Amy J. Hoffman

Relationships among pain, fatigue, insomnia, and gender in persons with lung cancer

PURPOSE/OBJECTIVES To examine the relationships among pain, fatigue, insomnia, and gender while controlling for age, comorbidities, and stage of cancer in patients newly diagnosed with lung cancer within 56 days of receiving chemotherapy. DESIGN Secondary data analysis. SETTING Accrual from four sites: two clinical community oncology programs and two comprehensive cancer centers. SAMPLE 80 patients newly diagnosed with lung cancer. METHODS Analysis from baseline observation of a randomized clinical intervention trial. Multinomial log-linear modeling was performed to explain the relationships among pain, fatigue, insomnia, and gender. MAIN RESEARCH VARIABLES Pain, fatigue, insomnia, and gender. FINDINGS For all people with lung cancer, fatigue (97%) and pain (69%) were the most frequently occurring symptoms; insomnia occurred 51% of the time. A model containing all main effects (two-way interactions of pain and fatigue, pain and insomnia, and insomnia and gender; and the three-way interaction of pain, fatigue, and insomnia, along with three covariates [age, comorbidities, and stage of cancer]) was a good fit to the data. Parameter estimates indicated that a statistically significant effect from the model was the three-way interaction of pain, fatigue, and insomnia. Gender did not make a difference. Age, comorbidities, and stage of cancer were not significant covariates. CONCLUSIONS For people newly diagnosed with lung cancer undergoing chemotherapy, multiple symptoms occur simultaneously rather than in isolation; a symptom cluster exists, consisting of pain, fatigue, and insomnia; and no relationship was found among gender, pain, fatigue, and insomnia. IMPLICATIONS FOR NURSING By understanding this symptom cluster, healthcare providers can target specific troublesome symptoms to optimize symptom management and achieve the delivery of high-quality cancer care.

Enhancing Self-Efficacy for Optimized Patient Outcomes through the Theory of Symptom Self-Management

Background: In today’s world, greater patient empowerment is imperative because 90 million Americans live with 1 or more chronic conditions such as cancer. Evidence reveals that healthy behaviors such as effective symptom self-management can prevent or reduce much of the suffering from cancer. Oncology nurses play a pivotal role in developing a symptom self-management plan that is critical to optimizing a patient’s symptom self-management behaviors. Objective: This article uses exemplars to describe how oncology nurses can apply a tested middle-range theory, the Theory of Symptom Self-management, to clinical practice by incorporating interventions to increase a patient’s perceived self-efficacy to optimize patient outcomes. Methods: The Theory of Symptom Self-management provides a means to understand the dynamic aspects of symptom self-management and provides a tested framework for the development of efficacy-enhancing interventions for use by oncology nurses in clinical practice. Results: Exemplars based on the Theory of Symptom Self-management depict how oncology nursing can use perceived self-efficacy–enhancing symptom self-management interventions to improve the functional status and quality of life of their patients. Conclusion: Guided by a theoretical approach, oncology nurses can have a significant positive impact on the lives of their patients by reducing the symptom burden associated with cancer and its treatment. Implications for Practice: Oncology nurses can partner with their patients to design tailored approaches to symptom self-management. These tailored approaches provide the ability to implement patient-specific behaviors that recognize, prevent, relieve, or decrease the timing, intensity, distress, concurrence, and unpleasant quality of symptoms.

Testing a Theoretical Model of Perceived Self-efficacy for Cancer-Related Fatigue Self-management and Optimal Physical Functional Status

Background: Critical gaps exist in the understanding of cancer symptoms, particularly for cancer-related fatigue (CRF). Existing theories and models do not examine the key role perceived self-efficacy (PSE) plays in a persons ability to manage symptoms. Objectives: The objective of this study was to test the hypothesis that physical functional status (PFS) is predicted through patient characteristics, CRF, other symptoms, and PSE for fatigue self-management in persons with cancer. Methods: This study is a secondary data analysis from the baseline observation of two randomized control trials. The combined data set includes 298 participants who were undergoing a course of chemotherapy. Key variables included physiological and contextual patient characteristics, the severity from CRF and other symptoms, PSE, and PFS. Path analysis examined the relationships among the variables in the proposed theoretical model. Results: Persons with cancer reported CRF as the most prevalent symptom among a mean of 7.4 other concurrent symptoms. The severity from CRF had a direct and indirect effect on PFS, with CRF having a direct adverse impact on PFS (t = −7.02) and an indirect adverse effect as part of the severity from the other symptoms (t = 9.69), which also adversely impacted PFS (t = −2.71). Consistent with the proposed theoretical model, PSE had a positive effect on the PFS (t = 2.87) of persons with cancer while serving as a mediator between CRF severity and PFS. Discussion: Cancer-related fatigue is prevalent and related to the presence of other symptoms, and PSE for fatigue self-management is an important factor influencing CRF and PFS. A foundation is provided for future intervention studies to increase PSE to achieve optimal PFS in persons with cancer.

Too Sick Not to Exercise: Using a 6-week, Home-based Exercise Intervention for Cancer-related Fatigue Self-management for Postsurgical Non–small Cell Lung Cancer Patients

Background: Two prevalent unmet supportive care needs reported by the non–small cell lung cancer (NSCLC) population include the need to manage fatigue and attain adequate exercise to meet the physical demands of daily living. Yet, there are no guidelines for routine rehabilitative support to address fatigue and exercise for persons with NSCLC during the critical transition from hospital to home after thoracotomy. Objective: The objective of this study was to evaluate the feasibility, acceptability, safety, and changes in study end points of a home-based exercise intervention to enhance perceived self-efficacy for cancer-related fatigue (CRF) self-management for persons after thoracotomy for NSCLC transitioning from hospital to home. Interventions/Methods: Guided by the principles of the Transitional Care Model and the Theory of Symptom Self-management, a single-arm design composed of 7 participants with early-stage NSCLC performed light-intensity walking and balance exercises in a virtual reality environment with the Nintendo Wii Fit Plus. Exercise started the first week after hospitalization for thoracotomy and continued for 6 weeks. Results: The intervention positively impacted end points such as CRF severity; perceived self-efficacy for fatigue self-management, walking, and balance; CRF self-management behaviors (walking and balance exercises); and functional performance (number of steps taken per day). Conclusions: A home-based, light-intensity exercise intervention for patients after thoracotomy for NSCLC is feasible, safe, well tolerated, and highly acceptable showing positive changes in CRF self-management. Implications for Practice: Beginning evidence suggests that a light-intensity in-home walking and balance intervention after hospitalization for thoracotomy for NSCLC is a potentially effective rehabilitative CRF self-management intervention. Next steps include testing of this health-promoting self-management intervention in a larger-scale randomized controlled trial.

Virtual reality bringing a new reality to postthoracotomy lung cancer patients via a home-based exercise intervention targeting fatigue while undergoing adjuvant treatment.

Background: Little is known about rehabilitation for postthoracotomy non–small cell lung cancer (NSCLC) patients. This research uses a perceived self-efficacy-enhancing light-intensity exercise intervention targeting a priority symptom, cancer-related fatigue (CRF), for postthoracotomy NSCLC patients. This article reports on phase II of a 2-phase study. Phase I focused on initiation and tolerance of exercise during the 6 weeks immediately after thoracotomy, whereas phase II addressed maintenance of exercise for an additional 10 weeks including participants initiating and completing chemotherapy and/or radiation therapy. Objective: The objective of this study was to investigate the feasibility, acceptability, and preliminary efficacy of an exercise intervention for postthoracotomy NSCLC patients to include those initiating and completing adjuvant therapy. Interventions/Methods: A single-arm design composed of 7 participants postthoracotomy for NSCLC performed light-intensity exercises using an efficacy-enhancing virtual-reality approach using the Nintendo Wii Fit Plus. Results: Despite most participants undergoing chemotherapy and/or radiation therapy, participants adhered to the intervention at a rate of 88% with no adverse events while giving the intervention high acceptability scores on conclusion. Likewise, participants’ CRF scores improved from initiation through the conclusion of the intervention with perceived self-efficacy for walking at a light intensity continuously for 60 minutes, improving significantly upon conclusion over presurgery values. Conclusions: Postthoracotomy NSCLC patients maintained exercise for an additional 10 weeks while undergoing adjuvant therapy showing rehabilitation potential because the exercise intervention was feasible, safe, well tolerated, and highly acceptable showing positive changes in CRF self-management. Implications for Practice: A randomized controlled trial is needed to further investigate these relationships.

The development and testing of an instrument for perceived self-efficacy for fatigue self-management.

Background: Persons with chronic illness commonly report fatigue. Measurement of perceived self-efficacy for fatigue self-management (PSEFSM) is essential if fatigue is to be monitored and enhanced to improve physical functional status. Objective: The objective of the study was to describe the development and testing of the PSEFSM instrument. Methods: The PSEFSM instrument was incorporated into 2 randomized controlled trials for secondary analysis (N = 298): 63 persons with lung cancer and 235 persons with other cancer diagnoses undergoing a course of chemotherapy. Results: Evidence for construct validity and generalizability was supported through hypotheses testing of the mediation pathway from fatigue to physical functional status through PSEFSM, with results indicating support for partial mediation. Structural modeling indicated a good model fit that further supported the construct validity of the PSEFSM instrument. Conclusions: The instrument provides a reliable and valid measure of PSEFSM that could be used in research to facilitate the development of interventions to increase perceived self-efficacy to achieve optimal symptom self-management. Implications for Practice: The PSEFSM instrument is brief and easy to complete, which results in a low response burden for persons who are already fatigued, providing for regular use in transdisciplinary research and practice settings. This is important because the use of this instrument can impact how we partner with our patients to better understand how to manage this troublesome symptom, fatigue.

A rehabilitation program for lung cancer patients during postthoracotomy chemotherapy

Objective The objective of this pilot study was to describe the effects of a 16-week home-based rehabilitative exercise program on cancer-related fatigue (CRF), other symptoms, functional status, and quality of life (QOL) for patients with non-small cell lung cancer (NSCLC) after thoracotomy starting within days after hospital discharge and continuing through the initiation and completion of chemotherapy. Materials and methods Five patients with NSCLC completed the Brief Fatigue Inventory (measuring CRF severity) and the MD Anderson Symptom Inventory (measuring symptom severity) before and after thoractomy, and at the end of each week of the 16-week exercise program. Additionally, the Medical Outcomes Study Short Form-36 (measuring physical and mental functional status) and the Quality of Life Index (measuring QOL) were completed before and after thoracotomy, after weeks 3, 6, 12, and 16 (the end of the exercise program). Further, the 6-minute walk test (measuring functional capacity) was administered before thoracotomy, prior to the initiation of chemotherapy and/or radiation therapy, and at the end of the 16-week exercise program, after completion of chemotherapy. Results Participants had a mean age of 63 years and a mean of five comorbid conditions; the exercise program was initiated within 4 days after hospital discharge. Participants’ CRF severity scores were reduced to mild levels, while the mean number of symptoms decreased from 9 postthoracotomy to 6 after the exercise program, with mean levels of severity and interference decreasing to below prethoracotomy levels. Likewise, participants’ functional status and QOL after completing the exercise program improved to near or above prethoracotomy levels. Conclusion The home-based, light-intensity exercise program for NSCLC patients receiving and completing adjuvant chemotherapy postthoracotomy showed promising trends in improving CRF severity, other symptom severity, functional status, and QOL. Further testing via a two-arm randomized controlled trial is being conducted.

Using Perceived Self-efficacy to Improve Fatigue and Fatigability In Postsurgical Lung Cancer Patients: A Pilot Randomized Controlled Trial.

Background: Fatigue remains a prevalent and debilitating symptom in persons with non–small cell lung cancer (NSCLC). Exercise has been shown to be effective in reducing fatigue, yet interventions are limited for postsurgical NSCLC patients. To date, while surgery is offered as a standard curative treatment for NSCLC, no formal guidelines exist for postsurgical rehabilitation. Objective: This study focuses on the design and testing of a postsurgical intervention for NSCLC patients to promote perceived self-efficacy for fatigue self-management targeting cancer-related fatigue (CRF) severity and its associated fatigability through exercise. Methods: A 2-arm randomized controlled trial was used to examine the impact of a 6-week rehabilitative CRF self-management exercise intervention on 37 NSCLC participants compared with 35 control group participants receiving usual care from diagnosis to 6 weeks’ postsurgical hospital discharge. Results: We exceeded goals for recruitment (66%), retention (97%), adherence (93%), and acceptability. Our 6-week exercise intervention demonstrated preliminary efficacy in significantly reducing CRF severity and fatigability as compared with usual care, with mean CRF levels restored to levels lower than presurgery. Likewise, the exercise group’s functional performance (physical and mental health scores) exceeded usual care. Furthermore, no adverse events were reported; participants had a mean age of 67 years and a mean of 8 comorbid conditions. Conclusions: An exercise intervention for postsurgical NSCLC patients is feasible, safe, and highly acceptable showing positive changes in CRF self-management. Implications for Practice: To advance practice, testing of the effectiveness of this health-promoting self-management exercise intervention in a larger-scale randomized controlled trial is needed.

A Home-based Exercise Intervention for Non–Small Cell Lung Cancer Patients Post-Thoracotomy

OBJECTIVES There are no evidenced-based rehabilitative guidelines for postsurgical non-small cell lung cancer (NSCLC) patients. This qualitative study provides evidence on the acceptability of an effective postsurgical exercise intervention targeting the self-management of cancer-related fatigue to fill this gap. DATA SOURCES Qualitative perspective of 37 individuals randomized to a 6-week exercise program following hospital discharge post-thoracotomy for NSCLC. CONCLUSION Postsurgical NSCLC participants found this rehabilitative exercise intervention highly acceptable because it removed traditional barriers to exercise. IMPLICATION FOR NURSING PRACTICE A highly acceptable and effective solution for meeting the unmet rehabilitative support needs of NSCLC patients has broader implications for extension to other vulnerable, aging, deconditioned populations.

Merging technology and clinical research for optimized post-surgical rehabilitation of lung cancer patients

BACKGROUND The 21(st) century has ushered in an age of wireless communication and technological breakthroughs providing researchers with opportunities and challenges as they incorporate this technology into their research. This paper presents the challenges our team encountered introducing new technologies and how they were overcome for an intervention for post-thoracotomy non-small cell lung cancer (NSCLC) patients. METHODS Our intervention incorporated the Nintendo Wii Fit Plus virtual-reality walking and balance exercise into a home-based rehabilitation program. The intervention is novel and innovative in that the intervention provides light-intensity exercise post-thoracotomy for NSCLC patients immediately after return to home from the hospital. The intervention overcomes the barriers of conventional exercise programs that require travel, conventional exercise equipment, and begin months after surgery. RESULTS When translating new technology to research, researchers need to consider a number of factors that need to be addressed. Institutional Review Boards may need further explanation as to why the technology is safe, potential participants may need to have unfounded concerns explained before enrolling, and the research team needs a plan for introducing the technology to participants with a vast range of skill sets and environments in which they will be using technology. In our study, we addressed each of these factors using varying approaches as we translated how the Wii would be used in a home-based exercise intervention by a highly vulnerable, post-thoracotomy NSCLC population. CONCLUSIONS While technology brings with it multiple barriers for successful implementation, our team showed that with proper planning and teamwork, researchers can navigate these issues bringing the full benefit of technology to even the most vulnerable of patient populations.