n CJON Writing Mentorship Article

Using Relaxation and Guided Imagery

to Address Pain, Fatigue,
and Sleep Disturbances: A Pilot Study
Angela K. Nooner, MBA, MSN, APRN, ACCNS-AG, OCN®, Kathleen Dwyer, PhD, RN, Lise DeShea, PhD,
and Theresa P. Yeo, PhD, MPH, AOCNP®
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Background: Few studies have been conducted on the use of patient-controlled relaxation and
guided imagery interventions for the symptom cluster of pain, fatigue, and sleep disturbance
during cancer treatment.
Objectives: The primary aim of this study was to evaluate the feasibility, acceptability, and
participant satisfaction with use of patient-controlled relaxation and/or imagery interventions
© Monkeybusinessimages/Thinkstock for pain, fatigue, and sleep disturbance. A secondary aim was to examine the data for trends in
pain, fatigue, and sleep improvement because of the effects of relaxation and guided imagery.
Methods: Twelve adult patients with cancer were randomized to one of four groups: a guided imagery intervention, a
relaxation intervention, a combined intervention using guided imagery and relaxation, or usual care. Pain, fatigue, and
sleep disturbance were assessed upon enrollment and at 30 and 60 days. Patients’ scores were obtained using the Patient-
Reported Outcomes Measurement Information System (PROMIS) Pain Interference Short Form, PROMIS Fatigue Short Form,
and PROMIS Sleep Disturbance Short Form tools.
Findings: Patients reported a high degree of satisfaction with the relaxation and guided imagery interventions. Patients in
the relaxation and guided imagery or combined groups showed a trend toward improvement in fatigue and sleep disturbance
scores. Pain remained a problem for the majority of patients. Difficulties in recruiting participants resulted in an insufficient
sample size for generalizable findings. With hospital environments tending to be noisy, relaxation and guided imagery may
facilitate rest and sleep for hospitalized patients. An examination of individual scores showed a trend toward improvement
in sleep quality.
Angela K. Nooner, MBA, MSN, APRN, ACCNS-AG, OCN®, is an oncology clinical nurse specialist at the Oklahoma University Medical Center in Oklahoma City; Kathleen
Dwyer, PhD, RN, is a professor and Henry J. Freede Chair in Nursing Science, and Lise DeShea, PhD, is a senior research biostatistician in the College of Nursing, both at
the University of Oklahoma Health Sciences Center in Oklahoma City; and Theresa P. Yeo, PhD, MPH, AOCNP®, is co-director of the Jefferson Pancreas Tumor Registry, a
surgical oncology nurse practitioner in the Department of Surgery at Thomas Jefferson University Hospital, and an adjunct associate professor in the Jefferson College
of Nursing at Thomas Jefferson University in Philadelphia, PA. The authors take full responsibility for the content of the article. Nooner and Yeo were participants in
the Clinical Journal of Oncology Nursing (CJON) Writing Mentorship Program. This study was supported, in part, by a grant from the DAISY Foundation. The content
of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships
relevant to the content of this article have been disclosed by the independent peer reviewers or editorial staff. Nooner can be reached at angela.nooner@hcahealthcare
.com, with copy to editor at CJONEditor@ons.org. (Submitted September 2015. Revision submitted November 2015. Accepted for publication November 28, 2015.)
Key words: disease management; pain management; fatigue; insomnia; guided imagery; relaxation techniques
Digital Object Identifier: 10.1188/16.CJON.547-552

D
espite improvements in diagnosis and treatment,
many patients with hematologic malignancies
still experience undesirable symptoms and side
effects that undermine quality of life. The pri-
mary purpose of this study was to evaluate the
feasibility, acceptability, and participant satisfaction with the
use of patient-controlled relaxation and imagery interven-
tions for pain, fatigue, and sleep disturbance in a population
of patients with hematologic malignances and solid tumors.
A secondary aim was to examine the data for trends in pain,
fatigue, and sleep improvement because of the effects of
relaxation and guided imagery.
Studies have shown that as many as 96% of patients with
cancer experience fatigue during treatment and after therapy
has been completed (Finnegan-John, Molassiotis, Richard-
son, & Ream, 2013; Yeo & Cannaday, 2015). The National

Clinical Journal of Oncology Nursing • Volume 20, Number 5 • Relaxation and Guided Imagery Interventions 547
 Comprehensive Cancer Network (2016) reported that fatigue
is rarely an isolated symptom and most commonly clusters
with other symptoms, such as pain, distress, anemia, and
sleep disturbance. In Coleman et al.’s (2011) study of 2,600
patients with cancer, 39% reported insomnia. As many as
95% of patients with advanced cancer experience a sleep
disorder (Ducloux, Guisado, & Pautex, 2012). Pain preva-
lence in patients with cancer is estimated to be as high as
53%–60% (Gorin et al., 2012; Montague & Green, 2009). Pain
may interrupt sleep and increase fatigue (Coleman et al.,
2011). A prospective study of 249 patients with newly diag-
nosed or recently relapsed acute leukemia identified a lack
of energy, difficulty sleeping, and pain as the most common
and distressing symptoms (Zimmermann et al., 2013). In ad-
dition, 91% of participants in the study reported more than
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five concurrent symptoms, and 61% reported more than 10
concurrent symptoms (Zimmermann et al., 2013).
Pharmacologic treatments alone often provide inadequate
relief for cancer-related symptoms and may cause additional
problems, such as respiratory depression, constipation, nau-
sea, vomiting, weakness, confusion, difficulty urinating, and
itching (Dalal, 2015; Dambrosio & Mazanec, 2013; Finnegan-
John et al., 2013). Few studies have been conducted on
the feasibility and effectiveness of relaxation and guided
imagery interventions in an inpatient cancer population.
Kwekkeboom, Abbott-Anderson, and Wanta (2010) evalu-
ated the efficacy of teaching patients with advanced cancer
to increase personal control over cancer symptoms, such as
pain, fatigue, and sleep disturbance, through relaxation, im-
agery, and distraction. The small study of 30 adult patients,
mostly Caucasian women with advanced colorectal, lung,
or gynecologic cancer receiving chemotherapy or radiation
therapy, found that severity scores for all three symptoms
were reduced immediately after using the strategies. Relax-
ation and guided imagery techniques can be used to distract
attention away from symptoms and assist patients in coping
with unpleasant thoughts and feelings associated with their
symptoms (Kwekkeboom et al., 2010). Guided imagery and
cognitive behavioral interventions have the potential to
reduce fear and distress and to teach self-regulatory skills
that assist with overall symptom management (Landier &
Tse, 2010).
Methods
Participants
The study used a convenience sample of men and women
aged 21 years or older with hematologic malignancies or
solid tumors who were admitted to the inpatient oncology
unit for chemotherapy or prior to hematopoietic stem cell
transplantation (HSCT). Participation was limited to those
who had at least 60 total days remaining in their current
treatment course, either as an inpatient or outpatient, and
were able to read, write, and understand English at a sixth-
grade level. Exclusion criteria were treatment exclusively
for symptom management, evidence of brain metastases,
a diagnosis of altered mental status by treating physician,
visual or physical impairments that would interfere with
548 October 2016 • Volume 20, Number 5 • Clinical Journal of Oncology Nursing
the completion of self-administered questionnaires, evi-
dence of hearing impairment, current psychiatric diagnosis
(e.g., severe depression, dementia), concurrent diagnosis of
medical disorders interfering with sleep (e.g., sleep apnea,
narcolepsy), and history of seizures.
One goal of the study was effect size estimation instead
of hypothesis testing. Therefore, the target sample size was
defined by the number of participants needed to obtain a
reasonable estimation of the effect for use in later studies,
rather than powered for statistical significance. Consistent
with recommendations made by Hertzog (2008), the target
sample size was 40 patients. The principal investigator (PI)
approached patients meeting the eligibility requirements
who were hospitalized prior to HSCT or for chemotherapy
administration. All participants received chemotherapy or
chemotherapy plus HSCT from October 2013 to February
2015. Twenty-seven patients who met the eligibility require-
ments were approached to participate in the study. Twelve
patients consented to participate in the study. Three partici-
pants were randomly assigned to each of the four groups.
Design
This exploratory pilot study used a repeated measures
design to evaluate the acceptability and feasibility of patient-
controlled relaxation and guided imagery interventions.
The PI reviewed potential participants’ medical records to
gather information on diagnosis, current treatment protocol,
and medications, as well as to determine eligibility for the
study. After obtaining informed consent, the PI collected
demographic data. Participants also were asked for demo-
graphic data, including date of birth, age at diagnosis, race,
gender, marital status, years of education, previous use of
guided imagery and relaxation techniques, presence of any
concurrent medical conditions, and current medication use.
Pain, fatigue, and sleep scores were collected at baseline
and at 30 and 60 days using the Patient-Reported Outcomes
Measurement Information System (PROMIS) Pain Interfer-
ence Short Form, PROMIS Fatigue Short Form, and PROMIS
Sleep Disturbance Short Form tools.
Participants in the three intervention groups received an
individually assigned MP3 player with headphones contain-
ing the assigned recording(s). They also received instructions
on how to use the MP3 player and headphones. The usual
care group received MP3 players containing the intervention
materials at the end of the study. The MP3 player contained
recordings created by the Monroe Institute (Holt, Recore, Sav-
age, Kiehl, & Doyle, 2008). For guided imagery, participants
received a 19-minute audio program, the Hemi-Sync® Morning
Exercise album (Holt et al., 2008). The recording guides the
listener through waking in the morning. For relaxation, par-
ticipants received a 39-minute audio program, the Hemi-Sync
Guide to Serenity album. The recording guides the listener
through a 10-point system of progressive relaxation.
Three scales were used: PROMIS Pain Interference Short
Form, PROMIS Fatigue Short Form, and PROMIS Sleep
Disturbance Short Form. The PROMIS Roadmap Initiative,
a cooperative research group, developed and validated
scales to measure patient-reported outcomes that are not
 disease-specific but are relevant across common medical
conditions (Cella et al., 2007).
The eight-item PROMIS Pain Interference Short Form as-
sesses the effect of pain on participants’ activities of daily
living and quality of life. For example, one item asks, “How
much did pain interfere with your enjoyment of life?” Re-
sponse options ranged from 1 (not at all) to 5 (very much).
This scale has been shown to have strong internal consis-
tency (a = 0.99) and test-retest reliability (r = 0.85) (Cella et
al., 2010).
The eight-item PROMIS Fatigue Short Form assesses a
range of self-reported symptoms of fatigue. For example,
one item asks participants to rate their agreement with the
statement, “I have trouble starting things because I am tired.”
This item was rated on a scale from 1 (not at all) to 5 (very
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interventions and how to complete the symptom and inter-
vention logs. The PI telephoned or sent follow-up letters to
participants two weeks after discharge and at the 30- and
60-day points during the study if participants were not read-
mitted during the study period. The purpose of the follow-up
was to track intervention fidelity and determine how often
participants had used the intervention materials since the
last contact. Ratings of pain, fatigue, and sleep quality since
the last contact were also collected at the same time as tele-
phone or follow-up letters.
All data were entered into a password-protected Micro-
soft ® Excel spreadsheet, which was used to analyze the
findings. Access to the data was limited to the study PI
and co-investigators and kept in a locked office to protect
data safety and confidentiality. Only deidentified data were

much). Strong internal consistency (a = 0.99) and test-retest transmitted electronically. The study was approved by the
reliability (r = 0.76) have been reported for this scale (Cella Scientific Review Committee of the Peggy and Charles Ste-
et al., 2010). phenson Cancer Center and by the University of Oklahoma
The eight-item PROMIS Sleep Disturbance Short Form Health Sciences Center Institutional Review Board. Informed
assesses self-reported perceptions of sleep quality, sleep consent was obtained from patients prior to enrollment and
depth, and restoration associated with sleep during the past randomization to treatment groups.
seven days. For example, one item asks participants to rate
their sleep quality using a scale from 1 (very poor) to 5 (very
good). Extremely high internal consistency (a = 0.99) and Results
test-retest reliability (r = 0.99) have been reported (Cella et
Of the 12 participants who consented, 11 completed at least
al., 2010).
one assessment. One patient withdrew on the same day that
Two additional instruments were administered: investigator-
consent was given. Reasons cited for declining study partici-
initiated tools and an intervention evaluation. Participants
pation (n = 15) were difficulty filling out forms because of
were asked to complete a symptom and intervention out-
changes in vision, prospective participant would be provid-
come log created by the PI for this study. They were asked
ing care for an ill relative after discharge from the hospital,
to record symptoms experienced, interventions that were
perceived lack of time to dedicate to study participation,
used for relief (including study audio programs or other
feeling guilty for taking an MP3 player if recordings did not
treatment), and how they felt after use of the interventions
work, and not feeling up to participating at this time. Four
in a daily log book. Participants were also asked to rate the
patients completed 60 days in the study. Four patients were
overall relevance, usefulness, and perceived helpfulness of
lost to follow-up, one patient withdrew before completing the
the intervention. Open-ended questions provided an oppor-
tunity for additional comments and suggestions.

Procedure TABLE 1. Sample Characteristics (N = 11)

Participants were randomized using a computer-generated Characteristic n

schedule and the sealed-envelope method to one of four Treatmenta
groups: a relaxation group, a guided imagery group, a group Chemotherapy 10
receiving guided imagery and relaxation, or a usual care Pre-HSCT 8
group. Participants in the relaxation group were asked to lis- Diagnosis
ten daily to the Guide to Serenity recording on their provided Hematologic malignancy 9
Solid tumor 2
MP3 players. Participants in the guided imagery group were
Medicationa
asked to listen daily to Morning Exercise on their provided Narcotics 5
MP3 players. Participants in the relaxation and guided im- Acetaminophen/NSAIDs 6
agery group were asked to listen to both Morning Exercise Antinausea medication 10
and Guide to Serenity once per day. The usual care group Education level
used pharmacologic interventions for symptom management Some high school 2
High school graduate 1
as prescribed by the treating physician. All participants were
Some college 5
asked to record severity of symptoms and to document steps Bachelor’s degree 1
that were taken to manage symptoms, as well as resulting Master’s degree or higher 2
feelings, in a daily log book. All participants were allowed
a
to keep the MP3 player after the study ended. Patients could choose more than one response.
Patients who were discharged during the study period HSCT—hematopoietic stem cell transplantation; NSAID—nonsteroidal
anti-inflammatory drug
were given instructions on how and when to use assigned

Clinical Journal of Oncology Nursing • Volume 20, Number 5 • Relaxation and Guided Imagery Interventions 549
 baseline measures, one withdrew before the 30-day follow-up
related to complications of HSCT, and two patients died dur-
ing the study period. No participants reported previous expe-
rience with guided imagery; two patients reported previous
experience with relaxation interventions. Because of the small
sample size, statistical significance testing was not conducted.
The data were explored graphically for individual trends.
The sample was fairly homogenous in that 10 of 11 self-
identified as Caucasian. Six men and five women partici-
pated, and the mean age was 41 years (range = 27–63). The
majority of patients (n = 9) had a hematologic malignancy;
two patients had a solid tumor. One patient had testicular
cancer in the relaxation group, and one patient had breast
cancer in the usual care group. Ten patients who answered
any questions were actively receiving chemotherapy in prep-
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tracted from the medical record and included hypertension,
cardiac problems, diabetes, obesity, and hypothyroidism.
Table 1 summarizes other details about the sample.
Symptom Assessment
The three PROMIS short-form assessment scale scores were
converted to T scores with standard errors using the PROMIS
instrument guides and conversion tables (PROMIS, 2015a,
2015b, 2015c). T scores are standardized scores based on test-
ing of a large group. The pain, fatigue, and sleep disturbance
scales are normed on a sample of the general population in the
United States. According to the PROMIS scoring guidelines, a
score greater than 50 indicates that the patient had a higher
level of that particular symptom than the average individual.

aration for HSCT. None of the participants had altered mental
status, but one person was diagnosed with brain metastases
after the study began, left the study, and entered a hospice
care program. All of the patients in the study were being
treated for pain, with medications ranging from nonsteroidal
anti-inflammatory drugs to narcotics. Comorbidities were ex-
At baseline, most patients scored above average on pain
that interfered with daily activities (n = 8), on fatigue that
was termed “bothersome” (n = 8), and with regard to sleep
disturbances (n = 9) (see Table 2).
Seven participants completed a 30-day PROMIS reassess-
ment of symptoms. Pain had declined in three patients, and

TABLE 2. Pain Interference, Fatigue, and Sleep Interference Scores Using Patient-Reported Outcomes Measurement
Information System Short Form at Baseline and 30 and 60 Days (N = 12)
Pain Interference Fatigue Sleep Interference

Baseline 30 Days 60 Days Baseline 30 Days 60 Days Baseline 30 Days 60 Days

Patient Score T Score T Score T Score T Score T Score T Score T Score T Score T

Relaxation

Patient 5 15 55 23 61 C C 21 55 25 59 C C 23 53 21 51 C C

Patient 7 8 41 8 41 8 41 12 44 8 33 8 33 19 49 17 49 20 50

Patient 9 8 41 8 41 C C 23 57 18 52 C C 25 55 29 59 C C

Guided imagery

Patient 2 8 41 17 57 23 61 35 69 31 64 30 63 25 55 20 50 26 56

Patient 3 10 50 C C C C 11 43 C C C C 35 66 C C C C

Patient 10 17 57 C C C C 34 68 C C C C 27 57 C C C C

Relaxation and guided imagery

Patient 1 32 67 C C C C 24 58 C C C C 28 58 C C C C

Patient 8 16 56 11 51 12 52 14 47 20 54 14 47 25 55 22 52 20 50

Patient 12 26 63 11 51 14 54 19 53 19 53 12 44 17 47 21 51 19 49

Usual care

Patient 4 12 52 8 41 C C 28 61 10 41 C C 22 52 21 52 C C

Patient 6 C C C C C C C C C C C C C C C C C C

Patient 11 25 62 C C C C 25 59 C C C C 20 50 C C C C

C—censored; T—T score

Note. Scores range from 8–40. T scores are standardized scores based on testing of a large group from the U.S. general population, with scores greater
than 50 being above average (SD = 10). Censored scores were participants who withdrew because of death, loss to follow-up, or patient request.

550 October 2016 • Volume 20, Number 5 • Clinical Journal of Oncology Nursing
 fatigue was improved in four patients. Pain decreased in two
patients in the relaxation group by 4 and 5 points, respec-
tively, and in one patient in the usual care group by 15 points;
therefore, no intervention group was superior to another in
this regard. Fatigue declined in one patient in the relaxation
group by 4 points, two patients in the relaxation plus guided
imagery group each by 5 points, and one patient in the usual
care group by 15 points. Sleep disturbances improved in two
patients in the relaxation group by 1 and 2 points, respec-
tively, one patient in the guided imagery group by 3 points,
and one patient in the relaxation plus guided imagery group
by 5 points. Overall, four of seven patients continued to report
pain, fatigue, and sleep disturbance scores that were greater
than the U.S. population average. Sleep quality and other
sleep characteristics improved. All but one patient reported
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more refreshing sleep and fewer sleep problems at 30 days
than at baseline.
Four patients remained in the study at 60 days: one patient
in the relaxation group, two patients in the guided imagery
group, and one in the combined relaxation and guided
imagery group. No one remained in the usual care group.
Eight patients’ scores were censored from the data for the
following reasons: death, loss to follow-up, or withdrawal
from the study. All four patients reported lower fatigue levels
than at 30 days, and only one still had a T score greater than
50. Two patients had less trouble sleeping, and the other two
patients reported slightly more sleep disturbances. Three of
four patients continued to report pain at 60 days.
Participant Evaluation of Study
Five patients completed the final program evaluation (one
from the relaxation group, two from the guided imagery
group, and two from the relaxation plus guided imagery
group). Patients overwhelmingly felt that the study interven-
tions were easy to use, that the directions were understandable
and relevant to their condition, and that the study was well
organized. Most were satisfied or very satisfied with the pro-
gram and would recommend the interventions to others. One
of the participants in the guided imagery group commented
that the intervention should be used in the evening and not
upon waking. Another guided imagery group participant com-
mented that the program was “too much to keep up” during
a complicated treatment course. Two critical comments con-
cerned the symptom log; patients felt it was too much work to
complete. Only two patients completed the symptom log. This
finding suggests the need to explore other methods by which
to track the patients’ experience and other adverse symptoms.
Discussion
Although the sample size was smaller than planned, in-
formative findings were possible through examination of
individual trends in the data. Overall, the interventions were
favorably viewed by the participants, as was evident from
their qualitative responses. Participants reported that the
relaxation and guided imagery interventions improved sleep
quality. An inpatient intervention may be helpful for future
participants, particularly considering that adult oncology
Clinical Journal of Oncology Nursing • Volume 20, Number 5 • Relaxation and Guided Imagery Interventions
Implications for Practice
u Offer patients the opportunity to use self-controlled guided
imagery for relaxation and symptom relief.
u Educate other members of the healthcare team about the
benefits of nontraditional relief measures.
u Elucidate the benefits for patients with cancer by perform-
ing nurse-initiated research in this area.
services at the study facility scored worse than the national
average for quietness of hospital environment on the Hospi-
tal Consumer Assessment of Healthcare Providers and Sys-
tems (2016) during the intervention period. Although noise
levels cannot always be controlled, the patients’ experience
may be improved through use of the relaxation recordings
or guided imagery.
Strengths and Limitations
Because of difficulties recruiting participants, the study
sample was not large enough to measure the statistical
significance of relaxation and guided imagery as adjunct
treatments for pain, fatigue, and sleep disturbances during
inpatient cancer treatment. However, qualitative data suggest
the intervention aided sleep and was useful in achieving a
restful state in a noisy hospital environment. The possibility
that the intervention may improve inpatient sleep and rest
quality should be explored in additional studies.
Implications for Practice
Oncology nurses, nurse practitioners, and clinical nurse
specialists serve in key positions as members of the oncology
patient care team. Patients trust the nursing staff’s experi-
ence and look to them for suggestions on symptom manage-
ment. Nurses may need to be aware of non-traditional relief
approaches and advise patients as they try different methods
for symptom relief. The findings and trends identified in this
small pilot study were shared with oncology nursing staff at
the study hospital and provide supporting evidence for the
importance of quality rest and sleep in creating a positive
healing environment. Sleep is essential for recovering from
treatment, general well-being, and survival. According to
the American Academy of Nursing (2016), “sleep deprivation
negatively affects ventilator, circulatory, immunologic, hor-
monal and metabolic stability” (para. 4). The study investiga-
tors have proposed conducting a subsequent study using the
remaining MP3 players as an intervention to improve sleep
quality and restfulness in adult patients with hematologic
malignancies receiving inpatient treatment for seven or more
consecutive days.
Conclusion
The use of relaxation and guided imagery techniques
are feasible interventions for inpatients with hematologic
551
 malignancies and solid tumors. Few adverse effects were
reported by patients who used these methods, and much
potential benefit exists. Additional studies using relaxation
and guided imagery interventions as adjunct therapy for
symptom management with a larger sample of patients with
cancer is recommended.
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