0
No votes yet
CJON Writing Mentorship Article

Using Relaxation and Guided Imagery to Address Pain, Fatigue, and Sleep Disturbances: A Pilot Study

Angela K. Nooner
Kathleen Dwyer
Lise DeShea
Theresa P. Yeo
CJON 2016, 20(5), 547-552 DOI: 10.1188/16.CJON.547-552

Background: Few studies have been conducted on the use of patient-controlled relaxation and guided imagery interventions for the symptom cluster of pain, fatigue, and sleep disturbance during cancer treatment.

Objectives: The primary aim of this study was to evaluate the feasibility, acceptability, and participant satisfaction with use of patient-controlled relaxation and/or imagery interventions for pain, fatigue, and sleep disturbance. A secondary aim was to examine the data for trends in pain, fatigue, and sleep improvement because of the effects of relaxation and guided imagery.

Methods: Twelve adult patients with cancer were randomized to one of four groups: a guided imagery intervention, a relaxation intervention, a combined intervention using guided imagery and relaxation, or usual care. Pain, fatigue, and sleep disturbance were assessed upon enrollment and at 30 and 60 days. Patients’ scores were obtained using the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference Short Form, PROMIS Fatigue Short Form, and PROMIS Sleep Disturbance Short Form tools.

Findings: Patients reported a high degree of satisfaction with the relaxation and guided imagery interventions. Patients in the relaxation and guided imagery or combined groups showed a trend toward improvement in fatigue and sleep disturbance scores. Pain remained a problem for the majority of patients. Difficulties in recruiting participants resulted in an insufficient sample size for generalizable findings. With hospital environments tending to be noisy, relaxation and guided imagery may facilitate rest and sleep for hospitalized patients. An examination of individual scores showed a trend toward improvement in sleep quality.

Despite improvements in diagnosis and treatment, many patients with hematologic malignancies still experience undesirable symptoms and side effects that undermine quality of life. The primary purpose of this study was to evaluate the feasibility, acceptability, and participant satisfaction with the use of patient-controlled relaxation and imagery interventions for pain, fatigue, and sleep disturbance in a population of patients with hematologic malignances and solid tumors. A secondary aim was to examine the data for trends in pain, fatigue, and sleep improvement because of the effects of relaxation and guided imagery.

Studies have shown that as many as 96% of patients with cancer experience fatigue during treatment and after therapy has been completed (Finnegan-John, Molassiotis, Richardson, & Ream, 2013; Yeo & Cannaday, 2015). The National Comprehensive Cancer Network (2016) reported that fatigue is rarely an isolated symptom and most commonly clusters with other symptoms, such as pain, distress, anemia, and sleep disturbance. In Coleman et al.’s (2011) study of 2,600 patients with cancer, 39% reported insomnia. As many as 95% of patients with advanced cancer experience a sleep disorder (Ducloux, Guisado, & Pautex, 2012). Pain prevalence in patients with cancer is estimated to be as high as 53%–60% (Gorin et al., 2012; Montague & Green, 2009). Pain may interrupt sleep and increase fatigue (Coleman et al., 2011). A prospective study of 249 patients with newly diagnosed or recently relapsed acute leukemia identified a lack of energy, difficulty sleeping, and pain as the most common and distressing symptoms (Zimmermann et al., 2013). In addition, 91% of participants in the study reported more than five concurrent symptoms, and 61% reported more than 10 concurrent symptoms (Zimmermann et al., 2013).

Pharmacologic treatments alone often provide inadequate relief for cancer-related symptoms and may cause additional problems, such as respiratory depression, constipation, nausea, vomiting, weakness, confusion, difficulty urinating, and itching (Dalal, 2015; Dambrosio & Mazanec, 2013; Finnegan-John et al., 2013). Few studies have been conducted on the feasibility and effectiveness of relaxation and guided imagery interventions in an inpatient cancer population. Kwekkeboom, Abbott-Anderson, and Wanta (2010) evaluated the efficacy of teaching patients with advanced cancer to increase personal control over cancer symptoms, such as pain, fatigue, and sleep disturbance, through relaxation, imagery, and distraction. The small study of 30 adult patients, mostly Caucasian women with advanced colorectal, lung, or gynecologic cancer receiving chemotherapy or radiation therapy, found that severity scores for all three symptoms were reduced immediately after using the strategies. Relaxation and guided imagery techniques can be used to distract attention away from symptoms and assist patients in coping with unpleasant thoughts and feelings associated with their symptoms (Kwekkeboom et al., 2010). Guided imagery and cognitive behavioral interventions have the potential to reduce fear and distress and to teach self-regulatory skills that assist with overall symptom management (Landier & Tse, 2010).

Methods

Participants

The study used a convenience sample of men and women aged 21 years or older with hematologic malignancies or solid tumors who were admitted to the inpatient oncology unit for chemotherapy or prior to hematopoietic stem cell transplantation (HSCT). Participation was limited to those who had at least 60 total days remaining in their current treatment course, either as an inpatient or outpatient, and were able to read, write, and understand English at a sixth-grade level. Exclusion criteria were treatment exclusively for symptom management, evidence of brain metastases, a diagnosis of altered mental status by treating physician, visual or physical impairments that would interfere with the completion of self-administered questionnaires, evidence of hearing impairment, current psychiatric diagnosis (e.g., severe depression, dementia), concurrent diagnosis of medical disorders interfering with sleep (e.g., sleep apnea, narcolepsy), and history of seizures.

One goal of the study was effect size estimation instead of hypothesis testing. Therefore, the target sample size was defined by the number of participants needed to obtain a reasonable estimation of the effect for use in later studies, rather than powered for statistical significance. Consistent with recommendations made by Hertzog (2008), the target sample size was 40 patients. The principal investigator (PI) approached patients meeting the eligibility requirements who were hospitalized prior to HSCT or for chemotherapy administration. All participants received chemotherapy or chemotherapy plus HSCT from October 2013 to February 2015. Twenty-seven patients who met the eligibility requirements were approached to participate in the study. Twelve patients consented to participate in the study. Three participants were randomly assigned to each of the four groups.

Design

This exploratory pilot study used a repeated measures design to evaluate the acceptability and feasibility of patient-controlled relaxation and guided imagery interventions. The PI reviewed potential participants’ medical records to gather information on diagnosis, current treatment protocol, and medications, as well as to determine eligibility for the study. After obtaining informed consent, the PI collected demographic data. Participants also were asked for demographic data, including date of birth, age at diagnosis, race, gender, marital status, years of education, previous use of guided imagery and relaxation techniques, presence of any concurrent medical conditions, and current medication use. Pain, fatigue, and sleep scores were collected at baseline and at 30 and 60 days using the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference Short Form, PROMIS Fatigue Short Form, and PROMIS Sleep Disturbance Short Form tools.

Participants in the three intervention groups received an individually assigned MP3 player with headphones containing the assigned recording(s). They also received instructions on how to use the MP3 player and headphones. The usual care group received MP3 players containing the intervention materials at the end of the study. The MP3 player contained recordings created by the Monroe Institute (Holt, Recore, Savage, Kiehl, & Doyle, 2008). For guided imagery, participants received a 19-minute audio program, the Hemi-Sync® Morning Exercise album (Holt et al., 2008). The recording guides the listener through waking in the morning. For relaxation, participants received a 39-minute audio program, the Hemi-Sync Guide to Serenity album. The recording guides the listener through a 10-point system of progressive relaxation.

Three scales were used: PROMIS Pain Interference Short Form, PROMIS Fatigue Short Form, and PROMIS Sleep Disturbance Short Form. The PROMIS Roadmap Initiative, a cooperative research group, developed and validated scales to measure patient-reported outcomes that are not disease-specific but are relevant across common medical conditions (Cella et al., 2007).

The eight-item PROMIS Pain Interference Short Form assesses the effect of pain on participants’ activities of daily living and quality of life. For example, one item asks, “How much did pain interfere with your enjoyment of life?” Response options ranged from 1 (not at all) to 5 (very much). This scale has been shown to have strong internal consistency (alpha = 0.99) and test-retest reliability (r = 0.85) (Cella et al., 2010).

The eight-item PROMIS Fatigue Short Form assesses a range of self-reported symptoms of fatigue. For example, one item asks participants to rate their agreement with the statement, “I have trouble starting things because I am tired.” This item was rated on a scale from 1 (not at all) to 5 (very much). Strong internal consistency (alpha = 0.99) and test-retest reliability (r = 0.76) have been reported for this scale (Cella et al., 2010).

The eight-item PROMIS Sleep Disturbance Short Form assesses self-reported perceptions of sleep quality, sleep depth, and restoration associated with sleep during the past seven days. For example, one item asks participants to rate their sleep quality using a scale from 1 (very poor) to 5 (very good). Extremely high internal consistency (alpha = 0.99) and test-retest reliability (r = 0.99) have been reported (Cella et al., 2010).

Two additional instruments were administered: investigator-initiated tools and an intervention evaluation. Participants were asked to complete a symptom and intervention outcome log created by the PI for this study. They were asked to record symptoms experienced, interventions that were used for relief (including study audio programs or other treatment), and how they felt after use of the interventions in a daily log book. Participants were also asked to rate the overall relevance, usefulness, and perceived helpfulness of the intervention. Open-ended questions provided an opportunity for additional comments and suggestions.

Procedure

Participants were randomized using a computer-generated schedule and the sealed-envelope method to one of four groups: a relaxation group, a guided imagery group, a group receiving guided imagery and relaxation, or a usual care group. Participants in the relaxation group were asked to listen daily to the Guide to Serenity recording on their provided MP3 players. Participants in the guided imagery group were asked to listen daily to Morning Exercise on their provided MP3 players. Participants in the relaxation and guided imagery group were asked to listen to both Morning Exercise and Guide to Serenity once per day. The usual care group used pharmacologic interventions for symptom management as prescribed by the treating physician. All participants were asked to record severity of symptoms and to document steps that were taken to manage symptoms, as well as resulting feelings, in a daily log book. All participants were allowed to keep the MP3 player after the study ended.

Patients who were discharged during the study period were given instructions on how and when to use assigned interventions and how to complete the symptom and intervention logs. The PI telephoned or sent follow-up letters to participants two weeks after discharge and at the 30- and 60-day points during the study if participants were not readmitted during the study period. The purpose of the follow-up was to track intervention fidelity and determine how often participants had used the intervention materials since the last contact. Ratings of pain, fatigue, and sleep quality since the last contact were also collected at the same time as telephone or follow-up letters.

All data were entered into a password-protected Microsoft® Excel spreadsheet, which was used to analyze the findings. Access to the data was limited to the study PI and co-investigators and kept in a locked office to protect data safety and confidentiality. Only deidentified data were transmitted electronically. The study was approved by the Scientific Review Committee of the Peggy and Charles Stephenson Cancer Center and by the University of Oklahoma Health Sciences Center Institutional Review Board. Informed consent was obtained from patients prior to enrollment and randomization to treatment groups.

Results

Of the 12 participants who consented, 11 completed at least one assessment. One patient withdrew on the same day that consent was given. Reasons cited for declining study participation (n = 15) were difficulty filling out forms because of changes in vision, prospective participant would be providing care for an ill relative after discharge from the hospital, perceived lack of time to dedicate to study participation, feeling guilty for taking an MP3 player if recordings did not work, and not feeling up to participating at this time. Four patients completed 60 days in the study. Four patients were lost to follow-up, one patient withdrew before completing the baseline measures, one withdrew before the 30-day follow-up related to complications of HSCT, and two patients died during the study period. No participants reported previous experience with guided imagery; two patients reported previous experience with relaxation interventions. Because of the small sample size, statistical significance testing was not conducted. The data were explored graphically for individual trends.

The sample was fairly homogenous in that 10 of 11 self-identified as Caucasian. Six men and five women participated, and the mean age was 41 years (range = 27–63). The majority of patients (n = 9) had a hematologic malignancy; two patients had a solid tumor. One patient had testicular cancer in the relaxation group, and one patient had breast cancer in the usual care group. Ten patients who answered any questions were actively receiving chemotherapy in preparation for HSCT. None of the participants had altered mental status, but one person was diagnosed with brain metastases after the study began, left the study, and entered a hospice care program. All of the patients in the study were being treated for pain, with medications ranging from nonsteroidal anti-inflammatory drugs to narcotics. Comorbidities were extracted from the medical record and included hypertension, cardiac problems, diabetes, obesity, and hypothyroidism. Table 1 summarizes other details about the sample.

Symptom Assessment

The three PROMIS short-form assessment scale scores were converted to T scores with standard errors using the PROMIS instrument guides and conversion tables (PROMIS, 2015a, 2015b, 2015c). T scores are standardized scores based on testing of a large group. The pain, fatigue, and sleep disturbance scales are normed on a sample of the general population in the United States. According to the PROMIS scoring guidelines, a score greater than 50 indicates that the patient had a higher level of that particular symptom than the average individual.

At baseline, most patients scored above average on pain that interfered with daily activities (n = 8), on fatigue that was termed “bothersome” (n = 8), and with regard to sleep disturbances (n = 9) (see Table 2).

Seven participants completed a 30-day PROMIS reassessment of symptoms. Pain had declined in three patients, and fatigue was improved in four patients. Pain decreased in two patients in the relaxation group by 4 and 5 points, respectively, and in one patient in the usual care group by 15 points; therefore, no intervention group was superior to another in this regard. Fatigue declined in one patient in the relaxation group by 4 points, two patients in the relaxation plus guided imagery group each by 5 points, and one patient in the usual care group by 15 points. Sleep disturbances improved in two patients in the relaxation group by 1 and 2 points, respectively, one patient in the guided imagery group by 3 points, and one patient in the relaxation plus guided imagery group by 5 points. Overall, four of seven patients continued to report pain, fatigue, and sleep disturbance scores that were greater than the U.S. population average. Sleep quality and other sleep characteristics improved. All but one patient reported more refreshing sleep and fewer sleep problems at 30 days than at baseline.

Four patients remained in the study at 60 days: one patient in the relaxation group, two patients in the guided imagery group, and one in the combined relaxation and guided imagery group. No one remained in the usual care group. Eight patients’ scores were censored from the data for the following reasons: death, loss to follow-up, or withdrawal from the study. All four patients reported lower fatigue levels than at 30 days, and only one still had a T score greater than 50. Two patients had less trouble sleeping, and the other two patients reported slightly more sleep disturbances. Three of four patients continued to report pain at 60 days.

Participant Evaluation of Study

Five patients completed the final program evaluation (one from the relaxation group, two from the guided imagery group, and two from the relaxation plus guided imagery group). Patients overwhelmingly felt that the study interventions were easy to use, that the directions were understandable and relevant to their condition, and that the study was well organized. Most were satisfied or very satisfied with the program and would recommend the interventions to others. One of the participants in the guided imagery group commented that the intervention should be used in the evening and not upon waking. Another guided imagery group participant commented that the program was “too much to keep up” during a complicated treatment course. Two critical comments concerned the symptom log; patients felt it was too much work to complete. Only two patients completed the symptom log. This finding suggests the need to explore other methods by which to track the patients’ experience and other adverse symptoms.

Discussion

Although the sample size was smaller than planned, informative findings were possible through examination of individual trends in the data. Overall, the interventions were favorably viewed by the participants, as was evident from their qualitative responses. Participants reported that the relaxation and guided imagery interventions improved sleep quality. An inpatient intervention may be helpful for future participants, particularly considering that adult oncology services at the study facility scored worse than the national average for quietness of hospital environment on the Hospital Consumer Assessment of Healthcare Providers and Systems (2016) during the intervention period. Although noise levels cannot always be controlled, the patients’ experience may be improved through use of the relaxation recordings or guided imagery.

Strengths and Limitations

Because of difficulties recruiting participants, the study sample was not large enough to measure the statistical significance of relaxation and guided imagery as adjunct treatments for pain, fatigue, and sleep disturbances during inpatient cancer treatment. However, qualitative data suggest the intervention aided sleep and was useful in achieving a restful state in a noisy hospital environment. The possibility that the intervention may improve inpatient sleep and rest quality should be explored in additional studies.

Implications for Practice

Oncology nurses, nurse practitioners, and clinical nurse specialists serve in key positions as members of the oncology patient care team. Patients trust the nursing staff’s experience and look to them for suggestions on symptom management. Nurses may need to be aware of non-traditional relief approaches and advise patients as they try different methods for symptom relief. The findings and trends identified in this small pilot study were shared with oncology nursing staff at the study hospital and provide supporting evidence for the importance of quality rest and sleep in creating a positive healing environment. Sleep is essential for recovering from treatment, general well-being, and survival. According to the American Academy of Nursing (2016), “sleep deprivation negatively affects ventilator, circulatory, immunologic, hormonal and metabolic stability” (para. 4). The study investigators have proposed conducting a subsequent study using the remaining MP3 players as an intervention to improve sleep quality and restfulness in adult patients with hematologic malignancies receiving inpatient treatment for seven or more consecutive days.

Conclusion

The use of relaxation and guided imagery techniques are feasible interventions for inpatients with hematologic malignancies and solid tumors. Few adverse effects were reported by patients who used these methods, and much potential benefit exists. Additional studies using relaxation and guided imagery interventions as adjunct therapy for symptom management with a larger sample of patients with cancer is recommended.

References

American Academy of Nursing. (2016). Fifteen things nurses and patients should question. Retrieved from http://www.aannet.org/assets/docs/aan_nursing%2015%20things%20list.pdf

Cella, D., Riley, W., Stone, A., Rothrock, N., Reeve, B., Yount, S., . . . Hays, R. (2010). The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005–2008. Journal of Clinical Epidemiology, 63, 1179–1194. doi:10.1016/j.jclinepi.2010.04.011

Cella, D., Yount, S., Rothrock, N., Gershon, R., Cook, K., Reeve, B., . . . Rose, M. (2007). The Patient-Reported Outcomes Measurement Information System (PROMIS): Progress of an NIH Roadmap cooperative group during its first two years. Medical Care, 45(Suppl. 1), S3–S11.

Coleman, E.A., Goodwin, J.A., Coon, S.K., Richards, K., Enderlin, C., Kennedy, R., . . . Barlogie, B. (2011). Fatigue, sleep, pain, mood, and performance status in patients with multiple myeloma. Cancer Nursing, 34, 219–227. doi:10.1097/NCC.0b013e3181f9904d

Dalal, S. (2015). Assessment and management of opioid side effects. In E. Bruera, I. Higginson, C.F. von Gunten, & T. Morita (Eds.), Textbook of palliative medicine (pp. 409–422). Boca Raton, FL: Taylor and Francis Group.

Dambrosio, N.M., & Mazanec, P. (2013). ‘Nurse, I can’t sleep!’ Approaches to management of insomnia in oncology patients. Journal of Hospice and Palliative Nursing, 15, 267–275. doi:10.1097/NJH.0b013e318296839b

Ducloux, D., Guisado, H., & Pautex, S. (2012). Promoting sleep for hospitalized patients with advanced cancer with relaxation therapy: Experience of a randomized study. American Journal of Hospice and Palliative Medicine, 30, 536–540. doi:10.1177/1049909112459367

Finnegan-John, J., Molassiotis, A., Richardson, A., & Ream, E. (2013). A systematic review of complementary and alternative medicine interventions for the management of cancer-related fatigue. Integrative Cancer Therapies, 12, 276–290. doi:10.1177/1534735413485816

Gorin, S.S., Krebs, P., Badr, H., Janke, E.A., Jim, H.S.L., Spring, B., . . . Jacobsen, P.B. (2012). Meta-analysis of psychosocial interventions to reduce pain in patients with cancer. Journal of Clinical Oncology, 30, 539–547. doi:10.1200/JCO.2011.37.0437

Hertzog, M.A. (2008). Considerations in determining sample size for pilot studies. Research in Nursing and Health, 31, 180–191. doi:10.1002/nur.20247

Holt, J., Recore, A., Savage, D., Kiehl, R., & Doyle, T. (2008). Hemi-Sync® and radiation oncology: A pilot study. Subtle Energies and Energy Medicine, 19(2), 49–56.

Hospital Consumer Assessment of Healthcare Providers and Systems. (2016). CAHPS® hospital survey. Retrieved from http://www.hcahpsonline.org/home.aspx

Kwekkeboom, K.L., Abbott-Anderson, K., & Wanta, B. (2010). Feasibility of a patient-controlled cognitive-behavioral intervention for pain, fatigue, and sleep disturbance in cancer [Online exclusive]. Oncology Nursing Forum, 37, E151–E159. doi:10.1188/10.ONF.E151-E159

Landier, W., & Tse, A.M. (2010). Use of complementary and alternative medical interventions for the management of procedure-related pain, anxiety, and distress in pediatric oncology: An integrative review. Journal of Pediatric Nursing, 25, 566–579. doi:10.1016/j.pedn.2010.01.009

Montague, L., & Green, C.R. (2009). Cancer and breakthrough pain’s impact on a diverse population. Pain Medicine, 10, 549–561. doi:10.1111/j.1526-4637.2009.00564.x

National Comprehensive Cancer Network. (2016). NCCN Clinical Practice Guidelines in Oncology: Cancer-related fatigue [v.1.2016]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/fatigue.pdf

Patient-Reported Outcomes Measurement Information System. (2015a). Fatigue: A brief guide to the PROMIS Fatigue instruments. Retrieved from https://www.assessmentcenter.net/documents/PROMIS%20Fatigue%20Scoring%20...

Patient-Reported Outcomes Measurement Information System. (2015b). Pain Interference: A brief guide to the PROMIS Pain Interference instruments. Retrieved from https://www.assessmentcenter.net/documents/PROMIS%20Pain%20Interference%...

Patient-Reported Outcomes Measurement Information System. (2015c). Sleep Disturbance: A brief guide to the PROMIS Sleep Disturbance instruments. Retrieved from https://www.assessmentcenter.net/documents/PROMIS%20Sleep%20Disturbance%...

Yeo, T., & Cannaday, S. (2015). Cancer-related fatigue:Iimpact on patient quality of life and management approaches. Nursing: Research and Reviews, 5, 65–76. doi:10.2147/NRR.S41957

Zimmermann, C., Yuen, D., Mischitelle, A., Minden, M.D., Brandwein, J.M., Schimmer, A., . . . Rodin, G. (2013). Symptom burden and supportive care in patients with acute leukemia. Leukemia Research, 37, 731–736. doi:10.1016/j.leukres.2013.02.009

About the Author(s)

Angela K. Nooner, MBA, MSN, APRN, ACCNS-AG, OCN®, is an oncology clinical nurse specialist at the Oklahoma University Medical Center in Oklahoma City; Kathleen Dwyer, PhD, RN, is a professor and Henry J. Freede Chair in Nursing Science, and Lise DeShea, PhD, is a senior research biostatistician in the College of Nursing, both at the University of Oklahoma Health Sciences Center in Oklahoma City; and Theresa P. Yeo, PhD, MPH, AOCNP®, is co-director of the Jefferson Pancreas Tumor Registry, a surgical oncology nurse practitioner in the Department of Surgery at Thomas Jefferson University Hospital, and an adjunct associate professor in the Jefferson College of Nursing at Thomas Jefferson University in Philadelphia, PA. The authors take full responsibility for the content of the article. Nooner and Yeo were participants in the Clinical Journal of Oncology Nursing (CJON) Writing Mentorship Program. This study was supported, in part, by a grant from the DAISY Foundation. 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 independent peer reviewers or editorial staff. Nooner can be reached at angela.nooner@hcahealthcare.com, with copy to editor at CJONEditor@ons.org. (Submitted September 2015. Revision submitted November 2015. Accepted for publication November 28, 2015.)

 

References 

American Academy of Nursing. (2016). Fifteen things nurses and patients should question. Retrieved from http://www.aannet.org/assets/docs/aan_nursing%2015%20things%20list.pdf

Cella, D., Riley, W., Stone, A., Rothrock, N., Reeve, B., Yount, S., . . . Hays, R. (2010). The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005–2008. Journal of Clinical Epidemiology, 63, 1179–1194. doi:10.1016/j.jclinepi.2010.04.011

Cella, D., Yount, S., Rothrock, N., Gershon, R., Cook, K., Reeve, B., . . . Rose, M. (2007). The Patient-Reported Outcomes Measurement Information System (PROMIS): Progress of an NIH Roadmap cooperative group during its first two years. Medical Care, 45(Suppl. 1), S3–S11.

Coleman, E.A., Goodwin, J.A., Coon, S.K., Richards, K., Enderlin, C., Kennedy, R., . . . Barlogie, B. (2011). Fatigue, sleep, pain, mood, and performance status in patients with multiple myeloma. Cancer Nursing, 34, 219–227. doi:10.1097/NCC.0b013e3181f9904d

Dalal, S. (2015). Assessment and management of opioid side effects. In E. Bruera, I. Higginson, C.F. von Gunten, & T. Morita (Eds.), Textbook of palliative medicine (pp. 409–422). Boca Raton, FL: Taylor and Francis Group.

Dambrosio, N.M., & Mazanec, P. (2013). ‘Nurse, I can’t sleep!’ Approaches to management of insomnia in oncology patients. Journal of Hospice and Palliative Nursing, 15, 267–275. doi:10.1097/NJH.0b013e318296839b

Ducloux, D., Guisado, H., & Pautex, S. (2012). Promoting sleep for hospitalized patients with advanced cancer with relaxation therapy: Experience of a randomized study. American Journal of Hospice and Palliative Medicine, 30, 536–540. doi:10.1177/1049909112459367

Finnegan-John, J., Molassiotis, A., Richardson, A., & Ream, E. (2013). A systematic review of complementary and alternative medicine interventions for the management of cancer-related fatigue. Integrative Cancer Therapies, 12, 276–290. doi:10.1177/1534735413485816

Gorin, S.S., Krebs, P., Badr, H., Janke, E.A., Jim, H.S.L., Spring, B., . . . Jacobsen, P.B. (2012). Meta-analysis of psychosocial interventions to reduce pain in patients with cancer. Journal of Clinical Oncology, 30, 539–547. doi:10.1200/JCO.2011.37.0437

Hertzog, M.A. (2008). Considerations in determining sample size for pilot studies. Research in Nursing and Health, 31, 180–191. doi:10.1002/nur.20247

Holt, J., Recore, A., Savage, D., Kiehl, R., & Doyle, T. (2008). Hemi-Sync® and radiation oncology: A pilot study. Subtle Energies and Energy Medicine, 19(2), 49–56.

Hospital Consumer Assessment of Healthcare Providers and Systems. (2016). CAHPS® hospital survey. Retrieved from http://www.hcahpsonline.org/home.aspx

Kwekkeboom, K.L., Abbott-Anderson, K., & Wanta, B. (2010). Feasibility of a patient-controlled cognitive-behavioral intervention for pain, fatigue, and sleep disturbance in cancer [Online exclusive]. Oncology Nursing Forum, 37, E151–E159. doi:10.1188/10.ONF.E151-E159

Landier, W., & Tse, A.M. (2010). Use of complementary and alternative medical interventions for the management of procedure-related pain, anxiety, and distress in pediatric oncology: An integrative review. Journal of Pediatric Nursing, 25, 566–579. doi:10.1016/j.pedn.2010.01.009

Montague, L., & Green, C.R. (2009). Cancer and breakthrough pain’s impact on a diverse population. Pain Medicine, 10, 549–561. doi:10.1111/j.1526-4637.2009.00564.x

National Comprehensive Cancer Network. (2016). NCCN Clinical Practice Guidelines in Oncology: Cancer-related fatigue [v.1.2016]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/fatigue.pdf

Patient-Reported Outcomes Measurement Information System. (2015a). Fatigue: A brief guide to the PROMIS Fatigue instruments. Retrieved from https://www.assessmentcenter.net/documents/PROMIS%20Fatigue%20Scoring%20...

Patient-Reported Outcomes Measurement Information System. (2015b). Pain Interference: A brief guide to the PROMIS Pain Interference instruments. Retrieved from https://www.assessmentcenter.net/documents/PROMIS%20Pain%20Interference%...

Patient-Reported Outcomes Measurement Information System. (2015c). Sleep Disturbance: A brief guide to the PROMIS Sleep Disturbance instruments. Retrieved from https://www.assessmentcenter.net/documents/PROMIS%20Sleep%20Disturbance%...

Yeo, T., & Cannaday, S. (2015). Cancer-related fatigue:Iimpact on patient quality of life and management approaches. Nursing: Research and Reviews, 5, 65–76. doi:10.2147/NRR.S41957

Zimmermann, C., Yuen, D., Mischitelle, A., Minden, M.D., Brandwein, J.M., Schimmer, A., . . . Rodin, G. (2013). Symptom burden and supportive care in patients with acute leukemia. Leukemia Research, 37, 731–736. doi:10.1016/j.leukres.2013.02.009