Nursing Interventions for Fatigue in Patients With Cancer,Research Proposal Example

Abstract

Patients who have been diagnosed with cancer face a number of critical challenges during the treatment and recovery phases. In particular, cancer treatments often wreak havoc on organs and body systems and cause a variety of symptoms. As a result, many cancer patients seek relief from the harsh nature of these symptoms and look for guidance from health professionals regarding symptom management and alleviation through various techniques and strategies. Cancer-related fatigue is of critical concern for many cancer patients and may create challenges in maintaining a comfortable routine. A number of techniques have been proven effective in relieving cancer-related fatigue, including a regular exercise routine. It is important for nurses and other care providers to offer recommendations and strategies for reducing cancer-related symptoms and fatigue, including a comprehensive evaluation of exercise as a positive influence in the lives of cancer patients. A research study considering the role of exercise and its impact on fatigue in cervical cancer patients will also be considered.

Statement and Significance of the Problem

Cancer patients experience a number of limitations and setbacks during the treatment phase which limit the recovery process. Many cancer patients are able to recover from this condition, depending upon its stage of development, its location, and the general health of the patient. Although cancer treatments are designed to improve health by destroying cancer-causing cells, many of these treatments have a number of significant side effects, such as nausea, vomiting, hair loss, and extreme fatigue. The latter will serve as the focus of the following discussion and will emphasize exercise and other related techniques in order to improve post-treatment fatigue for cancer patients. Prior studies indicate that there are a number of benefits associated with exercise and other interventions during the cancer treatment phase as a means of alleviating fatigue and other symptoms. In general, the quality of life for many cancer patients is improved with an increased level of physical activity and in reducing symptoms (Humpel and Iverson, 2010). Many research studies demonstrate the need for routine evaluations of patients undergoing cancer treatments so that their symptoms are better managed and alleviated as much as possible. Nurses play a critical role in this process in advising and guiding patients regarding education-based directives and other interventions which are designed to facilitate positive outcomes for cancer patients undergoing these treatments.

Literature Review

Prior research in the areaof cancer treatment demonstrates that there are a number of different factors which influence cancer patients during the treatment phase, including a myriad of side effects, some of which are more serious in nature. The impact of these symptoms is significant for many patients and represent a challenge that requires further evaluation and possible interventions. It is important to evaluate symptoms during and after cancer treatments in order to improve outcomes for patients by using a variety of resources, including education and various techniques which are designed to alleviate these symptoms as best as possible. The following paragraphs will address some of the most relevant research studies which provide evidence of the impact of education and other interventions designed to reduce the negative impact of cancer treatments for this patient population.

In general, many cancer treatments impact the quality of life of these patients and may limit emotional wellbeing (Williams et.al, 2011). A pilot study evaluated the impact of an intervention conducted by nurses to improve symptom management, and it was determined that this strategy is effective in reducing symptoms and in improving the quality of life for many cancer patients (Williams et.al, 2011). In particular, follow-up in the form of face-to-face discussions and telephone conversations were useful in alleviating symptoms for many patients, as they recognized how to better manage these symptoms in the home environment (Williams et.al, 2011). Oncology nurses play a critical role in providng patient education to reduce symptoms by using checklists, technology-based solutions, and telephone calls to promote patient wellbeing (Williams et.al, 2011).

Another study by Purcell et.al (2010) evaluated the benefits of CAN-FIT, an educational program for cancer patients with fatigue to determine if participation was beneficial in alleviating fatigue. The study indicated that the CAN-FIT program was effective in providing additional insight regarding fatigue and its triggers, as well as in reducing the level of anxiety related to fatigue for some participants (Purcell et.al, 2010). A group environment is beneficial to some patients and provides additional support as patients recognize that they are not alone and that many others experience the same symptoms (Purcell et.al, 2010). A discussion of specific symptoms and their impact on the body is beneficial to patients and is likely to reduce anxiety of the unknown and other perceptions regarding cancer (Purcell et.al, 2010).

Patients who suffer fatigue as a result of cancer treatments and must find ways to reduce this fatigue to improve the quality of their lives. Fatigue associated with cancer is difficult to manage in many patients, as it is often unpredictable yet likely to occur (Johnson and Matzo, 2012). According to The National Comprehensive Cancer Network (NCCN), fatigue is “a distressing, persistent, subjective sense of physical, emotional and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning” (Johnson and Matzo, 2012, p. 57). This complication of cancer is the most difficult symptom to manage for the majority of these patients (Johnson and Matzo, 2012). Therefore, an effective management tool for cancer-related fatigue must be identified in order to improve patient wellbeing and quality of life, which may included an organized educational program designed to improve symptom management (Johnson and Matzo, 2012). However, another study by Purcell et.al (2011) refutes this premise in stating that fatigue is not necessarily reduced by educational interventions, but that activities should be evaluated and adjusted to reduce or eliminate those factors which contribute to existing fatigue. It is believed that understanding outcomes associated with current activities is more relevant than the fatigue itself, because these activities can be adjusted accordingly (Purcell et.al, 2011).

For cancer patients experiencing fatigue, nursing practice guidelines must incorporate interventions for these patients which focus on activity-based approaches (Hilarius et.al, 2011). It is recommended that cancer-related fatigue (CRF) should be evaluated in the following manner: “Integrating the assessment of commonly experienced symptoms such as fatigue into daily clinical practice may have important implications for improving symptom management” (Hilarius et.al, 2011, p. 537). With this framework, nursing practice guidelines will better assess and evaluate cancer-related fatigue and focus on the appropriate areas of management, including activity-based modifications as needed (Hilarius et.al, 2011). With this framework, conditions are likely to improve when patients are provided with tools to better recognize which activities might trigger fatigue so that these activities are either eliminated or modified to reduce fatigue (Hilarius et.al, 2011).

A study conducted by Barsevick et.al (2010) evaluated the impact of an intervention for “energy and sleep enhancement” to alleviate fatigue and improve overall health and wellbeing. The study results demonstrated that fatigue is not the only symptom of chemotherapy and that interruptions to sleep are also common (Barsevick et.al, 2010). However, the intervention did not provide any real benefits and actually increased the level of fatigue and sleep disturbance for this patient population (Barsevick et.al, 2010). This evidence demonstrates that some interventions are not necessarily sufficient to have an yrealized impact on fatigue and other symptoms, particularly for patients undergoing chemotherapy, due in large part to its harsh outcomes (Barsevick et.al, 2010).

Von ah et.al (2011) evaluated existing studies in order to determine how cognitive impairment is impacted in cancer patients. According to the article, “Cancer and cancer treatment-related cognitive impairment has been reported to significantly impact the functional abil­ity and quality of life of cancer survivors “ (Von ah et.al, 2011, p. 608). Therefore, in order to better manage this symptom., a team of nurses was recruited to evaluate existing literature and make recommendations regarding cognitive impairment and its impact on cancer patients (Von ah et.al, 2011). Upon review of the literature, it was determined that there are a number of options to consider in improving the management of cognitive impairment and in reducing its prevalence, including exercise, cognitive training, and pharmacologic approaches (Von ah et.al, 2011). Nurses must take these alternatives into consideration when formulating approaches to improve cancer-related symptoms (Von ah et.al, 2011).

Another study by Hayama and Inoue (2012) considered the impact of deep breathing techniques on chemotherapy patients, as this technique has been proven effective in other areas (Hayama and Inoue, 2012). The study indicated the following: “even during rounds of chemotherapy, a nurse can spend just a short time with the patients and assist them in their deep breathing. In addition to the usual care they provide, our results suggest that nurses can contribute to reducing the ‘tensioneanxiety’ and fatigue experienced by patients undergoing chemotherapy by assisting them in performing deep breathing” (Hayama and Inoue, 2012, p. 97). These results are important in providing further evidence that deep breathing may serve as an effective tool in improving the outcomes associated with chemotherapy and even during the process itself because it may cause extreme stress and anxiety in some patients (Hayama and Inoue, 2012). It is important for nurses to consider deep breathing as a component of their intervention methods, particularly for patients undergoing chemotherapy due to its important benefits on relaxation and in calming nerves (Hayama and Inoue, 2012).

Many studies address the influence of exercise on cancer-related fatigue for this population group. There are a number of issues to consider which reflect the challenges of cancer-related fatigue and whether or not exercise is effective in alleviating this symptom. Several studies will be explored in the following paragraphs to provide evidence regarding exercise and its impact on cancer-related fatigue in different forms.

Fatigue in cancer patients is best managed through an intervention which includes a carefully planned exercise regimen (Arnold and Taylor, 2011). According to Arnold and Taylor (2011), “Systematic reviews have found that home-based, moderate-intensity aerobic exercise programs can reduce fatigue and improve cardiorespiratory fitness during and after cancer treatment” (p. 165). These findings suggest that “Exercise breaks the cycle of cancer-related fatigue by improving functional capacity, resulting in reduced effort required for physical activities and an improvement in the perception of fatigue” (Arnold and Taylor, 2011, p. 165). Nurses play a role in assisting patients in developing a carefully evaluated exercise program so that they are able to manage their bouts of fatigue more effectively and without significant consequences (Arnold and Taylor, 2011). The study also recommends that regular exercise is the preferred method over excessive periods of rest because this type of rest leads to decreased cardiorespiratory activity and muscle wasting for many patients, which has many severe disadvantages for this patient population over the long term (Arnold and Taylor, 2011).

A study by Windsor et.al (2009) considers the implementation of an education program and exercise routine to reduce fatigue prior to and after cancer treatment. The study results demonstrate that those who received education during the treatment phase were more likely to participate in a regular exercise program and to experience reduced levels of fatigue; however, those with more advanced cancer diagnoses or requiring chemotherapy were less likely to exercise and subsequently experience higher levels of fatigue (Windsor et.al, 2009). Therefore, the ability to have sufficient energy to exercise during cancer treatment is likely to reduce fatigue levels for those patients who make this choice (Windsor et.al, 2009). This study is relevant because providing information and guidance regarding exercise for this patient population is likely to spark interest in this activity and could potentially reduce fatigue for many patients (Windsor et.al, 2009).

Many cancer patients seek methods to reduce the incidence of fatigue and manage this symptom more effectively. This is a difficult challenge for many patients because they are perhaps fearful of their condition and are afraid to take any risks, even if they could potentially improve their symptoms. Therefore, many cancer patients lead sedentary lifestyles and do not participate in routine exercise (Blaney et.al, 2010). There are a number of barriers to consider, including a lack of motivation to exercise, limited physical strength, limited social contact, and environmental conditions (Blaney et.al, 2010). These factors play an important role in how cancer patients perceive the role of exercise in their lives; therefore, interventions must be conducted which include supervised exercise coaching for individual patients to improve motivation and strength over time (Blaney et.al, 2010).

For many cancer patients, exercise is thought to be beneficial in reducing fatigue and useful in reducing the symptoms associated with chemotherapy (Mock et.al, 2001). In one study, patients who exercised on a regular basis experienced fewer bouts with nausea and an increased level of physical stamina (Mock et.al, 2001). In addition, these patients also experienced psychological benefits which improved their overall health and wellbeing, in spite of their cancer treatements (Mock et.al, 2001). There are a number of existing studies which support the argument that exercise as a whole has primary benefits for patients with cancer because there is a greater likelihood of fatigue reduction over time (Mock et.al, 2001).

A study conducted by Velthius et.al (2010) evaluated the impact of exercise on fatigue for 150 breast and 150 colon cancer patients. A combination program which included strength training and aerobic activity was introduced to these participant groups in order to measure levels of fatigue, quality of life, and other related outcomes (Velthius et.al, 2010). A study of this nature is comprehensive because it provides further evidence that patients arelikely to benefit from routine exercise regimens in order to achieve improved physical health and well being, in spite of a cancer diagnosis and strict treatment regimen (Velthius et.al, 2010). Similarly, a study conducted by Chou et.al (2012) evaluated exercise in the lives of breast cancer patients at differnet stages prior to and after treatment to determine outcomes. The study determined that “the longer patients can maintain exercise behaviors, the greater the overall benefit; there­fore, future research should explore innovative and patient-friendly approaches to help patients integrate exercise in daily life and sustain a targeted exercise goal” (Chou et.al, 2012, p. 96). Furthermore, for women with breast cancer, “clinicians should encourage patients with breast cancer to start exercise at the beginning of chemotherapy treatment and con­tinue for as long as possible” (Chou et.al, 2012, p. 96). This information is relevant to the discussion of exercise for cancer patients because it supports the reduction of fatigue for these patients and improves the quality of life (Chou et.al, 2012).

For many patients with breast cancer, fatigue is one of the most significant side effects of treatment (Dirksen et.al, 2009). For early stage breast cancer patients, there are particularly challenging concerns associated with fatigue for up to six months after surgical treatment (Dirksen et.al, 2009). It is believed that fatigue may be part of a larger group of symptoms which impact this patient population and should explored in the form of a “cluster” to improve patient outcomes (Dirksen et.al, 2009). Nurses in practice should consider how groups of symptoms are often associated because treatment options and the alleviation of symptoms may be improved to accommodate these groupings (Dirksen et.al, 2009). Common symptoms to consider with fatigue include, depression, anxiety, and insomnia;t herefore, this group of symptoms should be evaluated concurrently as a means of improving outcomes for breast cancer patients (Dirksen et.al, 2009). Nurse researchers should also consider the impact of cytokines on these symptom groupings because they may have a direct impact on fatigue as related to cancer (Dirksen et.al, 2009). It is necessary for nurses to evaluate patients with these symptom groupings in mind so that all possible concepts are explored in treating patients in an effective and efficient manner that will improve their quality of life and general physical health over time (Dirksen et.al, 2009).

The study of cancer-related fatigue also represents an opportunity to improve outcomes for patients at various intervals after cancer treatments have begun (Goedendorp et.al, 2010). In general, “When patients are diagnosed with cancer, their activity pattern changes and they become physically less active, possible leading to deconditioning…This is the result of a negative spiral, because when patients become physically less active they become more easily fatigued, and when patients experience fatigue they react by becoming physically even less active” (Goedendorp et.al, 2010, p. 1123). Under these conditions, it is expected that exercise in different forms will be beneficial to patients; however, the cycle must be broken in order to achieve these outcomes (Goedendorp et.al, 2010). In a similar context, patients who have survived other forms of cancer should be considered as a means of improving patient physical wellbeing, but a number of conditions must be considered when performing physical activity so as not to worsen the patient’s condition (Donnelly et.al, 2011). Based upon the different studies that have been reviewed, it is evident that there are some gaps in research regarding the benefits of exercise and its relationship to fatigue in cancer patients. Therefore, an additional evaluation must be conducted in order to determine how to improve quality of life, physical health, and general wellbeing for cancer patients. The following discussion will address a potential research tool that may be effective in demonstrating the impact of exercise for patients with cancer-related fatigue.

Research Hypothesis

The following research study description will evaluate if exercise provides benfits to cancer patients in reducing their level of fatigue. It is proposed that for female patients ages 30-55 undergoing treatment for cervical cancer will experience a measurable increase in physical strength and stamina and a decrease in fatigue six months after the start of treatment. The key variables include 1) exercise as the independent variable; 2) fatigue as a dependent variable; and 3) physical strength and stamina as a dependent variable. The key population group is women between the ages of 30-55 who have been diagnosed with cervical cancer and have undergone treatment for at least six months. This research hypothesis will determine if exercise has any impact on the reduction of fatigue and the increase of physical strength and stamina for this patient population. For this study, the type of physical activity must be clearly defined, which includes walking three or more days per week, aerobic activity three or more days per week, and strength training twice per week. The study will examine if fatigue is reduced when exercise plans are implemented for cervical cancer patients six months post-treatment. Physical activities will be logged in a journal format by each study participant and results will be measured in terms of fatigue episodes, which will also be tracked by participants. For the first month, the intervention will be conducted in one-week intervals and will skip every other week. In other words, one week of exercise will occur on a strict regimen and the following week will not require the exercise regimen, only fatigue tracking.

Methodology

Study Setting

The proposed study will take place in a community surrounding a women’s cancer clinic. Each study participant will be a patient at the clinic and makes routine visits to the clinic on a weekly, bi-weekly, or monthly basis, based upon the required treatment. The patient population will be comprised of patients with Stage I or II cervical cancer and who have undergone treatment for at least six months. Treatment methods include chemotherapy, radiation, and pharmacological drugs. The clinic has a cumulative patient population of approximately 1,200 females with all types of cancers. It is expected that the study will recruit approximately 20-25 participants to fulfill the requirements, including keeping a journal to measure the key variables. The settting will be a combination of the clinic and the home environment for each study participant.

Research Design

A descriptive, longitudinal research study will be conducted and represents a means of evaluating the key variables. Exercise will be used to determine if fatigue is decreased and physical stamina and strength are increased. The descriptive, longitudinal design is most appropriate for this study because it supports work with a group of participants over a period of time to accomplish the desired objectives. This design is appropriate for the proposed study because it supports the capturing of data from a single group of participants over a period of time and will determine if there is a positive relationship between the independent variable and the dependent variables. This will also enable the researchers to obtain sufficient information regarding the patterns of fatigue of the study participants in order to determine if exercise has any real impact.

Sample and Sampling Procedure

A sample of convenience will be utilized for the research study in order to focus on a smaller population of cancer patients. Cervical cancer patients were selected for participation in the study who have had at least six months of treatment post-diagnosis. This population was chosen because these women are likely to experience at least intermittent bouts of extreme fatigue during the treatment process. Subjects will be selected from a local women’s cancer clinic from the cervical cancer roster. It is anticipated that 20-25 subjects will be selected for participation, and the majority of subjects will be middle class females. Study participants must have cervical cancer and have been undergoing treatment for six months or more and do not have metastasized cancer.

Ethics/Institutional Board Review

For this study, all subjects will remain anonymous and will be asked to provide informed consent prior to participation. Subjects will not be exposed to any danger and will only be asked to exercise if their fatigue is not severe.

Data Collection

Data collection will be conducted by providing each participant with a journal to record their exercise regimen as well as their bouts with fatigue. Subject journals will be collected and will be evaluated at one month, three months, and six months. The data will then be tabulated cumulatively after the six month period has ended and the results will be analyzed.

Data Analysis

Data analysis will be conducted using SPSS software in order to identify the impact of exercise on fatigue and physical strength. It is expected that there will be varying degrees of impact of the data that is collected and that each patient’s level of fatigue and physical strength will vary. However, it is believed that there will be sufficient data to analyze the results and to draw effective conclusions.

Strengths and Weaknesses

The study is likely to be strong in evaluating a small group of cervical cancer patients who experience fatigue during the treatment phase. It is believed that the small study population is conducive to a cohesive evaluation. However, this population group may be too specific to apply to other populations in future studies. Also, the level of exercise will not be completed in a controlled setting; therefore, the viability of the exercise data and its impact on fatigue may be called into question.

References

Arnold, M.E., and Taylor, N.F. (2011). Exercise for patients with cancer: reducing disease-related fatigue. Future Oncology, 7(2), 165-167.

Barsevick, A., Beck, S.L., Dudley, W.N., Wong, B., Berger, A.M., Whitmer, K., Newhall , T., Brown, S., and Stewart, K. (2010). Efficacy of an intervention for fatigue and sleep disturbance during cancer chemotherapy. Journal of Pain and Symptom Management, 40(2), 200-216.

Blaney, J., Lowe-Strong, A., Rankin, J., Campbell, A., Allen, J., and Gracey, J. (2010). The cancer rehabilitation journey: barriers to and faciltators of exercise among patients with cancer-related fatigue. Physical Therapy, 90(8), 1135-1147.

Chou, F.Y., Dodd, M.J., and Paul, S.M. (2012). Timing and sustainability of an exercise intervention in women with breast cancer during and after cancer treatment. Oncology Nursing Forum, 39(1), 91-97.

Dirksen, S.R., Belyea, M.J., and Epstein, D.R. (2009). Fatigue-based subgroups of breast cancer survivors with insomnia. Cancer Nursing, 32(5), 404-411.

Donnelly, C.M., Blaney, J.M., Lowe-Strong, A., Rankin, J.P., Campbell, A., McCrum- Gardner, E., and Gracey, J.H., (2011). A randomized controlled trial testing the feasibility and efficacy of a physical activity behavioral change intervention in managing fatigue with gynecological cancer survivors. Gynecologic Oncology, 122, 618-624.

Goedendorp, M.M., Peters, MEWJ, Gielissen, MFM, Witjes, J.A., Leer, J.W., Verhagen, C., and Bleijenberg, G. (2010). Is increasing physical activity necessary to diminish fatigue during cancer treatment? Comparing cognitive behavior therapy and a brief nursing intervention with usual care in a multicenter randomized controlled trial. The Oncologist, 15, 1122-1132.

Hayama, Y., and Inoue, T. (2012). The effects of deep breathing on ‘tension-anxiety’ and fatigue in cancer patients undergoing adjuvant chemotherapy. Complimentary Therapies in Clinical Practice, 18, 94-98.

Hilarius, D.L., Kloeg, P.H., van der Wall, E., Komen, M., Gundy, C.M., and Aaronson, N.K. (2011). Cancer-related fatigue: clinical practice versus practice guidelines. Support Care Cancer, 19,531-538.

Humpel, N., and Iverson, D.C. (2009). Sleep quality, fatigue, and physical activity following a cancer diagnosis. European Journal of Cancer Care, 19, 761-768.

Johnson, R.L., and Matzo, M. (2012). Cancer-related fatigue. American Journal of Nursing,112(4), 57-60.

Mock, V., Pickett, M., Ropka, M.E., Muscari, E., Stewart, K.J., Rhodes, V.A., McDaniel, R., Grimm, P.M., Krumm, S., and McCorkle, R. (2001). Fatigue and quality of life outcomes of exercise during cancer treatment. Cancer Practice, 9(3), 119-127.

Purcell, A., Fleming, J., Bennett, S., and Haines, T. (2010). Development of an educational intervention for cancer-related fatigue. British Journal of Occupational Therapy, 73(7), 327-333.

Purcell, A., Fleming, J., Burmeister, B., Bennett, S., and Haines, T. (2011). Is education an effective management strategy for reducing cancer-related fatigue? Support Care Cancer, 19, 1429-1439.

Velthuis, M.J., May, A.M., Koppejan-Rensenbrink, RAG, Gijsen, BCM, van Breda, E., de Wit, A., Schroder, C.D., Monninkhof, E.M., Lindeman, E., van der Wall, E., and Peeters, PHM. (2010). Physical activity during cancer treatment (PACT) study: design of a randomized clinical trial. BMC Cancer, 10:1-9.

Von Ah, D., Jansen, C., Hutchinson Allen, D., Schiavone, R.M., and Wulff, J. (2011). Putting evidence into practice: evidence-based interventions for cancer and cancer treatment-related cognitive impairment. Clinical Journal of Oncology Nursing, 15(6), 607-615.

Williams, P.D., Williams, K., Lafaver-Rolling, S., Johnson, R., and Williams, A.R. (2011). An intervention to manage patient-reported symptoms during cancer treatment. Clinical Journal of Oncology Nursing, 15(3), 253-258.

Windsor, P.M., Potter, J., McAdam, K., and McCowan, C. (2009). Evaluation of a fatigue initiative: information on exercise for patients receiving cancer treatment. Clinical Oncology, 21,473-482.