Exercise in Cancer Care in Ireland: a Survey of Oncology Nurses and Physiotherapists

Article Title: ‘Exercise in Cancer Care in Ireland: a survey of Oncology Nurses and Physiotherapists.’

Authors: Éadaoin O’Hanlon, BSc Physiotherapy. Email Address: [email protected] Mailing Address: Dept of Clinical Therapies, Faculty of Education and Health Sciences, University of Limerick, Ireland Tel: +353 (0)861616483

Dr. Norelee Kennedy, BSc (Physiotherapy), Grad Dip(Stats), Grad Cert T&L Higher Ed, PhD. Lecturer Dept of Clinical Therapies, University of Limerick, Ireland Email Address: [email protected] Mailing Address: Dept of Clinical Therapies, Faculty of Education and Health Sciences, University of Limerick, Ireland Tel: +353 (0)61 21 3371

Funding: No funding was provided for this study

Abstract Little is known about the extent of exercise prescription within cancer care. This cross sectional survey aims to identify Irish oncology nurses and physiotherapists’ current knowledge and practice in prescribing exercise for cancer care and barriers to such prescription. An online survey was distributed to the Chartered Physiotherapists in Oncology and Palliative Care (n=35) and the Irish Association for Nurses in Oncology (n=170). The response rate was 74% (26/35) for physiotherapists and 34% (58/170) for oncology nurses. Three quarters of physiotherapists recommended/prescribed exercise with 81% or more of cancer patients in the past 6 months, with the exercises prescribed largely in line with current guidelines. Patients’ family/friends advising rest was the most commonly reported exercise barrier by physiotherapists (89% (17/19)), with a lack of exercise guidelines for cancer patients being most problematic for oncology nurses (93% (50/54)). Only 33% (18/54) of oncology nurses felt they had sufficient knowledge regarding exercise in cancer care. In conclusion, exercise prescription by physiotherapists largely corresponds with current guidelines. A minority of nurses felt they had sufficient knowledge of exercise for this population. Further formal postgraduate educational opportunities are needed for oncology nurses and physiotherapists in this area.

Keywords: Cancer care; Exercise; Physiotherapist; Oncology nurses, Survey.

Introduction

Exercise is increasingly being promoted as an effective intervention to address the physical and psycho-social problems associated with cancer and its treatment (Kirshbaum, 2007). Several trials have shown that exercise and keeping active throughout the cancer journey can preserve or improve physical function and psychological well-being and reduce the negative impact of some cancer-related side-effects such as fatigue (Schmitz et al, 2010; Speck et al,

2 2010; Spence et al, 2010, Cramer et al, 2014). Additionally, two recently published Cochrane reviews found that exercise interventions may have beneficial effects on overall health-related quality of life (HRQoL) for those undergoing treatment (Mishra et al, 2012a) and for cancer survivors (Mishra et al, 2012b). Data is also emerging to support the premise that exercise and physical activity may reduce the risk of cancer recurrence and extend survival for breast, colorectal and prostate cancer survivors (Davies et al, 2011; Irwin et al, 2008; Irwin et al, 2009). However, no formal guidelines exist in Ireland on exercising during or after cancer to direct clinical practice. In the US, recommendations on exercise testing and prescription for people with cancer have been published by the American College of Sports Medicine (ACSM) (Schmitz et al, 2010). These recommend that cancer patients aim to achieve the guidelines set out for the general population i.e. 30 minutes a day of moderate-vigorous aerobic activity, 5 days a week, along with twice weekly strength training sessions and flexibility exercises on days when other exercises are performed. The need for specific adaptations to the exercise prescribed based on disease and treatment related adverse effects are also noted in this paper (Schmitz et al, 2010). These recommendations are in line with the British Association of Sport and Exercise Sciences (BASES) Expert Statement on Exercise and Cancer Survivorship (Campbell et al, 2011), the National Comprehensive Cancer Network (NCCN) practice guidelines (2013), the American Cancer Society’s recommendations (Rock et al, 2012) and the Australian Association for Exercise and Sport Science’s position stand (AAESS) (Hayes et al, 2009). Notably, all of the above guides strongly emphasise, that even where cancer patients are undergoing difficult treatments, or for those with complex co-morbidities, total inactivity should still be avoided. On the back of these recommendations and the ever growing evidence base, a survey of current practice in this area in Ireland is long overdue. Some explorations into this area have already been carried out in other countries (Donnelly et al, 2010; Jones et al, 2005; Stevinson and Fox, 2005). However, little is known about the extent of exercise prescription within cancer care in this country or how it relates to the research evidence and recommendations. The knowledge healthcare

3 professionals have regarding exercise in cancer care is also unknown and there is little data on the exercise services currently available or on the barriers health professionals encounter in recommending and using exercise with cancer patients in Ireland. As exercise therapy is recognised as a core physiotherapeutic skill, evaluating physiotherapists’ current knowledge and use of exercise with cancer patients will provide an insight into the current situation in Ireland. Establishing the viewpoint of oncology nurses will also be valuable as they have perhaps the greatest involvement in cancer patient care and rehabilitation (Stevinson and Fox, 2005). The information garnered from this evaluation of existing practice and services may be of benefit in influencing the provision of future exercises services in cancer rehabilitation here and ultimately in improving overall patient care. It will also provide a good basis for the development of further educational and research opportunities in this area. Thus the aim of the study is to investigate current knowledge and practice surrounding exercise and exercise prescription among physiotherapists and nurses working in oncology in Ireland who are members of the Irish Society of Chartered Physiotherapists in Oncology and Palliative Care (CPOPC) and the Irish Association for Nurses in Oncology (IANO). The specific objectives of the study are to a) establish the level of education received by physiotherapists and oncology nurses regarding exercise in cancer care b) determine overall practices in exercise prescription by physiotherapists working in oncology and compare these practices to the current guidelines, c) identify current exercise services available to the oncology population in Ireland and d) to identify the barriers health professionals encounter in prescribing exercise in cancer care in Ireland.

Methods

Participants

A cross sectional survey design was used. The survey was distributed to all members of the Chartered Physiotherapists in Oncology and Palliative Care (CPOPC) and all members of the Irish Association for Nurses in Oncology

4 (IANO). The CPOPC is a clinical interest group of the Irish Society of Chartered Physiotherapists (ISCP). This group was chosen as a purposive sample, as membership indicates a particular interest in cancer care, thus members are likely to be involved in the management of cancer patients. From discussions with the group Chairpersons it was determined that the membership of these groups is representative of the physiotherapists and nurses working in oncology in Ireland. The ISCP and the chairperson of CPOPC approved the questionnaire used and agreed for the CPOPC members to be surveyed. The IANO is a non-profit organisation for members of the oncology nursing profession in Ireland. Approval to survey the IANO was granted by the president of the organisation. Ethical approval for the survey was granted by the Education and Health Sciences Research Ethics Committee, University of Limerick, Ireland.

Procedure

The questionnaire used was a modified version of a questionnaire employed to successfully survey the UK Association of Chartered Physiotherapists in Oncology and Palliative Care and determine current practice of their members with regard to the management of cancer-related fatigue (Donnelly et al, 2010). Permission to use this questionnaire was granted by the original authors, Donnelly et al. (2010). Modifications were made to account for differences between the UK and Irish healthcare setting and to focus on more general exercise prescription in cancer care. Exercise was defined as ‘types of physical activity not carried out as part of the patient’s occupational or habitual chores.’ The questionnaire was divided into three sections; (1) professional profile, (2) Education received regarding exercise in cancer care and (3) exercise prescription in cancer care (physiotherapists) and Exercise and cancer care (nurses). Physiotherapists are the health care professional involved in exercise prescription in Ireland for clinical populations. Thus two surveys were designed for each professional group, with more detail on how exercise is prescribed included in the physiotherapists’ questionnaire. The physiotherapist survey contained 33 items (Appendix A.) and required approximately twenty minutes to

5 complete while the nurses survey included 16 items (Appendix B.) taking 5-10 minutes to complete. The majority of questions included in both were closed- choice questions. These can create false opinions if there is not a sufficient range of alternative answers provided (De Vaus, 2002). However this questionnaire went through significant pre-testing and piloting by the original author, Donnelly et al. (2010), which led to the development of a comprehensive range of responses. Additionally, by including an ‘other’ box any remaining unanticipated responses were able to be included and the inclusion of a ‘don’t know’ or a ‘none of the above’ option prevented a forced response.

Data Collection

The survey was conducted using SurveyMonkey®™ (SurveyMonkey.com, Palo Alto, California, USA). Advantages of delivering the questionnaire in this way include convenience to respondents, guaranteed respondent confidentiality and the capacity for widespread geographic distribution (Domholdt, 2005). An email containing information about the study and a hyperlink allowing access to the questionnaire on SurveyMonkey®™ was sent to the secretaries of the CPOPC and the IANO. Each secretary then forwarded this email to all members. Six weeks was allotted for completion of the questionnaire after which time a reminder email was sent to obtain the highest possible response rate. Data was collected four weeks after the reminder email was issued.

Data Analysis

Basic descriptive statistics to determine the frequency of responses to all questions for all respondents were generated by SurveyMonkey®™. This data was imported into the Statistical Package for the Social Sciences (SPSS) 20.0 for Windows to allow for further statistical analysis including percentages, means and medians to further describe the data. Following assessments of normality of the data, non-parametric statistical analysis involving Chi-square tests and, where appropriate, Fisher’s Exact tests (FET), were used to explore relationships between certain parameters including for example participants’

6 work setting and the responses to various questions. The level of significance was set at p<0.05.

Results

A response rate of 74% (26/35) was obtained for the CPOPC survey (physiotherapists) and 34% (58/170) for the IANO survey (oncology nurses). As not all questions were answered by all respondents, the response rate is indicated for each question. The demographic and professional profile of both samples is outlined in Table 1. The oncology nurses had a mean total of 19.1 years (± 3.8) clinical experience, with a mean of 13 years (± 4.8) in oncology and/or palliative care. The majority were working in specialist cancer centres/units (58% (38/57)). The physiotherapists surveyed had been practising for a mean of 13 years (± 5.2 years) with a mean of 6.4 years (± 3.8) oncology and/or palliative care experience. A large proportion were working in hospice/palliative care settings (42% (11/26)).

Education regarding Exercise in Cancer Care

Only 16.4% (9/55) of oncology nurses and 8% of physiotherapists (2/25) received undergraduate education regarding the use of exercise in cancer populations. Analysis revealed no difference regarding this receipt of undergraduate education between physiotherapists who had graduated less than 10 years ago and those graduated greater than 10 years (p=1.00, FET (two-tailed)), and between oncology nurses who graduated less than 20 years ago and those graduated greater than 20 years (p=1.00, FET (two-tailed)). However, 100% (25/25) of physiotherapists and 71% (39/55) of oncology nurses did report receiving some form of post-graduate education regarding the use of exercise in cancer populations, with the most common type of education undertaken by both being self-directed learning (88% (22/25) physiotherapists; 43.4% (24/55) oncology nurses). Workshops/conferences/seminars were the second most common source of post-graduate education in both cases (68% (17/25) physiotherapists; 29% (16/55) oncology nurses).

7 Further information regarding nurses and physiotherapists’ opinions of their current knowledge in this area was sought using a five-point likert scale whereby one equalled ‘Strongly disagree’, and five equalled ‘Strongly agree’. In this area, 78% (18/23) of physiotherapists agreed or strongly agreed with the statement ‘I have sufficient knowledge about the use of exercise in cancer populations’, compared with 33% (18/54) of oncology nurses. The majority of physiotherapists (83% (19/23)) also agreed or strongly agreed with the statement ‘I am familiar with the current evidence base on exercise in cancer populations’. The oncology nurses response on this was diverse: 41% (22/53) stating they disagreed or strongly disagreed and 36% (19/53) stating they agreed or strongly agreed with the statement. Both professions stated that they would like further information on exercise prescription for cancer populations (83% (19/23) of physiotherapists; 98% (53/54) of oncology nurses).

Exercise Prescription by Physiotherapists

Seventy-six percent (16/21) of physiotherapists reported recommending and/or using exercise with 81% or more of their cancer patients, in the past six months. This figure remained the same despite the type of cancer involved (Table 2.). Exercise was also recommended and used across the disease course, from pre-treatment to advanced stages of disease. Results demonstrated that physiotherapists less commonly recommended and used exercise pre- treatment compared with other stages. Over 80% of physiotherapists reported recommending and using the following exercise types with their cancer patients: walking, resistance exercises, bed and chair based exercises, and flexibility and stretching. Approximately 70% were also recommending and using Pilates/core stability exercises and exercise bikes, while half were recommending and using mobility and strengthening exercises classes. When asked to identify exercise intensities they commonly recommend and/or use, the majority of physiotherapists selected comfort/symptom limited low intensity exercise, low to moderate aerobic interval training and resistance exercises. High intensity continuous aerobic exercise was rarely used.

8 Respondents commented that intensity was ‘patient dependent’, ‘based on disease stage’ and ‘individual capabilities and goals.’ The exercise duration most commonly recommended and/or used involved either an exercise session of 30 minutes/once a day (46.7% (7/15) or short bouts throughout the day involving 10 minutes/three times a day (46.7% (7/15)) or 5 minutes/three times a day (40% (6/15)). The most common exercise frequency was 5 days per week (67% (14/21)), followed by 7 days per week (24% (5/21)) and 4 days per week (19% ((4/21)).

Barriers to Exercise in Cancer Care

The most common difficulties encountered by oncology nurses and physiotherapists when recommending and using exercise are displayed in Table 3. Although the top six barriers were the same for both professions, oncology nurses identified the lack of exercise guidelines for patients with cancer (93% (50/54)) as the biggest difficulty, while physiotherapists identified patients’ family and friends advising patients to rest and avoid activity (89% (17/19)) as being most problematic. Limited time with patients and poor staffing levels were amongst the three least encountered difficulties in practice for both professions.

Exercise Service Provision

Information on the exercise services currently available within respondents’ current setting was also sought. The exercise service identified as most commonly available by both professions was information resources on exercise, with physiotherapists noting individual exercise counselling sessions and exercise diaries as the next most common exercise services available (Figure 1). Less than 20% of nurses meanwhile identified any of the other listed services as being available. Relating to this, 81% (44/54) of oncology nurses and 95% (22/23) of physiotherapists agreed or strongly agreed that there is a need to improve exercise services available in their area.

9 The exercise services physiotherapists and nurses felt should be more readily available to cancer patients were also identified. These included, supervised group programmes during and post-treatment, community based group exercise programmes and group exercise counselling sessions (Figure 1).

10 Discussion

This survey of exercise prescription among Irish physiotherapists and oncology nurses has a number of noteworthy findings. Firstly, undergraduate education regarding exercise in cancer care was not commonplace amongst the respondents. This is not surprising, given that it is only in the last ten to fifteen years that concrete evidence in favour of prescribing exercise in cancer populations has emerged, and the nursing and physiotherapy samples surveyed have been qualified for a mean of 19.1 and 13 years respectively. These findings correlate with a UK study of oncology nurses where 88.7% of those surveyed reported little (one lecture) or no education on exercise promotion as part of their professional training (Stevinson and Fox, 2005). Similarly, a UK study of physiotherapists and their management of cancer related fatigue (CRF) noted minimal levels of undergraduate education in this area (Donnelly et al, 2010). Notably newer graduates of both professions were no more likely to have received undergraduate education in this area than those graduated 10 or 20 years suggesting that deficiencies remain in undergraduate education as regards exercise in cancer care. This resonates with the findings of an Irish survey on physical activity and exercise promotion and prescription in undergraduate physiotherapy curricula (O’Donoghue et al 2011) which also reported on the low level of education relating to exercise prescription. Such findings raise interesting questions on the adequacy of the knowledge around exercise prescription for this population. This is particularly important given that 75% of respondents reported postgraduate education through self-directed learning and not formal education. Nurses, as the health care professionals who consult with every patient and are thus ideally placed to promote exercise and physical activity, reported insufficient knowledge on exercise in cancer care. This finding has been reported elsewhere with over half of UK oncology nurses counterparts reporting being unaware or unfamiliar with evidence regarding exercise and cancer rehabilitation (Stevinson and Fox, 2005). Similarly, US oncology nurses also reported that they were not comfortable with their knowledge levels regarding complementary therapies such as exercise (Hessig

11 et al, 2004). Thus, there is a clear need for formal education on exercise in cancer at an undergraduate and postgraduate level for both professions.

Physiotherapists prescription of Exercise in cancer care

Three quarters of physiotherapists reported using and/or recommending exercise with 81% or more of their cancer patients in the previous six months, regardless of cancer type. Exercise was recommended and used across the disease course including in advanced progressive disease. This finding is hugely positive given that all guidelines stress the importance of keeping active throughout the cancer journey and avoiding total inactivity even for patients undergoing difficult treatments or with poorer health status (Campbell et al, 2011; Hayes et al, 2009; Schmitz et al, 2010). Notably, exercise prescription was lowest pre-treatment with only two-thirds recommending exercise and only one third using exercise with patients in this phase. This may be because some patients do not encounter physiotherapy services pre-treatment and may only meet the physiotherapist in pre-surgical cases. This is unfortunate as research suggests receptivity is high among cancer patients soon after diagnosis for health promotion interventions including exercise promotion (Jones and Courneya, 2002; Denmark-Wahnefried et al, 2000). In terms of exercise type, walking was the most commonly recommended and used exercise. This is consistent with findings by Donnelly et al. (2010). Studies have shown that walking programmes are beneficial for cancer patients undergoing treatment (Griffith et al, 2009; Yang et al, 2011) and for cancer survivors (Fillion et al, 2008; Matthews et al, 2007; Tang et al, 2010). Walking has also been reported as a preferred exercise of cancer populations (Jones and Courneya, 2002; Karvinen et al, 2007; Rogers et al, 2007; Stevinson et al, 2009) and conforms to recommendations in the guidelines such as in the AAESS position stand which recommends any aerobic exercise involving large muscle groups (Hayes et al, 2009). Resistance exercise was the next most commonly prescribed exercise type, again conforming to recommendations from the ACSM, the American Cancer Society, AAESS and BASES (Campbell et al, 2011; Hayes et al, 2009;

12 Rock et al, 2012; Schmitz et al, 2010), that strengthening exercises be included in programmes for cancer patients and survivors. In terms of exercise intensity, the majority utilised comfort/symptom limited intensities and low to moderate intensity aerobic interval training. In contrast, the majority of research to date and the guidelines in this area endorse moderate intensity aerobic exercise (Hayes et al, 2009) or moderate-vigorous intensity activity (Campbell et al, 2011; Rock et al, 2012; Schmitz et al, 2010). However, the guidelines do cite the need to tailor exercise parameters based on individuals’ presentations with many of the surveyed physiotherapists commenting likewise. Therefore, although this survey indicates inadequate utilisation and promotion of moderate intensity exercise, it remains important to consider each patient individually and address their needs appropriately when devising exercise programmes. Finally, the most commonly prescribed exercise duration involved either, one exercise session of 30mins/once a day, the standard recommendation of the guidelines, or 10min/three times a day. This division of exercise into shorter bouts is also in line with recommendations especially for de-conditioned patients or those experiencing severe treatment side-effects (Hayes et al, 2009). The most commonly prescribed exercise frequency at 5 days per week was again in line with guidelines in the area (Campbell et al, 2011; Hayes et al, 2009; Rock et al, 2012; Schmitz et al, 2010).

Barriers to Exercise in Cancer Care

The survey also examined the barriers encountered by health professionals in relation to exercise in cancer care. These barriers can be subdivided into three categories; patient related barriers, system related barriers, and health-care- provider related barriers (Passik, 2004 cited by Donnelly et al, 2010). The latter was the most common amongst oncology nurses, with 93% (50/54) finding the lack of guidance on using exercise for patients with cancer problematic. Similar findings were reported in the UK study of oncology nurses (Stevinson and Fox, 2005) and in Donnelly et al. (2010) who investigated physiotherapists’ management of cancer-related fatigue. These findings suggest that greater

13 guidance on recommending exercise in cancer care should be provided to healthcare professional to direct clinical practice. Relating to this, the provision of multi-disciplinary evidence based guidelines on this area in Ireland would also be beneficial. Another healthcare-provider related problem encountered by both professions was that of other professions advising patients to rest and avoid activity. In a 2003 survey investigating the status of cancer fatigue in Ireland, rest/relaxation was physicians and nurses’ number one recommendation for cancer patients experiencing cancer-related fatigue, despite evidence indicating the benefits of exercise for such individuals (Dillon and Kelly, 2003). Such practice must be rectified as conflicting messages to patients can be detrimental. In a Scottish study of colorectal cancer survivors, participants noted that conflicting messages from health care providers about their ability to exercise was a barrier to their exercise participation (Anderson et al, 2010). Therefore education initiatives targeting healthcare providers should be rolled out to eradicate outdated views and ensure everyone is on the same page with regard to recommending and using exercise with cancer populations. Patient related barriers were most commonly reported by physiotherapists. Patients’ families and friends recommending rest and avoidance of activity was the number one problem followed by poor exercise compliance amongst cancer patients. These were also amongst the top three rated barriers in the survey by Donnelly et al. (2010). These findings suggest that education regarding the benefits of exercise in cancer care is necessary not only for patients but for caregivers too. Furthermore, efforts are required to improve exercise compliance and participation in cancer patients. Taking the exercise preferences of cancer patients into account when designing exercise programmes, for example, can have important effect on both patients’ primary motivation to participate in such programmes and, on their long-term adherence to same (Courneya et al, 2002). Interestingly system-related barriers such as limited time with patients and poor staffing levels were amongst the least encountered difficulties for both professions.

14 Exercise Service Provision

Both professions reported, that providing cancer patients with written information resources on exercise, was the most commonly available exercise service. However, such impersonal approaches involving written information materials, are not the desired format of exercise counselling for all cancer patients (Jones and Courneya, 2002; Gjerset et al, 2011). A stronger preference and openness towards face-to-face counselling from an exercise specialist has been reported (Jones and Courneya, 2002; Gjerset et al, 2011). Encouragingly, the physiotherapists surveyed noted that such individual exercise counselling was the next most commonly available exercise service. However, it was not specified by participants whether physiotherapists alone provided this exercise counselling, or if other healthcare professions were also involved. Overall, both professions were in agreement on the need to improve the exercise services available. Unfortunately, the Health Service Executive’s (HSE) ‘Strategy for Cancer Control in Ireland’ (2006), while stressing the importance of physical activity promotion in cancer prevention and control, makes no specific provision for exercise services for cancer patients in Ireland. The services both professionals felt should be made available to cancer patients were supervised group exercise programmes during and post treatment, community based group programmes and group exercise counselling sessions. This group approach to exercise can be time efficient for healthcare providers, and beneficial for cancer patients, in providing social support as well as opportunities for social comparison and modelling which can enhance self- efficacy to exercise (van Weert et al, 2008). However, several studies have found there is a desire for unsupervised and home-based exercise programmes amongst cancer populations (Jones and Courneya, 2002; Karvinen et al, 2007; Rogers et al, 2009). Home-based interventions are free of scheduling and transportation issues and are less costly (Pinto et al, 2005). Therefore, in practice there may be demand for both types of programme delivery in this country. Consequently, healthcare professionals could have a role in facilitating group programmes and, in prescribing exercise that can be performed without supervision and exercise equipment (Jones and Courneya, 2002).

15 Limitations

There are some limitations that must be considered when interpreting the results of this study. Firstly, by only surveying physiotherapists and nurses who are members of clinical interest groups in oncology and palliative care, a sampling bias exists as those working in oncology and not members of these groups, were not surveyed. This limits findings being generalised to wider physiotherapy and oncology nursing practice. Future studies should aim to determine the views of physiotherapists and nurses who are not members of such groups but who are nonetheless involved in the management of cancer patients. Only surveying the clinical interest group also meant the physiotherapy sample, at 26 respondents, was quite small and may be a limitation to the study. This number did represent a 74% response rate from the surveyed group however and the respondents were from a range of clinical settings with varying staff grades and levels of experience. The relatively low response rate of the oncology nurses (34%) is another limiting factor. This is not unusual however with surveys of nurses often characterised by low response rates (VanGeest and Johnson, 2011). Also postal and telephone strategies have generally been more successful in surveying this population than a web-based approach (VanGeest and Johnson, 2011). However financial reasons prevented such strategies in this study. Another limitation of this study was that oncology nurses were not surveyed on whether they recommend exercise to their cancer patients. This is regrettable as promotion of physical activity is well within the oncology nursing role (Jankowski and Matthews, 2011; Stricker et al, 2004). Also, with a recent UK study, reporting that 79% of cancer patients received no information on the importance of being physical active during or after treatment from their clinical nurse specialist (Macmillan Cancer Support, 2012), such a survey would have provided valuable information on this area of oncology nursing practice. However, due to time constraints it was not possible to undertake this survey at this time. Another factor which must be considered when interpreting the results of this study is that, in general, physiotherapists in Ireland only see patients the oncology patients that are

16 referred to them and not all oncology patients, thus creating another bias. Also with all self-report data, there is a risk that social desirability may have biased responses (van de Mortel, 2008) and resulted in a more positive and less realistic representation of current practice. Ensuring participants’ confidentiality may have lessened the effect of this however. Finally, it was not possible to include clinical exercise physiologists in this survey as the profession does not exist in Ireland.

Recommendations

Further research is necessary to determine how frequently oncology nurses are promoting exercise and physical activity to cancer patients in Ireland. Further studies are also required to ascertain the knowledge and practice of other healthcare professionals with regard to exercise use in cancer populations in this country, namely oncologists, general practitioners, community nurses and community physiotherapists, all of whom are involved in the care of those living with and beyond cancer. Efforts should also be made to enhance educational opportunities for nurses in the area of exercise prescription in cancer care.

Conclusion

This is the first study to examine exercise in cancer care in Ireland. The findings demonstrate that physiotherapists are recommending and using exercise with the majority of their cancer patients, across all cancer types and disease stages. The parameters of exercise prescribed largely correspond with current exercise guidelines for cancer populations (Campbell et al, 2011; Hayes et al, 2009; Rock et al, 2012; Schmitz et al, 2010) except for exercise intensity, with only half of physiotherapists prescribing the recommended moderate intensity exercise. The study also indicates that undergraduate education regarding exercise in cancer care appears to be lacking for both professions. Oncology nurses in particular reported insufficient knowledge in this area and felt the lack of exercise guidance was the greatest barrier to using exercise in cancer care. This underlines the need for greater educational and training

17 opportunities on exercise in cancer care to be afforded to oncology nurses. The barrier most frequently identified by physiotherapists related to patients’ family/friends advising the patient to rest and avoid activity. This highlights the importance of educating patients’ caregivers regarding the benefits of exercise in cancer. Finally, this study also uncovered the limited nature of the exercise services currently available to cancer patients in Ireland with both professions in agreement on the need for improvements in this area.

Conflict of interest statement: The authors have no conflicts of interest to disclose.

Acknowledgements: The authors would like to thank the Chartered Physiotherapists in Oncology and Palliative Care and the Irish Association of Nurses in Oncology for their participation in this study.

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25 Table 1. Demographic and professional profile of physiotherapists & oncology nurses. Physiotherapists Oncology Nurses Total No. of Respondents 26 Total No. of Respondents 58 % Female 96.1 % Female 98.3

Physiotherapy Grade % (no. of Nursing Grade % (no. of respondent respondent s) s) - Basic Grade 3.9 (1) - Staff Grade 20.7 (12) - Senior Grade 69.2 (18) - Clinical Nurse Specialist 17.2 (10) - Clinical Specialist 11.5 (3) - Clinical Nurse Manager 1 5.2 (3) - Physiotherapy Manager 7.7 (2) - Clinical Nurse Manager 2 26 (15) - Other* e.g. Lecturer, 7.7 (2) - Clinical Nurse Manager 3 5.2 (3) Researcher - Public Health Nurse 1.7 (1) - ADN 5.2 (3) - Advanced Nurse Practitioner 8.6 (5) - Director of Nursing 1.7 (1) - Other* e.g. lecturer, nurse 8.6 (5) councillor

Work Setting % (no. of Work Setting % (no of respondent respondent s) s) - Specialist Cancer 19.2 Specialist Cancer Centre/Unit 58 (33) Centre/Unit (5) - General Hospital (HSE) 7.7 (2) General Hospital (HSE) 19.3 (11) - Private Hospital 7.7 (2) Private Hospital/Sector 3.5 (2) - Paediatric Centre 3.8 (1) Hospice 1.75 (1) - Hospice 34.6 (9) Community 5.25 (3) - Community 11.5 (3) Charity Organisation 5.25 (3) e.g. Irish Cancer Society - Specialist Palliative Care 7.7 (2) Cancer Support Services 7 (4) incl. education, information and psychology services

- Other* : Research 7.7 (2)

26 Table 2. The percentage of physiotherapists that recommend and/or use exercise with different cancer types.

Cancer populations physiotherapists recommended and/or used % (no. of exercise with: respondents

Prostate (all stages) 83 (15/18) Lung (all stages) 84 (16/19) Colorectal (all stages) 83 (15/18) Breast (all stages) 80 (16/20) Haematological malignancies (all stages) 82 (14/17) *Other cancer types (not stage specific) 90 (9/10)

*Other: paediatric cancers, brain tumours, head and neck cancers, sarcomas, pancreatic cancers.

27 Table 3. Barriers encountered when recommending and using exercise with cancer patients.

Physiotherapis Oncology ts Nurses (n=19) (n=54) Barrier Encountered Ranking (%) Ranking (%) Patients’ family/friends advise patients to rest & 1* 89 2* 78 avoid activity

Poor exercise compliance among cancer patients 2* 68 6 41

Other professionals advise patients to rest & avoid 3* 58 4 46 activity

Lack of patient referral for physiotherapy 4 53 5 44

Lack of exercise guidelines for patients with cancer 5 47 1* 93

Limited exercise resources for patients with cancer 6 42 3* 63 e.g. space & equipment Limited time with patients 7 37 7 39

Poor staffing levels 8 26 8 35

Other** 9 21 9 13

* Top three most common responses. ** Other: patient fatigue; lack of knowledge about the benefits of exercise by patients and staff; severity of patients’ illness.

28 Appendix A.: Questionnaire for Physiotherapists

SECTION 1: YOUR PROFESSIONAL PROFILE

1) Please indicate your physiotherapy grade by ticking the appropriate box:

Basic Grade Physiotherapist Senior Grade Physiotherapist Clinical Specialist Other If you answered “other”, please specify in the box provided.

2) Are you? Male Female

3) How many years have you been qualified as a physiotherapist?

0-5 years 6-9 years 10–19 years ≥20 years

4) How many years of clinical experience do you have working within oncology and/or palliative care?

0-5 years 6-9 years 10–19 years ≥20 years

5) Please indicate your work setting. (Tick all that apply)

Specialist Cancer Centre/unit Hospice Community General Hospital (HSE) Other/s (Please specify below) Private Hospital

29 6) Approximately how many patients with cancer do you treat on a weekly basis?

< 10 31-40 61-70 91-100 11-20 41-50 71-80 > 100 21-30 51-60 81-90

7) Below is a list of the types of cancer care. (a) Please tick the type(s) of care during which you treat patients? (Tick all that apply) (b) Please rank in numerical order, the types of cancer care in which you treat patients most commonly?(1= most commonly treated, 2= less commonly treated, or rank with equal numbers any types you treat in equal numbers) (a) Tick (b) Rank Curative Palliative/ End of life care Other (please specify below)

8) Do you specialise in treating a specific type or group of cancer patients?

Yes

If yes, please describe below. e.g. Head and Neck cancer

SECTION 2: EDUCATION RE: EXERCISE IN CANCER CARE

9) (a) During your undergraduate education training did you receive information regarding prescribing exercise in cancer populations?

30 Yes

Don’t know

(b) Since qualifying, have you received any information regarding prescribing exercise in cancer populations? Yes

Don’t know

(a) If yes, how was this information provided? (Please tick all that apply) Occasional lecture Workshop/conference/seminar

Core module In-service training

Elective module Informal discussion

Supervised clinical placement Self-directed learning

Study day Other/s (please describe below)

10) On a five point scale where 1 is Strongly Disagree and 5 is Strongly Agree, please tick the appropriate box that best represents your level of agreement with each of the following statements

Strongly Strongly Disagree Agree

1 2 3 4 5

“I have sufficient knowledge about exercise prescription in cancer populations.”

31 “I am familiar with the current evidence base on exercise in cancer populations.”

“There is a need to improve the exercise services available to cancer patients in my area.”

11) Would you like further information on exercise prescription for cancer populations? Yes No

If yes, how would you like to receive this information on exercise prescription for cancer populations? CPOPC study day In-service training Self-directed learning Other/s (please specify below)

SECTION 3: EXERCISE PRESCRIPTION

 This section relates to exercise prescribed to your patients. Some questions are dived into parts regarding EXERCISE RECOMMENDED to patients and EXERCISE USED with patients.

 ‘Exercise’ constitutes types of physical activities not carried out as part of the patient’s occupational or habitual chores.

32  It is understood that decisions regarding when to maintain and initiate exercise vary depending on individual patients. However to answer some of the following questions it is required that you answer in general terms.

12) What are your main rehabilitation objectives in prescribing exercise to patients with cancer? (Please tick all that apply) Maximise physical functioning Manage treatment side effects (specify below) Reduce hospital stay Manage cancer-related fatigue Improve quality of life Other/s (please specify below)

13) Of the patients with cancer you have treated in the past six months, with what percentage of patients did you recommend and/or use exercise? (Please tick the appropriate box) <10% 41-50% 71-80% 81-90% 11-20% 51-60% 91-100% 21-30% 61-70% 100% 31-40% Don’t know

33 14) Below is a list of stages of post cancer diagnosis.

(a) From the list please tick the stages during which you RECOMMEND/ADVISE your patients to exercise. Tick all that apply at part (a) (b) Of the stages you have ticked in (a), on a five-point scale where 1= Rarely and 5 = Commonly, please tick how commonly you RECOMMEND/ADVISE your patients to exercise during each of these stages?

(a) Tick (b)Rarely Commonly 1 2 3 4 5 1. Before treatment       2. During treatment       3. 0-2 months post treatment       4. 3-6 months post treatment       5. ≥ 6months post treatment       6. Advanced progressive disease      

(c) From the list please tick the stages during which you USE EXERCISE with your patients. Tick all that apply at part (c) (d) On a five-point scale where 1= Rarely and 5= Commonly, please indicate how commonly you USE EXERCISE with your patients during the stages you have ticked.

(c) Tick (d)Rarely Commonly 1 2 3 4 5 1. Before treatment       2. During treatment       3. 0-2 months post treatment       4. 3-6 months post treatment       5. ≥ 6months post treatment       6. Advanced progressive disease      

15) Below is a list of prevalent cancer types and their stages.

(a) Please tick if you use and/or recommend exercise with patients who have the following cancer types and stages. (Tick all that apply)

Stage I Stage II Stage III Stage IV ALL STAGES I-IV Prostate      Lung      Colorectal      Breast      Haematological Malignancies     

34 (b) Additionally write below any other cancer types in which you use and/or recommend exercise.

16) Below is a list of exercise intensities.

(a) From the list please tick the intensities you use and/or recommend with your patients. (Tick all that apply or write below the exercise intensities)

(b) On a five-point scale where 1= Rarely and 5= Commonly, please indicate how frequently you use and/or recommend the intensities you ticked with your patients.

(a) Tick (b) Rarely Commonly 1 2 3 4 5 1. Comfort or symptom-limited       low intensity exercise 2. Low to moderate aerobic       interval training 3. Moderate intensity continuous       aerobic exercise 4. High intensity continuous       aerobic exercise 5. Resistance exercise      

17) Below is a list of exercise types.

(a) From the list please tick the type(s) of EXERCISE YOU RECOMMEND/ADVISE to your cancer patients. (Tick all that apply)

Walking Swimming Exercise Bicycle Aqua aerobics Flexibility/Stretching Yoga Resistance exercises Pilates/Core Stability Exercise classes (please describe below) Tai Chi Bed/chair based exercises Other/s (please specify below)

35 (b) From the list please tick the type(s) of EXERCISE YOU USE with your cancer patients. (Tick all that apply)

18) Exercise intensity and frequency. (a) Please tick the daily exercise duration that you commonly use and/or recommend with your patients. (Tick all that apply or write below the exercise duration)

Once a day Twice a day Three times a day 5 mins    10 mins    15 mins    20 mins    30 mins    60 mins   

(b) Please tick the number of days per week of exercise that you commonly use and/or recommend to your patients. (Tick all that apply)

1 day per week 4 days per week 7 days per week 2 days per week 5 days per week

36 3 days per week 6 days per week

19) Below is a list of possible difficulties encountered when recommending and using exercise with cancer patients. From the list please tick any difficulties you feel apply to your current practice. (Tick all that apply)

1. Poor exercise compliance among cancer patients  2. Patients’ family/friends advise patients rest and avoid activity  3. Other professionals advise patients rest and avoid activity  4. Lack of exercise guideline for patients with cancer  5. Limited exercise resources for patients with cancer e.g. space & equipment  6. Limited time with patients  7. Poor staffing levels  8. Lack of patient referral for physiotherapy  9. None of the above  10. Other reason/s (expand below) 

20) Below is a list of exercise services, please tick which of the following service(s)

(a) are CURRENTLY AVAILABLE to your cancer patients. (Tick all that apply) (b) you feel SHOULD BE MADE AVAILABLE to cancer patients. (Tick all that apply) Currently Should be available available 1. Information resources on exercise   2. Supervised group exercise programmes during treatment   3. Supervised group exercise programmers post treatment   4. Community based group exercise programmes   5. Individual exercise counselling sessions   6. Group exercise counselling sessions   7. Exercise counselling via telephone   8. Exercise diary   9. None of the above   10. Other exercise services (please describe below)  

37 21) What research questions would be most useful to inform your practice regarding the prescription of exercise in cancer populations? Please describe below.

Thank you for taking the time to complete this questionnaire.

Appendix B.: Questionnaire for Oncology Nurses SECTION 1: YOUR PROFESSIONAL PROFILE

1) Please indicate your job title by ticking the appropriate box:

Student Nurse Staff Grade CNM1 CNM2 CNM3 PHN ADN ANP Director Other If you answered “other”, please specify in the box provided.

2) Are you? Male Female

3) How many years have you been qualified as a nurse? 0-5 years

38 6-9 years 10–19 years ≥20 years

4) How many years of clinical experience do you have working within oncology and/or palliative care? 0-5 years 6-9 years 10–19 years ≥20 years

5) Please indicate your work setting. (Tick all that apply)

Specialist Cancer Hospice Centre/unit Community General Hospital (HSE) Other/s (Please specify Private Hospital below)

39 6) Below is a list of the types of cancer care.

(c) Please tick the type(s) of care during which you care for patients? (Tick all that apply) (d) Please rank in numerical order, the types of cancer care in which you care for patients most commonly? (1= most commonly treated, 2= less commonly treated, or rank with equal numbers any types you treat in equal numbers)

(b) Tick (c) Rank

Curative

Palliative/ End of life care

Other (please specify below)

SECTION 2: EDUCATION RE: EXERCISE IN CANCER CARE

7) (a) During your undergraduate education training did you receive information regarding the use of exercise in cancer populations?

Yes

Don’t know

40 (b) Since qualifying, have you received any information regarding the use of exercise in cancer populations? Yes

Don’t know

(d) If yes, how was this information provided? (Please tick all that apply)

Occasional lecture Workshop/conference/seminar

Core module In-service training

Elective module Informal discussion

Supervised clinical placement Self-directed learning

Study day Other/s (please describe below)

Strongly Strongly Disagree Agree

1 2 3 4 5

“I have sufficient knowledge about the use of exercise in cancer populations.” “I am familiar with the current

41 evidence base on exercise in cancer populations.”

“There is a need to improve the exercise services available to cancer patients in my area.” 8) On a five point scale where 1 is Strongly Disagree and 5 is Strongly Agree, please tick the appropriate box that best represents your level of agreement with each of the following

9) Would you like further information on exercise for cancer populations?

Yes No

If yes, how would you like to receive this information on exercise prescription for cancer populations? In-service training Self-directed learning Postgrad course Other/s (please specify below)

SECTION 3: EXERCISE USE IN CANCER CARE

10) What do you believe are the main rehabilitation objectives in prescribing exercise to patients with cancer? (Please tick all that apply)

42 Maximise physical functioning Manage treatment side effects (specify below) Reduce hospital stay Manage cancer-related fatigue Improve quality of life Other/s (please specify below)

11) Barriers can exist to using exercise in cancer care. From the list below please tick what you believe may be the main difficulties encountered when recommending and using exercise with cancer patients. (Tick all that apply)

12) Below is a list of exercise services, please tick which of the following: (a) are CURRENTLY AVAILABLE to your cancer patients. (Tick all that apply) (b) you feel SHOULD BE MADE AVAILABLE to cancer patients. (Tick all that apply)

Currently Should be available available 1. Information resources on exercise   2. Supervised group exercise programmes during treatment  

43 3. Supervised group exercise programmers post treatment   4. Community based group exercise programmes   5. Individual exercise counselling sessions   6. Group exercise counselling sessions   7. Exercise counselling via telephone   8. Exercise diary   9. None of the above   10. Other exercise services (please describe below)  

44 45