CRITICAL APPRAISAL OF EVIDENCE-BASED JOURNAL ARTICLE

The effectiveness of a nurse-led exercise and health education informatics

program on exercise capacity and quality of life among cancer survivors after
esophagectomy: A randomized controlled trial

SUBMITTED BY:

LADY JOWAHER ALLAS RN

SUBMITTED TO:

ALFREDO Z. FELICIANO, RN, PhD

PART 1

1. Does the research show the authors' names, and affiliations to indicate substantial
knowledge of the field?

a a,b,c d e
YES. The authors are Yu-Lin Chang , Yun-Fang Tsai , Chien-Lung Hsu , Yin-Kai Chao , Chih-
f g
Chin Hsu , Kuan-Chia Lin
a
School of Nursing, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
b
Department of Nursing, Chang Gung University of Science and Technology, Tao-Yuan
c
Department of Psychiatry, Chang Gung Memorial Hospital in Keelung, Keelung, Taiwan
d
Department of Information Management, College of Management, Chang Gung University, Tao-
Yuan, Taiwan
e
Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Tao-Yuan; College of
Medicine, Chang Gung University, Tao-Yuan, Taiwan
f
Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital at
Keelung, Keelung; College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
g
Institute of Hospital and Health Care Administration, Community Medicine Research Center,
Preventive Medicine Research Center, National Yang-Ming University, Taipei,Taiwan

2. Is the research title corresponding to clarity and relevance to the research design
employed?

YES. A single blind randomized control trial was designed with repeated measures to determine
the effect of a a12 week exercise and health education informatics program for patients with
esophageal cancer who had been treated with an esophagectomy. The CONSORT statement for
the study design and reporting was adopted from Schulz et al. (2010).

The study was designed to assess the outcomes of an intervention and focused on the
population, interventions given and outcome measures.

3. What is the research gap?

The authors stated in the introduction that the major treatment for esophageal cancer is
esophagectomy. However, complications post operation affects the patients’ quality of life.
Alternate treatments are needed to improve quality of life. Currently, there are no nurse-led
exercise informatics programs that included walking and health education for survivors of
esophageal cancer.

Although patients who have undergone an esophagectomy need to provide data regarding their
health status at multiple times postsurgery, they often lack access to their health information and
ability to easily contact their health care providers.

The authors stated some limitations of the study. First, the intervention effect in the present study
should be considered with caution, given the small sample size and recruitment of participants
from a single center. A second limitation is that all participants in the study received rehabilitation
exercises during hospitalization following surgery; therefore it is possible the control group
continued to perform exercises at home following discharge. Third, the smart bracelet recorded
only the number of exercise steps, not intensity; therefore intensity is not confirmed. Finally, half
of all the participants received treatment with adjuvant therapy; side effects of concurrent
chemoradiotherapy could be a confounding bias. Further research will be needed to analyze
influencing variable as well as if there are long term benefits such as increase rates of survival
and reduced cancer recurrence.
4. What is the study's overall aim/ objective?

The aim of the study was to examine the effects of a nurse-led 12 week exercise informatics
program that included walking and health education for survivors of esophageal cancer who had
undergone an esophagectomy. Quality of life was assessed as the primary outcome, measures of
nutrition and exercise capacity were secondary outcomes.

5. Does the research show its methodology reflected from philosophical underpinnings?

YES. The authors used quantitative methodology. Quantitative methodology seeks to confirm (or
reject) ideas constructed. It is characterized as experimental strategy of inquiry to find or test the
hypothesis.

A single blind random control trial was used. Baseline characteristics such as clearly set out and
collected through medical records. Clearly define instrumentation used to both study group. The
intervention group received a 12 week exercise and nursing education health informatics program
in addition to usual care. While the control group received regular care, which included
conventional postoperative feeding, wound care, and regular postoperative rehabilitation
exercises on a daily basis. Physical and cardiopulmonary rehabilitation was also conducted in the
hospital Follow up intervals are the same for each group.

6. Does it address sampling strategy and ethical considerations?

YES. Participants were recruited by purposive sampling from December 2015 to December 2017
at a hospital medical center in Northern Taiwan where approximately 80 patients undergo
esophagectomy annually. A total of 110 patients were assessed for eligibility (inclusion and
exclusion criteria); 17 patients did not meet the inclusion criteria, and 5 patients refused to
participate. 88 patients agreed to participate. The research nurse used a randomized block
design and a sealed ballot to randomly assign participants to an exercise and nursing education
health informatics program (44 patients in intervention group) or usual post-surgery care (44
*
patients in control group). The sample size was calculated using G Power 3.1 (Altman, 1991). A
minimum number of patients was 70, with 35 patients in each group.

The study was conducted in accordance with the Helsinki Delaration (Wikepedia, 20160 and was
approved by the Regional Ethics Board, Taiwan (Chang Gung Memorial Hospital IRB: 104-
8289B). All patients received both written and oral information regarding the purpose of the
research. They were informed they were free to withdraw from the study at any time for any
reason without any need for explanation and that confidentiality of the data sets would be
maintained.

7. Does it provide a logical sequencing of data collection procedures?

YES. Baseline and clinical characteristics of patients were obtained. Data included age, gender,
body mass index, albumin, type of surgery, histology of tumor and neoadjuvant therapy.
Esophageal Cancer staging was based on the 2010 Manual of the American Joint Committee on
Cancer . Quality of life was assessed by responding to quality of life questionnaires in one on one
interviews prior to discharge and 1, 3, and 6 months after discharge. Secondary outcomes of
nutrition (albumin, body mass index) and exercise capacity (maximal oxygen uptake, the 6-minute
walking test) were conducted prior to and 3 months following discharge.
 8. Is the data analysis appropriate for the type of data collected?

YES. Data analysis was performed using the statistical software package SPSS/PC for Windows
17.0 (SPSS Inc., Chicago, IL, USA.) Descriptive statistics were used for patient demographic and
clinical characteristics. Demographic and clinical data and measurements at baseline were
compared between groups with Chi-square test and fischer’s exact test for nominal data and t-
test for continuous data. If a variable was significant, it was considered a covariant, and the
difference was adjusted. Data were analyzed using general estimating equation models with
variable factors controlled (Liang & Zeger, 1986) to compare primary and secondary outcomes.
Statistical significance was set to standard of p < .05.

9. Is the discussion comprehensive to answer research questions?

YES. The study explored the effect of an exercise and nursing education health informatics
program for cancer survivors after esophagectomy. The authors stated that this is the first study
to demonstrate the use of an exercise and education-linked health informatics program for cancer
survivors following an esophagectomy. The findings suggest an exercise program might
effectively improve exercise capacity, nutrition and quality of life for cancer survivors who undergo
esophagectomy.

PART 2

What implication does the research article create on you as (1) a nurse; and (2) the nursing
practice?

1. As a nurse, we play a unique role as part of multidisciplinary care team for oncology patients.
Nurses have an opportunity to educate, support, and advocate for their patients during recovery
and throughout the cancer care continuum.

Possible application of the research would create a positive attitude towards a nurse productivity,
offering more powerful nursing care which directly and indirectly influence patient health
positively. Involvement will improve the nurses’ quality of health care and change the culture in
this regard.

2. In today’s world the potential for information and communication technology application is
increasing so that it can enhance the quality of nursing practice. Based on the research,
Informatics-based nursing care can be suggested to become part of the routine of care for cancer
due to the ability to provide information tailored to each patient, such as push notifications, health
tracking and monitoring of rehabilitation progress (Harder et al., 2017; Post and Flanagan, 2016),
which could improve quality of care for patients with esophageal cancer.

It is also recommended to set educational arrangements for nurses to adopt to quality-based

information technology to improve nursing outcomes.
 REFERENCES

Yu-Ling Chang , Yun-Fang Tsai , Chien-Lung Hsu , Yin-Kai Chao , ChihChin Hsu , Kuan-Chia Lin (2019).
The effectiveness of a nurse-led exercise and health education informatics program on exercise
capacity and quality of life among cancer survivors after esophagectomy: A randomized
controlled trial. International Journal of Nursing Studies. doi:
https://doi.org/10.1016/j.ijnurstu.2019.103418

Sousa-Poza,A. Siangchokyooo, N. (2012). Research Methodologies: A look at the Underlying

Philosophical Foundations of Research.
https://www.researchgate.net/publication/261703881_Research_Methodologies_A_Look_at_the_
Underlying_Philosophical_Foundations_of_Research

Darvish, A. Bahramnezhad, F. Keyhanian, S. Navidhamidi, M. (2014). The Role of nursing informatics on

promoting quality of health care and the need for appropriate education. Global Journal of Health
Science.
https://www.researchgate.net/publication/261703881_Research_Methodologies_A_Look_at_the_
Underlying_Philosophical_Foundations_of_Research