary disease (COPD). These themes reveal the dynamic interplay between professional competence, relational care, system constraints, and cultural context in shaping nursing practice. Nurses described their work not merely as technical instruction but as an ongoing partnership that empowers patients to “breathe again”, physically, emotionally, and socially. Table 2 summarizes the themes, subthemes, and brief descriptions.

Table 2.

Themes, sub-themes, and descriptions

Theme	Sub-Theme	Description
1. “We Teach Them How to Breathe Again”: The Educator as Lifeline	1.1 Coaching Beyond the Disease	Nurses viewed themselves as educators and motivators who translate complex medical regimens into everyday routines, teaching patients to recognize triggers, use inhalers correctly, and manage breathlessness with confidence.
	1.2 Empowering Through Demonstration and Repetition	Practical, hands-on training,especially repeated demonstrations of inhaler use and breathing exercises,was seen as crucial for developing patients’ self-efficacy and sustaining adherence to treatment plans.
2. Between Protocols and People: Negotiating System Constraints	2.1 Time Pressure and Staffing Shortages	Heavy workloads and limited consultation times often forced nurses to condense educational content, compromising depth and follow-up.
	2.2 Fragmented Care Pathways	Participants highlighted a lack of structured continuity between outpatient clinics, hospitals, and pulmonary rehabilitation programs, which hindered sustained patient engagement and monitoring.
3. Culture, Family, and the Silent Burden	3.1 Family as Co-Learners and Gatekeepers	Nurses frequently involved family members,especially spouses or adult children,in education, recognizing their pivotal role in medication adherence and daily support, yet also acknowledging occasional resistance or misinformation.
	3.2 Cultural Taboos and Health Beliefs	Some patients avoided discussing breathlessness, smoking, or symptom progression due to fear, shame, or fatalistic beliefs (“God’s will”), limiting proactive self-management conversations.
4. Building Trust, Breathing Hope: Relational Care in Action	4.1 Partnership Through Empathy and Presence	Nurses emphasized compassionate communication, active listening, and consistent follow-up as foundations of therapeutic relationships that motivate patients to take ownership of their care.
	4.2 Small Successes, Big Impact	Witnessing patients’ incremental progress,improved breathing technique, reduced anxiety, or independence in self-care,reinforced nurses’ sense of professional purpose and commitment to advocacy.

“We teach them how to breathe again”: the Educator as lifeline

Coaching beyond the disease

Nurses portrayed themselves as “coaches” rather than mere conveyors of information. the education of nursing students. In the clinic, I am teaching the nursing students how to provide a COPD patient entire care and how to make tailored treatment regimens depending on the patient’s requirements. (N06, Nurse, 12 years experience)

This coaching viewpoint beyond just symptom management to include emotional support and lifestyle modification. Nurses often characterized reframing COPD as a controllable illness instead of a terminal prognosis. Nurses utilized metaphors and real-life examples to make learning useful.Another nurse said,

I don’t just explain inhalers; I talk about what it’s like not to be able to breathe, and I try to connect with patients’ fear so they will trust me enough to try. (N03, Charge Nurse, Family Medicine, 8 years)

“Most of them come frightened—especially after an exacerbation. I tell them, ‘Breathlessness doesn’t always mean you are dying; it’s a signal you can manage.’ When we practise the breathing together and I explain what is happening in their lungs, you can see the fear reduce. Then they start to believe they can control it”. (N05, Respiratory nurse)

Sometimes the biggest problem is panic, not oxygen. I coach them to slow down, sit forward, and focus on the breathing pattern. I say, ‘You are safe, we will take it step by step.’ When they feel they can calm their body, they become more confident to manage at home”. (N07, Staff nurse)

By giving tailored coaching like this, nurses linked biology education with empathy, which helped patients feel more in control and capable. They used an iterative, human-centered strategy that focused on tiny, doable objectives instead of big, scary orders. A number of participants observed that even little adjustments in behavior, such as administering medicine prior to physical exercise, often resulted in substantial enhancements in patients’ confidence and involvement. But nurses also knew that coaching doesn’t always work in places with little resources. Their capacity to provide continuous follow-up was limited by short sessions and a lot of patients. But they typically made up for it in other ways, including phone reminders, quick check-ins on unrelated trips, or getting relatives to help.

“I never give them everything in one visit. I choose one small target today, we fix the inhaler technique, and next time we talk about triggers or the action plan. I ask them to show me again ‘teach me how you will do it at home’because if they can’t demonstrate it here, they won’t do it correctly outside”. (N04, Nurse educator)

“We break it into small changes they can actually do: ‘two minutes of walking after prayer,’ or ‘one reminder for the inhaler.’ Then I ask, ‘What will stop you?’ and we plan around that. At the next visit, I start by asking them to repeat the steps and tell me what worked and what didn’t”. (N12, Nurse Educator)

Empowering through demonstration and repetition

Practical demonstration and repetition were fundamental tactics by which nurses enabled patients to successfully control COPD. Participants consistently characterized “showing, not telling” as the most dependable approach for promoting learning and enduring commitment. Teaching was characterized as an embodied practice; nurses exhibited inhaler techniques, facilitated breathing exercises, and used visual aids to enhance understanding, particularly for patients with little literacy.

“Many patients nod as if they understood, but when I observe them, they push the inhaler without breathing. So, I keep showing them until I’m sure they can do it. (N09, Staff Nurse, Family Medicine, 3 years)

Repetition was not seen as unnecessary, but rather as an important way to reinforce learning, particularly in a chronic condition that causes changes and relapses. Nurses said that regular reinforcement helped patients remember their routines and stick to them even when their symptoms were worse. It was a common problem that people misused their inhalers, and the only way to fix it was to watch and practice it again and again. “Some patients forget after a week.

” I tell them, “Every time you come, you get to practice again.” I never think they recall; it’s all about creating muscle memory. (N17, Staff Nurse, Respiratory Clinic, 6 years)

Repetition was also a way to motivate people, in addition to showing them how to do something. Every educational experience, regardless of its brevity, was seen as a progression towards empowerment. Several nurses connected repetition to relationship trust, saying that patients felt valued when nurses took the time to educate them again without judging them.

” I describe self-management as the skills and habits that patients need to learn in order to take care of their own health. (N04, Nurse Educator, Training Unit, 10 years)

Participants also spoke about imaginative ways to change how they educate, such utilizing colorful labeling, diagrams, or patients’ cell phones to video inhaler demonstrations for later use. These new ideas were a practical way to deal with a lack of time and educational resources. They showed how nurses turned little chances into enduring learning.

In the end, demonstration and repetition were called the two pillars of empowerment. These were real actions that nurses took to assist patients take back control of their breathing and, by extension, their everyday lives. By making education a collaborative, ongoing process, nurses made themselves not aloof experts but collaborators who helped patients gain confidence, skills, and optimism.

Between protocols and people: negotiating system constraints

Time pressure and staffing shortages

Nurses similarly rated time limitations as one of the most major challenges to successful COPD teaching. People said that outpatient treatment was like “a race against the clock,” as each visit had to include patient education, clinical evaluation, and paperwork in a short amount of time. Participants often managed 20 to 30 patients per shift, which restricted chances for comprehensive talks or experiential learning.

“We may have five minutes until the next patient. You can’t teach someone how to use an inhaler or do breathing exercises in five minutes. You simply give them the booklet and hope they read it. (N01, Staff Nurse, Family Medicine, 2 years)

These challenges were made worse by not having enough personnel, especially not having enough chronic illness educators or respiratory nurses. Because of this, education became a shared obligation among generalist personnel who frequently didn’t have formal training in how to treat COPD. Even so, participants came up with inventive ways to keep the quality up, such organizing informal lessons during vital sign checks, utilizing waiting time for short demonstrations, or encouraging families to watch and repeat teachings at home.

“We try to teach even when we’re just checking someone’s oxygen or medication.” There isn’t any additional personnel, therefore every minute counts. (N07, Staff Nurse, Chronic Disease Unit, 5 years)

A number of nurses said they felt morally upset that they couldn’t provide patients the level of instruction they needed, especially those who had trouble understanding health information or were having trouble breathing. They spoke of a sensation of “partial care” that kept coming back, where they did their best but felt like the task was never done.

“It’s hard to watch the same patient come back with another flare-up since we didn’t have enough time the previous time. It seems like work that isn’t done yet. (N10, Staff Nurse, Respiratory Clinic, 7 years)

The persistent lack of time and people made nurses switch between being efficient and caring. Despite these challenges, their stories showed that they were determined to create “micro-opportunities” for effect within structural limits. This is a subtle but potent kind of lobbying that is built into everyday practice.

Participants emphasized that time pressure and staffing shortages were not unique to respiratory services but reflected a broader polyclinic environment characterized by high patient throughput, documentation demands, and short appointment templates across specialties. However, nurses perceived COPD education as particularly vulnerable under these constraints because it requires hands-on demonstration, repeated teach-back, and emotionally supportive coaching—activities that are difficult to complete within brief encounters. Thus, COPD self-management support became a visible “pressure point” where general clinic workload constraints most clearly translated into reduced educational depth and follow-up continuity.

Fragmented care pathways

Participants recognized the lack of integrated care pathways, along with time limitations, as a major barrier to the ongoing provision of COPD self-management support. Several nurses reported that the recommendations for regular follow-up and coordinated referrals to pulmonary rehabilitation were not always clear, consistent, or well-communicated across primary and secondary care.

“We don’t know what happens after the patient leaves our clinic. Did they go to rehab, get a new inhaler, or need to come back?” There is no way to get feedback. Nurse Educator, Training Unit, with 10 years of experience (N04)

This fragmentation often led to the loss of patient progress between sessions, and the instruction given in one setting was not retained in other ones. Participants described a “start-and-stop” cycle, in which every exacerbation or missed appointment restarted the teaching process.

“We teach and plan with them here, but when they get to the hospital, the whole process starts over.” Each service works on its own. N15, Staff Nurse, General Outpatient Department, 2 years

Most nurses thought that pulmonary rehabilitation programs were very important but not utilized enough because of problems with logistics and communication. Referral systems were frequently manual, depended on professionals, and didn’t include ways for people to provide feedback. To fill this void, several nurses took the initiative to contact rehabilitation centers or tell families about the benefits of the program.

“There’s no notification from the system or a shared record.” We need to ask the patient ourselves whether they have joined rehabilitation. It depends on how much work each person puts in. N08, Nurse Educator, Clinical Education, 10 Years of Experience

This broken flow of information made people unhappy and feel like they were disconnected. Nurses indicated that self-management support should be a constant, collaborative effort, but it primarily relied on each person’s initiative instead than the system’s design. Despite these challenges, the contestants showed determination and creativity. Many useful solutions have been suggested, such as using shared electronic records, hiring COPD instructors, and making referral communication more consistent. Their opinions stressed a common goal of “one integrated system,” in which each encounter builds on the last to provide a seamless flow of assistance.

“We need one voice to talk to the patient, not a bunch of different ones.” Education should be ongoing, not starting over every time. N16, Nurse Educator, Nursing Administration, 10 years of experience

Culture, family, and the silent burden

Caregivers as co-learners and gatekeepers

Participants emphasized that in Saudi outpatient settings, COPD education often focuses primarily on the patient. Family members, usually spouses, adult children, or siblings, help each other learn by following lessons and reinforcing them at home. “Gatekeeping” refers to situations where a caregiver/family member controls access to information or speaks on behalf of the patient, shaping what is discussed and what education is received. Nurses believed that family engagement was essential to ensure that individuals took their medications, modified their diets, and received emotional support. In this study, caregivers refer to family members or other key persons who provide day-to-day support (e.g., medication organization, symptom monitoring, accompaniment to clinic visits) and who often participate directly in education encounters.

“I always ask a family member to watch when I teach breathing exercises.” They are the ones who assist the patient in remembering later and practicing. (N12, Staff Nurse, General OPD, 4 years)

Nurses often modified educational sessions to include family members, simplifying intricate terminology into accessible language and designating collective duties, such as overseeing inhaler use or promoting physical exercise. This collaborative strategy was said to work particularly well for older people or those who don’t read well. However, participants also said that family relations may make care more difficult when family members were too protective and made patients less independent, or when family members didn’t understand COPD.

“Some families believe that if the patient walks or does breathing exercises, they will get worse.” We need to teach them too, or else they would stop the patient from attempting. (N05, Staff Nurse, Family Medicine, 2 years)

The function of the family as “gatekeepers” was equally significant. Nurses said that family members regularly made decisions about health information and access to it, particularly for elderly males. Sometimes family kept things from the patient that made the disease seem less serious or stopped specific conversations out of fear or cultural modesty.

“Sometimes the son speaks for his father.” The patient is simply sitting there. He doesn’t ask questions since he respects her. (N14, Staff Nurse, Family Medicine, 3 years)

Even with these problems, nurses knew that families could be great partners in self-management if they were involved in the right way. Many people worked hard to build trust with both patients and their families. They did this by employing group education to change caring from control to partnership. This approach emphasized a holistic model of treatment based on the cultural truth that disease in the area is experienced collectively rather than individually.

Cultural taboos and health beliefs

Participants clarified how deeply ingrained cultural taboos and religious interpretations influenced patients’ views of COPD and their reactions to self-management advice. People in the past usually considered it was shameful or pointless to speak about long-term illness. People typically assumed that smoking and shortness of breath were moral or spiritual issues instead of physical ones. This caused people either avoid them or accept them as destiny.

Some people who are sick say, “If Allah wills, I will get better; it’s not up to me.” They believe that becoming ill is destiny, thus they don’t always follow the plan. For 8 years, I was the Charge Nurse for Family Medicine. (N03)

This belief system changed how patients perceived advice on how to remain healthy. Some individuals, for example, didn’t want to undergo pulmonary rehabilitation or breathing exercises because they considered that praying and relaxing were better methods to cope with being unwell. Nurses respected these beliefs by considering self-management as a way to show stewardship and gratitude for health, seeing it as an act of faith rather than a challenge to fate.

“We don’t fight; we tell them that taking care of your lungs is part of taking care of the body that Allah gave you.” They pay attention when we talk about religion. (N08, Nurse Educator, Clinical Education, 10 years)

Another hard thing was giving up smoking. Most of the people who took part spoke to patients about quitting on a frequent basis. However, some men believed these talks were intrusive or judgmental, and other men kept their smoking a secret from their families. Because of societal assumptions about masculinity and guilt, these chats were hard to have.

“An old man told me that his sons didn’t know he still smoked.” He asked me not to tell them. We worked quietly on cutting down on smoking before we spoke about quitting. (N09, Staff Nurse, Family Medicine, 3 years)

These stories illustrated how cultural taboos might make it hard to talk to others and obtain aid. Nurses, on the other hand, utilized analogies, humor, or gentle questions to talk about sensitive topics without starting a conflict. They understood that in order to educate successfully in this scenario, you needed to know how to conduct clinical work, be aware of other cultures, and be adept at reading people’s emotions.

Building trust, breathing hope: relational care in action

Partnership through empathy and presence

Nurses constantly articulated that empathy and “being present” are fundamental to establishing therapeutic connections with patients afflicted with COPD. People showed empathy not only by what they said, but also by how they said it, how patient they were, and how much attention they paid to someone who was having trouble breathing or was upset. Participants said that a lot of patients thought that being out of breath meant they were about to die or were having a panic attack, and that being calm and comforting at these times was frequently more helpful than medicine.

“When a patient can’t breathe, they’re scared. You lose them if you panic too. I sit next to them, hold their hand, and tell them to breathe more slowly. They feel better because they know someone is with them. (N11, Charge Nurse, Family Medicine, 9 years)

This empathetic position was characterized as a manner of “silent teaching,” serving to exemplify emotional regulation and bolster self-efficacy via nonverbal engagement. Nurses saw every interaction as a chance to listen to more than just the symptoms. They wanted to hear what patients were afraid of, including becoming dependent on others, putting a strain on their family, or dying.

“Sometimes what the patient needs most isn’t an inhaler; it’s to be heard.” Their respiration slows down as they converse. Empathy itself becomes therapeutic. (N03, Charge Nurse, Family Medicine, 8 years)

Continuity was also a part of presence, as the same person was there for each visit, which made people feel comfortable and built trust. Several nurses said that long-term follow-up in polyclinic settings let them see how patients’ lives changed over months or years, which helped them understand each other better. This ongoing relationship enabled them pick up on subtle emotional signs, make instruction more relevant, and deal with problems with care.

“They know who I am and say, ‘You’re the nurse who taught me how to breathe.’ That makes them more open the next time.” (N07, Staff Nurse, Chronic Disease Unit, 5 years)

So, empathy was not just a way to help people feel better, but it was also a way to teach them, making them more receptive to learning and following the rules. By being totally present in each interaction, nurses built trust that made self-management a group effort instead of a solo one.

Small successes, big impact

Nurses found significant satisfaction in observing little, steady improvements in their patients, even though systemic constraints and the disease’s chronicity often made progress appear slow. Participants spoke excitedly about “the joy of small wins,” which were moments when a patient learned how to use an inhaler, learned how to manage their breathing on their own, or exhibited more confidence in regulating their symptoms. People said that these little wins showed that they were strong and hopeful.

“When a patient comes back and says, ‘I can climb the stairs without fear now,’ that’s a win.” This means that what we taught worked. (N10, Staff Nurse, Respiratory Clinic, 7 years)

Nurses felt like professionals and were inspired by these types of situations. A lot of individuals stated they felt good about themselves when they witnessed patients progress from being helpless to being able to do things. They thought these improvements showed that relationship care could be able to influence the course of a disease.

“We may not be able to cure COPD, but when a patient says, ‘I can breathe easier now,’ it feels like a cure in itself.” (N08, Nurse Educator, Clinical Education, 10 years)

Nurses reported that even little signals of improvement helped both the patient and the nurse want to keep going, even though COPD is a long-term illness. A single successful demonstration of an inhaler or a moment of quiet breathing at a time of worry was considered as a good place to start making further progress. These “small successes” offered patients optimism and confidence, which helped them remain interested in the long term. A lot of them were often fatigued and disheartened.

“I tell my patients, ‘Every breath you take is a win.’” When people see that their situation is getting better, they start to believe they can handle it. (N13, Charge Nurse, Chronic Care Unit, 11 years)

Nurses also reported that celebrating little victories helped them cope with the emotional exhaustion that comes with working in chronic care. Even when they were under a lot of stress and had limited resources, they were able to recall why they were doing what they were doing by recognizing even small successes. This subtheme reveals that hope may be both an emotional and a medical way to cure COPD. Nurses develop regular teaching into a routine that helps both patients and caregivers feel better by always demonstrating empathy, support, and celebration of achievement.

Conceptual model of the findings

Figure 2 conceptualizes COPD self-management support in this setting as a dynamic interaction between [1] nursing work (education-as-lifeline, demonstration and repetition, relational coaching) [2], service conditions (time pressure, staffing, and fragmented pathways), and [3] sociocultural context (caregiver gatekeeping, stigma, and fatalistic beliefs). The model proposes that nurses enable self-management most effectively when teaching practices are embedded within trusting relationships and reinforced over time; however, this mechanism is moderated by whether clinics can provide protected time (refers to dedicated, workload-adjusted clinic time allocated for education (e.g., inhaler technique rehearsal, teach-back, action planning) that is not competed away by throughput and documentation demands), continuity, and closed-loop referral systems (e.g., pulmonary rehabilitation feedback).

Fig. 2.

Factors influencing COPD self-management support

In the local polyclinic context in Al-Ahsa—where outpatient visits are time-limited and families commonly accompany patients—self-management support becomes a shared social process rather than an individual task. Accordingly, the model highlights caregiver inclusion as an intervention lever (improving caregiver understanding and attitudes) and identifies system-level redesign targets (e.g., brief standardized inhaler-check routines, structured follow-up, and integrated documentation) that could increase fidelity to guideline-recommended self-management support within realistic workflow constraints.

Discussion

This study shows that nurses in university-affiliated polyclinics enact COPD self-management as a relational, practice-proximal craft: they translate guidelines into lived capability through hands-on teaching, repeated rehearsal, and trust-building, while continuously negotiating time and pathway constraints. The central theme,the educator as lifeline,aligns with GOLD 2025, which elevates supported self-management (SM), inhaler technique review, breathlessness management, vaccination, smoking cessation, and pulmonary rehabilitation (PR) as routine standards of care [29, 30]. Our findings extend this guidance by specifying how: demonstration plus repetition embedded in empathic partnerships is what converts protocol into everyday competence. This is congruent with high-certainty evidence that structured SM programs reduce COPD-related hospitalizations and health-care use and improve health-related quality of life (HRQoL) when anchored by individualized action plans and iterative coaching [31, 32].

Nurses’ emphasis on “show, practice, and re-check” directly targets a persistent quality gap: critical inhaler errors remain common and clinically consequential. Systematic reviews,including the CRITIKAL program and subsequent syntheses,document high rates of device errors, which are associated with poorer symptom control, more exacerbations, and greater resource use [33, 34]. Participants’ habit of reassessing technique at every contact mirrors recommendations to treat inhaler coaching as an iterative skill rather than a one-off instruction. It also reflects a realistic appraisal of memory and motor learning in older adults: repetition builds “muscle memory,” especially when literacy is limited or multiple devices are prescribed. Targeted, repeated instruction is therefore not a redundancy but a safety practice that aligns with evidence-to-impact pathways [35].

A second explanatory thread is relational care,empathy, presence, and continuity,which nurses framed as the emotional infrastructure for learning. The wider adherence literature supports this mechanism: patient–provider communication quality and therapeutic alliance are repeatedly linked to medication adherence and clinical outcomes in chronic illness, including COPD [36]. Recent observational analyses also suggest that higher adherence halves post-discharge exacerbation risk, underscoring why nurses’ work to reduce fear, normalize breathlessness, and instill confidence is not merely “soft” care but a determinant of hard endpoints [37]. Our theme “small successes, big impact” is consistent with behavior-change theory and with evidence that early, observable gains (e.g., calmer episodes of dyspnea, correct device priming) accumulate into sustained adherence [38].

The culture–family nexus emerged as both facilitator and filter. In the Gulf context, family members often act as co-learners who cue exercises, supervise medications, and buffer anxiety; yet they may also gatekeep conversations, minimize severity, or discourage activity out of protectiveness [39]. Health-literacy constraints amplify this dynamic. Reviews and recent empirical studies associate low health literacy with impaired SM skills, worse HRQoL, and greater hospitalization in COPD, while literacy-informed educational designs improve understanding and engagement [40, 41]. Our participants’ strategies,inviting relatives into demonstrations, translating biomedical concepts into faith-congruent narratives, recording videos on patients’ phones,map closely to literacy-informed and culturally tailored care, offering practical levers for ambulatory services in Saudi Arabia and similar settings.

At the system level, two friction points constrained fidelity (Fidelity of COPD self-management support refers to the extent to which recommended educational and coaching components are delivered as intended, including repetition, teach-back, follow-up, and caregiver involvement) [1]: time pressure and staffing; and [2] fragmented pathways. Nurses’ reports of “five-minute education” and reliance on personal initiative echo implementation studies showing that awareness without workflow anchoring produces fragile uptake. Evidence suggests that continuity and structured follow-up mitigate this fragility: higher relational continuity in primary care associates with lower COPD hospitalizations, and early post-discharge follow-up reduces 90-day readmissions [42]. Transitional care bundles that include standardized inhaler education and coordinated scheduling likewise cut readmissions in real-world settings [43]. These data, coupled with our themes, point to actionable meso-level fixes: (i) micro-routines (e.g., a 60-second inhaler check embedded in vitals); (ii) templated “what I checked today” notes to promote cross-visit reinforcement; and (iii) scheduled, team-owned follow-ups (in person or telehealth) to consolidate gains after acute care.

Our findings also illuminate the PR paradox: nurses strongly endorse PR but encounter referral and uptake barriers,limited awareness, logistics, anxiety, and weak feedback loops. Contemporary syntheses reaffirm PR’s robust benefits for exercise capacity, dyspnea, and HRQoL, yet uptake remains suboptimal across health systems [44, 45]. Reviews in low- and middle-income countries (LMICs) highlight additional access and coordination barriers, mirroring the “start-and-stop” cycle nurses described [46]. Practical implications include: automatic PR referral prompts in the EHR for eligible patients; brief, scripted “PR conversations” that align benefits with patient goals; closed-loop referral tracking so clinics receive attendance feedback; and family-inclusive orientation to demystify programs. Such steps align front-line experience with a systems approach to increase PR uptake.

Implications for Nursing education and practice

Findings suggest redefining COPD self-management as a key ability in undergraduate and graduate nursing programs. Nursing education should emphasize experiential and simulation-based learning that simulates clinical issues, including time-sensitive communication, family-inclusive education, and cross-cultural sensitivity. Chronic care programs must include pulmonary rehabilitation referral channels, inhaler strategies, and motivational interviewing.

The findings emphasize the necessity to include self-management assistance into treatment processes rather of treating it as an add-on. Healthcare facilities must build standardized instructional toolkits tailored to local literacy levels and cultural norms, hire chronic respiratory care nurse educators, and schedule teaching time. Electronic messages or reminder calls may improve compliance and continuity. Leadership must acknowledge relational care as a quality requirement to create a culture where empathy, trust, and education are regarded as interwoven components of good COPD treatment.

Conclusion

This research showed that nurses use a relational approach based on empathy, repetition, and patient-centered education to help people with COPD manage their own care, while also responding to the reality of the system and culture. Nurses turn technical education into powerful relationships that restore both breath and confidence by becoming teachers, advocates, and emotional anchors. But they can’t provide full self-management help because they don’t have enough time, personnel, or care coordination. To improve care for people with COPD, we need to make sure that policy, education, and system design all work together to help nurses teach by giving them training, protected time, and integrated pathways. When these things are present at the same time, self-management goes beyond teaching; it becomes a shared, long-lasting process of hope and healing that improves both the quality of nursing practice and patient outcomes.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

YSA contributed to the study conception and design, coordinated access to the polyclinic sites, and supported data interpretation from a respiratory care perspective. MNA contributed to the study design, facilitated clinical recruitment, and eligibility verification. FAA contributed to the qualitative methodology, developed the interview guide, led data collection, and participated in the thematic analysis. IAE had overall responsibility for the study, supervised all phases of the project, led the data analysis and synthesis, and drafted the initial version of the manuscript. All authors contributed to revising the manuscript critically for important intellectual content, approved the final version to be published, and agree to be accountable for all aspects of the work.

Funding

This work was supported by the Deanship of Scientific Research, Vice Presidency for Graduate Studies and Scientific Research, King Faisal University, Saudi Arabia (KFU260088).

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to confidentiality and privacy restrictions, but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval for this study was obtained from the institutional review board (IRB) of King Faisal University, Saudi Arabia (approval No.: KFU-2025-ETHICS3666). All participants received verbal and written information about the study aims and procedures. Written informed consent was obtained prior to participation, and participants were reminded of their right to withdraw at any time without consequences. Ethical principles of confidentiality, voluntary participation, and respect for autonomy were strictly maintained in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable. The manuscript does not contain any individual person’s data in any form (including individual details, images, or videos).

Competing interests

The authors declare no competing interests.