Lessons learned from the delivery of virtual integrative oncology interventions in clinical practice and research during the COVID-19 pandemic.

The outbreak of the coronavirus disease 2019 (COVID-19) and subsequent need for disease transmission mitigation efforts have significantly altered the delivery of cancer care (e.g., rise of telemedicine), including within the field of integrative oncology. However, little has been described about how National Cancer Institute-Designated Cancer Centers have transformed integrative oncology care delivery in response to the COVID-19 pandemic. The purpose of this commentary is to describe the delivery of integrative oncology clinical services and conduct of research at The Leonard P. Zakim Center for Integrative Therapies and Healthy Living at Dana-Farber Cancer Institute during the COVID-19 pandemic. Clinical services transitioned from an array of in-person appointment-based services, such as acupuncture and massage, and group programs, such as yoga and nutrition seminars to a combination of live-streamed and on-demand virtual group programs and one-on-one virtual appointments for services such as acupressure and self-care massage. Group program volume grew from 2189 in-person program patient visits in the 6 months prior to onset of the COVID pandemic to 16,366 virtual (e.g., live-streamed or on-demand) patient visits in the first 6 months of the pandemic. From a research perspective, two integrative oncology studies, focused on yoga and music therapy, respectively, were transitioned from in-person delivery to a virtual format. Participant accrual to these studies increased after the transition to virtual consent and intervention delivery. Overall, our clinical and research observations at Dana-Farber Cancer Institute suggest that the delivery of virtual integrative oncology treatments is feasible and appealing to patients. Trial Registration: NCT03824860 (Yoga); NCT03709225 (Music Therapy).

Systematic Review: Expressive arts interventions to address psychosocial stress in healthcare workers.

AIMS: To synthesize evidence about the effectiveness of expressive arts interventions used to reduce psychosocial stress among healthcare workers. DESIGN: Quantitative systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES: SocINDEX, PsycINFO, Pubmed, CINAHL. REVIEW METHODS: Databases were searched from 1997-2017. Fourteen studies met the criteria for final selection. RESULTS: Most studies occurred in the US (N = 11). Of the 897 participants, 59% were nurses. Two studies were randomized controlled trials and the others were a variation of a 1-group or 2-group pre- or quasi-experimental study. The intervention characteristics included 50% art-based, 29% music-based, and 21% used storytelling or narrative. The length of intervention varied from 1 hr to 13 weeks; 5 lasted 6 weeks. Improved outcomes were found in 13 of 14 studies reviewed and the greatest improvements were seen in burnout, stress, and emotional outcomes. Overall, music and art-based interventions had greater impact on well-being than storytelling or narrative. CONCLUSIONS: This systematic review provides preliminary evidence for the effectiveness of expressive arts interventions. IMPACT: Care for others is a preeminent value in health care; however, this can come at the expense of caring for oneself. Psychosocial stress poses a significant threat to the well-being of the healthcare workforce. Expressive arts interventions provide a creative means for reducing caregiver stress to remain well and able to provide high quality care to patients. The use of arts for healing has global application because expressive arts intervention can be culturally tailored and relevant.

Expressive Arts Interventions to Improve Psychosocial Well-Being in Caregivers: A Systematic Review.

CONTEXT: Over 43 million caregivers provide care and support in the United States. Increased stress and burden may contribute to poor psychosocial well-being. Recently, there has been an emergence of art-based interventions to improve well-being among care receivers and caregivers. A synthesis of this literature evaluating expressive arts interventions (EAIs) with caregivers is needed. OBJECTIVES: Identify the nature and impact of EAIs for caregivers and outline directions for future research. METHODS: Systematic searches were conducted in PubMed/MEDLINE, CINAHL, PsychINFO, and Web of Science for relevant studies between 2001 and 2022. Inclusion criteria included EAI addressing psychosocial well-being of caregivers, quantitative and mixed methods studies, and written in English. RESULTS: Twenty-seven studies were included (1359 participants). There was a diverse global representation of countries (n = 14). Twelve studies were randomized controlled trials. The majority (n = 11) were conducted with dementia/alzheimers caregivers and 41% (n = 11) were delivered to the caregiver/receiver dyad. Fifty-nine percent of the EAIs were music-based, 22% were visual arts, and 10% were writing. Intervention length varied from a single one-hour session to biweekly for 10-months; eight lasted two-weeks. Overall, stress improved in 80% of the studies, anxiety in 69%, caregiver burden in 57%, and depressive symptoms in 31%. CONCLUSION: Caregivers are essential to the care of people with medically complex and life-limiting conditions. EAIs hold the potential to improve psychosocial outcomes for caregivers, are used globally, and can be culturally tailored. Future research should examine intervention duration and intensity, measures to address additional dimensions of psychsocial well-being, and implementation in additional caregiver populations.

A Systematic Review and Meta-analytic Evaluation of Moral Distress in Oncology Nursing.

BACKGROUND: Weighing implications of multiple intensive cancer-directed therapies over time, oncology nurses are more prone to intrinsic distress compared to nurses in non-oncologic settings. This vulnerability may give rise to moral distress. Yet, little is known about moral distress experiences of oncology nurses. OBJECTIVE: This systematic review and meta-analysis examined the frequency and intensity of moral distress among oncology nurses with an exploratory focus on nurse-level and work-related characteristics. METHODS: We conducted a systematic search of 7 electronic databases (2000-2020) supplemented by hand-search strategy. Means and standard deviations of moral distress scores in the included studies were extracted and pooled in our meta-analysis. RESULTS: Our sample of 8 cross-sectional studies consisting of 2686 participants with 1654 oncology nurses met criteria for inclusion. A random-effects model was used in our meta-analysis given considerable heterogeneity. Our results suggest that moral distress was of low to moderate frequency, but of high intensity. Moral distress among oncology nurses was a significant predictor for burnout, provider communication, decisions surrounding end-of-life care, work conditions (eg, patient assignment, type of unit), and inability to provide compassionate care. CONCLUSION: Moral distress in oncology nurses is associated with burnout syndrome, compassion fatigue, and secondary traumatic stress syndrome, all of which are linked to poor patient care and outcomes. Robust psychological well-being is critical in minimizing unintended consequences of moral distress. IMPLICATIONS FOR PRACTICE: Oncology nurses are at high risk for moral distress due to the nature of their work. Future studies should examine the prevalence among oncology nurses to help inform targeted interventions.

Exploring Young Adults' Perspectives of Participation in a Mindfulness-Based Music Therapy Intervention Before and During the COVID-19 Pandemic.

Purpose: To explore adolescent and young adults' (AYAs) experiences with participation in a mindfulness-based music therapy intervention during cancer treatment before and during the COVID-19 pandemic. Methods: Sixteen young adults (20-39 years old) who received cancer treatment and participated in a mindfulness-based music therapy intervention for anxiety and stress were interviewed using a semistructured interview guide. Interviews were audio recorded and transcribed verbatim. The interview guide contained prompts about reasons for joining the study, usual coping strategies, experience with the in-person and virtual delivery formats of the intervention, and suggestions for improvement. Themes were derived from the data using inductive content analysis methods. Results: Findings from the interviews included the following: (1) virtual group participants reported difficulty finding a private place to attend the intervention sessions, (2) participants experienced a sense of relaxation in response to intervention participation, (3) in-person group participants felt a sense of connection to the music and their family members who were present during the intervention, while virtual group participants felt a sense of connection to mindfulness, (4) virtual group participants reported that practicing music and mindfulness together was synergistic, and (5) in-person intervention delivery was preferred to virtual intervention delivery. Conclusion: This study provides insight into the contextual factors that impact satisfaction with the intervention and the effect of the intervention on anxiety and stress. Overall, while virtual mindfulness-based music therapy delivery may be more feasible, there are still important advantages to in-person delivery that should be considered in the design of future mindfulness-based music therapy interventions. ClinicalTrials.gov Identifier: NCT03709225.

Exploring Influencing Factors of Anxiety Improvement Following Mindfulness-Based Music Therapy in Young Adults with Cancer.

The purpose of this secondary analysis was to explore physiological, psychological, and situational influencing factors that may affect the impact of a mindfulness-music therapy intervention on anxiety severity in young adults receiving cancer treatment. Young adults receiving cancer treatment for ≥ eight weeks were recruited from adult and pediatric oncology outpatient centers at Dana-Farber Cancer Institute. Participants were asked to attend up to four, in-person (offered virtually via Zoom video conference after the onset of the COVID-19 pandemic) 45-min mindfulness-based music therapy sessions over twelve weeks with a board-certified music therapist. Participants completed questionnaires about anxiety, stress, and other cancer treatment-related outcomes before and after participating in the intervention. Changes in anxiety (i.e., PROMIS Anxiety 4a) over time were compared among baseline physiological (e.g., age or sex), psychological (e.g., stress), and situational influencing (i.e., intervention delivery format) factors using Wilcoxon-rank sum tests. Thirty-one of the 37 enrolled participants completed the baseline and post-intervention measures and were eligible for inclusion in the secondary analysis. Results revealed that higher baseline physical functioning (median change = -6.65), anxiety (median change=-5.65), fatigue (median change = -5.6), sleep disturbance (median change = -5.6),female sex (median change = -5.15), or virtual intervention delivery(median change = -4.65) were potential physiological, psychological, or situational influencing factors associated with anxiety improvement following mindfulness-based music therapy. Additional investigation into physiological, psychological, or situational influencing factors associated with anxiety response will help to tailor the design of future mindfulness-music therapy interventions to decrease psychological distress and address the unique psychosocial concerns among young adults receiving cancer treatment. Trial Registration ClinicalTrials.gov Identifier: NCT03709225.

Exploring the Feasibility of a Mindfulness-Music Therapy Intervention to Improve Anxiety and Stress in Adolescents and Young Adults with Cancer.

CONTEXT: Adolescent and young adults (AYAs) with cancer experience significant psychological distress due to cancer treatment that can persist long after treatment. However, little is known regarding optimal interventions to support the psychosocial needs of AYAs with cancer. OBJECTIVE: The overall objective of this single arm, longitudinal, pilot study was to determine the feasibility of implementing a mindfulness-based music therapy intervention to improve anxiety and stress in AYAs receiving cancer treatment. METHODS: AYAs (15 - 39 years old) who were to receive cancer treatment for ≥ eight weeks were recruited from the pediatric, melanoma, sarcoma, breast, lymphoma, and leukemia oncology outpatient centers at Dana-Farber Cancer Institute. The music therapy intervention included four sessions of individual mindfulness-based music therapy in-person or using Zoom over twelve weeks. Prior to-and after the intervention period, participants completed the Patient-Reported Outcomes Measurement Information Anxiety 4a and Perceived Stress Scale. Changes in patient-reported outcomes are compared using Wilcoxon signed-rank tests. RESULTS: Over ∼14 months, 37 of 93 eligible AYAs were enrolled to the study (39.8% consent rate). Overall, 27 of 37 (73%) participants (Median age=32; 56.8% Female) completed at least two music therapy sessions and the baseline measures and end of study measures. Participation in the mindfulness-based music therapy sessions resulted in significant pre-to-posttest improvements in perceived stress (median change: -4.0, P = 0.013) and non-significant changes in anxiety (median change: -1.9, P = 0.20). Satisfaction and acceptability were highly rated. CONCLUSIONS: The delivery of a four-session mindfulness-based music therapy intervention to AYAs receiving chemotherapy was feasible and significantly improved perceived stress. These preliminary findings should be confirmed in a randomized controlled trial. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03709225.

Psychosocial Well-Being: An Exploratory Cross-Sectional Evaluation of Loneliness, Anxiety, Depression, Self-Compassion, and Professional Quality of Life in Oncology Nurses.

BACKGROUND: In addition to heavy workloads, oncology nurses are confronted with emotionally demanding caregiving moments with little training or institutional support for coping and emotional well-being. OBJECTIVES: The aim of this study was to explore the associations and potential predictors among self-compassion, loneliness, anxiety, depression, and professional quality of life in oncology nurses. METHODS: Participants were recruited throughout central Texas. Descriptive statistics, bivariate correlations, and multivariate regression analyses were conducted on survey data. FINDINGS: Burnout and compassion satisfaction were strongly related to loneliness, self-compassion, and depression. Compassion fatigue was most highly related to anxiety and depression. Loneliness made the strongest unique contribution to burnout and compassion satisfaction, and depression was the only statistically significant predictor of compassion fatigue.

Storytelling Through Music to Improve Well-being in Oncology Nurses: A Feasibility Study.

BACKGROUND: Professional grief is one cause of psychosocial stress that, if not attended to, may contribute to burnout and compassion fatigue. Oncology nurses often avoid their emotions and learn to cope with professional grief in isolation. Interventions aimed at professional grief are limited. OBJECTIVES: To determine the feasibility of implementing a multidimensional intervention, Storytelling Through Music, with oncology nurses. INTERVENTION/METHODS: This was a 2-group, quasi-experimental design utilizing both qualitative and quantitative methods. The 6-week intervention combined storytelling, reflective writing, music, and psychoeducation. Descriptive statistics and conventional content analysis were used to analyze the feasibility data. RESULTS: Most participants (n = 43) were female, white, working full-time in the outpatient oncology setting, with an average 8.5 years (range, 2-36 years) of oncology experience. Ninety-eight percent of the intervention was completed, and 98% of participants were retained. Analysis indicates that the intervention was acceptable, the participants learned they were not alone in their feelings, and they were supported by the group. CONCLUSIONS: Results indicate that Storytelling Through Music is a feasible and acceptable intervention to address work-related emotions and psychosocial stress in this group of oncology nurses. IMPLICATIONS FOR PRACTICE: In 2017, the National Academy of Medicine stated clinician well-being must be a priority. Participation in this study was independently sought out by the oncology nurses and completed during their personal time. A future policy recommendation is to make participation in wellness interventions part of the mandatory competency training required by accrediting bodies so that institutions ensure the well-being of clinicians as a priority.

Adapting a health behavioral change and psychosocial toolkit to the context of physical disabilities: Lessons learned from disabled women with young children.

BACKGROUND: Mothers with physical disabilities (MPDs) face the behavioral and psychosocial changes of the motherhood transition with fewer resources, additional barriers, and higher risks than nondisabled mothers. In this study we sought guidance from MPDs on adaptations needed to a health promotion toolkit for behavioral and psychosocial health that was originally developed for nondisabled, primarily low-income, women. OBJECTIVE: To identify general themes for adaptations that would increase the suitability of the toolkit for MPDs. METHODS: 11 MPDs were interviewed by videoconferencing in a mixed-methods study about their perspectives on improving relevance of the existing toolkit for this population. The toolkit contained three components: assessment scale, feedback template on assessment results, and a decision aid related to behavior change. Interviews were analyzed using qualitative content analysis. RESULTS: Nine themes for improving suitability of the toolkit for MPDs were identified. Themes covered: Using non-judgment language; including strengths, not just risks; using exercise items applicable to persons with physical disabilities; being aware that functional ability was the key body image concern; considering motivational stages of behavioral change; providing choice in goal-setting for change; including suggestions for social support; identifying resources for health and adaptive parenting; and making health promotion resources available in alternative platforms (paper, electronic). CONCLUSIONS: The MPDs' feedback revealed ways that our toolkit for behavioral and psychosocial health could be improved to be inclusive of MPDs. The participatory methods utilized here are also recommended in designing new or revising existing materials aimed at enhancing health promotion for people with disabilities.

Health and Well-Being among Women with Physical Disabilities After Childbirth: An Exploratory Study.

PURPOSE: Although research about pregnancy for women with disabilities has increased, their postpartum experience has received little attention. Studies generally focus on parenting, not on the health of the mothers themselves, despite recent studies underscoring the health risks they may face. Thus, our purpose was to examine postpartum health among women with physical disabilities, including how they maintain or improve their health. METHODS: Semistructured interviews were conducted with eleven new mothers with physically disabling conditions. A qualitative descriptive approach was used to analyze the transcribed interviews and identify themes. RESULTS: Nine women had delivered via cesarean section, and most had mobility impairments. Their average age was 35 years; 91% were college educated and 82% had a partner. Six overarching themes were identified: paying a price to have the baby, focus on the baby, supports-or a lack thereof, feelings of isolation, getting challenges under control/overcoming barriers, and not quite there yet/getting back to health promotion. CONCLUSIONS: Despite their resilience in dealing with the challenges of caring for their babies within the context of their disabling conditions (including recovery from complications from the birth experience), these women clearly identified the need for additional resources and supports. They also recognized limitations to their own health that came along with their parenting responsibilities. Health care providers should be more attuned to the postpartum needs of women with physical disabilities, and policies should provide additional supports such as insurance coverage for home visits to help maximize women's health and well-being during this important life transition.

Riding the Roller Coaster: A Qualitative Study of Oncology Nurses' Emotional Experience in Caring for Patients and Their Families.

BACKGROUND: Rates of burnout and compassion fatigue among oncology nurses are rising, and the emotional impact of the work increases the risk. This study examined how oncology nurses describe the evolution of emotions from first significant patient loss through cumulative patient death. OBJECTIVE: To explore the emotional evolution of being an oncology nurse. METHODS: Semistructured interviews with 7 oncology nurses. Thematic analysis was used to analyze the data. RESULTS: Participant's mean age was 41.3 years, with 13.9 years of nursing experience and 10.6 years of oncology experience. One metatheme, "riding the roller coaster," described the overall emotional experience of the nurses. Three subthemes, "all in and then," "finding your way," and "impact on self," further outlined the process taken to cope with workplace emotions. CONCLUSIONS: Oncology nurses are frequently exposed to loss and suffering. Findings from this study suggest that new nurses are underprepared for the emotional experience of being an oncology nurse. Further, they define their emotional boundaries in isolation and without guidance on how to develop healthy coping skills. Changing the culture of silence around mental health and well-being among healthcare professionals can provide space for important conversations to occur. IMPLICATIONS FOR PRACTICE: Oncology nurses have few resources to teach them how to cope with the emotions experienced while caring for oncology patients. These findings suggest that alternative approaches to the traditional bereavement programs and innovative interventions offered to new oncology nurses within their first few years are needed.

Storytelling Through Music: A Multidimensional Expressive Arts Intervention to Improve Emotional Well-Being of Oncology Nurses.

PURPOSE: Rates of burnout among health care professionals are rising. Oncology nurses are at the forefront of cancer care, and maintenance of their well-being is crucial to delivering high-quality care to people with cancer. The purpose of this pilot study was to implement a novel intervention, Storytelling Through Music, and examine the effects on depression, insomnia, loneliness, self-awareness, self-compassion, burnout, secondary traumatic stress, and compassion satisfaction in oncology nurses. METHODS: This two-group (intervention and control), quasi-experimental study of a 6-week intervention combined storytelling, reflective writing, songwriting, and stress management skills. RESULTS: Participants (N = 43) were predominately white (98%), with 27% reporting Hispanic ethnicity, and female (95%); their average oncology experience was 8.5 years. Both groups improved significantly over time on all measures. Compared with the control group, participants in the intervention group also had significantly less loneliness (F[3, 98] = 7.46; P < .001) and insomnia (F[3, 120] = 5.77; P < .001) and greater self-compassion (F[3, 105] = 2.88; P < .05) and self-awareness (F[3, 120] = 2.42; P < .10). CONCLUSION: There are few opportunities for health care professionals to reflect on the impact of caregiving. The Storytelling Through Music intervention provided a structured space for reflection by participants, individually and among their peers, which decreased loneliness and increased self-compassion. Both factors relate to the burnout that affects the oncology health care workforce.