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To Peter, and Ed and all those others who fed my spirit
Purpose of the article
Magnan, M.A, and Mood, D.W. (2003). The
effects of health state, hemoglobin, global
symptom distress, mood disturbance, and
treatment site on fatigue onset, duration and
distress in patient receiving radiation
therapy. Oncology Nursing Forum 30(2).
Purpose was to seek out correlates of early
onset, long-lasting duration, and severe
fatigue-related distress in persons
receiving radiation for treatment of cancer.
Introduction
• How does cancer-related fatigue differ
from general fatigue
• Scope of the problem
• Purpose of the article reviewed
• Significance to nursing
Faces of Fatigue
Energy Crisis
At first I was energized
The diagnosis shocked me into action
The clutching fear galvanized me
The details demanded attention
The family’s tears called for comfort
The decisions were made
The adrenaline flowed and I was energized
But one day all the energy was gonePhysical, psychic, emotional –
The days turned into weeks
And the weeks into months
Now I search
Each cell of my body
Each corner of my mind
For one tiny spark
Faces of Fatigue
Energy Crisis
At first I was energized
The diagnosis shocked me into action
The clutching fear galvanized me
The details demanded attention
The family’s tears called for comfort
The decisions were made
The adrenaline flowed and I was energized
But one day all the energy was gonePhysical, psychic, emotional –
The days turned into weeks
And the weeks into months
Now I search
Each cell of my body
Each corner of my mind
For one tiny spark
Faces of Fatigue
Mental fatigue often
results from the
intensive mental
effort and
excessive attention
that is necessary
when coping with a
serious illness.
A woman with newly diagnosed breast cancer must absorb the impact of
the diagnosis as well as make treatment decisions to go on with her life
• Before I joined the
“Cancer Club”, I shared
similar thinking with many
people that cancer is a
death sentence and
something to fear. After
diagnosis, I realized it
was really a gift that
provided clarity and
direction for the second
half of my life.
•I no longer wait for "someday". I make sure every day is as fulfilling as
possible. I value every single interaction I have with people. And I live
every day fully and with dignity. Survivorship is really the power to face
something so scary with fortitude and tenacity of being. I can't say I am
positive every day, but I can firmly say I am thankful for the warning to
slow down and smell the flowers.
Cancer-Related Fatigue
• CRF is more rapid in onset,
more energy draining, more
intense, longer lasting, more
severe, and more unrelenting
when compared with "typical"
fatigue.
•
CRF causes distress in the
physical, social, spiritual,
psychological, and cognitive
domains.
• CRF is different than the
typical fatigue of everyday life.
Scope of the Problem
• 8,000,000 persons are living with cancer in
the US.
• 60-96% of cancer patients experience
fatigue at some point during their
treatment
• Cancer fatigue is a major troubling
symptom and the primary cause of
distress as persons try to contend with the
illness and treatment regimen
Significance to Nursing:
Significance to nursing:
Improve the timing of education and the content of what
is being presented.
Currently little significance is given to baseline
measurements when assessing for fatigue from
radiation. If correlates point to initial levels of
hemoglobin, or health state, then particularly vulnerable
patients can be more carefully counseled.
Complexity of nursing care increases with patients who
suffer with the worst symptoms so these high risk
patients should be identified
Overview of the article reviewed
• Quantitative: descriptive quasiexperimental correlational study utilizing
secondary data from a large data bank.
General Reading
Burns, N. & Groves, S.K. (2007).
Understanding Nursing Research (4th ed.). St. Louis:
Saunders.
Hanna, A., Sledge, G., Mayer, M.L., Hanna, N., Einhorn, L.,
Monahan, P., Daggy, J., and Bhatia, S. (2006). A phase II
study of methylphenidate for the treatment of fatigue.
Support Care Cancer 14: 210-215.
Holley, S. (2000). Cancer-related fatigue. Suffering a
different fatigue. Cancer Practice 8(2) 87-95.
Highlight the findings
• Literature review:
– Very nice review of the current literature on
fatigue associated with radiation treatment of
cancer
– Persons fatigue can persist 6-months to a
year after last radiation treatment
– 37 primary sources and 4 secondary sources
cited. All primary sources from peer-reviewed
literature
Overview of article reviewed
• 2 Clear research questions
– Correlation between site and 3 outcome variables
– Correlation between baseline characteristics and 3
outcome variables
• Methods
• Sample: 384 subjects from 2 clinics
• Inclusions – age, language, number of treatments
scheduled
• Exclusions (extraneous variables)– brain radiation,
extremities as sole site, any cognitive compromise
Methods (cont’d)
Dependent and independent variables
Dependent: onset of fatigue, duration of fatigue, and
fatigue-related distress
Independent: site of radiation, hemoglobin level, health
state, global symptom disturbance, mood disturbance
Potential confounding variables
Amount and type of radiation
Prior or concurrent treatment
Nutrition, self-care
Demographic variables: sex, age, marital status,
education, ethnicity, education, location of cancer,
cancer stage, income, socioeconomic class
Methods (cont’d)
• Instruments – reliability and validity
• This is where things either come together or fall
apart! Was there a choice? Big data bank from
parent study
– They did have trained research assistants administer
the questionnaires
– They did measure hemoglobin and used a standard
tool for health state and mood disturbance. Health
state tool is well established in cancer (alpha .93-.95)
Functional Assessment of Cancer
Therapy 5-point Likert
Functional Well-Being
•
My work (including housework) is fulfilling
•
I am able to enjoy life “in the moment”
•
I have been able to work (including
housework)
•
I have accepted my illness
•
I am sleeping well
•
I am enjoying my usual leisure pursuits
•
I am content with the quality of my life right
now
Physical Well-Being
•
I have nausea
•
I have trouble meeting the needs of my
family
•
I have pain
•
I am bothered by side effects of treatment
•
In general I feel sick
•
I am forced to spend time in bed
Emotional Well-Being
•
I feel sad
•
I am proud of how I’m coping with my
illness
•
I am losing hope in the fight against my
illness
•
I feel nervous
•
I worry about dying
•
I worry that my condition will get worse
Social Well-Being
•
I feel distant from my friends
•
I get emotional support from my family
•
I get support from my friends and
neighbors
•
My family has accepted my illness
•
Family communication about my illness
is poor
•
I feel close to my partner (or main
support)
•
I am satisfied with my sex life
Methods (cont’d)
• Mood State – POMS modified – unclear as to
whether this is a standard tool in cancer
research but it is used in at least one other
cancer study
• Global Symptom Distress – use in cancer is
unclear
• Attributes of Fatigue – patient self-report of
date of onset and duration. Fatigue distress 5-point
Likert scale of unestablished and unpublished
origin (a better tool is on the next slide).
Data Analysis
• Multivariate data – standard SPSS PC9
• Paired sample t tests (to assess
significance of change from baseline at
different time intervals), analysis of
variance
Statistical significance set at 0.05
Power test at a level .97
Results – Did Address the Purpose
• Sample Characteristics – 2 outpatient clinics in Midwest,
sex, age (24-87), ethnic, socioeconomic, education, etc.
– Half African-American, half European-American, middle-class
– All 20 radiation treatments – none to extremities only, nor to
brain, or otherwise cognitively compromised
– Stage: 265 0-II, 161 III-IV
– Site: 37% breast, 32% prostate
• Fatigue onset, duration, distress
Onset average 8 days, but 20% reported onset at
day 1
Duration 1 to 78 days – avg 32 days
Distress worst at the end of treatment
Results cont’d
• Correlates
– Health state, hemoglobin, = delayed onset, less
distress, shorter duration
– Global distress, Low mood = earlier onset, more
fatigue distress, longer duration
– Site = prostate cancer: shorter duration
Gynecologic, and lung cancer: most severe
distress
(concern regarding stage and site –
confounding )
Limitations
• A better psychometric tool for fatigue is
needed – BIF .96 alpha to support
reliability
• Karnofsky scale would have been
beneficial
• Concern about the 20% fatigue reported
on the first day needed to be more clearly
identified.
Limitations cont’d
• Confounding variables.
– Unclear how persons with stage 0 (carcinoma
in-situ or precancerous) to stage I can be
scheduled for 20 courses of radiation
– Type and amount of radiation
Implications for Nursing
• Preassessment of baseline Hgb, Health
Status, Mood, Distress is important
because it can guide timing of educational
interventions
• Patients need to understand fatigue is an
individualized experience and they should
not compare their experiences with those
of others.
Significance to nursing:
Sit down to bathe: instead of wasting energy drying off, wear a terrycloth
robe that does the job for you.
When bathing or dressing, minimize leaning down or reaching. There are
many helpful gadgets that can help you with washing yourself, getting
dressed or reaching objects
Do housework sitting down when possible, and delegate heavier tasks to
others. Take frequent rest breaks, and stop working before you become tired.
Use convenience foods that can be prepared in a microwave
Prepare double portions of food and freeze half.
When shopping, make a list by grocery aisle to eliminate unnecessary
walking. Let a grocery store worker carry your bags to the car.
Avoid lifting your children whenever possible. When playing with them,
choose activities that allow you to sit down.
Use a wheelchair or cane
Future research/ Frustration
Assess fatigue with respect to the stage of
cancer
Examine data sets from other institutions
“Mantras in the literature” delay progress
Common Lexicon is essential for integrative
studies