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Critically examine the literature related to the specific clinical question and to consider how the findings of the review might be implemented in a clinical setting, as a basis of evidence-based health care.

Causes and Prevalence of Cancer-Related Fatigue

As stated by the Cancer Council of Western Australia, ‘cancer’ is characterized by occurrences of debilitating conditions due to abnormalities in cell growth and division in the human body (Carter et al., 2015). While traditional procedures of cell multiplication are imperative for the growth, development and recuperation of essential tissues, cancer is defined by a morbid distortion in these processes (Lebel et al., 2016). The resulting abnormalities, caused due to a host of factors functioning at lifestyle and genetic platforms, escalate into formation of malignant tumors, circulated via the vascular or lymphatic systems (Urrutia-Ortega et al., 2016). The increased presence of certain components such as excessive alcohol ingestion and adherence to smoking, faulty dietary and physical exercise habits, increased exposure to dangerous environmental components, further heightened by genetic susceptibility are some of the reasons advancing cancer affliction (Revenco et al., 2017). However, with advancements in science and technology, patients victimized by cancer are gifted with a number of lucrative treatment opportunities, such as surgical operations, endocrinal therapy, radiation treatment, immunotherapy, targeted therapy and chemotherapy (Chesson&Zlosa, 2017).While most of these treatments outline beneficial outcomes, individuals are burdened with several complications, of which, cancer related fatigue continues to be widely prevalent (Berger et al., 2015).

The prevalence of cancer-related fatigue is not new upon the progress, as well as completion of cancer treatment, as evident in occurrences in over 25 to 99 percent of the patient population affected by cancer (Jones et al., 2016). Often, the presence of lasting symptoms of fatigue and physiological distress, at magnitudes of moderate to severe, hinders the procedures of treatment, further leading to discontinuation. While eradication of cancer related fatigue undertakes occurrences within a year pertaining to the conductance of treatment, individuals afflicted by cancer have been observed to report symptoms for a decade (Pattanshetty, Moniz &Patil, 2018).  The prolonged prevalence of cancer related fatigue is associated with increased mortality rates. The occurrence of cancer related fatigue is dependent upon the active performance of pro-inflammatory cytokines and morbid regulatory mechanisms of cytokine functioning (Dehkordi, Kahangi&Babashahi, 2018). Additionally, excessive damage of muscles pertaining to cancer cachexia due to abnormally increased metabolic functioning, prevalence of anemia and a dysfunctional axis of the hypothalamus, pituitary and adrenal glands, are some of the key underlying factors (Minto, Wee & Stone, 2014).

There is a wide availability of treatment choices, each associated with beneficial impacts. Ingestion of appropriate medications, psychological and psychosocial treatment and engagement in physical activity are some of the procedures implicating significant benefits on the health of patients suffering from cancer related fatigue (Spathis et al., 2014).With respect to evidences concerning the beneficial implications on cancer patients partaking in exercising, a number of variations have proven to be advantageous, such as engagement in home as well as laboratory supervised physical activity routines, aerobic regimes, as well as resistance training (Tian et al., 2016).In accordance to the Australian scenario, organizations such as ‘Exercise and Sports Science Australia’ and the ‘Clinical Oncology Society of Australia’, have advocated clinical professionals to incorporate physical activity amongst patients inflicted cancer related fatigue (Braun et al., 2014). However, the incorporation of exercise is not without the presence of considerable shortcomings in adequate literature and research, where there lies a conflict of interest regarding the usage of exercise in patients exhibiting severely debilitating symptoms of cancer related fatigue, where the very occurrence of fatigue may serve as a major barrier to the performance by the patient (Sekse, Hufthammer&Vika, 2015).

Available Treatment Choices for Cancer-Related Fatigue

The following paper aims to review the existing literature pertaining to the usage of exercise as an intervention for the management of cancer related fatigue in the occurrences of positive quality of life outcomes. A total of six researches were appraised critically, and their findings summarized in a tabular form, followed by recommendations regarding the implementations of the same in the field of practices pertaining to nursing.

The PICOT format for the derivation of clinical questions has been considered useful for researchers attempting to pursue novel research (Elias et al., 2015). The research question required for the following clinical problem has been formulated with the utilization of the PICOT format implying Population, Intervention, Comparison, Outcome and Time. Hence, for the purpose of improvement of the quality of life of individuals suffering from cancer, there is emergence of the following clinical question: For patients inflicted with cancer-related fatigue, does the implementation of exercise, in comparison to usage of standard care, positively impact their quality of life?

The searching procedures of the required literatures were conducted electronically. ClinicalKey for Nursing, CochranE, Medline and Apais were some of the databases utilized for the required research. The search for literature was also conducted with the usage of Mesh such as ‘Cancer’, ‘Cancer-related fatigue’, ‘Exercise’ and ‘Cancerintervention’. The researches utilized for the critical appraisal were limited to systematic reviews with meta-analysis, conducted during the years 2013 and 2018.

Upon conductance of the search, a total of 60 researches were uncovered, of which 6 systematic reviews were chosen, due to their adherence to the PICOT framework for clinical research. Articles which focused only on randomized controlled trials without the absence of reviews were excluded, as well as articles which did not assess the effects of exercise in the presence of cancer related fatigue. The inclusion criteria of the articles was based upon studies which highlighted the presence of systematic reviews assessing populations who were cancer victims undergoing cancer related fatigue, and receiving exercise as the primary intervention with the outcome of improvement of quality of life.

The literature studies were selected after thorough monitoring concerning the availability of valid data, the procedures conducted, the appropriate utilization of research procedures, and lastly, the degree to which the researches were found to be credible and useful (Zeng et al., 2015). Hence, upon due consideration of the above guidelines, as stated in accordance to the Critical Appraisal Skills Program, the following six systematic reviews accompanied by meta-analysis were utilized for the purpose of critical research appraisal.

Current Research on Exercise Intervention for Cancer-Related Fatigue Management

An elaborate research was conducted by Kessels et al., (2018), which aimed at conducting a systematic reviewand meta-analysis, in order to investigate the consequences of the implementation of physical exercise strategies in patients who had survived cancer, in comparison to conventional care strategies (Kessels, Husson&Feltz-Cornelis, 2018). There has been a widespread recognition pertaining to the beneficial effects of exercise as an effective intervention strategy for beneficial health outcomes. The symptoms associated with cancer-related fatigue have been linked to similarities with Chronic Fatigue Symptom, for which, exercise has been implicated with beneficial effects (Lucas et al., 2015). The following systematic review conducted by Kessels et al., (2018), was performed through searches utilizing COCHRANE databases, followed by meta analysis. The systematic review was further performed utilizing the PICOT framework, where the population included adults aged beyond 18 years of age, with the inclusion of randomized controlled trials ranging from the 1st of January 2000 to the 17th of August 2016. The cancer related fatigues symptoms were considered for the following cancers: gynecological, prostrate, breast and mixed variants, followed by the exercises intervention strategies classified into aerobic, resistance and a combination of both, in varying intensities. The procedures of aerobic exercises are outlined by the active metabolism of oxygen, for the performance of tasks such as running, walking, cycling and swimming (Keating et al., 2015). Resistance training it outlined by anaerobic metabolism as a resultant of muscular contractions (Schoenfeld et al., 2016).

The results of the systematic review conducted by Kessels et al., (2018), highlighted positive health implications of exercise as effective intervention strategies pertaining to cancer related fatigue. The results indicated positive implications for patients who underwent aerobic exercise strategies, as compared to the resistance training, with 95% Confidence Interval of 0.235-0.975. However, the rate of patient adherence to exercise, was considered of important- as evident by the beneficial results implicated in patients who displayed increased dedication (Kessels, Husson&Feltz-Cornelis, 2018).

The systematic review performed by Kessels et al., (2018), was not absent without shortcomings. A highly limited number of studies were included amounting to only 6 out of 11 randomized controlled trials. In comparison to the exercise intervention strategies, there was no specific mention regarding patient reception of palliative care and hence, non-exercise intervention care included unspecified conditions such as the use of surgical operations, chemo or radiation therapy. The details of the treatment procedures of the concerned patients were also undefined. The research only mentioned that certain patients were undergoing cancer treatment, without highlighting the details concerning the type of treatment utilized or the duration. Hence, the beneficial effects of exercise of cancer related fatigue as reviewed by Kessels et al., (2018), contained no specified treatment nature. The participants included were young adults and hence, there is a need for further research regarding the effects of exercise on individuals below 18 years of age. Additional benefits included absence of effects pertaining to conductance of low intensity exercises such as yoga or stretching, the effects of exercise in prolonged cancer survivors as well as the health implications of alternative cancers. However, the systematic review of exercise intervention strategies conducted by Kessels et al., (2018), provides evidence of the various types of exercises along with their adherence. The review also establishes impressive associations with the occurrences of chronic fatigue symptoms in individuals, which may present underlying causes of inflammation and cytokine malfunctioning, paving the way for future research concerning diagnosis and treatment procedures (Lucas et al., 2015).

Critical Appraisal of Relevant Studies

Similar to Kessels et al., (2018), a systematic review accompanied by meta-analysis was conducted by Kelley and Kelley (2016). The authors studied the execution of exercise intervention strategies considering the usage of aerobic, resistant as well as a combination of strategies upon individuals suffering from cancer related fatigue, concerning no specific type of cancer (Kelley & Kelley, 2016).As opined by The National Comprehensive Cancer Network’s Clinical Practice Guidelines in Oncology, there is an increasingly credible recommendation pertaining to the implementation of various types of aerobic, resistance and combination exercise strategies, as non-medical strategies concerned with the improvement of quality of life (Ettinger et al., 2016).The information required for the completion of this systematic review was conducted through performance of a search electronically, utilizing over six databases such as Cochrane, Sports Discus, Pub Med, Scopus, Proquest and Web Science, dating till July 2016. The characteristics of the population concerned with this systematic review by Kelley and Kelley (2017), including individuals who were above the age of 18 years and were ongoing or surviving patients of cancer. A total of sixteen randomized controlled trials were selected where the subjects were undertaking various forms of exercise for a period of a minimum three to a maximum of fifty two weeks. The studies traced their origins to countries such as France, Germany, Columbia, China and Netherlands (Kelley & Kelley, 2016).

With respect to the findings highlighted by Kelley and Kelley (2016), there was observation of varied outcomes as compared to the specific positive health outcomes of exercise intervention reported by Kessels et al., (2018), possibly due to the analysis of additional types of cancers. For patients suffering from leukemia and colorectal cancers, there seemed to be a lack of implication of positive health outcomes pertaining to the quality of life. With respect to all the types of cancers highlighted in this review, the presence of beneficial health effects were not dependent upon factors pertaining to the conductance of radiation therapy, the duration of the exercise program or the frequency of exercise sessions. However, with respect to the usage of resistance training, followed by the usage of sufficient theoretical strategies pertaining to their effective conductance, there was a resultant beneficial effect in the alleviation of symptoms pertaining to cancer related fatigue, with a standard mean deviation of -1.05 to -0.01, of which 52% meta-analysis, were statistically significant, with 95% confidence interval non-overlapping.Engagement in light to moderate rates of exercise were also reported to be statistically significant, while execution of exercises devoid of any supervised theoretical backgrounds yielded an absence of positive health outcomes (Kelley & Kelley, 2016).

Results and Implications of Studies Reviewed

However, certain sections of the studies reviewed by Kelley and Kelley (2016), yielded varied outcomes stating enhanced exercise benefits with regards to the length and frequency of the same, with a beneficial results in patients suffering from cancer related fatigue pertaining to breast cancers, and additional implications concerned with the utilization of home based exercise regimens. Hence, with regards to the credibility of findings, the systematic review performed by Kelley and Kelley (2017), yielded impressive information. This systematic review sheds light on supplementary factors such as duration and frequency of the exercise concerned, and focusing on additional types of cancers. A greater number of randomized controlled trials were included which further highlighted varied outcomes along with percentile information of the same. Additionally, the systematic review by Kelley and Kelley (2016), utilized statistical methods of prediction intervals, which recently, has been highlighted as inappropriate, in case of decreased rates of heterogeneity (Quan, Srinivasan &Khosravi, 2014). The systematic review so conducted, also researched on previous reviews and hence, may be subject to errors pertaining to previous reviews. There was also an absence of alternative intervention strategies or low intensity exercises, and their possible benefits for cancer related fatigue.

Based upon the salient research features outlined by Kelley and Kelley, as well as Kessels et al., (2018), a similar systematic review accompanied by meta-analysis was conducted by Meneses-Echávez, González-Jiménezand Ramírez-Vélez (2014), highlighting the positive health implications of exercise as intervention strategies for cancer-related fatigue. The criteria of sample selection was determined utilizing the PICOT framework. The population selected as participants included in the randomized controlled trials reviewed were above the age group of 18 years, inflicted with any variation of cancer, irrespective of race, gender or ethnical backgrounds. With respect to the type of exercise intervention employed, the aforementioned research paper highlighted the health implications of conductance of multimodal forms of exercise, which took into account, variations such as aerobic, resistance as well stretching counterparts of the concerned exercise. The literature search conducted analyzed the databases of EMBASE, OVID, CENTRAL and PubMed ranging from January 2014 to March 2014 (Meneses-Echávez, González-Jiménez &Ramírez-Vélez, 2014),

With respect to this systematic review, it was found that multimodal exercise relieved cancer related fatigue symptoms, with 95% confidence interval -0.37 to -0.09, a standard mean deviation of -0.23 and a p-value of 0.001. Statistically insignificant results were recorded for resistance training only, with a p-value of 0.30.

The cancer patients assessed were primarily females undergoing chemotherapy in the age group of 46 to 60 years. A majority of the studies, highlighted the beneficial impacts of exercise performance in the conductance of intervention strategies for the management of cancer related fatigue. Enhanced beneficial health implications were emphasized by the utilization of resistance-based exercise modules, in the absence of supervised frameworks. A primary feature researched was the conductance of exercise during ongoing chemotherapy procedures of the patients, highlighting alleviation in the symptoms of cancer related fatigue during hospital stay. Further, two of the researches reviewed by the authors for the aforementioned systematic reviews, conducted the performance of follow up sessions, prior to six months after cancer treatment. While one research reported beneficial outcomes, an additional reported beneficial effects accompanied by increased levels of anxiety. Despite the essential information presented by this systematic review, there were several shortcomings. While chemotherapy patients were extensively assessed for exercise, there was an absence of participants undergoing additional cancer therapy procedures as well as patients surviving after treatment. Owning to the nine trials researched, an additional error would be the large scale of heterogeneity and statistical tools employed to evaluate the outcome measures of the concerned participants. There is also an absence of specified effects of exercise regarding the varied types of cancers, as mentioned in the previous systematic reviews.

The critical appraisals conducted for the systematic reviews of Kessels et al., (2018, Kelley and Kelley (2017), and Meneses-Echávez, González-Jiménezand Ramírez-Vélez (2014), revealed extensive analysis on the beneficial health implications of various types and forms of exercise conducted as intervention strategies for the purpose of improvement in the quality of life of cancer patients inflicted with cancer-related fatigue. However, similar to, with yet alternative parameters, the systematic reviews accompanied by meta-analysis conducted by Hilfiker et al., (2017), assessed the health impact of exercise in cancer-related fatigue victims, in comparison to additional non-medical procedures.Considering the availability of insufficient evidence regarding the usage of medicinal strategies, the aforementioned systematic review was conducted with the recent recommendations of advocating non-medicinal procedures for the treatment of cancer related fatigue (Yennurajalingam et al., 2015). The research for the required literature was conducted electronically with the usage of CENTRAL and PubMed databases, from their conception to the 4th of January 2017. The trails researched were selected based on randomized or quasi-randomized experimental evidences assessing individuals with any type of cancer, assuming the occurrences of cancer-related fatigue, where the evaluation of exercise intervention was conducted, along with additional treatment procedures such as relaxation strategies or cognitive behavioral treatments. Experiments which included the intervention of nutritional or pharmaceutical intervention strategies were excluded, along with studies which were performed for a period greater than 3 weeks. The population studied were patients suffering from various types of cancer under the ongoing reception of chemotherapy or radiation therapy, or post therapeutic maintenance patients (Hilfiker et al., 2017).

The researches selected were categorized in a time span ranging between the years 1989 and 2017, with the inclusion of patients suffering from cancers of the breast, prostate, colorectal, haematopoietic stem cell transplantation, along with combination types. The various types of intervention strategies were cognitive behavioral theory, multi-modal exercise strategies, resistance and anaerobic training procedures, relaxation strategies with inclusion of meditation, yoga, dance, and music and also, massage therapies. It was observed that, during treatment, relaxation yielded strongest results, with a standard mean deviation of -0.77, with 95% Credible interval of -1.22 to -0.31, followed by therapies with the inclusion of massage with -0.78 standard mean deviation and 95% credible interval-1.55 to -0.01, a combination intervention strategy of exercise and cognitive behavioral therapy with -0.72 deviation, -1.34 to -0.09 credible interval, multimodal exercise strategies with -0.67 deviation, 95% credible interval of -1.01 to -0.34, resistance training with -0.53 deviations, 95% CI -1.02 to -0.03, exercises with aerobic interventions with -0.53 deviation, 95% CI , and yoga with -0.51 deviation, and 95% CI -1.01 to 0.00. During post treatment phases of the patients, yoga was observed to yield beneficial results with -0.68 deviation and 95% CI -0.93 to -0.43. Negligible health implications were recorded for aerobic or resistance exercise alone (Hilfiker et al., 2017).

One of the major strengths of the systematic review and meta-analysis conducted by Hilfiker et al., (2017), was the utilization of ranking procedures via Bayesian strategies, which will prove to be beneficial in the process of recommendation of various intervention strategies by clinicians to their cancer patients (Newcombe et al., 2017). Additionally, a greater availability of varied intervention strategies will be beneficial for patients in opting for the same, with respect to their individual physiological capabilities. An additional beneficial information was the yielding of relaxation procedures as beneficial intervention strategies during cancer treatment in patients, with however reduced effect post treatment, hence, empowering the requirement for usage of additional exercise intervention strategies. Hence, the assessment of a number of intervention strategies proved to be a major advantage of this systematic review. However, the specifications of various strategies remained highly undefined, with the inclusion of relaxation strategies under cognitive behavioral therapy. There was an also an absence of assessment of the health implications resulting from high or low intensity training modules. Furthermore, the large scale of heterogeneity is a major shortcoming due to the varied populations examined, followed by the access of merely two databases, hence highlighting the lack of sufficient information availability.

An additional systematic review was conducted by Meneses-Echávez, González-Jiménez and Ramírez-Vélez (2015), which focused on a specific type of cancer. The systematic review and meta-analysis conducted, evaluated the symptoms of cancer related fatigue in breast cancer survivors, as a result of exercise associated with supervision. The prevalence of breast cancer, has been an emerging phenomena worldwide, with fatal implications. As opined by the World Health Organization, breast cancer inflicts 23% of the global population, with over 14% of succumbing to the condition (Ginsburg et al., 2017).The symptoms of cancer related fatigue yield detrimental impact on the concerned patients, often serving as an indicator of high susceptibility to mortality. The literature searches conducted for the following was based between the periods of December 2013 and January 2014, with the utilization of databases such as EMBASE, CENTRAL, Scopus, MEDLINE and PubMed. Additional journals such as Journal of Breast Cancer, The Lancet Oncology, and Journal of the National Cancer Institute and Journal of Clinical Oncology were also assessed. The selection criteria included patients who had survived breast cancer, without the specification of any particular cancer stage, undertaking exercising strategies with supervision as an intervention program in comparison to conventional treatment care procedures. A total of nine studies were selected, with countries of Australia, North America, Turkey, the United Kingdom and Finland as their origins of conductance. The patients were under the age group of 48 and 60 years, with the reception of radiation or chemotherapy (Meneses-Echávez, González-Jiménez &Ramírez-Vélez, 2015),

The supervised exercise strategies ranged for 3 weeks, lasting over 40 minutes, with the incorporation of relaxation, resistance and aerobic training strategies. The systematic review uncovered the beneficial effects of exercise intervention, with resistance training implicated highest rates of impacting the quality of life of patients inflicted with cancer related fatigue., with a standard mean deviation of  -0.41, and confidence interval of 95% ranging from -0.76 to -0.05.Resistance training, accompanied by supervision has been found to yield beneficial health implications upon breast cancer patients, with the advancement of strength in the muscular system, further enhancing body composition (Steindorf et al., 2014). The utilization of supervision is essential for the management of effective exercise treatment, due to the increased rates of confidence, safety and adherence experienced by cancer patients. Exercise also empowers breast cancer survivors with positive consequences in their quality of life, through greater wellbeing and decreased anxiety and fatigue (Casla et al., 2015).However, due to limited number of trials conducted, there is still a need for research pertaining to the occurrences of depression and body mass index in individuals suffering from cancer related fatigue (Kang et al., 2016). While the low quantity of research conducted and the large occurrences of heterogeneity prove to be major shortcomings in this systematic review, there is also an absence in the assessment of cytokine evaluation and biomarkers as a response to exercise. Concerning the fact that cancer related fatigue has underlying inflammatory causes, it is imperative to consider that exercise may yield further enhancement of such pro-inflammatory regulations (Repka& Hayward, 2018).

The coordinated efforts of exercise along with nutritional procedures have been found to yield beneficial effects for alleviating the symptoms of cancer related fatigue. While extensive availability of recent research advocate the positive health implications of exercise procedures, additional diet therapy strategies are often not taken under consideration (Berger et al., 2015). The following systematic review conducted by Baguley et al., (2017), explored the consequences of supervised exercise and nutrition on cancer-related fatigue in patients with prostate cancer. While numerous varied treatment procedures have been advocated for treatment of prostate cancer, such as radiation therapy, chemotherapy, androgen deprivation therapy and surgical procedures, the resultant debilitating complications of cancer related fatigue negatively affect the quality of life of cancer patients. The research for the aforementioned literature review was conducted with the utilization of six online databases, such as CENTRAL, EMBASE, Proquest, CINAHL, PubMed and EMtree. The criteria of selection was determined utilizing the PICOT frame work, which included male patients inflicted with any stage of prostate cancer, with the reception of any form of supervised exercise and structure dietary modifications, in comparison to a patient group with the provision of conventional care, devoid of exercise intervention strategies. A total of 20 researches were taken under inclusion for the purpose of this systematic review, of which 17 studies utilized exercise only as an intervention strategy, 2 researches utilized a combination of diet and exercise and only one research studied the health implications of only diet for the treatment of cancer related fatigue (Baguley et al., 2017).

Upon assessing the results investigated in this systematic review, it was uncovered that a combination strategy, utilizing the coordinated effects of resistance as well as aerobic exercise training, has been found to be beneficial in improving the symptoms of cancer related fatigue, with a p-value of 0.0.80.The utilization of supervision in the implementation of exercise training is imperative to enhance patient adherence and dedication (Casla et al., 2015). However, the positive health benefits exhibited by intervening with exercise, seems to be irrespective upon additional factors, such as duration or frequency. Nevertheless, combination training strategies and resistance training alone have been associated with yielding positive life quality impacts in cancer related fatigue patients of prostate cancer. The studies pertaining to combination intervention strategies of diet as well as exercise, displayed beneficial but inconclusive results. Hence, greater research is required prior to recommendation of the same.

However, the review stated limited research on the implications of dietary modifications. A single review paper suggesting the implementation of soy supplementation in prostate cancer patients, yielded beneficial results, but was associated with low adherence and adverse follow up outcomes. A diet rich in phytonutrients derived from fruits and vegetables, followed by intake of fatty fish, have been recommended traditionally for cancer prevention and treatment, pertaining to the inflammatory processes associated with the detrimental health impacts of cancer (Zhnag et al., 2015). However, the availability of negligible research, related to the same in relation to its effects on cancer related fatigue, empowers the need for greater future study (repka& Hayward, 2018). While this systematic review was one of the first of its kind to reveal the effects of exercise coordinated with nutritional interventions in cancer related fatigue, the limited research findings, high scale of heterogeneity and lack of research with regards to the amount, duration and frequency of physical exercise execution, are some of the major shortcomings of this systematic review.

Level 1 evidence and summary of results: The systematic reviews highlighted above can be classified under level 1 evidence, with due respect to the large number of randomized controlled trials included in the above researches (Barton et al., 2015). While Kessels et al., (2018) highlighted the benefits of aerobic training on cancer related fatigue, with further emphasis of associated mechanisms of chronic fatigue symptom (Kessels et al., 2018). it is to be noted that Kelley and Kelley (2016), studies the negligible effects of the same on additional cancers such as leukemia and colorectal cancers, as well as the need to implement supervision without prioritized emphasis on the duration and frequency of exercise (Kelley & Kelley, 2016). The review conducted by Meneses-Echávez, González-Jiménezand Ramírez-Vélez (2014), emphasized the need for multimodal intervention strategies as a beneficial module of exercise procedures in cancer patients (Meneses-Echávez, González-Jiménez&Ramírez-Vélez, 2014). However, the systematic review by Hilfiker et al., (2017) sheds an impressive light on the usage of additional procedures such as relaxation techniques, which have proven to yield beneficial effects during the treatment of cancer patients, followed by implementation of resistance training post treatment to alleviate the symptoms of cancer related fatigue (Hilfiker et al., 2017).Meneses-Echávez, González-Jiménezand Ramírez-Vélez (2015), systematically reviewed the effects of exercise in the treatment of breast cancer patients (Meneses-Echávez, González-Jiménez &Ramírez-Vélez, 2015).Finally, Baguley et al., (2017), emphasized the need for future dietary protocols combined with exercise as intervention strategies, hence paving the way for further nutritional research of the same (Baguley et al., 2017).

Strategies for implementation: Hence, as evident from the above results, exercise as an intervention strategy for the implication of positive health outcomes in cancer related fatigue, should be implemented, with the utilization of the following strategies, for the purpose of usage in an Australian medical setup. Hence, concerning the implementation of recommending exercise as implementation strategies forcancer related fatigue, it is imperative for the nurse to educate herself adequately concerning the guideline pertaining to the ongoing treatment procedures of the oncology patient, the stage of cancer and treatment and individual intervention preferences. Nursing practice will require the utilization of empathy and establishment of clarified communication strategies concerning the patient’s needs and interests (Runowicz et al., 2016). Considering the documented evidence regarding the beneficial implications of resistance training in the muscle recuperation and body composition in breast cancer survivors, as opined by Meneses-Echávez, González-Jiménezand Ramírez-Vélez (2015), nurses may communicate the same to the patient (Meneses-Echávez, González-Jiménez&Ramírez-Vélez, 2017).During the ongoing process of treatment, as documented by Hilfiker et al., (2017), the usage of relaxation-based intervention strategies such as stretching, yoga and cognitive behavioral therapy have been found to be beneficial, and hence the concerned nurse may implement a multidisciplinary approach to involve additional professionals for the implementation of the same in radiation or chemotherapy patients (Hilfiker et al., 2017).Documenting evidence from, Kelley and Kelley (2016), as well as Meneses-Echávez, González-Jiménezand Ramírez-Vélez (2015), the nurse may also recommend resistance and multimodal exercise patterns (Kelley & Kelley, 2016), since the utilization of a combination of various exercise intervention strategies have been proven to be beneficial for the alleviation of cancer related fatigue (Meneses-Echávez, González-Jiménez&Ramírez-Vélez, 2015).

Barriers and Incentives: One of the key barriers for the implementation of exercise in the treatment of cancer-related fatigue, is the need for supervision, as evident from the results above. Hence, prior to the recommendation of the sufficient exercise patterns for cancer related fatigue, the implementation of supervision is imperative for which, the nurse may require additional professional aid, since the utilization of adequate supervision has been found to yield beneficial effects on the rates of adherence and confidence (Zhang et al., 2018). Hence, a major strategy required for the removal of such barriers may be the integration of exercise training for cancer-related fatigue in the nursing curriculum, or the addition of a supplementary course. The time period of such changes will be dependent upon the duration of the nursing course in Australia, which is generally four years. Nevertheless the supplementary course may be integrated as an additional diploma course of 1 year for the purpose of exercise education, with the provision of incentives for nurses who have undertaken such course. An additional barrier may be the requirement of a multidisciplinary team for the purpose of supervising exercise to patients, which may further increase hospital costs. Hence, hospitals may need to establish collaborations with various exercise and fitness centers for this purpose (Casla et al., 2015).

Patient preferences: For the purpose of assessing the preference of the patient, the nurses and associated clinicians may first engage in imparting knowledge and awareness concerning the need for exercise in cancer related fatigue. This may be followed by the usage of feedback procedures such as interview, surveys or questionnaires, in order to evaluate the needs and interests of the patient. Additionally, follow up studies may be used for the purpose of evaluating the health implications of undertaking the exercise preferred by the patient (Ross et al., 2018).

PARIHS Framework: Hence, for the implementation of the above changes for the purpose of improved nursing practice, the PARIHS Framework can be used. Hence, based on the principle of evidence on the current study of exercise in cancer related, it can be observed that the systematic reviews used utilized sufficient amount of randomized controlled trials over large population groups, further highlighting the credibility of the evidence. Hence the change in nursing practice must be advocated in the context of hospitals providing cancer treatments (Harvey &Kitson, 2015). With respect to the principle of context, the above reviews focused on a relevant problem of cancer related fatigue which is widely prevalence in hospitals upon commencement of treatment. The evidence also clearly elaborated on the detailed organizational structure in the clinical settings outlined in the reviews, where nurses and medical practitioners actively engaged in patient supervision of exercise intervention. Sufficient feedback and follow up were also gathered from the patients. Hence, for implementation of change in nursing practice, nurses and clinicians should clearly delegate the roles of staff engaged in required exercise intervention, followed by gathering consent from patients and the required feedback to assess the outcome in cancer related fatigue. In accordance to the PARIHS framework, the required change must be facilitated through the usage of sufficient communication and empathy, followed by adoption of a flexible approach to suit the needs of the patients in exercise intervention (Tian et al., 2017).

Sustainability of changes over time: Cancer related fatigue is said to occur over a continuous period of almost a year and hence, it is expected that usage of exercise as intervention will lead to beneficial changes of a prolonged time period of one year, unless there is occurrence of relapse. However, with respect to the usage of exercise amongst patients with severe fatigue, there may a lack of sustainability over due to lack of adherence by such a individuals, which may lead to occurrences of disuse syndrome. However, the implementation of mild exercise methods such as yoga or stretching, have been found to be equally beneficial and sustainable due to their less strenuous effects, and hence can be executed in patients with severe cancer related fatigue with greater benefits (McNeely et al., 2015).

Conclusion

In conclusion, exercise has been considered as an essential intervention tool, with sufficient documented evidence highlighting its beneficial implications. However, further research is required concerning the effects on additional types of cancers, as well as the coordinated efforts of nutrition in improving the efforts of cancer related fatigue.

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