Introduction
Palliative care is very important in the medical practice where some effort is meant to eliminate the symptoms or at least prevent aggravation of the disease. Cancer is a major disease of concern since in most cases treating the disease is usually very hard. It usually presents itself with some critically serious symptoms that pose a threat to the patients. Patients suffer physically and emotionally. Dyspnea is very uncomfortable responsiveness to difficulty in breathing. Such feeling makes the patients feel claudication in the chest and feel breathless. The symptom is very common and very devastating in cancer patients. In the cases of advanced cancer, the purpose of a dependable assessment of the condition, Dyspnea is basically to be able to determine the best and most effective way of managing the perception of breathlessness. Regrettably, the only information and experience that has been used in Dyspnea have been obtained from practical interaction with actual patients with pulmonary disease and in the dearth of knowledge about specific assessments of cancer, yet Dyspnea is a very complex problem.
Background Information and Vocabulary
Dyspnea has been specially defined by the American Thoracic Society as the “subjective occurrence of breathing discomfort that consists of qualitatively different sensations that fluctuate greatly in intensity”. It is a subjective symptom experienced by the individual, rather than a noticeable or measurable sign (Meek, 2004, p 21). Dyspnea can be dominant, incapacitating, and a horrifying personal experience. This is usually presented in a majority of patients with advanced cancer. It has various elements that are required in the definition of the problem. And they include terms like air hunger, suffocation, rapid shallow breathing, and chest tightness (Meek, 2004, p 21). Dyspnea during exertion is the most general presenting complaint about terminal stage cancer patients. It is a subjective and multi-dimensional personal experience among advanced cancer patients; it is a physical abnormality and is affected by psychological, emotional, environmental, and social factors.
The causes of Dyspnea in cancer patients are varied and in some cases, they could be some of the undesirable side effects medications in cancer treatment such as chemotherapy or radiation therapy (Meek, 2004, p. 28). Some chemotherapy interventions result in anemia, pulmonary toxicity, cardiac problems, restrictive cardiomyopathies, and radiation pneumonitis or fibrosis. The causes of dyspnea in cancer patients could also be a result of the progress of cancer itself. For instance, pulmonary parenchymal growth, lymphatic carcinomatosis, obstruction of the pulmonary system by tumor, pericardial effusions, ascites, hepatomegaly, superior vena cava syndrome, and pulmonary leukostasis (Moy, et al, 2000, p. 453) all play a role.
The Dyspnea increases as the cancer stage advances especially if the death is imminent, it can be seen up to 50% – 70% of terminally ill cancer patients experience dyspnea in the last 6 weeks of life and the symptoms aggravated with disease progress (Aharon, et al., 2008, p. 2396). Dyspnea can be a serious barrier not only to normal life but also to other crucial factors of quality life, extended to affect physiological and psychological well-being. Dyspnea is not necessary to be hypoxia or hypercapnia. As with pain, Dyspnea is a combination of sensation and perception, but in contrast to pain, the neural pathways underlying Dyspnea are not well understood. Thus, it brought difficulty in assessing Dyspnea (Moy, et al, 2000, p. 453).
Dyspnea may consist of psychological, emotional, and functional factors among cancer patients. Respiratory distress causes a state of anxiety and even panic, which will increase the intensity of respiratory distress. Therefore the pulmonary function cannot appraise the dyspnea exclusively. An individual’s perception of breathlessness is not only a physical component, but also an affective one, thus the assessment of dyspnea has to be thorough, including the period the disease has lasted, frequency of attack, time of the episode, and the triggering factors (Moy, et al, 2000, p. 453). In general, the triggering factors of dyspnea are either the inherent characteristics of the patient or external factors, such as physical activities including walking; psychosocial factors such as loneliness and concerns to be the burden of loved ones, which affect the state of mind and emotional status, thus increase anxiety; and the environmental factors most likely due to weather change either warm, cold, or windy. There are immediate reactions from dyspnea, including real presenting physical impacts such as body weakness, fatigue, and inactivity. The psychological impacts are manifested in terms of expressive presentation as in stress, anxiety, state of vigilance, dependency, loss of autonomy, hopelessness, social isolation, and negative influence on concentration (Moy, et al, 2000, p. 453.
Management of Dyspnea has to apply the dynamic intervention to incorporate pharmacological, psychological, and social approaches of interventions that are based on individual care plans. Immediate-release opioids such as morphine and the use of oral and parenteral drug therapy have better relief on the intensity of Dyspnea. The respiratory rate and the etiology of drug intervention could be the effect of pain-relieving has to impact on the perception of breathlessness (Viola, et al., 2008, p.336). Oral transmucosal fentanyl citrate appears to be safe and effective for dyspnea in terminally ill patients. Dihydrocodeine also significantly reduces Dyspnea feeling. Oral promethazine may also be used as secondly managing dyspnea in cancer patients. There is no significant correlation between dyspnea and pulse saturation (O’donnell et al 2007, p 147). Nursing-guided non-pharmacologic interventions seem valuable, optimal management will always entail an appreciation of the complex psychosocial and spiritual support with individual counseling. Environment alteration will also help, for example, keep the room cool and well ventilated by using a fan.
Assessment Process
Just like pain, Dyspnea is considered to be a subjective problem and it, therefore, requires patients’ reports as the basis for evaluating whatever is possible. The process of assessments starts by assessing the beginning of symptom presentation (chronic or acute); the frequency, severity, and the factors that exacerbate or alleviate the problem (O’donnell et al 2007, p 147). The effects of the condition are on mood, daily activities, and insomnia, and also appetite. It is also important to consider some of the therapeutic processes that have been used like opioids whether past or those that are used currently (O’donnell et al 2007, p 147). The components involved in the assessments of Dyspnea can be summed as beginning with a past medical history, the physical examination, and emotional assessments. The next step is to carry out the diagnostic processes including CT scan, X-rays, chest function tests, and heart characteristics. Social, emotional, and environmental assessments are all equally important (O’donnell et al 2007, p 147).
The Assessment of Dyspnea Problem
In XXX Heritage Cancer Center, the Quality Oncology Practice program as an initiative (QOPI) was measured quarterly. The data collection is proceeded backwards in time, select charts of Patients who were diagnosed in the past two years, those who died from the invasive malignancy of cancer or cancer intervention in the past six months with the documented date of death (O’donnell et al 2007, p 147). Dyspnea is one of the QOPI measures. Tracking down the QOPI measures in fall 2008, spring 2009, and fall 2009. Here are the reports. In the Fall of 2008, Dyspnea was assessed on second to the last visit before death was 41.18 in 2954 charts; action taken to ease Dyspnea on second to last or last visit before death is 60% in 836 charts; Dyspnea addressed appropriately (combined measure, 42 and 43 is 35.29% in 2954 charts. In Spring 2009, Dyspnea assessed on either of the last two visits before death is 11.76% in 2892 charts; Dyspnea assessed on either of the last two visits before death is 50% in 886 charts; Dyspnea addressed appropriately (defect-free measure, 39 and 40) is only 5.88% in 2892 charts.
In Fall 2009, Dyspnea was assessed on either of the last two visits before death is 35.29% in 3641 charts; Dyspnea addressed on either of the last two visits before death is 55.56% in 1051 charts; Dyspnea addressed appropriately (defect-free measure, 39 and 40) is 23.53% in 3641 charts. In contrast, pain assessment and intervention were well done (Wilcock et al, 2002, p.183). Take a brief look in Fall 2009, pain assessed on either of the last two visits before death is 100% in 3641 charts; pain intensity qualified on either of the last two visits before death is 100% in 2048 charts; plan of care for moderate to severe pain documented on either of the last two visits before death is 91.67% in 1015 charts; and pain assessed appropriately (defect-free measure, 35, 36, and 37) is 97.06% in 3641 charts. As mentioned earlier, pain and Dyspnea are a combination of perception and sensation, but Dyspnea is never assessed very well and intervened appropriately like pain does (Wilcock et al, 2002, p.183).
Purpose of Change Project
The purpose of the change project is to improve the assessment, management, and documentation of dyspnea among cancer patients in St. Jude Heritage Cancer Center. Enhancing awareness and reporting of dyspnea cases among cancer patients, ultimately, improves the quality of life of cancer patients.
Lewin’s three-step Change Theory
There are several change theories including Lippitt’s phases, Prochaska and DiClementer, social cognitive, and Lewins three-step change theory. This paper focuses on Lewin’s theory. He introduced the three-step change model: unfreezing, change, and refreezing. The model is to assist the organization to overcome obstacles and bring an effective change (Bruera et al, 2000, p. 357). His theory of planned change has been widely used in nursing practices.
Step 1: Unfreezing
Identification of the Need for Change
According to Lewin, the first step of trying to impact change is to make out the need for change. Lewin believed that scientific analyses of social phenomena require that both researchers and social planners have a systematic analysis that permits the representation of social forces in a group setting (Wilcock et al, 2002, p.183). First, a comparison was made between Dyspnea and pain assessment and intervention in QOPI measurement, we found out the consistent unsatisfied dyspnea assessment. Second, a comparison between the QOPI measurement in 2008, 2009, and 2010, again, were identified and the problem recognized in dyspnea assessment and management.
“Unfreezing” prevailing equilibrium
Disconfirming current pattern of practice: We searched the possible root causes of insufficient assessment of dyspnea. A systematic analysis in the field, we look at the situation as a whole. We carried analysis that one of the pathways underlying dyspnea is not well understood by nurses and medical assistants. Second, there is a lack of a template for dyspnea documentation. We communicated with medical assistants in the clinic and found out there is no template to automatically document dyspnea, but the pain does have a template to record the 1 – 10 scale, the duration, the relief agents, and the effectiveness of relief agents. So that it is easy to forget inquiring for dyspnea at home or exertion on activities if not presented on the time to the clinic. Moreover, it is not mandatorily required to document dyspnea. Third, the priority and awareness to assess dyspnea in cancer patients are not emphasized.
Some other factors may include limited time to do the complete assessment for medical assistants due to tight appointment scheduling. Furthermore, leadership involvement is needed to improve assessment, management, and document of dyspnea in cancer patients (Dudgeon et al, 2001, p. 95). Dyspnea may not be presented at the time of clinic visiting after sitting in the waiting area for a certain period.
The unwanted behavior by unfreezing the existing condition – dyspnea is not sufficiently assessed and managed among cancer patients. We outlined the benefits of intervention of dyspnea; one is to improve the QQPI score of the dyspnea section, which is important to measure the quality of care in cancer patients. Moreover, the QOPI data is a good advertisement for the organization (Dudgeon et al, 2001, p. 95).
“Unfreezing” prevailing equilibrium
Unfreezing the environment is the first step. It can be done by removing the resistance and some undesirable group conformity. Unfreezing can be succeeded by using three methods. One is to increase the driving force by taking away the unwanted behavior from the current situation. The driving force is to share the QOPI measurement score with staff and verbalize the concerns about improving assessment, documenting, and managing dyspnea. The unwanted behaviors are lacking awareness and low priority in assessing dyspnea in cancer patients. In addition, it is important to ensure that the restraining forces are reduced. This is because they often affect the movement of the prevailing equilibrium in a negative way (Dudgeon et al, 2001, p. 95). Persuading leaders to buy the idea to place a dyspnea template, which will be easier for staff to chart. Make sure to involve and encourage staff to in participate the innovation of the dyspnea template. Thirdly, there is the need to integrate the two aforementioned techniques. Undertaking these activities is to motivate members of the staff in a positive manner ahead of the expected changes. In addition, this also helps in winning their trust as they realize the benefits of change. Consequently, they are more likely to actively participate in the change process (Robbins, 2008, p. 564).
We created the guilt or anxiety by introducing the consequences of not assessing properly about dyspnea in cancer patients. Very often, staff like medical assistants and nurses don’t see that, those patients could be confined in the home and unable to have normal activities even walking will be difficult for them. It is because of the ineffective management of dyspnea. Introducing the case study to staff, which may create anxiety, thus wanting to have a change?
Change or Moving is Lewin’s Next Step
Lewin’s next step in the process of altering behavior is action. In this step, it is Important to implement new ideas, values into the system by moving the problem area to the new level of equilibrium. Three actions that can assist in this step, one is persuading nurses to look at QOPI measurement score, it is the existing problem and consequences to the cancer patients for insufficient assessment, management, and document of dyspnea. Encouraging staff to view the problem from a fresh perspective, Journal Club was held to introduce the research articles about dyspnea in definition, causes, triggering factors, consequences, management, and outcomes.
The QOPI data of dyspnea was introduced by the Clinical Nurse Specialist (CNS) initially, then brought this information to the nurses, and consulted ling navigator. The issue of lacking a template could be the root of the problem. Mandatory recording the dyspnea can be a short-term goal. However, the dyspnea template program placement will be the long-term goal; it will bring permanent change and increase the performing of assessment of dyspnea. The resistance to change will be also decreased if it is convenient to record and not required much time-consuming work. Third, introduce the views of needed change in improving assessment and management of dyspnea to the cancer center manager. The CNS, lung navigator, and charge nurse may work together to create the best solution for short-term and long-term to improve the dyspnea assessment and management. The short-term goal could be carried out by implementing the rule of recording manually about dyspnea. It can be done by reinforcing the rule thru staff monthly meetings.
The lead nurse can educate the medical assistants with the basic knowledge of how to assess and record dyspnea. But, the long-term goal is to create a workable template. Again, CNS and lung navigators are the ones to get the leader of the cancer center to buy this idea. Then the leader can ask the computer engineer to work with CNS and lung navigator to produce the dyspnea template in the computer system. The leader may approve the change finally once the dyspnea template is formed. It will be the Permanent implementation to document assessment and intervention of dyspnea in cancer patients.
Step 3. Refreezing
The third step of Lewin’s three-step change model is refreezing. This step needs the change that has been implemented already. In this step, it is the actual process to integrate the new behavior into the tradition of the practice. The assessment and management will be the routine once the permanent charting tool – the template is available.
Actions can be taken in the refreezing process getting new rules to reinforce new patterns and institutionalize them through formal and informal mechanisms including policies and procedures is mandatory charting dyspnea.
Lewin’s model illustrated the effects of forces that either promote or inhibit change. Interestingly, driving forces promote change while restraining forces against change. The change will occur when one of the forces is greater than the other force (Robin, 2008, p. 564). Effective assessment and management of dyspnea will happen in place once the change force exceeds the resistance due to a comfortable level of staff for change and desire to improve the QOPI score, ultimately, improve the quality service and thus improved image and attract more patients into the cancer center (Hallenbeck, 2005,p. 2274).
Strategies of Implementation
- Journal Club for nurses. We introduced the research articles on dyspnea to a group of nurses. We had a successful and interesting discussion about dyspnea. As Lewin’s theory, unfreezing can be done by education and thus softening the resistance. In addition, group-carried changes work better than individual approaches.
- Educational poster and flyers to medical assistants and nurses. This is the application of unfreezing the environment and preparing them for change (Hallenbeck, 2005,p. 2274).
- Involve lung navigator and CNS, the gatekeepers to change, such as implement the template for effective assessment, document, and management of dyspnea. The gatekeepers are the ones to persuade the leader to buy the idea and staff the follow the change (Hallenbeck, 2005,p. 2274).
Prospective Outcome
We look at the QOPI data of spring 2010 in the cancer center, dyspnea is not documented which is 67.65% in 23 cases. In that, 2 cases have no dyspnea, the rate of no dyspnea is 5.88%. However, the rate of having dyspnea is 26.47% in 9 cases. The good news is the 9 cases with documented dyspnea, which was treated at the rate of 88.89%. In conclusion, we see the importance of assessment and documentation of Dyspnea (Hallenbeck, 2005, p. 2274).
The implementation of the template will be the final goal to make this change permanent and successful. The template will be left to the gatekeepers-lung navigator and CNS to continue work on and the leader of the cancer center to place the template eventually within two years. If for any reason the template is not able to be placed in the current computer system, a simple note or addendum of dyspnea may be introduced by CNS and lung navigator to the leader of the cancer center. The leader can then make the rule of recording dyspnea, meanwhile, set the expectation of achievement by following up the QOPI measurement score in the dyspnea section. On-site job education to medical assistants and nurses has to be held regularly to continue improving the quality care of cancer patients especially recording and managing dyspnea.
The potential for success of this planned change will happen eventually in about one year with QOPI measurement score, navigator and CNS involvement, and leadership attention. Moreover, it will improve the quality of life in these cancer patients. Whether assessment, management, or document, their goal is to give the cancer patients the remaining time as comfortable as much can be.
The factors that will enhance the achievement of this project will be to get the staff to actively participate in the change project. First is increasing awareness of dyspnea assessment. The second is showing positive outcomes which will be the improved QOPI score to staff and management team. Third, encourage anticipation and give input on how this change process will take place.
The factors will distract from the achievement of the identified plan of change. One is staff may see this change will increase their workload. Secondly, the leadership cannot visualize the change effect which will benefit the organization in the quality of care of cancer patients, thus improving the image of the organization among top cancer centers.
Reference List
Aharon, I. B. (2008).Interventions for Alleviating Cancer-Related Dyspnea: A Systematic
Bruera E, et al. (2000). The frequency and correlates of dyspnea in patients with advanced cancer. J Pain Symptom Manage, 19 (5): 357-62.
Dudgeon, D.J.et al (2001). Dyspnea in cancer patients: prevalence and associated factors. J Pain Symptom Manage, 21 (2): 95-102.
Hallenbeck, J. (2005). Palliative Care In The Final Days Of Life: They Were Expecting It At Any Time. JAMA, 293(18): 2265 – 2271. 2005
Meek, P.M (2004).Measurement Of Dyspnea In Chronic Obstructive Pulmonary Disease: What Is The Tool Telling You? Chronic Respiratory Disease, 1(1): 29 – 37.
Moy, E et al. (2000). Quality Of Dyspnea In Bronchoconstriction Differs From External Resistive Loads. Am. J. Respir. Crit. Care Med., 162(2): 451 – 455.
O’donnell, DE et al. (2007). Pathophysiology Of Dyspnea In Chronic Obstructive Pulmonary Disease: A Roundtable. Proceedings Of The Ats, 4(2): 145 – 168. Review. JAMA. 299(14):1698-1709
Review.Journal of Clinical Oncology, 26(14): 2396-2404
Wilcock A, et al.(2002). Descriptors of breathlessness in patients with cancer and other cardiorespiratory diseases. J Pain Symptom Manage, 23 (3): 182-9.
Zimmermann, C. (2008). Effectiveness of Specialized Palliative Care, A Systematic.