A Dyspnea Assessment Tool to Improve Care at the End of Life

Abstract and Introduction

Abstract

Dyspnea is experienced by 15% to 70% of patients at end of life. Because of cognitive changes before death, patients may be unable to self-report dyspnea, which requires nurses to accurately assess and initiate symptom management. This study compared practicing nurses' experiential practice in the assessment and management of dyspnea in patients unable to self-report to practice using of the Respiratory Distress Observation Scale (RDOS). This pre-experimental pretest/posttest study evaluated nurse outcomes following a structured educational program aimed at preparing them to use the RDOS. Nurses (n = 39) who provide end-of-life care were recruited for the study. After receiving the educational program, there was not a significant difference in the nurse's ability to assess the patient's overall level of perceived comfort and determine a differential diagnosis. There was, however, improvement in the nurse's ability to correctly determine a patient's level of dyspnea (P = .021) and also in their ability to select appropriate treatment options. This study demonstrates applicability of the RDOS to the end-of-life population replacing experiential practice with an evidence-based tool for the assessment and treatment of dyspnea in patients who cannot self-report.

Introduction

Many nurses rely on experiential practice when assessing and treating patients, which can result in care inconsistencies.^[1] It is unknown whether the nurse's assessment and treatment options guided by previous experience are consistent with the use of a validated assessment and treatment tool. This study compared experiential assessment and treatment of end-of-life dyspnea in standardized patient scenarios that could not self-report before and after incorporating the Respiratory Distress Observation Scale (RDOS) into their practice. To date, no studies have been done with the end-of-life population comparing the nursing assessment and management of dyspnea using experiential practice and practice after the incorporation of the RDOS tool. The purpose of this study was to compare experiential end-of-life dyspnea assessment and management before and after nurses received a structured educational program on the RDOS focused on preassessment/postassessment skills, treatment selections, identifying degrees of dyspnea, and ease of use/satisfaction with the scale.

Table 1. Sociodemographic Data
Sociodemographic Data	Values	Hospice Registered Nurses (n = 32)	Medical Registered Nurses (n = 7)	Results (n = 39)
Age	Age in years	Mean: 49.35	Mean: 34.86	Mean: 46.68
SD: 11.42	SD: 11.87	SD: 12.69
Range: 41	Range: 46	Range: 44
Minimum: 29	Minimum: 26	Minimum: 26
Maximum: 70	Maximum: 60	Maximum: 70
Gender	Female	32 (100%)	7 (100%)	39 (100%)
Nursing experience	Years	Mean: 18.28	Mean: 11.0	Mean: 16.97
SD: 15.11	SD: 12.0	SD: 14.73
Range: 47	Range: 34	Range: 49
Minimum: 3	Minimum: 1	Minimum: 1
Maximum: 50	Maximum: 35	Maximum: 50
Hospice experience	Years	Mean: 6.10	Mean: 6.0	Mean: 6.06
SD: 7.11	SD: 6.19	SD: 6.88
Range: 27	Range: 16	Range: 27
Minimum: 0	Minimum: 0	Minimum: 0
Maximum: 27	Maximum: 16	Maximum: 27
Nursing education	Associate degree in nursing Diploma Bachelor of science in nursing Master of science in nursing	12 (37.5%)	5 (71.4%)	17 (43.6%)
12 (37.5%)	0 (0%)	12 (30.8%)
6 (18.8%)	2 (28.6%)	8 (20.5%)
2 (6.3%)	0 (0%)	2 (5.1%)
Employment status	Full-time Part-time Per diem	28 (87.5%)	6 (85.7%)	34 (87.2%)
1 (3.1%)	1 (14.3%)	2 (5.1%)
3 (9.4%)	0 (0%)	3 (7.7%)
Current specialty certifications	Yes No	7 (21.9%)	4 (57.1%)	11 (28.2%)
25 (78.1%)	3 (42.9%)	28 (71.8%)
End-of-Life Nursing Education Consortium education	Yes No	3 (9.4%)	0 (0%)	3 (7.7%)
29 (90.6%)	7 (100%)	36 (92.3%)
Prior Respiratory Distress Observation Scale education	Yes No	5 (15.6%)	1 (14.3%)	6 (15.4%)
27 (84.4%)	6 (85.7%)	33 (84.6%)
Confidence level	Very confident Mostly confident Somewhat confident Not confident	16 (50.0%)	0 (0%)	16 (41.0%)
10 (31.3%)	4 (57.1%)	14 (35.9%)
5 (15.6%)	2 (28.6%)	7 (17.9%)
1 (3.1%)	1 (14.3%)	2 (5.2%)

Table 1. Sociodemographic Data

Sociodemographic Data

Values

Hospice Registered Nurses (n = 32)

Medical Registered Nurses (n = 7)

Results (n = 39)

Age

Age in years

Mean: 49.35

Mean: 34.86

Mean: 46.68

SD: 11.42

SD: 11.87

SD: 12.69

Range: 41

Range: 46

Range: 44

Minimum: 29

Minimum: 26

Maximum: 70

Maximum: 60

Maximum: 70

Gender

Female

32 (100%)

7 (100%)

39 (100%)

Nursing experience

Years

Mean: 18.28

Mean: 11.0

Mean: 16.97

SD: 15.11

SD: 12.0

SD: 14.73

Range: 47

Range: 34

Range: 49

Minimum: 3

Minimum: 1

Maximum: 50

Maximum: 35

Maximum: 50

Hospice experience

Years

Mean: 6.10

Mean: 6.0

Mean: 6.06

SD: 7.11

SD: 6.19

SD: 6.88

Range: 27

Range: 16

Range: 27

Minimum: 0

Maximum: 27

Maximum: 16

Maximum: 27

Nursing education

Associate degree in nursing
Diploma
Bachelor of science in nursing
Master of science in nursing

12 (37.5%)

5 (71.4%)

17 (43.6%)

12 (37.5%)

0 (0%)

12 (30.8%)

6 (18.8%)

2 (28.6%)

8 (20.5%)

2 (6.3%)

0 (0%)

2 (5.1%)

Employment status

Full-time
Part-time
Per diem

28 (87.5%)

6 (85.7%)

34 (87.2%)

1 (3.1%)

1 (14.3%)

2 (5.1%)

3 (9.4%)

0 (0%)

3 (7.7%)

Current specialty certifications

7 (21.9%)

4 (57.1%)

11 (28.2%)

25 (78.1%)

3 (42.9%)

28 (71.8%)

End-of-Life Nursing
Education Consortium education

3 (9.4%)

0 (0%)

3 (7.7%)

29 (90.6%)

7 (100%)

36 (92.3%)

Prior Respiratory
Distress Observation
Scale education

5 (15.6%)

1 (14.3%)

6 (15.4%)

27 (84.4%)

6 (85.7%)

33 (84.6%)

Confidence level

Very confident
Mostly confident
Somewhat confident
Not confident

16 (50.0%)

0 (0%)

16 (41.0%)

10 (31.3%)

4 (57.1%)

14 (35.9%)

5 (15.6%)

2 (28.6%)

7 (17.9%)

1 (3.1%)

1 (14.3%)

2 (5.2%)

Table 2. Differences Between Preprogram/Postprogram Assessment and Management
	Pre, Mean (SD)	Post, Mean (SD)	t	P
Assessment skills	2.10 (1.05)	2.53 (1.56)	−1.90	.066
Treatment selection	2.33 (1.01)	2.89 (1.89)	−2.42	.021
Degrees of dyspnea	1.90 (1.07)	3.31 (1.32)	−5.80	<.001

Table 3. Individual Pretest and Posttest Item Analysis
Question/Scenario	Pretest Mean	Posttest Mean	P
Question 1: Does the patient appear comfortable?
Scenario 1: moderate	0.15	0.35	.017
Scenario 2: severe	1.00	0.78	.003
Scenario 3: moderate	0.69	0.67	.771
Scenario 4: moderate	0.85	0.79	.422
Scenario 5: mild	0.26	0.31	.600
Scenario 6: severe	0.75	0.66	.184
Question 2: Degree of assessed dyspnea
Scenario 1: moderate	0.24	0.61	.003
Scenario 2: severe	0.32	0.91	.000
Scenario 3: moderate	0.62	0.59	.812
Scenario 4: moderate	0.51	0.40	.324
Scenario 5: mild	0.21	0.29	.263
Scenario 6: severe	0.09	0.67	.000
Question 3: What is your differential diagnosis?
Scenario 1: moderate	0.28	0.56	.001
Scenario 2: severe	0.09	0.26	.32
Scenario 3: moderate	0.72	0.69	.712
Scenario 4: moderate	0.66	0.69	.712
Scenario 5: mild	0.04	0.13	.162
Scenario 6: severe	0.38	0.44	.488
Question 4: Is symptom management required?
Scenario 1: moderate	0.63	0.78	.134
Scenario 2: severe	1.00	1.03	.324
Scenario 3: moderate	0.91	0.94	.661
Scenario 4: moderate	0.97	1.00	.325
Scenario 5: mild	0.31	0.50	.032
Scenario 6: severe	0.88	0.97	.184
Question 5: Which intervention is most appropriate?
Scenario 1: moderate	0.18	0.48	.002
Scenario 2: severe	0.43	0.66	.009
Scenario 3: moderate	0.16	0.56	.000
Scenario 4: moderate	0.34	0.56	.051
Scenario 5: mild	0.00	0.11	.083
Scenario 6: severe	0.53	0.68	.134

Table 3. Individual Pretest and Posttest Item Analysis

Question/Scenario

Pretest Mean

Posttest Mean

Question 1: Does the patient appear comfortable?

Scenario 1: moderate

0.15

0.35

.017

Scenario 2: severe

1.00

0.78

.003

Scenario 3: moderate

0.69

0.67

.771

Scenario 4: moderate

0.85

0.79

.422

Scenario 5: mild

0.26

0.31

.600

Scenario 6: severe

0.75

0.66

.184

Question 2: Degree of assessed dyspnea

Scenario 1: moderate

0.24

0.61

.003

Scenario 2: severe

0.32

0.91

.000

Scenario 3: moderate

0.62

0.59

.812

Scenario 4: moderate

0.51

0.40

.324

Scenario 5: mild

0.21

0.29

.263

Scenario 6: severe

0.09

0.67

.000

Question 3: What is your differential diagnosis?

Scenario 1: moderate

0.28

0.56

.001

Scenario 2: severe

0.09

0.26

.32

Scenario 3: moderate

0.72

0.69

.712

Scenario 4: moderate

0.66

0.69

.712

Scenario 5: mild

0.04

0.13

.162

Scenario 6: severe

0.38

0.44

.488

Question 4: Is symptom management required?

Scenario 1: moderate

0.63

0.78

.134

Scenario 2: severe

1.00

1.03

.324

Scenario 3: moderate

0.91

0.94

.661

Scenario 4: moderate

0.97

1.00

.325

Scenario 5: mild

0.31

0.50

.032

Scenario 6: severe

0.88

0.97

.184

Question 5: Which intervention is most appropriate?

Scenario 1: moderate

0.18

0.48

.002

Scenario 2: severe

0.43

0.66

.009

Scenario 3: moderate

0.16

0.56

.000

Scenario 4: moderate

0.34

0.56

.051

Scenario 5: mild

0.00

0.11

.083

Scenario 6: severe

0.53

0.68

.134

Using a Dyspnea Assessment Tool to Improve Care at the End of Life

Abstract and Introduction

Abstract

Introduction

Tables

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

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