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Abstract of dissertation entitled
An evidence-based guideline of using massage therapy to reduce pain
and anxiety level in oncology patients
Submitted by
Tse Wing Chi
for the degree of Master of Nursing at the University of Hong Kong
in July 2016
Pain and anxiety are the most common physiological and psychological distress experienced
by oncology patients. Most of the physiological and psychological distresses of cancer are treated
with pharmacological methods only. The cancer distress is underestimated by the health care
professionals. One of the non-pharmacological methods, massage therapy, is used in relieving pain
and anxiety level of cancer patients. Several findings have reported the beneficial effects of
massage therapy in reducing pain and anxiety level in oncology patients. However, this application
has not been well developed and adopted by our current clinical settings.
The aim of this dissertation is to develop an evidence-based guideline of using massage
therapy to reduce pain and anxiety level in oncology patients. The objectives of this dissertation are
to evaluate current evidence on the effectiveness of using massage therapy to reduce pain and
2
anxiety level in oncology patients, to assess the implementation potential including the
transferability and feasibility of using massage therapy, to develop an evidence-based guideline on
the implementation of massage therapy and to develop an implementation plan and evaluation plan
for massage therapy on cancer patients in local oncology ward.
A systematic review has been performed to investigate if massage therapy can be useful in relieving
cancer pain and anxiety. Using two electronic databases, PubMed and CINAHL plus (EBSCOhost)
via the University of Hong Kong Library database, a search was conducted to identify eligible
studies. Quality of the eligible studies were assessed and criticized by the use of appraisal checklist
of Scottish Intercollegiate Guidelines Network (SIGN) (2015). The evidences are then summarized
and synthesized. An evidence-based practice guideline of using massage therapy to reduce pain and
anxiety level in oncology patients is made based on the evidence retrieved from the selected
reviews. The implementation potential of the evidence-based guideline is assessed according to the
target setting, target audience, transferability of the findings, feasibility and cost-benefit ratio. It is
highly transferable and feasible for the guideline to be implemented in the target setting for the
target audience. After the evidence-based guideline has been developed, an implementation plan
including the communication plan with stakeholders and formulation of a team is formulated. A
pilot study is required and finally an evaluation plan is made including the evaluation on the clinical
outcomes, health care providers outcomes and system outcomes. It is expected that the proposed
massage therapy innovation would be considered an effective measure in reducing pain and anxiety
level in oncology patients.
3
An evidence-based guideline of using massage therapy to reduce pain
and anxiety level in oncology patients
by
Tse Wing Chi
Bachelor of Nursing, Registered Nurse
A dissertation submitted in partial fulfillment of the requirements for the degree of
Master of Nursing
at The University of Hong Kong
July 2016
4
Declaration
I declare that this dissertation represents my own work, except where due acknowledgement
is made, and that it has not been previously included in a thesis, dissertation or report submitted to
this University or to any other institution for a degree, diploma or other qualifications.
Signed: _____________________________________
Tse Wing Chi
5
Acknowledgements
I would like to express my sincere gratitude to my supervisor Dr Patsy Chau, who provided
guidance and inspirations on this dissertation. Her encouragement and support throughout these two
years has enabled me to complete this dissertation.
Finally, I would like to thank my family, friends and colleagues for their constant love and
support to complete this master programme.
6
Table of Contents
Declaration……………………………………………………………….………………………......4
Acknowledgements…………………………………………………………………………………..5
Table of contents……………………………………………………………………………………..6
Chapter 1: Introduction
1.1 Background……………………………………………………………………………….7
1.2 Affirming the Need……………………………………………….………………………9
1.3 Objectives and Significance ……………...…………………….……………………....12
Chapter 2: Critical Appraisal
2.1 Search and Appraisal Strategies………………………………..……………………….13
2.2 Results………………………………………………………….……………………….15
2.3 Summary and Synthesis………………………………..…………………………….....17
Chapter 3: Translation and Application
3.1 Implementation Potential …………………………………………………………….....20
3.2 Evidence-based Practice Guideline …………………………….…………..…………..28
Chapter 4: Implementation Plan
4.1 Communication Plan…………………………………………..…………..…………........29
4.2 Pilot Study…………………………………………………….…………..………….........33
4.3 Evaluation Plan ………………………………………………..…………..…………........35
4.4 Basis for Implementation…………………………………………………..………….......38
Chapter 5: Conclusion…………………………………………………. …………..…………........39
Appendix A: Summary of Database Search Strategy and Result……....…………..………….........40
Appendix B: PRISMA Flow Diagram………………………………….…………...………….......41
Appendix C: Table of Evidence ………………………………………..…………..…………........42
Appendix D: SIGN Checklists ………………………………………………………...…………...44
Appendix E: Timeline for Implementation of the Massage Program…...……………..…………...54
Appendix F: Estimated Number of Massage Therapists Recruited………..…………...…………..55
Appendix G: Estimated Material Costs for the Innovation ……………....…………....……...……56
Appendix H: Cost/Benefit Ratio of Implementing the Innovation……........…………..………......57
Appendix I: Level of Evidence SIGN Grading System…………........…...………...………….......58
Appendix J: SIGN grading system: Grade of Recommendation……….……..……..……………...59
Appendix K: Evidence-based Practice Guideline …………………….………………………........60
Appendix L: Assessment Form for Massage Treatment………………………………...…..……...66
Appendix M: Patient’s Questionnaire on Satisfaction towards Massage Therapy…….…………...67
Appendix N: Staff Self-reported Questionnaire on the use of Massage Innovation…………….....68
References ……………………………………………………………...…………………………..69
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Chapter 1: Introduction
Pain and anxiety are the most common physiological and psychological distress experienced by
oncology patients. Most of the physiological and psychological distresses of cancer are treated with
pharmacological methods only. The cancer distress is underestimated by the health care
professionals as they rely on pharmacological method and think it could help in relieving most of
the cancer distresses. One of the non-pharmacological methods, massage therapy, is used in
relieving pain and anxiety level of cancer patients. In this chapter, the significance of implementing
massage therapy for oncology patients to reduce their pain and anxiety level would be illustrated.
1.1 Background
According to the World Health Organization (2015), cancer is defined as the rapid creation of
abnormal cells which grow beyond their normal boundaries, and maybe invading neighbouring
parts of the body and also spreading to other organs. The spreading process is called metastasis.
Cancer causes a lot of deaths among the world. In 2012, there are 14 million new cancer cases and
8.2 million cancer related deaths. In Hong Kong, according to the Centre for Health Protection
(2014), malignant neoplasms is found to be the first leading causes of death in 2014, compared to
other causes such as pneumonia and coronary heart disease. The morality rate of cancer is 190.6 per
100,000 populations, which accounts for 30.2% of death in Hong Kong in 2014. From 2001 to
2014, there has been an increasing number of deaths for cancer every year from 169.9 per 100000
population in 2001 to 190.6 per 100000 population in 2014. According to the Hospital Authority
(2014), cancer remains a burden to the Hong Kong society and the new cancer cases has risen at an
annual rate of 2.5% on average but the population just grew at an annual rate of 0.6% only from
2002-2012. It is found that the rise in number of oncology patients and deaths is due to the growing
8
population and the ageing society. If the current trends continue, the number of new cases for
cancer patients would continue to increase.
Cancer patients suffer from both physical and psychosocial distress which is a significant issue in
our society. Cancer pain is one of the most important symptoms for cancer patients which cause a
lot of distress to them. It causes not only a lot of distress to the oncology patients but also to their
families (Saturno et al, 2014). More than one-third oncology patients have given a rate to their pain
level to be moderate or severe (van den Beuken-van Everdingen et al., 2007). However, the World
Health Organization (2015) estimated that 80% or more patients in the world are inadequately
treated even if they got moderate to severe pain. Nowadays, the cancer pain is usually treated
pharmacologically. According to Kim, Ahn and Minerva (2015), 86% of the patients have reported
that cancer pain affect activities of daily living, including 87% of sleep, 92% their focus and
concentration and 67% excessive reliance on others. According to the study, only 34% of the people
having cancer pain reported a good quality of life.
Anxiety is also a common distress in cancer patients. Cancer is a threatening event which made
patients feel anxious. According to Jenkins et al (1998), the anxiety in cancer population is more
common than the general population without any chronic medical condition. According to Stark and
House (2000), anxiety can affect the quality of life of cancer patients, especially impaired social
functioning, physical and impairment and fatigue. Anxiety would produce a lot of typical signs and
symptoms including palpitation, sweating and restlessness. Cancer patients with anxiety may also
have poor concentration, muscle tension or fatigue.
According to Cassileth and Vickers (2004), human touch can be useful as an intervention to treat
against pain and other sign and symptoms. It can be a non-invasive and inexpensive intervention for
pain management and other symptoms for patients with chronic illness. Massage therapy is defined
9
as the manipulation of the body’s soft tissue areas, which help to assist people to relax, facilitate
sleep and also relieve muscular aches and pains (Vickers and Zollman, 1999). Several findings have
reported the beneficial effects of massage therapy in reducing pain and anxiety level in oncology
patients.(Cassileth and Vickers, 2004; Gatlin and Schulmeister, 2007) Massage therapy may help in
relieving pain and anxiety level of cancer patients in the current setting.
1.2 Affirming the Need
The target setting is the adult Haematology and Oncology wards and Oncology Day Care Centre of
a private hospital in Hong Kong (Hospital A). Every year, there would be around 8000 inpatients
and 4000 outpatients. Around 80% of the inpatients are oncology patients. Others may be overflow
medical patients. About 40% of the patients are admitted for chemotherapy. 25% of the patients are
admitted for palliative care while 35% are admitted for supportive treatments. Most of the patients
admitted to the oncology ward claimed that they feel pain and are very anxious about their illness.
About 60% of the patients in the target setting complain poor pain control and are given
pharmacological treatments. For patients having metastatic cancer, they suffer cancer pain more.
The World Health Organization has developed a three step ladder for cancer pain relief in adults.
The pain-relief medications should be from non-opioids to mild opioids to strong opioids. However,
cancer pain still remains a problem in the health care settings and would seriously affect the quality
of life of patients. Some of the patients refused to used a high dose of opioids to relive their pain
level as they afraid of being addiction or drug tolerance (Gatlin & Schulmeister, 2007). Some
patients are afraid of having the side effects of analgesics including nausea and vomiting,
respiratory distress, drowsiness, confusion and urinary retention (Falkensteiner et al, 2011). Patients
always ask if they could take fewer pills.
10
Anxiety in cancer patients can be divided into four different types, including situational anxiety,
disease related anxiety, treatment related anxiety and an exacerbation of pre-treatment anxiety
disorder (Pandey et al, 2006). In the Hospital A, patients usually got disease related anxiety as they
are fear of the side effects of cancer and are afraid of death. Over half of the admitted patients will
feel anxious towards their treatment plans and also fear of the future. Cancer patients needing
chemotherapy in the target setting are very worried about the side effects of the drugs such as
nausea and vomiting, fatigue and altered body function. Severe anxiety would induce cancer related
depression which is a pathological response to the loss of normality and one’s personal world due to
the cancer diagnosis, treatments or the complications. As mentioned above, Hospital A has patients
having cancer related depression. However, anxiety is always left ignored in the health care
settings. Doctors and nurses will just ask the cancer patients not to be nervous and anxious but
nothing will be done. Some doctors may prescribe the anxiolytic drugs. However, some of the
widely used anxiolytic drugs would induce side effects of amnesia, interaction with alcohol,
drowsiness or withdrawal effects (Spooren et al, 2000). If severe anxiety developed causing
psychological depression, clinical psychologist will then be referred. Luckily, only 5% of the
anxiety cases have to be referred to the clinical psychologist.
11
In some studies, massage therapy could lead to large and immediate improvements in relieving
signs and symptoms in cancer patients (Cassileth and Vickers, 2004). Although massage therapy
has been used as an adjuvant strategy in reducing cancer pain and anxiety for oncology patients in
some other countries, there is no clear evidence-based guideline for massage therapy in Hong Kong
health care clinical settings. In the target ward, there is no guideline for the manipulation of
massage therapy for cancer patients. Pain and anxiety are treated pharmacologically. If massage
therapy can be applied in the target ward, cancer patients would benefit from the intervention and
hence relieve their signs and symptoms of cancer pain and cancer-related anxiety.
No evidence-based guidelines about massage therapy in relieving pain and anxiety of cancer
patients were done before. There is no published systematic review done on this topic. However,
there are some good studies which could help to develop certain evidence-based guidelines for
cancer patients. Therefore, a systematic review will be performed to investigate if massage therapy
can be useful in relieving cancer pain and anxiety.
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1.3 Objectives and Significance
In order to develop an evidence-based guideline of using massages therapy to reduce pain and
anxiety level in oncology patients, the following objectives are formed:
1. To evaluate current evidence on the effectiveness of using massage therapy to reduce pain and
anxiety level in oncology patients.
2. To assess the implementation potential including the transferability and feasibility of using
massage therapy for oncology patients in a local oncology ward.
3. To develop the evidence-based guideline on the implementation of massage therapy to reduce
pain and anxiety level of cancer patients.
4. To develop an implementation plan and evaluation plan for the massage therapy on cancer
patients in a local oncology ward.
Pain and anxiety distress affect most of the cancer patients. A good and effective evidence-based
guideline for pain management and anxiety relief by massage therapy would be beneficial to
patients, relatives and health care professionals.
An evidence-based guideline of massage therapy can help to standardize the treatment in our
nursing practices. It can relieve the pain and anxiety level of cancer patients, hence improving their
quality of life. Some of the patients may refuse active treatments such as chemotherapy due to the
high intensity of distress and side effects caused by the treatments. The introduction of massage
therapy could help build up a supportive relationship among the patients and the health care
professionals. Family members can also learn to use the massage techniques to help support the
patients at home after discharge. If pain and anxiety of the patients are relieved, they may have a
better quality of life and create a positive attitude towards their life.
13
Chapter 2: Critical Appraisal
Appropriate searching strategies of different relevant evidence and results would be demonstrated in
this chapter. Critical appraisal would be performed and each relevant evidence would be rated using
the Scottish Intercollegiate Guidelines Network (SIGN) checklist (SIGN,2015). Finally, a summary
of the selected studies and synthesis would be presented.
2.1 Search and Appraisal Strategies
2.1.1 Inclusion and exclusion criteria for the study selection
Before the selection, inclusion and exclusion criteria have to be developed to determine eligible
studies. For the inclusion criteria, the methodology of the studies should be randomized controlled
trials (RCT) as RCTs have the high level of evidence. Besides, the studied participants should be
aged 18 years old or above and are diagnosed with cancer as the target population is adult oncology
patients. Furthermore, massage therapy should be used as an intervention in all the studies. At least
one of the outcome measures of each study should be related to either pain or anxiety. For exclusion
criteria, massage therapy for other cancer symptoms relief would be excluded.
14
2.1.2 Search Strategy
Using two electronic databases, PubMed and CINAHL plus (EBSCOhost) via the University of
Hong Kong Library database, a search was conducted on 10th December, 2015 to identify eligible
studies. First of all, the term “chemotherapy”, “oncology”, ”cancer”, “malignant” and “carcinoma”
were searched using the function “OR” to identify studies for the target population oncology
patients. After that, the term “pain”, “anxiety”, “anxious”, “mood”, “cortisol” and “psychological”
were searched using the function “OR” to identify the outcome measures of the study. Finally,
using the combination of all the above search results together with “massage” which is the
intervention, a list of results would be listed out. Studies were screened using the above inclusion
and exclusion criteria by title, abstract, and followed by full text. For the year of publication, there
is no restriction. Reference list of the search results are gone through to identify additional studies.
2.1.3 Appraisal strategies
The quality of the identified studies was assessed by SIGN checklist (2015). The level of evidence
was rated according to the critical items of the SIGN Randomized Controlled Trial checklist.
15
2.2 Results
2.2.1 Search Results
After using the above keywords for search and filtered with RCT, 28 articles were identified from
PubMed and 8 articles were identified from CINAHL plus. After eliminating the duplicated studies,
35 articles were found. After screening each of the 35 articles manually and by using the above
inclusion and exclusion criteria, 5 RCTs were selected. For details, please refer to the search history
in Appendix A.
Records identified through database searching of PubMed and CINAHL plus is 35. No more study
is retrieved after screening reference list of the selected articles. Hence, 35 records were screened.
After looking at the title and the abstract of the records, 21 records are excluded. Fourteen full text
articles were assessed for eligibility. After reviewing for the full text articles, 9 articles were
excluded as the target groups and the outcome measures did not match the selection criteria. Finally
5 studies were included in the qualitative synthesis. No addition is made from the reference list. For
details, please refer to the PRISMA flow diagram in Appendix B.
2.2.2 Data Extraction
In the table of evidence (Appendix C), all the key information of the selected studies was extracted.
The study design, quality, patients’ characteristics, intervention, control, outcome measures and
effect size of each of the studies were included in the table of evidence. The countries involved are
Taiwan (Wang et al, 2014), the United Kingdom (Stringer,Swindell and Dennis, 2008), the United
States (Toth et al, 2013 & Mehling et al, 2007) and Spain (Sedin et al, 2012). The sample size
ranged from 30 to 138. The intervention is massage therapy done on cancer patients while the
control is having no massage therapy.
16
2.2.3 Appraisal results
All studies stated clearly-focused research questions. All the five selected studies have listed out the
use of randomization method. Only one study (Mehling et al, 2007) has mentioned an adequate
concealment method. An opaque envelopment was used. Most of the studies are single-blinded. It is
not possible for the patients to be blinded as they are the one who received the interventions. All
relevant outcomes are measured in a standard, valid and reliable way. Using the SIGN checklist to
evaluate the level of evidence of the RCTs, two studies are rated at 1- and three studies are rated as
1+. No studies are rated as 1++. For details, please refer to Appendix D.
17
2.3 Summary and Synthesis
2.3.1 Summary of studies
Patients’ characteristics
The studied participants are patients with malignant ascites (Wang et al, 2014), non-malignant
ascites (Stringer, Swindell & Dennis,2008), haematology patients (Stringer, Swindell &
Dennis,2008), cancer patients having surgery (Mehling et al, 2007) or other cancer patients
(Toth,2013; Sendin et al,2012) All patients were recruited from oncology center in hospitals in
different countries (Wang et al, 2014; Stringer, Swindell & Dennis,2008; Toth,2013;Sendin et
al,2012; Mehling et al, 2007).
Intervention
Massage therapy was used as an intervention and was given by massage therapists from 15 minutes
to 45 minutes in all the studies. Massage was performed on the abdomen of the patients in one of
the studies (Wang et al, 2014). Specific area of massage was performed in other studies such as
massage over four limbs, back and head (Stringer, Swindell & Dennis,2008; Toth,2013). Massage
on the trigger points was also common (Sendin et al,2012). Full body massage was not possible in
all of the studies as the time is not feasible.
Swedish massage was used in most of the studies which include gentle effleurage and petrissage
Wang et al, 2014; Stringer, Swindell & Dennis,2008; Toth,2013). In general, massage therapy was
delivered during the hospitalization for two to three times per week except one which was carried
out in patients’ home (Toth et al, 2013).
18
Control
For all studies, the control is the same which is receiving no massage therapy. The control group
receives no treatment or just having 15 minute social interaction. Only one study control group is
having a simple hand contact on the pain area (Sendin et al, 2012).
Outcomes
All five studies focused on the anxiety level among patients. One of the studies (Stringer, Swindell
& Dennis, 2008) focus on the serum cortisol level as the outcome measure. The serum cortisol level
is known to be directly linked with the hypothalamic pituitary adrenal axis and it is a hormone
influenced by chronic stress. Therefore, the higher the serum cortisol level, the higher is the stress
and anxiety level. Four studies focus on the pain level as the outcome measures except one focus on
just anxiety (Stringer, Swindell & Dennis, 2008). The common scale measures used in the Numeric
Rating Scale (NRS). One study use the Memorial Pain Assessment Card (MAPC) measuring the
pain intensity (Sendin et al, 2012).
2.3.2 Synthesis of studies
Massage therapy is shown to have significant effects of reducing pain or anxiety level in all of the
five studies. None reduced both pain and anxiety significantly. According to the results of the five
studies, massage therapy is suitable for all types of cancer patients. After studying the data of all the
five studies, the use of massage therapy in reducing pain and anxiety level in oncology patients are
synthesized as follow.
19
Massage Method
Swedish massage was used in three of the studies (Wang et al, 2014; Stringer, Swindell &
Dennis,2008; Toth,2013). Swedish massage use smooth, long and rhythmical strokes as well as
gentle kneading of the body to provide comfortable feeling to cancer patients (Billhult, et al, 2007)
The other two studies did not mention the type of massage being used (Sendin et al, 2012; Mehling
et al, 2007).
Massage Duration
The massage duration of the studies ranged from 15 to 45 minutes in the 5 studies (Wang et
al ,2014; Stringer, Swindle and Dennis, 2008;, Toth et al,2013; Sendin et al,2012 and Mehling et al,
2007) The average duration of massage therapy would be 30 minutes. Longer duration did not give
a larger effect size. However, too short duration is not too good. Therefore, an average of 30
minutes for massage duration is chosen. In order to make the patients more satisfied and benefit
more from massage therapy, performing the massage therapy for two to three time per week (Wang
et al ,2014; Toth et al,2013). Several massage therapy sessions have to be performed but not too
often. Therefore two to three week per time would be the most suitable.
According to the five studies, the intervention lasts from one day to one month. There is no relation
between implementation duration and the effect size.
2.3.3 Conclusion
To conclude, massage therapy can be effective in reducing pain and anxiety level of oncology
patients after systematic review. Therefore, a massage program in the target oncology ward would
be proposed to be implemented using Swedish massage for 30 minutes, two to three times per week.
It is believed that the massage problem would reduce the pain and anxiety level of cancer patients in
the local oncology ward.
20
Chapter 3: Translation and Application
In the previous chapters, the literature reviews of certain research studies have shown the
effectiveness of using massage therapy in reducing pain and anxiety level in oncological patients. In
this chapter, the implementation potential of this innovation would be assessed and hence an
evidence-based practice guideline would be developed to be applied in the target setting.
3.1 Implementation Potential
The transferability and feasibility of the massage therapy would be examined and assessed in the
following sessions. Therefore, the potential of implementing the innovation in the target setting can
be determined.
3.1.1 Target Setting
The target setting is the Haematology and Oncology wards and Oncology Day Care Centre of a
private hospital in Hong Kong (Hospital A). There are two wards including general ward and semi-
private ward for in-patients and the Oncology Day Care Centre for outpatients. General ward has 44
beds including 8 rooms which contains 3 to 6 beds and 2 isolation rooms while semi-private ward
has 25 beds in single room which includes 4 isolation rooms and 2 reverse isolation rooms. Both
wards are mixed ward. The Oncology Day Care Centre contains 15 beds for day care of oncology
patients providing chemotherapy or other palliative treatment. Every year, there would be around
8000 inpatients and 4000 outpatients. Around 80% of the inpatients are oncology patients. Others
may be overflow medical patients. There are around 70 patients eligible for the innovation every
day. It is estimated that around 70% of the eligible patients, that is 50 patients, would be fit for the
innovation as some eligible patients may refuse treatment. There are around 18,250 patients who
would be beneficial in one year.
21
3.1.2 Target Users of the guideline
The target users are the nurses in the oncology ward and other allied health staff who assist in
massage therapy.
The target population are cognitively competent adult oncology patients who has experienced
anxiety and pain from different types of cancer with or without metastasis. Exclusive criteria of the
target population are patients who have any open wound over the body or patients having any
dermatitis. If patients’ platelet count is lower than 100,000/mm3 or have spinal cord injury or
having altered level of consciousness, they are also excluded (Wang et al ,2014; Stringer, Swindle
and Dennis, 2008;, Toth et al,2013; Sendin et al,2012 and Mehling et al, 2007).
3.1.3 Philosophy of care
“Quality in Service, Excellence in Care” is the motto of the target private hospital. The hospital
aims at providing the best medical treatments and hospital care for the patients and provide patient-
centered care with well-qualified and experienced nurses, doctors and other allied health
professionals. The mission and vision of the hospital is to increase the quality of life of patients. We
hope to minimise the suffer, both physiological and psychological distress, from cancer such as
anxiety and pain. Therefore, the dignity of the patients would be increased.
Massage therapy falls in the above philosophy of care. It is an alternative way other than
pharmacological methods to relieve the distress of oncology patients. Massage therapy is believed
to minimize the suffer of cancer patients and hence increase the quality of life of patients.
22
3.1.4 Transferability of the findings
The innovation as mentioned above fit in the proposed settings. The target population in the above 5
research studies is similar to the target setting as the target settings in the studies are oncology
centers and the target patients in the research is adult oncology patients. All the research studies
have similar philosophy of care which is patient centered care. It is hoped that patients’ quality of
life would be increased and hence increase the dignity of patients. Around 80% of the target setting
patients can be benefited from the innovation.
3.1.5 Timeline for Implementation of the innovation
The first 4 weeks would be the preparation stage, including forming a communication team and
seeking approval from the Hospital Management and Nursing Administration. The next four weeks
would be the development of the evidence-based guideline and training. The next 4 weeks would be
pilot study. The next week would be amending guidelines and flow of the full-scale program. The
following 2 months would be implementation of the innovation and it takes one month for the
evaluation. In total, it takes around 7 months for the innovation. The total time for the innovation is
reasonable and acceptable. For details, please refer to Appendix E.
3.1.5 Feasibility of the innovation
3.1.5.1 Organizational and administrative support
Nurses would be the leader of the massage team, including members of massage therapists,
physiotherapists and other health care workers. Nurses have the autonomy to start or terminate the
massage therapy according to their clinical knowledge and patients’ condition. Hospital
23
Management Committee and Nursing administration of the target hospital totally support for this
innovation as it is an evidence-based practice. Besides, the target hospital is a teaching hospital, all
the stakeholders understand well the importance of evidence-based practices to facilitate patient-
centered care and hence improve quality of life of patients. Recently, a donation of $ 50,000,000 is
donated by a celebrity for the nursing research and development. Therefore, extra manpower can be
recruited.
3.1.5.2 Continuous education for staff development
Nursing staffs and other allied health staff including ward assistant, physiotherapists may have
different attitude towards the implementation of this innovation which would affect the feasibility
of the implementation. However, hospital requires staff to have continuous education and
development on different aspects. Nurses and other allied health staff are required to take courses
organised by the hospital. Otherwise, their contract may not be renewed or they are not promoted.
Besides, staff attending the lectures of massage therapy or other courses related to this innovation
can have CNE points for nursing staff and time off may be given.
3.1.5.3 Support from frontline staff
Some of the frontline staff may dislike the additional workload. However, as the target setting is a
private hospital, it can provide a higher salary for staff and requires staff to be responsible and
comprehensive. Besides, as mentioned above, a large amount of donation is collected recently and
hence extra manpower can be recruited. This would not really interfere too much with the staff
function. This would increase the feasibility of implementing the innovation.
24
3.1.5.4 Skills and equipment available
Professional massage therapists are employed to teach the skills of massage therapy to the nurses
and other allied health staff. Recruitment of professional massage therapists is easy as Hospital A is
the most famous private hospital which give higher salary for professional massage therapists then
other companies. The basic equipment of massage therapy includes mainly the staff, which are
well-equipped.
3.1.5.5 Evaluation tools
Patient’s outcome, patients’ satisfaction and nurse’s job satisfaction would be evaluated. The
evaluation tools are questionnaire and it can be easily prepared using the numeric rating scale
(Wang et al, 2014; Toth et al, 2013;Mehling et al, 2007) and the 5-point Likert Survey.
3.1.6 Cost-Benefit Analysis of the innovation
3.1.6.1 Potential Benefits of the innovation
As mentioned in previous chapter, oncology patients would experience both physical and
psychological distress. One of the non-pharmacological methods, massage therapy, can be used in
relieving pain and anxiety level of cancer patients (Wang et al ,2014; Stringer, Swindle and Dennis,
2008;, Toth et al,2013; Sendin et al,2012 and Mehling et al, 2007). With the help of non-
pharmacological agent, the use of pharmacological drugs could be minimised. Sometimes, there
may be side effects caused by medications. However, massage therapy does not cause side effects
25
(Wang et al, 2014). Patients would not need to pay more for the drugs. Patients have less complaint
and hence would decrease nurses’ workload.
Besides, it would decrease the length of hospitalisation of patients (Mehling et al, 2007), therefore
increase patients’ satisfaction. Patients would be more willing to choose to stay and spend in the
target hospital for the next admission. It would also increase the reputation of the target hospital.
3.1.6.2 Potential Risks of the innovation
No adverse event for patients is reported in the research studies (Wang et al ,2014; Stringer,
Swindle and Dennis, 2008;, Toth et al,2013; Sendin et al,2012 and Mehling et al, 2007). Any
discomfort of patients would be stopped immediately.
3.1.6.3 Risk of the current practice
In current practice, pharmacological methods are used in target settings to treat pain and anxiety.
However, sides effects of pain killers and anti-anxiety drugs would cause adverse effects for
patients. Some may got constipation, nausea and vomiting. If pain and anxiety are not treated
properly, the patients would suffer from the adverse effects and hence have a negative feelings
towards the disease. It may develop a poor quality of life.
26
3.1.6.4 Non-material costs and benefits of the innovation
For the potential non-material costs of implementing the innovation, nursing staff and other allied
health staff such as ward assistant and physiotherapists may think it is an increase in workload as
they have to learn the skills of massage therapy at the beginning of the programme. However,
patients would have less complaint and hence the workload of staff would be decreased after
several sessions of massage therapy. That would then become the potential non-material benefit.
For a private hospital, there is no material savings for the hospital for the reduce use of
pharmacological drugs. However, it would increase the patient satisfaction of staying in the hospital
and hence improve the reputation of the hospital. Reputation of hospital is also a non-material
benefit. It would make the patients feel comfortable to choose Hospital A again. This would then
increase the income of the hospital.
3.1.6.6 Cost-Benefit Ratio
There are material costs and non-material costs. For the material costs, it includes the set up cost
and the operational costs. Set up cost include all the materials needed for massage therapy including
the recruitment of massage therapists and also the training costs of massage therapy for staff. For
the operational cost, it includes the regular recruitment of massage therapists and regular training
for staff.
Number of patients eligible for the innovation in the target setting is 70 patients per day. Assume
70% of the patients fit in the innovation, there are around 50 patients every day. Estimated time for
each treatment is 30 minutes. Number of massage therapists recruited at the beginning of the
27
innovation is 2 (Appendix F) After 8 weeks, the nursing staff and other allied health workers can
perform the massage without the supervision of massage therapists. For the estimated set-up costs
of the innovation, it includes the training of massage therapy by massage therapists and equipment
costs. The monthly salary of massage therapist would be $40000. The salary of the nurses would be
the same. Only time off would be given to the nurses and allied health staff to attend the training
sessions. The set up costs include the recruitment of massage therapists for training of nurses and
other allied health staff ($80,000), time off given for staff to attend training sessions ($26000) and
also the notes costs ($1000). The operational costs include the recruitment of continuous training of
frontline staff ($5200). The set up costs and operational costs are calculated. For details, please refer
to Appendix G.
If the pain and anxiety level of patients is treated well, the estimated day of hospitalization would be
reduced by one day. According to the admission information of Hospital A, the average length of
stay of each patients in Hospital A is 5 days. Therefore, if massage therapy is implemented, the
number of patients admitted more in one month would be 10. The average spent for each stay for
each patient for either chemotherapy or palliative treatment would be $100,000. This would also
increase the hospital income by $1,000,000. The detail is shown in Appendix H.
In conclusion, implementing massage therapy to relieve pain and anxiety level of cancer patients
has a high cost-benefit ratio (around 1:9). It is transferable and feasible to implement this evidence-
based practice in the target setting.
28
3.2 Evidence-based Practice Guideline
The evidence-based practice guideline is developed according to the systematic reviews done in the
previous chapter. The evidenced-based practice guideline would provide clear and structural details
for nurses on the use of massage therapy on adult oncology patients to reduce their pain and anxiety
level in the target setting. The level of evidence and recommendations of the five randomized
controlled trails extracted from the previous chapter are graded according to the Scottish
Intercollegiate Guideline Network (SIGN, 2008), which would be shown in appendix I and
appendix J respectively. “ 1+ “ means well-conducted meta-analyses, systematic reviews, or RCTs
with a low risk of bias. “1-“ means meta-analyses, systematic reviews, or RCTs with a high risk of
bias. Grade A of Scottish Intercollegiate Guideline Network means there is at least one meta-
analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population.
In the evidence-based practice, the aim, objectives, target group, recommendations and evidence
supporting the recommendations would be mentioned in details. There are 6 recommendations and
three are in Grade A and three are in Grade B. The detailed evidence-based practice guideline
would be shown in appendix K.
29
Chapter 4: Implementation Plan
After the evidence-based guideline being developed in the last chapter, an implementation plan and
evaluation plan will be focused and elaborated in this chapter. An implementation plan can facilitate
effective communication for illustrating the program of massage therapy into the target setting for
oncology patients to reduce their pain and anxiety level.
4.1 Communication Plan
The communication plan includes the introduction of the stakeholders for the program, introduction
of the process of forming a communicating team to sustain the change. A comprehensive
communication plan would be formed according to the feasibility of the massage therapy mentioned
in previous chapter. For the details of timelines of the program, please refer to appendix E.
4.1.1 Identification of stakeholders
The stakeholders are the key persons who would affect the successfulness of implementing the
evidence-based guideline of the massage program. The key stakeholders include the Hospital
Management Committee, Director of Nursing Administration, ward manager of Oncology
Department, oncologists, oncology nurses and finically the oncology patients.
The Hospital Management Committee and the Director of Nursing Administration are the most
important stakeholders as they are the one who make the decision and make guidelines and
implement the interventions in the target setting. Approval has to be obtained by the Nursing
Administration followed by the Hospital Management Committee before any actions can be done.
30
Another stakeholder would be the ward manager of Oncology Department. Massage therapy would
be done in oncology ward and oncology center. The ward manager has to supervise the flow of the
massage intervention and she has to ensure that the program would not interfere with the normal
routine practice of the target setting.
Five Oncologists and around 30 oncology nurses are the frontline staff responsible for giving
treatments to oncology patients. They are the one who keep in contact with the patients every day.
They are the one who understand the patients’ condition well. Oncologists would be one of the key
stakeholders as oncologists are responsible for the overall health condition of the patients. and make
sure the patients are fit for the massage treatment. For oncology nurses, they are the one who would
assess the eligibility of oncology patients for the massage program and hence run the massage
program. They are also the one who give the massage therapy or supervise others allied health staff
to perform the massage therapy. Other allied health staff such as physiotherapists would also help in
performing the massage therapy, depending on the current workload of them.
Another important stakeholder is the oncology patients because they are the receiver of the massage
intervention. Reducing pain and anxiety level of cancer patients is important.
4.1.2 Communication Plan with Stakeholders
To initiate with the massage therapy program, effective communication has to be done to ensure we
could get supports from different parties including the hospital management committee, nursing
administrators, nursing leaders, oncologists, frontline nurses and oncology patients. The aim of the
communication plan is to make the stakeholder understand well of the program and increase the
successful rate of the implementation.
31
4.1.2.1 Communication in initiating the change
To start with, a communication team is formed which includes three oncology nurses in the first 4
weeks. First of all, the ward manager of the oncology department would be approached by the
communication team. Tell the ward manager the proposed program in a meeting. Explain the
significance, transferability, feasibility and the potential cost and benefits of the innovation. Identify
the expected barriers for implementing the program and discuss the solutions for the innovation.
The ward manager has a higher authority in policy making related to nursing practice than frontline
nurses. The ward manager can also give comments and see how the implementation can be more
successful. If it is supported by the ward manager, she will mention the innovation to the Nursing
Administration and meeting would be arranged.
Communicate with the Nursing Administration, give written proposal and presentation to the
Nursing Administration by the communication team. If it is supported and approved by the Nursing
Administration, the next step is to contact and communicate with the Hospital Management
Committee to see how the innovation can be implemented. The Hospital Management Committee
would study the proposal which include the aim and objectives of the guidelines and also the
implementation potential, effectiveness of the innovation and the cost of and benefit of the massage
program. If it is approved by the Hospital Management Committee, financial support would be
granted and hence a massage therapy team could be formed.
32
4.1.2.2 Communication in forming a massage therapy team
After being approved by the Nursing Administration and Hospital Management Committee, a
communication team for massage therapy on oncology patients would be formed to plan and launch
the innovation. The massage therapy team would include the oncology nurse as a team leader,
which includes members of 5 nursing staffs, 2 temporarily employed massage therapists,4
physiotherapists and 5 other allied health staff. Meetings would be organized and held regularly to
discuss the planning of the program. Besides, recruitment of massage therapists to give training
sessions for nursing staff and other allied health staff to perform massage therapy.
Frontline nurses and allied health staff would be informed about the proposal through internal
poster and email. Evidence-based guidelines would be distributed to oncology ward and oncology
center. Staff are compulsory to attend the training session organized by the massage therapy team
and they are required to be assessed from time to time as it is a continue educational and
developmental program developed by the hospital. The importance of the massage innovation
would be emphasized during the communication to the frontline staff. Performing quality of care
and service are the motto of Hospital A. It is for the patients’ benefit and frontline should be happy
about helping the oncology patients.
33
4.2 Pilot Study
A pilot study would be performed so that the logistics of the proposed innovation would be studied.
The pilot study is a small scale preliminary study which will be done in the target settings for a
short period of time with a small amount of cancer patient in oncology wards and oncology center.
The data collected from this pilot study would be useful in determining whether the proposed
innovation and evidence-based guideline is feasible and workable. Further modification can be
made on the guideline and the financial planning can be adjusted for the large scale implementation
when necessary.
4.2.1 Objectives of the pilot study
(i) Identify the barriers and difficulties of implementing the innovation.
(ii) Collect information to fine-tune the logistics for the full-scale implementation.
4.2.2 Study Setting of the target population
The study will be conducted in the oncology wards by nurses and other allied health professionals.
First of all, a training program of massage therapy would be conducted by a massage therapist.
Oncology nurses are the major target of being trained. Besides, allied health care professionals such
as physiotherapists, health care workers are also trained with the techniques of massage therapy.
The training would be a 5 session training courses with each session of 2 hours. The training
program would last for 2 weeks.
34
After training, 4weeks would be used to recruit eligible patients for massage therapy. The eligible
patients are mentioned in previous chapter. Patients having diagnosis of cancer who are aged 18 or
above which are cognitive competent and have experienced pain or anxiety are eligible for the
program. Convenience sampling is used and 20 patients would be recruited for the study. 30
minutes would be provided to the patients having pain or anxiety level for at least twice per week
during hospitalization. Details are based on the evidence-based guidelines. Pre and Post pain
assessment and anxiety assessment would be done to evaluate the massage therapy program.
After 4 weeks, a short evaluation by interview of frontline staff and oncology patients who receive
massage therapy would be done before proceed to the full-scale implementation. Further
modification of the full-scale innovation would be made according to the flow of the pilot study and
make better outcomes. The pilot study would make a better flow and better logistics of the program.
35
4.3 Evaluation Plan
Evaluation is an essential part of assessment for the implementation of the massage program. It is a
tool to determine the effectiveness of the program. Outcome benefits regarding patients, health care
providers and hospitals will be illustrated in the following sessions.
4.3.1 Identifying Outcomes
4.3.1.1Primary Outcome
Patient outcome is the primary outcome of the above innovation. Pain and anxiety level of oncology
patients are the primary outcomes. The patient outcomes could determine the effectiveness of the
program. Pre massage therapy pain and anxiety level would be assessed as baseline and then post
massage therapy pain and anxiety level would be assessed and compared. Numeric rating scale
(NRS) in which zero represents symptom absent and 10 represents the worst possible symptom
would be used to measure the pain and anxiety level. Time for collecting the patient outcomes is
right before the massage procedure and 30 minutes after the procedure. For the details of the
assessment form, please refer to Appendix L
4.3.1.2 Secondary Outcome— Patient Outcome
One of the secondary outcomes is the satisfaction level of the patients. The higher the satisfaction of
the patients, the higher the effectiveness of the massage innovation and hence increase the
reputation of the hospital. A 5-point Likert Survey would be done to measure the satisfaction level.
The higher the score (0-5), the better the satisfaction level. There are 6 questions on the
questionnaire. The patient will complete the questionnaire before discharge. The average score of
36
questionnaire would be calculated. For the details of the questions in the questionnaire, please refer
to Appendix M.
4.3.1.3 Secondary Outcome— Health Care Provider Outcome
The nurse’s job satisfaction is another secondary outcome of the innovation. Nursing job
satisfaction has to be evaluated every 2 weeks of the implementation. The job satisfaction of nurses
would be assessed via a self-reported questionnaire. A 5-point Likert Survey would be done to
measure the job satisfaction level of nurses. The higher the score (0-5), the better the satisfaction
level. There are 5 questions in total. The nurse would complete the questionnaire at the end the
implementation period. The mean score would be calculated. For details of the staff self-reported
questionnaire on the use of the massage innovation, please refer to Appendix N.
4.3.1.4 Secondary Outcome – System Outcome
For the system outcomes, the costs and utilization of the innovation would be measured to ensure
the effectiveness of the massage programme. The implementation of the innovation can cause the
reduced length of hospitalization of the patients and hence getting more number of patients admitted
in one month. The estimated expenditure of the innovation is calculated and the money gained for
extra patients per month is compared.
37
4.3.2 Nature and number of patients to be involved
Target patients of the innovation are oncology patients having experience of pain or anxiety during
hospitalization. The eligible criteria of the patients are mentioned in previous chapter. Patients
should be aged 18 or above and be cognitively competent who should have GCS =15/15. Exclusive
criteria of the patients include patients having any open would over the body, any dermatitis, lower
platelet count, spinal cord injury and altered level of consciousness. In order to carry out a
comprehensive intervention and evaluation, an adequate sample size is needed. The sample size
calculation is based on the five selected research articles. A two tailed t-test would be used to
determine the reduction of pain and anxiety level. With reference to previous research studies, a
standard deviation of 1, a mean difference of 0.5 with alpha= 0.05 and power =80% were used to
calculate the sample size. 33 patients have to be recruited according to the sample size calculation.
However, if we assume there is a 5% drop out rate due to change in condition of patients, the
number of patients needed to be recruited is around 40. It is estimated to take 3 months to recruited
40 patients to have completed at least one massage intervention.
4.3.3 Data analysis
The baseline and post massage intervention pain and anxiety level collected using the Numeric
Rating Scale would be used for data analysis using the Statistical Package for Social Sciences
(SPSS) program. A two tailed t-test would be done to test whether the pain and anxiety level
significantly declined by at least 0.5 units or not.
For the other secondary outcomes, the patients’ satisfaction level and the nurse’s job satisfaction
level would be calculated using the 5-point Likert scale. An average score would be calculated. The
higher the score (0-5), the better the satisfaction level. The 95% confidence interval of the
percentage of mean score greater than or equal to 4 would be calculated. Descriptive statistics
would also be generated for system outcomes.
38
4.4 Basis for Implementation
The guideline is said to be effective is based on the basis for the outcome achievement. If the
following outcomes can be achieved, the innovation is said to be effective.
4.4.1 Patient’s Outcome
The innovation is said to be effective if patients’ pain or anxiety level have a reduction of 0.5 or
more points using the Numeric Rating Scale.
4.4.2 Patients’ Satisfaction and Nurse’s Job Satisfaction
If more than 70% of the patients’ satisfaction towards the massage therapy and nurse’s job
satisfaction have an average score of 4 or above, then the innovation is said to be effective.
The massage therapy innovation is said to be effective in the target setting if all the above
achievements are made.
39
Chapter 5: Conclusion
Pain and anxiety are the most common physiological and psychological distress experienced
by oncology patients. A translational nursing approach is adopted to develop an evidence-based
guideline on reducing the pain and anxiety level of oncology patients for a local oncology center. A
pilot study plan, implementation plan and finally an evaluation plan are developed including the
evaluation on the clinical outcomes, health care providers’ outcomes and system outcomes. It is
believed that the proposed massage therapy innovation would be considered an effective measure in
reducing pain and anxiety level in oncology patients. Reduction in pain and anxiety level of patients
would bring a better quality of life to patients, improving the nurse job satisfaction and also increase
the reputation of Hospital A.
40
Appendix A: Summary of Database Search Strategy and Result
Summary of Database Search Strategy and Result
Search Items Electronic Databases
PudMed CINAHLplus (EBSCOhost)
S1: Chemotherapy OR
oncology OR cancer OR
malignant OR carcinoma
5380440 61992
S2: pain OR anxiety OR
anxious OR mood OR cortisol
OR psychological
1682801 87943
Massage AND S1 AND S2 570 68
Limit to Randomized Control
Trial
28 8
Addition from reference list 0 0
Total number of articles
retrieved without overlapping
35
41
Appendix B: PRISMA Flow Diagram
Records identified through database PudMed and CINAHLplus
(n = 36 )
Scr
een
ing
Incl
ud
ed
Eli
gib
ilit
y
Iden
tifi
cati
on
Additional records identified through other sources
(n =0 )
Records after duplicates removed (n = 35 )
Records screened (n = 35 )
Records excluded (n =21 )
Full-text articles assessed for eligibility
(n =14 )
Full-text articles excluded, (n = 9 )
Reasons: Target groups are different (n=5)
Outcome measure are different (n=4)
Studies included in qualitative synthesis
(n = 5 )
42
Appendix C: Table of evidence
Citation /
Design (Study
Quality)
Sample
Characteristics
Intervention Control Outcomes (Assessment
time)
Effect Size
(Intervention -
Control)
1 Wang, T.J
et al (2014)
1+
1. Cancer patients
with malignant
ascites
2. Studied in
Northern
Taiwan
15 minute gentle
abdominal massage
twice daily for 3
consecutive days
(Swedish Massage)
(n=40)
15 minute social
interaction
contact with the
patient twice
daily for 3
consecutive days
with the same
nurse
(n=40)
1. Anxiety
(NRS)*
2. Pain (NRS)
(measured in
the morning for
3 consecutive
days from pre-
to post-test)
Measure from
Day 3:
1. Difference of
Mean: -0.58;
SE: 0.16, p=
<0.001
2. mean:0.37,
p=0.187 (Not
significant)
2 Stringer, J,
Swindell,
R, Dennis,
M (2008)
1+
1. Haematology
patients
including non-
malignant
patients.
2. Studied in
oncology centre
of the Christie
Hospital in
Manchester
1. Massage for 20
min (with base
oil) for two days
(Swedish Massage)
2.
(N= 13)
3. Aromatherapy
for 20
min(Massage
with blended
oils) for two days
(N=13)
Rest
(Patients were
made
comfortable,
offered reading
material and soft
drinks and are not
disturbed by staff
for 20 min)
(N=13)
1. Serum
Cortisol
Level ^
(measured at 24
hour follow
up)
Compared
between Massage
and Control:
1. Median: -
18.3,
p=<0.0005
Compared with
Aroma and
Control:
1. Median: -
12.5, p=0.034
3 Toth, M. et
al (2013)
1-
1. Patients with
metastatic
cancer
2. Studied in Beth
Israel
Deaconess
Medical Center
in Boston
massage treatments
by massage therapists
three time per week
for 15 to 45 min
(Swedish Massage)
(n=20)
Patient received
no massage
treatment
(n=19)
1. Pain (NRS)
2. Anxiety
(NRS)
(assessment
time: one
month)
1. Mean: -0.9 ;
p= 0.04
2. Mean: -0.3;
p=0.72 (Not
significant)
4 Sendin, N.
L et al
(2012)
1-
1. Terminal
cancer patients
2. Studied in
Oncology
University
Hospital
Salamanca
massage was done on
the tender points for
30 minutes once
(Type of massage
therapy not
mentioned)
n= 15
receive a simple
hand contact on
the pain area
once
n=15
Primary
outcome:
1. Pain
(MPAP)#
Secondary
outcome:
2. Mood
(MPAP)
(measured at 30
minutes after
massage)
1. Mean: 0.2
p= 0.07
(not
significant)
2. Mean: 1.7
p<0.01
43
*Numeric rating scale (NRS) in which 0=symptom absent and 10=worst possible symptom
^High serum cortisol level means increase in stress and anxiety level
#Memorial Pain Assessment Card (MPAC) measuring the changes of pain intensity (0-10 ; 10: worst pain)
5 Mehling,
W,E. el at
(2007)
1+
1. Cancer patients
having surgery
2. Studied in
California
1. Massage were
given on post-
operation Day 1
and Day 2 at
bedside for 30
minutes
2. Acupuncture
treatment based
on symptom
report and
physical exam
(Type of massage
therapy not
mentioned)
(N=93)
Usual care with
no massage or
acupuncture
(N=45)
Primary
Outcome:
1. Pain
(NRS)
Secondary
Outcomes:
2. Anxiety
(NRS)
(assessment
time: day 3)
1. Mean Score: -
0.8, p=0.038
2. Mean
Change:-0.28,
p=0.15 (not
significant)
44
Appendix D: SIGN Checklists Record 1:
S I G N
Methodology Checklist 2: Controlled Trials
Study identification (Include author, title, year of publication, journal title, pages)
Wang, T. J., Wang, H. M. & Yang, T. S. (2015). The effect of abdominal massage in reducing malignant ascites symptoms.
Research in Nursing & Health, 38 51-59.
Guideline topic: Key Question No: Reviewer:
Before completing this checklist, consider:
1. Is the paper a randomised controlled trial or a controlled clinical trial? If in doubt, check the study design algorithm
available from SIGN and make sure you have the correct checklist. If it is a controlled clinical trial questions 1.2, 1.3, and
1.4 are not relevant, and the study cannot be rated higher than 1+
2. Is the paper relevant to key question? Analyse using PICO (Patient or Population Intervention Comparison Outcome). IF
NO REJECT (give reason below). IF YES complete the checklist.
Reason for rejection: 1. Paper not relevant to key question ⬜ 2. Other reason ⬜ (please specify):
SECTION 1: INTERNAL VALIDITY
In a well conducted RCT study… Does this study do it?
1.1 The study addresses an appropriate and clearly focused question. Yes
1.2 The assignment of subjects to treatment groups is randomised. Yes
Use random allocation software
1.3 An adequate concealment method is used. No
1.4 The design keeps subjects and investigators ‘blind’ about treatment allocation. Yes
Outcome assessor is blinded.
However, blinding is impossible for
patients as they received the
treatment.
1.5 The treatment and control groups are similar at the start of the trial Yes
45
1.6 The only difference between groups is the treatment under investigation. Yes
1.7 All relevant outcomes are measured in a standard, valid and reliable way. Yes.
1.8 What percentage of the individuals or clusters recruited into each treatment arm of
the study dropped out before the study was completed?
None
1.9 All the subjects are analysed in the groups to which they were randomly allocated
(often referred to as intention to treat analysis).
Yes
1.10 Where the study is carried out at more than one site, results are comparable for all
sites.
Does not apply
study was carried out in a medical
center in northern Taiwan
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise bias?
Code as follows: High quality (++)
Acceptable (+)
Low quality (-)
Unacceptable – reject 0
2.2 Taking into account clinical considerations, your
evaluation of the methodology used, and the statistical
power of the study, are you certain that the overall effect is
due to the study intervention?
Yes
2.3 Are the results of this study directly applicable to the
patient group targeted by this guideline?
Yes
2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own assessment of the study, and the extent to
which it answers your question and mention any areas of uncertainty raised above.
Abdominal massage is useful for ascites symptoms. The study shows that abdominal massage twice daily for 3 days
significantly reduced the severity of depression, anxiety, poor wellbeing, and perceived abdominal bloating. However,
only short term effects of 3 days of abdominal massage were tested in this study, the long term outcomes and potential
side effects is undetermined
1+
46
Record 2:
S I G N
Methodology Checklist 2: Controlled Trials
Study identification (Include author, title, year of publication, journal title, pages)
Stringer, J., Swindell, R. & Dennis, M. (2008). Massage in patients undergoing intensive chemotherapy
reduces serum cortisol and prolactin. Psycho-Oncology, 17 1024-1031.
Guideline topic: Key Question No: Reviewer:
Before completing this checklist, consider:
1. Is the paper a randomised controlled trial or a controlled clinical trial? If in doubt, check the study design
algorithm available from SIGN and make sure you have the correct checklist. If it is a controlled clinical trial
questions 1.2, 1.3, and 1.4 are not relevant, and the study cannot be rated higher than 1+
2. Is the paper relevant to key question? Analyse using PICO (Patient or Population Intervention Comparison
Outcome). IF NO REJECT (give reason below). IF YES complete the checklist.
Reason for rejection: 1. Paper not relevant to key question ⬜ 2. Other reason ⬜ (please specify):
SECTION 1: INTERNAL VALIDITY
In a well conducted RCT study… Does this study do it?
1.1 The study addresses an appropriate and clearly focused question. Yes
1.2 The assignment of subjects to treatment groups is randomised. Yes By computerised randomisation
block method
1.3 An adequate concealment method is used. No.
1.4 The design keeps subjects and investigators ‘blind’ about treatment
allocation.
Yes
It is only possible to use single
blinding. The lab staff
performing the hormone assays
and research assistnat collecting
psychological data were unaware
of the treatment allocation.
47
1.5 The treatment and control groups are similar at the start of the trial Yes
1.6 The only difference between groups is the treatment under investigation. Yes
1.7 All relevant outcomes are measured in a standard, valid and reliable way. Yes. Serum cortisol and prolactin levels
is measured
1.8 What percentage of the individuals or clusters recruited into each treatment
arm of the study dropped out before the study was completed?
None
1.9 All the subjects are analysed in the groups to which they were randomly
allocated (often referred to as intention to treat analysis).
Yes
1.10 Where the study is carried out at more than one site, results are comparable
for all sites.
Does not apply
Study is carried in one
hospital only.
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise bias?
Code as follows: High quality (++)
Acceptable (+)
Low quality (-)
Unacceptable – reject 0
2.2 Taking into account clinical considerations, your
evaluation of the methodology used, and the
statistical power of the study, are you certain that the
overall effect is due to the study intervention?
Yes.
2.3 Are the results of this study directly applicable to the
patient group targeted by this guideline?
Yes
2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own assessment of the study, and the
extent to which it answers your question and mention any areas of uncertainty raised above.
Massage can have psychological effects on patients. Reduced cortisol level due to reduction of stress and
anxiety. However, sample size is not large enough as n=39
1+
48
Record 3:
S I G N
Methodology Checklist 2: Controlled Trials
Study identification (Include author, title, year of publication, journal title, pages)
Toth, M., Marcantonio, E. R. & Davis, R. B. (2013). Massage Therapy for patients with metastatic cancer: A
pilot Randomised controlled Trial. The journal of alternative and complementary medicine, 19 (7), 650-656.
Guideline topic: Key Question No: Reviewer:
Before completing this checklist, consider:
1. Is the paper a randomised controlled trial or a controlled clinical trial? If in doubt, check the study design
algorithm available from SIGN and make sure you have the correct checklist. If it is a controlled clinical trial
questions 1.2, 1.3, and 1.4 are not relevant, and the study cannot be rated higher than 1+
2. Is the paper relevant to key question? Analyse using PICO (Patient or Population Intervention Comparison
Outcome). IF NO REJECT (give reason below). IF YES complete the checklist.
Reason for rejection: 1. Paper not relevant to key question ⬜ 2. Other reason ⬜ (please specify):
SECTION 1: INTERNAL VALIDITY
In a well conducted RCT study… Does this study do it?
1.1 The study addresses an appropriate and clearly focused question. Yes
1.2 The assignment of subjects to treatment groups is randomised. Yes
By computerised randomisation
1.3 An adequate concealment method is used. No
1.4 The design keeps subjects and investigators ‘blind’ about treatment
allocation.
No The authors not able to
blind the pre-post intervention
data collection
1.5 The treatment and control groups are similar at the start of the trial Yes
1.6 The only difference between groups is the treatment under investigation. Yes
49
1.7 All relevant outcomes are measured in a standard, valid and reliable way. Yes. outcome measure Pain: NRS
Anxiety: NRS
1.8 What percentage of the individuals or clusters recruited into each treatment
arm of the study dropped out before the study was completed?
None
1.9 All the subjects are analysed in the groups to which they were randomly
allocated (often referred to as intention to treat analysis).
Yes
1.10 Where the study is carried out at more than one site, results are comparable
for all sites.
Does not apply
Studied in Medical Centre in
Boston only
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise bias?
Code as follows: High quality (++)
Acceptable (+)
Low quality (-
Unacceptable – reject 0
2.2 Taking into account clinical considerations, your
evaluation of the methodology used, and the
statistical power of the study, are you certain that the
overall effect is due to the study intervention?
Yes
2.3 Are the results of this study directly applicable to the
patient group targeted by this guideline?
Yes
2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own assessment of the study, and the
extent to which it answers your question and mention any areas of uncertainty raised above.
Patient expectation for better outcome from massage might have biased the study against the control. The
small sample size limits the statistical power. Need to have larger sample size
1-
50
Record 4:
S I G N
Methodology Checklist 2: Controlled Trials
Study identification (Include author, title, year of publication, journal title, pages)
Sendin L., Sedin, F. A. & Cleland, J. A. (2012). Effects of physical therapy on pain and mood in patients with
terminal cancer: a pilot randomised clinical trial. the journal of alternative and complementary medicine, 18
(5), 480-486.
Guideline topic: Key Question No: Reviewer:
Before completing this checklist, consider:
1. Is the paper a randomised controlled trial or a controlled clinical trial? If in doubt, check the study design
algorithm available from SIGN and make sure you have the correct checklist. If it is a controlled clinical trial
questions 1.2, 1.3, and 1.4 are not relevant, and the study cannot be rated higher than 1+
2. Is the paper relevant to key question? Analyse using PICO (Patient or Population Intervention Comparison
Outcome). IF NO REJECT (give reason below). IF YES complete the checklist.
Reason for rejection: 1. Paper not relevant to key question ⬜ 2. Other reason ⬜ (please specify):
SECTION 1: INTERNAL VALIDITY
In a well conducted RCT study… Does this study do it?
1.1 The study addresses an appropriate and clearly focused question. Yes
1.2 The assignment of subjects to treatment groups is randomised. Yes
computer-generated randomized
table of numbers
1.3 An adequate concealment method is used. No
1.4 The design keeps subjects and investigators ‘blind’ about treatment
allocation.
Yes A therapist blinds to
group assignment collected all
outcomes. However, patients
are not blinded.
1.5 The treatment and control groups are similar at the start of the trial Yes
51
1.6 The only difference between groups is the treatment under investigation. Yes
1.7 All relevant outcomes are measured in a standard, valid and reliable way. Yes.
MPAP for pain and mood
1.8 What percentage of the individuals or clusters recruited into each treatment
arm of the study dropped out before the study was completed?
37.5%
(due to death, sedation or
refused)
1.9 All the subjects are analysed in the groups to which they were randomly
allocated (often referred to as intention to treat analysis).
Can’t say.
1.10 Where the study is carried out at more than one site, results are comparable
for all sites.
Does not apply
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise bias?
Code as follows: High quality (++)
Acceptable (+)
Low quality (-)
Unacceptable – reject 0
2.2 Taking into account clinical considerations, your
evaluation of the methodology used, and the
statistical power of the study, are you certain that the
overall effect is due to the study intervention?
Yes
2.3 Are the results of this study directly applicable to the
patient group targeted by this guideline?
Yes
2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own assessment of the study, and the
extent to which it answers your question and mention any areas of uncertainty raised above.
Sample size is small and drop out rate is too high.
1-
52
Record 5:
S I G N
Methodology Checklist 2: Controlled Trials
Study identification (Include author, title, year of publication, journal title, pages)
Mehling, W. E., Jacobs, B. & Acree, M. (2007). Symptom management with massage and acupuncture in
postoperative cancer patients: a randomised controlled trial . Journal of pain and symptom management, 33
(3), 258-266
Guideline topic: Key Question No: Reviewer:
Before completing this checklist, consider:
1. Is the paper a randomised controlled trial or a controlled clinical trial? If in doubt, check the study design
algorithm available from SIGN and make sure you have the correct checklist. If it is a controlled clinical trial
questions 1.2, 1.3, and 1.4 are not relevant, and the study cannot be rated higher than 1+
2. Is the paper relevant to key question? Analyse using PICO (Patient or Population Intervention Comparison
Outcome). IF NO REJECT (give reason below). IF YES complete the checklist.
Reason for rejection: 1. Paper not relevant to key question ⬜ 2. Other reason ⬜ (please specify):
SECTION 1: INTERNAL VALIDITY
In a well conducted RCT study… Does this study do it?
1.1 The study addresses an appropriate and clearly focused question. Yes
1.2 The assignment of subjects to treatment groups is randomised. Yes
(Using a computerised random
number generator prepared by study
statistician who has no contact with
participants)
1.3 An adequate concealment method is used. Yes
(An Opaque envelop is used)
1.4 The design keeps subjects and investigators ‘blind’ about treatment
allocation.
Yes
1.5 The treatment and control groups are similar at the start of the trial Yes
53
1.6 The only difference between groups is the treatment under investigation. Yes
1.7 All relevant outcomes are measured in a standard, valid and reliable way. Yes.
using NRS for pain and POMS-SF
for mood
1.8 What percentage of the individuals or clusters recruited into each treatment
arm of the study dropped out before the study was completed?
4%
1.9 All the subjects are analysed in the groups to which they were randomly
allocated (often referred to as intention to treat analysis).
Can't Say
1.10 Where the study is carried out at more than one site, results are comparable
for all sites.
Does not apply
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise bias?
Code as follows: High quality (++)
Acceptable (+)
Low quality (-)
Unacceptable – reject 0
2.2 Taking into account clinical considerations, your
evaluation of the methodology used, and the
statistical power of the study, are you certain that the
overall effect is due to the study intervention?
Yes
2.3 Are the results of this study directly applicable to the
patient group targeted by this guideline?
Yes
2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own assessment of the study, and the
extent to which it answers your question and mention any areas of uncertainty raised above.
Primary outcome, pain, is significant but secondary outcome, anxiety, is not significant. Concealment method
is mentioned. Sample size is large.
1+
54
Appendix E: Timeline for implementation of the massage program
Week 0-4 Week 5-8 Week 9-12 Week 13 Week 14-
week 25
week 26-28 week 30
1. Formation
of a
communicati
on team
————>
2. Seeking
approval
from the
Hospital
Management
and Nursing
Administrati
on.
————>
3. Refining
the guideline ————>
4. Training
to nurses
and allied
health
professional
————>
5. Pilot
Study ————>
6. Amending
guidelines
and flow of
the full-scale
program
————>
7.Implement
ing the
program
————>
8.Evaluating
the
Outcomes
————>
9.Generating
report from
the findings
————>
55
Appendix F:
Estimated number of massage therapists recruited
Estimated Number of massage therapists recruited
No. of patients eligible for the
innovation
70 patients/day
No. of patients fit for the
innovation
70 X 70 %
= 49
i.e ~ 50 patients/day
* 70% of the patients eligible
would be fit for the
innovation as some may
refuse the treatment
Massage time for each
patient per day
15-30 min 22(=50x3/7) “30-min” session
of massage therapy every day
Working minute for each
massage therapist per day
8 X 60
= 480 min
each massage therapist work 9
hours with 1 hour for
lunchtime
No of “30-min” sessions for
each massage therapist can
conduct each day at the
beginning of the innovation
480/ 30
= 16 sessions
No of massage therapists
have to be recruited
22/16
= 1.4
Spare time will be used to train
nurses are allied health staff are
trained. So the estimated
number of massage therapy
would be two.
However, the massage therapists are recruited for giving training sessions and
supervisor the staff’s performance, therefore 2 massage therapists could be
recruited for the first 8 weeks.
56
Appendix G:
Estimated Material costs for the innovation
Estimated materials costs for the innovation
Set up Costs
Operational Costs
Items
Calculations Items Calculations
Recruitment of
massage therapists for
training of nurses and
other allied health staff
(cover the first 8
weeks)
$40000 x 2 =$80000
Time off given for around
10 staff to attend the
training sessions (at least 5
sessions of 2 hours)
$260 X2X5 X10 = $26000
Time off given for
around 10 staff to
attend the training
sessions (have
continuous training for
staff)
(one session per month
of 2 hour)
$260 X 2 X 10 =$5200
Equipment costs (e.g
notes)
$1000
Amount
$107,000 Amount $5200
Total amount of
materials costs
$112,200
57
Appendix H:
Benefit of implementing the innovation
Benefit of implementing the innovation
Estimated day of hospitalization decreased
1 day per patient
No. of day saved
50
No. of patients admitted more in one
month
50/5
=10
* average length of stay for
each patients= 5
Average spent for each stay for each
patient (either chemotherapy or palliative
treatment)
$100,000
Total money gained for the extra patients
per month
$1,000,000
Benefit > Cost
58
Appendix I: Level of Evidence SIGN grading system: Level of evidence (Scottish
Intercollegiate Guidelines Network, 2008)
1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very
low risk of bias
1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2++ High quality systematic reviews of case control or cohort or studies High quality case
control or cohort studies with a very low risk of confounding or bias and a high
probability that the relationship is causal
2+ Well-conducted case control or cohort studies with a low risk of confounding or bias and
a moderate probability that the relationship is causal
2- Case control or cohort studies with a high risk of confounding or bias and a significant
risk that the relationship is not causal
3 Non-analytic studies, e.g. case reports, case series
4 Expert opinion
Scottish Intercollegiate Guidelines Network. (2008). Key to evidence statements and grades of
recommendations. Retrieved 16th February, 2016, from
http://www.sign.ac.uk/guidelines/fulltext/50/annexb.html
59
Appendix J:
Grade of recommendation
SIGN grading system: Grade of Recommendation (Scottish Intercollegiate Guidelines
Network, 2008)
A At least one meta analysis, systematic review, or RCT rated as 1++, and directly
applicable to the target population; or
A systematic review of RCTs or a body of evidence consisting principally of
studies rated as 1+, directly applicable to the target population, and
demonstrating overall consistency of results.
B A body of evidence including studies rated as 2++, directly applicable to the
target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C A body of evidence including studies rated as 2+, directly applicable to the target
population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Scottish Intercollegiate Guidelines Network. (2008). Key to evidence statements and grades of
recommendations. Retrieved 16th February, 2016, from
http://www.sign.ac.uk/guidelines/fulltext/50/annexb.html
60
Appendix K: Evidence-based practice guideline
Evidence-based practice guideline of using massage therapy to reduce
pain and anxiety level in oncology patients
Aim
The aim of this protocol is to develop guidelines for nurses and other allied health staff in day care
center and oncology wards of Hospital A on the use of massage therapy so as to reduce the pain and
anxiety level of oncology patients in the target setting.
Objectives
The objectives of this protocol are to:
1. Summarize the evidence-based practices on the use of massage therapy.
2. Formulate the evidence-based clinical practice instructions on massage therapy for oncology
patients.
3. Reduce pain and anxiety level through relaxing massage therapy over the body.
4. Provide a safe and cost-effective evidence-based practice for pain reduction and anxiety
relaxation.
61
Target Group
The protocol is to support nurses and other allied health staff to initiate and terminate the massage
therapy on cancer patients who have experienced pain or anxiety when admitted to day care center
or oncology wards in Hospital A. Nurses and allied health staff would perform the massage therapy.
However, only nurse can make the decision to initiate or terminate the massage therapy.
Inclusive criteria of the target patients:
1. Patients should be aged 18 or above.
2. Patients should be cognitively competent who should have GCS =15/15.
Exclusive criteria of the target group:
1. Patients who have any open wound over the body.
2. Patients who have any dermatitis.
3. Patients’ platelet count lower than 100,000/mm3.
4. Patients who have spinal cord injury.
5. Patients who have altered level of consciousness.
62
Recommendations
The levels of evidence were graded under the Scottish Intercollegiate Guidelines Network (SIGN,
2008). There are several grade of recommendation, grade A, B, C and D. Grade A recommendation
refer to there is a systematic review of RCTs or a body of evidence consisting principally of studies
rated as 1+ or there is at least one meta analysis, systematic, or RCT rated as 1++ and directly
applicable to the target population. Grade B of recommendation refers to a body of evidence
including studies rated as 2++. For details of Grade A to Grade D, please refer to Appendix J.
Recommendation 1
Assessment should be conducted by nurses so as to exclude any high risk group as listed in the
exclusion criteria from entering the massage program.
(Grade of recommendation: A )
Evidence:
Patients with certain medical problems, including low platelet count, altered level of consciousness,
dermatitis, spinal cord injury were excluded (Wang et al, 2014; Stringer, Swindell,Dennis, M, 2008;
Toth,et al, 2013; Mehling et al,2007) (1+, 1+,1-,1+). It is essential to exclude these conditions as
massage therapy may cause complications on the above patients such as neuropathy damage,
bleeding or even death.
63
Recommendation 2
Informed consent should be obtained from patients before any massage therapy.
(Grade of recommendation: A)
Evidence:
Not all of the oncology patients would like to have massage therapy. Some may have very negative
feelings towards massage or other body contact. Therefore, informed consent from patients is
necessary. All studies have obtained informed consent before any interventions. (Wang et al ,2014;
Stringer, Swindle and Dennis, 2008;, Toth et al,2013; Sendin et al,2012 and Mehling et al, 2007)
(1+, 1+, 1-, 1-, 1+)
Recommendation 3
Swedish Massage would be used as the method of massage therapy.
(Grade of recommendation: B)
Evidence:
Three studies use Swedish massage as the intervention method (Wang et al ,2014; Stringer, Swindle
and Dennis, 2008;, Toth et al,2013) (1+, 1+, 1-,).
64
Recommendation 4
The duration of massage therapy is recommended to be around 30 minutes, once per day and
two to three times per week, depending on the condition of patients and the time available of
massage therapists.
(Grade of recommendation: A)
Evidence:
Five of the reviewed studies showed that 15-30 minutes of massage therapy had significant effects
in reducing pain or anxiety level of oncology patients. (Wang et al ,2014; Stringer, Swindle and
Dennis, 2008;, Toth et al,2013; Sendin et al,2012 and Mehling et al, 2007) (1+, 1+, 1-, 1-, 1+)
Recommendation 5
Pain intensity level of each patient should be collected as baseline before the start of any
massage therapy intervention. Numeric rating scale (NRS) is the recommended scale.
(Grade of recommendation: B)
Evidence:
Numeric rating scale (NRS) in which zero represents symptom absent and 10 represents the worst
possible symptom. Three studies use NRS (Wang et al ,2014; Toth et al,2013; Mehling et al, 2007)
(1+,1-, 1+). .
Recommendation 6
Anxiety level of each patient should be collected as baseline before the start of any massage
therapy intervention. Numeric rating scale (NRS) is the recommended scale.
(Grade of recommendation:B)
Evidence:
Three studies use Numeric rating scale (NRS) to represents the anxiety level. (Wang et al ,2014;
Toth et al,2013; Mehling et al, 2007) (1+,1-, 1+). .
65
References
Mehling, W. E., Jacobs, B. & Acree, M. (2007). Symptom management with massage and
acupuncture in postoperative cancer patients: a randomised controlled trial . Journal of pain and
symptom management, 33 (3), 258-266.
Sendin L., Sedin, F. A. & Cleland, J. A. (2012). Effects of physical therapy on pain and mood in
patients with terminal cancer: a pilot randomised clinical trial. the journal of alternative and
complementary medicine, 18 (5), 480-486.
Scottish Intercollegiate Guidelines Network. (2008). Key to evidence statements and grades of
recommendations. Retrieved 16th February, 2016, from
http://www.sign.ac.uk/guidelines/fulltext/50/annexb.html
Stringer, J., Swindell, R. & Dennis, M. (2008). Massage in patients undergoing intensive
chemotherapy reduces serum cortisol and prolactin. Psycho-Oncology, 17 1024-1031.
Toth, M., Marcantonio, E. R. & Davis, R. B. (2013). Massage Therapy for patients with metastatic
cancer: A pilot Randomised controlled Trial. The journal of alternative and complementary
medicine, 19 (7), 650-656.
Wang, T. J., Wang, H. M. & Yang, T. S. (2015). The effect of abdominal massage in reducing
malignant ascites symptoms. Research in Nursing & Health, 38 51-59.
66
Appendix L : Assessment Form for massage treatment
Patient ID:_____________________
Pre and Post assessment form for massage treatment
Pain level before massage therapy NRS (0-10)
Pain level 30 minutes after massage
therapy NRS (0-10)
Pre and Post assessment form for massage treatment
Anxiety level before massage
therapy NRS (0-10)
Anxiety level 30 minutes after
massage therapy NRS (0-10)
67
Appendix M: Patient’s Questionnaire on Satisfaction towards Massage Therapy
Please choose the scale (5= total agree; 4=agree; 3=no comment; 2=disagree; 1= total disagree
1. I am satisfied with the massage therapy provided.
2. Massage therapy is useful in reducing pain level.
3. Massage therapy is useful in reducing anxiety level.
4. The hospital environment is comfortable for massage
therapy
5. I am satisfied with the staff who perform the massage
treatment
6. I would recommend the massage therapy to the others
who have experienced pain or anxiety from cancer
68
Appendix N: Staff Self-reported Questionnaire on the use of massage innovation
Please choose the scale (5= total agree; 4=agree; 3=no comment; 2=disagree; 1= total disagree
1. I am satisfied with the instruction and
recommendation of the guideline
2. Staff training is good and appropriate.
3. I have confident to perform massage therapy
4. The innovation has increased nursing autonomy
5. I am wiling to perform massage therapy to the
patients who are eligible for the massage intervention.
69
References
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Billhult, A., Bergbon, I. & Stener-Victorin, S. (2007). Massage Relieves Nausea in Women with
Breast Cancer Who Are Undergoing Chemotherapy. The Journal of Alternative and
Complementary Medicine, 13(1), 53-57.
Cassileth, B. R. & Vickers, A. J. (2004). Massage therapy for symptom control: Outcome study at a
major cancer center. Journal of Pain and Symptom Management, 28 (3), 244-249.
Centre for Health Protection- Vital statistics (2015). Retrieved December 10, 2015 from Centre for
Health Protection, Web site: http://www.chp.gov.hk/en/data/4/10/27/117.html
Falkensteiner, M., Mantovan, F., Muller, I. & Them, C. (2011). The Use of Massage Therapy for
Reducing Pain, Anxiety, and Depression in Oncological Palliative Care Patients: A Narrative
Review of the Literature. International Scholarly Research Network (ISRN) Nursing, 1-8.
Gatlin, C.G. & Schulmeister, L. (2007).When Medication Is Not Enough: Nonpharmacologic
Management of Pain. Clinical Journal of Oncology Nursing, 11(5), 699-704.
Hong Kong Cancer Registery. (2014, November ). Hospital Authority
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Kim YC, Moon H, Ahn JS, Minerva M, et al. Cancer pain management practices and their impact
on quality of life for Asian cancer patients. Abstract 6531. ASCO 2015: Annual Meeting of the
American Society of Clinical Oncology. May 29-June 2, 2015. Chicago, IL
Pandey, M., Sarita, G. P. & Devi, N. (2006). Distress, anxiety, and depression in cancer patients
undergoing chemotherapy. World Journal of Surgical Oncology, 4 (68), 1-5.
Saturon, P. J., Martinez-nicolas, I. & Robles-garcia, I. S. (2014). Development and pilot test of a
new set of good practice indicators for chronic cancer pain management. European Journal of Pain,
1 1-11.
SIGN checklist (2015). Retrieved December 10, 2015 from
http://www.sign.ac.uk/methodology/checklists.html
Spooren, W. P., Vassout, A. & Neijt, H. C. (2000). Anxiolytic-Like Effects of the Prototypical
Metabotropic Glutamate Receptor 5 Antagonist 2-Methyl-6-(phenylethynyl)pyridine in Rodents.
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Start, D. & House, A. (2000). Anxiety in cancer patients. British Journal of Cancer, 83 (10), 1261-
1267.
Vickers A, Zollman C. ABC of complementary medicine. Massage therapies. BMJ 1999; 319
(7219):1254-1257
WHO- Cancer (2015). Retrieved December 10, 2015 from World Health Organization, Web site:
http://www.who.int/mediacentre/factsheets/fs297/en/