Implementing Physical Activity Recommendations in Clinical Practice: A Survey of Oncology Nurses’ Perspectives

Abstract

Objectives

To understand oncology nurses’ perspectives about how interventions should be designed to promote physical activity in clinical settings.

Sample and Setting

Seventy-five oncology nurses completed online surveys.

Methods and variables

A published survey, guided by the Consolidated Framework for Implementation Research, was used to assess multi-level factors that influence implementation of evidence-based interventions. Descriptive statistics were applied to quantitative data; directed content analyses were applied to qualitative data.

Results

Oncology nurses believed it was important to discuss physical activity with patients; however, they had limited self-efficacy and resources to provide physical activity counseling. Barriers to providing such counseling include competing clinical demands, lack of education about physical activity for cancer survivors, and lack of resources.

Implications for Nursing

Findings inform how interventions can be designed for implementation and sustained practice change in clinical settings. Integration of physical activity education in routine clinical practice will lead to increased physical activity and, ultimately, improved quality of life among cancer survivors.

Knowledge translation

1. Oncology nurses may deliver brief education-based PA interventions as part of their clinical practice.

2. PA interventions should be tested that account for oncology nurses having little training about PA or time to discuss PA with patients.

3. Oncology nurses may seek continuing education on PA evidence-based resources to implement PA-focused quality improvement projects.

Physical activity (PA) promotion has always been part of oncology nursing. The field of exercise oncology was initiated by nurses who, countering beliefs about patients needing to rest and avoid activity during cancer treatment, were the first to test an exercise intervention and discover that exercise decreases chemo-induced nausea (Jones & Alfano, 2013; MacVicar et al., 1989; Winningham & MacVicar, 1988; Winningham et al., 1989). Despite widely agreed-upon PA guidelines and decades of evidence that PA improves cancer outcomes, few people living beyond a cancer diagnosis engage in PA as recommended (Campbell et al., 2019; Patel et al., 2019; Schmitz et al., 2019). Nurses have a critical role to play in leading practice changes to better support patients to engage in PA as recommended.

PA is recognized as an important aspect of cancer care that is safe both for patients on active treatment and for those who have completed treatment, regardless of cancer type (Campbell et al., 2019; Rock et al., 2022). For people living past a cancer diagnosis, guidelines are in place from the American Cancer Society (ACS) and the American College of Sports Medicine (ACSM) to ensure the maximum benefit can be gained. These guidelines include recommendations for 150-300 weekly minutes of moderate activity, or 75-150 weekly minutes of vigorous activity, or a combination of moderate and vigorous activity, combined with muscle-strengthening activities two times per week (Campbell et al., 2019; Rock et al., 2022). PA benefits the physical, mental, and emotional health of people living past a cancer diagnosis (Turner et al., 2018). These benefits can include a reduction in mortality, the recurrence of some cancers, the side effects/symptoms of cancer and cancer treatment (e.g., fatigue, pain, sleep), as well as improved quality of life, physical function, and mental and emotional wellbeing (Rock et al., 2022; Turner et al., 2018).

Despite documentation of PA’s beneficial effects, people living past a cancer diagnosis continue to have low levels of PA participation. A recent cross-sectional study of people living past a cancer diagnosis indicated that 93% of the studied population was not active at levels recommended by the ACSM (Avancini et al., 2020). These low participation levels indicate that decades of evidence supporting the benefits of PA for survivors of cancer and accepted national recommendations are insufficient to promote PA in this population. There is a pressing need to understand how patients living beyond a cancer diagnosis may be better supported to achieve evidence-based PA recommendations.

Although multiple evidence-based PA interventions exist, numerous barriers impact their delivery. While clinicians have the unique ability to influence patient lifestyle and health behaviors—including PA education and promotion (Alderman et al., 2020)—no clear policy or practice establishes which member of the clinical team should provide PA education to people living beyond a cancer diagnosis. This lack of clarity creates a clinical gap, leaving the ownership of PA education within the oncology setting without a specific champion. Oncology nurses are ideally suited to meet this need by initiating early and continuous conversations about PA and linking patients with PA resources (Keogh et al., 2017). Compared to other members of the oncology care team, nurses have more frequent communication with patients; this creates strong nurse-patient relationships that significantly impact patients’ experiences and outcomes (Prip et al., 2018). Additionally, because nurses are the most trusted professionals in the United States, (Saad, 2022) the education they provide is likely to be effective. Findings from a systematic review indicate that patients want to receive PA counseling through cancer treatment centers from cancer-specific fitness experts or clinicians, including nurses (Wong et al., 2018). Oncology nurses can lead the way in promoting PA among patients by providing critically needed education and introducing patients to options for incorporating PA into their treatment plan.

Prior research indicates that oncology nurses should assess patients’ current PA, review established evidence-based PA recommendations with patients, and link patients with resources to support engagement in PA (Bernardo & Becker, 2016; Rock et al., 2022; Schmitz et al., 2019). Current literature has identified barriers to oncology nurses providing such PA education: limited knowledge about PA recommendations and a lack of PA resources to share with patients (Alderman et al., 2020; Cantwell et al., 2018; Hardcastle et al., 2018; Nadler et al., 2017). Thus, in order for oncology nurses to provide PA education, interventions that consider nurses’ clinical demands and perspectives are needed. A systematic and comprehensive understanding of the factors that affect nurses’ provision of PA can lead to the development of PA interventions that are feasible to implement and sustain as part of nursing practice.

This study sought to provide an in-depth understanding of oncology nurses’ provision of PA by drawing on the principles of implementation science. Implementation science seeks to understand the factors that impact the adoption and maintenance of evidence-based practices into clinical settings (National Institute of Health, 2016). The oncology nursing society’s current research agenda advises the use of implementation frameworks to improve translation of research into clinical practice (Von Ah et al., 2019). One such framework is the Consolidated Framework for Implementation Research (CFIR); CFIR describes levels (i.e., intervention, outer setting, inner setting, and individual level) that influence implementation (Breimaier et al., 2015; Damschroder et al., 2022; Damschroder et al., 2009; Leeman et al., 2019). In this study, the CFIR framework was used to organize oncology nurses’ perspectives on the barriers and facilitators to providing PA recommendations to patients. The purpose of this study was to inform the development of a nurse-led PA intervention that considers implementation factors at the time of its design. Findings from this study will lay the groundwork for future interventions by identifying nurses’ perspectives on the multi-level factors that influence the uptake of evidence-based PA interventions in clinical practice.

Methods

Oncology nurses were surveyed between March and May 2020. Eligibility criteria included having a registered nursing license and at least 6 months of experience caring for oncology patients within the last year. The aim of this implementation research study was to understand the multilevel factors that influence implementation in the oncology setting; thus, target enrollment was set at 100 to meet the laws of normal data distribution and provide a range of responses. To account for participant burden and the COVID-19 pandemic, the research team shared study information on their local ONS chapter’s Facebook page to assess interest in participation. This decision was made based on consultation with the chapter leadership and the research team’s personal experiences during the pandemic.

Following a convenience sampling approach, Facebook postings were used to recruit participants. The study’s Facebook page linked potential participants to a REDCap (Harris et al., 2009) secure study screening, consent, and survey completion site. Participants who completed the survey were mailed a $30.00 gift card.

The survey included a questionnaire that is published elsewhere (Hirschey et al., 2021); it contained seven open-ended and 26 closed-ended questions. The research team designed the questionnaire to elicit oncology nurses’ perspectives on the multi-level factors that influence the implementation of PA recommendations in clinical practice (Figure 2) (Younas & Porr, 2018). Prior to administration, the questionnaire was refined through two rounds of cognitive interviewing, with oncology nurses, in which a think aloud process was used to establish the validity of survey questions. Examples of questions are in Tables 2, 3 and 4. This cross-sectional study was approved by the University of North Carolina Institutional Review Board (#19-1288).

Figure 2.

Consolidate Framework for Implementation Research Framework domains assessed and identified by the study survey

Table 2:

Oncology nurse self-efficacy, knowledge, and beliefs about discussing PA with patients (CFIR Characteristics of Individuals)

	M(SD)	Median	Range
With what percentage of your cancer survivor patients do you talk about PA?	59.38(34.08)	70	0-100
How important do you think it is to talk about PA with survivors who…a
Have completed curative treatment	6.50(0.94)	7	2-7
Are recovering from a cancer related surgery	6.22(1.04)	7	3-7
Are undergoing immunotherapy	6.20(1.02)	7	3-7
Are receiving hormone therapy	6.16(1.17)	7	2-7
Are undergoing chemotherapy	6.15(1.08)	6	2-7
Are undergoing radiation	6.05(1.13)	6	3-7
Are newly diagnosed with cancer	6.04(1.43)	7	2-7
Are awaiting a cancer related surgery	5.78(1.43)	6	2-7
Do you agree that talking about physical activity is within the scope of nursing? b	5.72(2.12)	7	1-7
How confident are you to talk about physical activity with cancer survivors who…a
Have completed chemotherapy, immunotherapy and/or radiation	6.12(1.14)	6.50	2-7
Are receiving chemotherapy	5.71(1.42)	6	1-7
Are undergoing immunotherapy	5.60(1.51)	6	1-7
Are receiving radiation	4.99(1.74)	5	1-7
How confident are you in identifying when the following is necessary for a cancer survivor, prior to doing physical activity? a
Mobility assessment	5.14(1.60)	5	1-7
Balance assessment	4.82(1.77)	5	1-7
Cardiovascular assessment	4.51(1.64)	5	1-7
How confident are you that you know how physical activity should be adapted for cancer survivors who are experiencing or have the following:
Low platelet count	5.58(1.42)	6	1-7
Low white blood cell count	5.53(1.43)	6	1-7
Low red blood cell count	5.47(1.43)	6	1-7
Nausea/Vomiting	5.15(1.43)	5	1-7
Diarrhea	5.10(1.44)	5	1-7
Neuropathy	4.85(1.58)	5	1-7
Indwelling catheter	4.81(1.77)	5	1-7
Skin irritation	4.49(1.51)	4.50	1-7
Lymphedema	4.40(1.68)	4	1-7
Ostomy	4.21(1.81)	4	1-7
Stoma	4.17(1.82)	4	1-7

Notes.

^a1=not at all – 7=extremely.

^b1=strongly disagree – 7=strongly agree.

Table 3:

Oncology Nurse Input on Factors in Their Workplace that May Impact Them Talking about PA with Patients (CFIR Inner Setting)

	M(SD)	Median	Range
How many minutes do you have to talk about PA with patients?	7.70(8.11)	5	0-60
What percent of your colleagues at your workplace do you think talk about PA with cancer survivors?	43.62(28.66)	50	0-100
How important do you think the following people think it is to talk about physical activity with cancer survivors? a
Other nurses who work in your unit/department	5.17(1.34)	5	1-7
Your nurse manager	4.74(1.84)	5	1-7
Your charge nurse	4.73(1.70)	5	1-7
The chief nursing officer of your institution	4.21(1.91)	4	1-7
	n (%) “Yes” responses
Does your workplace provide continuing education or training about physical activity for cancer survivors?	10 (13)
Does your workplace have any written policies or guidelines about discussing physical activities with cancer survivors?	8 (11)
Is there a place for you to document or chart physical activity assessments or conversations you have with cancer survivors?	39 (52)
In your workplace, is there a physical space where your patients can do physical activity (e.g., a walking route through the hallways, an exercise room)?	49 (65)

Notes.

^a1=not at all – 7=extremely.

Table 4:

Oncology Nurse Input on How External Factors Impact Them Talking about PA with Patients (CFIR Outer Setting)

	M(SD)	Median	Range
To what extent do you agree that the following reflects the importance of nurses discussing PA with cancer survivors:
Nursing conferences	4.84(1.48)	5	1-7
My national professional nursing organizations	5.07(1.45)	5	1-7
Nursing journals	4.81(1.30)	5	2-7
My local chapter of my professional nursing organizations	4.25(1.60)	4	1-7
How important do you think other oncology nurses across the US think it is to talk about physical activity with cancer survivors? We are interested in your perceptions of other people. b	5.33(1.20)	5	2-7
What % of your colleagues across the US do you think talk about PA with cancer survivors?	37.81(22.95)	30	0-90

Notes.

^a1=strongly disagree – 7=strongly agree.

^b1=not at all – 7=extremely.

Analyses

Descriptive statistics were conducted in R to describe the study sample and analyze quantitative data. Directed content analysis was applied to qualitative data from the open-ended questions (Hsieh & Shannon, 2005). Specifically, the CFIR domains were used as coding categories to group participant responses as they related to (1) characteristics of individuals (e.g. self-efficacy, knowledge, beliefs of the individuals implementing intervention), (2) characteristics of the inner setting (e.g. relative priority, resources, readiness for implementation), (3) characteristics of the outer setting (e.g. policies, organizations meeting patient needs), or (4) characteristics of the interventions (e.g. feasibility and adaptability of the intervention, evidence). All codes were applied by one researcher (MW) and reviewed through discussion with a second researcher (RH).

Results

Participant Demographics

A total of 109 nurses completed the screening process. Of these, 105 nurses were eligible for the survey, and 77 gave online informed consent. Seventy-five participants completed the survey (see Figure 1). Responses to open-ended questions ranged from 1 to 78 words long, with an average of 17 (SD 6) words long. Most participants were non-Hispanic, White, cis-gender females who held a Bachelor’s degree; about one-third were oncology-certified (Table 1). Participants worked in a variety of clinical oncology settings (see Figure 3) and cared for patients living beyond a wide range of cancer diagnoses (see Figure 4). Survey findings are organized by CFIR domains (i.e., characteristics of the individual, inner setting, outer setting, and intervention characteristics) and detailed below.

Figure 1.

Participant flow diagram

Table 1:

Participant Demographics

	n(%)/M(SD)	Median	Range
Age	38.11 (10.23)	38	23~66
Sex assigned at birth
Male	1(1.33)
Female	74(98.67)
Current gender identity
Male	1(1.33)
Female	74(98.67)
Race
White	58(77.33)
Asian	5(6.67)
Black or African American	8(10.67)
Hispanic or Latino/a	3(4.00)
Prefer not to answer	1(1.33)
Ethnicity
Hispanic, Latino/a or of Spanish origin	3(4.00)
Not Hispanic, Latino/a or of Spanish origin	71(94.67)
Prefer not to answer	1(1.33)
Marital status
Single (never married)	26(34.67)
Married or domestic partnership	42(56.00)
Widowed	1(1.33)
Divorced	5(6.67)
Separated	1(1.33)
Prefer not to answer	1(1.33)
Education degree
Associate	7(9.33)
Bachelor	48(64.00)
Master	16(21.33)
Doctorate	4(5.33)
Weekly minutes of exercise	164.89 (153.90)	120	0~720
Number of years as RN	12.32 (9.98)	10	1.5~44.0
Number of years as Oncology RN	10.12 (8.24)	9	0~39

Note: Because some people identify Hispanic as their race (Cohn et al., 2021; Gonzalez-Hermoso & Santos, 2019; Parker et al., 2015) participants were given the option to self-report their race as Hispanic or Latino/a and were also given the options to report their ethnicity separately.

Figure 3.

Participants’ current practice settings

Figure 4.

Types of cancer diagnoses treated in participants’ practice setting

CFIR Domain: Characteristics of individuals (oncology nurses)

Self-efficacy, knowledge, and beliefs.

We identified several characteristics of oncology nurses that influence how they provide PA recommendations to patients. On average, participants reported that they talk about PA with 59% (SD 34) of their patients. As detailed in Table 2, quantitative data revealed that participants believe it is important to talk about PA with all patients, but they did not have high self-efficacy about their ability to do so. Many participants were not aware of ACS or ACSM PA guidelines. When the published guidelines were listed at the conclusion of the survey, several participants left open-ended comments such as “[I] Did not know these recommendations existed,” and “I wasn’t aware of these recommendations, but I enjoyed learning about them.” In summary, the most common responses about why oncology nurses were not talking about PA were related to feelings of unpreparedness and lack of knowledge.

Across participants, various personal beliefs were held about the appropriateness of talking about PA with patients. Participants shared that they will not talk about PA with all patients because “some patients are very sick, recovering from surgery, have activity restrictions, can’t leave their room, have restrictions of going into public” and that nurses are “not wanting to overwhelm patients in circumstances that are already overwhelming.” Another participant explained that “when patients are diagnosed, the focus tends to be on pharmacological treatment plans, coping, and emotional/ physiological strength to tolerate treatment plan” and there is so much for patients to process. However, participants also shared that despite these challenges, they prioritize PA promotion because they believe “it should be as high of a priority as taking medications appropriately because PA can drastically affect how well patients respond to treatment.” Further, one person said that they have “taken personal initiative to work PA recommendations into the personal care they provide because they have seen the benefits for patients.” Findings indicate there is a range in nurses’ beliefs about if they should recommend PA to patients, especially those newly diagnosed with cancer.

CFIR Domain: Inner setting (oncology clinics / hospitals)

Quantitative data (see Table 3) revealed that oncology nurses have little time—on average less than 8 minutes—to talk about PA with patients and that they believe less than half (44%) of their nurse colleagues talk about PA with patients. Additionally, few resources were identified in participants’ workplaces to support them in providing PA recommendations, as only 13% indicated they are offered continuing education on the topic and 48% indicated that there is not a place for them to chart their PA assessment and patient education.

As detailed below, findings from qualitative data identified several workplace barriers that impede oncology nurses from providing PA counseling in the outpatient setting and facilitators in both the outpatient and inpatient settings.

Relative priority.

Participants identified lack of time as the biggest barrier in their workplace for them to talk about PA with patients. They explained that they have limited time with patients and need to prioritize accordingly. For example, one participant said, “it can be difficult at times to focus on PA when nurses have so many tasks at hand to accomplish in a shift. PA can be pushed to the side if a patient is really sick and requires a lot of medical intervention.” Similarly, another participant expressed that “in [the] outpatient infusion center, time is so limited because of patient load and emphasis on finishing treatment and getting another patient for treatment.” Overall, oncology nurses indicated that they simply do not have enough time with patients to assess patients’ PA and provide PA recommendations.

Lack of Resources and Institutional Readiness.

Findings also revealed that many oncology care settings do not provide standard resources and procedures to support nurses in talking about PA with patients. One participant stated: “It’s never really been addressed, such as during orientation and training for the oncology unit. Therefore, nurses don’t feel comfortable discussing it, or [know] how to suggest PA to patients with a specific condition.” Across the 75 participants, only twelve identified resources at their workplace, including “inpatient exercise programs,” “discharge instructions,” “survivorship clinic,” “nurse educator plans activities for staff,” “telehealth lectures,” and “lunch and learn activities.” Only eight participants identified institutional policies that support nurses in promoting PA, which consisted of “inclusion in patient education materials or handbooks” and “access to the intranet.” When provided an open text field to indicate where nurses may chart PA assessment or education, a variety of places were listed including “nurses note,” “education tab,” “care plan,” “daily care activity flowsheet,” “discharge paperwork,” “activity assessment,” “rounding section of chart,” “whiteboard,” and “body systems charting.” Across all participants, no well-established consistent standard practices, policies, or procedures related to conducting PA assessments were identified.

In-patient exercise spaces.

Among participants who worked in in-patient settings, facilitators to nurses supporting patients to do PA were identified. Specifically, the existence of an exercise room, the ability to put an exercise bike in a patient’s room, space to walk in hallways, and/or having a recreation therapist who could meet with inpatients were cited as beneficial.

CFIR Domain: Outer setting (oncology nursing profession at large and external oncology and nursing organizations)

Quantitative data (Table 4) revealed that participants believe that nationally, across the oncology nursing profession, a minority of oncology nurses talk about PA with patients. When asked on a 1-7 scale (1=strongly disagree, 7= strongly agree), they rated their agreement that nursing organizations, conferences, and journals reflect the importance of promoting PA for their patients about a five. Open-ended response questions provided no additional insights into how the oncology nursing profession supports nurse recommendation of PA.

Resources that meet patient needs.

Participants identified the need for resources that meet the needs of patients recovering from cancer treatments. For example, in referring to challenges for hospitalized patients, one nurse expressed the “need [for] options for patients who can’t leave room often like those on contact or enteric precautions.” Another nurse expressed that they didn’t know of resources to support their patients after discharge “because they are very restricted in terms of going out in public, outside, to a gym, etc. There are a lot more barriers to exercise after discharge and I’m not sure how to suggest they continue PA.” Across participants, a need for additional patient PA resources was consistently noted.

CFIR Domain: Intervention characteristics (nurses providing PA recommendations)

As detailed in Figure 5, quantitative data indicate that when oncology nurses were asked to identify all of the people on the oncologic team who should talk about PA with patients, the nurse practitioner was the one most often selected (selected by 95% of participants), followed by the physician’s assistant and medical oncologist (both 92%), the bedside nurse (88%), and the clinic nurse (85%).

Figure 5.

Participants’ preferences for which oncology team members should talk about physical activity with cancer survivors

As detailed below, findings from qualitative data offer several specific suggestions from oncology nurses about characteristics that should be incorporated in PA interventions. These specific suggestions relate to nurses’ perspectives about what will increase the feasibility and adaptability of PA interventions, as well as their ability to deliver such interventions.

Feasibility and Adaptability.

Participants provided a wide range of suggestions that would make PA counseling feasible in their clinical setting, which indicates a need for interventions that are adaptable to the specific circumstances of a given clinical setting. For example, one person suggested that a physician initiate the first conversation; other members of the interdisciplinary team would then reinforce the message, especially nurses because they have the most contact with patients. Participants also indicated that they thought intervention should begin with discussions about the importance of PA at diagnosis (and before, if possible, in a preventative capacity) and continue throughout survivorship visits. Finally, participants identified several specific materials that could be incorporated into interventions to promote oncology nurses’ discussion of PA with patients, including “resources that show patients what to do,” “monthly support groups,” “virtual visits (video and phone),” “community forums,” “newsletters to patients,” “podcasts,” “handouts,” ‘websites,” and “referrals to exercise therapy programs.” Across participants, there was enthusiasm for support in discussing PA with patients.

Evidence-based guidance.

Participants indicated that nursing education about the evidence of PA guidelines for cancer survivors is needed, in particular around safety considerations. For example, one participant indicated that receiving guidance on “best practices on timing for discussing PA & resources for SAFE PA for different diagnoses would be ideal.” Another said that they would like to receive “education for all levels (e.g. repositioning in a chair to prevent decline, muscles to promote on and off toilet – functional movement is key, provided space and recommendations on consistent assessment and documentation).” One participant shared at the conclusion of the survey that “Even the act of completing this survey brought to my attention areas where I could and should expand my knowledge regarding how/when to encourage PA for patients. It is so important and should be standard discussion, not a low priority!”. Across the board, participants noted a need for interventions that include nursing education about PA recommendations for individuals living beyond a cancer diagnosis.

Discussion

Collectively, findings from this study identify details about multi-level factors that influence the design of a nurse-level PA intervention that will fit within the oncology clinic setting. Importantly, these findings are from the perspective of oncology nurses, who lead the way in patient education, spend the most time with patients. Additionally, patients may be especially receptive to this information coming from nurses because nurses are consistently rated as the most trusted profession in the Gallup poll, which regularly assess Americans’ opinions (Saad, 2022). This perspective is critical for interventionists to take into account when designing future PA recommendations that are conducive to uptake and sustainable in clinical oncology settings.

Notably, the findings indicate that oncology nurses have various beliefs about the appropriateness of recommending PA for patients, especially those newly diagnosed with cancer. Noted concerns included being perceived as insensitive and burdening patients with instructions to do something that may be challenging during a difficult time. Yet, research shows that patients want guidance on PA during cancer treatments. For example, a cross-sectional study of 392 patients receiving outpatient cancer treatments reported that 80% of participants expressed interest in PA programs (Avancini et al., 2020). Additionally, the ACS recommends that PA counseling begin as soon as possible after a cancer diagnosis because it can significantly help patients prepare for and manage treatment and side effects, as well as improve their long-term outcomes and quality of life (Rock et al., 2022). These findings point to the need for interventions that include nursing continuing education about the benefits of PA and the clinical importance of incorporating it into clinical oncology care.

The findings also indicate that while oncology nurses believe it is important to discuss PA, they feel underprepared to do so. These findings are supported by the results from a recent qualitative study with fourteen oncology nurses; the authors indicate that education about PA for individuals living beyond a cancer diagnosis is necessary in order for nurses to encourage PA for this population (Avancini et al., 2021). Nurses’ feelings that they are underprepared to speak about PA recommendations and the necessary precautions to address for different patients may contribute to another of the current study’s findings—nurses not feeling that they have enough time to discuss PA. It is reasonable that a lack of confidence surrounding PA recommendations may cause nurses to overestimate the amount of time needed to address PA.

Finally, findings indicate that oncology nurses need resources to support them in providing PA education to patients. Professional organizations have created clinician resources including the Oncology Nursing Society’s Get-up-Get-Moving Campaign (Oncology Nursing Society) and the American College of Sports Medicine’s Moving through Cancer Campaign (American College of Sports Medicine). Additionally, nursing journals have published recommendations on how to incorporate considerations of the social determinants of health into PA counseling (Hirschey, Tan, et al., 2021), and the oncology nursing podcast has discussed this topic (Hirschey, 2022). A recent study demonstrated that nurse PA coaching guided by ONS’s Get-up-Get-Moving Campaign, delivered both in an infusion center and via telephone, positively impacted PA among individuals receiving chemotherapy and/or radiation for breast, colon, or prostate cancer (Forner et al., 2021). Another nurse-led counseling PA intervention improved pain and quality of life among patients newly diagnosed with head and neck cancer (Hong et al., 2022). PA guidelines and resources put forth by national organizations can be used in oncology nurse-led interventions to promote PA among patients.

This research is not without limitations. First, most of the study participants met national PA recommendations themselves. Thus, it is reasonable that they had more favorable attitudes toward PA and were therefore likely to discuss PA with patients because they were personally familiar with the general benefits. Thus, it is possible that the broader oncology nursing population is in even greater need of education about the importance of PA as part of cancer and survivorship treatment. Further, effective interventions may need to engage oncology nurses in PA so that they may become personally more favorable to and knowledgeable about PA.

Second, data were collected in 2020 during the COVID-19 pandemic. This could have a multitude of implications: due to the pandemic, the health care workforce, and especially nurses, have become more overworked and may have even less time now to consider PA for patients. Thus, the importance of providing resources and using a variety of intervention formats such as those that are distance-based and supported by technology may be even more important. Finally, findings are solely from nurses’ perspectives. Perspectives from other members of the oncology care team as well as patients may also inform the design of PA interventions for implementation in oncology clinical settings. However, given that nurses are the people on the interprofessional care team who spend the most time with patients and provide the most patient education, these findings are valuable and represent an important first step for improving delivery of PA recommendations to patients.

Implications for research

Findings from this study show that researchers designing PA interventions should consider how limited nursing time and training about PA will influence intervention implementation and sustainability beyond a research study period. Such approaches will lead to effective interventions that are feasible beyond research settings that provide extra resources and support for PA intervention delivery. Additionally, future research may focus on developing PA interventions for clinical settings that consider organizational readiness for change and perspectives from the other members of the clinical care team. Finally, findings may be applied to inform quality improvement efforts in which nurses may focus on setting-specific circumstances to lead PA promotion efforts specific to their practice.

Implications for practice

While this study is focused on using implementation science approaches to inform the design of implementable and sustainable interventions, its findings are immediately relevant for oncology nursing practice. Oncology nurses should seek continuing education about PA and become familiar with available evidence-based resources from the ONS and ACSM and work within their settings to implement PA-focused quality improvement projects. Additionally, it is critical that clinical settings are adaptive to the relative priorities of tasks that nurses must consider during a given patient interaction. It is reasonable for nurses to provide brief, education-based interventions. The success of such education is likely to depend on additional support from cancer centers, which may include resources and referrals to PA programs and professionals. Particularly, providing PA education for non-English speaking patients will require additional materials and translation services from cancer centers.

Conclusion

Patients living beyond a cancer diagnosis can benefit substantially from engaging in PA. Oncology nurses are poised to lead the way in improving the information that patients receive about the benefits of PA during and after cancer treatment. To support nurses in this important endeavor, researchers must design interventions that are responsive to the needs and circumstances in which oncology nurses may deliver such interventions. This study’s novel approach of beginning intervention design with the endpoint of clinical translation in mind holds promise for the development of a new wave of PA nursing interventions that are not only effective but—equally important—are also implementable and sustainable in nursing practice.