In their own words: using the common sense model to analyze patient descriptions of cancer-related fatigue.

PURPOSE/OBJECTIVES: To describe cancer-related fatigue (CRF) from the perspective of individuals experiencing it and examine the fit of their descriptions with the concepts from the Common Sense Model (CSM). DESIGN: Exploratory, qualitative design, SAMPLE: A convenience sample of eight patients with cancer known to be experiencing fatigue from the outpatient clinic. METHODS: Content analysis of data obtained from focus groups. FINDINGS: All statements describing CRF could be classified using the major constructs of the CSM: representation, coping, and appraisal. The majority of statements were classified as representations of fatigue (67%), with smaller proportions classified as coping (26%) and appraisal (7%). CONCLUSIONS: This study provides evidence to support the validity of the CSM constructs as an organizing framework in the conduct of research. IMPLICATIONS FOR NURSING PRACTICE: This study demonstrates the usefulness of the model In clinical assessment of patient representations of CRF as well as coping strategies for managing it The model is particularly useful in targeting knowledge deficits and inaccuracies.

Communicating genetic test results to the family: a six-step, skills-building strategy.

As the availability of tests to identify hereditary predisposition to chronic diseases continues to grow, a need has arisen to prepare individuals receiving genetic test results to share this highly sophisticated and value-laden information with other at-risk family members. Responding to this need, a communication skills-building intervention, based on Buckman's model of "Breaking Bad News," was developed for use in the setting of genetic testing for BRCA1 and BRCA2 mutations. Outcomes will include knowledge, attitudes, and health behavior on the part of both the proband and her first-degree relatives.

Breast cancer detection: knowledge, attitudes, and behaviors of women from Pennsylvania.

PURPOSE/OBJECTIVES: To assess relationships among breast cancer detection behaviors and selected variables in healthy women. DESIGN: Correlational study. SETTING/SAMPLE: A sample of 1,000 women was selected randomly from the 16,500 members of the General Federation of Women's Clubs of Pennsylvania. Respondents (N = 538; 54% response rate) were predominately white, well educated, lived in urban areas, and had an average age of 60 years. METHODS: Mailed packets with a professionally designed, scannable survey instrument that included questions related to detection behaviors, a risk index, health behaviors, attitudes, and knowledge. MAIN RESEARCH VARIABLES: Breast cancer detection behaviors: mammography, clinical breast examination (CBE), breast self-examination (BSE). Structural/demographic variables: age, education, residence, knowledge of breast cancer and detection methods, teaching history, encouragement, and risk index (family/medical history). Predisposing variables: susceptibility, benefits/barriers, confidence, social norms and influence, and general health motivation. FINDINGS: Women reported moderate/high adherence to recommendations for early detection of breast cancer. Mammography behavior was predicted by older age, being encouraged by a doctor or nurse, and greater risk. CBE predictors were greater knowledge and risk along with greater benefits, social norms, and health motivation. BSE behavior was predicted by having had BSE technique checked, greater knowledge, greater risk, decreased barriers to BSE, and higher health motivation. CONCLUSIONS: Common predictors of breast screening behaviors include risk (family/medical history), knowledge, and general health motivation. IMPLICATIONS FOR NURSING PRACTICE: Educational efforts can be designed specifically to influence variables related to compliance with early breast cancer detection behaviors.

Psychometric testing of fatigue instruments for use with cancer patients.

BACKGROUND: Cancer treatment-related fatigue (CRF) is a common side effect of cancer treatment. A problem identified in most reviews of CRF is lack of sound approaches to measurement that are congruent with the conceptualization of CRF as a self-perceived state. The diversity of instruments available to measure fatigue and the lack of comprehensive testing of several promising instruments with cancer patients undergoing treatment provided the rationale for this study. The purpose of this article is to report the results of psychometric testing of several fatigue instruments in patients undergoing cancer treatment. OBJECTIVES: The aims of this study were to determine the reliability, validity, and responsiveness of each instrument and to determine the ability of each instrument to capture CRF. METHODS: Existing fatigue instruments with published psychometric information that indicated suitability for further testing were selected and included the Profile of Mood States Short Form fatigue subscale (F_POMS-sf), Multidimensional Assessment of Fatigue (MAF), Lee Fatigue Scale (LFS), and the Multidimensional Fatigue Inventory (MFI). Data were collected at a university-based clinical cancer center and a freestanding comprehensive cancer center. Subjects completed all study instruments, which were presented in random order, at a time when CRF was expected to be high and again when it was expected to be low. A subset of subjects completed the instruments within 48 hours of one of the data collection points when CRF was expected to be relatively unchanged to provide stability data. RESULTS: Reliability estimates using Cronbach's alpha indicated that all instruments examined had good internal consistency. Test-retest correlations showed good stability for total scores on all the instruments, but some subscales of the LFS and MFI had marginal stability. Factor analysis of all instruments indicated that only the LFS and the F_POMS-sf fully supported their construct validity. All of the instruments showed responsiveness to changes in CRF related to treatment. CONCLUSIONS: The results of the study provide researchers and clinicians with detailed comparisons of the performance of established fatigue measures in cancer patients undergoing treatment to use when selecting measures of CRF.

Fatigue patterns observed in patients receiving chemotherapy and radiotherapy.

The purpose of this study was to describe the patterns of cancer-related fatigue (CRF) and vigor in patients receiving chemotherapy or radiation therapy. Five studies that measured fatigue and vigor with the Profile of Mood States were used to describe the pattern of CRF and vigor during and after both types of treatment. Repeated-measures ANOVA was used to determine differences over time in each study. Results demonstrate different patterns of CRF for patients receiving chemotherapy and radiation therapy. Chemotherapy-related CRF peaks in the days after chemotherapy, whereas radiation therapy-related CRF gradually accumulates over the course of treatment. The CRF associated with both forms of treatment gradually declines over time. The prevalence, intensity, and persistence of CRF during treatment and for months after treatment is complete make this symptom one that cannot be ignored.

NCCN Practice Guidelines for Cancer-Related Fatigue.

These guidelines propose a treatment algorithm in which patients are evaluated regularly for fatigue, using a brief screening instrument, and are treated as indicated by their fatigue level. The algorithm's goal is to identify and treat all patients with fatigue that causes distress or interferes with daily activities or functioning. Management of fatigue begins with primary oncology team members who perform the initial screening and either provide basic education and counseling or expand the initial screening to a more focused evaluation for moderate or higher levels of fatigue. At this point the patient is assessed for the five primary factors known to be associated with fatigue: pain, emotional distress, sleep disturbance, anemia, and hypothyroidism. If any of these conditions are present, it should be treated according to practice guidelines, and the patient's fatigue should be reevaluated regularly. If none of the primary factors is present or the fatigue is unresolved, a more comprehensive assessment is indicated--with referral to other care providers as appropriate. The comprehensive assessment should include a thorough review of systems, review of medications, assessment of comorbidities, nutritional/metabolic evaluation, and assessment of activity level. Management of fatigue is cause-specific when conditions known to cause fatigue can be identified and treated. When specific causes, such as infection, fluid and electrolyte imbalances, or cardiac dysfunction, cannot be identified and corrected, nonpharmacologic and pharmacologic treatment of the fatigue should be considered. Nonpharmacologic interventions may include a moderate exercise program to improve functional capacity and activity tolerance, restorative therapies to decrease cognitive alterations and improve mood state, and nutritional and sleep interventions for patients with disturbances in eating or sleeping. Pharmacologic therapy may include drugs such as antidepressants for depression or erythropoietin for anemia. A few clinical reports of the use of corticosteroids and psychostimulants suggest the need for further research on these agents as a potential treatment modalities in managing fatigue. Basic to these interventions, the effective management of cancer-related fatigue involves an informed and supportive oncology care team that assesses patients' fatigue levels regularly and systematically and incorporates education and counseling regarding strategies for coping with fatigue (Johnson, 1999), as well as using institutional fatigue management experts for referral of patients with unresolved fatigue.

Planning and conducting a multi-institutional project on fatigue.

PURPOSE/OBJECTIVES: To describe the process used in proposal development and study implementation for a complex multisite project on cancer treatment-related fatigue (CRF), identify strategies used to manage the project, and provide recommendations for teams planning multisite research. DATA SOURCES: Information derived from project team meeting records, correspondence, proposals, and personal recollection. DATA SYNTHESIS: The project was built on preexisting relationships among the three site investigators who then built a team including faculty, research coordinators, staff nurses, and students. Study sites had a range of organizational models, and the proposal was designed to capitalize on the organizational and resource strengths of each setting. Three team members drawn from outside oncology nursing provided expertise in measurement and experience with fatigue in other populations. Planning meetings were critical to the success of the project. Conference calls, fax technology, and electronic mail were used for communication. Flexibility was important in managing crises and shifting responsibility for specific components of the work. The team documented and evaluated the process used for multisite research, completed a major instrumentation study, and developed a cognitive-behavioral intervention for CRF. CONCLUSIONS: Accomplishments during the one-year planning grant exceeded initial expectations. The process of conducting multisite research is complex, especially when the starting point is a planning grant with specific research protocols to be developed and implemented over one year. Explicit planning for decision-making processes to be used throughout the project, acknowledging the differences among the study settings and planning the protocols to capitalize upon those differences, and recruiting a strong research team that included a member with planning grant and team-building expertise were essential elements for success. IMPLICATIONS FOR NURSING PRACTICE: Specific recommendations for others planning multisite research are related to team-building, team membership, communication, behavioral norms, role flexibility, resources, feedback, problem management, and shared recognition.

Natural killer cells over time in patients with colorectal cancer.

PURPOSE: The purposes of the investigation were: 1) to examine the natural killer (NK) cell levels in a homogeneous group of patients with cancer between the presurgical period and 6 months after surgery; 2) to identify changes in the number of NK cells over time; and 3) to determine whether an association exists among the number of NK cells, demographics, stage of cancer, and treatment variables. DESCRIPTION OF STUDY: A longitudinal descriptive design was used to study biopsychosocial factors in persons newly diagnosed with colorectal cancer over a 6-month period. RESULTS: Patients without ostomies had a significant decrease in NK levels over time, whereas patients with ostomies had a significant increase in NK levels over time. There was a difference in NK level over time for patients who were receiving the additional therapy of radiation alone and a combination of radiation and chemotherapy from those patients who were not receiving additional therapy. Natural killer levels in patients who were receiving radiation alone or a combination of radiation and chemotherapy significantly declined over time, where NK levels in patients receiving no additional treatment significantly increased over time. CLINICAL IMPLICATIONS: Patients with low NK levels should be monitored during the course of their illness and cancer treatment to determine the relationship to immune status of other variables such as nutritional status, infection rates, and functional status.

Quality of life and nutritional support in patients with cancer.

Nutritional support is often initiated in patients with cancer who are unable to meet their nutritional needs by the oral route. Much has been written about the effect of nutritional support on physiological outcomes in patients with cancer. However, less is known about the relationship between improvement of nutritional status and quality of life. Trends in the treatment of cancer highlight the need for an examination of home nutrition support and quality of life. The purpose of this article is to describe the state of knowledge about the relationship of home enteral and parenteral nutrition support and quality of life. Research exploring the dimensions of quality of life (physical functioning, psychological status, interpersonal relationships and social functioning, financial concerns, and symptoms, and complications of nutritional support) is presented. Implications for clinical practice and research are identified. The trend for increased numbers of patients on home nutrition support emphasizes the need to understand the patient's and family's experience in managing this treatment in the home.

Psychological distress and functional dependency in colorectal cancer patients.

This research was done to describe the nature and degree of psychological distress persons experience after receiving a diagnosis of colorectal cancer and to describe the effect on functional dependency of that distress during the first 3 months of treatment. The sample consisted of 66 persons who completed interviews before surgery and 1 and 3 months after surgery. Depressive symptoms changed substantially over time in relation to the events of diagnosis and treatment. Having an ostomy, additional treatment, and depressive symptoms were predictors of functional dependency after surgery. The findings suggest that depressive symptoms, even at low levels, are important to address because they may reduce patients' ability to function in their usual roles and activities for considerable periods after colorectal cancer surgery.

A descriptive study of immune status in patients undergoing colorectal surgery: lymphocyte phenotypes.

PURPOSE/OBJECTIVES: To describe immune status in patients prior to colorectal surgery for cancer, to establish values to serve as a baseline for subsequent analyses, and to describe a procedure for studying phenotypes of the immune system, elucidating its advantages. DESIGN: One component of a larger longitudinal survey. SETTING: Two large, inner-city university hospitals and two of their affiliated hospitals in the northeastern United States. SAMPLE: Patients undergoing surgery for colorectal cancer (N = 94). Subjects were primarily male (n = 57) and Caucasian (n = 85) and ranged in age from 26-88 years (mean = 63). Seventy-seven percent (n = 73) had cancer, 23% (n = 21) had benign diseases or conditions. METHODS: Flow cytometry analysis of lymphocyte phenotypes was performed on blood samples drawn from patients before they underwent surgery for colorectal cancer. MAIN OUTCOME MEASURES: The average absolute lymphocyte subset levels and the average relative lymphocyte subset levels of blood samples taken from patients undergoing surgery for colorectal cancer were compared (using t-tests) with the subset levels of two normal reference samples. FINDINGS: The average absolute lymphocyte subset levels and average relative lymphocyte subset levels of patients undergoing surgery for colorectal cancer fell within normal ranges. CONCLUSIONS: These findings suggest that this sample of patients undergoing surgery has one essential element of an intact immune system--normal levels of lymphocyte subsets. IMPLICATIONS FOR NURSING PRACTICE: There is no indication preoperatively that this population is at a higher risk for infection or delayed wound healing. However, there may be other times in the illness trajectory when the immune system does become compromised, and these values prior to surgery will serve as a baseline to identify changes in patients' immune status over time. Further longitudinal studies are necessary.

Communication between patients with breast cancer and health care providers. Determinants and implications.

BACKGROUND: This study evaluated the perceptions of patients with breast cancer of their medical interactions with providers. The determinants and psychological consequences of communication problems also were examined. METHODS: Ninety-seven patients with Stage I or II breast cancer completed a set of validated questionnaires before initiating postoperative therapy. Data on psychological distress were collected at baseline and 3-month follow-up, and multivariate models were fit to explain the relationship between pretreatment communication problems and subsequent psychological distress. Data on clinical variables were abstracted from medical records. RESULTS: A substantial proportion of patients (84%) reported difficulties communicating with the medical team. Communication problems were more common among patients who were less optimistic about their disease and had less assertive coping styles. Patient-reported communication problems were associated with increased anxiety, depression anger, and confusion at the 3-month follow-up. The association between communication problems and mood disturbance remained significant, although small, after adjusting for baseline mood disturbance, demographic, clinical, and coping style variables. CONCLUSION: Interventions that enhance communication between patients with breast cancer and their providers may improve patients' psychological adjustment to treatment. Conversely, interventions that lower distress and modify coping style may enhance communication.

Spontaneous causal searching and adjustment to abnormal Papanicolaou test results.

A search for the cause of unexpected negative events has been proposed to occur commonly and to promote adjustment. The purpose of this descriptive study was to determine the frequency of spontaneous causal searching about abnormal Papanicolaou test (Pap) results and the relationship between searching and adjustment to these results. Participants (N = 118) had abnormal Pap results indicating a need for follow-up with colposcopy. The questions asked on hearing these results were coded for content reflecting spontaneous causal searching. Measures of adjustment (type of expectations about follow-up, negative emotions, and prompt attendance) were obtained at follow-up. Only 34% of participants spontaneously asked causal questions. Causal searching was not associated with expectations, emotions, or attendance.

Preference for information and involvement, information seeking and emotional responses of women undergoing colposcopy.

The relationship of individual differences in preference for information and involvement, information-seeking behaviors, and emotional responses was examined in 36 women undergoing colposcopy, a stressful medical procedure. The findings revealed that individual differences in preference for information and behavioral involvement in health care influenced women's information seeking about colposcopy. Women who asked more questions during their clinic visits reported higher preferences for information. Women who sought an information sheet about colposcopy reported higher preference for behavioral involvement in their health care. The findings also revealed that information seeking was associated with the positive emotional response confidence but not with fear or anger/depression.

Women's informational needs about colposcopy.

Questions asked by 36 women during colposcopy, a stressful medical procedure, were examined to determine their specific informational needs about the exam and its results. Of the 226 questions posed, 52 percent were exam related--on the sensations experienced, the nature of the procedure and self-care activities; 34 percent were results related and focused on the meaning of the results, treatment options and treatment procedures; 14 percent of the questions were incidental. The present research documents women's need for information about the medical procedure of colposcopy. The implications for nursing practice are outlined.

A comparison of the anxiety-reducing potential of two techniques of bathing.

This study compared the effects of the towel bath and the conventional bed bath on patient anxiety. The sample of 105 patients were divided into two groups--those who would be having invasive procedures and those with unrelieved pain. Anxiety was measured using the State-Trait Anxiety Inventory (STAI), the Palmar Sweat Index (PSI), and the Behavioral Cues Index (BCI). The scores from the STAI A-State subscale supported the hypothesis that the towel bath resulted in a significant decrease in anxiety for the sample as a whole and for the invasive procedure subsample. The hypothesis was rejected for the unrelieved pain subsample. Scores from the Palmar Sweat Index and the Behavioral Cues Index did not support any of the hypotheses. Based on the findings of this study, bathing is recommended for its anxiety-reducing effects.