Fatigue as a response to environmental demands in women's lives

A human factors approach to evaluate predicators of acute care nurse occupational fatigue

Nurses function at the point of care and assume a significant role in intercepting errors. They work in a mentally and physically demanding profession that is comprised of shift-work, subjecting nurses to considerable fatigue. Yet, few studies constructed a comprehensive model that integrates personal and occupational factors to explore their relationship with various types of fatigue (acute, chronic, physical, mental, and total). Here, we examine this type of comprehensive fatigue-model, in a report that represents one aim of a larger, mixed-methods study. The study sample comprised of 1137 registered nurses working in eight hospitals in a Midwestern state. Nurses reported higher levels of acute and total fatigue than chronic and physical fatigue. Staffing and resource adequacy, exercise, and sleep were among the strongest predictors. Since fatigue is a multi-faceted construct, a comprehensive fatigue-management strategy that targets both day and night-shift nurses is the optimal way to manage nurse fatigue.

A 4-Month Whole-Systems Ayurvedic Medicine Nutrition and Lifestyle Intervention Is Feasible and Acceptable for Breast Cancer Survivors: Results of a Single-Arm Pilot Clinical Trial

PURPOSE

Ongoing symptoms and impairments in quality of life (QOL) among breast cancer survivors remain a significant problem. We tested the feasibility and acceptability of a manualized Ayurvedic nutrition and lifestyle intervention for breast cancer survivors.

METHODS

Eligible participants had Stage I-III breast cancer, underwent treatment within the past year that included chemotherapy, and were without active disease. The 4-month individualized Ayurvedic intervention included counseling on nutrition, lifestyle, yoga, and marma (like acupressure) during 8 one-on-one visits with an Ayurvedic practitioner. Feasibility and acceptability were the primary outcomes. QOL (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire [EORTC QLQ C30]) and symptoms-sleep disturbance (General Sleep Disturbance Scale [GSDS]), fatigue (Lee Fatigue Scale [LFS]), depressive symptoms (Center for Epidemiological Studies-Depression Scale [CES-D]), anxiety (Spielberger State-Trait Anxiety Inventory [STAI-S, STAI-T]), and stress (Perceived Stress Scale [PSS])-were measured prior to, at midpoint, and at the end of the 4-month intervention. Effect sizes (Cohen's d) were calculated along with paired t tests comparing baseline to end of month 4 time points. Mixed effects models were used for repeated measures analyses.

RESULTS

Participants (n = 32) had a mean age of 48 years (SD = 10). Retention at the end of the intervention was 84%. Among those who completed the intervention (n = 27), adherence was high (99.5% of visits with practitioners attended). Large improvements were seen in QLQ-C30 emotional functioning (d = 0.84, P < 0.001), QLQ-C30 cognitive functioning (d = 0.86, P < 0.001), GSDS (d = -1.23, P < 0.001), and CES-D (d = -1.21, P < 0.001). Moderate improvements were seen in QLQ-C30 global health (d = 0.65, p = 0.003), LFS (d = -0.68, P = 0.002), and PSS (d = -0.75, P < 0.001). No adverse events were observed due to the intervention.

CONCLUSION

This 4-month Ayurvedic whole-systems multimodal nutrition and lifestyle intervention was feasible and acceptable for breast cancer survivors. Promise of clinical benefit was seen in terms of improvements in symptoms and QOL that warrants further investigation.

Changes in Fatigue Recovery and Muscle Damage Enzymes after Deep-Sea Water Thalassotherapy

The purpose of this study was to verify the effect of deep-sea water thalassotherapy (DSWTT) on recovery from fatigue and muscle damage. The same exercise program is conducted in general underwater and deep-sea water to confirm the characteristics of deep-sea water through fatigue recovery and muscle damage enzymes. A total of 30 male college students were studied, including 10 belonging to the control group (CG), 10 in the water exercise group (WEG), and 10 in the deep-sea water exercise group (DSWEG). The DSWTT treatment consists of three components—preheating, treatment, and cooling—and the DSWTT program stretches and massages the entire upper body, lower body, back, and the entire body for a total of 25 min in a deep-sea tank. After the DSWTT program, blood tests were conducted to confirm the level of fatigue-related parameters and muscle damage enzymes. Fatigue-related parameters including glucose, lactate, ammonia, and lactate dehydrogenase (LDH), and the levels of muscle damage enzymes such as creatinine kinase (CK) and aspartate aminotransferase (AST) were measured. The results revealed that fatigue had a primary effect (p < 0.001) and exhibited strongly significant interaction (p < 0.001) with lactate, ammonia, and LDH levels, whereas the glucose level remained unchanged. The post hoc results showed a significant decrease in these parameters among DSWEG compared to CG and WEG (p < 0.01). Muscle damage enzymes showed a main effect (p < 0.001) and significant interaction (p < 0.001) with CK and AST (p < 0.001). The post hoc results showed a significant decrease in DSWEG compared with CG and WEG (p < 0.01). In conclusion, the DSWTT program applied to this study showed significant effects on muscle fatigue and muscle damage recovery. When the DSWTT program is applied in hot springs, it can have a positive effect on muscle fatigue and muscle damage recovery and can contribute to improving national health and quality of life. Further studies are needed to investigate DSWTT programs with various research subjects at different program temperatures, exercise times, and frequencies of treatment and exercise.

Perceived HIV-related physical fatigue, sociodemographic characteristics and physical activity: A cross-sectional study

AIMS AND OBJECTIVES

To get a deeper understanding of correlates of perceived HIV-related fatigue by exploring its associations with sociodemographic characteristics and physical activity level of HIV-infected people.

BACKGROUND

Previous studies on HIV-related fatigue have mainly focused on physiological and psychological characteristics, but few have considered its associations with sociodemographic variables. In addition, while physical activity has been found to reduce acute fatigue among HIV-infected people, its links with chronic HIV-related fatigue remain to be explored.

DESIGN

The study employed an observational and cross-sectional survey design. The manuscript was organised according to STROBE guidelines.

METHOD

A total of 560 people living with HIV in France completed a measure of perceived physical fatigue using the Fatigue Intensity Scale. The predictors targeted sociodemographic characteristics and two measures of individuals' reported level of physical activity. Data were analysed by a stepwise multiple regression model.

RESULTS

The results showed that lower age, higher physical activity level and socio-economic status were significantly associated with reduced perceived physical fatigue, explaining 25% of the variance.

CONCLUSIONS

The results highlighted the importance of considering sociodemographic and lifestyle characteristics to better characterise HIV-related fatigue, in particular in an era where HIV as a chronic illness challenges questions of quality of life throughout increasingly longer lifespans.

RELEVANCE TO CLINICAL PRACTICE

The results of this study have implications for HIV care professionals in terms of improving strategies for managing chronic fatigue or promoting physical activity according to more specific profiles of HIV-infected people.

Comparison of Fatigue Severity and Quality of Life between Unexplained Fatigue Patients and Explained Fatigue Patients

Background

Recently, despite the high prevalence of fatigue in patients, there is a lack of research on the quality of life (QoL) in unexplained fatigue patients, indicating that they are not properly diagnosed and treated. The aim of this study was to compare fatigue severity and QoL between patients with explained and unexplained fatigue.

Methods

The study consisted of 200 Korean adults who complained of fatigue without underlying disease. Fatigue Severity Scale, Short Form Health Survey-36 version 2 (SF-36v2), and Beck Depression Inventory-II (BDI-II) self-questionnaires were administered. Participants were dichotomized to two groups, namely, patients with unexplained or explained fatigue, sorted according to laboratory examination results. The chi-square test, t-test, and Wilcoxon rank-sum test were used, and analysis of covariance was calculated after adjusting for age, sex, body mass index, smoking status, and physical component summary (PCS) of SF-36v2 or BDI-II.

Results

PCS of SF-36v2 between the two groups showed significant difference. Compared to patients with explained fatigue, those with unexplained fatigue showed lower physical component scores of QoL.

Conclusion

QoL of patients with unexplained fatigue could largely diminish than those with explained fatigue. The primary clinician should be aware of poor QoL in patients with unexplained fatigue to identify who is in need of more attention and intervention.

To be or not to be sick and tired: Managing the visibility of HIV and HIV-related fatigue

This article takes a new direction in exploring HIV-related fatigue by adopting a qualitative interactionist approach. We analyse the social meanings attributed to fatigue among people living with HIV in France, the social gains and losses of its visibility and the social frames that condition its discursive and physical expression. The two-part methodology combines grounded theory analysis of 50 transcribed unstructured interviews conducted across France and participant observations within four HIV-related associations. Results reveal that the visibility of fatigue is in part dependent on the visibility of this stigmatized illness. The expression of fatigue is therefore closely linked with disclosure and concerns about HIV stigma. The degree to which HIV and HIV-related fatigue are rendered (in)visible also depends on structural factors including gender prescriptions, as well as context effects such as the type of social or 'care' relations involved in the social frame of interaction.

The Lived Experience of Feeling Very Tired: A Study Using the Parse Research Method

The purpose of this study was to answer the research question, What is the structure of the lived experience of feeling very tired? The Parse research method was used to discover the meaning of feeling very tired for 10 women volunteer participants. The major finding of the study is the structure: The lived experience of feeling very tired is devitalizing languor arising with engaging endeavors amid pulsating moments of repose-revive . The study finding contributes knowledge about feeling very tired and its connection to health and quality of life. The structure is discussed in light of the principles of human becoming, and suggestions are made for future research.

Community Dwellers' Perspectives on the Experience of Feeling Very Tired

Feeling very tired is a phenomenon experienced by all humans at some point in their life. As a means of more fully understanding the human experience of feeling very tired, this concept was explored with a group of 10 community dwelling individuals who had no expressed health concerns. The Parse research method was used to answer the research question, What is the structure of the lived experience of feeling very tired? The central finding of this study is the structure: The lived experience of feeling very tired is dissipated vigor arising with monotonous disquietude amid spirited cherished engagements . The structure was conceptually integrated with the human becoming theory as: feeling very tired is powering the languaging of valuing connecting-separating. The findings are discussed in relation to human becoming and future research.

Predictors and Trajectories of Morning Fatigue Are Distinct From Evening Fatigue

CONTEXT

Fatigue is the most common symptom in oncology patients during chemotherapy. Little is known about the predictors of interindividual variability in initial levels and trajectories of morning fatigue severity in these patients.

OBJECTIVES

An evaluation was done to determine which demographic, clinical, and symptom characteristics were associated with initial levels as well as the trajectories of morning fatigue and to compare findings with our companion paper on evening fatigue.

METHODS

A sample of outpatients with breast, gastrointestinal, gynecological, and lung cancer (n = 586) completed demographic and symptom questionnaires a total of six times over two cycles of chemotherapy. Fatigue severity was evaluated using the Lee Fatigue Scale. Hierarchical linear modeling was used to answer the study objectives.

RESULTS

A large amount of interindividual variability was found in the morning fatigue trajectories. A piecewise model fit the data best. Patients with higher body mass index, who did not exercise regularly, with a lower functional status, and who had higher levels of state anxiety, sleep disturbance, and depressive symptoms reported higher levels of morning fatigue at enrollment. Variations in the trajectories of morning fatigue were predicted by the patients' ethnicity and younger age.

CONCLUSION

The modifiable risk factors that were associated with only morning fatigue were body mass index, exercise, and state anxiety. Modifiable risk factors that were associated with both morning and evening fatigue included functional status, depressive symptoms, and sleep disturbance. Using this information, clinicians can identify patients at higher risk for more severe morning fatigue and evening fatigue, provide individualized patient education, and tailor interventions to address the modifiable risk factors.

Trajectories of Evening Fatigue in Oncology Outpatients Receiving Chemotherapy

CONTEXT

Fatigue is a distressing persistent sense of physical tiredness that is not proportional to a person's recent activity. Fatigue impacts patients' treatment decisions and can limit their self-care activities. Although significant interindividual variability in fatigue severity has been noted, little is known about predictors of interindividual variability in initial levels and trajectories of evening fatigue severity in oncology patients receiving chemotherapy.

OBJECTIVES

To determine whether demographic, clinical, and symptom characteristics were associated with initial levels and the trajectories of evening fatigue.

METHODS

A sample of outpatients with breast, gastrointestinal, gynecological, and lung cancer (N = 586) completed demographic and symptom questionnaires a total of six times over two cycles of chemotherapy. Fatigue severity was evaluated using the Lee Fatigue Scale. Hierarchical linear modeling was used to answer the study objectives.

RESULTS

A large amount of interindividual variability was found in the evening fatigue trajectories. A piecewise model fit the data best. Patients who were white, diagnosed with breast, gynecological, or lung cancer, and who had more years of education, childcare responsibilities, lower functional status, and higher levels of sleep disturbance and depression reported higher levels of evening fatigue at enrollment.

CONCLUSION

This study identified both nonmodifiable (e.g., ethnicity) and modifiable (e.g., childcare responsibilities, depressive symptoms, sleep disturbance) risk factors for more severe evening fatigue. Using this information, clinicians can identify patients at higher risk for more severe evening fatigue, provide individualized patient education, and tailor interventions to address the modifiable risk factors.

Lee Fatigue And Energy Scales: exploring aspects of validity in a sample of women with HIV using an application of a Rasch model

This study examines the psychometric properties of the Lee Fatigue and Energy Scales (visual analog version) using a Rasch model application. The relationship between fatigue and energy is also described for a convenience sample of 102 women with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) who completed the Lee Fatigue and Energy Scales in the morning and evening. Both scales were assessed for internal scale validity, unidimensionality, and uniform differential item functioning in relation to morning and evening ratings. Analyses confirmed that both the Fatigue and Energy Scales demonstrated evidence of internal scale validity and unidimensionality. Mean fatigue measures were also higher in the evening than in the morning and mean energy measures were higher in the morning than in the evening (both p<0.001), indicating that time of day is an important consideration. Fatigue and energy measures were moderately correlated with each other in the morning but not in the evening. The concepts of energy and fatigue were inversely related, but not polar opposites in this sample. Fatigue and energy may therefore be distinct constructs that should not be used interchangeably, either in measurement or when interpreting outcomes for research or clinical purposes.

Development of a short version of the Lee Visual Analogue Fatigue Scale in a sample of women with HIV/AIDS: a Rasch analysis application

PURPOSE

To develop a psychometrically sound short version of the 13-item Lee Fatigue Scale using a Rasch model application.

METHODS

A convenience sample of 102 women with HIV/AIDS completed the Lee Fatigue Scale in the morning and evening. The scale was assessed using a Rasch analysis approach. We used a stepwise approach of removing the item with the least goodness-of-fit for internal scale validity in sequential analyses while monitoring unidimensionality and sensitivity to detect levels of fatigue.

RESULTS

The item reduction process terminated with a 5-item version (items 1, 4, 5, 11, and 12 from the original 13-item version). Analyses confirmed that both the original and short-form versions of the Lee Fatigue Scale demonstrated evidence of internal scale validity, unidimensionality, and sensitivity to at least three levels of fatigue (low, moderate, and high severity). Differential test functioning indicated that the original and short-form versions yielded similar ratings for 95 % of respondents.

CONCLUSION

A 5-item version of the Lee Fatigue Scale has satisfactory measurement properties and met criteria related to unidimensionality and ability to separate levels of fatigue. This version may be useful in studies measuring fatigue repeatedly over relatively short intervals.

A longitudinal study of measures of objective and subjective sleep disturbance in patients with breast cancer before, during, and after radiation therapy

CONTEXT

Sleep disturbance is a significant problem in oncology patients.

OBJECTIVES

To examine how actigraphy and self-report ratings of sleep disturbance changed over the course of and after radiation therapy (RT); investigate whether specific patient, disease, and symptom characteristics predicted the initial levels and/or the characteristics of the trajectories of sleep disturbance; and compare predictors of subjective and objective sleep disturbance.

METHODS

Patients (n=73) completed self-report questionnaires that assessed sleep disturbance, fatigue, depressive symptoms, anxiety, and pain before the initiation of RT through four months after the completion of RT. Wrist actigraphy was used as the objective measure of sleep disturbance. Hierarchical linear modeling was used for data analyses.

RESULTS

Mean wake after sleep onset was 11.9% and mean total score on the General Sleep Disturbance Scale was 45. More than 85% of the patients had an abnormally high number of nighttime awakenings. Substantial interindividual variability was found for both objective and subjective measures of sleep disturbance. Body mass index predicted baseline levels of objective sleep disturbance. Comorbidity, evening fatigue, and depressive symptoms predicted baseline levels of subjective sleep disturbance, and depressive symptoms predicted the trajectory of subjective sleep disturbance.

CONCLUSION

Different variables predicted sleep disturbance using subjective and objective measures. The slightly elevated wake after sleep onset found may be an underestimation of the degree of sleep disturbance when it is evaluated in the context of the high number of nighttime awakenings and patient's perception of poor sleep quality and quantity.

Patterns of morning and evening fatigue among adults with HIV/AIDS

AIMS AND OBJECTIVES

Describe patterns of morning and evening fatigue in adults with HIV and examine their relationship to demographic and clinical factors and other symptoms.

BACKGROUND

Most studies of HIV-related fatigue assess average levels of fatigue and do not address its diurnal fluctuations. Patterns of fatigue over the course of the day may have important implications for assessment and treatment.

DESIGN

A cross-sectional, correlational design was used with six repeated measures over 72 hours.

METHOD

A convenience sample of 318 HIV-infected adults was recruited in San Francisco. Socio-demographic, clinical and symptom data were collected with questionnaires. CD4+ T-cell count and viral load were obtained from medical records. Participants completed a four-item version of the Lee Fatigue Scale each morning and evening for three consecutive days. Participants were grouped based on their diurnal pattern of fatigue (high evening only, high morning only, high morning and evening and low morning and evening). Group comparisons and logistic regression were used to determine the unique predictors of each fatigue pattern.

RESULTS

The high evening fatigue pattern was associated with anxiety and the high morning pattern was associated with anxiety and depression. The morning fatigue pattern showed very little fluctuation between morning and evening, the evening pattern showed the largest fluctuation. The high morning and evening pattern was associated with anxiety, depression and sleep disturbance and this group reported the most fatigue-related distress and interference in functioning.

CONCLUSIONS

These results provide initial evidence for the importance of assessing the patient's daily pattern of fatigue fluctuation, as different patterns were associated with different symptom experiences and perhaps different aetiologies.

RELEVANCE TO CLINICAL PRACTICE

Different fatigue patterns may benefit from tailored intervention strategies. Management of depressive symptoms could be tested in patients who experience high levels of morning fatigue.

Differences in self-reported attentional fatigue between patients with breast and prostate cancer at the initiation of radiation therapy

BACKGROUND

Attentional fatigue is experienced as a decreased ability to concentrate, engage in purposeful activity, and maintain social relationships when there are competing demands on attention. Breast and prostate cancer are the 2 most common cancers in women and men, respectively. Most previous studies on self-reported attentional fatigue evaluated patients with breast cancer.

OBJECTIVES

The objectives of the study were to determine if self-reported attentional fatigue differed in patients with breast cancer and prostate cancer before radiation therapy (RT) and to determine the relationships between attentional fatigue and other symptoms in these 2 groups.

METHODS

Patients (n = 155) completed questionnaires before RT. Descriptive statistics, Pearson correlations, and analysis of covariance were used for data analyses.

RESULTS

After controlling for age, patients with breast cancer reported significantly higher levels of attentional fatigue. In both groups, more attentional fatigue correlated significantly with more anxiety, depression, sleep disturbance, and physical fatigue. These correlations were stronger for patients with breast cancer.

CONCLUSIONS

The present study is the first to identify differences in self-reported attentional fatigue between these 2 groups before RT. Additional research is warranted to determine factors that contribute to these differences, as well as mechanisms that underlie the development of attentional fatigue.

IMPLICATIONS FOR PRACTICE

Clinicians should consider the capacity of their patients to direct attention when learning about RT and other treatments. It is important to simplify confusing healthcare terminology and reinforce teaching that is most important both verbally and in writing. Appropriate interventions for anxiety and depression may decrease attentional fatigue in these patients.

Predictors of the trajectories of self-reported sleep disturbance in men with prostate cancer during and following radiation therapy

STUDY OBJECTIVES

To examine how self-reported ratings of sleep disturbance changed from the time of the simulation visit to four months after the completion of radiation therapy (RT) and to investigate whether specific patient, disease, and symptom characteristics predicted the initial levels of sleep disturbance and/or characteristics of the trajectories of sleep disturbance.

DESIGN

Prospective longitudinal study.

SETTING

Two radiation therapy centers.

PATIENTS

Patients (n = 82) who underwent primary or adjuvant RT for prostate cancer.

MEASUREMENTS AND RESULTS

Changes in self-reported sleep disturbance were measured using the General Sleep Disturbance Scale (GSDS). Depressive symptoms were assessed using the Center for Epidemiologic Studies-Depression Scale. Trait and state anxiety were measured using the Spielberger State-Trait Anxiety Inventory. Hierarchical linear modeling was used to answer the study aims. Self-reported sleep disturbance increased during the course of RT and then decreased following the completion of RT. Predictors of higher levels of sleep disturbance included younger age, higher levels of trait anxiety, higher levels of depressive symptoms, and higher levels of sleep disturbance at the initiation of RT.

CONCLUSIONS

Sleep disturbance is a significant problem in patients with prostate cancer who undergo RT. Younger men with co-occurring depression and anxiety may be at greatest risk for sleep disturbance during RT.

Predictors of the trajectories of self-reported attentional fatigue in women with breast cancer undergoing radiation therapy

PURPOSE/OBJECTIVES

To examine how attentional fatigue changed from the time of simulation to four months after the completion of radiation therapy and to investigate whether specific variables predicted initial levels and trajectories of attentional fatigue.

DESIGN

Descriptive, longitudinal study.

SETTING

Two radiation therapy departments.

SAMPLE

73 women with breast cancer who received primary or adjuvant radiation therapy.

METHODS

Participants completed questionnaires prior to, during, and after radiation therapy. Descriptive statistics and hierarchical linear modeling were used for data analysis.

MAIN RESEARCH VARIABLES

Attentional fatigue; demographic, clinical, and symptom characteristics.

FINDINGS

Large amounts of interindividual variability were found in the trajectories of attentional fatigue. At baseline, higher levels of attentional fatigue were associated with younger age, not working, a higher number of comorbidities, and higher levels of trait anxiety. The trajectory of attentional fatigue improved over time for women with higher body mass index at baseline.

CONCLUSIONS

This study is the first to identify predictors of interindividual variability in attentional fatigue in women with breast cancer undergoing radiation therapy. The predictors should be considered in the design of future correlational and interventional studies.

IMPLICATIONS FOR NURSING

Nurses could use knowledge of the predictors to identify patients at risk for higher levels of attentional fatigue. In addition, nurses could use the information to educate patients about how attentional fatigue may change during and following radiation therapy for breast cancer.

Trajectories of fatigue in patients with breast cancer before, during, and after radiation therapy

BACKGROUND

Fatigue is a significant problem associated with radiation therapy (RT).

OBJECTIVE

This study examined how evening and morning fatigue changed from the time of simulation to 4 months after the completion of RT and investigated whether specific demographic and disease characteristics and baseline severity of symptoms predicted the initial levels of fatigue and characteristics of the trajectories of fatigue.

METHODS

Seventy-three women with breast cancer completed questionnaires that assessed sleep disturbance, depression, anxiety, and pain prior to the initiation of RT and the Lee Fatigue Scale, over 6 months. Descriptive statistics and hierarchical linear modeling were used for data analysis.

RESULTS

Large amounts of interindividual variability were found in the trajectories of fatigue. Evening fatigue at baseline was negatively influenced by having children at home and depression. The trajectory of evening fatigue was worse for women who were employed. Morning fatigue at baseline was influenced by younger age, lower body mass index, and the degree of sleep disturbance and trait anxiety. Trajectories of morning fatigue were worse for patients with a higher disease stage and more medical comorbidities.

CONCLUSION

Interindividual and diurnal variability in fatigue found in women with breast cancer is similar to that found in men with prostate cancer. However, the predictors of interindividual variability in fatigue between these 2 cohorts were different.

IMPLICATIONS FOR PRACTICE

Diurnal variability and different predictors for morning and evening fatigue suggest different underlying mechanisms. The various predictors of fatigue need to be considered in the design of future intervention studies.

Poststroke fatigue--a review

Although fatigue is a common complaint after stroke, relatively little is known about how poststroke fatigue is experienced and what its related factors are. An in-depth understanding is necessary to develop effective and patient-centered poststroke rehabilitation programs. This review was undertaken to provide a comprehensive synthesis of knowledge from the literature concerning the description, definition, and measurement of fatigue and its relationship to sociodemographic and clinical factors. A search in PubMed, CINAHL, EMBASE, and PsychInfo was performed using "stroke" or "cerebrovascular accident" as medical subject headings in combination with "fatigue" as a key word. Descriptions of fatigue revealed multiple dimensions of the phenomenon. Although no specific theoretical definition of fatigue as a poststroke condition was found, a case definition has recently been published to be used as a tool to determine the presence of fatigue in poststroke patients. Poststroke fatigue is most frequently measured by using the general fatigue scales such as the Fatigue Severity Scale and a Fatigue Visual Analogue Scale, as there is no scale developed to measure poststroke fatigue specifically. Age, sex, living conditions, and personality were associated with poststroke fatigue, albeit with some conflicting findings. Conflicting results also were found in the relationships between fatigue and stroke-related characteristics such as stroke location/type, the number of strokes, and neurological deficits. There is an indication that prestroke and poststroke fatigue are related. Possible antecedent components identified are personal factors, biomarkers, stroke characteristics, prestroke fatigue, and comorbidity. As knowledge regarding poststroke fatigue remains limited, there is a need to continue empirical research with various theoretical orientations.

Childbirth-related fatigue trajectories during labour

AIM

This paper is a report on a study identifying trajectories of childbirth-related fatigue intensity changes over time and the influencing factors related to specific trajectory patterns.

BACKGROUND

Childbirth is a period of time that encompasses considerable physiological and psychological fatigue, often having an adverse impact on women in labour. Empirical studies on this issue are scarce. How childbirth-related fatigue changes over time, and factors influencing fatigue development, remain unclear.

METHOD

A prospective, correlational design with repeated measures was used. Data were collected by self-reported measures and laboratory analysis of blood specimens. From December 2004 to November 2005 a convenience sample of 209 low-risk pregnant Taiwanese women was followed throughout the labour process. Repeated measures of fatigue were analysed by using a semiparametric mixture model. Variables explaining trajectory class membership were identified by means of logistic regression.

RESULTS

Two distinct trajectories of childbirth-related fatigue were identified: low intensity (30.8% of women) and high intensity (69.2% of women). Fatigue level of both classes intensified following labour. The fastest period of fatigue-increasing rate was in the active phase. After birth, fatigue levels in the high-fatigue intensity class remained high. Primiparas in the high-fatigue intensity class experienced significantly more anxiety and higher lactate concentration at admission than the low-intensity class.

CONCLUSION

Caregivers should endeavour to prevent high levels of fatigue once women enter the labour phase. Women who present with high fatigue at onset of labour should be targeted for early intervention, especially in the period of rapid fatigue increase.

Trajectories of fatigue in men with prostate cancer before, during, and after radiation therapy

Fatigue is the most common and distressing symptom reported by patients undergoing radiation therapy (RT). However, limited information is available on the trajectories of fatigue, as well as on the predictors of interindividual variability in fatigue. This study evaluated a sample of patients who underwent RT for prostate cancer to examine how ratings of evening and morning fatigue changed from the time of simulation to four months after the completion of RT and to investigate whether specific patient, disease, and symptom characteristics predicted the initial levels of fatigue and/or characteristics of the trajectories of evening and morning fatigue. Using hierarchical linear modeling, a large amount of interindividual variability was demonstrated in the trajectories of evening and morning fatigue. Findings from this study suggest that younger men with a higher level of fatigue at the time of the simulation visit were at increased risk for higher levels of evening and morning fatigue over the course of RT. In addition, the level of morning fatigue over the course of RT appears to depend on the patient's level of depression at the time of the simulation visit. In future studies, the use of hierarchical linear modeling as an analytic tool will assist in the identification of patients who are most at risk for prolonged fatigue trajectories. This type of analysis may lead to the identification of subgroups of patients who are at higher risk for negative outcomes and who require different types of interventions for the fatigue associated with RT.

A randomized trial of modafinil for the treatment of fatigue and excessive daytime sleepiness in individuals with chronic traumatic brain injury

BACKGROUND

This study examines the efficacy of modafinil in treating fatigue and excessive daytime sleepiness in individuals with traumatic brain injury (TBI).

METHODS

A single-center, double-blind, placebo-controlled cross-over trial, where 53 participants with TBI were randomly assigned to receive up to 400 mg of modafinil, or equal number of inactive placebo tablets. Main eligibility criteria were being at least 1 year post-TBI severe enough to require inpatient rehabilitation. The primary outcome measures were fatigue (Fatigue Severity Scale, FSS) and daytime sleepiness (Epworth Sleepiness Scale, ESS).

RESULTS

After adjusting for baseline scores and period effects, there were no statistically significant differences between improvements seen with modafinil and placebo in the FSS at week 4 (-0.5 +/- 1.88; P = .80) or week 10 (-1.4 +/- 2.75; P = .61). For ESS, average changes were significantly greater with modafinil than placebo at week 4 (-1.2 +/- 0.49; P = .02) but not at week 10 (-0.5 +/- 0.87; P = .56). Modafinil was safe and well tolerated, although insomnia was reported significantly more often with modafinil than placebo (P = .03).

CONCLUSIONS

While there were sporadic statistically significant differences identified, a clear beneficial pattern from modafinil was not seen at either week 4 or week 10 for any of the 12 outcomes. There was no consistent and persistent clinically significant difference between treatment with modafinil and placebo.

The use of a responder analysis to identify differences in patient outcomes following a self-care intervention to improve cancer pain management

Previously, we demonstrated, in a randomized clinical trial, the effectiveness of a psychoeducational intervention to decrease pain intensity scores and increase patients' knowledge of cancer pain management with a sample of oncology patients with pain from bone metastasis. In the present study, we evaluated for changes in mood states (measured using the Profile of Mood States), quality of life (QOL; measured using the Medical Outcomes Study Short Form-36 (SF-36)), and pain's level of interference with function (measured using the Brief Pain Inventory (BPI)) from baseline to the end of the intervention first between the intervention and the standard care groups and then within the intervention group based on the patients' level of response to the intervention (i.e., patients were classified as non-responders, partial responders, or responders). No differences were found in any of these outcome measures between patients in the standard care and intervention groups. However, when patients in the intervention group were categorized using a responder analysis approach, significant differences in the various outcome measures were found among the three respondent groups. Differences in the physical and mental component summary scores on the SF-36 and the interference items on the BPI, among the three respondent groups, were not only statistically significant but also clinically significant. The use of responder analysis in analgesic trials may help to identify unique subgroups of patients and lead to the development of more effective psychoeducational interventions.

Effects of regular exercise on pain, fatigue, and disability in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is a major health problem in Korea. To explore the effects of regular exercise on pain, fatigue, and disability, a descriptive study was conducted in 435 Korean patients with RA. Exercisers were defined as those who are currently exercising more than 3 times a week, for at least 20 minutes, and for more than 6-consecutive months after being diagnosed with RA. The primary finding was that exercisers had significantly less fatigue and disability compared with nonexercisers. Results suggest that regular exercise has advantages for patients with RA to decrease fatigue and disability.

The experience of fatigue for adults living with HIV

AIMS

The aim of this study was to go beyond objective clinical assessment and explore the experience of fatigue and self-care strategies with adults who live with HIV.

RATIONALE

This study responded to a perceived lack of available evidence to inform the practice of service providers about ways fatigue impacts on the lives of people with HIV. Prior understandings of fatigue are derived from survey or instrument-based tools or studies that do not consider the complexities of the personal experience that in-depth interviews can elicit. The focus remains generally on description, measurement or management from a biomedical perspective.

METHODS

A qualitative study using participatory action research methods was conducted during 2003 with 15 adults diagnosed with HIV who perceived fatigue was a problem in their lives. Data were collected by individual interviews, researcher's notes and two participatory action research groups.

RESULTS

Thematic analysis of data demonstrated that fatigue remains silent and invisible to participant's families, friends and employers. Fatigue experienced by people living with HIV generally also met with a lack of acknowledgement and understanding from health professionals. People developed self-care strategies over many years of trial and error.

RELEVANCE TO CLINICAL PRACTICE

People living with a HIV seek to be acknowledged that fatigue is a legitimate concern, not only by health care professionals, but also people with whom they live. It is imperative that nurses who work with people living with HIV-related fatigue consider the wider social aspects of the person's life as well as physical symptoms. Most importantly, there then needs to be a process of engagement and active listening to the individual's account of their experience of fatigue. Advocating that fatigue is a legitimate complaint to the person living with HIV as well as the wider public and professional community is imperative.

Women's experiences of fatigue in chronic illness

AIM

The aim of this paper is to add a qualitative dimension to the body of knowledge about fatigue by revealing the meaning given by women living with chronic illness to the experience of fatigue.

BACKGROUND

Fatigue is a common symptom experienced by people who live with chronic illness. It pervades every aspect of life and may be experienced in physical, psychological, emotional or social dimensions. Management of fatigue relies heavily on the individual's ability to employ self-care actions. The invisibility of fatigue is recognized as one of the most frustrating aspects, which can lead to lack of understanding and misunderstanding by others.

METHOD

We report the findings of data from research in progress (2003-2005). Data were generated via email group conversations between us and 30 women who live with long-term illness.

FINDINGS

A recurring conversational thread has been women's experiences of fatigue when living with long-term illness. Although fatigue has been reported to be a major obstacle to maintaining usual daily activities and quality of life, few studies have explored this common symptom from the perspective of people themselves. Common themes found in the experience of fatigue as described by women are the meaning of fatigue, awareness as self-care, fatigue as invisible to others, seeking medical validation and accountability for self-care.

CONCLUSION

It is vital for healthcare workers to give opportunities for women to talk about fatigue, validate their experiences and provide support with self-care. Healthcare workers are encouraged to challenge their own meanings and expectations surrounding a person's report of fatigue so that opportunities for therapeutic intervention can be facilitated.

Postoperative recovery at home after ambulatory gynecologic laparoscopic surgery

The purposes of this descriptive, correlational study were to measure pain, fatigue, and functional limitations affecting the "at home" recovery process for ambulatory gynecologic laparoscopic surgery and to explore the relationships between these variables and the return to normal activities. Subjects (N = 91) recorded daily ratings of pain, fatigue, and function on a Home Recovery Log for 6 days postoperatively. The findings indicate that 95% of subjects resumed basic self-care activities such as dressing, bathing, and eating by postoperative day (POD) 3; however, less than 40% of subjects were able to perform other role functions such as shopping, laundry, and work outside of the home. A logistic regression model indicated that pain ratings and functional status on POD 2 were the best predictors of subjects who would need more than 5 days to resume their usual activities and routines. The findings have implications for preoperative teaching and telephone follow-up for ambulatory surgery patients. Preoperative teaching should prepare women for the additional days needed for recovery of instrumental activities of daily living to enable them to make alternate plans as necessary. Furthermore, because pain on POD 2 was the single most significant predictor of delayed recovery, moving the follow-up phone call from the morning to the late afternoon of POD 1 may help the nurse to identify patients who will need extra assistance with pain management.

The Basic Shelf Experience: a comprehensive evaluation

The Basic Shelf Experience is a program designed to assist people living on limited incomes to make better use of their food resources. The purpose of this research was to learn if the Basic Shelf Experience program helps such people to 1. utilize food resources more effectively and 2. cope, through group support, with poverty-associated stressors that influence food security. Both quantitative and qualitative methods were used to evaluate the program objectives. Participants completed a questionnaire at the beginning and end of the six-week program. The questionnaire asked about their food access, food security, and feelings about themselves. Participants returned for a focus group discussion and completed the questionnaire again three months after the program ended. The focus group was designed to elicit information about perceived changes, if any, attributed to the program. Forty-two people completed the questionnaires pre-program and 20 post-program; 17 participated in the three-month follow-up session. While results from quantitative data analysis indicate that program objectives were not met, qualitative data provide evidence that the program did achieve its stated objectives. Our results suggest such programs as the Basic Shelf Experience can assist people living on limited incomes to achieve food security.

Relationship as an inherent component in healthy women's fatigue

The notion of fatigue has remained ambiguous despite more than 100 years of study. Fatigue is recognized as subjective in nature, and it is studied and clinically managed as primarily intrapersonal in scope, with treatment approaches often based in an established, if unfounded, hierarchy of assumptions. When a physiologic cause for fatigue is not identifiable, fatigue complaints often are considered illegitimate. This article builds on data from the literature and from the author's previous work in women's fatigue and relatedness to suggest that interpersonal relationships may serve to exacerbate healthy women's fatigue experiences. The importance of relationship to women's life experience and the inherently relational character of women's fatigue are discussed. The author proposes the importance of including interpersonal experiences as a component of the definition of fatigue for healthy women.

A comparison of fatigue and energy levels at 6 weeks and 14 to 19 months postpartum

It has been assumed that women recover from pregnancy and childbirth within 6 weeks. Recent research shows that women's fatigue levels are the same, or higher, at 6 weeks postpartum as at the time of delivery. This study determined the differences in primiparous women's fatigue and energy levels at 6 weeks and 14 to 19 months postpartum. Determinations of how some contributing factors and outcomes of postpartum fatigue relate to each other and to fatigue and energy at 14 to 19 months postpartum were also made. Analyses revealed that women are more fatigued and less energetic at 14 to 19 months than they were at 6 weeks postpartum. Quality of sleep did not correlate with fatigue or energy. At 14 to 19 months postpartum return to full functional status is almost complete, with household and infant care responsibilities being most complete. The women were experiencing mild life crises of various sorts, were somewhat depressed, and were gratified in the mothering role.

Pain, fatigue, and sleep disturbances in oncology outpatients receiving radiation therapy for bone metastasis: a pilot study

Pain and fatigue are two of the most common problems experienced by oncology patients. This study evaluated 24 oncology patients who were receiving radiation therapy for bone metastases to (1) describe the patterns of pain intensity and fatigue severity over a 48-hour period; (2) evaluate for sleep disturbances; (3) describe the relationships between these symptoms and various treatment characteristics; and (4) describe the self-care strategies used by patients to manage pain and fatigue. Patients reported moderate amounts of pain and fatigue. Average pain scores did not vary significantly over a 48-hour period. However, patients reported significantly lower fatigue scores in the morning compared to the evening. In addition, patients experienced significant sleep disturbances, with a mean sleep efficiency index of 70.7% (estimated using wrist actigraphy). Patients with lower Karnofsky Performance Status scores reported more sleep disturbances. In addition, patients who had received a higher percentage of their radiation treatment reported more sleep disturbances. Patients used a variety of self-care strategies to manage pain and fatigue. Additional research is warranted to describe more completely the patterns of pain, fatigue, and sleep disturbances in oncology outpatients receiving radiation therapy.

The middle-range theory of unpleasant symptoms: an update

A detailed description of the newly revised and updated theory of unpleasant symptoms is provided. Revisions have resulted in a more accurate representation of the complexity and interactive nature of the symptom experience. Examples are provided to demonstrate the implications of the revised theory for measurement and research, and its application in practice. A detailed exemplar describes how it guided the design of a multifaceted intervention to encourage successful breastfeeding.