Basic training in the management of anxiety-related breathlessness Dr Nick Brace, Chartered Macmillan Clinical Psychologist Alison Docherty, Macmillan Occupational Therapist Sharon Thomas, Macmillan Physiotherapist

Background to the project Breathlessness is relatively common in our patients. Frequently associated with increased emotional distress (fear, anxiety, helplessness, even thoughts of death). Distressing for patients, friends and relatives, and staff alike. Evidence for moderate efficacy of full breathlessness training (Cochrane, 2008). Evidence for breathlessness clinic type training. Little around in regard to effects of ‘first response’ training for staff.

Trigger for the training One experience highlighted inconsistent messages from ward staff No training to encourage consistent approach Doing what comes naturally “Breathe deeply” “Breathe slowly” “Take big breaths in” “Just try to stay calm” “Just relax” Use of medication and objective tests

Development of the project Development of training schedule. Roll out the training to all qualified nurses and healthcare assistants on the ward. Evaluation forms for training sessions. Follow-up evaluation of clinical use of training.

The training schedule; topics covered Anatomy of breathing. Reactions. Environment. Communication. Touch. Breathing out. Use of other currently adopted interventions (O2 monitoring and lorazepam).

Initial evaluation of training Questionnaires given to all attendees (n=18). Appropriateness, usefulness, and content of the sessions. Level of understanding before and after the training. Value of any increased knowledge or skills. Open questions allowing free responses. All responses were entirely anonymous. 17 questionnaires returned completed (94%).

Summary of evaluation outcomes Mean ‘appropriateness’ of training was rated 9.82 / 10. Mean ‘usefulness’ of training was rated 9.76 / 10. Self-rated knowledge and skills pre-training 3.94 / 7. Self-rated knowledge and skills post-training 6.71 / 7. 88.2% of respondents rated the content of the sessions as ‘very good’ or ‘excellent’ (11.8% rated as ‘good’). 100% of respondents indicated improved knowledge and/or skills after training. 100% of respondents indicated a ‘great value’ of increased knowledge and/or skills.

Comments on the training Good/helpful/useful. x8 Will improve confidence in handling such situations. x6 Will improve consistency. Positive approach. Anatomy and physiology. x4 Emphasis on exhalation. x3 Best things to say in a situation. Getting down to eye level with patients. Impact of environment. Interesting being asked how I feel in coping with difficult situations.

Suggested improvements Would be better with food and drink. x3 Handout of hints/tips/reminders of what to say/do would be helpful. Slightly rushed due to the busy workload of the nurses involved.

Subsequent discussions… Informally, unsolicited feedback was extremely positive. Several staff reported opportunities to use the strategies discussed in the training, both at work and in some instances with relatives. Numerous spontaneous reports that using these strategies had been easier and proved more effective.

Follow-up evaluation Follow-up questionnaires distributed to all 17 attendees who completed the first questionnaire. 13 questionnaires returned (76.5% response rate) 6/9 nurses responded. 7/8 healthcare assistants responded. Assessed benefits to self and patient. Assessed changes in understanding. Assessed changes in confidence. Assessed specific areas of understanding.

Follow-up evaluation summary Nurse mean response Healthcare mean response Personally beneficial 3.83 / 5 5 / 5 Beneficial to patients 4.17 / 5 Increased understanding 3.67 / 5 Increased confidence

Improvements in understanding? Would you say that since attending the course you have been better able to understand… Yes No Unsure Anatomy of the lungs 10 2 1 Personal reactions 13 Impact of environment Importance of communication Therapeutic use of touch Importance of breathing out

Nurse comments at follow-up Updated/refreshed knowledge or practice. x4 Heightened awareness. Was already aware. Extremely beneficial. Quicker patient response using these methods. Improved confidence that all staff would take the same approach. x2 Improved confidence that I know what to do. x2 Some aspects slightly patronising. Before, I was doing it all wrong.

Healthcare comments at follow-up Beneficial. x3 Now know what to do / increased skills to help. x5 Has improved consistency among staff. x2 More confident in dealing with these problems. x5 Have used training methods to good effect. x4 Did not understand anything about anxiety and breathlessness before the training. Have changed the way I handle these situations.

Conclusions Simple approach. Training generally well received. Evidence of increased knowledge in every evaluation. Evidence of change of practice in follow-up evaluations. Evidence of increased confidence among staff in follow-up evaluations. Positive effects reported on levels of distress among staff.