Support Care Cancer DOI 10.1007/s00520-015-2723-8
ORIGINAL ARTICLE
Cancer-related fatigue: a survey of health practitioner knowledge and practice Elizabeth J. M. Pearson 1 & Meg E. Morris 2 & Carol E. McKinstry 3
Received: 11 February 2015 / Accepted: 23 March 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose This study aims to identify the current practices of health professionals in the assessment and treatment of cancerrelated 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 posttreatment triage a high priority for CRF in some organisations yet not others. Participants identified a need for improved
Electronic supplementary material The online version of this article (doi:10.1007/s00520-015-2723-8) contains supplementary material, which is available to authorized users. * Elizabeth J. M. Pearson [email protected] 1
La Trobe Rural Health School, College of Science, Health and Engineering, La Trobe University, Bundoora, Victoria 3086, Australia
2
Allied Health, College of Science, Health and Engineering, La Trobe University, Bundoora, Victoria 3086, Australia
3
La Trobe Rural Health School, College of Science, Health and Engineering, La Trobe University, Bendigo, Victoria 3552, Australia
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. Keywords Cancer . Fatigue . Practice . Knowledge . Survey . Health professional
Introduction Fatigue is a common and debilitating symptom of cancer [1], and the assessment and management of cancer-related fatigue (CRF) is central to contemporary cancer care [2]. Research from several health disciplines has contributed to the current evidence-based guidelines for treating CRF, yet studies in the USA and Europe indicate guidelines may be inconsistently implemented [3–5]. While the body of evidence supporting interventions for CRF is growing, there has been limited research into how clinicians assess and treat CRF. An interprofessional approach using interventions tailored to individuals’ needs is arguably optimal [1]. On examination, current guidelines lack clarity surrounding the specific roles of different health care professionals involved in assessing or treating CRF, such as medical practitioners, nurses, occupational therapists, physiotherapists and psychologists. It is recommended that scope of practice for health professionals and clear referral pathways be locally defined for implementation of comprehensive care models for CRF [6]. This study seeks to identify current practice as well as barriers and solutions to optimal care for those with CRF. The main purpose of this study was to explore clinical assessment and management of CRF to inform the design of
Support Care Cancer
comprehensive cancer care. The research questions for this study were—what do health practitioners know about CRF; how do they assess and treat CRF; and what are perceived barriers to optimal treatment?
Methods A cross-sectional survey was developed to obtain data from Australian health professionals who worked with people with a cancer diagnosis in their practice. Using a Question Appraisal System methodology described by Willis [7], questions were drafted to gather data to answer the research questions including as few items as possible to encourage completion of the survey [8]. The survey was tested using cognitive interviews with five current or recently practising health professionals to increase rigour and reduce ambiguity in question and answer choices [7]. Cognitive interviews required participants to ‘think out loud’ about their responses, and the interviewer used probe questions to clarify thoughts. Post-graduate university students were recruited via posters and electronic mail. Several minor amendments were made following cognitive interviews with one nurse and four allied health professionals. The final survey, comprising 20 questions, was entered into Qualtrics® survey software to enable electronic distribution. For ease of completion and to obtain maximum data, the respondents were able to skip redundant items and add comments in the ‘other’ category for most questions. The question categories and number of items are listed below. See Appendix 1 for the survey. Survey question categories 1. Demographic details of the respondent: age, gender, professional discipline, years of experience and Australian state (five questions) 2. Details relating to practice setting: type of facility/service, practice involving clients with cancer and referral management processes (five questions) 3. Knowledge and practice relating to CRF: guideline use, proactive screening for CRF, screening or assessment tools, outcome measures and knowledge of interventions (eight questions) 4. Barriers to practice: perceptions and suggestions to overcome barriers and facilitate CRF management (two questions) To obtain a broad representation of health professional disciplines across Australia, eight national professional associations and oncology societies were approached to distribute the survey in routine electronic communications between January and April 2014. Six organisations distributed the survey: the Australian Physiotherapy Association, Cancer
Nurses Society of Australia, Exercise and Sports Science Australia, Occupational Therapy Australia, Palliative Care Australia and Psycho-Oncology Cooperative Group. A link to the survey was also posted on the staff intranet of a specialist cancer hospital for 2 weeks. Health professionals who had practiced within the past 12 months and encountered people with cancer in their practice were eligible to participate. Consent to participate was implied by survey completion. Timely completion was encouraged by a one in five chances to receive a cinema ticket for the first 100 respondents. Ethical approval for the study was obtained from La Trobe University (Australia), Faculty of Health Sciences ethics committee (FHEC13/216). Data analysis Survey data were exported into Microsoft Excel® to enable data analysis. Due to the broad sample of cancer health professionals and small numbers within most disciplines, analysis was limited to descriptive statistics and tests of statistical significance were not performed. Sum, average and standard deviations were extracted as relevant to each question and percentages were calculated. Qualitative thematic analysis was applied to free-text data in the final two questions, because of its suitability for analysis of fragmented text [9]. Thematic analysis used open coding of data and categorisation of codes to develop themes as described by Elo and Kyngäs [10]. Codes were counted to determine frequency of similar views.
Results Survey participants Of the 129 participants who commenced the electronic survey, 112 completed the survey. Sixty-six allied health professionals, 44 nurses and ten medical practitioners participated. Others included a music therapist, a radiotherapist, a counsellor, two pastoral workers and three research or project officers. The average age of participants was 43.2 years, 94 % were female and their average years practising was 16.2 (range 1.5–50). Most participants practiced in a metropolitan location. Participants practiced in six Australian states or territories with most from Victoria. Table 1 summarises participant demographics. Participants (n =127) reported their clinical practice settings as acute hospital 40 %, community health 15 %, palliative care centre 14 % and private practice 9 %. A range of other practice settings was reported by 17 % of participants, including domiciliary and rehabilitation services. Thirty-nine per cent indicated that they worked in a specialist oncology setting.
3
3.3
9.1
SD
1
4 1 9
10 50 40.0 31-53 13.2 9 1 5
Doctor
7.2
8.3
SD
7 1
44 95 45.3 24-68 21.8 24 20 5 3 7 19 10 36
Nurse
11.5
10.5
SD
6
13
19
19 100 35.0 24-49 9.6 18 1
OT
8.7
9.2
SD
4 1
11 82 44.1 33-53 21.8 10 1 1 3 1 3 3 7
PT
8.6
7.3
SD
5
1 13
18 100 41.7 27-62 10.9 13 5 13 3 1
Psych
8.1
12.1
SD
2 1
13 77 47.8 27-61 16.3 8 5 3 1 3 4 2 10
SW
10.1
11.7
SD
1
2 1 4 2 7
9 89 46.4 27-68 11.1 9 0
Other
b
a
Clinical contact with oncology clients
Some respondents did not state their age
ACT Australian Capital Territory, EP exercise physiologist, OT occupational therapist, PT physiotherapist, Psych psychologist, SD standard deviation, SW social worker
Weekly to monthly contactb Occasional contactb
2 1 2
5 20 33.6 25-49 7.3 3 2 1 1
EP
Survey participant demographics
Number of participants Percentage of female participants Mean age (N=126)a Age range (years) Years of practice Metropolitan Rural/regional New South Wales and ACT Queensland South Australia Victoria Western Australia Daily contactb
Table 1
9.1
16.5
SD
28 4
129 94 43.2 24-68 16.2 94 35 28 13 13 55 20 97
Total
(22 %) (3 %)
10.8 (73 %) (27 %) (22 %) (10 %) (10 %) (43 %) (16 %) (76 %)
11.5
SD/(%)
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Support Care Cancer
Health professionals’ knowledge and expertise in cancer-related fatigue Fifteen percent of the sample reported receiving specialist education on CRF. A further 68 % of participants had some knowledge of CRF, either through reading journal articles, undergraduate coursework, informal learning in the workplace or personal experience of CRF. Participants were asked to list up to five interventions for CRF, with 27 % able to name five interventions while 28 % listed none. Participants’ awareness of fatigue management strategies was focused to their discipline practice area. Occupational therapists listed the most CRF interventions. Significantly fewer participants in acute hospital settings listed three to five CRF interventions compared with participants in both specialist oncology and combined sub-acute/communitybased settings (Chi-squared test, p
ORIGINAL ARTICLE
Cancer-related fatigue: a survey of health practitioner knowledge and practice Elizabeth J. M. Pearson 1 & Meg E. Morris 2 & Carol E. McKinstry 3
Received: 11 February 2015 / Accepted: 23 March 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose This study aims to identify the current practices of health professionals in the assessment and treatment of cancerrelated 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 posttreatment triage a high priority for CRF in some organisations yet not others. Participants identified a need for improved
Electronic supplementary material The online version of this article (doi:10.1007/s00520-015-2723-8) contains supplementary material, which is available to authorized users. * Elizabeth J. M. Pearson [email protected] 1
La Trobe Rural Health School, College of Science, Health and Engineering, La Trobe University, Bundoora, Victoria 3086, Australia
2
Allied Health, College of Science, Health and Engineering, La Trobe University, Bundoora, Victoria 3086, Australia
3
La Trobe Rural Health School, College of Science, Health and Engineering, La Trobe University, Bendigo, Victoria 3552, Australia
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. Keywords Cancer . Fatigue . Practice . Knowledge . Survey . Health professional
Introduction Fatigue is a common and debilitating symptom of cancer [1], and the assessment and management of cancer-related fatigue (CRF) is central to contemporary cancer care [2]. Research from several health disciplines has contributed to the current evidence-based guidelines for treating CRF, yet studies in the USA and Europe indicate guidelines may be inconsistently implemented [3–5]. While the body of evidence supporting interventions for CRF is growing, there has been limited research into how clinicians assess and treat CRF. An interprofessional approach using interventions tailored to individuals’ needs is arguably optimal [1]. On examination, current guidelines lack clarity surrounding the specific roles of different health care professionals involved in assessing or treating CRF, such as medical practitioners, nurses, occupational therapists, physiotherapists and psychologists. It is recommended that scope of practice for health professionals and clear referral pathways be locally defined for implementation of comprehensive care models for CRF [6]. This study seeks to identify current practice as well as barriers and solutions to optimal care for those with CRF. The main purpose of this study was to explore clinical assessment and management of CRF to inform the design of
Support Care Cancer
comprehensive cancer care. The research questions for this study were—what do health practitioners know about CRF; how do they assess and treat CRF; and what are perceived barriers to optimal treatment?
Methods A cross-sectional survey was developed to obtain data from Australian health professionals who worked with people with a cancer diagnosis in their practice. Using a Question Appraisal System methodology described by Willis [7], questions were drafted to gather data to answer the research questions including as few items as possible to encourage completion of the survey [8]. The survey was tested using cognitive interviews with five current or recently practising health professionals to increase rigour and reduce ambiguity in question and answer choices [7]. Cognitive interviews required participants to ‘think out loud’ about their responses, and the interviewer used probe questions to clarify thoughts. Post-graduate university students were recruited via posters and electronic mail. Several minor amendments were made following cognitive interviews with one nurse and four allied health professionals. The final survey, comprising 20 questions, was entered into Qualtrics® survey software to enable electronic distribution. For ease of completion and to obtain maximum data, the respondents were able to skip redundant items and add comments in the ‘other’ category for most questions. The question categories and number of items are listed below. See Appendix 1 for the survey. Survey question categories 1. Demographic details of the respondent: age, gender, professional discipline, years of experience and Australian state (five questions) 2. Details relating to practice setting: type of facility/service, practice involving clients with cancer and referral management processes (five questions) 3. Knowledge and practice relating to CRF: guideline use, proactive screening for CRF, screening or assessment tools, outcome measures and knowledge of interventions (eight questions) 4. Barriers to practice: perceptions and suggestions to overcome barriers and facilitate CRF management (two questions) To obtain a broad representation of health professional disciplines across Australia, eight national professional associations and oncology societies were approached to distribute the survey in routine electronic communications between January and April 2014. Six organisations distributed the survey: the Australian Physiotherapy Association, Cancer
Nurses Society of Australia, Exercise and Sports Science Australia, Occupational Therapy Australia, Palliative Care Australia and Psycho-Oncology Cooperative Group. A link to the survey was also posted on the staff intranet of a specialist cancer hospital for 2 weeks. Health professionals who had practiced within the past 12 months and encountered people with cancer in their practice were eligible to participate. Consent to participate was implied by survey completion. Timely completion was encouraged by a one in five chances to receive a cinema ticket for the first 100 respondents. Ethical approval for the study was obtained from La Trobe University (Australia), Faculty of Health Sciences ethics committee (FHEC13/216). Data analysis Survey data were exported into Microsoft Excel® to enable data analysis. Due to the broad sample of cancer health professionals and small numbers within most disciplines, analysis was limited to descriptive statistics and tests of statistical significance were not performed. Sum, average and standard deviations were extracted as relevant to each question and percentages were calculated. Qualitative thematic analysis was applied to free-text data in the final two questions, because of its suitability for analysis of fragmented text [9]. Thematic analysis used open coding of data and categorisation of codes to develop themes as described by Elo and Kyngäs [10]. Codes were counted to determine frequency of similar views.
Results Survey participants Of the 129 participants who commenced the electronic survey, 112 completed the survey. Sixty-six allied health professionals, 44 nurses and ten medical practitioners participated. Others included a music therapist, a radiotherapist, a counsellor, two pastoral workers and three research or project officers. The average age of participants was 43.2 years, 94 % were female and their average years practising was 16.2 (range 1.5–50). Most participants practiced in a metropolitan location. Participants practiced in six Australian states or territories with most from Victoria. Table 1 summarises participant demographics. Participants (n =127) reported their clinical practice settings as acute hospital 40 %, community health 15 %, palliative care centre 14 % and private practice 9 %. A range of other practice settings was reported by 17 % of participants, including domiciliary and rehabilitation services. Thirty-nine per cent indicated that they worked in a specialist oncology setting.
3
3.3
9.1
SD
1
4 1 9
10 50 40.0 31-53 13.2 9 1 5
Doctor
7.2
8.3
SD
7 1
44 95 45.3 24-68 21.8 24 20 5 3 7 19 10 36
Nurse
11.5
10.5
SD
6
13
19
19 100 35.0 24-49 9.6 18 1
OT
8.7
9.2
SD
4 1
11 82 44.1 33-53 21.8 10 1 1 3 1 3 3 7
PT
8.6
7.3
SD
5
1 13
18 100 41.7 27-62 10.9 13 5 13 3 1
Psych
8.1
12.1
SD
2 1
13 77 47.8 27-61 16.3 8 5 3 1 3 4 2 10
SW
10.1
11.7
SD
1
2 1 4 2 7
9 89 46.4 27-68 11.1 9 0
Other
b
a
Clinical contact with oncology clients
Some respondents did not state their age
ACT Australian Capital Territory, EP exercise physiologist, OT occupational therapist, PT physiotherapist, Psych psychologist, SD standard deviation, SW social worker
Weekly to monthly contactb Occasional contactb
2 1 2
5 20 33.6 25-49 7.3 3 2 1 1
EP
Survey participant demographics
Number of participants Percentage of female participants Mean age (N=126)a Age range (years) Years of practice Metropolitan Rural/regional New South Wales and ACT Queensland South Australia Victoria Western Australia Daily contactb
Table 1
9.1
16.5
SD
28 4
129 94 43.2 24-68 16.2 94 35 28 13 13 55 20 97
Total
(22 %) (3 %)
10.8 (73 %) (27 %) (22 %) (10 %) (10 %) (43 %) (16 %) (76 %)
11.5
SD/(%)
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Health professionals’ knowledge and expertise in cancer-related fatigue Fifteen percent of the sample reported receiving specialist education on CRF. A further 68 % of participants had some knowledge of CRF, either through reading journal articles, undergraduate coursework, informal learning in the workplace or personal experience of CRF. Participants were asked to list up to five interventions for CRF, with 27 % able to name five interventions while 28 % listed none. Participants’ awareness of fatigue management strategies was focused to their discipline practice area. Occupational therapists listed the most CRF interventions. Significantly fewer participants in acute hospital settings listed three to five CRF interventions compared with participants in both specialist oncology and combined sub-acute/communitybased settings (Chi-squared test, p
