Electronic ISSN 2287-0237




Currently, cancer patients require more aggressive andsystemic treatments. However, chemotherapy often causesdiscomfort which affects patient’s well-being during andafter cancer treatment.1 The nursing mission then focuses onpatient’s comfort and the interventions offered to relieve discomfort.The care is delivered after an assessment of patients’ needs,implementations of care, and outcomes from such interventions.These nursing interventions include physical and psycho-spiritualcontexts intended to alleviate the patient’s discomfort observedfrom signs and symptoms. There is a great opportunity to addressthe patient’s needs and to understand him/her, which increases thelikelihood that patient will be safe during treatment. This isconsidered a relief effort.2 Comfort is theoretically defined at thispoint as the state of being meeting the basic human need for ease,relief, and transcendence.3

Nurse-led care and management have a significant impacton patient experience and outcomes. However, currently there areno definitive criteria in establishing what constitutes sufficientevidence of this beyond using the outcome. Previous reviews haveused an overview of evidence-based intervention studies.4Evidence-base-nursing outcomes in the physical dimensions ofcancer patients during chemotherapy were reviewed and used todevelop a set of indicators that are suitable for performancemeasurement and to identify the need for quality improvement.

An integrative review was used to identify the format,questionnaires, inclusion and exclusion criteria, literaturereview, decision on the information to be obtained from thestudies selected, interpretation of results, and synthesis ofknowledge.5 This integrative review aims to answer the guidingquestions that identify the nursing outcomes concerningcomfort during neoplastic chemotherapy. A well-definedstrategy was used to search for available literature and toanalyze data in relevant research. Both quantitative andqualitative reports based on the use of different networkingtools used by nursing professionals were included. Theresearchers in this study have searched literature publishedover the past 5 years (2012-2018), using a variety of databasesincluding PUBMED, MEDLINE, Cochrane, CINALH, ScienceDirect, and others for methods, techniques and tools to link tonursing and health care practice areas. The search strategy wasbased on SPIDER (Samples, Phenomenon of Interest, Design,Evaluation, and Research type). The problems of indexing thequalitative research in electronic databases have beenextensively reported and can be aggravated by research articlesthat provide non-specific titles, unstructured abstracts, andpoor definition of qualitative methodology. Therefore, manyqualitative searchers have identified the need to expand thebasic bibliographic search using alternative techniques.6

The following keywords and descriptors were used tosearch for the most possible articles regarding these researchquestions: Chemotherapy; antineoplastic drugs; chemotherapeuticanticancer drug; chemotherapeutic anticancer; antitumor drugs;cancer chemotherapy agents; chemotherapeutic anticanceragents; antitumor agents and comfort or discomfort or impairedcomfort and nursing outcomes.

The data used in this study were derived from full textsof primary studies addressing physical nursing outcomes aftermanaging patients discomfort during neoplastic chemotherapyin English. Data from letters, editorials, case studies, and pilotstudies were not included.

Figure 1: Flowchart of the current integrative review.

The researchers of this study read all selected researchpapers until reaching the relevant information. Topics retrievedin research papers include the following development stages:Problem identification; Research topics; Rationale for thereview; Identification of studies; Introduction; Scientificliterature with prior establishment of inclusion and exclusioncriteria to point and organize primary research on the problem/topic; objectives; methodological characteristics; andcategorization, organization, and data collection. The researchersused a standard form to extract information that is importantin analyzing the retrieved studies; assessing the collected data;presenting and comparing the results/interpretation; reviewingand synthesizing knowledge; and conclusion.5,7

The level of evidence in this study was classified byMelnyk and Fineout-Overholt (2010) as follows:

  • Level 1: Strong Evidence (Systematic review orMeta-Analysis)
  • Level 2: Strong Evidence (Well-designed randomizedcontrolled clinical trials)
  • Level 3: Moderate Evidence (Non-randomized controlledclinical trials)
  • Level 4: Moderate Evidence (Case control or Cohort studies)
  • Level 5: Weak Evidence (Systematic reviews, Descriptiveand Qualitative studies)
  • Level 6: Weak Evidence (Descriptive or Qualitative studies)
  • Level 7: Weak evidence (Opinion of authorities and/orReports of expert committees)

The researchers categorized each selected research studyand found that only 15 out of 44 studies could be used in thisstudy. A total review of 15 studies that related to nursing outcomesto alleviate physical discomfort for cancer patientsreceiving chemotherapy is shown in Table 1.

Table 1: Pharmacological properties of NOACs

Table 2: Systemic alterations, Nursing outcomes and Themes of nursing outcomes

Nursing outcomes of patient comfort during neoplasticchemotherapy in this integrative review are based on Kolcaba’sComfort Theory. She discusses in her book that comfort is acomplex concept that involves multiple dimensions of humanexperience and is subject to considerable variation acrosspeople and time. She defined 3 types of comfort: ease, relief,and transcendence which can happen in all human lifedimensions and several contexts: physical, psychological,spiritual, social, cultural, and environmental.31

Physical comfort

The researchers in terms of comfort mention the decreasein the occurrence, intensity of symptoms, changes infunctional status and symptomatic control. Other researchershave been studying the side effects of neoplastic chemotherapythat generally depend on the patients’ demographics, conditions,mental status, age groups, educational status, and gender.Concurrently, several aspects including time since beingdiagnosed, treatment options, disease severity, and patient’srole to participate in treatment decisions affect the need forcancer-related information to involve patients in self-managementwhen experiencing side effects.22 Side effects can occur withany type of chemotherapy drugs. However, not everyoneexperiences the same side effects or in the same way. Moreover,patients with side effects may occur at any time or immediatelyor days or weeks after chemotherapy.

Psycho spiritual comfort

Researchers mention pain control, psycho spiritualreflecting, patient’s inner consciousness and self-esteem,patient satisfaction, compassionate care, reinforced bodyimage. They describe patients that can understand and acceptchanges resulting from treatment, meaning of life, self-careand self-management, emotional functioning and beingcognitively alert but sometimes we cannot separate fromphysical and psychological. It will be related and supportedby previous studies found the following symptom clusters incancer patients receiving chemotherapy: nausea, vomiting,weakness, fatigue, alopecia, loss of appetite, pain, constipation,oral mucositis, numbness or tingling, and changes in bowelpatterns are physical side effects commonly mentioned in manystudies. Some studies include skin and nails problems, infectioussigns, shortness of breath, and peripheral neuropathy. Mostside effects disappear or can be treated whereas late side effectscan develop months or years after chemotherapy. In addition,some side effects may last a long time or become permanent.Psychological distress, fatigue-pain; abdominal discomfort;flu-like symptoms; fluid accumulation; and peripheralneuropathy; and a high level of anxiety or depression thatinfluenced all aspects of the patients’ quality of life.23

Sociocultural and Environmental comfort

Reviewed studies found that communication andknowledge about hope, interpersonal, transpersonal andintrapersonal relationships, quality of patient experience andsocial functioning and the theme of environmental comfort foundthat mention on safe medication administration and differentiatedenvironment. The most reliable results in this study are fromphysical and psychological aspects, especially as they opposethe symptom management programs. Socio-cultural andenvironmental issues are less used to measure and determinethe outcome of the study. However, the discomfort associatedwith socio-demographic factors is mainly related to physicalactivities from nursing interventions offered.24 One aspect thatis clearly evident in the previous studies is that the nursingoutcomes were developed from the nurse’s perspective; notfrom the patient’s’ perception. This may be considered negligence.The relationship between patient expectations and chemotherapyrelatedside effects indicates that expectations can be a usefulintervention to reduce the burden of the adverse effects.25 Patientneeds arising from patient interviews are very important in thedesign of efficiency and safety in treatment.26

Figure 2: Common concepts in nursing outcomes of patient’s comfort during neoplastic chemotherapy.

The definition of comfort outcomes from the integrativestudies was that symptoms are relieved or discomfort isrelieved in terms of physical and psychological symptoms.Comfort outcomes need to be supported by a good socioculturaland environmental status which allows the patients to engagein effective self-management and also to adapt well totreatment.

Alleviation of symptoms by self-management supportrelies on active exploration of the patient’s feelings andsymptom-management patterns. Professional care should betailored to the patient’s perspective and environmentaldeterminants. The key factors that influence their selfmanagementwith chemotherapy-related symptoms involvesthe process of experiencing and learning how the side effectsare holding over time and how to deal with them. Patients willexperience symptoms personally. Their symptom-managementpatterns are shaped by personal factors including physical andpsychosocial aspects; coping with cancer and cancer treatment;perceived level of control; and environmental factors, such asprofessionals’ attitude and resources of information.27

The development of services and interventions that meetthe complex needs of the patients potentially prevent latereferral to psychological services.28 Recommendations fromKolcaba’s Middle-Range Theory of Comfort states thatnurses use comfort content to identify health care needs anddesign interventions for the person in care; and nurses mustidentify intervention variables that affect the success of theintervention. The effectiveness of the intervention(s) is/aredetermined by comparing patients’ comfort before and afterimplementation of intervention.29 The nursing outcomes ofcancer patients receiving chemotherapy are connected tocollaboration among multidisciplinary team and settings.Early detection is important to continue to examine strategiesthat help improve symptom management during chemotherapy.30

The gap identified in this study is that the nursing outcomesof the patients’ comfort after receiving chemotherapydid not address the patient’s needs or perception; but ratherwere based on the stakeholders’ perspectives. Furthermore,the patient’s view about the meaning of comfort is quite vague.If the purpose is to measure the effectiveness of interventionsto relieve discomfort, researchers should conduct a qualitativestudy to explore the patient’s feelings first before developinga standardized intervention program that covers all facets ofcomfort for desirable nursing outcomes. This could create aninnovative approach to enhance the patient’s quality of lifeand satisfaction.