Nursing Outcomes of Patient ’ s Comfort during Neoplastic Chemotherapy : An Integrative Review

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


Method
An integrative review was used to identify the format, questionnaires, inclusion and exclusion criteria, literature review, decision on the information to be obtained from the studies selected, interpretation of results, and synthesis of knowledge. 5This integrative review aims to answer the guiding questions that identify the nursing outcomes concerning comfort during neoplastic chemotherapy.A well-defined strategy was used to search for available literature and to analyze data in relevant research.Both quantitative and qualitative reports based on the use of different networking tools used by nursing professionals were included.The researchers in this study have searched literature published over the past 5 years (2012-2018), using a variety of databases including PUBMED, MEDLINE, Cochrane, CINALH, Science Direct, and others for methods, techniques and tools to link to nursing and health care practice areas.The search strategy was based on SPIDER (Samples, Phenomenon of Interest, Design, Evaluation, and Research type).The problems of indexing the qualitative research in electronic databases have been extensively reported and can be aggravated by research articles that provide non-specific titles, unstructured abstracts, and poor definition of qualitative methodology.Therefore, many qualitative searchers have identified the need to expand the basic bibliographic search using alternative techniques. 6e following keywords and descriptors were used to search for the most possible articles regarding these research questions: Chemotherapy; antineoplastic drugs; chemotherapeutic anticancer drug; chemotherapeutic anticancer; antitumor drugs; cancer chemotherapy agents; chemotherapeutic anticancer agents; antitumor agents and comfort or discomfort or impaired comfort and nursing outcomes.
The data used in this study were derived from full texts of primary studies addressing physical nursing outcomes after managing patients discomfort during neoplastic chemotherapy in English.Data from letters, editorials, case studies, and pilot studies were not included.
The researchers of this study read all selected research papers until reaching the relevant information.Topics retrieved in research papers include the following development stages: Problem identification; Research topics; Rationale for the review; Identification of studies; Introduction; Scientific literature with prior establishment of inclusion and exclusion criteria to point and organize primary research on the problem/ topic; objectives; methodological characteristics; and categorization, organization, and data collection.The researchers used a standard form to extract information that is important in analyzing the retrieved studies; assessing the collected data; presenting and comparing the results/interpretation; reviewing and synthesizing knowledge; and conclusion. 5,7e level of evidence in this study was classified by Melnyk and Fineout-Overholt (2010) as follows: • The researchers categorized each selected research study and found that only 15 out of 44 studies could be used in this study.A total review of 15 studies that related to nursing outcomes to alleviate physical discomfort for cancer patients receiving chemotherapy is shown in Table 1.

Integrative issue and discussion
Nursing outcomes of patient comfort during neoplastic chemotherapy in this integrative review are based on Kolcaba's Comfort Theory.She discusses in her book that comfort is a complex concept that involves multiple dimensions of human experience and is subject to considerable variation across people and time.She defined 3 types of comfort: ease, relief, and transcendence which can happen in all human life dimensions and several contexts: physical, psychological, spiritual, social, cultural, and environmental. 31

Physical comfort
The researchers in terms of comfort mention the decrease in the occurrence, intensity of symptoms, changes in functional status and symptomatic control.Other researchers have been studying the side effects of neoplastic chemotherapy that generally depend on the patients' demographics, conditions, mental status, age groups, educational status, and gender.Concurrently, several aspects including time since being diagnosed, treatment options, disease severity, and patient's role to participate in treatment decisions affect the need for cancer-related information to involve patients in self-management when experiencing side effects. 22Side effects can occur with any type of chemotherapy drugs.However, not everyone experiences the same side effects or in the same way.Moreover, patients with side effects may occur at any time or immediately or days or weeks after chemotherapy.

Psycho spiritual comfort
Researchers mention pain control, psycho spiritual reflecting, patient's inner consciousness and self-esteem, patient satisfaction, compassionate care, reinforced body image.They describe patients that can understand and accept changes resulting from treatment, meaning of life, self-care and self-management, emotional functioning and being cognitively alert but sometimes we cannot separate from physical and psychological.It will be related and supported by previous studies found the following symptom clusters in cancer patients receiving chemotherapy: nausea, vomiting, weakness, fatigue, alopecia, loss of appetite, pain, constipation, oral mucositis, numbness or tingling, and changes in bowel patterns are physical side effects commonly mentioned in many studies.Some studies include skin and nails problems, infectious signs, shortness of breath, and peripheral neuropathy.Most side effects disappear or can be treated whereas late side effects can develop months or years after chemotherapy.In addition, some side effects may last a long time or become permanent.Psychological distress, fatigue-pain; abdominal discomfort; flu-like symptoms; fluid accumulation; and peripheral neuropathy; and a high level of anxiety or depression that influenced all aspects of the patients' quality of life. 23

Sociocultural and Environmental comfort
Reviewed studies found that communication and knowledge about hope, interpersonal, transpersonal and intrapersonal relationships, quality of patient experience and social functioning and the theme of environmental comfort found that mention on safe medication administration and differentiated environment.The most reliable results in this study are from physical and psychological aspects, especially as they oppose the symptom management programs.Socio-cultural and environmental issues are less used to measure and determine the outcome of the study.However, the discomfort associated with socio-demographic factors is mainly related to physical activities from nursing interventions offered. 24One aspect that is clearly evident in the previous studies is that the nursing outcomes were developed from the nurse's perspective; not from the patient's' perception.This may be considered negligence.The relationship between patient expectations and chemotherapyrelated side effects indicates that expectations can be a useful intervention to reduce the burden of the adverse effects. 25Patient needs arising from patient interviews are very important in the design of efficiency and safety in treatment.

Conclusion and suggestion
The definition of comfort outcomes from the integrative studies was that symptoms are relieved or discomfort is relieved in terms of physical and psychological symptoms.Comfort outcomes need to be supported by a good sociocultural and environmental status which allows the patients to engage in effective self-management and also to adapt well to treatment.
Alleviation of symptoms by self-management support relies on active exploration of the patient's feelings and symptom-management patterns.Professional care should be tailored to the patient's perspective and environmental determinants.The key factors that influence their selfmanagement with chemotherapy-related symptoms involves the process of experiencing and learning how the side effects are holding over time and how to deal with them.Patients will experience symptoms personally.Their symptom-management patterns are shaped by personal factors including physical and psychosocial aspects; coping with cancer and cancer treatment; perceived level of control; and environmental factors, such as professionals' attitude and resources of information. 27e development of services and interventions that meet the complex needs of the patients potentially prevent late referral to psychological services. 28Recommendations from Kolcaba's Middle-Range Theory of Comfort states that nurses use comfort content to identify health care needs and design interventions for the person in care; and nurses must identify intervention variables that affect the success of the intervention.The effectiveness of the intervention(s) is/are determined by comparing patients' comfort before and after implementation of intervention. 29The nursing outcomes of cancer patients receiving chemotherapy are connected to collaboration among multidisciplinary team and settings.Early detection is important to continue to examine strategies that help improve symptom management during chemotherapy. 30e gap identified in this study is that the nursing outcomes of the patients' comfort after receiving chemotherapy did not address the patient's needs or perception; but rather were based on the stakeholders' perspectives.Furthermore, the patient's view about the meaning of comfort is quite vague.If the purpose is to measure the effectiveness of interventions to relieve discomfort, researchers should conduct a qualitative study to explore the patient's feelings first before developing a standardized intervention program that covers all facets of comfort for desirable nursing outcomes.This could create an innovative approach to enhance the patient's quality of life and satisfaction.

5 .
Alterations in Hematologic and Immune Function -Infection -Nutritional state and the activities of daily life -Nutritional deficit and morbidity and mortality rates -Malnutrition (PG-SGA) -Weight gain -Infection rates -Hospitalization time and response to the proposed therapy -Time to visit emergency care -Signs and symptoms related to dose changes -Skin temperatures -Percentage of hair preservation -Level of peripheral neuropathy, Calcium and Magnesium levels in the plasma, -Treatment adherence -Patient -Clinician relationship -Patient -Clinician communication -Patient satisfaction with information received -Infection rate Physical comfort -Decrease in the occurrence -Intensity of symptom -Functional status -Symptomatic control Psycho Spiritual comfort -Pain control -Psycho Spiritual context reflecting patient's inner consciousness and self-esteem -Patient satisfaction -Compassionate care -Reinforced body image -Patient could understand and accepted changes resulting from treatment -Meaning of life -Self-care and self-management -Emotional functioning -Cognitively alert Sociocultural comfort -Communication and knowledge about hope -Interpersonal, transpersonal and intrapersonal relationships -Quality of patient experience -Social functioning -Environmental comfort -Safe medication administration -Differentiated environment

•Figure 2 :
Figure 2: Common concepts in nursing outcomes of patient's comfort during neoplastic chemotherapy.
Flowchart of the current integrative review.

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

Table 1 :
Pharmacological properties of NOACs