Identifying strategies for implementing a clinical guideline for cancer-related fatigue: a qualitative study.

BACKGROUND: Clinical practice guidelines assist health professionals' (HPs) decisions. Costly to develop, many guidelines are not implemented in clinical settings. This paper describes an evaluation of contextual factors to inform clinical guideline implementation strategies for the common and distressing problem of cancer-related fatigue (CRF) at an Australian cancer hospital. METHODS: A qualitative inquiry involving interviews and focus groups with consumers and multidisciplinary HPs explored key Canadian CRF guideline recommendations. Four HP focus groups examined the feasibility of a specific recommendation, while a consumer focus group examined experiences and preferences for managing CRF. Audio recordings were analysed using a rapid method of content analysis designed to accelerate implementation research. Strategies for implementation were guided by the Consolidated Framework for Implementation Research. RESULTS: Five consumers and 31 multidisciplinary HPs participated in eight interviews and five focus groups. Key HP barriers to fatigue management were insufficient knowledge and time; and lack of accessible screening and management tools or referral pathways. Consumer barriers included priority for cancer control during short health consultations, limited stamina for extended or extra visits addressing fatigue, and HP attitudes towards fatigue. Enablers of optimal fatigue management were alignment with existing healthcare practices, increased HP knowledge of CRF guidelines and tools, and improved referral pathways. Consumers valued their HPs addressing fatigue as part of treatment, with a personal fatigue prevention or management plan including self-monitoring. Consumers preferred fatigue management outside clinic appointments and use of telehealth consultations. CONCLUSIONS: Strategies that reduce barriers and leverage enablers to guideline use should be trialled. Approaches should include (1) accessible knowledge and practice resources for busy HPs, (2) time efficient processes for patients and their HPs and (3) alignment of processes with existing practice. Funding for cancer care must enable best practice supportive care.

Cancer related fatigue: implementing guidelines for optimal management.

BACKGROUND: Cancer-related fatigue (CRF) is a key concern for people living with cancer and can impair physical functioning and activities of daily living. Evidence-based guidelines for CRF are available, yet inconsistently implemented globally. This study aimed to identify barriers and enablers to applying a cancer fatigue guideline and to derive implementation strategies. METHODS: A mixed-method study explored the feasibility of implementing the CRF guideline developed by the Canadian Association for Psychosocial Oncology (CAPO). Health professionals, managers and consumers from different practice settings participated in a modified Delphi study with two survey rounds. A reference group informed the design of the study including the surveys. The first round focused on guideline characteristics, compatibility with current practice and experience, and behaviour change. The second survey built upon and triangulated the first round. RESULTS: Forty-five health practitioners and managers, and 68 cancer survivors completed the surveys. More than 75% of participants endorsed the CAPO cancer related fatigue guidelines. Some respondents perceived a lack of resources for accessible and expert fatigue management services. Further barriers to guideline implementation included complexity, limited practical details for some elements, and lack of clinical tools such as assessment tools or patient education materials. Recommendations to enhance guideline applicability centred around four main themes: (1) balancing the level of detail in the CAPO guideline with ease of use, (2) defining roles of different professional disciplines in CRF management, (3) how best to integrate CRF management into policy and practice, (4) how best to ensure a consumer-focused approach to CRF management. CONCLUSIONS: Translating current knowledge on optimal management of CRF into clinical practice can be enhanced by the adoption of valid guidelines. This study indicates that it is feasible to adopt the CAPO guidelines. Clinical application may be further enhanced with guideline adaptation, professional education and integration with existing practices.

Cancer-related fatigue: appraising evidence-based guidelines for screening, assessment and management.

PURPOSE: There is inconsistent management of cancer-related fatigue (CRF) by health professionals worldwide. This research aims to identify the most appropriate guidelines for the management of cancer-related fatigue. METHODS: A systematic search of international literature identified evidence-based clinical practice guidelines for CRF. Four reviewers independently appraised the highest quality guidelines using the AGREE-II instrument and National Heath and Medical Research Council (NHMRC) guideline standards. RESULTS: Five guidelines met the inclusion criteria. Of these, the 2015 Canadian Association of Psychosocial Oncology (CAPO) CRF guidelines and the 2014 American Society of Clinical Oncology (ASCO) fatigue guidelines for cancer survivors were selected for in-depth appraisal. The CAPO guideline scored higher than the ASCO for five domains of the AGREE-II. For one domain, the differences were statistically significant (p ≤ 0.05). The CAPO guideline met 37 of 47 NHMRC mandatory guideline standards and the ASCO guideline met 20. The difference in the proportion of standards met was statistically significant for one domain (p ≤ 0.05). Both guidelines had low scores for applicability and implementation. CONCLUSIONS: Currently, the CAPO guideline for cancer-related fatigue has the strongest evidence for use. To enhance implementation, further strategies for guideline dissemination and application are needed.

Cancer-related fatigue: a survey of health practitioner knowledge and practice.

PURPOSE: This study aims to identify the current practices of health professionals in the assessment and treatment of cancer-related fatigue (CRF). METHODS: Health professionals working with oncology clients participated in an electronic survey distributed via professional associations and oncology societies. RESULTS: One hundred twenty-nine professionals from nursing, medical, and allied health disciplines participated in an electronic survey. Overall, there was a perception that CRF was inadequately managed at some facilities. Routine fatigue screening processes in the workplace were reported by more than half of participants; however, less than one quarter used a clinical guideline or conducted in-depth CRF assessments. Awareness of interventions for CRF varied amongst participants with one quarter able to list five appropriate interventions for cancer-related fatigue. Access to services for managing fatigue was inconsistent across service types, with post-treatment triage a high priority for CRF in some organisations yet not others. Participants identified a need for improved guidelines, enhanced expertise and better access to services for people with CRF. CONCLUSIONS: There is a need for further education in CRF management for a range of health disciplines in oncology and additional resources to facilitate translation of CRF guidelines into clinical practice.

Virtual Delivery of Stepped-Care Cognitive Behaviour Therapy for Cancer Related Fatigue: A Feasibility Study.

PURPOSE: About 1 in 3 people experience persistent fatigue after cancer treatment. People with severe fatigue describe a disabling lack of stamina, anxiety, depression and distressing cognitive changes. Cognitive behavior therapy (CBT) is recommended for people with severe fatigue after cancer treatment, however due to limited resources and lack of available clinicians very few people with cancer have access. This study explored feasibility of a virtual stepped-care CBT program. METHODS: English speaking adults experiencing persistent fatigue who had either completed cancer treatment, or with stable disease on maintenance therapies were recruited. All participants engaged in a 6-week supported self-help program using a CBT workbook targeting fatigue (STEP 1). After the self-help program, participants with severe ongoing fatigue were stepped-up to a telehealth CBT group focused to fatigue led by a Clinical Psychologist (STEP 2). Feasibility and perceived changes were assessed at baseline, 6 and 12 weeks. RESULTS: Of 19 participants, 17 completed STEP 1 and 8 completed STEP 2. Remotely delivered CBT was feasible with high retention, adherence, participant feasibility and satisfaction scores. Cost to deliver STEP 1 was AUD $145 and STEP 2, AUD $280 per participant. Overall, fatigue and self-efficacy improved significantly following STEP 1. Participants with higher baseline fatigue achieved limited improvements with self-help alone, requiring guidance to set achievable goals and reframe cognitions. Fatigue, self-efficacy and mood improved with STEP 2. CONCLUSIONS: Remotely delivered CBT for cancer fatigue was feasible. The effectiveness of stratified rather than stepped CBT approach, based on fatigue severity should be trialed. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ACTRN # 11 12622000420741).

Stepped-care cognitive behaviour therapy program for treating cancer-related fatigue: protocol for a feasibility study.

BACKGROUND: Cancer-related fatigue (CRF) is a commonly experienced and often debilitating side effect of cancer treatment that can persist for years after treatment completion. The benefits of cognitive behaviour therapy (CBT) for CRF are well established; however, these interventions are typically not included in standard clinical care. Traditional CBT is resource-intensive, limiting implementation in hospital settings. Stepped-care approaches can offer benefits to more people, using the same personnel as traditional models. METHOD/DESIGN: This is a single-arm feasibility study. Fifty people with a cancer diagnosis, at least 12 weeks post-treatment or on long-term maintenance treatment, with persistent CRF that is affecting daily activities, will enrol in a stepped-care CBT program. INTERVENTION: The stepped-care program involves two steps. Step 1: All participants begin with a 5-week supported self-management CBT progam targeting fatigue. Step 2: If fatigue remains severe or has changed less than the minimal clinically important difference on the fatigue measure after step 1, participants will be offered four sessions of therapist-directed group CBT. MEASURES: Participants will complete questionnaires at baseline and 6 and 10 weeks. The primary outcome is feasibility of the REFRESH program. The implementation evaluation comprises acceptability, satisfaction, appropriateness, and feasibility of the study intervention, along with administrative data including cost, processes, procedures and implementation. Secondary outcomes are changes in fatigue, quality of life and self-efficacy. CONCLUSION: The REFRESH program will be the first stepped-care CBT intervention for persistent CRF in Australia. Assessing feasibility of REFRESH is an important first step to establishing future implementation and efficacy.

Exploring the Use of Two Brief Fatigue Screening Tools in Cancer Outpatient Clinics.

PURPOSE: Cancer fatigue guidelines recommend routine fatigue screening, with further assessment for people reporting moderate to severe fatigue. There is neither a gold-standard, nor a broadly accepted screening method, and knowledge about the impact of screening on care processes is limited. This study aimed to explore the feasibility of 2 fatigue screening methods and current clinical practice in cancer outpatient clinics. METHODS: Hospital outpatients attending cancer clinics during 1 week completed a five-item survey: a numeric scale for current tiredness, 2 categorical pictorial scales rating tiredness last week and the impact of fatigue (Fatigue Pictogram), screening tool preference and help needed for survey completion. Participant demographics and fatigue documentation by clinical staff for that appointment were extracted from medical records. Analyses used descriptive statistics. Groups were compared using appropriate statistical tests. RESULTS: Over 75% of participants rated their fatigue consistently as mild or significant on both screening tools. Of 1709 eligible outpatients, 533 (31%) completed the survey. Records were audited for 430 (81%) identifiable participants. Over half of the participants reported moderate or severe tiredness either "now" (237, 57%) and/or "last week" (226, 53%). Clinician documentation of fatigue seldom matched self-reports. Fatigue was rated as severe by 103 participants (24%), yet was noted in only 21 (20%) of these individuals' clinical notes. Both screening tools were equally preferred. CONCLUSION: The numeric rating scale and Fatigue Pictogram are equally applicable for screening fatigue in cancer outpatient care. There is a high prevalence of clinically significant fatigue in a hospital outpatient setting that is not documented. Adequate care pathways for further management should be established alongside fatigue screening.

Oncology staff reflections about a 52-year-old staff Christmas choir: constructivist research.

OBJECTIVE: Peter MacCallum Cancer Centre has one of the world's most enduring staff Christmas choirs. Commencing in 1956, the choir performs in a cafeteria, patient wards, and outpatient waiting areas before each Christmas. With recent emphasis on oncology staff support needs the choir's relevance warranted investigation. This constructivist research examined what effect the staff Christmas choir had on the choir members and staff bystanders in 2008. METHODS: Sampling was convenience and purposive. Staff choir members were invited to participate during rehearsals, and staff bystanders were invited at seven choir performances in the hospital. Respondents completed anonymous and semistructured questionnaires and the conductor (of 29 years) was interviewed. The inductive, comparative, and cyclic data analyses were informed by grounded theory and qualitative interrater reliability was performed. RESULTS: Questionnaires from 64 staff were returned. The choir elicited positive emotions, memories, Christmas spirit, hospital community and/or work-life effects for many staff, in a cancer context described as sometimes "overwhelming" and "stressful." Choir members' reactions included stress relief, friendship and feeling rewarded. Bystanders' reactions included feeling uplifted, inspired and moved. Suggestions for future performances were offered, including musical acknowledgement of other religious festivals. Two respondents were concerned about intrusive effects on patients and work practices. DISCUSSION: A staff Christmas choir supported most choir member and staff bystander respondents in an oncology hospital and is recommended in comparable contexts. Further investigation is warranted to extend understanding about Christmas music's effects in palliative care settings.

"The moment is all we have": patients and visitors reflect on a staff Christmas choir.

OBJECTIVE: To examine how performances by the Staff Christmas Choir of the Peter MacCallum Cancer Centre ("Peter Mac") affected inpatients, outpatients and visitors in 2008. DESIGN, SETTING AND PARTICIPANTS: During the Christmas season 2008, the Peter Mac Staff Christmas Choir gave seven performances at the Centre. Locations included inpatient wards, outpatient waiting areas and a cafeteria. To assess their response to the choir, oncology inpatients, outpatients and visitors (including early-departing bystanders) were given anonymous, semi-structured questionnaires during and after performances. To analyse the responses, we used a constructivist research approach informed by grounded theory. MAIN OUTCOME MEASURES: Participants' descriptions of the choir's effects on them. RESULTS: Questionnaires were returned by 111 people. The performances were received favourably by 93.7% of respondents, including nine from Jewish, Hindu or atheist backgrounds. Many said the music aroused positive emotions and memories. Several described transformative thoughts and physical reactions, felt affirmed by the Christmas spirit or message, and/or appreciated the peaceful or enlivened and social atmosphere. The choir also elicited personal perspectives about Christmas and Judaism, and the importance of "enjoying the moment". Only three respondents (2.7%) reported adverse effects, relating to emotional and audible intrusiveness. CONCLUSIONS: The Staff Christmas Choir created a supportive and uplifting atmosphere for many oncology patients and their visitors. However, responses from people from non-Christian backgrounds were limited, and further investigation is warranted to extend our understanding of the effect of Christmas music in Australian public health settings.

How can occupational therapists measure outcomes in palliative care?

The objective of this paper is to identify an outcome measure for occupational therapy interventions with palliative clients, in particular Home Assessments. Several possibilities beyond traditional functional measures are considered, and the notion of quality of life (QoL) as a potential measure and routine part of assessment is discussed.A systematic literature search resulted in 45 QoL tools that might be suitable for palliative care. The validation or development papers for these tools were closely examined. Twenty-four instruments met the inclusion criteria for further consideration for use by occupational therapists. The research found that it may be feasible for occupational therapists to use a QoL tool as a routine part of assessing each palliative patient, with the objective of focusing interventions to priority areas identified by the patient. Further work in this area will identify a range of established and validated methods of assessing QoL, suitable for different stages within the palliative phase of illness for purposes including assessment, support and targeted interventions.