Routine dyspnea assessment and documentation: Nurses’ experience yields wide acceptance
© The Author(s). 2017
Received: 19 July 2016
Accepted: 12 December 2016
Published: 14 January 2017
Dyspnea (breathing discomfort) is a common and distressing symptom. Routine assessment and documentation can improve management and relieve suffering. A major barrier to routine dyspnea documentation is the concern that it will have a deleterious effect on nursing workflow and that it will not be readily accepted by nurses. Nurses at our institution recently began to assess and document dyspnea on all medical-surgical patients upon admission and once per shift throughout their hospitalization. A year after dyspnea measurement was implemented we explored nurses’ approach to dyspnea assessment, their perception of patient response, and their perception of the utility and burden of dyspnea measurement.
We obtained feedback from nurses using a three-part assessment of practice: 1) a series of recorded focus group interviews with nurses, 2) a time-motion observation of nurses performing routine dyspnea and pain assessment, and 3) a randomized, anonymous on-line survey based, in part, on issues raised in focus groups.
Ninety-four percent of the nurses surveyed reported administering the dyspnea assessment is “easy” or “very easy”. None of the nurses reported that assessing dyspnea negatively impacted workflow and many reported that it positively improved their practice by increasing their awareness. Our time-motion data showed dyspnea assessment and documentation takes well less than a minute. Nurses endorsed the importance of routine measurement and agreed that most patients were able to provide a meaningful rating of their dyspnea. Nurses found the patient report very useful, and used it in conjunction with observed signs to respond to changes in a patient’s condition.
In this study, we have demonstrated that routine dyspnea assessment and documentation was widely accepted by the nurses at our institution. Our nurses fully incorporated routine dyspnea assessment and documentation into their practice and felt that it improved patient-centered care.
KeywordsDyspnea Dyspnea assessment Nurse assessment of dyspnea
Dyspnea is a prevalent symptom in a wide variety of disease states, not limited to cardiopulmonary disorders. Dyspnea is often as distressing as the more commonly experienced symptom of pain. It has been argued that proper management of dyspnea, like management of pain, should be expected as standard of care [1–3]. Routine pain assessment and documentation is nearly universal; dyspnea assessment is not. Barriers to routine dyspnea documentation include concerns that it will have a deleterious effect on nursing workflow and that it will not be readily accepted by nurses . The present study addresses these concerns.
Dyspnea assessment and documentation upon admission and once per shift throughout hospitalization for all medical-surgical patients was recently initiated at our institution. In this study, we explored nurses’ approach to dyspnea assessment, their perception of patient response, and their perception of the utility and burden of dyspnea measurement. Our assessment of practice included a time-motion study, focus group interviews, and a randomized anonymous on-line survey. All studies were approved by the Institutional Review Board (IRB) at Beth Israel Deaconess Medical Center (BIDMC). Our findings provide guidance for other institutions wishing to include dyspnea measurement in routine patient assessment.
Routine dyspnea assessment in clinical practice
Description of study components
Nursing focus groups
Between April and November 2014, a convenience sample of 63 nurses from six medical-surgical units participated in 12 half-hour focus group sessions. Eighty-two percent of the nurses who participated reported having received some educational training on dyspnea and the new dyspnea assessment scale. Focus session data were analyzed qualitatively using standard content analysis methods. Focus groups provided information on which to base a subsequent anonymous survey, as well as provided direct quotations from nurses to illustrate the issues.
A nurse researcher (SD-M) experienced with conducting focus groups asked for the nurses’ views on the following topics: the process nurses used for assessment of dyspnea, importance of dyspnea assessment and awareness, patients’ ability to rate and use the dyspnea scale, impact of routine assessment on workflow, and suggestions for improvement. The nurse researcher explained at the outset that the session was voluntary and that anonymity and confidentiality would be maintained. Research assistants and graduate student nurses attended the meetings and took notes; nurses were identified by number code only. Sessions were also recorded using an audio recorder to confirm verbatim quotations.
Focus group sessions were scheduled 2–3 days in advance in consultation with unit leadership and were held in unit conference rooms during regular work shifts. Nurses attending the focus groups were provided a fact sheet describing the purpose of the session, risks/benefits of participation, and reiteration that participation was entirely voluntary.
An objective measure of the time nurses take to perform dyspnea assessment and documentation is key to understanding workload implications and to compare with nurses’ perceptions of the burden imposed. A total of 40 registered nurses representing the 14 medical-surgical inpatient units were chosen randomly for recruitment. Subjects were provided an information sheet describing the purpose of the study and verbal consent was obtained. All nurses who were asked to be observed for this study agreed to participate. The purpose of the observation was also explained to the patients. No protected patient information was recorded.
Additional feedback was obtained from the nurses using an anonymous on-line survey through REDCap . The survey was sent to 70 nurses randomly selected from the 14 inpatient medical-surgical units, or approximately 10% of clinical nurses employed on those units. Names were selected randomly from the list of nurses on each unit, and the names were sent to nursing leaders on the respective units to ensure these nurses were appropriate candidates for the survey; nurses were not eligible for participation if they were on a medical leave, had been employed less than 6 months, or were per diem status and worked infrequent shifts. A replacement name was randomly selected for each nurse that did not meet eligibility criteria. Reminders to complete the survey were sent by nurse leaders at the institution.
The survey was sent in April 2015 and nurses were allowed 6 weeks to respond; 67 surveys (96%) were completed. Demographics can be found in the online supplement (Additional file 1: Table S1; Additional file 2: Table S2; Additional file 3: Table S3 and Additional file 4: Figure S1 & Additional file 5: Figure S2). The majority of responding nurses (73%) reported they had not attended a research focus group on dyspnea (Additional file 6: Figure S3). Most nurses (67%) reported receiving education on the new dyspnea assessment: of those receiving training, 78% received an informal in-service, 20% received a PowerPoint presentation with question and answer, and 40% received an email announcement (Additional file 7: Figure S4 & Additional file 8: Figure S5).
Effect of routine dyspnea assessment and documentation on practice
Perceived importance of dyspnea assessment and documentation
“Yes, now we compare previous scores and see if there has been an improvement.”
“[Assessing] shortness of breath does assist the medical team to see….changes and help with the management and treatment of our patients.”
“…it can be the first sign of bad things to come.”
“It’s not something I really focused on before, so I think the fact that the tool is there, reminds me to be more attentive.”
“You have patients that look like they are resting easy and you ask them about it [dyspnea] and they say, ‘I’ve felt short of breath for the last 2 days.’ I never would have asked about that before.”
Impact of routine dyspnea assessment on workflow
Nurses overwhelmingly (94%) reported that performing routine dyspnea assessment is “easy” or “very easy” and many (42%) reported that the implementation of q-shift assessment had “positively” or “very positively” affected workflow (Additional file 15: Figure S12 & Additional file 16: Figure S13).
“I feel like it’s always been part of our workflow, I don’t think adding a number takes much more time.”
“It’s just like a motion. It’s part of my routine, now, because we have to document it. It’s part of what I just do, it doesn’t really hinder or make a difference.”
Processes nurses use for assessment of dyspnea
Typically, nurses first asked a patient a Yes/No question, e.g., “are you short of breath?” If the answer was “no”, most nurses skipped asking for a rating and recorded “0” on the flowsheet (Additional file 17: Figure S14 a & b). If ‘yes’, the nurse often proceeded to obtain a patient rating. Nurses commonly use these phrases to explain to the patient what they were supposed to rate: most often “difficulty/trouble breathing” or “short of breath” and less commonly “breathing discomfort” or “can’t catch your breath” (Additional file 18: Figure S15).
“I usually do it after the pain score, if you ask about pain, then give them the scale (0 to 10), then repeat the same thing with the dyspnea rating.”
Patients’ ability to rate breathing discomfort using the 0–10 scale
“I feel people usually get [i.e., understand] shortness of breath. I feel like people give me a more accurate rating of their shortness of breath than of pain.”
“I ask if they have trouble breathing; if yes, then I ask if it is mild/moderate, and then I ask “would you say it is a 5?” Then the patient says yes.”
Nurses’ suggestions for dyspnea assessment
Assess patients for exertional dyspnea
“People tend to not have shortness of breath when they are lying down, but after physical therapy, they have shortness of breath.”
“They might say a ‘3’ [on initial assessment] but when they get up to walk it’s an ‘8’.”
Request for a pictorial scale
Although most nurses found the scale adequate, some suggested that a picture scale, similar to those developed for pain assessment Palos et al. , might help patients use the scale. One nurse remarked in the focus group session, “They [patients] can’t relate it [the number scale] to how they are breathing so I have to coach them [on how to use the scale]. I wish there were pictures like the pain scale or more adjectives.”
Request for systematic observation scale
“The scoring system should ask whether accessory muscles are involved, whether the respiratory rate is greater than normal, etc. There should be physical characteristic assessment questions involved in deriving…the ultimate number.”
“Maybe for a population that can’t speak, we [could] have some other kind of scale, something like the pain scale where you can see clinical [signs], like the FLACC (Faces, Legs, Activity, Cry, Consolability) scale, or looking at a patient, we can give them a number.” (FLACC scale )
Our data show that assessment and documentation of dyspnea took less than a minute of a nurse’s time and the overwhelming majority of nurses reported that it is easy to do. Many considered it an important improvement for patient-centered care.
Nurses understood the importance of routinely measuring dyspnea and were very supportive of using a uniform tool to assess and document upon admission and every shift. Nurses further stated that implementation of routine dyspnea measurement increased their awareness of dyspnea. Our survey showed that nurses endorsed the idea that routine assessment can improve management and relieve suffering in patients. In fact, nurse adherence to the every-shift assessment of dyspnea was 86%, equivalent to reported adherence rates for pain assessment [9–14].
Effect on workflow
Quantitative measurement of dyspnea is not performed routinely at most hospitals. A survey of hospitalists, regarding only patients admitted for acute cardiopulmonary disease, suggested that the addition of dyspnea assessment would “have a significant effect on existing nursing and physician workflows” . However, our data show the majority of clinical nurses readily adopted routine dyspnea measurement on all patients, finding it easy to incorporate the new documentation into their workflow. Routine assessment and documentation did not hinder workflow.
Dyspnea assessment and documentation was easily accomplished by nurses, not just in high-risk patients, but in the general medical-surgical population. Nurses often stated that measurement of dyspnea has always been a part of patient assessment, but the use of a standard tool to assess actually improved workflow and standardized documentation was more easily followed by colleagues.
Why universal assessment?
Nurses reported that a standardized, documented dyspnea rating improved tracking of patient condition. The ability to trend a change in dyspnea over time may provide actionable information on patient clinical decline; lead to early interventions, ascertain whether interventions were helpful, and decrease symptom burden. Dyspnea assessment is of obvious importance in cardiopulmonary diseases and advanced cancer, but all hospitalized patients are at increased risk of cardiopulmonary issues such as pulmonary embolus and hospital-acquired pneumonia. For instance, pulmonary embolism carries a high fatality rate: 4.2% in hospital and 13.8% at 90 days after hospital discharge . These events often occur in patients admitted for non-cardiopulmonary disorders including pregnancy, cancer, surgery, and trauma. There is preliminary evidence that a dyspnea score during hospitalization may be useful for predicting adverse outcomes in patients. Universal dyspnea assessment may reduce the risk that emerging or latent cardiopulmonary issues will be missed.
The problem of symptom vs sign
The value of symptom reports
Expert statements emphasize that patient self-report of symptoms such as dyspnea and pain is the single most reliable measure of symptom intensity [3, 16]. The majority of nurses we surveyed agreed that patients usually give meaningful ratings of both dyspnea and pain. Although pain ratings are much more familiar, nurses have only slightly less faith in dyspnea ratings than in pain ratings (Fig. 8).
Although patient self-reports can provide the best information, they are not a perfect gold standard. Our studies using controlled laboratory stimuli have shown that about 85% of healthy individuals are able to reliably scale respiratory discomfort [17, 18]. There are, however, several reasons that an individual patient’s report of symptoms may not be an accurate reflection of that patient’s primary sensation . We also know that dyspnea, like pain, is a multidimensional experience – when patients are asked to rate pain or dyspnea on a one-dimensional scale, they may focus on (hence rate) different aspects of the experience . There are two recently developed instruments that incorporate multiple dimensions [21, 22]. Such instruments may be useful for follow-up in problematic cases, but single-dimension scales are better suited for the task of routine administration by busy nurses in an acute care setting.
Despite “subjective” distortions, patients’ reports of dyspnea are the best measure of what the patient feels, and they have proven very effective in predicting objective outcomes, particularly predicting survival in patients with chronic obstructive pulmonary disease (COPD), cancer, and cardiac disease [23–27].
Use of signs as a proxy for symptoms
“When the patient is able to report pain, the patient’s behavior or vital signs should never be used in lieu of self-report’ ; this principle also applies to dyspnea . Although this concept was emphasized in training, many nurses reported using their observations of physical signs to modify or replace the patient’s report of dyspnea (Fig. 6). Unfortunately, the structure of our questionnaire does not allow us to understand fully how nurses incorporated their observation of signs with the patient’s symptom report.
Although nurses usually used signs appropriately (in sedated patients or patients unable to understand the concept of numerical rating), they sometimes used signs when they were skeptical about the reliability of patients’ ratings. Studies in which patients’ ratings of current dyspnea have been compared with concurrent physicians’ and nurses’ inference of dyspnea from observed signs have shown poor concordance as indicated by Cohen’s kappa for inter-rater agreement < 0.2 and/or coefficient of determination, r2, <0.2 [28, 29]. These studies show that both nurses and physicians tend to greatly underestimate dyspnea most of the time. Despite poor agreement on the individual level, health care professionals’ estimates are better than nothing at all in the case of the patient who is unable to communicate.
Some nurses asked for a more structured method to infer dyspnea from signs, and one such instrument has recently been developed, the 8-item Respiratory Distress Observation Scale (RDOS) . However, in the only study comparing RDOS scores with unstructured observation, the RDOS did not perform as well as unstructured observation by bedside nurses . Further refinement of the RDOS may improve concordance with patient ratings , and the instrument may help to educate inexperienced nurses and physicians.
Although published studies show a tendency for nurses observing the patient to provide a lower rating for dyspnea than the patient, nurses in our study did not feel that patients were rating their dyspnea “too high” (Fig. 9). The nearly neutral bias in our survey may result from nurses learning to “calibrate” their observations by repeatedly asking patients for dyspnea ratings.
Improving dyspnea assessment
Provide space for reporting observation of signs
Our focus group discussions with nurses suggested that when they used observed signs to inform the documented dyspnea rating, they were not simply ignoring the concept that the patient’s discomfort is what the patient says it is. Rather, the nurses were attempting to report suffering or distress that they inferred from observation when they felt the patient was unable to provide a report, or unwilling to admit suffering. We suggest that a major improvement to the dyspnea assessment process would be to add an optional second scale for nurses to record their observation of respiratory distress based on signs. This would 1) reduce the tendency for nurses to modify the patient’s report, 2) provide additional clinically useful information, and 3) simplify the nurse’s task because s/he would not be forced to decide whether to report symptom or sign.
Nurses should not skip scale after yes-no question
More than half the nurses skipped asking for a numerical rating if the patient denied breathing discomfort in a preliminary yes-no question. This procedure saves a few seconds, but is less than optimal. Binary responses to a query about the presence of a discomfort require the patient to make a decision about how much discomfort merits a ‘yes’ response; an answer of “no” is often given for values above zero on a rating scale. The level of sensation required to elicit a “yes” response is known as the ‘decision criterion’, a phenomenon well known in psychophysics . Our experience is that patients will often follow a ‘no’ response with a non-zero rating. We suggest that if the patient answers ‘no’, that the nurse continues to the scale with a transition such as “Even though you said ‘no’, it would be helpful to us if you could indicate your pain on this scale so that we can track it easily from one time to the next.”
Document exertional dyspnea
During our focus groups, nurses reported that the every-shift dyspnea assessment performed while the patient is at rest does not fully capture patients’ dyspnea during activities, such as rising to use the lavatory or working with physical therapy. Patients experiencing dyspnea limit their activities to minimize symptom burden. Nurses felt that assessment could be improved by capturing patients’ breathing discomfort with various activities throughout the day. The numeric scale is easy to administer both at rest and with activity. We suggest that dyspnea assessment could be improved by measuring breathing discomfort during periods of exertion, and recording the nature of activity that produced the rating – similar to our IPA.
Nurses at our institution feel severe dyspnea should be treated and that an algorithm with possible treatment modalities would be helpful (Additional file 26: Figure S23). An increase in dyspnea can be a warning of worsening condition, so the first response should be to discover the underlying problem, and if possible address it. This is an opportunity for integrated care, and the surveyed nurses reported that physicians took appropriate actions in the large majority of cases (Additional file 27: Figure S24a-f). When underlying causes have been addressed and dyspnea persists, there are effective strategies to alleviate dyspnea, including repositioning, use of a facial fan, providing reassurance, and use of opioid therapy .
The study was conducted at a single academic tertiary care hospital, and may not generalize to all care settings. The questions for the survey were investigator developed and some questions could have been worded differently for improved clarity. For example, the question “do patients give a meaningful number rating for dyspnea?” did not separately account for patients with cognitive impairment. We were unable to capture all information during the focus groups sessions (e.g., nods of agreement). For this reason, the quantitative data in this report rely entirely on the randomized anonymous survey.
Patient self-report has long been the standard for assessment and management of pain. Lack of routine dyspnea assessment and documentation is a barrier to improving management of dyspneic patients. Our data show that nurses endorsed routine dyspnea documentation, and did not find it burdensome.
Dyspnea is an under-recognized and distressing symptom. Prior to our standardization of assessment, dyspnea was documented inconsistently in our hospital. The numeric/word scale, though unidimensional, is fast, patient-focused, and easy to administer at rest or with activity. Dyspnea, like pain, is what the patient says it is and must be treated as such. Nurses caring for patients must promptly assess dyspnea and intervene to minimize this frightening sensation. Only then will we have the ability to relieve suffering and improve patient centered care through symptom management.
Beth Israel Deaconess Medical Center
Clinical nurse specialist
Chronic obstructive pulmonary disease
Faces, Legs, Activity, Cry, Consolability (non-verbal pain scale)
Initial Patient Assessment
- iPAD Mini:
Tablet brand used
Institutional Review Board
Kathy M. Baker (author)
National Institute of Health
Robert B. Banzett (co-author)
Respiratory Distress Observation Scale
Susan DeSanto-Madeya (co-author)
The authors are very grateful to Meaghan Gauthier, Meghan Mahoney, and Rachel Martinez for sharing their experiences of dyspnea assessment and their generous time taking notes during the group sessions. We also thank Heather Bernstein, Dora Huang, Victoria Molina, Robert W. Lansing, Richard M. Schwartzstein, Jennifer Stevens, and Carl O’Donnell for valuable input on survey design and development of the manuscript; Andrew Sheridan for his assistance in preparing this manuscript; the Lois E. Silverman Department of Nursing for enabling and supporting this project; and the unit nurses for their enthusiastic participation.
This project was funded by National Institute of Health (NIH) Grant NR10006, PI Robert Banzett.
Availability of data and materials
All data generated or analyzed during this study are included in this published article [and its additional files].
KMB contributed to the design of all phases of the study, participated in data collection, provided analysis and interpretation of data, and drafted the manuscript. SD-M led the focus group discussions, participated in data analysis and interpretation of the findings, and contributed to the manuscript. RB served as senior author; participated in development of all phases of the study; guided the data analysis and interpretation; and contributed to and provided critical review of the manuscript. All authors read and approved the final draft of the manuscript.
1. Kathy M. Baker, RN, MSN is a Nurse Specialist at the Lois E. Silverman Department of Nursing, Beth Israel Deaconess Medical Center, Boston, MA, USA. Email: Kbaker2@bidmc.harvard.edu.
2. Susan DeSanto-Madeya, RN, PhD is Associate Clinical Professor, Connell School of Nursing, Boston College, Chestnut Hill, MA, USA and Nurse Scientist at Beth Israel Deaconess Medical Center. Email: Sdesanto@bidmc.harvard.edu.
3. Robert B. Banzett, PhD is Associate Professor, Harvard Medical School and Director of the Dyspnea Lab, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center. Email: Rbanzett@bidmc.harvard.edu.
The authors declare that they have no competing interests.
Consent for publication
Ethical approval and consent to participate
Ethical clearance was obtained from the Institutional Review Board (IRB) of Beth Israel Deaconess Medical Center, prior to commencement of the data collection. Ethics committee approval was not required. Participants were informed about the purpose of the study and consent was obtained before conducting the data collection.
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