NURSING RESEARCH

ANDREA M. BARSEVICK, R.N., D.N.Sc., Director of Nursing Research

The nursing research program focuses on symptom management and quality of life, concentrating on cancer-related fatigue and other symptoms of the cancer experience. In addition, we have added another dimension to this work, the development of an evidence-based clinical program. This program, the Fatigue Management Program, is now a part of The Complete Care Medicine Program at Fox Chase. In this program, individuals receive a comprehensive assessment of their fatigue. They also may receive education about energy or attention conservation strategies and may participate in an exercise program.

As we build our knowledge base about fatigue and other symptoms, we are continually seeking new information and skills to teach our patients about coping more effectively with the cancer experience. There is a growing body of research suggesting that information about unfamiliar health care experiences, including symptoms, tests, and procedures, can dramatically improve an individual's coping efforts and favorably impact quality of life.

Although the problem of cancer treatment related fatigue was first reported as early as 1897, only recently have health care professionals begun to address its management. The Fatigue Management Program is a nurse-managed program coordinated with medical therapy that focuses on the assessment and management of cancer-related fatigue (CRF). The care provided is state of the art and scientifically based. The program has three components: assessment, fatigue management, and outcome evaluation. Assessment includes a health, fitness, nutrition, medical and fatigue history, review of laboratory findings, and brief cardiovascular examination. The fatigue assessment focuses on the experience of fatigue, potential causes, patterns, controllability, and consequences. Medical problems such as uncontrolled symptoms or anemia are referred to the oncologist for follow-up. Fatigue management interventions include information about CRF and may include specific fatigue management skills such as energy or attention conservation and exercise. Based on the participant's interests and the nurse's recommendations, a personalized fatigue management program is developed for each individual. Outcomes to be evaluated include satisfaction with the program, level of fatigue and quality of life, and referrals to other health professionals or programs. This demonstration project has the potential to impact oncology nursing practice as a model for nurse-initiated symptom management.

A telephone-based psychoeducational intervention to manage CRF has been developed and tested in a pilot study. Seventy-nine individuals who were initiating therapy for breast, lung, colorectal, or prostate cancer are being studied. Participants received three telephone counseling sessions during the first three weeks of chemotherapy or the last three weeks of radiation therapy. In the first session, a nurse gave information about CRF and energy conservation skills were taught. The individual assessed his/her own fatigue by completing a daily journal for one week to monitor fatigue and other symptoms, and by making a list prioritizing usual activities. The journal and priority list provided the basis for the second session in which the individual made a plan for managing valued activities to minimize the interference of fatigue. In the third session, the individual evaluated and revised the plan. Perception of fatigue, limitation of functioning, and mood were measured prior to treatment and at follow-up points of peak and low fatigue. A preliminary analysis was conducted after the first 44 participants had been enrolled. These preliminary results provided evidence that more than 80% of participants found the intervention to be credible. Final analyses include an examination of the relationships between the outcomes of interest (fatigue, limitation of functioning, and mood) and potential confounding variables including social support, sleep disruption, other symptoms, demographics and clinical factors. Multivariate procedures are being used to examine changes over time in level of fatigue, functional limitations, and mood. The findings of this research will provide important information about the efficacy of an energy conservation intervention for fatigue and the clinical, behavioral, and demographic factors that influence CRF.

Walking has received attention as a potential means for reducing the intensity of cancer fatigue. The purpose of this feasibility study is to examine the predictors of completing the walking program, including age, fatigue, treatment-related anemia, intensity of treatment, frequency/intensity of other symptoms, and motivation. A quasi-experimental design is being used to determine changes in fatigue, as well as psychological well being and conditioning. Women with Stage I and II breast cancer are recruited prior to adjuvant therapy. While receiving multimodal therapy, the experimental group participants follow an 8-week walking program. An attentional control group participates in all aspects of the study except the walking program. At baseline and after completion of the program, quality of life and fatigue are assessed. Treadmill tests at baseline and completion determine metabolic equivalents (METS), which are extrapolated to oxygen consumption as a measure of conditioning. To date, of 31 eligible women, 21 have enrolled, four of whom have withdrawn from the study. Study participants are characterized by an average age of 50 years; 80% are married, 25% are African American, 80% have Stage I breast cancer and 33% are receiving radiation as adjuvant therapy. Once a target sample of 94 women has been obtained, descriptive statistics will be used to characterize the study participants. Compliance with the walking program will be examined with Chi-square statistical analyses. This walking program offers a low risk strategy that can empower women to self manage the symptom of fatigue and relieve suffering.

CRF is described as a subjective experience. Yet, most of the research has focused on objective, quantifiable aspects of CRF. The purpose of this study is to describe CRF from the perspective of the individuals who experience it. The Common Sense Model is used to guide the study because it describes symptoms from the individual's perspective. Two focus groups were held to gather data because this method is useful to explore ordinary descriptions of reality shared by those experiencing a particular phenomenon. Three questions were posed: 1) What is your experience of fatigue? 2) What does the experience of fatigue mean to you? 3) What do you do about it? Content analysis guided by the model will be used to analyze the data. Transcripts are being reviewed using coding categories defined by the components of these models. The findings will enhance our understanding of the CRF experience and provide a basis for oncology nurses to educate their patients about CRF and its management.

Quality of life methodology is divided between two complementary measurement approaches. The psychometric approach emphasizes the health status of the individual, but does not provide a rating of patient preferences or value. The General Functional Assessment of Cancer Therapy (FACT-G) is a measure that describes physical, psychological, social, and functional well being. The utility approach is explicitly concerned with treatment values and decision-making. The Time Trade Off (TTO) interview is a utility measure based on a simple interview in which the individual chooses between two alternatives: current health for a fixed period of time or perfect health for a shorter period of time. The score is expressed as the amount of time an individual would be willing to give up to experience a better state of health. The TTO interview and FACT-G were administered to 844 individuals with breast, colorectal, lung, and prostate cancers. In response to the FACT-G, individuals with breast and prostate cancer reported better quality of life than those with lung or colorectal cancer. Individuals who reported better performance status and had better FACT-G scores were receiving no treatment, or had a longer interval since diagnosis. With regard to the TTO, one-third of the participants were unwilling to trade off any time for a better health state. The majority of these had no evidence of disease and a normal performance status. At the opposite extreme, about 1% stated they would prefer immediate death to their current health state. The majority of these patients had advanced disease and were confined to bed for a least part of the day. There was a significant correlation between FACT-G and TTO scores indicating that each measure provides unique yet complementary information. The FACT-G provides information about symptoms, emotional state, and functional level. The TTO expresses quality of life in terms of the individual's willingness to continue in his/her current health state.

This study examined the benefit of nurse-initiated communication skills training for women with breast cancer. Two hundred forty-two women participated in the study. The communication skills training intervention consisted of individualized information about breast cancer, an exploration of the woman's questions and concerns, and the development of skills in discussing concerns with her providers to obtain information. Younger women in the experimental group maintained their baseline level of assertiveness at one month after intervention while older women in this group and the control group had lower assertiveness. The experimental group demonstrated improvement in physical and psychosocial functioning and no increase in symptom distress one and four months after the intervention, while the control group had poorer functioning and greater symptom distress at one month with improvement by the fourth month. The results demonstrate that fairly simple communication skills intervention can enhance women's communication with health care providers, participation in decision-making and health care outcomes.

This outreach project was designed by the pain management center to assist five network hospitals to improving clinical outcomes in cancer pain management. To modify each institution's approach to pain management, a series of goal-directed activities was assigned to a specially trained and supported Cancer Pain Resource Team (CPRT). Five CPRT's, comprising an oncology nurse and pharmacist, were provided backup from a staff oncologist and telephone consultation with the research staff. CPRT training consisted of an initial didactic conference and clinical practicum followed by annual didactic conferences. CPRT activities included case consultation, case conferences, continuing staff education, patient education, community outreach, and quality management. CPRT impact was measured by an audit of 25 charts from each hospital at the beginning and end of the three-year project. CPRT's improved the use of objective pain ratings from 8% to 36% (p=.001), documentation of pain description by both nurses and physicians from 66% to 78% (p=.04), and documentation of pain location from 75% to 91% (p=.001). Changes in pain treatment included an increase in the use of opioids around-the-clock plus supplements from 53% to 64% (p=.03), a decrease in intramuscular opioid administration from 41% to 30% (p=.05), an increase in intravenous opioid administration from 22% to 42% (p=.0002), and an increase in the use of Step 3 opioids from 62% to 79% (p=.002). Documentation of response to analgesic therapy increased from 54% to 66% (p=.05) and inclusion of pain assessment in the nursing care plan increased from 56% to 72% (p=.007). There were no significant differences in patient sex, age or primary cancer in pre and post-intervention charts. This study demonstrates that nurse-pharmacist teams can improve pain management in community hospitals through a plan of institutional change.

The purpose of this study is to describe the presence, severity, and impact of symptoms on quality of life in individuals who have undergone esophageal resection for cure. Patients complete measures of quality of life, symptoms, and impact prior to all treatment, including chemo-radiation, and again prior to surgery. Follow-up points are three and six months after surgery. Eighteen persons have been referred for esophageal resection. Fourteen were able to receive the procedure. Of the 14, ten have reached the 3-month quality of life evaluation and were able to complete it; one is still pending. Five individuals have completed the six-month evaluation and 6 others are still pending. A preliminary examination of the data is currently underway to examine pre- and post-surgical symptom levels, as well as functional limitations. The analysis will provide important information about quality of life that can be used to guide patient education about surgery, as well as symptom management efforts.

Research utilization is an important practice to provide a scientific basis for the development of nursing standards and quality improvement. The purpose of this study was to examine factors that influence oncology nurses' attitudes about research utilization. A convenience sample of 75 nurses was surveyed. A statistically significant relationship was identified between nurses' attitudes and awareness of resources, level of education, and membership in a research related organization or committee. Barriers to research utilization were lack of knowledge, time, authority, and support. Age, number of years as a registered nurse, number of years at the cancer center, unit, setting, and job title did not influence attitudes about research utilization. This research points out the need to promote research utilization and to identify and remove barriers to the use of research in clinical practice.

BARSEVICK, A.M., HAMBLETON, J. Practice tips from Fox Chase Cancer Center, Philadelphia, PA. Oncol. Nurs. Forum 25:987-991, 1998.

MEEK, P.M., NAIL, L.M., BARSEVICK, A., SCHWARTZ, A.L., STEPHEN, S., WHITMER, K., BECK, S.L., JONES, L.S., WALKER, B.L. Psychometric testing of fatigue instruments for use with cancer patients. Nurs. Res. (in press).

MUCH, J., BARSEVICK, A. Depression. In Cancer Symptom Management, edited by S. Groenwald, M. Goodman, M. Frogge and C.H. Yarbro. Jones and Bartlett Publishers, Boston, 2nd Edition, 1998.

SCHWARTZ, A.L., NAIL, L.M., CHEN, S., MEEK, P., BARSEVICK, A.M., KING, M.E., JONES, L.S. Fatigue patterns observed in patients receiving chemotherapy and radiotherapy. Cancer Invest. (in press).

MAIL, L., BARSEVICK, A. MEEK, P., BECK, S., JONES, L. WALKER, L., WHITMER, K., SCHWARTZ, A., STEPHEN, S., KING, M. Planning and conducting a multi-institutional project on fatigue. Oncol. Nurs. Forum 25:1398-1403, 1998.

^§   Fox Chase researcher

^a   J. Much: Cancer Center of New Jersey, New Brunswick, NJ 08901

^b   D. Cella: Evanston Hospital, Evanston, IL 60201

^c   D. Adler: Temple University, Philadelphia, PA 19140

^d   M. Schwartz, C. Lerman: Lombardi Cancer Center, Washington DC 20007

^e   M. Grant: City of Hope Medical Center, Duarte, CA 91010

Illustrations or unpublished data in these reports should not be used without permission of the author.

Fox Chase Cancer Center

Scientific Report 1998