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October 2014, Volume 18, Number 5
Journal
Club Article
The Effects of Education on Anxiety Levels in Patients Receiving
Chemotherapy for the First Time: An Integrative Review
Sarah Garcia, DNP, FNP-BC
Anxiety is one of the most common symptoms
experienced by patients receiving their first chemotherapy treatment. Improper
prevention and management of anxiety can lead to poor psychosocial outcomes,
dissatisfaction with care, and decreased adherence to treatment. A review of
the literature was conducted to analyze the effectiveness of patient education
at decreasing anxiety. Consistencies were found throughout the literature regarding
patient education for this population. Information regarding side effects of
treatment, side-effect management strategies, and orientation to the infusion
center are the most important topics of education that reduce anxiety. In
addition, education performed by nurses before the first chemotherapy infusion
in a quiet environment is most effective. Integration of effective patient
education programs improves holistic care by increasing emphasis on
psychosocial aspects of oncology.
Cancer affects millions of people in the United
States each year, leading many to face the difficult road of chemotherapy. When
patients are ill-prepared for chemotherapy treatments, they “often tend to
envision the worst-case scenarios, possibly making the anticipation more
difficult than the event itself” (Borsellino & Young, 2011, p. 311). They
experience anxiety about the unknowns of chemotherapy and its side effects. The
incidence of anxiety in patients with cancer is as high as 47% (National
Comprehensive Cancer Network [NCCN], 2013).
Anxiety can cause patients to feel a loss of control
over their disease, which is associated with poor psychosocial outcomes such as
depression (Leighl, Gattellari, Butow, Brown, & Tattersall, 2001). Patients
experiencing depression are less capable in performing self-care behaviors,
which are necessary to manage common side effects of chemotherapy (Williams
& Schreier, 2004).
Oncology
nurses educate patients about chemotherapy side effects; however, most patients
receive only written information during their first chemotherapy treatment
(Keller, 2006; Malone, 2007; Sheldon, Swanson, Dolce, Marsh, & Summers, 2008; Williams & Schreier, 2004, 2005). The
purpose of this integrative review is to synthesize the current literature
regarding the effectiveness of patient education at decreasing anxiety levels
in patients receiving chemotherapy for the first time.
Methods
A literature search was performed to answer the
clinical question, “What are the most effective interventions for anxiety in
patients beginning chemotherapy?” Six databases were examined: CINAHL®,
MEDLINE®
via PubMed, ProQuest Nursing and Allied Health Source, Joanna Briggs Institute
Clinical Online Network of Evidence for Care and Therapeutics, Cochrane
Collaboration and Library, and National Guidelines Clearinghouse using the key
words of patient education, health promotion, education
intervention, chemotherapy, cancer, anxiety, treatment
management, and prevention. Articles were included if they were
English language, had an adult population, were peer reviewed, and were
published from 2003–2013. Exclusion criteria included patients receiving
radiation therapy, oral chemotherapy, prevention of cancer, and foreign study
participants.
Ten articles were found pertinent to the clinical
question and were appraised for quality and methodologic rigor using
standardized assessment tools. The Appraisal of Guidelines for Research and
Evaluation (AGREE II), Critical Appraisal Skills Programme (CASP), Joanna
Briggs Institute–Meta Analysis of Statistics Assessment and Review Instrument
(JBI-MAStARI), and the Joanna Briggs Institute Narrative, Opinion, and Text
Assessment and Review Instrument (JBI-NOTARI) were used to critically appraise
the evidence (see Table 1).
Results
Nine studies have shown patient education is
effective in decreasing anxiety in patients newly diagnosed with cancer who are
receiving chemotherapy (Jacobsen & Jim, 2008; Malone, 2007; Mann, 2011;
NCCN, 2013; Prouse, 2010; Sheldon et al., 2008; Stephenson, 2006; Traeger,
Greer, Fernandez-Robles, Temel, & Pirl, 2012; Williams & Schreier,
2005). Five consistencies were identified within these articles.
·
Specific education topics that decrease
anxiety include information about treatment, side-effect management, and a
brief orientation to the chemotherapy setting.
·
Education is most effective in preventing and
managing anxiety when performed prior to the initiation of chemotherapy.
·
Format of patient education is important to
maximize retention of information.
·
Education is most effective when performed in
a quiet environment that supports learning.
·
Oncology nurses in the primary oncology
setting are effective providers of patient education.
Psychoeducation
Pyschoeducation is a term used by many authors to
describe the delivery of information aimed at decreasing uncertainty and
increasing knowledge of a specific subject (Jacobsen & Jim, 2008). Many
authors have found specific educational topics that are more beneficial than
others, most commonly side-effect management and orientation to the staff and
facility (American Society of Clinical Oncology [ASCO]/Oncology Nursing Society
[ONS], 2012; Jacobsen & Jim, 2008; Malone, 2007; Prouse, 2010; Sheldon et
al., 2008; Stephenson, 2006; Williams & Schreier, 2005).
Side-effect
management: Sheldon et al. (2008) identified chemotherapy
side-effect education as recommended practice in the prevention and management
of anxiety. That guideline divided psychoeducation into three categories: (a)
treatment facility, staff, and community resources; (b) cancer diagnosis and
treatment; and (c) self-care and side-effect management. Self-care and
side-effect management involve educating patients on the management of long-
and short-term side effects of chemotherapy (ASCO/ONS, 2012).
Prouse (2010) found that patient education about
chemotherapy side effects can decrease anxiety. The author analyzed six
randomized, controlled trials (RCTs) that examined patient comprehension of
chemotherapy-related side effects and the use of self-care behaviors to treat
or prevent chemotherapy side effects. Thomas, Daly, Perryman, and Stockton
(2000) found that the use of a 20-minute preparatory video in addition to
written and verbal information reduced anxiety compared to written and verbal
information alone.
Williams and Schreier (2005) also found
psychoeducation to be effective. Their RCT (N = 71) involved random assignment
to an experimental group (n = 38) in which participants received the standard
of care and a 20-minute audiotape describing evidence-based strategies
(exercise and relaxation) to manage fatigue, sleep disturbances, and anxiety.
The control group (n = 33) received the standard of care, which consisted of
verbal and written information from nurses about chemotherapy side effects, but
no discussion of side-effect management strategies. Anxiety, measured using the
State Trait Anxiety Inventory (STAI), was assessed before the first
chemotherapy treatment, one month post-treatment, and three months
post-treatment. A higher percentage of participants in the control group (n =
16) reported anxiety at one month post-treatment as compared to the
experimental group (n = 10). A statistically significant (p = 0.001) decrease
in anxiety occurred between the first and second self-care diary (SCD) for the
experimental group. In addition, STAI scores were higher in the control group
at all three measurement times as compared to the experimental group, although
the results were not statistically significant. The STAI
scoring ranges from 20 (low anxiety) to 80 (high anxiety).
Malone (2007) found similar results as Williams and
Schreier (2005) in a pilot study involving a one-hour educational intervention
that involved verbal instruction along with hand-written materials about
chemotherapy side effects and management strategies. Results from open-ended
questions on the survey indicated that the class helped reduce patients’
anxiety.
Stephenson (2006) provided expert opinion on
psychoeducation through self-regulation theory, which assumes that patients
respond to disease through objective (functional) or subjective (emotional)
mechanisms. Subjective responses include anxiety, which can lead to feelings of
vulnerability or distress. The nurse should help redirect patients’ energy from
the emotional response to the functional response to foster increased
involvement in their own care. This theory posits that information given to
patients should be derived from four concrete variables: (a) description of
symptoms that may be experienced from treatment, (b) description of the
environment, (c) description of the physical experiences during the event, and
(d) the duration of the event.
Orientation:
Unfamiliarity with the treatment environment may increase anxiety. Some
researchers (Jacobsen & Jim, 2008; Sheldon et al., 2008; Stephenson, 2006)
found that a brief orientation to the infusion center and staff was effective
at reducing uncertainty and in preventing anxiety.
Self-regulation theory (Stephenson, 2006) supports
orientation as well. Temporal and environmental characteristics of an event
(i.e., chemotherapy) have a significant impact on anxiety. Describing the
typical routine during chemotherapy infusion and exposing patients to the
infusion area before treatment reduces uncertainty and allows patients to
redirect emotional responses, such as anxiety, toward functional responses.
Functional responses improve coping and increase patient involvement in his or
her care (Stephenson, 2006).
Format
Standard of care for patient education most often
consists of written information (ASCO/ONS, 2012; Mann, 2011; Sheldon et al.,
2008). Verbal instruction also is frequently used and was the medium most often
added to the standard of care (Malone, 2007; Mann, 2011; Williams &
Schreier, 2005). Providing written materials with verbal instruction allows
patients to continue learning and review materials after the initial education
is performed (Stephenson, 2006).
Researchers used a variety of media to provide
information, including audiotapes, pamphlets, PowerPoint®
presentations, videos, and interactive computer programs (Malone, 2007; Mann,
2011; Prouse, 2010; Sheldon et al., 2008; Williams & Schreier, 2005). Using
multiple types of media with the same patient can be advantageous (Sheldon et
al., 2008). However, not all patients have access to the resources required for
multimedia interventions. Prouse (2010) found that use of multimedia
interventions, in general, did not result in improved information recall
related to the side effects of chemotherapy; however, some studies (Olver,
Whitford, Denson, Peterson, & Olver 2009; Thomas et al., 2000) in the
systematic review found decreased anxiety from the use of multimedia
interventions.
Williams and Schreier (2005) used audiotapes to
provide education in their study. The audiotapes consisted of calming
background music and a female voice providing information about exercise and
relaxation to manage anxiety, fatigue, and sleep problems associated with
chemotherapy. Patients in the experimental group received the audiotapes in
addition to verbal and written information regarding chemotherapy side effects.
Patients were instructed to listen to the tapes in their homes 12–24 hours
before the start of chemotherapy, or as often as desired. At all measurements of
anxiety, patients in the control group experienced more anxiety than those who
used the audiotapes in addition to the standard of care, although results were
not statistically significant.
Timing
Temporal characteristics of patient education are
important in decreasing anxiety (ASCO/ONS, 2012; Malone, 2007; Mann, 2011;
Stephenson, 2006; Traeger et al., 2012; Williams & Schreier, 2005).
ASCO/ONS (2012) guidelines state that patient education should be performed
prior to the start of chemotherapy; however, the guidelines do not provide
specifications regarding the amount of time prior to chemotherapy. Williams and
Schreier (2005) specifically studied the effect of timing in their RCT. They
proposed that anxiety levels may be elevated immediately before receiving the
first chemotherapy treatment, which may interfere with retention of information
(Stephenson, 2006; Williams & Schreier, 2005). Patients in the experimental
group received education 12–24 hours before initiation of chemotherapy, whereas
patients in the control group received education during the first infusion. As
mentioned previously, patients in the control group exhibited higher STAI
scores than patients in the experimental group.
In Mann’s (2011) study (N = 72), the intervention
group (n = 32) received education prior to the start of chemotherapy, whereas
the control group (n = 40) received the same education during the first
chemotherapy infusion. The author did not state how long before chemotherapy
the education was provided. Data from patient satisfaction surveys indicate
that 28 patients in the intervention group were satisfied with the education.
Of note, 22 participants in the experimental group stated that their anxiety
was reduced as a result of the intervention compared to 12 participants in the
control group. The control group expressed a desire for information before the
first day of chemotherapy.
Malone (2007) provided education about one week
before the start of chemotherapy. Findings were obtained using patient
satisfaction surveys that addressed the relevance, effectiveness, and
organization of the education. Results of the surveys were not explicitly
discussed; however, 84% of respondents rated the educational session as
“excellent” or “good.” Malone (2007) concluded that information given prior to
the start of chemotherapy may increase coping strategies.
Environment
The environment in which the education occurs
impacts its effectiveness. Performing education in an environment that supports
learning may increase retention (Malone, 2007; Mann, 2011). Malone (2007) and
Mann (2011) performed an educational intervention in a quiet area of a
facility, whereas the control group received education in a busy infusion
center. Mann (2011) found that 100% of participants in the experimental group
reported the educational environment was conducive to learning, whereas only
10% of patients in the control group reported the same. Malone also found
similar results. Of the 60% of participants to complete the satisfaction
survey, 84% rated the class as “excellent” or “good.”
Williams and Schreier (2005) recorded an audiotape
describing side-effect management strategies so patients could receive the
information in the comfort of their homes. This also allowed patients to listen
to information as often as needed and at an appropriate time. Williams and
Schreier (2005) suggested that the treatment setting is distracting and,
therefore, not suitable for learning.
The
Role of the Nurse
A consistent theme throughout the literature is the
use of oncology nurses as educators. According to the NCCN (2013), the
primary oncology team is responsible for developing a mutually trusting
relationship with patients to facilitate learning. This also encourages
patients to ask questions and can promote security and comfort during infusion
(NCCN, 2013; Stephenson, 2006).
Nurses possess the skills to effectively provide
patient education. In addition, oncology nurses are knowledgeable about
chemotherapy and play an integral role in helping patients manage side effects
(Williams & Schreier, 2005). Therefore, they can provide education that
assists patients in effectively managing side effects at home (Williams &
Schreier, 2005). Nurses are the healthcare professionals who interact with
patients most frequently (Mann, 2011); therefore, they are in a prime position
to provide education. Nurses provided education in both pilot studies (Malone,
2007; Mann, 2011), which found education effective at reducing anxiety.
Providing patient education about expected side effects and self-management
strategies may decrease unwarranted hospitalizations, emergency department
visits, and telephone calls (NCCN, 2013; Stephenson, 2006).
Limitations
Additional research is needed regarding the
effectiveness of group versus individual patient education sessions. In
addition, specific information regarding timing of education before
chemotherapy also is important; however, many researchers did not specify the
time frame. In addition, finding relevant articles was difficult because little
research has been published on preventing and managing anxiety related to
chemotherapy.
Implications for Nursing
Since 2007, the Institute of Medicine has considered
psychosocial health as an aspect of quality cancer care and states that it
should be integrated into routine practice (Adler & Page, 2008). The NCCN
(2013) suggests that screening for anxiety should be implemented in community
oncology practices. Instituting nursing measures to decrease anxiety related to
chemotherapy treatment is one way oncology nurses can integrate psychosocial
care into their existing framework. Holistic nursing care includes providing
education about treatment side effects and self-care behaviors as a means of
reducing anxiety (ASCO/ONS, 2012; Malone, 2007; Mann, 2011; NCCN, 2013; Prouse,
2010; Sheldon et al., 2008; Stephenson, 2006; Williams & Schreier, 2005).
Certain aspects of patient education should be
considered for the development or revision of patient education programs.
Evidence suggests that RNs are appropriate healthcare providers to lead
educational sessions. Nurses must remember that education is most effective
when performed before the patient receives the first infusion in an environment
that is quiet and supports learning (ASCO/ONS, 2012; Malone, 2007; Mann, 2011;
Stephenson, 2006; Traeger et al., 2012; Williams & Schreier, 2005).
As leaders of change, nurses should advocate for
holistic care and encourage the use of education as a means to improve
psychosocial health of patients. The role of the nurse can be expanded in
oncology to include nurse educators who dedicate their career to properly
educating patients throughout the journey of cancer. Nurses must engage in
continuing education regarding new chemotherapy medications and evidence-based
strategies to manage side effects to remain effective educators.
Conclusion
When done appropriately, patient education is
effective at preventing and reducing anxiety in patients receiving chemotherapy
for the first time. Adequate time with a nurse discussing side effects of
treatment and management strategies before the first chemotherapy infusion
helps ease worry. A brief orientation to the infusion center and expectations
for the treatment day greatly decreases fear of the unknown. As integration of
psychosocial care into practice progresses, mechanisms for increasing quality
of life and improving psychosocial outcomes are of increasing importance to
nurses (NCCN, 2013).
Implications for Practice
Ř
Screen for anxiety in all patients diagnosed
with cancer and scheduled to receive chemotherapy.
Ř
Promote holistic care by providing education
about treatment side effects and self-care behaviors.
Ř
Provide education before the initiation of
chemotherapy in an environment that is quiet and supports learning.
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Use
This Article in Your Next Journal Club
Sarah
Garcia, DNP, FNP-BC, is a family nurse practitioner at North Shore Health
Center in Merrillville, IN. The author takes full responsibility for the
content of the article. The author did not receive honoraria for this work. The
content of this article has been reviewed by independent peer reviewers to
ensure that it is balanced, objective, and free from commercial bias. No
financial relationships relevant to the content of this article have been
disclosed by the author, planners, independent peer reviewers, or editorial
staff. Garcia can be reached at sarah.garcia@valpo.edu,
with copy to editor at CJONEditor@ons.org.
(Submitted December 2013. Revision submitted January
2014. Accepted for publication January 29, 2014.)
Key words: patient education; chemotherapy; cancer;
anxiety
http://dx.doi.org/10.1188/14.CJON.18-05AP
