Developing a nursing approach to managing dyspnoea in lung cancer

Development of nurse-led follow-up in the management of patients with lung cancer

This paper describes the first two phases of an NHS R&D-funded study to develop and evaluate an alternative model of nurse-led follow-up care in the management of patients with lung cancer. Phase I of the study identified the needs of lung cancer patients during their follow-up period of care. This was achieved through observation of outpatient consultations and an audit of patients' medical records. Phase two of the study developed and piloted a nurse specialist-led model of follow-up care. This model moved away from the existing medical one focusing on disease surveillance towards a more patient-centred model responsive to the specific needs of lung cancer patients that were identified during Phase 1. The paper concludes that nurse-led follow-up care of lung cancer patients was demonstrated to be safe, acceptable and appropriately managed. Patients in the study reported positive benefits from a model of care responsive to the experience of, and needs arising from, living with lung cancer.

Association of Descriptors of Breathlessness With Diagnosis and Self-Reported Severity of Breathlessness in Patients With Advanced Chronic Obstructive Pulmonary Disease or Cancer

CONTEXT

Verbal descriptors are important in understanding patients' experience of breathlessness.

OBJECTIVES

The aim of this study was to examine the association between selection of breathlessness descriptors, diagnosis, self-reported severity of breathlessness and self-reported distress due to breathlessness.

METHODS

We studied 132 patients grouped according to their diagnosis of advanced chronic obstructive pulmonary disease (n = 69) or advanced cancer (n = 63), self-reported severity of breathlessness as mild breathlessness (Numerical Rating Scale [NRS] ≤ 3, n = 53), moderate breathlessness (4 ≤ NRS ≥ 6, n = 59) or severe breathlessness (NRS ≥ 7, n = 20), and distress due to breathlessness as mild distress (NRS ≤ 3, n = 31), moderate distress (4 ≤ NRS ≥ 6, n = 44), or severe distress (NRS ≥ 7, n = 57). Patients selected three breathlessness descriptors. The relationship between descriptors selected and patient groups was evaluated by cluster analysis.

RESULTS

Different combinations of clusters were associated with each diagnostic group; the cluster chest tightness was associated with cancer patients. The association of clusters with patient groups differed depending on their severity of breathlessness and their distress due to breathlessness. The air hunger cluster was associated with patients with moderate or severe breathlessness, and the chest tightness cluster was associated with patients with mild breathlessness. The air hunger cluster was associated with patients with severe distress due to breathlessness.

CONCLUSION

The relationship between clusters and diagnosis is not robust enough to use the descriptors to identify the primary cause of breathlessness. Further work exploring how use of breathlessness descriptors reflects the severity of breathlessness and distress due to breathlessness could enable the descriptors to evaluate patient status and target interventions.

WITHDRAWN: Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases

This review is now out of date although it is correct as of the date of publication [Issue 2, 2008]. The authors are developing a new protocol which will replace this review. Publication of the protocol is expected in 2014, and serves to update the existing review and incorporate the latest evidence into a new Cochrane Review. The latest version of this review (available in 'Other versions' tab on The Cochrane Library) may still be useful to readers until the new review is published.

In 2016, the replacement review titled 'Non‐pharmacological interventions for breathlessness in advanced stages of malignant and non‐malignant diseases' was deregistered and split into four separate reviews of individual interventions: Respiratory interventions for breathlessness in adults with advanced diseases; Physical interventions for breathlessness in adults with advanced diseases; Cognitive‐emotional interventions for breathlessness in adults with advanced diseases; Multi‐dimensional interventions for breathlessness in adults with advanced diseases.

At September 2020, these replacement titles were deregistered (Multi‐dimensional interventions) or the protocols withdrawn (Cognitive‐emotional interventions; Multi‐dimensional interventions; Respiratory interventions) as they did not meet Cochrane standards or expectations.

The editorial group responsible for this previously published document have withdrawn it from publication.

Individual experiences and impacts of a physiotherapist-led, non-pharmacological breathlessness programme for patients with intrathoracic malignancy: a qualitative study

BACKGROUND

Non-pharmacological breathlessness management programmes have been shown to be beneficial in the management of lung cancer-related dyspnoea for more than 10 years. What is not so clear is how they work.

AIM

To evaluate how patients with intrathoracic malignancy (lung cancer or pleural mesothelioma) undergoing the non-pharmacological breathlessness management programmes benefited from the programme, using a qualitative methodology.

DESIGN AND SETTING

Consecutive patients completing the programme were invited to be interviewed (semi-structured and audio-recorded) about their experiences of the programme, what had helped them and how. Interviews were transcribed and analysed using interpretative phenomenological analysis.

RESULTS

Nine patients were interviewed. Seven major themes emerged, they are summarised as follows: (1) Mixed prior expectations of the programme, (2) flexibility of delivery and additional support needs, (3) physiotherapist attributes and skills in developing an effective helping relationship, (4) adoption of new techniques, (5) the effects and impact of the programme and new techniques, (6) difficulties and barriers to achieving change and (7) facing an uncertain future beyond the programme.

CONCLUSION

The non-pharmacological breathlessness management programme appears to offer a wide range of benefits to patients, including improving functional capacity, coping strategies and self-control. Such benefits are most likely to be due to a combination of breathing control, activity management and the therapist qualities.

The lived experience of breathlessness and its implications for care: a qualitative comparison in cancer, COPD, heart failure and MND

BACKGROUND

Breathlessness is one of the core symptoms, particularly persistent and frequent, towards the end of life. There is no evidence of how the experience of breathlessness differs across conditions. This paper compares the experience of breathlessness in cancer, COPD, heart failure and MND, four conditions sharing heavy symptom burdens, poor prognoses, high breathlessness rates and palliative care needs.

METHODS

For this qualitative study a purposive sample of 48 patients was included with a diagnosis of cancer (10), COPD (18), heart failure (10) or MND (10) and experiencing daily problems of breathlessness. Patients were recruited from the respective clinics at the hospital; specialist nurses' ward rounds and consultations, and "Breathe Easy" service users meetings in the community. Data were collected through semi-structured, in-depth interviews and participant observation. Breathlessness was compared according to six components derived from explanatory models and symptom schemata, first within groups and then across groups. Frequency counts were conducted to check the qualitative findings.

RESULTS

All conditions shared the disabling effects of breathlessness. However there were differences between the four conditions, in the specific constraints of the illness and patients' experiences with the health care context and social environment. In cancer, breathlessness signalled the (possible) presence of cancer, and functioned as a reminder of patients' mortality despite the hopes they put in surgery, therapies and new drugs. For COPD patients, breathlessness was perceived as a self-inflicted symptom. Its insidious nature and response from services disaffirmed their experience and gradually led to greater disability in the course of illness. Patients with heart failure perceived breathlessness as a contributing factor to the negative effects of other symptoms. In MND breathlessness meant that the illness was a dangerous threat to patients' lives. COPD and heart failure had similar experiences.

CONCLUSION

Integrated palliative care is needed, that makes use of all appropriate therapeutic options, collaborative efforts from health, social care professionals, patients and caregivers, and therapies that acknowledge the dynamic interrelation of the body, mind and spirit.

The lived experience of breathlessness and its implications for care: a qualitative comparison in cancer, COPD, heart failure and MND

BACKGROUND

Breathlessness is one of the core symptoms, particularly persistent and frequent, towards the end of life. There is no evidence of how the experience of breathlessness differs across conditions. This paper compares the experience of breathlessness in cancer, COPD, heart failure and MND, four conditions sharing heavy symptom burdens, poor prognoses, high breathlessness rates and palliative care needs.

METHODS

For this qualitative study a purposive sample of 48 patients was included with a diagnosis of cancer (10), COPD (18), heart failure (10) or MND (10) and experiencing daily problems of breathlessness. Patients were recruited from the respective clinics at the hospital; specialist nurses' ward rounds and consultations, and "Breathe Easy" service users meetings in the community. Data were collected through semi-structured, in-depth interviews and participant observation. Breathlessness was compared according to six components derived from explanatory models and symptom schemata, first within groups and then across groups. Frequency counts were conducted to check the qualitative findings.

RESULTS

All conditions shared the disabling effects of breathlessness. However there were differences between the four conditions, in the specific constraints of the illness and patients' experiences with the health care context and social environment. In cancer, breathlessness signalled the (possible) presence of cancer, and functioned as a reminder of patients' mortality despite the hopes they put in surgery, therapies and new drugs. For COPD patients, breathlessness was perceived as a self-inflicted symptom. Its insidious nature and response from services disaffirmed their experience and gradually led to greater disability in the course of illness. Patients with heart failure perceived breathlessness as a contributing factor to the negative effects of other symptoms. In MND breathlessness meant that the illness was a dangerous threat to patients' lives. COPD and heart failure had similar experiences.

CONCLUSION

Integrated palliative care is needed, that makes use of all appropriate therapeutic options, collaborative efforts from health, social care professionals, patients and caregivers, and therapies that acknowledge the dynamic interrelation of the body, mind and spirit.

Study protocol: Phase III single-blinded fast-track pragmatic randomised controlled trial of a complex intervention for breathlessness in advanced disease

Background

Breathlessness in advanced disease causes significant distress to patients and carers and presents management challenges to health care professionals. The Breathlessness Intervention Service (BIS) seeks to improve the care of breathless patients with advanced disease (regardless of cause) through the use of evidence-based practice and working with other healthcare providers. BIS delivers a complex intervention (of non-pharmacological and pharmacological treatments) via a multi-professional team. BIS is being continuously developed and its impact evaluated using the MRC's framework for complex interventions (PreClinical, Phase I and Phase II completed). This paper presents the protocol for Phase III.

Methods/Design

Phase III comprises a pragmatic, fast-track, single-blind randomised controlled trial of BIS versus standard care. Due to differing disease trajectories, the service uses two broad service models: one for patients with malignant disease (intervention delivered over two weeks) and one for patients with non-malignant disease (intervention delivered over four weeks). The Phase III trial therefore consists of two sub-protocols: one for patients with malignant conditions (four week protocol) and one for patients with non-malignant conditions (eight week protocol). Mixed method interviews are conducted with patients and their lay carers at three to five measurement points depending on randomisation and sub-protocol. Qualitative interviews are conducted with referring and non-referring health care professionals (malignant disease protocol only). The primary outcome measure is 'patient distress due to breathlessness' measured on a numerical rating scale (0-10). The trial includes economic evaluation. Analysis will be on an intention to treat basis.

Discussion

This is the first evaluation of a breathlessness intervention for advanced disease to have followed the MRC framework and one of the first palliative care trials to use fast track methodology and single-blinding. The results will provide evidence of the clinical and cost-effectiveness of the service, informing its longer term development and implementation of the model in other centres nationally and internationally. It adds to methodological developments in palliative care research where complex interventions are common but evidence sparse.

Trial Registration

ClinicalTrials.gov: NCT00678405

ISRCTN: ISRCTN04119516

Managing symptoms in patients with advanced lung cancer during radiotherapy: results of a psychoeducational randomized controlled trial

CONTEXT

Breathlessness, fatigue, and anxiety are distressing symptoms for patients with advanced lung cancer. Usually managed as isolated symptoms, they often can occur simultaneously. Previous research often has addressed management of discrete symptoms rather than considering them as a cluster, which, in reality, is the situation faced by patients.

OBJECTIVES

This study aimed to examine the effectiveness of a psychoeducational intervention (PEI) on the symptom cluster of anxiety, breathlessness, and fatigue, compared with usual care.

METHODS

A pretest/post-test, two-group, randomized, controlled trial was conducted. Education on symptom management and coaching in the use of progressive muscle relaxation were delivered to patients one week prior to commencing radiotherapy (RT), and repeated three weeks after beginning RT. Symptom data were collected at four time points: prior to the intervention, three weeks, six weeks, and 12 weeks postintervention.

RESULTS

One hundred forty lung cancer patients receiving palliative RT were recruited from a publicly funded hospital in Hong Kong. Doubly multivariate analysis of variance revealed a significant difference (time×group interaction effect, P=0.003) over time between the PEI and usual care control group on the pattern of change of the symptom cluster. Significant effects on the patterns of changes in breathlessness (P=0.002), fatigue (P=0.011), anxiety (P=0.001), and functional ability (P=0.000) also were found.

CONCLUSION

PEI is a promising treatment for relieving the symptom cluster and each of the individually assessed symptoms. More effort needs to be directed at studying impact of interventions on common symptom clusters.

Symptom management in palliative care and end of life care

There is a need for generalist- and specialist-level palliative care clinicians proficient in symptom management and care coordination. Major factors contributing to this need include changed disease processes and trajectories, improved medical techniques and diagnostic testing, successful screening for chronic conditions, and drugs that often prolong life. The rapid progressive illnesses and deaths that plagued the first half of the twentieth century have been replaced in the twenty-first century by increased survival rates. Conditions that require ongoing medical care beyond a year define the current chronic illness population. Long years of survival are often accompanied by a reduced quality of life that requires more medical and nursing care and longer home care. This article reviews the management of selected symptoms in palliative and end of life care.

Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases

BACKGROUND

Breathlessness is a common and distressing symptom in the advanced stages of malignant and non-malignant diseases. Appropriate management requires both pharmacological and non-pharmacological interventions.

OBJECTIVES

The primary objective was to determine the effectiveness of non-pharmacological and non-invasive interventions to relieve breathlessness in participants suffering from the five most common conditions causing breathlessness in advanced disease.

SEARCH STRATEGY

We searched the following databases: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, British Nursing Index, PsycINFO, Science Citation Index Expanded, AMED, The Cochrane Pain, Palliative and Supportive Care Trials Register, The Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effectiveness in June 2007. We also searched various websites and reference lists of relevant articles and textbooks.

SELECTION CRITERIA

We included randomised controlled and controlled clinical trials assessing the effects of non-pharmacological and non-invasive interventions to relieve breathlessness in participants described as suffering from breathlessness due to advanced stages of cancer, chronic obstructive pulmonary disease (COPD), interstitial lung disease, chronic heart failure or motor neurone disease.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed relevant studies for inclusion. Data extraction and quality assessment was performed by three review authors and checked by two other review authors. Meta-analysis was not attempted due to heterogeneity of studies.

MAIN RESULTS

Forty-seven studies were included (2532 participants) and categorised as follows: single component interventions with subcategories of walking aids (n = 7), distractive auditory stimuli (music) (n = 6), chest wall vibration (CWV, n = 5), acupuncture/acupressure (n = 5), relaxation (n = 4), neuro-electrical muscle stimulation (NMES, n = 3) and fan (n = 2). Multi-component interventions were categorised in to counselling and support (n = 5), breathing training (n = 3), counselling and support with breathing-relaxation training (n = 2), case management (n = 2) and psychotherapy (n = 2). There was a high strength of evidence that NMES and CWV could relieve breathlessness and moderate strength for the use of walking aids and breathing training. There is a low strength of evidence that acupuncture/acupressure is helpful. There is not enough data to judge the evidence for distractive auditory stimuli (music), relaxation, fan, counselling and support, counselling and support with breathing-relaxation training, case management and psychotherapy. Most studies have been conducted in COPD patients, only a few studies included participants with other conditions.

AUTHORS' CONCLUSIONS

Breathing training, walking aids, NMES and CWV appear to be effective non-pharmacological interventions for relieving breathlessness in advanced stages of disease.

Promoting Enhanced Patient and Family Caregiver Congruence on Lung Cancer Symptom Experiences

PURPOSE/OBJECTIVES

To test the effects of different perspective-taking instructional sets, gender, caregivers' personal histories with cancer, and caregiving relationship factors on family caregiver and patient perceptual agreement of symptom experiences of patients with lung cancer.

DESIGN

Counterbalanced.

SETTING

Thoracic oncology outpatient clinical setting in Canada.

SAMPLE

98 dyads consisting of patients with lung cancer and their family caregivers.

METHODS

Data were collected on a one-time basis by employing an abbreviated version of the Memorial Symptom Assessment Scale targeting lack of energy and worrying. Caregivers were randomized to one of six counterbalanced conditions of perspective-taking instructions.

MAIN RESEARCH VARIABLES

Caregiver discrepancy scores, instructional sets (i.e., neutral, self-report, and imagine-self and imagine-patient perspective-taking), order effects, gender, caregivers' personal history with cancer, and caregiving relationship factors.

FINDINGS

No order effects were found for the instructional sets. Instructions to imagine the patient's perspective over imagining how the caregiver would feel if he or she had cancer were most effective in enhancing the caregiver's ability to estimate the patient's lack of energy and worrying. Gender had no significant effects. The amount of patient-caregiver communication had a positive impact on the accuracy of caregivers' perspectives.

CONCLUSIONS

The patient-oriented instructions had a limited impact on enhancing patient-caregiver congruence on patient symptoms. This likely is related to the study's convenience sample of caregivers who appear to naturally engage in empathic processes of patient-oriented perspective-taking when they assessed and reported on patient symptom conditions.

IMPLICATIONS FOR NURSING

Further exploratory work should identify interpersonal conditions that negatively hamper the effects of caregiver perspective-taking on their reasonable understanding of patient symptoms.

Non-Pharmacological Interventions in Older People with Heart Failure: Effects of Exercise Training and Relaxation Therapy

BACKGROUND

Effective management of heart failure relies on optimal use of non-pharmacological therapy alongside medical treatment. Yet, there is an inadequate use of non-pharmacological therapy in caring for older people with heart failure.

OBJECTIVE

To examine the effects of relaxation therapy and exercise training on psychological outcomes and disease-specific quality of life of older heart failure patients.

METHODS

Subjects undertook relaxation (n = 59), exercise training (n = 32) or received attention placebo (n = 62) for 12 weeks. The relaxation group attended two training sessions, one revision workshop, and continued with twice-daily taped-directed home relaxation practice, with support from the intervener through bi-weekly telephone contact, for 12 weeks. The exercise group undertook 12 weekly sessions of resistance training and aerobic exercise and thrice weekly home exercise. The control group received regular telephone calls for general 'greetings'.

RESULTS

The relaxation and exercise groups reported a significantly greater improvement in psychological [F(2, 149) = 6.69, p = 0.002] and various disease-specific quality of life outcomes [dyspnea: F(2, 149) = 5.72, p = 0.004; fatigue: F(2, 149) = 3.78, p = 0.25; emotion: F(2, 149) = 6.68, p = 0.001], compared with those who received the attention placebo. While relaxation therapy was more effective to reduce psychological distress, with depression in particular (p < 0.001), exercise therapy worked better to control fatigue symptoms (p = 0.03).

CONCLUSION

Relaxation therapy and exercise training are effective to improve the psychological and physical health of older heart failure patients. They should be used as an individual treatment modality, or as care components of a disease management program.

Exploring the experience of weight loss in people with advanced cancer

AIM

This paper reports a study of the experience of and concerns about weight loss described by patients with advanced cancer, their caregivers and nurse specialists.

BACKGROUND

Weight loss is reported to be one of the commonest symptoms experienced by patients with advanced cancer. There is evidence that it can be of concern to patients and their caregivers. However, little is known about why this is the case or how people might be helped to live with the symptom.

METHOD

An exploratory study with a purposive sample of 30 patients, 23 caregivers, and 14 specialist nurses from the South of England was conducted in 2003. The in-depth interviews focused on the experience of weight loss and its management. Interviews were transcribed verbatim, then analysed using an approach informed by Wolcott's framework for qualitative data analysis and Miles and Huberman's 'mixed strategy for cross-case analysis'.

FINDINGS

Concern was experienced when advanced cancer became visible through weight loss. Visible weight loss symbolized proximity to death, loss of control and both physical and emotional weakness. Despite this, weight loss was not routinely assessed by palliative care nurse specialists, who, like others in the patient's social network, respected a weight loss taboo in the belief that little could be done to help people live with the symptom.

CONCLUSION

Weight loss-related concern might be mitigated if clinicians adopted a systematic and proactive approach to the management of the symptom that breaks through the weight loss taboo.

The Relationship Between Meaning of Illness, Social Support, Coping Strategies, and Quality of Life for Lung Cancer Patients and Their Family Members

This article explores the relationship between meaning of illness, perceived social support resources, coping strategies used, and quality of life (QOL) by patients with lung cancer and their family members. The study was cross-sectional using interview data from 85 patients and associated family members. Regression results showed that total QOL in patients with lung cancer is predicted most by meaning of illness, specifically, the illness being perceived as manageable. QOL in family members is predicted most by meaning of illness, specifically, less adverse impact. Interestingly, the overall meaning of illness, coping strategies used, and social support were similar in the 2 groups. The results of the study emphasize the importance of acknowledging the circumstances of people's lives, both patients surviving lung cancer and their family members, which contribute to QOL.

End of life care: a discursive analysis of specialist palliative care nursing

AIM

The aim of this paper is to consider alternative approaches to service delivery for patients with chronic life-limiting illnesses other than cancer. It will also discuss the issues that arise when considering specialist palliative care services within a broader public health context in the United Kingdom.

BACKGROUND

Contemporary specialist palliative care in the United Kingdom can be said to have two main client groups: the majority are people with a diagnosis of cancer, and a minority are those with a number of other chronic illnesses. From the evidence to date, patients dying from chronic, non-malignant disease experience a considerable number of unmet needs in terms of symptom control and psychosocial support. Although debates in the literature over the last decade have challenged the focus of specialist palliative care services on patients with a cancer diagnosis, only a minority of those with other chronic illnesses receive specialist palliative care services.

DISCUSSION

Current models of specialist palliative care may not be the most appropriate for addressing the complex problems experienced by the many patients with a non-cancer diagnosis. We suggest that care should be structured around patient problems, viewing specialist palliative care as a service for those with complex end of life symptoms or problems. A role for innovative nurse-led care is proposed.

CONCLUSION

Reframing the approach to specialist palliative care in the United Kingdom will require great effort on the part of all health and social care professionals, not least nurses. Critical and creative thinking are prerequisites to the development of new models of working. We suggest that a more coherent approach to research and education is required, in particular strategies that explore how patients and nurses can work together in exploring experiences of illness in order to develop more proactive approaches to care.

Palliative care for patients with cancer: district nurses' experiences

AIM

This paper reports a study exploring district nurses' experiences of providing palliative care for patients with cancer and their families.

BACKGROUND

There is an increasing demand for palliative care in the community, as many patients wish to die at home. District nurses are central to providing palliative care in the community, but there is a dearth of literature on district nurses' experiences in palliative care.

METHOD

A Husserlian phenomenological approach was adopted with a purposive sample of 25 female district nurses. Data were collected using unstructured, tape-recorded interviews and analysed using Colaizzi's seven stages of data analysis.

FINDINGS

Four themes were identified: the communication web; the family as an element of care; challenges for the district nurse in symptom management and the personal cost of caring.

CONCLUSIONS

District nurses' experiences of providing palliative care to family units was challenging but rewarding. The emotive nature of the experience cannot be under-estimated, as many district nurses were touched by the varying situations. Whilst acknowledging the need to maintain an integrated approach to care, district nurses should be identified as the key workers in the complex situation of palliative care.

Advanced practice nursing roles: development, implementation and evaluation

AIM

The aim of this paper is to discuss six issues influencing the introduction of advanced practice nursing (APN) roles: confusion about APN terminology, failure to define clearly the roles and goals, role emphasis on physician replacement/support, underutilization of all APN role domains, failure to address environmental factors that undermine the roles, and limited use of evidence-based approaches to guide their development, implementation and evaluation.

BACKGROUND

Health care restructuring in many countries has led to substantial increases in the different types and number of APN roles. The extent to which these roles truly reflect advanced nursing practice is often unclear. The misuse of APN terminology, inconsistent titling and educational preparation, and misguided interpretations regarding the purpose of these roles pose barriers to realizing their full potential and impact on health. Role conflict, role overload, and variable stakeholder acceptance are frequently reported problems associated with the introduction of APN roles.

DISCUSSION

Challenges associated with the introduction of APN roles suggests that greater attention to and consistent use of the terms of the terms advanced nursing practice, advancement and advanced practice nursing is required. Advanced nursing practice refers to the work or what nurses do in the role and is important for defining the specific nature and goals for introducing new APN roles. The concept of advancement further defines the multi-dimensional scope and mandate of advanced nursing practice and distinguishes differences from other types of nursing roles. Advanced practice nursing refers to the whole field, involving a variety of such roles and the environments in which they exist. Many barriers to realizing the full potential of these roles could be avoided through better planning and efforts to address environmental factors, structures, and resources that are necessary for advanced nursing practice to take place.

CONCLUSIONS

Recommendations for the future introduction of APN roles can be drawn from this paper. These include the need for a collaborative, systematic and evidence-based process designed to provide data to support the need and goals for a clearly defined APN role, support a nursing orientation to advanced practice, promote full utilization of all the role domains, create environments that support role development, and provide ongoing evaluation of these roles related to predetermined goals.

Developing advanced clinical skills in the management of breathlessness: evaluation of an educational intervention

The dissemination of knowledge regarding care interventions is often supported through educational initiatives. However, the efficacy of education to make a difference to practice is not always demonstrated. An educational course has been developed and piloted that aimed to educate nurses about skills for the management of breathlessness. The course was developed with, and utilised the expertise of, researchers, practitioners and educators experienced in the management of breathlessness. Twelve clinical nurse specialists, from Scotland and South East England, working in oncology and palliative care, participated in the first course. A longitudinal evaluation was undertaken to consider the impact of the course upon the participants' practice and the care of people who are breathless. Interviews were conducted at two time points and a self-rated familiarity and confidence tool was completed by the participants at three time points. The participants rated themselves as improving their familiarity and confidence with the different aspects of the intervention. Attendance on the course also impacted upon the care of people who were breathless, improving their ability to self-manage their condition. Recommendations for future educational developments of this type are provided.

Guidelines on the role of the specialist nurse in supporting patients with lung cancer

Recently, there has been a significant increase in the number of nurse specialist posts working with patients with lung cancer in the UK. This has been in response to a recognized need to improve lung cancer services. However, there is concern that these posts have been developed quickly with little strategic planning or evaluation. This paper is a collaborative project by the members of The London and South East Lung Cancer Forum for Nurses and aims to offer guidelines to managers and practitioners on areas where improvements may be made in the care of patients with lung cancer. Recommendations are based on Government guidelines, evidence from recent research studies and the experience of the members of the Forum.

Can oncology nurses treat depression? A pilot project

BACKGROUND

Depression is a common problem in all medically ill populations. Reported prevalence rates of major depression in patients with cancer are up to 50%. Cancer patients attending primary care and medical outpatient clinics with comorbid major depressive disorder frequently do not receive effective treatment. More effective ways of identifying and treating patients with both cancer and depression are therefore urgently required.

AIM

The paper reports a study addressing the question of whether oncology nurses can be trained to take on a greater role in the management of major depression in their patients.

METHOD

We developed and piloted an intervention that can be delivered by a specially trained oncology nurse. The intervention is multifaceted and based on a problem-solving model. It requires a widening of the role and expertise of specialist nurses.

DISCUSSION

The challenges this role presents to the nurses are discussed. We suggest that they must have a varied work programme that is not exclusively about managing depression, that they require adequate peer support and are likely to be most effective when working as part of a multidisciplinary psycho-oncology team.

CONCLUSION

We conclude that it is possible to train selected specialist oncology nurses to manage major depression in patients with cancer in the context of an appropriately constituted multidisciplinary team.

Assessing fatigue and self-care strategies in patients receiving radiotherapy for non-small cell lung cancer

Lung cancer represents a major public health problem worldwide (ISD 2000) with approximately 80% of patients presenting with locally advanced or metastatic disease. Treatment is essentially palliative; therefore, symptom management is important. This paper describes the findings from a prospective study of fatigue in newly diagnosed patients with non-small cell lung cancer. Fifty-three patients undergoing radical or high-dose palliative radiotherapy for Stage I, II and III disease were recruited to the study. Patients completed a structured health diary throughout radiotherapy and for up to 1 month post-treatment. Tape-recorded interviews were conducted with a sub-sample (n=11) to explore the nature of fatigue. Complete data sets were available on 46 patients. Consistent with current literature, the study findings demonstrated the progressive nature of this symptom throughout treatment; however, the levels of distress reported and interference with daily living were not found to be as overwhelming in this group of patients as the literature thus far suggests.

Onward in my journey: preparing nurses for a new age of cancer care

Cancer nursing education in the United Kingdom currently is the subject of widespread debate. The imperative to improve cancer care is driven by professional and ethical obligations for clinical excellence and an aggressive political agenda seeking to demonstrate tangible improvements through centrally administered targets and benchmarks. Attempts to provide a holistic approach to care have engendered a range of alternative approaches underpinned by an appreciation of the "cancer journey." Despite the laudable intent of national policy initiatives aimed at improving the experience of cancer treatment, they have evidenced an emerging polarization in the practice arena. Nursing interventions, priorities, and goals are at risk of becoming confused by the competing paradigms of an outcome-driven strategy and a less focused humanistic philosophy of care. This dilemma presents significant problems in the planning of appropriate and effective education preparation for cancer nurses. This article aims to address the tensions produced by a dichotomy between the pragmatics of clinical practice and a professional quest for holism. It focuses on a specialist practitioner cancer nursing program, using case examples to illustrate innovations in teaching and learning. Embracing a postmodern perspective, reflection, and critical thinking, the discussion offers a challenge to diagnostic clinical language through the discursive structures of metaphor, narrative, and story.

Non-pharmacological management of breathlessness: a collaborative nurse--physiotherapist approach

Breathlessness is a common and challenging symptom in palliative care. A simple audit of 470 patients under the St Christopher's Hospice Homecare team found that 43% complained of breathlessness. Research has indicated that non-pharmacological management can be of benefit to terminally ill patients with breathlessness. Knowing that both nurses and physiotherapists each have core skills to offer these patients, the authors aimed to integrate and consolidate their approach to enhance best practice. The supportive care and advice of the clinical nurse specialist was combined with physiotherapy sessions. The aim of this collaborative approach was to reduce patient anxiety, maximize respiratory function and provide information to help patients understand, adapt and regain some control of their breathing. A leaflet containing simple written information for patients was developed and found to be useful. It was found that supportive professional relationships strengthened links between the multiprofessional team. Positive feedback has been received from patients and health-care professionals about the sessions and breathlessness leaflet. By establishing this combined approach the authors have contributed to significant practice development at St Christopher's Hospice.

Research into practice: the reality of implementing a non-pharmacological breathlessness intervention into clinical practice

The work of Corner and colleagues in the non-pharmacological management of breathlessness in patients with lung cancer has aroused considerable interest. Cancer and palliative care nurses are encouraged to incorporate the breathlessness intervention into their clinical practice but this has not always proved easy or straightforward. This paper draws on the authors' experience as lung cancer nurse specialists to explore some of the difficulties nurses in clinical practice may encounter when attempting to translate the research findings into their own areas and suggests ways these difficulties may be overcome.

Improving the management of breathlessness using a clinical effectiveness programme

Breathlessness represents a significant problem for the person with advanced cancer. Uncontrolled breathlessness ranks highly in terms of uncomfortable symptoms experience, causing pain and distress to the patient and resulting in significant anxiety to their carers. The key to the provision of effective care lies in the informed application of the nursing process, underpinned by a sound knowledge base in relation to the nursing management of breathlessness. Theoretical knowledge enables nursing staff to offer appropriate interventions for the management of breathlessness in collaboration with other members of the multidisciplinary team. This article will discuss the cause and management of breathlessness in the person with advanced cancer; the discussion focuses on the application of research-based interventions and the evaluation of clinical outcomes in a UK clinical governance context.

Cancer nursing practice development: understanding breathlessness

This paper considers methodological and philosophical issues that arose during a multi-centre, randomized controlled trial of a new nursing intervention to manage breathlessness with patients with primary lung cancer. Despite including a diverse range of instruments to measure the effects of the intervention, the uniqueness of individuals' experiences of breathlessness were often hidden by a requirement to frame the study within a reductionist research approach. Evidence from the study suggests that breathlessness is only partly defined when understood and explored within a bio-medical framework, and that effective therapy can only be achieved once the nature and impact of breathlessness have been understood from the perspective of the individual experiencing it. We conclude that to work therapeutically we need to know how patients interpret their illness and its resultant problems and that this demands methodological creativity.

Development of a breathlessness assessment guide for use in palliative care

The complex nature of breathlessness in advanced cancer makes it a difficult symptom to understand and control. Measurement instruments applied to breathlessness have thus far failed to consider the multivariant components of this symptom. This study developed a breathlessness assessment guide for use in the clinical practice setting, that may be completed by any member of the health care team. The guide aims to encourage breathlessness to be addressed as a multidimensional problem, in which the emotional experience of breathlessness is inseparable from the sensory experience and the causative biological mechanisms. This guide provides the foundation for understanding the symptom of breathlessness in advanced cancer, and in turn promotes the development of management strategies to deal with this complex symptom.

Nursing, morality, and emotions: phase I and phase II clinical trials and patients with cancer

This article reflects three nurses' views of the moral dimensions of their work in caring for patients receiving phases I and II of cancer clinical trials in a dedicated cancer clinical trials unit (CCTU). The nurses took part in a semistructured, tape-recorded, group interview in which they talked about any aspect of their work that they felt demonstrated its ethical or moral dimensions. The nurses were not employed as research nurses, but had chosen to specialize in cancer and palliative care in a CCTU environment. Three key themes emerged from the interview: being valued and moral distress; caring in a climate of scientific research; and care, cure, and consequences for moral reasoning. Working in an environment suffused with moral conflicts can be painful and damaging for the professionals involved. It would appear that if nurses are to function effectively, they need to be proactive in promoting an exploration of the role that emotions play in moral decision making and in examining the contribution of emotions to what they care about and why. A commitment to a shared understanding and valuing of divergent ethical reasoning in and across professional cultures of care and research paradigms also appears to be necessary. The terms "ethics" and "morals" are used interchangeably throughout this article.

Multicentre randomised controlled trial of nursing intervention for breathlessness in patients with lung cancer

OBJECTIVE

To evaluate the effectiveness of nursing intervention for breathlessness in patients with lung cancer.

DESIGN

Patients diagnosed with lung cancer participated in a multicentre randomised controlled trial where they either attended a nursing clinic offering intervention for their breathlessness or received best supportive care. The intervention consisted of a range of strategies combining breathing control, activity pacing, relaxation techniques, and psychosocial support. Best supportive care involved receiving standard management and treatment available for breathlessness, and breathing assessments. Participants completed a range of self assessment questionnaires at baseline, 4 weeks, and 8 weeks.

SETTING

Nursing clinics within 6 hospital settings in the United Kingdom.

PARTICIPANTS

119 patients diagnosed with small cell or non-small cell lung cancer or with mesothelioma who had completed first line treatment for their disease and reported breathlessness.

OUTCOME MEASURES

Visual analogue scales measuring distress due to breathlessness, breathlessness at best and worst, WHO performance status scale, hospital anxiety and depression scale, and Rotterdam symptom checklist.

RESULTS

The intervention group improved significantly at 8 weeks in 5 of the 11 items assessed: breathlessness at best, WHO performance status, levels of depression, and two Rotterdam symptom checklist measures (physical symptom distress and breathlessness) and showed slight improvement in 3 of the remaining 6 items.

CONCLUSION

Most patients who completed the study had a poor prognosis, and breathlessness was typically a symptom of their deteriorating condition. Patients who attended nursing clinics and received the breathlessness intervention experienced improvements in breathlessness, performance status, and physical and emotional states relative to control patients.

The experience of breathlessness in lung cancer

Breathlessness is a common problem in advanced cancer ranked amongst the 10 most common symptoms in patients admitted to palliative care units. Alongside coughing, it is the most commonly reported symptom in lung cancer. Despite the prevalence of breathlessness, little research has been undertaken on the experience of the symptom, or on the restrictions it imposes on daily life. The data reported in this paper were collected as part of a study piloting new non-pharmacological intervention for patients with breathlessness as a result of lung cancer. Data on the experience of breathlessness from assessment notes recorded by nurses during conversations with 52 patients with lung cancer, were analysed using content analysis. Both physical and emotional sensations were associated with descriptions of breathlessness, such as the feeling of being unable to get enough breath, or of panic or impending death. Breathlessness was only continuous in eight patients, the remainder (85%) had an intermittent pattern of the symptom, usually triggered by exertion or, less commonly, emotion. Numerous restrictions on activity were reported as a result of breathlessness, on functioning inside and outside the home, to social life, and its implications for feelings about oneself. Most patients had attempted to find ways of managing the problems for themselves since, prior to receiving nursing intervention, little or no help had been forthcoming from health professionals.

Teaching a research-based approach to the management of breathlessness in patients with lung cancer

Breathlessness is a common but complex symptom experienced by patients with lung cancer. Corner and colleagues have developed a therapeutic nursing intervention for the management of breathlessness. The Macmillan Practice Development Unit (MPDU) have recently undertaken a multi-centre evaluation of the intervention. The authors were involved in this multi-centre study as clinical practitioners offering the intervention in a randomised control trial. There is strong evidence to suggest that much research fails to influence clinical practice. A commitment to practice development led us to explore the reasons for this research-practice gap. This paper considers the factors that facilitate implementation of research and, in particular, how this applies to the breathlessness intervention. Practitioners need to feel competent in the skills described in the intervention to implement the research findings into their practice. Therefore, we developed a course to teach the breathlessness intervention. A description of the course is presented, together with the theoretical basis for the course design and the tools used to evaluate it.

Developing nursing research with people

This paper explores issues surrounding the role and capacity of research to inform practice. Through a consideration of three research projects undertaken by cancer nurses, some questions concerning nurse-led research and practice development initiatives are raised. Philosophical tenets of collaborative inquiry and action research from the basis of the exploration, articulating the essence of the way in which the research endeavours described, were undertaken. It is an attempt at describing research that moves away from traditional approaches that have so often depersonalised those involved.

Stress and quality of life in the renal transplant patient: a preliminary investigation

End-stage renal disease is a chronic condition which reduces the life-span of its victims. At present there is no cure. Renal transplantation, currently the treatment of choice for many patients, is potentially associated with a number of drawbacks: constant risk of rejection, especially during the first six months, the need to comply with a complex regime of medication capable of producing pronounced side-effects and need for ongoing medical supervision. Despite these problems, little research has been undertake with patients following renal transplantation. The aim of the small-scale, exploratory study reported here was to explore patients' perceptions of stress and quality of life at different stages following a first, functioning renal graft: within six months, between one and five years and over five years later (n = 10 in each group). From the results it became apparent that patients had a number of concerns, of which fear of rejection was the most frequently mentioned, followed by stress generated through altered body image (a product of immunosuppressive therapy). Nevertheless, all reported a significant increase in quality of life after transplantation, although improvement was least marked in patients in the intermediate group (1-5 years after surgery) who also experienced most stress. A larger scale study is recommended to increase the validity of findings which clinicians could then use to design patient interventions to enhance quality of care and quality of life.

Beyond survival rates and side effects: cancer nursing as therapy. The Robert Tiffany Lecture. 9th International Conference on Cancer Nursing, Brighton, UK, August 1996

Survival rates and side effects have become the dominant constructs of cancer treatment and care, to the detriment of more supportive and patient-focused approaches. The concept of quality of life introduced to address this has failed to temper the language of oncology. Here an argument is made for the place of cancer nursing as a therapeutic enterprise in its own right, which warrants much greater recognition. Clear evidence for the therapeutic effects of cancer nursing intervention from a series of meta-analyses of cancer nursing interventions exists. Cancer nursing as therapy has the potential to operate on four levels and can effect radical change by reconstructing care, cancer services, and wider health care environments so that they are much more patient focused and offer nursing therapy as an integral part of care. These include fundamental knowledge or theory generation for therapeutic practice, therapeutic interventions for individuals or problems, developing and changing health systems or environments, or critique and reconstruction of care from a societal perspective. The features of cancer nursing as therapy can be identified and are described. Cancer nurses are encouraged to take up the challenge offered by the concept of therapeutic cancer nursing so that its potential for nurses, patients, and cancer services can be realised.

Nursing as therapy in the management of breathlessness in lung cancer

Breathlessness has been described as an unpleasant sensation, but if it encompasses suffering, as some argue, it is much more than this. Breathlessness is also a major issue for people with cancer. Much of the effort to manage breathlessness has thus far focused on the treatment of underlying causes or on pharmacological strategies. In this paper, broader rehabilitative goals of care and treatment for breathlessness in lung cancer are addressed. Breathing control techniques have been developed to help patients with non-malignant disease to avoid breathlessness at rest or on exertion. A study is described (Corner et al., 1995) which evaluated the effectiveness of breathing retraining and psychosocial support for breathlessness in lung cancer. Breathlessness can be a frightening and powerful experience. It can symbolize a threat to life itself. In these circumstances, the goal of therapy is to alleviate loss of function and to ease the psychological burden that so restricts the individual. An 'integrative' model of breathlessness is discussed, in which the emotional experience of breathlessness is considered inseparable from the sensory experience and the biological mechanisms. Evidence is presented from a small study of the experiences of nurses working in the experimental clinic for breathlessness which suggests that the emotional consequences of breathlessness have a profound influence on how it is managed in practice. Finally, it is argued that symptoms are sometimes generalized too much. Experience is particular, not universal, and an open, accepting and therapeutic approach to managing illness has to be involved with messy and sometimes frightening emotions.