de Nijs, E. J., Ros, W., & Grijpdonck, M. H. (2008). Nursing intervention for fatigue during the treatment for cancer. Cancer Nursing, 31, 191–208.

To conduct a systematic review to identify which nursing interventions are used to reduce fatigue caused by cancer treatment and to identify the level of evidence for those interventions.

Databases searched were PubMed and CINAHL (1995–February 2005).

Search keywords were cancer, cancer treatment, chemotherapy, distraction, education, exercise, fatigue, nursing intervention, radiotherapy, and sleep promotion.

Studies were included in the review if 

• The intervention was performed by nurses
• The study was conducted by nurses
• The intervention was performed with adults
• The intervention was performed during cancer treatment.

An initial search was performed to find systematic reviews. No reviews of studies meeting the inclusion criteria were found. A second search to locate intervention studies yielded 192 studies in CINAHL and 78 in PubMed. Screening for inclusion criteria resulted in the identification of 18 studies that were then included in the review. Ten studies reported the effects of exercise, five reported education and counseling, two reported distraction and relaxation, and one reported sleep promotion.

The sample was comprised of 904 patients across 18 studies.

Exercise Studies

• Sample sizes varied from 22 to 119 patients.
• Kind of exercise varied from a seated video exercise program to an aerobic program at home or in a supervised clinic.
• Intensity of exercise varied.
• Patient adherence to exercise programs was a problem, and not all studies accounted for this factor.
• Only five studies divided patients into exercisers and nonexercisers based on usual activity. 
• Five studies demonstrated significant effects in the intervention group.
• One qualitative study was found in which fatigue changed from a negative to a positive experience with exercise, and patients experienced increased physical activity and increased level of energy.

Education and Counseling

• Three studies were randomized, controlled trials (RCTs), one used a pre-/posttest design, and one was longitudinal.
• Information was provided on tape, by telephone, or in person.
• Information was given in 3 to 10 sessions and included information about other symptoms in addition to fatigue in four out of the five studies.
• In two studies, fatigue increased with the intervention, and in three studies, a decrease was found in the experimental group.
• Talking to someone was an important aspect, a trend associated with group interaction was found, and one study found a significant effect over time.

Distraction and Relaxation

• One RCT used relaxation breathing every day for six weeks in patients who received stem cell transplantation. The intervention group experienced significantly less fatigue.
• One crossover design study used virtual reality during intravenous chemotherapy treatment. There was a significant effect, but the posttest was performed immediately after treatment.

Sleep Promotion

• One study used a pre-/posttest design using an individualized sleep promotion plan. No significant effects were found.

Sleep promotion was identified as a promising intervention despite the single study results because other studies have shown a relationship between fatigue and sleep disorders. More research is warranted in this area. Lack of effect seen with education and counseling studies may be due to small sample sizes, lack of equivalent control groups, and lack of sensitivity in fatigue measurement. It is also possible that education alone is not enough to change patient behavior. Exercise is shown to be effective, but nothing is known about the long-term effects of exercise after treatment and whether exercise can prevent the beginning of fatigue. Adherence to exercise programs is an area that requires attention. No data were available regarding the level of activity prior to cancer treatment, which might influence the findings in this area.

• None of the studies used a theoretical framework, likely explained by the fact that no satisfactory theory has been formulated to explain fatigue in this population. Some studies did not even use a definition of fatigue.
• Fatigue was measured differently, and three different measures were used.
• In two-thirds of the studies, the sample was breast cancer patients receiving chemotherapy, limiting the external validity of the findings.
• Half of the studies had very small sample sizes of less than 30 patients.
• Study of distraction and relaxation was limited by the timing of fatigue measurement.
• No long-term effects or ongoing intervention was studied.

There are several promising interventions that can be provided by nurses. It is likely that a combination of interventions may be most helpful for patients. More research is specifically needed on the effects of interventions that enhance the quality of sleep, education, and counseling related to fatigue management and prevention.