Nonpharmacological nursing interventions for the management of patient fatigue: a literature review

REVIEW

Nonpharmacological nursing interventions for the management of

patient fatigue: a literature review

Erin Patterson, Yi Wai Teresa Wan and Souraya Sidani

Aims and objectives. To identify and describe nonpharmacological interventions for the management of fatigue that are

within the scope of nursing practice.

Background. Fatigue is a complex multidimensional symptom experienced by patients with varying diagnoses. Limited

details are available on the nature of nursing interventions to manage fatigue, which preclude fidelity of implementation in

day-to-day practice.

Design. Literature review.

Methods. Multiple databases were searched for publications reporting on the evaluation of nurse-delivered interventions for

the management of fatigue. Data were extracted on study and intervention characteristics and results pertaining to the

effects of the intervention on fatigue.

Results. The studies (n = 16) evaluated eight interventions: psycho-education, cognitive behavioural therapy, exercise, acupressure,

relaxation, distraction, energy conservation and activity management, and a combination of exercise, education and support.

Conclusion. Psycho-education was evaluated in several studies and demonstrated effectiveness when delivered in both acute

and community settings.

Relevance to clinical practice. This review focused on interventions that are within the scope of nursing practice for the

management of fatigue. The findings provide nurses with an overview of the effectiveness of interventions they may use in

their day-to-day practice to help patients manage fatigue. A detailed description of interventions found effective is provided

to assist nurses in translating evidence into practice.

Key words: acupressure, cognitive behavioural therapy, distraction, effectiveness, energy conservation, exercise, fatigue,

nursing interventions, psycho-education, relaxation

Accepted for publication: 27 November 2012

Introduction

Fatigue is a symptom experienced by patients suffering

from chronic and acute conditions. Patients diagnosed with

cardiac diseases, chronic obstructive pulmonary disease,

end-stage renal disease, multiple sclerosis, rheumatoid

arthritis, chronic fatigue syndrome, Parkinson’s disease,

human immunovirus/autoimmune deficiency syndrome,

cancer and systematic lupus erythematosus may experience

fatigue at some point during their illness (Neill et al. 2006,

Jacobsen et al. 2007, Smith & Hale 2007, Bonner et al.

2008, Lee et al. 2008, Kirshbaum 2010). In addition,

patients suffering from acute illnesses such as pneumonia

or the flu and those who have undergone surgery may also

experience fatigue (Kuchinski et al. 2009). Patients experi-

encing fatigue may be admitted to inpatient units for

medical or surgical treatment of acute illness or exacerba-

tion of chronic conditions. Nurses in acute care and

Authors: Erin Patterson, BScN, RN, MN, PhD Student, Lawrence

S. Bloomberg Faculty of Nursing, University of Toronto, Toronto,

ON; Yi WT Wan, BScN, RN, MN, Public Health Nurse, Peel Pub-

lic Health, Mississauga, ON; Souraya Sidani, PhD, Professor and

Canada Research Chair in Health Interventions, Daphne Cockwell

School of Nursing, Ryerson University, Toronto, ON, Canada

Correspondence: Erin Patterson, PhD Student, 130-155 College

Street, Toronto, ON M5T 1P8, Canada. Telephone: +1 416 978

6913.

E-mail: [email protected]

© 2013 John Wiley & Sons Ltd

2668 Journal of Clinical Nursing, 22, 2668–2678, doi: 10.1111/jocn.12211

community settings are responsible for assisting patients in

the management of fatigue. The overall goal of this litera-

ture review is twofold: to identify nonpharmacological

interventions that nurses can implement to help patients

address this symptom effectively, and to describe the com-

ponents and activities of which these interventions are com-

prised. The intervention description can facilitate the

translation and implementation of the interventions in day-

to-day practice.

Background

Fatigue is a complex multidimensional symptom (Prue et al.

2006, Smith & Hale 2007, Kuchinski et al. 2009,

Kirshbaum 2010) experienced by patients with different

diagnoses and in relation to diverse physiological, psychoso-

cial and environmental factors. Specifically, these factors

may include but are not limited to fluid, electrolyte or hor-

mone imbalance, alterations in oxygenation, build-up of

waste products that results from various treatments, most

notably those used in the treatment of cancer, experience of

other symptoms (e.g. pain), changes to regular sleep patterns

and increased emotional and physical demands associated

with dealing with an illness or its exacerbation. Fatigue is a

subjective experience that affects patients physically, emo-

tionally, cognitively and behaviourally (Kirshbaum 2010).

Fatigue negatively impacts usual functioning and quality of

life for many of those who experience it during the course of

their illness and recovery (Neill et al. 2006, Jacobsen et al.

2007, Smith & Hale 2007, Kirshbaum 2010). Patients’ expe-

rience of fatigue may result in decreased ability to perform

regular physical activities, withdrawal from social activities

and changes in one’s ability to perform mental work (Gray-

don et al. 1998). The impact of fatigue on quality of life

requires effective management.

Given the impact fatigue has on patients’ functional

status, assisting patients in the management of fatigue is a

concern to nurses in acute care, long-term care, rehabilita-

tion and community settings. Limitations in physical and

mental function restrict patients’ ability to carry out treat-

ment and self-care recommendations in the postdischarge

period, potentially jeopardising recovery. Strategies to man-

age fatigue include a combination of pharmacological and

nonpharmacological interventions (Neill et al. 2006). Phar-

macological treatments such as iron or electrolyte supple-

ments and pain killers improve fatigue indirectly by treating

physiological factors contributing to fatigue. Nonpharmaco-

logical interventions such as rest, exercise and counselling

assist patients in preventing and/or managing fatigue.

Although nurses are involved in the implementation of

pharmacological and nonpharmacological interventions,

they are in a position to initiate and carry out the latter

type of interventions independently. Providing nonpharma-

cological interventions is within the scope of nursing

practice as delineated by professional organisations (e.g.

Canadian and American Nurses Associations) and as identi-

fied in best practice guidelines for fatigue (e.g. National

Comprehensive Cancer Network and National Cancer

Institute).

However, a gap in the literature exists as the available

evidence related to nonpharmacological interventions for

the management of fatigue is limited in guiding nurses’

implementation of these interventions in day-to-day prac-

tice. Although a number of systematic reviews (Neill et al.

2006, Smith & Hale 2007, Bonner et al. 2008, Lee et al.

2008, Kirshbaum 2010) and one meta-analysis (Jacobsen

et al. 2007) reported on the effectiveness of nonpharmaco-

logical interventions for fatigue, they did not clearly iden-

tify the interventionist who delivered the treatment and did

not explicitly and comprehensively describe the interven-

tions. Failure to clarify the professional qualities (i.e. pro-

fession and educational background) of the interventionist

ascribed the responsibility of delivering the intervention

raises questions about the suitability or appropriateness of

the intervention to nurses’ practice. Thus, nurses desiring to

apply the intervention wonder if the intervention is within

their scope of practice and if they have acquired the theo-

retical and practical knowledge that enables them to carry

out the intervention. Failure to comprehensively describe

the intervention creates challenges for nurses who want to

implement evidence-based interventions in their day-to-day

practice. Nurses need to be aware of the name or label of

the intervention (e.g. patient education), but most impor-

tantly, they require an adequate understanding of what the

intervention is about. Knowledge of the components and

activities of which the interventions are comprised, their

mode of delivery and the dose at which they should be

given to produce the intended outcomes is critical to guide

nurses’ practice (Sidani & Gottlieb, 2007) related to the

initiation and implementation of the interventions

independently.

Aims

This literature review addresses the gap in the literature by

identifying nonpharmacological interventions for the man-

agement of fatigue that nurses can initiate and implement

independently, and describing these interventions in detail.

The ultimate goal was to provide nurses with specific

knowledge related to the interventions that is needed to


Journal of Clinical Nursing, 22, 2668–2678 2669

Review Interventions for fatigue

direct their delivery in day-to-day practice. The objectives

were as follows:

1 To generate a list of nonpharmacological interventions

for the management of fatigue that nurses can initiate

and implement in acute, rehabilitation, long-term and

community care settings.

2 To determine the effectiveness of nonpharmacological

interventions, delivered by nurses for the management

of fatigue.

3 To describe the components, activities, mode of delivery

and dose of nonpharmacological interventions deliv-

ered by nurses and found effective in addressing

fatigue.

Methods

Inclusion/exclusion criteria

To address the above objectives, research articles reporting

on the evaluation of interventions meeting the preset inclu-

sion criteria were selected for this review. The criteria

included the following:

1 Nonpharmacological interventions concerned with the

management of fatigue. Nonpharmacological interven-

tions encompassed treatments that are physical,

behavioural, psychological or cognitive in nature

(excluding medication).

2 Interventions delivered by nurses, including registered

practical nurses, registered nurses (RN), advanced prac-

tice nurses (APNs) and nurse researchers.

3 Interventions targeting adult (� 18 years of age)

patients experiencing fatigue related to acute or chronic

illness that was managed with medical and/or surgical

treatments.

4 Use of an experimental or quasi-experimental design

for evaluating the effects of the intervention on fatigue.

5 Study reports published in English or French.

Exclusion criteria included the following:

1 Use of nonexperimental research design.

2 Interventions delivered by nonnursing healthcare pro-

viders (e.g. physiotherapists, occupational therapists,

music therapists and physicians).

3 Interventions not within the scope of nursing practice

(i.e. interventions that cannot be initiated and imple-

mented by nurses, without the need for a medical

order).

Studies reporting on nonexperimental research were

excluded, as such designs are limited in generating evidence

to determine the effectiveness of interventions. Studies in

which the interventionist was a nonnursing professional

and studies reporting on interventions outside the nurses’

scope of practice were excluded keeping with the aim of

identifying and describing interventions that nurses can ini-

tiate and implement independently. Interventions were

deemed outside nurses’ scope of practice when their deliv-

ery requires knowledge and/or skills that are not tradition-

ally part of the nursing role (e.g. planning and initiating a

complex exercise regime or nutrition programme) as

delineated by nursing regulatory organisations.

Search strategies

To locate relevant publications, the following electronic

databases were searched: Cumulative Index to Nursing and

Allied Health Literature, HEALTHSTAR, MEDLINE (PUB-

MED), PSYCINFO, COCHRANE and MEDLINE (OVID).

The search time frame was 1990–2012, ensuring that inter-

ventions reflected current clinical practice. Search terms used

included ‘fatigue’ and alternate key words such as ‘tiredness’

and ‘exhaustion’. Each of these terms was used in various

combinations with ‘intervention’, ‘nursing intervention’,

‘nursing’, ‘treatment’, ‘strategies’, ‘nursing process’, ‘nurses’,

‘advanced practice nurse’ and ‘nurse practitioner’.

In addition to searching the relevant electronic databases,

the reference lists of articles was reviewed for additional

reports of studies meeting the inclusion criteria. The grey

literature was also explored, and best practice guideline da-

tabases from the Registered Nurses Association of Ontario,

the National Cancer Institute, the National Comprehensive

Cancer Network and the National Guideline Clearinghouse

were searched for guidelines relevant to the management of

fatigue. The reference list of each guideline was also

reviewed for relevant publications.

The initial screening of publication titles and abstracts

was conducted by two researchers working independently.

The researchers read the abstracts carefully to determine

the general nature of the intervention addressing fatigue.

The characteristics of the target population or sample, the

professional designation of the interventionist (as explicitly

stated in the report or as inferred from the professional

affiliation of the researcher who implemented the interven-

tion) and the type of design used in the study were consid-

ered. The researchers documented pertinent information on

a screening form that listed the study selection criteria.

When abstracts did not provide all information required to

determine eligibility, the full study reports were reviewed.

Studies for which both researchers indicated they met the

selection criteria were included in the literature review. In

case of disagreement, the researchers discussed and resolved

differences in perspective with a third researcher.


2670 Journal of Clinical Nursing, 22, 2668–2678

E Patterson et al.

Data extraction

Data were extracted on study characteristics, intervention

characteristics and results pertaining to the effects of the

intervention on fatigue. Data extraction was performed by

two researchers. The first read the study report carefully

and documented relevant information in a table; the second

reviewed the study report and confirmed the accuracy of

the tabled information.

Data on study characteristics included the following: (1)

research design used, which was categorised as experimen-

tal, quasi-experimental involving treatment and comparison

group or quasi-experimental consisting of a treatment group

with repeated measures; (2) target population described

relative to illness or disease with which patients presented;

(3) sample socio-demographic characteristics represented by

the reported mean age, percentage of women and percent-

age of white (or Caucasian) participants; (4) sample size,

that is, total number of participants and number of partici-

pants assigned to the treatment and comparison groups

(where applicable); and (5) setting in which the intervention

was delivered, which was categorised into acute, long-term,

rehabilitation or community care settings. In addition, study

limitations were identified as a means of determining qual-

ity. The limitations included major threats to internal valid-

ity, specifically selection bias (i.e. noncomparability of the

treatment and comparison groups on baseline measures)

that was not controlled statistically and contamination (i.e.

dissemination of the intervention to participants in the com-

parison group). Studies for which these two threats were

present, as stated by the authors or as inferred by the

researchers conducting the review, were excluded.

The intervention characteristics of concern were as

follows: (1) the type of nonpharmacological intervention

under evaluation. Pertinent information was abstracted

from the name of the intervention mentioned in the study

report (e.g. education, exercise and relaxation); (2) the

components and activities of which the intervention was

comprised. An intervention component is a set of interre-

lated activities that are directed toward achieving a com-

mon goal (Sidani & Braden 1998). For instance, psycho-

educational intervention consists of two components: a

psychological component aimed at promoting patients’

emotional well-being and an educational component

aimed at enhancing their knowledge of the health problem

and self-management strategies. Intervention activities

refer to the specific actions that the interventionist per-

forms when delivering the intervention or its components

(Sidani & Braden 1998); (3) the dose at which the inter-

vention was given. The dose was operationalised in terms

of the number of sessions and length of sessions offered

to deliver the intervention, and the frequency with which

the sessions were offered over a specified time period such

as a week; (4) the mode of intervention delivery, which

represents the format for providing the intervention to

patients. Mode of delivery was categorised as: face-to-face

interactions between the interventionist and patients in

individual or group sessions, telephone contact or written

materials (e.g. leaflet). Information on intervention compo-

nents, activities, dose and mode of delivery was extracted

from the description of the treatment protocol in the

selected reports.

Data on the intervention’s effects on fatigue entailed the

following: (1) whether or not the intervention had a

statistically significant effect, evidenced by a significant

between-group difference in fatigue levels observed at post-

test, or a significant change in fatigue levels from pretest to

post-test in a one-group repeated measure design and (2)

effect size, computed as the standardised difference in

groups’ means at post-test or in means observed at pretest

and post-test in a single-group repeated measure design. The

effect size reflects the magnitude of the intervention’s effect

and is of clinical relevance in determining its benefits.

Data analysis

Data pertaining to study characteristics (i.e. design, sample

and setting) were analysed descriptively. To generate a list of

nonpharmacological interventions for the management of

fatigue (objective 1), the frequency with which a particular

type of intervention was examined across all studies meeting

the inclusion criteria was calculated. To determine the effec-

tiveness of these interventions (objective 2), the frequency

with which each type of intervention was found to have a sta-

tistically significant effect across all studies that evaluated the

same type of intervention was calculated, and the mean effect

size across all studies testing each type of intervention was

computed. In addition, a description of each type of interven-

tion found effective (i.e. had a statistically significant effect)

was generated (objective 3) by comparing and contrasting

the components and activities across all studies evaluating

each type of intervention, and synthesising those components

and activities common to each intervention type.

Literature search

The search of the literature resulted in 288 hits. Two hun-

dred and thirty-three publications were excluded because

(1) an intervention was not tested, (2) the intervention

being tested did not target fatigue directly or (3) the




publication reported on a systematic review or meta-analy-

sis. Of the remaining 55 publications reporting on the test-

ing of an intervention to manage fatigue, 32 were

eliminated because they were not delivered by a nurse, and

23 met all inclusion criteria preset for this review. Figure 1

summarises the results of the literature search.

Results

Study characteristics

The studies included in this review were published between

1993–2012. An experimental design was used in 18

(78�3%) studies, and a quasi-experimental design was used

in five (21�7%). The setting in which the intervention under

investigation was implemented varied across studies.

The majority (n = 21) of studies took place in outpatient

settings including outpatient cancer clinics (n = 12) and an

outpatient dialysis unit (n = 2). Seven study reports

mentioned unspecified outpatient settings. Only two studies

were conducted in acute care settings, which involved an

oncology and a haematology inpatient unit.

Participant characteristics

The sample size ranged from 14–396 across studies. Partici-

pants’ age varied between 21–91 years with a mean of

50 years. The mean percentage of female participants

(reported in 22 studies) was 74�7% (range: 17–100%); in

particular, six of the studies reported on interventions tar-

geting women with breast cancer. The mean percentage of

white participants (reported in nine studies) was 83�7%(range: 79–95�5%).

Interventions targeted different populations. The most

prevalent population was patients with cancer (78�2%).

Types of cancer included breast cancer (21�74%), solid

tumour cancers and nonHodgkin’s lymphoma (8�7%),

colon and gastric cancer (8�7%), malignant melanoma

(4�35%), pancreatic cancer (4�35%), lung cancer (4�35%)

and unspecified types of cancer (21�74%). Other popula-

tions targeted were patients with lupus (4�35%), end-stage

renal disease (8�7%), chronic fatigue syndrome (4�35%),

neuromuscular disease (4�35%) and patients undergoing

haemopoietic stem cell transplantation (4�35%).

Intervention characteristics

The 23 studies evaluated eight types of interventions for the

management of fatigue. Psycho-educational interventions

were most often tested (52�17%). Exercise and a combina-

tion of exercise, education and psychological support were

both tested in three studies (13�04%). Other interventions

included cognitive behavioural therapy, exercise, relaxation,

acupressure, energy conservation and activity management,

and distraction. Each of these interventions was investi-

gated in one study.

Interventions were delivered by registered nurses (52�2%)

or nurse researchers (47�8%). Implementation of the inter-

ventions frequently involved multiple modes of delivery.

In 17 studies, the interventions were given in individual or

group face-to-face sessions. In addition to these sessions,

the interventions incorporated telephone contacts with par-

ticipants (n = 5 studies), written material (n = 5 studies),

audio-taped instructions (n = 2 study), or audio-visual

material and computer-assisted learning (n = 1 study). Six

interventions involved a self-directed intervention compo-

nent with either individual or group sessions.

The intervention dose varied with the type of interven-

tion. Educational interventions, cognitive behavioural ther-

apy, and energy conservation and activity management

were delivered in multiple sessions over a 3- to 10-week

period, with sessions lasting between 15 minutes and two

hours. Interventions involving exercise also spanned several

weeks, with participants following an exercise regime at

home in-between sessions. Acupressure was delivered three

times a week over four weeks, with each session lasting

15 minutes. The relaxation breathing intervention lasted

30 minutes daily for six weeks.

Intervention effects on fatigue

Table 1 summarises the number of studies reporting the eight

types of intervention as having a statistically significant effect

Records identified through database searching(n = 288)

Records screened (n = 288)

Records excluded (No intervention tested, intervention

did not target fatigue, systematic review/meta analysis)

(n = 233)

Full text articles assessed for eligibility (n = 55)

Full text articles excluded (Intervention not delivered by a

nurse)(n = 32)

Full text articles included in the review

(n = 23)

Figure 1 Results of literature search.



E Patterson et al.

out of the total number of studies that tested it as well as

the mean effect size (averaged across studies). The effective-

ness of each type of intervention is discussed below.

Psycho-education

Twelve studies evaluated psycho-education, which consisted

of education and support for the management of fatigue.

Eight studies (Sohng 2003, Badger et al. 2005, Ream et al.

2006, Armes et al. 2007, Yesilbalkan et al. 2009, Wearden

et al. 2010, Chan et al. 2011, Reif et al. 2012) reported the

intervention as having a statistically significant effect on

participants’ experience of fatigue. In seven studies, the

intervention was provided in outpatient settings (Sohng

2003, Badger et al. 2005, Ream et al. 2006, Yesilbalkan

et al. 2009, Wearden et al. 2010, Chan et al. 2011, Reif

et al. 2012), and in one study the intervention was

provided in an acute care setting (Armes et al. 2007). The

intervention targeted patients diagnosed with cancer (n = 5

studies), systematic lupus erythematosus (n = 1 study),

chronic fatigue syndrome (n = 1 study) or patients with

end-stage renal disease (n = 1 study).

The four studies (Fawzy 1995, Godino et al. 2006, Kurtz

et al. 2008, Boosman et al. 2011) showing no statistically

significant effect of the intervention on fatigue were

conducted in outpatient settings involving participants

diagnosed with cancer or neuromuscular diseases. The

mean effect size across the eight studies (Table 1) indicated

that psycho-education is moderately effective in improving

fatigue.

Psycho-educational interventions, which produced statis-

tically significant effects on participants’ experience of

fatigue, were comprised of the following components:

assessment of fatigue, education, training and coaching in

self-care strategies for managing fatigue. The interventions

were provided in sequential face-to-face sessions each last-

ing between one and two hours. Six of the interventions

were delivered to participants individually (Badger et al.

2005, Ream et al. 2006, Armes et al. 2007, Yesilbalkan

et al. 2009, Wearden et al. 2010, Chan et al. 2011), and

two were delivered in group sessions (Sohng 2003, Reif

et al. 2012).

Across studies evaluating psycho-educational interven-

tions for the management of fatigue, small sample size

(seven of 12 studies) and application of a within-group

design (three of 12 studies) were commonly identified as lim-

itations. In addition, authors of one study cited participant

access to educational resources outside of those provided to

participants during the study as a confounding variable

potentially affecting the study results (Ream et al. 2006).

Cognitive behavioural therapy

One study evaluated a cognitive behavioural intervention

targeting patients with cancer attending outpatient clinics

(Sherwood et al. 2005). However, it was not reported as

effective (Sherwood et al. 2005) in lowering levels of fati-

gue. An explanation of this finding is that the outcome

measure used captured overall symptom severity, not specif-

ically fatigue severity. A high attrition (49�6%) rate was

identified as a limitation of this study.

Exercise, education and support

Three studies reported on rehabilitation interventions to

assist patients with cancer in the management of fatigue

(Mock et al. 1994, Goedendorp et al. 2010, Wang et al.

2011). Two of the interventions had a statistically signifi-

cant effect on fatigue. Both incorporated exercise, education

and support through walking programmes and individual

or group support. The walking programmes were outlined

in booklets that were provided to participants. The

programmes consisted of regular brisk walks (three to five

times per week), which increased in length from

10–50 minutes. The education and support components of

the interventions were given biweekly during group sessions

or a combination of telephone contracts and individual

meetings for the duration of their chemotherapy treatment.

Although the interventions’ effects on fatigue were

statistically significant, the authors of one study (Mock

et al. 1994) failed to report the effect size or sufficient

information to calculate it. The small sample size, with only

14 participants across both the treatment (n = 9) and the

control groups (n = 5), is also a limitation (Mock et al.

Table 1 Intervention effectiveness by type of intervention

Type of

intervention

Number of studies

reporting significant

effect

Mean

effect size

Psycho-education 8 of 12 0�65Cognitive

behavioural

therapy

0 of 1 Could not compute

Exercise,

education

and support

2 of 3 Could not compute

Exercise 2 of 3 Could not compute

Acupressure 1 of 1 0�62Energy conservation

and activity

management

1 of 1 0�28

Relaxation breathing

exercise

1 of 1 2�1

Distraction 1 of 1 0�41




1994). The second study (Wang et al. 2011) presented suffi-

cient information to calculate an effect size of 1�2. This

suggests that interventions incorporating exercise, education

and support may have a strong effect on patients’ experi-

ence of fatigue.

The study showing no statistically significant effect of the

intervention on fatigue also consisted of a walking

programme for patients diagnosed with cancer. However,

there were only two support sessions over the course of the

intervention, which was acknowledged as a limitation of

the intervention design (Goedendorp et al. 2010).

Exercise

Exercise was evaluated as an intervention targeting fatigue

in three studies. Two of the interventions involved home-

based walking programmes for participants diagnosed with

cancer (Payne et al. 2008, Yeo et al. 2012). The results of

one study (Payne et al. 2008) indicated a nonsignificant

effect on participants’ levels of fatigue (Payne et al. 2008).

Study limitations included a small sample size and reliance

on self-report measures to monitor participants’ adherence

to the exercise programme.

Yeo et al. (2012) also evaluated an exercise intervention

consisting of a self-directed walking programme for outpa-

tients diagnosed with cancer. Participants were provided

with a booklet containing instructions on how to progress

through a graduated walking programme lasting three

months. This intervention significantly reduced participants’

levels of fatigue.

The third study reported a different type of exercise inter-

vention to assist patients with end-stage renal disease receiv-

ing outpatient haemodialysis manage fatigue (Chang et al.

2010). The intervention had a statistically significant effect

on fatigue. It incorporated leg exercises performed by

patients during haemodialysis treatments (three times

weekly for eight weeks). The duration of exercise increased

from 10–30 minutes over the first three sessions and then

remained constant for the duration of the intervention

period. The effect size of 0�56 indicates that this exercise

intervention had a moderate effect. The authors cite

small sample size as a limitation of this study (Chang et al.

2010).

Acupressure

Acupressure was tested as an intervention targeting fatigue

in participants with cancer. The intervention consisted of

acupressure massage three times a week for four weeks.

During acupressure sessions, a three-minute massage was

delivered to relax participants, and then pressure was

applied to four points on both legs and both feet for a total

duration of 12 minutes (Tsay 2004). This intervention

significantly reduced participants’ levels of fatigue and dem-

onstrated moderate effectiveness (Table 1). The author

cited the short follow-up period as one limitation of the

study.

Energy conservation and activity management

One study reported the effects of an energy conservation

and activity management intervention in patients suffering

from cancer-related fatigue (Barsevick et al. 2004). The

intervention was comprised of three telephone sessions

given to participants in outpatient cancer centres. During

the first session, lasting 30 minutes, information was pro-

vided on cancer-related fatigue and energy conservation

skills to assist participants in managing fatigue. The second

session, also lasting 30 minutes, consisted of the creation of

an energy conservation plan. The third session, lasting

15 minutes, involved evaluation and revision of the plan.

Participants were responsible for completing a journal

between sessions in which they were requested to monitor

their sleep, rest, activity and fatigue as well as any other

symptoms experienced (Barsevick et al. 2004). This inter-

vention had a statistically significant effect on participants’

levels of fatigue over time. The effect size of 0�28 indicates

that this energy conservation and activity management

intervention had a small effect on fatigue.

Relaxation breathing exercise

A relaxation breathing exercise was evaluated in one study

as an intervention to manage fatigue experienced by partici-

pants receiving haemopoietic stem cell transplantation (Kim

& Kim 2005). This intervention resulted in a statistically

significant improvement in participants’ level of fatigue,

demonstrating a large effect (Table 1). This intervention

was delivered via audio cassette. The tape was 30 minutes

in length and provided instructions on how to complete

relaxation breathing exercises. The relaxation breathing

exercise was comprised of three components: (1) prelimin-

ary exercise where participants assume a comfortable posi-

tion and focus their attention on the lower abdomen; (2)

relaxation breathing exercise, where participants relax by

taking deep breaths and letting them out slowly; and (3)

finish exercise, where patients keep their mind clear and

stretch their arms and legs. Prior to providing the tape, the

nurse researcher spent 10 minutes explaining the use of the

tape and appropriate body positioning for the breathing

exercise. Participants independently listened to the tape and

completed the relaxation breathing exercise daily for six

weeks (Kim & Kim 2005). Small sample size was a

limitation.



E Patterson et al.

Distraction

Distraction for the management of fatigue was examined in

participants diagnosed with breast cancer. This intervention

involved the use of virtual reality equipment during partici-

pants’ chemotherapy treatment sessions. During either the

participants’ first or second chemotherapy treatment session,

the researcher assisted participants in donning the virtual

reality headset. Participants then selected one of three possi-

ble scenarios and used the equipment for five to 10 minutes

prior to the commencement of their chemotherapy treat-

ment to get used to the equipment. Participants continued

to use the virtual reality equipment for the duration of their

chemotherapy treatment session (Schneider et al. 2004).

This distraction intervention had a statistically significant

and moderate (Table 1) effect on participants’ levels of

fatigue immediately following the implementation of the

intervention, but not at 48 hours postintervention/postche-

motherapy treatment (Schneider et al. 2004). The mecha-

nism responsible for producing the effects of this

intervention on fatigue is not clearly delineated and remains

to be explained, which is a limitation of this study.

Discussion

In this literature review, eight interventions for the manage-

ment of fatigue that can be initiated and implemented by

nurses were identified. The interventions were psycho-

education, cognitive behavioural therapy, acupressure,

energy conservation and activity management, relaxation

breathing exercise, distraction and the combination of exer-

cise, education and support. All interventions were imple-

mented by either staff or research nurses, and with the

exception of cognitive behavioural therapy, all were found

effective in relieving the experience of fatigue. Excluding

psycho-education, the evidence supporting the effectiveness

of the interventions was limited to a few studies character-

ised by some limitations. Psycho-education was evaluated in

several studies and demonstrated effectiveness in managing

fatigue across different patient populations and in a variety

of healthcare settings. The evidence suggests that psycho-

education is a nursing intervention successful in reducing

fatigue among patients in acute and community care

settings. Further research is required to determine its appro-

priateness in rehabilitation and long-term care settings.

Nurses can deliver this intervention, guided by the clinical

information presented in Table 2. The information identifies

the essential elements of psycho-education that distinguish

this intervention from others; as well, it delineates the most

suitable mode for delivering the intervention and the mini-

mal dose at which the intervention is to be given to achieve

the desirable outcome. Consistent application of the essential

elements, by different nurses to different patients over time,

is necessary to maintain fidelity of implementation and hence

to produce the beneficial effects (Sidani & Braden, 2011).

The findings of this review demonstrate that psycho-

education is the most well-supported intervention for the

management of fatigue. This is not congruent with conclu-

sions reached in the previously published systematic reviews

and/or best practice guidelines, which cite exercise as the

most effective and hence most frequently recommended

nonpharmacological intervention for the management of

fatigue. The difference in the findings between the previous

and current reviews relates to the focus of the current review

on interventions that can be initiated and implemented by

nurses within acute and community settings. Exercise-based

interventions often require an interdisciplinary approach in

which a physician assesses the patients’ overall health status

and the suitability of exercise; a physiotherapist plans, trains

and supervises the exercise programme; and a nurse offers

support, coaching and encouragement. In contrast, psycho-

education, operationalised as the relay of information and

the provision of support, is the responsibility of nurses as

identified by regulatory bodies and standards of practice in

many countries. Nurses can plan and deliver psycho-educa-

tional interventions autonomously and independently.

Highlighted by this review is the small number of pub-

lished studies addressing patient fatigue in the context of

nursing care. Fatigue is a common patient concern that is

responsive to nursing care and as such is of concern to

front-line nurses and nurse researchers alike. Although


fatigue are within the scope of nurses’ practice, few studies

have evaluated such interventions. As a result, it is chal-

lenging to draw conclusions, with confidence, around which

nursing interventions are most effective for the management

of fatigue. Based on the limited number of studies included

in this review, the evidence in support of nurse-delivered

psycho-education is the strongest. Although other interven-

tions had similar (acupressure) or larger (relaxation breath-

ing) effect sizes, these interventions were evaluated in only

a single study limiting the researchers’ ability to draw

conclusions around their effectiveness. Further research is

needed to evaluate the effect of interventions such as

acupressure, relaxation breathing, cognitive behavioural

therapy, energy conservation and nurse-delivered exercise

interventions on patients’ experience of fatigue.

This literature review is not without limitations. First,

a limited number of studies evaluating nurse-delivered


patient fatigue were found. Besides psycho-education, the




researchers could not draw definitive conclusions as to

the effectiveness of other interventions delivered by nurses

for the management of patient fatigue. Second, a number of

studies included in the review did not report an effect size

or sufficient information to calculate effect size. Although

effect size was used to describe the effectiveness of interven-

tions (when available), effect size could not be used to com-

pare effectiveness of different types of nonpharmacological

interventions for the management of fatigue.

Conclusion

In this review, eight interventions for the management of fati-

gue that are within the scope of nurses’ practice were identi-

fied. These interventions included psycho-education,

cognitive behavioural therapy, acupressure, energy conserva-

tion and activity management, relaxation breathing, exercise,

distraction and the combination of exercise, education and

support. All of the interventions, with the exception of

cognitive behavioural therapy, were found effective in the

management of fatigue when delivered by nurses. However,

only psycho-educational intervention demonstrated strong

evidence of effectiveness across patient populations and prac-

tice settings. Details on the elements of psycho-education

were provided to facilitate its implementation in practice.

Relevance to clinical practice

This review addresses a gap in the literature examining

interventions for the management of fatigue by focusing

on interventions that can be initiated and delivered by

nurses. In addition, the previously published reviews failed

to provide sufficiently detailed descriptions of the interven-

tions to guide nurses in implementing the interventions in

practice. This highlights the contribution of this review, as

a detailed description of the intervention found to have

the strongest evidence of effectiveness in the literature

(psycho-education) is provided. The description delineates

the intervention name, components and activities, mode of

delivery and dose. The aim of preparing the description

was to inform nurses willing to implement the nonphar-

macological intervention for the management of fatigue, of

the essential elements that characterise the intervention

that should be delivered with fidelity to achieve intended

outcomes. More specifically, the description helps nurses

determine what should be done, in what way, how fre-

quently and for how long, to produce improvement in

patients’ experience of fatigue. Such information could

contribute to the closure of the gap between research and

practice.

Contributors

Study design: SS; data collection and analysis: EP, YWTW

and manuscript preparation: EP, SS, YWTW.

Funding source

The study was funded by Ontario Ministry of Health and

Long-Term Care.

References

Armes J, Chalder T, Addington-Hall J,

Richardson A & Hotopf M (2007) A

randomized controlled trial to evaluate

the effectiveness of a brief, behaviorally

oriented intervention for cancer-related

fatigue. Cancer 110, 1382–1395.

Badger T, Segrin C, Meek P, Lopez AM,

Bonham E & Sieger A (2005) Tele-

phone interpersonal counseling with

women with breast cancer: symptom

management and quality of life. Oncol-

ogy Nursing Forum 32, 273–297.

Barsevick AM, Dudley W, Beck S, Swee-

ney C, Whitmer K & Nail L (2004)

A randomized clinical trial of energy

conservation for patients with cancer-

related fatigue. Cancer 100, 1302–

1310.

Bonner A, Wellard S & Caltabiano M

(2008) Levels of fatigue in people with

ESRD living in far North Queensland.

Journal of Clinical Nursing 17, 90–98.

Boosman H, Visser-Meily JM, Meijer JW,

Elsinga A & Post MW (2011)

Table 2 Description of a psycho-educational Intervention for the management of fatigue by nurses

Intervention

name Mode Dose Components and activities

Psycho-education Fact-to-face

session

with the

patient

One, one-

hour

session

� Assess the patients’ experience of fatigue and its contributing factors

� Monitor the patients’ level of fatigue and use of existing strategies to manage it

� Instruct patients in the application of strategies to manage fatigue

such as physical activity, energy conservation, relaxation, diversion,

sleep promotion and proper nutrition

� Coach patients in the selection and performance of strategies to manage fatigue



E Patterson et al.

Evaluation of change in fatigue, self-

efficacy and health-related quality of

life, after a group educational inter-

vention programme for persons with

neuromuscular diseases or multiple

sclerosis: a pilot study. Disability and

Rehabilitation 33, 690–696.

Chan CW, Richardson A & Richardson J

(2011) Managing symptoms in

patients with advanced lung cancer

during radiotherapy: results of a psy-

choeducational randomized controlled

trial. Journal of Pain and Symptom

Management 41, 347–357.

Chang Y, Cheng SY, Lin M, Gau FY &

Chao YF (2010) The effectiveness of

intradialytic leg ergometry exercise for

improving sedentary life style and

fatigue among patients with chronic

kidney disease: a randomized clinical

trial. International Journal of Nursing

Studies 47, 1383–1388.

Fawzy NW (1995) A psycho-educational

nursing intervention to enhance coping

and affective state in newly diagnosed

malignant melanoma patients. Cancer

Nursing 18, 427–438.

Godino C, Jodar L, Duran A, Martinez I

& Schiaffino A (2006) Nursing educa-

tion as an intervention to decrease

fatigue perception in oncology

patients. European Journal of Oncol-

ogy Nursing 10, 150–155.

Goedendorp MM, Peters ME, Gielissen

MF, Witjes JA, Leer JW, Verhagen

CA & Bleijenberg G (2010) Is increas-

ing physical activity necessary to

diminish fatigue during cancer treat-

ment? Comparing cognitive behavior

therapy and a brief nursing interven-

tion with usual care in a multicenter

randomized controlled trial. The

Oncologist 15, 1122–1132.

Graydon J, Sidani S, Irvine D, Vincent L,

Bubela N & Harrison D (1998) Liter-

ature review on cancer-related fatigue.

Canadian Oncology Nursing Journal

8, S5.

Jacobsen PB, Donovan KA, Vadaparampil

ST & Small BJ (2007) Systematic

review and meta-analysis of psycholog-

ical and activity-based interventions for

cancer-related fatigue. Health Psychol-

ogy: Official Journal of the Division of

Health Psychology, American Psycho-

logical Association 26, 660–667.

Kim SD & Kim HS (2005) Effects of a

relaxation breathing exercise on fatigue

in haemopoietic stem cell transplanta-

tion patients. Journal of Clinical Nurs-

ing 14, 51–55.

Kirshbaum M (2010) Cancer-related fati-

gue: a review of nursing interventions.

British Journal of Community Nursing

15, 214–219.

Kuchinski AM, Reading M & Lash AA

(2009) Treatment-related fatigue and

exercise in patients with cancer: a sys-

tematic review. Medsurg Nursing 18,

174–180.

Kurtz ME, Kurtz JC, Given CW & Given

BA (2008) Patient optimism and mas-

ter – do they play a role in cancer

patients’ management of pain and fati-

gue? Journal of Pain and Symptom

Management 36, 1–9.

Lee D, Newll R, Ziegler L & Topping A

(2008) Treatment of fatigue in multi-

ple sclerosis: a systematic review of

the literature. International Journal of

Nursing Practice 14, 81–93.

Mock V, Burke MB, Sheehan P, Creaton

EM, Winningham ML, Mckenney-

Tedder S, Schwager LP & Liebman M

(1994) A nursing rehabilitation program

for women with breast cancer receiving

adjuvant chemotherapy. Oncology

Nursing Forum 21, 899–907.

Neill J, Belan I & Reid K (2006) Effec-

tiveness of non-pharmacological inter-

ventions for fatigue in adults with

multiple sclerosis, rheumatoid arthri-

tis, or systematic lupus erythematosus:

a systematic review. Journal of

Advanced Nursing 56, 617–635.

Payne JK, Held J, Thrope J & Shaw H

(2008) Effect of exercise on biomar-

kers, fatigue, sleep disturbances, and

depressive symptoms in older women

with breast cancer receiving hormonal

therapy. Oncology Nursing Forum 35,

635–642.

Prue G, Rankin J, Allen J, Gracey J &

Cramp F (2006) Cancer-related fati-

gue: a critical appraisal. European

Journal of Cancer 42, 846–863.

Ream E, Richardson A & Alexander-Dann

C (2006) Supportive intervention for

fatigue in patients undergoing chemo-

therapy: a randomized controlled trial.

Journal of Pain and Symptom Man-

agement 31, 148–161.

Reif K, de Vries U, Petermann F & Gorres S

(2012) A patient education program is

effective in reducing cancer-related fati-

gue: a multi-centre randomised two-

group waiting-list controlled interven-

tion trial. European Journal of Oncol-

ogy Nursing [Epub ahead of print].

Schneider SM, Prince-Paul M, Allen MJ,

Sliveramn P & Talaba D (2004)

Virtual reality as a distraction inter-

vention for women receiving chemo-

therapy. Oncology Nursing Forum 31,

81–88.

Sherwood P, Given BA, Given CW, Cham-

pion VL, Doorenbos AZ, Azzouz F,

Kozachik S, Wagler-Ziner K &

Monahan PO (2005) A cognitive

behavioural intervention for symptom

management in patients with

advanced cancer. Oncology Nursing

Forum 32, 1190–1198.

Sidani S & Braden CJ (1998) Evaluating

Nursing Interventions: A Theory Dri-

ven Approach. Sage, Thousand Oaks,

CA.

Sidani S & Braden CJ (2011) Design, Eval-

uation, and Translation of Nursing

Interventions. John Wiley & Sons Inc,

West Sussex, UK.

Sidani S & Gottlieb LN (2007) Guidelines

for translating RCT findings into prac-

tice. Canadian Journal of Nursing

Research 39, 191–197.

Smith C & Hale L (2007) The effects of

non-pharmacological interventions on

fatigue in four chronic illness condi-

tions: a critical review. Physical

Therapy Reviews 12, 324–334.

Sohng KY (2003) Effects of a self-manage-

ment course for patients with systemic

lupus erythematosus. Journal of

Advanced Nursing 42, 479–486.

Tsay SL (2004) Acupressure and fatigue in

patients with end-stage renal disease –

a randomized controlled trial. Interna-

tional Journal of Nursing Studies 41,

99–106.

Wang YJ, Boehmke M, Wu YW, Dicker-

son SS & Fisher N (2011) Effects of a

6 week walking program on Taiwan-

ese women newly diagnosed with

early-stage breast cancer. Cancer

Nursing 34, E1–E13.

Wearden AJ, Dowrick C, Chew-Graham C,

Bentall RP,Morriss RK, Peters S& Fati-

gue Intervention by Nurses Evaluation

(FINE) trial writing group and the FINE

trial group (2010) Nurse led, home

based self-help treatment for patients in

primary care with chronic fatigue syn-

drome: randomised controlled trial.

BritishMedical Journal 340, c1777.




Yeo TP, Burrell SA, Sauter PK, Kennedy EP,

Lavu H, Leiby BE & Yeo CJ (2012) A

progressive postresection walking

program significantly improves fatigue

and health-related quality of life in

pancreas and periampullary cancer

patients. Journal of the American

College of Surgeons 214, 463–475;

discussion 475–7.

Yesilbalkan OU, Karadakovan A & Goker

E (2009) The effectiveness of nursing

education as an intervention to

decrease fatigue in Turkish patients

receiving chemotherapy. Oncology

Nursing Forum 36, E215–E222.

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Nonpharmacological nursing interventions for the management of patient fatigue: a literature review