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The Effect of Education in Managing Side Effects
in Women Receiving Chemotherapy for Treatment
of Breast Cancer
Susan A. Williams, DNS, RN, and Ann M. Schreier, PhD, RN
Key Points . . .
Purpose/Objectives: To determine the effectiveness of informational
audiotapes on self-care behaviors, state anxiety, and use of self-care be-
haviors; to describe the occurrence and intensity of common side ef-
Informational audiotapes can be an effective means for pro-
fects in patients with breast cancer.
viding instruction about self-care behaviors.
Design: Randomized clinical trial.
Patients who used audiotapes demonstrated effective self-care
Setting: Outpatient chemotherapy clinics operated by a university
center in a rural area.
behaviors over time, whereas patients in the control group ap-
Sample: 70 women receiving their first treatment of chemotherapy.
peared to experiment to find effective self-care behaviors.
Methods: Subjects completed demographic data and the Spielberger
Patients who used audiotapes had lower anxiety at each mea-
State-Trait Anxiety Instrument (STAI). The experimental group received
surement point than patients in the control group.
two audiotapes. At one and three months, subjects completed the modi-
fied Nail Self-Care Diary and STAI via telephone.
Main Research Variables: State anxiety, side-effect severity, and
use and efficacy of self-care behaviors.
Findings: The most frequent side effects were fatigue, nausea and
Many patients with cancer experience anxiety related to
vomiting, and taste change. The experimental group reported symp-
their diagnosis and the side effects of chemotherapy (Greene,
tom improvements that were not found in the control group. The ex-
Nail, Fieler, Dudgeon, & Jones, 1994). Anxiety can trigger
perimental group increased the use of recommended self-care behav-
depression, and some researchers have found evidence that
iors, whereas the control group continued to use the same self-care
suggests that women who are depressed may be less able to
behaviors without effectiveness. State anxiety for both groups dimin-
perform self-care behaviors (Siegel, 1997). Teaching patients
ished over time; however, anxiety in the control group was consis-
how to reduce their anxiety may help them to manage side
tently higher.
effects through self-care behaviors (Arakawa, 1997; Blan-
Conclusions: Audiotapes are effective teaching tools. Self-care be-
chard, Courneya, & Laing, 2001; Longman, Braden, &
haviors can be taught and can be effective in managing side effects.
Mishel, 1997; McDaniel & Rhodes, 1998).
Anxiety was high in both groups, but the symptom decreased in the
women who received audiotapes and telephone calls.
Researchers have identified self-care behaviors to manage
Implications for Nursing: Constraints on nurses decrease the length
the common side effects of treatment such as nausea and vom-
of teaching time available, but audiotapes provide effective teaching and
iting (Dodd, 1988; Foltz, Gaines, & Gullatte, 1996; Jordon,
reinforcement of education. Anxiety in clinical environments interferes
1989; Lo, 1990; Nail, Jones, Greene, Schipper, & Jensen,
with patient learning. Teaching effective self-care behaviors enhances
1991), loss of appetite (Foltz et al.), fatigue and sleep prob-
patients' independence, comfort, control, and quality of life.
lems (Foltz et al.; Nail et al.; Skalla & Lacasse, 1992;
hemotherapy often causes serious side effects in
C
Susan A. Williams, DNS, RN, and Ann M. Schreier, PhD, RN, both are
women receiving treatment for breast cancer. Fatigue,
associate professors in the School of Nursing at East Carolina Uni-
nausea and vomiting, sleep disturbances, changes in
versity in Greenville, NC. Support for this research was received from
the Pitt County Chapter of the American Cancer Society (ACS), an
bowel function, and an altered sense of taste are common
ONS Foundation grant supported by GlaxoSmithKline, the Leo
problems. These side effects can be overwhelming. If women
Jenkins Cancer Center, and the ACS Institutional Research Grant.
are unable to develop effective self-care behaviors to manage
(Submitted February 2003. Accepted for publication August 3, 2003.)
these side effects, they may delay or terminate their treatment
regimen prematurely (Dodd, 1997, 1999).
Digital Object Identifier: 10.1188/04.ONF.E16-E23
ONCOLOGY NURSING FORUM VOL 31, NO 1, 2004
E16
motherapy through effective self-care behaviors. Patients who
Winningham, 1991), and anxiety (Devine & Westlake, 1995;
received the intervention were compared to a control group
Poroch, 1995). In addition, education about treatment, side
that received standard care. The study examined the occur-
effects, and self-care behaviors can minimize the side effects
rence and severity of side effects experienced by women with
of chemotherapy, decrease symptom distress, and improve
breast cancer receiving chemotherapy, the effects of educa-
quality of life (Dodd & Dibble, 1993; Hoskins, 1997; Long-
tional audiotapes on the number of self-care behaviors used
man et al., 1996, 1997; Orem, 1995). However, although the
by women to minimize or eliminate these side effects, and the
importance of education for these patients is well recognized,
effects of self-care behaviors in reducing or eliminating side
several factors limit the ability of nurses to provide patients
effects. In addition, the level of anxiety experienced by each
with effective education. In particular, chemotherapy proto-
group was examined.
cols increasingly are performed on an outpatient basis. Infor-
mation about treatment, side effects, and self-care behaviors
Methods
must be provided in a limited time frame (Craddock, Adams,
Usui, & Mitchell, 1999; Griffiths & Leek, 1995). Many pa-
Design
tients have limited attention spans because of fatigue or nau-
sea. Therefore, nurses must rely on written materials for edu-
The study used an experimental design in which subjects
cating these women. Researchers have found that health
were assigned randomly to a treatment or control group after
materials often are written at a reading level that is too ad-
informed consent was obtained. Study approval was received
vanced for many patients to read and comprehend (Baker,
from a university institutional review board, and the study was
Parker, & Clark, 1998; Cooley et al., 1995; Williams et al.,
conducted over a period of three years.
1995). Thus, printed materials used in oncology clinics often
Setting and Sample
are ineffective in meeting the information needs of these pa-
tients (Doak, Doak, & Root, 1996).
The setting for the study was a cancer center in the south-
As a result, researchers have begun to explore alternatives
eastern United States operated by a university medical center
to written materials for teaching patients undergoing chemo-
and a satellite cancer treatment clinic located 70 miles from
therapy (Craddock et al., 1999; McDaniel & Rhodes, 1998;
the medical center. The medical center serves a 29-county
Wydra, 2001). Videotaped information about the manage-
rural area with a diverse population.
ment of chemotherapy side effects can enhance the consis-
All subjects were newly diagnosed with breast cancer, and
tency of patients' adherence to chemotherapy treatments
none previously received chemotherapy. Medical records
(McDaniel & Rhodes). Similarly, through interactive media,
confirmed that the patients had not had prior experience with
Wydra taught patients receiving cancer treatment about self-
cancer or chemotherapy treatments. All were receiving IV
care behaviors related to fatigue and found that patients who
chemotherapy; these chemotherapy regimes included cyclo-
consistently used the media practiced more self-care behav-
phosphamide, methotrexate, and fluorouracil or doxorubicin
iors and experienced less fatigue. Craddock et al. determined
and cytoxan (AC). Subjects were included in the study if they
that patients who received telephone calls from healthcare
were 18 years of age or older; English-speaking; capable of
professionals providing information about self-care behaviors
hearing normal conversation; oriented to time, place, and per-
initiated more self-care measures than patients who did not re-
son; and living in a community setting. All subjects had a rat-
ceive this intervention. Chelf et al. (2001) evaluated the use of
ing of more than 70% on the Karnofsky Performance Scale
computer-assisted learning and printed, telephone, audio, and
and were not receiving any concurrent therapy. Potential sub-
video information for patients with cancer and found that no
jects were identified through oncology breast cancer rounds
one type of information delivery was superior to another.
and by clinic nursing staff. Potential subjects were contacted
Thus, many methods of patient education may be effective.
by one of the researchers, the study was explained, and in-
Structured audiotapes that patients can take home show
formed consent was obtained. The subjects were assigned
promise for assisting outpatients receiving chemotherapy be-
randomly to the control or experimental group, and the date
cause they can be used regardless of literacy. Audiotapes also
and time of the first telephone interview were established.
allow patients to control the amount of information they re-
Intervention
ceive as well as the timing of the education. Patients can re-
play the tapes for information that they do not understand, and
Two 20-minute audiotapes were developed to provide infor-
they can play the tapes when they are less anxious and at
mation about the nutritional management of side effects and
home rather than in the clinic. Hagopian (1996) demonstrated
exercise and relaxation techniques to manage fatigue, anxiety,
that informational audiotapes are an effective educational
and difficulty sleeping. The transcripts of the tapes were written
strategy for teaching self-care behaviors to patients who were
at a fifth-grade reading level in an attempt to present the mate-
receiving radiation therapy.
rial at a level that patients could comprehend. The computerized
Orem's (1995) self-care deficit nursing theory provided the
Flesch Readability Scale was used to determine reading level.
theoretical framework for this study. Orem regarded individu-
The audiotapes were reviewed for clarity and inclusiveness by
als as being responsible for and actively involved in their self-
three professional nurses and three former patients who had
care. Patients engage in self-care to maintain health and well-
been treated for breast cancer. A professional female orator was
being; therefore, to perform self-care, patients must have a
contracted to vocally perform the transcripts, which were re-
learned ability to meet their needs and access to resources to
corded in a sound studio where background music was added.
enhance their knowledge.
Instruments
The study reported here examined the use of a structured
audiotaped educational intervention to assist patients with
Self-care diary (SCD): The SCD (Nail et al., 1991) is a
breast cancer in reducing or relieving the side effects of che-
self-report of occurrence and intensity of side effects and the
ONCOLOGY NURSING FORUM VOL 31, NO 1, 2004
E17
use and effectiveness of self-care behaviors. The instrument
Patients in the experimental group received the standard
measures the number of side effects experienced, severity of
education and care from the clinic staff and were mailed the
each of the side effects experienced, number of self-care be-
audiotapes and a printed SCD. Patients in the experimental
haviors performed for a given side effect, and effectiveness of
group who did not have access to a cassette player were
the self-care behaviors. Content validity of the original instru-
loaned one. Subjects were instructed to listen to the audio-
ment was established by Nail et al. in a study of two patients
tapes 1224 hours prior to the start of a chemotherapy cycle
and three oncology nurse specialists. Foltz et al. (1996) re-
and as often as desired during the entire course of their treat-
ported a test-retest reliability of 0.80.
ment.
For the current study, the SCD was modified by reducing
Three interviewers were trained by the researchers prior to
the number of side effects studied and using a telephone in-
subject enrollment. The interviewers were senior-level nurs-
terview rather than a written survey. In the interest of short-
ing students who were chosen for their interpersonal skills,
ening the SCD and reducing subjects' burden, the less com-
maturity, and scholastic ability. The researchers reviewed the
mon side effects of eye sensitivity, rectal irritation, headache,
project with the interviewers until they were completely famil-
pain at the IV insertion site, and numbness or tingling of the
iar with it. The interviewers rehearsed the telephone inter-
hands and feet were eliminated (Foltz et al., 1996; Nail et al.,
views with the researchers until the interviewers were consis-
1991). Hair loss also was eliminated because of the paucity of
tent in administering the questionnaires.
self-care behaviors to reduce the symptom's severity. The
All subjects were interviewed three times by telephone by
SCD used in this study examined difficulty sleeping, de-
the same interviewer. At interview 1, prior to the first chemo-
creased appetite, constipation, diarrhea, sore mouth, nausea or
therapy treatment, demographic data were obtained and STAI
vomiting, change in taste or smell, anxiety, and fatigue. Nau-
was administered. Interview 2 took place one month after
sea and vomiting self-care measures were grouped together
treatment began, at which time the second state anxiety
because their self-care behaviors were identical.
subscale and first SCD were administered. Interview 3 oc-
A printed version of the modified SCD that corresponded
curred three months after treatment began, at which time the
to the audiotapes was developed for the women to have at
third state anxiety subscale and second SCD were adminis-
home. The modified SCD was written at or below a fifth-
tered. Thus, by the end of the study, each subject had com-
grade level as determined by the Flesch Readability Scale.
pleted one STAI, three state anxiety subscales, and two SCDs.
Because patients found remembering the possible answers for
The surveys were administered in 30 minutes or less.
each question to be difficult, the answers were printed on a
card. Patients were able to refer to the card during the tele-
phone interview.
Table 1. Description of Sample
State-Trait Anxiety Instrument (STAI): STAI (Spiel-
berger, 1983) has been used extensively in assessing anxiety
Control Group
Experimental Group
in medical-surgical, psychosomatic, and psychiatric patients.
(N = 33)
Characteristic
(N = 38)
The state anxiety scale measures transitory anxiety, whereas
the trait anxiety scale measures general anxiety. The score
50.42
Mean age (range = 3074)
50.39
for each item ranges from 14, with 1 indicating low anxiety
n
Characteristic
n
%
%
and 4 indicating high anxiety. An individual's total score on
each scale is obtained by adding the scores for the 20 items.
Marital status
Test-retest and alpha coefficients demonstrate that STAI is a
23
Married
19
58
61
reliable instrument with internal consistency and stability. As-
10
Divorced, separated, or
33
11
27
sessments of concurrent, convergent, divergent, and construct
widowed
1
validity indicate that STAI is a valid instrument (Spielberger).
15
Single, never married
19
13
13
Education level
Procedure
< High school
12
14
14
11
High school graduate
16
10
30
43
Patients in both groups received the standard education pro-
11
Some college
27
19
30
vided to all patients with breast cancer in the clinics. Informa-
16
College graduate or above
30
10
16
tion was given in the chemotherapy clinic at the time of the
Race
patients' first treatment visit when their anxiety most likely
19
African American
36
12
50
was high. The general instructions included information about
19
Caucasian
20
61
50
how to handle more frequent side effects, such as nausea, hair
Hispanic
11
13
loss, and mucositis. The depth of the instructions depended on
Stage
various factors such as the nurse's time and teaching ability
10
I
18
28
37
and the patient's ability to attend and understand the informa-
14
II
17
59
52
12
10
III
13
17
tion. Information was given verbally, and some patients re-
11
11
13
14
IV
ceived printed information published by a national organiza-
Income level
tion. The information given to patients did not include content
17
33
< $19,000
10
53
about fatigue, anxiety, or sleep disturbances, and no standard-
17
17
23
22
$20,000$29,999
ized plan existed about the information that should be pro-
20
13
$30,000$39,999
16
19
vided to patients; therefore, patients received varying amounts
15
> $40,000
23
17
16
of information depending on the situation. Additional side
effects were discussed at later treatment visits as patients re-
Note. Because some data are missing for some variables, the n values may
ported them.
not equal the total N. Because of rounding, percentages may not total 100.
ONCOLOGY NURSING FORUM VOL 31, NO 1, 2004
E18
Table 2. Mean Number of Side Effects Reported
quently experienced side effects of fatigue, nausea and vom-
iting, and taste changes, no significant differences were docu-
Control Group
Experimental Group
mented between groups. However, significant differences
were found in the number of self-care behaviors used for sore
--
--
Self-Care Diary
N
N
X
X
mouth and anxiety on the first SCD with the experimental
group reporting the use of more self-care behaviors. At the
First
4.38
34
5.18
38
time of the second SCD, no significant differences were found
Second
4.58
34
4.54
34
between the groups in mean numbers of self-care behaviors
used for these side effects (see Table 4).
Note. Possible range of side effects is 09.
The control and experimental groups were similar in the
number of self-care behaviors used for fatigue; both groups
Results
increased their exercise level and caffeine intake between
first and second SCD. A significant difference was found in
Seventy subjects were enrolled in the study with 33 in the
the effectiveness of taking naps and getting up later reported
control group and 38 in the experimental group. No signifi-
by the control and experimental groups at the second SCD.
cant differences were documented between the groups on any
The control group reported greater effectiveness of both of
of the demographic variables. The sample ranged in age from
these self-care behaviors. Engaging in other activities was
3074, and half were younger than age 50. The participants'
rated fairly high by both groups on the first and second SCD.
average educational level was 13.23 years (range = 624
Interestingly, caffeine use increased in both groups by the
years). Sixty-six percent of the women had an income less
time of the second SCD, but the effectiveness of this mea-
than $29,000, and approximately 60% were married. Eighty-
sure increased for the control group and decreased for the
eight percent of the sample had stage I or II breast cancer.
experimental group (see Table 5). Other self-care behaviors
Forty-three percent were African American, with one His-
used were keeping busy, going to bed earlier, getting fresh
panic (see Table 1). The majority of the women was treated
air, and exercising more.
with AC, and 14% were receiving cytoxan, adriomycin, and
More self-care behaviors were used for nausea and vomiting
5-fluorouracil. Thirty-eight percent of the educational group
than for the other side effects experienced by subjects. Both
reported listening to the audiotapes at least once, 31% listened
groups, however, reported decreased effectiveness for most
two to six times, 28% listened one to three times per week,
behaviors by the time of the second SCD. Patients in both
and one individual (3%) listened to the tapes four to five times
groups reported on the first and second SCD that prescription
per week. Helpfulness of the tapes was rated on a 010 scale.
medications were the most frequently used self-care behaviors
Scores ranged from 010, with a median rating of 8. Sixty
and were effective over time. Patients in both groups reported
percent of subjects who listened to the tapes mentioned spe-
that avoiding the sight and smell of foods increased in efficacy
cific self-care behaviors for fatigue, anxiety, sore mouth, and
over time. On the first SCD, patients in both groups reported
nausea and vomiting that they found helpful.
that the least-used self-care behaviors were eating sour foods or
The number of side effects experienced by subjects ranged
mints and using nonprescription medications. Nonprescription
from 09, with a mean of 4.8 (n = 72) on the first SCD and
medications were taken by a few patients in both groups at
4.56 (n = 68) on the second SCD. On the first SCD, the ex-
varying times, but no patients found this to be an efficacious
perimental group experienced more side effects than the con-
method of controlling nausea and vomiting (see Table 6). Ad-
trol group. However, on the second SCD, the mean number of
ditional self-care behaviors, in order of frequency of use, in-
side effects for the experimental group declined whereas the
cluded eating cold foods and crackers, avoiding sweets, eating
number for the control group increased (see Table 2).
more slowly, and getting fresh air.
Overall, the most frequently experienced side effects were
fatigue, nausea and vomiting, and taste change (see Table 3).
Table 3. Incidence and Mean Severity of Most Frequently
More women in the experimental group reported these side
Reported Side Effects
effects on the first SCD than the control group. However, the
number of women in the experimental group experiencing
Control Group
Experimental Group
side effects diminished on the second SCD. In fact, in this
(N = 33)
(N = 38)
group, the number of women reporting nausea and vomiting
was reduced by nearly half between the first and second SCD.
--
--
Self-Care Diary
n
n
X
X
At the same time, the severity of fatigue increased for both
groups. At the first SCD, more women in the experimental
First diary
group experienced difficulty sleeping, yet by the second SCD,
3.26*
27
Fatigue
3.67*
30
Nausea and vomiting
3.04*
23
3.04*
29
difficulty sleeping was a problem for more women in the con-
Taste change
3.00*
18
3.81*
26
trol group and fewer women in the experimental group. On
3.25*
12
Difficulty sleeping
2.96*
23
the second SCD, difficulty sleeping was perceived by the ex-
Second diary
perimental group as more severe than by the control group.
Fatigue
3.15*
26
3.75*
24
Additional side effects reported included appetite loss, consti-
3.11*
18
Nausea and vomiting
15
3.20*
pation, anxiety, sore mouth, and diarrhea. Using t tests for
Taste change
3.18*
22
3.36*
22
independent samples, no significant differences were found
Difficulty sleeping
2.80*
15
3.36*
14
between the groups in the mean severity of side effects.
When the current study's researchers examined the number
* p < 0.05
and effectiveness of self-care behaviors used for the most fre-
Note. Severity ranges from 05.
ONCOLOGY NURSING FORUM VOL 31, NO 1, 2004
E19
Table 4. Mean Number of Most Frequently Used Self-Care
receiving chemotherapy for breast cancer. Initially, more sub-
Behaviors
jects in the experimental group reported side effects than those
in the control group, yet by the second SCD, the number of
Experimental
Maximum
Control
women in the control group reporting side effects had in-
--
--
--
Group X
Self-Care Diary
Group X
X
creased whereas the number of women in the experimental
group reporting side effects had decreased. This finding is
First diary
consistent with previous studies that found self-care measures
14.1*
Fatigue
18
14.04
could be learned and could have a positive effect on side ef-
10.5*
Nausea and vomiting
18
19.70
fects (Dodd, 1983) and lends support to Orem's (1995) theory
14.1*
Taste change
17
13.60
that patients can engage in effective self-care.
15.5*
Sore mouth
11
13.60
For both groups, the most common side effects reported on
16.0*
Anxiety
18
14.20
Second diary
the first and second SCDs were fatigue, nausea and vomiting,
14.0*
Fatigue
18
14.30
and taste changes. Other researchers also have found that
10.1*
Nausea and vomiting
18
10.40
these side effects are the most common and distressing for
13.3*
Taste change
17
13.10
patients (Longman et al., 1997; Northouse et al., 1999). Some
14.8*
Sore mouth
11
13.60
side effects became more severe over time, including changes
14.3*
Anxiety
18
14.30
in taste and nausea and vomiting. Although women used more
self-care behaviors for nausea and vomiting, they experienced
* p < 0.05
less effectiveness over time. Prescription drugs were the most
effective method of controlling nausea and vomiting for
Patients in both groups initially reported using the same self-
women in both groups.
care behaviors for the side effect of taste changes. By the time
Women in the experimental group experienced some im-
of the second SCD, the experimental group cleaned the mouth
portant improvements in symptoms that did not occur in the
significantly more frequently than the control group and re-
control group. Women in the experimental group reported that
ported more effectiveness of this behavior. In addition, patients
the incidence of nausea and vomiting was reduced by nearly
in the experimental group who stopped eating certain foods and
half by the second SCD. The number of women in the experi-
ate cold foods reported significantly more efficacy for these
mental group who reported difficulty sleeping on the second
behaviors than the control group (see Table 7). By the time of
SCD was almost half the number who reported it on the first
the second SCD, the frequency of avoiding the sight and smell
SCD, whereas the women in the control group reported an
of food had increased in the control group. Additional self-care
increase in sleeping difficulty.
behaviors used included eating different foods, avoiding the
The frequency and effectiveness of self-care behaviors for
sight and smell of foods, and eating sour foods.
fatigue, nausea and vomiting, and taste changes differed be-
This study also examined the impact of the educational in-
tween the groups. The frequency of the majority of self-care
tervention on anxiety. No difference in trait anxiety was found
behaviors used by the control group did not change between
between the control and experimental groups at the first inter-
the first and second SCDs over time. The control group tended
view. State anxiety was high for both groups. However, al-
to use the same self-care behaviors during their treatment
though state anxiety decreased over time for both groups, the
despite the fact that they did not seem to be working. These
control group consistently exhibited higher state anxiety levels
women may have been unaware of additional options. In con-
than the experimental group (see Table 8).
trast, by the second SCD, the experimental group had in-
creased the number of self-care behaviors they tried. This is
Discussion
consistent with Craddock et al.'s (1999) research that demon-
strated that patients initiated more self-care behaviors when
they had received information on symptom management.
This study examined how an audiotape intervention could
These findings are similar to those of Dodd, Thomas, and
increase the frequency of self-care behaviors used by women
Table 5. Fatigue: Most Frequently Used Self-Care Behaviors and Effectiveness on First and Second Self-Care Diary
Control Group
Experimental Group
First Self-Care Diary
Second Self-Care Diary
First Self-Care Diary
Second Self-Care Diary
(N = 27)
(N = 26)
(N = 30)
(N = 24)
--
--
--
--
Self-Care Behavior
%
X Efficacy
%
X Efficacy
%
X Efficacy
%
X Efficacy
Took naps
78
3.23
73
3.7**
73
3.27
58
2.7**
48
62
53
46
Got up later
3.38
3.1**
3.10
2.3**
Caffeine
19
2.40
23
2.7**
17
2.80
29
2.0**
Got more exercise
26
2.86
31
2.5**
37
2.64
46
2.4**
Other activity
11
3.30
12
4.0**
23
4.00
25
3.7**
* p = 0.05
**p = 0.001
Note. Possible efficacy ranges from 05.
ONCOLOGY NURSING FORUM VOL 31, NO 1, 2004
E20
Table 6. Nausea and Vomiting: Most Frequently Used Self-Care Behaviors and Effectiveness on First and Second Self-
Care Diary
Experimental Group
Control Group
Second Self-Care Diary
Second Self-Care Diary
First Self-Care Diary
First Self-Care Diary
(N = 26)
(N = 24)
(N = 27)
(N = 30)
--
--
--
--
X Efficacy
Self-Care Behavior
X Efficacy
%
X Efficacy
%
X Efficacy
%
%
3.6
Took prescription medication
3.5
194
3.6
97
3.2
93
96
3.1
Rested in a quiet place
3.3
100
3.1
83
3.8
93
74
2.9
Rested after meals
2.9
177
2.5
79
3.2
87
61
2.9
Cleaned mouth more often
2.6
177
2.8
79
2.9
73
61
2.8
Ate small, frequent meals
2.9
165
3.1
73
3.1
67
65
3.3
Avoided sight and smell of foods
2.5
172
2.8
69
3.0
87
61
2.8
69
Kept busy
2.8
158
3.0
3.6
60
78
2.5
Drank clear liquids
2.9
172
2.8
66
3.4
87
68
2.6
Ate less
2.4
171
2.6
66
3.1
60
78
13
Took nonprescription medication
115
5.0
Note. Possible efficacy ranges from 05.
economically disadvantaged and African American; as a re-
Dibble (1991) who found that patients with information about
sult, their previous experiences with the healthcare system
self-care behaviors used them earlier in their treatment and
patients without information about self-care behaviors tended
might have been less than optimal. This study may have pro-
vided them with an important new resource for dealing with
to experiment with self-care behaviors until they found some-
anxiety. This is an area that needs to be explored in further
thing that worked. This approach is not the most desirable
research.
because patients may experiment with interventions that have
negative effects. For example, in this study, the subjects in the
Limitations
control group used several self-care behaviors that could be
detrimental over time, such as eating less food to control nau-
sea.
The limitations in this study must be addressed. No control
One of the most interesting findings in the study related to
or assessment was available regarding the type or amount of
additional information either group received from the health-
the anxiety experienced by the subjects. Trait anxiety levels
were similar in both groups at the beginning of the study.
care facility, family, friends, or community resources. The
State anxiety decreased over time for both groups but was
researchers assumed that the women in the control group did
higher at each measurement point for the control group. The
not have the same amount or depth of information as the
consistently lower anxiety levels experienced by the experi-
women in the experimental group.
mental group may have been related to their greater self-con-
The telephone intervention may have had a substantial ef-
fidence in managing their side effects. However, anecdotal
fect on patients' behaviors. The questions asked during each
data from the interviewers suggest that these subjects were
telephone interview reinforced the self-care behaviors to the
appreciative that someone was calling to ask about their
women in the experimental group and provided information
symptoms and self-care behaviors.
to the women in the control group that they may not have had
Because subjects were interviewed by the same interviewer
otherwise.
at each point in time, they became familiar with one another,
The small number of subjects in this study was a limitation,
which may have reduced anxiety. Many of the subjects were
and, although the study was funded for a three-year period,
Table 7. Taste Change: Most Frequently Used Self-Care Behaviors and Effectiveness on First and Second Self-Care Diary
Control Group
Experimental Group
First Self-Care Diary
Second Self-Care Diary
First Self-Care Diary
Second Self-Care Diary
(N = 18)
(N = 22)
(N = 26)
(N = 22)
--
--
--
--
Self-Care Behavior
%
X Efficacy
%
X Efficacy
%
X Efficacy
%
X Efficacy
Cleaned mouth more often
78
2.6
62
2.5*
89
3.1
77
3.4*
61
62
Stopped eating certain foods
3.4
57
2.4*
3.4
55
3.5*
Ate cold food
50
3.2
38
2.3*
58
3.1
50
3.4*
Avoided sight and smell of foods
61
3.5
57
3.3*
58
3.4
46
3.7*
* p < 0.05
Note. Possible efficacy ranges from 05.
ONCOLOGY NURSING FORUM VOL 31, NO 1, 2004
E21
Nursing Implications
Table 8. Measure of State Anxiety Over Time in Control
and Experimental Subjects Using a Repeated Measure
Effective self-care behaviors can assist patients in minimiz-
Analysis of Variance
ing the side effects of chemotherapy, decreasing symptom dis-
tress, and improving quality of life. Although research has
Control Group
Experimental Group
shown that no one particular method of education is more ef-
Interview
State
Trait
State
Trait
fective than another (Chelf et al., 2001), the use of audiotapes
in addition to printed literature does provide benefits to pa-
1
41.53
33.55
34.9
33.6
tients.
2
33.62
30.91
This study suggests that nurses in chemotherapy clinics
3
31.44
27.80
need to use alternative methods for providing information to
Note. F = 6.05 and p = 0.017
patients about management of side effects. Supportive tele-
phone calls as well as informational audiotapes can foster self-
care behaviors and reduce anxiety. Teaching materials that
the researchers lost several months of data because of a hur-
can be taken home and referred to when needed can be very
ricane and the subsequent flooding of most of the 29 counties
helpful in reinforcing information. Women who have limited
in the region. The majority of the subjects lived in the flooded
reading skills can benefit from audiotaped information about
area, and many who were enrolled had not yet completed the
self-care behaviors.
three interviews. These potential participants were lost to the
Fatigue, nausea and vomiting, and taste changes are signifi-
study because they were in temporary housing, their location
cant and difficult to control through self-care behaviors. Pa-
was unknown to the researchers, they had no phone, or they
tients should be encouraged to use the self-care behaviors that
stopped or delayed treatment. The chemotherapy clinic was
are known to be effective and should be prepared for the side
closed for some time; therefore, no new patients were re-
effects that may be more difficult to control with self-care
cruited during that time. This, in turn, required additional time
behaviors. For instance, where appropriate, nurses should re-
for the researchers to recruit more subjects.
inforce the importance of taking prescription medications for
The number of times women listened to the audiotapes var-
symptoms such as nausea and vomiting as opposed to less-
ied widely among patients and could have affected the results
effective self-care behaviors.
of the study. For some side effects, women indicated that they
Patients who learn that they can manage many of their side
used other interventions. The women believed that delineat-
effects may gain self-confidence and improve their physical and
ing other behaviors that were useful for managing side effects
psychological well-being. In addition, teaching self-care behav-
would be helpful.
iors that are known to be effective will allow women to use
appropriate self-care behaviors rather than experimenting. Pa-
Future Studies
tients who understand that some side effects may not be as
manageable as others through self-care behaviors may be more
Future studies of the effect of education on self-care behav-
likely to seek help from the healthcare community when they
iors could provide more information for clinicians. This study
experience these side effects.
should be repeated with the following modifications: Increase
Improving patients' abilities to perform effective self-care
the number of subjects, control the type and amount of infor-
behaviors and lowering their anxiety levels can enhance qual-
mation the women receive in the clinic, and ascertain how
ity of life, give women more self-confidence and a sense of
much information the women receive from sources in the
control, and likely diminish the possibility of terminating
community. Additional research should evaluate how the fre-
treatment because of side effects (Longman et al., 1996).
quency of listening to the tapes influenced the use of self-care
behaviors and other behaviors women engaged in to manage
their side effects beyond those specifically asked about in this
Author Contact: Susan A. Williams, DNS, RN, can be reached at
study. Studies are planned to further evaluate self-care behav-
williamssus@mail.ecu.edu, with copy to editor at rose_mary@earth
iors to lessen the anxiety of women receiving chemotherapy.
link.net.
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