title: Manoeuvring along the edge of breathlessness: an ethnographic case study of two nurses.
abstract: BACKGROUND
  There appears to be divergence between nurses' and patients' perceptions of dyspnoea onset and on how help should be given. This may affect how nurses understand and assess their patients' anxiety and the severity of dyspnoea, potentially diminishing their chances of relieving patients' dyspnoea. The aim of this study was to explore nurse-patient interaction in situations where patients with chronic obstructive pulmonary disease are experiencing acute or worsened dyspnoea in a hospital setting.
  
  
  METHODS
  An ethnographic study using participant observation of two nurses' interactions with six patients, followed by qualitative in-depth interviews with the nurses. Data were analysed in three steps. First, they were coded for identification of preliminary themes. Second, data were regrouped into preliminary themes for focused analysis which led to formulation of themes and subthemes. Third, hermeneutical principles were used as all data were interpreted from the viewpoint of each theme.
  
  
  RESULTS
  Three themes were identified: Manoeuvring along the edge; Dyspnoea within the pattern; and Dyspnoea outside the pattern. They were encompassed by the main finding: Manoeuvring along the edge of breathlessness. The nurses attempted to navigate between implicit and explicit care approaches and to create a sphere for relieving or avoiding further worsening of dyspnoea. Depending on the identified pattern for a particular dyspnoeic episode, nurses attributed different significance to the dyspnoea.
  
  
  CONCLUSIONS
  Interacting in dyspnoeic situations places nurses in a dilemma: an implicit approach risk, deriving from exclusion of patients and performing hesitantly; or an explicit negotiation risk, where patients are exhausted and removed from focusing and breathing. The dilemma weakens nurses' opportunities to relieve or avoid a worsening of the dyspnoea. Likewise, the divergence between nurses' and patients' assessment of dyspnoea as within or outside the pattern appears to jeopardize the efficiency of care. Our findings contribute to a deeper understanding of the challenges of respiratory nursing care in general, and the challenges of relieving in-patients' dyspnoea in particular.
authors.affiliation: Department of Pulmonary and Infectious Diseases, North Zealand Hospital, Hilleroed, Denmark.
authors.forename: Maria Omel
authors.initials: MO
authors.lastname: Jellington
authors.affiliation: Department of Nursing, Metropolitan University College, Copenhagen, Denmark.
authors.forename: Dorthe
authors.initials: D
authors.lastname: Overgaard
authors.affiliation: Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000 Aalborg, Denmark ; Clinical Nursing Research Unit, Aalborg University Hospital, Sdr. Skovvej 15, 9000 Aalborg, Denmark.
authors.forename: Erik Elgaard
authors.initials: EE
authors.lastname: Sørensen
keywords: Anxiety; Breathlessness; COPD; Chronic obstructive pulmonary disease; Dyspnea; Dyspnoea; Ethnographic research; Nurse–patient interaction; Qualitative research; Respiratory nursing