Research
Palliative care and nursing support for
patients experiencing dyspnoea
Ayumi Sugimura, Shoko Ando and Koji Tamakoshi
Abstract
To investigate the association between the type of support provided by
nurses for dyspnoea and palliative care practice in Japan, a
cross-sectional questionnaire survey was conducted in 2015. Of the
535 questionnaires sent to nurses working at 22 designated cancer
hospitals, 344 were returned. The questionnaire assessed the
demographic characteristics of the nurses, nursing support for
dyspnoea, and palliative care practice measured by the ‘Palliative care
self-reported practices scale’. Multivariate analysis showed that the
domains of palliative care practice influenced the provision of nursing
support for patients with dyspnoea. In conclusion, palliative care
practice is important for supporting patients with dyspnoea, and nurses
should possess the requisite knowledge and skills to deliver this care
appropriately.
Key words: l Nursing support l Dyspnoea l Lung cancer
This article has been subject to double-blind peer review
I
n recent years, there has been an overall
improvement of cancer mortality. Lung
cancer has the highest mortality rate among
all cancers in Japan (The Ministry of Health,
Labour and Welfare, 2014). Lung cancer patients
experience various symptoms, including
dyspnoea and fatigue (Sanders, 2010), that are
often distressing both during treatment and in
the terminal stage. Recently, a number of new
diagnostic techniques and treatments have been
developed for lung cancer, but these have made
Sugimura Ayumi, RN, little contribution to alleviating dyspnoea.
MSN, Doctoral Program,
Fundamental and
Dyspnoea is defined as ‘sustained and severe
Clinical Nursing resting breathing discomfort that occurs in
Ando Shoko, RN, PhD,
patients with advanced, often life-limiting illness
Fundamental and and overwhelms the patient and caregivers’ by
Clinical Nursing
American Thoracic Society (Mularski et al, 2013).
Tamakoshi Koji, MD, Dyspnoea causes weakness and fatigue, and places
PhD, Nursing for
Developmental Health
limitations on work and social activities because
of the resulting decreased independence. It also
All at the Department of
increases stress, feelings of helplessness, anxiety,
Nursing, Nagoya
University Graduate loss of control, and fear of death (Carrieri-
School of Medicine
(Health Sciences)
Kohlman and Gormley, 1997; Henoch et al, 2008;
Nagoya, Japan Hashimoto and Kanda, 2011). Lung cancer
Corresponding author:
patients tend to have greater awareness of death
a-sugimura@nagoya-u.jp than patients with chronic respiratory disease
342
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(Dunger, 2015), and have the ‘total pain’, meaning
pain having physical, psychological, social,
emotional, and spiritual components. Common
palliative management strategies for dyspnoea
include medications, oxygen therapy, and non-
drug therapies. Among non-drug therapies, there
has been some noteworthy research on complex
nursing interventions such as breathing training by
nurses (Bredin et al, 1999; Connors et al, 2007;
Hately et al, 2003).
Palliative care has been defined as ‘an approach
that improves the quality of life of patients and
their families facing the problems associated with
life-threatening illness’ (World Health
Organization, 2002). In Japan, the government
established the Cancer Control Act where the
Ministry of Health Labour and Welfare required
all medical staff to engage in the study of cancer
care and basic palliative care.
Palliative care is recommended for lung cancer
patients with a poor prognosis who suffer from
‘total pain’, and it was reported that early
introduction of palliative care for these patients
was effective in facilitating recuperation and
improving quality of life (Temel et al, 2010). It
was also reported that palliative care integrated
with specific lung cancer care improves
recuperation, cancer symptoms, and quality of life
(Higginson et al, 2014; Ferrell et al, 2015), so
palliative care has an important role in the
management of lung cancer.
The available literature on the type of support
nurses provide patients with dyspnoea in Japan
only provides data for local communities or
small geographical areas, so it is difficult to
determine how much support and care patients
actually receive for dyspnoea (Kako and Sasai,
2014; Sugimura and Ando, 2013). The authors
thought that there might be important factors for
nurses to consider in addition to symptom-
© 2017 MA Healthcare Ltd
specific dyspnoea care techniques, such as
palliative care practice, because many lung cancer
patients are affected by both the fear of death
and ‘total pain’. The authors hypothesise that
nursing care for dyspnoea is influenced by the
International Journal of Palliative Nursing 2017, Vol 23, No 7
 Research

Dyspnea in lung cancer patients

Weakness and fatigue Stress and sense of helplessness

Physical support Difficulties of daily and Loss of feeling of

Dyspnea Psychological support
social activity control/anxiety

Increased dependance Fear of death

Decreased self-concept
losing hope to live

Social/enviromental support

Palliative care practice

Dying phase Patient family

Pain Dyspnea Delirium Communication
care centred care

The authors developed this figure based on a previous studies (Hashimoto and Kanda, 2011; Henoch et al, 2008; Carrieri-Kohlman and Gormley,
1997)

Figure 1. Conceptual framework

palliative care practice (Figure 1). The purpose of
this study is to investigate the relationship
between palliative care and the provision of
nursing support for dyspnoea.
Conceptual framework
Figure 1 shows a summary of our hypothesis and
conceptual framework. Dyspnoea causes ‘total
pain’ such as weakness, anxiety, fear of death and
loss of will to live (Carrieri-Kohlman and
Gormley, 1997; Henoch et al, 2008; Hashimoto
and Kanda, 2011); nurses are required to care
and provide support for all these aspects. The
care provided for lung cancer patients with
dyspnoea can be classified into physical,
psychological, and social–environmental care
(Carrieri-Kohlman and Gormley, 1997). Our
hypothesis was that palliative care practice, a
prerequisite for all medical professionals engaged
in cancer care, would be the main factor
© 2017 MA Healthcare Ltd
sent to nurses that explained the aim and
methods of this study and also stated that
returning the questionnaire within 2 weeks
would be taken as consent to participation. This
study was approved by the Ethics Review
Committee of Nagoya University, School of
Health Sciences.
Subjects
The authors selected 100 hospitals with at least
one respiratory medical ward from among 409
designated cancer care hospitals using a random
sampling technique. Of these 100 hospitals, the
authors obtained consent from 22 hospitals. Of
the 535 questionnaires sent to nurses working
the hospitals which consented, 344 were
returned. Data from the questionnaires were
collected only from nurses who routinely
provided in nursing care in a respiratory ward.

underlying nursing support for dyspnoea. Questionnaire

Demographic characteristics
Methods Participants were asked to provide information
A cross-sectional survey was conducted from about the number of years they had worked in
February to April 2015 in Japan. A letter was nursing and the number of years they had worked

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Research
❛Lung cancer Table 1. Demographic characteristics
patients tend to
have a greater Age
awareness of Number of years in nursing
Number of years working in respiratory wards
death than
1–2 years
patients with 3–4 years
chronic ≥5 years
respiratory Education background
disease.❜ Vocational school (2-year course)
Junior college or vocational school (3-year course)
University or graduate school
Certified nurse license
Clinical nurse specialist license
Respiratory therapist license
Uses a clinical guideline for palliative sedation
Attended training in palliative care
Attended training in pulmonary rehabilitation
Number of dyspnea patients cared for in the previous month
The percentages do not add up to 100% due to missing values
in respiratory wards, their age and educational
background, use of a clinical guideline for
palliative sedation, their certification as certified
nurse, clinical nurse specialist and/or respiratory
therapist, whether they had received training in
palliative care or pulmonary rehabilitation, and
the number of patients they had cared for in the
previous month. Certified nurse and clinical nurse
specialist are certifications issued by Japanese
Nursing Association to licensed registered nurses
who have an advanced skill set in a specific field
of nursing.
Nursing for dyspnoea questionnaire
This questionnaire was designed to clarify the
nursing support provided for dyspnoea during
daily patient care. It was developed for the
present study based on a systematic review of the
literature and the results of a previous survey
(Yamaguchi T et al, 2016; Bredin et al, 1999;
Ozalevli et al, 2010; Connors et al, 2007; Hately
et al, 2003). Thirty items were selected and
content validity was confirmed by agreement
among the authors. Each response was rated on a
five-point scale from 1 (never) to 5 (always), and
the total score per care subscale was calculated.
A higher score corresponded to more frequent
performance of nursing for patient with
dyspnoea in clinical practice.
Palliative care self-reported practices scale
The authors used the ‘Palliative care self-reported
practices scale’ to assess palliative care. This scale
can be applied to all health professionals working
344
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mean ± SD n (%)
33.0±9.7
10.5±9.4
3.7.0±2.7
133 (39.8)
97 (29.0)
101 (30.2)
49 (14.9)
189 (52.3)
91 (27.6)
8 (2.3)
4 (1.2)
19 (5.7)
72 (21.6)
158 (47.3)
139 (42.6)
5.3±8.4
in the hospital or home care settings and was
developed to quantify the quality of performance
in providing palliative care. The validity and
reliability of the scale for use in Japan has been
established (Nakazawa et al, 2010). In this study,
the scale was used to evaluate the palliative care
practice of the nurses by measuring the following
six subscales: pain, dyspnoea, delirium, terminal
care, communication, and patient and family
centered care (3 items per subscale for a total of 18
items). The frequency of each item in daily practice
was assessed by using a Likert scale from 1 (never)
to 5 (always), and the mean of each subscale was
calculated according to the guidelines. A higher
score corresponded to more frequent performance
of the recommended practices.
Knowledge and use of dyspnoea
assessment scales
This questionnaire was based on a systematic
literature review and the results of a previous
survey (Dorman et al, 2007). The questionnaire
included items asking about the following seven
scales: Support Team Assessment Schedule-
JSTAS-J), visual analogue scale VAS), numerical
rating scale NRS), modified Borg Scale, Cancer
Dyspnoea Scale (CDS), M.D. Anderson Symptom
Inventory (MDASI), and Hugh-Jones score.
Knowledge of each item was evaluated using a
© 2017 MA Healthcare Ltd
five-point Likert scale. We calculated the total of
the knowledge score (range of the score: 0–35)
and used this as an independent variable. A
higher score indicated greater knowledge of these
dyspnoea assessment scales.
International Journal of Palliative Nursing 2017, Vol 23, No 7
 Research

Table 2. Factor analysis of the nursing support for dyspnea in lung cancer practice scale
n(%)aI I II III IV V Cronbach's
Physical support Psychological Social / a

Breathing Respiratory Adjusting support environmental

control muscle the body support
conditioning position
Breathing with pursed lips 196 (59.8) 0.88 -0.19 0.07 -0.03 0.06
Diaphragmatic breathing 131 (39.9) 0.81 -0.01 0.01 -0.12 -0.04
Squeezing 103 (31.4) 0.68 0.09 -0.03 0.05 -0.01
Pacing breath 112 (34.3) 0.42 0.12 -0.06 0.05 0.06 0.82
Postual drainage 151 (46.2) 0.36 0.12 0.08 0.07 0.12
Sputum expectoration by nebulizer 227 (69.4) 0.32 0.00 0.23 0.11 -0.09
Sputum expectoration by vibration 58 (17.6) 0.31 0.20 -0.10 -0.01 0.24
Massaging respiratory muscles 35 (10.7) -0.07 0.96 0.01 0.05 -0.08
Stretching respiratory muscles 28 (8.5) -0.02 0.94 0.09 -0.11 -0.02 0.76
Facial cooling (with a fan) 36 (10.9) 0.10 0.29 -0.10 0.04 0.20
Adjusting the body position to Fowler's or lateral 271 (82.4) 0.05 0.02 0.83 0.00 0.00
position
Adjusting the body position and using pillows to 283 (86.5) -0.01 0.03 0.77 0.10 0.02 0.77
increase comfort
Selecting loose fitting bed linen and clothing 213 (65.5) 0.09 0.02 0.32 0.10 0.21
Touching 256 (78.0) -0.08 -0.06 -0.02 0.97 -0.06
Talking with the patient to provide reassurance 273 (83.5) -0.06 -0.05 0.07 0.94 -0.09
Being with the patient 224 (68.3) 0.02 0.06 -0.12 0.81 0.03 0.90
Talk slowly and clearly 253 (76.9) 0.01 -0.11 0.06 0.69 0.05
Visiting the sickroom frequently 254 (77.2) 0.07 -0.01 0.07 0.67 0.09
Explaining dyspnea support to the family 132 (40.2) -0.14 -0.07 0.03 -0.08 0.97
Explaining dyspnea to family members (causes, 118 (36.0) -0.03 -0.10 0.05 -0.02 0.82
pathology, and effect on daily activities)
Explaining the importance of spending time with the 106 (32.4) -0.04 -0.02 -0.04 0.02 0.75
patient to family members
Explaining to family members about adapting the 123 (37.4) 0.03 0.04 0.07 -0.13 0.72 0.89
patient's home to facilitate living there
Explaining how to check breathing 148 (45.0) 0.08 -0.10 -0.01 -0.15 0.57
Adjusting the daily schedule to relieve dyspnea 110 (33.7) 0.08 0.07 -0.12 0.08 0.56
Explaining how to control panic attacks 60 (18.6) 0.10 0.21 -0.08 0.01 0.45
Explaining dyspnea to patients (causes, pathology, and 180 (54.7) 0.11 0.03 0.04 0.24 0.45
effect on daily activities)
Adjusting the environment (room temperature, 173 (52.7) -0.10 0.09 0.24 0.04 0.42
humidity, brightness, and noise)
The results are for respondents who gave an answer of 4 or 5..

Statistical analysis school, 3-year course at a junior college or

Data on the demographics of the participants are
presented as percentages and as the mean ±
standard deviation (SD) (Table 1). The scores for
knowledge and use of the assessment scale for
dyspnoea, palliative care self-reported practices
scale and nursing support for dyspnoea were
© 2017 MA Healthcare Ltd
vocational school, and university or graduate
school), participation in palliative care education,
and participation in pulmonary rehabilitation
classes. We also analysed the structure of nursing
support for dyspnoea by factor analysis
(maximum likelihood).

compared by one-way analysis of variance In the present study, we aimed to investigate

among groups categorised according to the factors related to advanced nursing support for
number of years worked in the respiratory ward dyspnoea. Therefore, the subjects were divided
(1–2 years, 3–4 years, or ≥5 years), educational into two groups, which were those in the top
background (2-year course at a vocational quartile of each nursing support score calculated

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Research
❛Training in
pulmonary by factor analysis versus the others outside this
rehabilitation quartile. The odds ratios (OR) and 95%
confidence interval (CI) for being in the top
was not quartile were calculated by multiple logistic
associated regression analysis to identify factors
with greater independently associated with advanced nursing
implementation support for dyspnoea. The following independent
variables were assessed: the number of years of
of breathing experience working in respiratory wards,
control.❜ participation in palliative care education,
participation in pulmonary rehabilitation classes,
knowledge of dyspnoea assessment scale and
performance of palliative care. These items were
found to be significant according to the crude
ORs obtained by univariate analysis or else were
clinically important.
All analyses were performed using SPSS 23.0J
version for Windows software (IBM, NY, USA)
and p<0.05 was considered statistically significant.
Results
Demographic characteristics
We sent questionnaires to 535 nurses working at
22 hospitals, and 344 (64.3%) nurses responded.
Table 1 summarises the background of the
respondents. Their mean age was 33.0 ± 9.7
years, the mean duration of nursing experience
was 10.5 ± 9.4 years, and the mean duration of
working in a respiratory ward was 3.7 ± 2.7
years (Table 1).
Nursing support for dyspnoea
When providing support for patients with
dyspnoea, >80% of nurses chose these practices:
‘adjusting the body position’, ‘oxygen therapy’,
and ‘talking with the patient to provide
reassurance’. In contrast, <10% of nurses
performed ‘aromatherapy’, ‘music therapy’, or
‘stretching respiratory muscles’.
By analysing the ceiling effect and floor effect,
we deleted three items, and finally adopted 27
items from the questionnaire (Table 2). By
performing factor analysis, five practices were
extracted: ‘breathing control’ ‘respiratory muscle
conditioning’, ‘adjusting the body position’,
‘psychological support’, and ‘social-environmental
support’. When reliability was assessed by
calculation of Cronbach’s alpha, all subscales
demonstrated acceptable to excellent reliability
(α= 0.76–0.90).
Palliative care self-reported
practices scale
With regards to palliative care practice, the
highest domain was ‘pain’ and the lowest domain
was ‘delirium’.
346
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Knowledge and use of dyspnoea
assessment scales
With respect to knowledge and use of the various
dyspnoea assessment scales, >50% of the nurses
knew and used the ‘NRS’. In contrast, <20% of
the nurses knew and used any of the other
assessment scales.
Association between nurse
demographics and type of support
Table 3 shows the correlations between
demographic factors and the variables assessed.
The ‘dyspnoea’ domain was lower among nurses
who had been working for 3–4 years (p<0.05),
whereas knowledge of dyspnoea assessment
scales was higher among nurses with university
or graduate school qualifications (p<0.01).
Except for knowledge of assessment scales,
variables showed higher ratings among nurses
who used a clinical guideline for palliative
sedation (p<0.01–0.05). With regard to the
knowledge/use of assessment scales, scores for
the domains of ‘terminal care’, ‘communication’,
and ‘patient and family centered care’, as well as
for implementation of ‘breathing control’
‘respiratory muscle conditioning’, and
‘psychological nursing support’, were higher for
nurses who had attended palliative care training
(p<0.01–0.05). In addition, scores for knowledge
of the assessment scales, the ‘delirium’ domain,
and implementation of ‘breathing control’ and
‘respiratory muscle conditioning’ were higher for
nurses who had attended pulmonary
rehabilitation training (p<0.01–0.05).
Factors influencing nursing support
for dyspnoea
According to logistic regression analysis, higher
performance in the ‘delirium’ domain was
significantly associated with ‘breathing control’
(OR 3.12, 95% CI 1.70–5.73, p<0.001) and was
also significantly associated with ‘respiratory
muscle conditioning’ (OR 1.99, 95% CI 1.15–
3.44, p<0.05). In addition, higher performance
in the ‘communication’ domain was significantly
associated with ‘adjusting the body position’
(OR 2.41, 95% CI 1.04–5.59, p<0.05), while
higher performance in the ‘communication’ and
‘patient and family centered care’ domains was
associated with psychological support for
dyspnoea (OR 2.15, 95% CI 1.01–4.61, p<0.05;
© 2017 MA Healthcare Ltd
OR 3.52, 95%CI 1.65–7.48, p<0.01). Finally,
higher performance in the ‘dyspnoea’ domain
was associated with social–environmental
support for dyspnoea (OR 3.10, 95%CI 1.27–
7.59, p<0.05) (Tables 3).
International Journal of Palliative Nursing 2017, Vol 23, No 7
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Table 3. Factors Related to Nursing Support for Dyspnea

Crude Odds Ratioa) Adjusted Odds Ratioa)
OR OR95% CI P OR OR95% CI P
min max min max
Physical support
Breathing control
Number of years working in respiratory wards 1.01 0.91 1.12 0.812 1.00 0.88 1.14 0.987
Attended training in palliative care (n=158) 0.45 0.25 0.81 0.007 0.57 0.28 1.15 0.115
Attended training in pulmonary rehabilitation 0.41 0.23 0.73 0.002 0.63 0.31 1.28 0.199
(n=139)
Knowledge of dyspnea assessment scalesa) 1.04 0.99 1.11 0.139 0.96 0.89 1.03 0.222
Palliative Care Self‑reported Practices Scale
Pain 2.26 1.32 3.88 0.003 0.77 0.333 1.79 0.539
Dyspnea 2.64 1.64 4.26 <0.001 1.33 0.63 2.79 0.453
Delirium 4.15 2.58 6.67 <0.001 3.12 1.70 5.73 <0.001
Terminal care 3.18 2.01 5.04 <0.001 1.46 0.71 2.99 0.301
Communication 2.90 1.80 4.66 <0.001 0.81 0.36 1.81 0.599
Patient and family centered care 2.99 1.81 4.93 <0.001 1.52 0.69 3.33 0.301
Respiratory muscle conditioning
Number of years working in respiratory wards 1.03 0.94 1.14 0.540 0.96 0.85 1.09 0.521
Attended training in palliative care (n=158) 0.63 0.36 1.08 0.092 1.07 0.56 2.07 0.836
Attended training in pulmonary rehabilitation 0.49 0.28 0.84 0.010 0.65 0.33 1.26 0.201
(n=139)
Knowledge of dyspnea assessment scalesa) 1.16 1.09 1.24 <0.001 1.11 1.03 1.18 0.003
Palliative Care Self‑reported Practices Scale
Pain 1.30 0.82 2.06 0.271 0.67 0.31 1.41 0.288
Dyspnea 1.82 1.19 2.78 0.006 1.26 0.63 2.52 0.508
Delirium 2.57 1.73 3.82 <0.001 1.99 1.15 3.44 0.014
Terminal care 1.91 1.29 2.82 0.001 1.39 0.72 2.71 0.326
Communication 1.75 1.15 2.66 0.008 0.86 0.41 1.80 0.695
Patient and family centered care 1.66 1.08 2.57 0.021 1.02 0.51 2.03 0.967
Adjusting the body position
Number of years working in respiratory wards 0.97 0.87 1.08 0.560 0.95 0.83 1.09 0.482
Attended training in palliative care (n=158) 0.97 0.56 1.70 0.918 1.61 0.78 3.32 0.196
Attended training in pulmonary rehabilitation 0.70 0.40 1.23 0.217 0.75 0.36 1.57 0.444
(n=139)
Knowledge of dyspnea assessment scalesa) 1.09 1.03 1.15 0.004 1.07 1.00 1.15 0.069
Palliative Care Self‑reported Practices Scale
Pain 4.85 2.61 9.00 <0.001 1.41 0.58 3.43 0.449
Dyspnea 4.30 2.51 7.39 <0.001 1.82 0.84 3.84 0.129
Delirium 2.40 1.60 3.59 <0.001 0.83 0.46 1.47 0.512
Terminal care 3.58 2.24 5.74 <0.001 1.31 0.64 2.69 0.464
Communication 5.38 3.12 9.26 <0.001 2.41 1.04 5.59 0.040
Patient and family centered care 3.98 2.34 6.77 <0.001 1.26 0.56 2.82 0.571
a)
The variable represents the total of the knowledge score.

Discussion caring for cancer patients, indicating that the

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In this study, the authors surveyed randomly
selected nurses from respiratory wards throughout
Japan. The mean age of the respondents and the
mean level of nursing experience were similar to
those reported in prior surveys of Japanese nurses
respondents were representative of general nurses
in Japan. Respondents were asked questions about
nursing support for patients with dyspnoea and
their palliative care practice was assessed using a
validated scale.

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Research

Table 3. Factors Related to Nursing Support for Dyspnea (continued)

Crude Odds Ratioa) Adjusted Odds Ratioa)
OR OR95% CI P OR OR95% CI P
min max min max
Psychological support
Number of years working in respiratory wards 0.96 0.87 1.06 0.378 0.93 0.82 1.06 0.250
Attended training in palliative care (n=158) 0.59 0.35 0.99 0.046 0.85 0.44 1.66 0.637
Attended training in pulmonary rehabilitation 0.79 0.47 1.32 0.363 1.45 0.71 2.95 0.305
(n=139)
Knowledge of dyspnea assessment scalesa) 1.08 1.03 1.14 0.003 1.05 0.98 1.13 0.190
Palliative Care Self‑reported Practices Scale
Pain 3.48 2.05 5.91 <0.001 0.88 0.41 1.92 0.751
Dyspnea 2.98 1.90 4.66 <0.001 1.05 0.53 2.04 0.897
Delirium 2.38 1.65 3.45 <0.001 1.03 0.60 1.79 0.906
Terminal care 4.40 2.77 6.99 <0.001 1.52 0.78 2.98 0.219
Communication 6.40 3.78 10.83 <0.001 2.15 1.01 4.61 0.048
Patient and family centered care 8.39 4.63 15.18 <0.001 3.52 1.65 7.48 0.001
Social/environmental support
Number of years working in respiratory wards 0.99 0.89 1.10 0.823 0.92 0.80 1.07 0.273
Attended training in palliative care (n=158) 0.65 0.37 1.13 0.127 0.83 0.39 1.77 0.636
Attended training in pulmonary rehabilitation 0.64 0.37 1.13 0.123 0.79 0.36 1.72 0.550
(n=139)
Knowledge of dyspnea assessment scalesa) 1.10 1.04 1.17 0.001 1.04 0.97 1.12 0.293
Palliative Care Self‑reported Practices Scale
Pain 5.59 3.01 10.40 <0.001 0.87 0.34 2.24 0.769
Dyspnea 8.47 4.54 15.80 <0.001 3.10 1.27 7.59 0.013
Delirium 5.18 3.12 8.59 <0.001 1.88 0.98 3.57 0.056
Terminal care 6.34 3.65 11.01 <0.001 2.18 0.99 4.82 0.054
Communication 6.64 3.75 11.74 <0.001 1.79 0.74 4.31 0.197
Patient and family centered care 4.29 2.50 7.37 <0.001 0.89 0.37 2.16 0.798
a)
The variable represents the total of the knowledge score.

Factor analysis of nursing support caregivers typically only recognise delirium in

for dyspnoea
This study revealed that the range of support
nurses provide dyspnoea patients in Japanese
respiratory wards include: ‘breathing control’,
‘respiratory muscle conditioning’, ‘adjusting the
body position’, ‘psychological support’ and
‘social–environmental support’. Nursing support
for dyspnoea, as found in this study, covered all
aspects of support provided in current clinical
practice, with a confidence coefficient of ≥ 0.76
after items with a factor loading of ≤ 0.4 was
included. Internal consistency of nursing support
for dyspnoea was established.
Physical support for dyspnoea
50% of the patients who develop this symptom
(Fang et al, 2008).The causes of delirium in
terminal cancer patients are complex, so it is
necessary to assess potential contributing factors
at an early stage (Sagawa et al, 2009). Delirium is
also closely related to respiratory failure and
hypoxia (Senel et al, 2015; Lawlor et al, 2000),
so nurses need to provide symptomatic care and
attempt to alleviate the causes. Nurses who were
able to care for patients with delirium could
recognise that dyspnoea was the cause of
delirium, leading to higher implementation of
management for dyspnoea.
However, training in pulmonary rehabilitation
was not associated with greater implementation
© 2017 MA Healthcare Ltd

Breathing control of breathing control, suggesting that such

Higher performance in the ‘delirium’ domain was pulmonary rehabilitation training may not be
significantly associated with ‘breathing control’. reflected in daily nursing care. Further
Delirium occurs in approximately half of all investigation is needed about effective methods
patients with terminal cancer, but professional of breathing control.

348 International Journal of Palliative Nursing 2017, Vol 23, No 7

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Respiratory muscle conditioning
Higher performance in the ‘delirium’ domain
was significantly associated with the
performance of ‘respiratory muscle
conditioning’. Since such muscle conditioning
included massage and stretching of the
respiratory muscles, nurses required expert and
current knowledge and skills for
implementation. In addition, respiratory muscle
conditioning was connected to high care
practice and to knowledge of the assessment
scales. In a previous study (Sugimura and Ando,
2013), nurses who had more knowledge of
assessment scales were more likely to implement
dyspnoea care. In this study, it was found that
knowledge of assessment scales particularly
influenced respiratory muscle care (as part of
dyspnoea care) suggesting that education about
assessment scales could enhance implementation
of dyspnoea care.
Adjusting the body position
Ventilation is influenced by the body’s position
(Lee et al, 2010), and ventilation increases in
Farrar’s position and the sitting position in
comparison with the decubitus position.
However, terminal lung cancer patients have
difficulty in maintaining those positions because
of pleural effusion and bone metastasis, so
nurses need to respond to requests by patients to
adjust the body position. Many lung patients
cannot describe distress by verbal
communication due to dyspnoea (Hashimoto
and Kanda, 2011). This study suggested that
nurses who can understand the distress caused
by dyspnoea will adjust the body position.
Psychological support for dyspnoea
Questions were asked about verbal
communication to relieve anxiety and ‘cognitive’
influences on dyspnoea. Higher performance in
the ‘communication’ and ‘patient and family
centered care’ domains was associated with
providing psychological support. As stated
above, lung cancer patients often cannot
perform verbal communication effectively and
this leads to anxiety that worsens dyspnoea
(Tanaka et al, 2002). Therefore, nurses need to
assess factors that modify dyspnoea by helping
patients recognise dyspnoea as distress.
Thus, better performance with regards to
‘communication’ and ‘patient and family
© 2017 MA Healthcare Ltd
centered care’ would help nurses to understand
the distress and the hopes/fears of patients and
their families, leading to the implementation
of better approaches for supporting and
treating dyspnoea.
International Journal of Palliative Nursing 2017, Vol 23, No 7
Research
Social–environmental support for dyspnoea ❛It is important
Higher performance in the ‘dyspnoea’ domain to provide
was associated with providing social– education about
environmental support for dyspnoea. It is difficult palliative care
to manage the dyspnoea of lung cancer patients in
in addition
the terminal stage (Chiu TY et al, 2004; Ekström
M et al, 2015), since nurses cannot directly treat
to specific
the causes of dyspnoea, pain and fatigue. knowledge and
Therefore, the main interventions performed as techniques
part of palliative care routinely focus on the related to
patient’s distress, and environmental approaches dyspnoea in
such as improving the bedside environment or
order to
social support systems. Social-environmental
support involves providing support for daily
promote better
activities and family care. Therefore, dyspnoea nursing care for
care and palliative care become similar in content, patients.❜
and it is thought that nurses with higher
performance recognised this connection.
Factors affecting nursing support for dyspnoea
Multivariate analysis identified the domains of
palliative care practice that influenced the
provision of support for patients with dyspnoea.
Temel et al. (2010) reported that early initiation
of palliative care by a palliative care team led by
doctors could prolong survival and improve the
quality of life of lung cancer patients. Higginson
et al (2013) revealed that integration of
respiratory care by rehabilitation staff with
palliative care by a respiratory/palliative
physician improved dyspnoea in lung cancer
patients. Therefore, it has been shown that
integration of disease-specific care with palliative
care is important. However, there has been no
research about nursing care.
This is the first study that has revealed the
importance of integrating nursing care with
palliative care. In lung cancer patients, dyspnoea
causes severe distress and awareness of death, and
can promote isolation of patients by affecting
daily activities and communication. Thus, nurses
caring for such patients need to be with the
patients, understand the distress of patient and
family, and ease the patient’s isolation and fear
through direct contact in addition to physical care
such as providing body position adjustments,
respiratory assistance, and environmental
adjustments. To promote appropriate supportive
care for patients with lung cancer and dyspnoea,
we recommend that a new education programme
that include palliative care practice as well as
specific knowledge and skills for dyspnoea
management should be developed to assist nurses.
Conclusion
There were several limitations of this study. First,
data on variables such as nursing support for
349
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Research
dyspnoea and palliative care practice were
obtained through self-evaluation by the
participating nurses, making it possible that
current nursing practice was not accurately
reflected. Second, concerning knowledge of
alternative therapy and psychological care,
availability of appropriate local services may
have influenced the responses.
We clarified an association of palliative care
practice with provision of nursing support for
patients with dyspnoea secondary to lung cancer.
These findings suggested that it is important to
provide education about palliative care in
addition to specific knowledge and techniques
related to dyspnoea in order to promote better
nursing care for patients with dyspnoea. I●
JPN
Declaration of interests
The author have no conflict of interest to declare
Acknowledgements:
The authors would like to thank all of the nurses who
participated in this study. This work was supported by The
Yasuda Medical Foundation.
AS was involved in creating the research concept and
design, data collection and analysis, and drafting the
manuscript. SA advised to the implications on originals and
throughout the research process. KT performed statistical
analysis. All authors approved the final version of the
manuscript.
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