INTRODUCTION:

Cancer is a major global health crisis and is among the foremost causes of death in high-income countries. Worldwide, around 3.91 million cancer cases and 1.93 million deaths due to cancer were recorded in 2020 (Sung et al., 2021)¹. Although cancer diagnosis and treatment have advanced and succeed in extending patients ‘survival rate, the QOL for patients has not been significantly enhanced³. Generally, cancer affects patients’ QOL through the side effects associated with treatment. Insufficient management of these side effects may also adversely affect patients’ QOL. Therefore, detecting the side effects in the early stages of cancer helps in relieving suffering and enhancing patients’ QOL⁴.

Friedenreich, Ryder-Burbidge and McNeil in 2021 found that PE was associated with a decreased risk for some malignancies, such as colorectal, breast, lung, and pancreatic cancers⁵. In addition, offering meticulously constructed programs of moderate to aggressive PE for patients with cancer can have the advantages of increasing patients’ QOL, reducing CRF, improving cardiovascular fitness, and reducing visceral fat mass⁶. Moreover, Ferioli et al. (2018) emphasized that cancer-specific persistence was shown to be improved through PE⁷. However, concerns have been raised about the lack of PE counselling for patients because of insufficient knowledge among oncology nurses, who are patients’ main point of contact with healthcare and play an important role in patient education.⁸

In response to the current Coronavirus Disease (COVID-19) pandemic, Grazioli et al. (2020) noted that despite the expanding body of evidence regarding the usefulness of PE for patients with cancer either during or after treatment, the pandemic circumstances presented a major impediment to PE for patients. That study suggested a new approach involving engaging oncology patients in proper and successful online home-based PE courses. Healthcare providers should therefore feel comfortable and knowledgeable in recommending an online PE program for patients under their care⁹. The present thesis focused on nurses’ knowledge and awareness of PE for patients with cancer undergoing treatment. This chapter introduces the topic under study and provides a background to contextualize and rationalize the significance of this study. In addition, the chapter describes the study aim and objective, outlines the research question, and provides a definition for the main study variables.

Fatigue is classified as the most common side effect experienced by patients with cancer and has a major impact on patients’ QOL. CRF differs from fatigue because of its severity and perseverance, which is not relieved through rest or sleep. The European Society for Medical Oncology (ESMO) (2020) reported that 25%–99% of patients with cancer suffer from CRF¹⁰. CRF is described as “a distressing, persistent, subjective sense of physical fatigue that is not proportional to the recent activity and interferes with usual functioning”¹¹. Most (80%–90%) patients with cancer undergoing chemotherapy experience CRF. In addition, 21%–80% of those undergoing radiotherapy and 37%–71% of those receiving immunotherapy experience CRF¹².

Hilfiker et al. (2018) found that PE may reduce CRF associated with cancer treatment. Furthermore, that study suggested that maintaining an exercise routine was important to enhance QOL and decrease treatment-induced cardiovascular toxicity, cognitive decline, and CRF among patients with cancer. Those authors reported that PE counselling for patients positively reduce CRF in 63% of cases¹³.

Because oncology nurses are the primary point of contact to assist patients during the treatment journey, their knowledge regarding the benefits of PE should be evaluated to ensure good quality information is delivered to patients¹⁴. Okechukwu (2021) investigated nurses’ awareness of the physiological processes underlying the advantageous effects of exercise therapy and found there was insufficient knowledge regarding the benefits of exercise for patients with cancer among nurses¹⁵. Similarly, Veen et al. (2017) conducted a cross-sectional study to assess oncology nurses’ knowledge about the benefits of PE and found that 46% of oncology nurses had insufficient knowledge when providing advice about PE to patients¹⁶. Schmitz et al. (2019) discussed the American College of Sports Medicine (ACSM) (2018) guidelines that focus on the value of assessing nurses’ knowledge and skills to expand PE among patients with cancer through education¹⁷.

In the oncology center in which the present study was conducted, the hospital quality department aimed to maintain a high-quality of patient care in the face of a continuous increase in the number of patients. In 2021, the oncology center had 47,220 outpatient clinics visits, with 4,290 newly referred cases and 2,179 admissions. The underlying causes of recurrent admissions suggests that patients are readmitted or admitted because of severe side effects, which often involve fatigue or pain. Those side effects negatively affect patients’ QOL and interrupt their treatment plans. The delay in treatment varied depending on the underlying causes and the patient’s condition.

Unfortunately, despite the number of patients delaying their treatment because of CRF, the center did not use a specific form to assess patients’ CRF level during their treatment. However, nurses were performing their own assessments when reporting CRF level through their nursing notes. In addition, no clear guidelines that could be implemented to reduce patients’ CRF level were available. The challenges facing oncology nurses working in the center when advising patients about PE and managing CRF were identified by the present researcher from the findings published by the center’s quality department. Moreover, in addition to the lack of a specific scale to assess fatigue, there was no established PE program for patients with cancer at the center, and no specific guidelines available to nurses to guide them in educating patients about PE.

To the researcher’s knowledge, no studies that assessed oncology nurses’ knowledge regarding the benefits of PE for patients with cancer have been published in Kingdom of Bahrain. The present research will therefore be important for nursing practice because it aimed to establish baseline information on current knowledge in this area among oncology nurses. The findings of this study may contribute to improving nursing practice in the studied oncology department. In addition, the results of the study may be used to establish and implement a strategy to enhance oncology nurses’ knowledge and awareness of the benefits of PE for patients with cancer. For example, a potential strategy is developing a training and education program to ensure that nurses can educate patients about PE.

This study aims to assess the current level of knowledge among oncology nurses regarding the benefits of PE for patients with cancer undergoing treatment. The main objective of this study was to measure the associations between participants’ demographic characteristics and their level of knowledge regarding PE for patients with cancer. While the research question that this study set out to answer was: “What is the level of knowledge among oncology nurses regarding PE for patients with cancer undergoing treatment?”.

During the search strategy, literature related to the benefits of PE, oncology nurses’ knowledge, CRF, and patients with cancer for this study involved searching several databases, including: CINAHL, Medline, EBSCO Host, Google Scholar, ProQuest, PubMed, and the Cochrane Library. In addition, professional websites were searched to identify any updated guidelines related to PE for patients with cancer (e.g., the National Comprehensive Cancer Network (NCCN) guidelines and ESMO guidelines), and relevant e-books. The search was limited to research studies that were published in the last 6 years (from 2015 onward). The review included research papers published in English that were available in full text. A PRISMA flow chart was used to summarize the screening process (Figure-1). 35 primary research papers were selected for inclusion in this review.

1. Incidence of Cancer:

Cancer is a major global health crisis and is classified as a leading cause of death and a vital impediment to extending life¹⁸. In 2019, the WHO reported that cancer was the first or second leading cause of death in those aged 70 years in 112 of the 183 countries studied. Among women, breast cancer is the most diagnosed cancer (11.7% of all cases), followed by lung cancer (11.4%). In men, lung cancer is the most commonly diagnosed cancer and the primary cause of cancer-related death (18.0%).

Cancer can generate various symptoms, which can be minor or severe. Moreover, anticancer treatment is associated with severe adverse drug effects that can have detrimental effects on patients’ QOL. Despite anticancer treatment modalities having beneficial effects, they demand an extended length of administration to achieve the required results, which can cause severe symptoms that negatively affect the patient’s QOL. Therefore, anticancer therapy, cancer type, and cancer stage are associated with significant individual, mental, and emotional stress among patients with cancer, all of which affect their general QOL¹⁹.

1.1 Cancer Treatment Side Effects and Impact on Quality of Life:

The WHO Organization (2020) defined QOL as “individual perception of life, values, objectives, standards, and interests in the framework of culture¹⁹.” Although cancer diagnoses and treatment modalities (e.g., radiation therapy, surgery, general treatment including chemotherapy, hormonal therapy, targeted therapy, and immunotherapy) have been developed and are successful in extending patients’ survival, their QOL has not been significantly enhanced²⁰. Insufficient management of side effects also adversely affects patients’ QOL. Therefore, detecting the side effects in the early stages will help relieve suffering and enhance patients’ QOL²¹.

Nayak et al. (2017) reported that this study experiments have shown that improvement in side effects experienced by patients with cancer were linked to a marked improvement in their QOL²². Study reveals that cancer patient with inadequate management of those symptoms has negatively affect their daily QOL. Therefore, research relating to QOL among oncology patients receiving cancer treatments has increased over the past few years.

A cross-sectional study that involved 120 patients with cancer found that patients reported low QOL during their chemotherapy treatment, which was considered a stressful therapy that influenced both mental and physical well-being.²³

1.2 Cancer related Fatigue:

Fatigue is classified as the most common side effect experienced by patients with cancer during and after treatment. Overall, 25%–99% of patients with cancer experience CRF, with this this reported by 80%–90% of patients undergoing chemotherapy and 21%–80% of those undergoing radiotherapy and immunotherapy. CRF is described as “a distressing, persistent, subjective sense of physical fatigue that is not proportional to the recent activity and interferes with usual functioning”²⁴.

To date, the main factors that cause CRF remain unknown. However, in 2012, the Centers for Disease Control and Prevention indicated that CRF level can be defined by several traits: (1) when it happens progressively, (2) when it is alleviated by rest, and (3) when it lasts more than 6 months²⁵.

Price and Sikora (2020) reported that although all cancer treatments affect QOL, fatigue is known to be the most common side effect related to cancer treatment²⁶. Fabi et al. (2020) discussed the difference between CRF and other types of fatigue, as CRF severity and perseverance was not relieved through rest or sleep. In addition, CRF is thought to affect nearly 85% of patients with cancer, with 80%–90% of patients reporting CRF during chemotherapy or radiotherapy²⁷. Charalambous and Kouta (2016) reported that CRF was a frequent and unbearable symptom that had an effect on QOL among patients with cancer; CRF in patients with cancer was considered to be constant, destructive, and enduring. In that study, 66.9% of patients had a high CRF score²⁸.

1.3 Physical Exercise:

Physical inactivity is the leading modifiable cause of the burden of illness attributable to non-communicable diseases such as cancers. Nearly 80% of patients with cancer have low levels of PE.^29,30

Escalante (2021) conducted a qualitative study that revealed a range of non-pharmacological interventions were helpful for improving CRF in patients receiving active cancer treatment. That study concluded that some of patients undergoing cancer treatment preferred to rest and minimize their daily activities and assumed that exercise would worsen their symptoms; however, PE was able to recover CRF symptoms and increase their functional capacity to enhance their QOL³¹. Furthermore, Kessels, Husson and van der Feltz-Cornelis (2018) emphasized that although PE was identified as one of the most efficient non-pharmacological interventions for treating CRF, the processes by which exercise decreased CRF have not been clarified³². Moreover, Ferioli et al. (2018) reported a significant number of studies involving patients with cancer after treatment that showed PE drastically reduced CRF by 32% or 38%³³.

Avancini et al. (2020) described several well-known advantages of PE for patients with cancer, such as improving fatigue level, QOL, cardiorespiratory health, pulmonary function, muscle size and strength, and psychological condition³⁴. Both Alderman et al. (2020) and Freene et al. (2019) found that despite the growing evidence that confirmed the safety and value of PE during and after cancer treatment, patients were not sufficiently active. Both studies agreed that physical inactivity was a leading modifiable source of burden of illness due to non-communicable diseases such as cancers. These findings suggested that nurses and doctors are ideally situated to endorse PE in a range of different situations^29,30

An intervention comparison study by Twomey et al. (2018) divided participants into two groups (active control vs. tailored exercise) and assessed CRF severity before and after a PE intervention. That study showed that although both groups had several benefits post-intervention, the active control group showed higher positive effects on QOL by reducing patients’ CRF level. Another randomized controlled trial study Witlox et al. (2018) emphasized that enabling PE during and after cancer treatment improved short- and long-term health outcomes. That study showed substantially higher levels of energy and lower levels of CRF (around a 63.3% reduction) among patients during their treatment³⁵.

Despite the growing body of evidence confirming the usefulness of PE for patients with cancer either during or after treatment, the current COVID-19 pandemic formed a major impediment to patients with cancer engaging in PE. In response to this issue, Grazioli et al. (2020) developed an approach to engage oncology patients in PE via a proper and successful online home-based course. That study involved supervised home-based exercise for 2 hours per week and reported 70% improvement in participants’ QOL and 66% improvement in their fatigue level³⁶.

Meneses-Echávez, González-Jiménez and Ramírez-Vélez (2015) also found that supervised exercise enhanced CRF symptoms in 48 patients receiving cancer treatment during their hospitalization period. Nurses have an important role in facilitating implementation of a PE strategy³⁷. Abbott and Hooke (2017) indicated that oncology patients accepted advice about managing CRF and the benefits of PE from oncology nurses, meaning they were the first point of contact to assist patients during their treatment journey. Patients depend on nurses to deliver guidance and knowledge³⁸.

1.4 Oncology Nurses’ Role in Physical Exercise:

Despite the encouraging findings about the beneficial effects of PE, patients’ adherence to PE is relatively low. Findings from one study revealed that only 25%–40% of patients with cancer followed PE advice (Haussmann et al., 2018). Therefore, Büntzel et al. (2017) recommended patient education on the benefits of PE as a useful method to overcome CRF³⁹.

To verify the relationship between the importance of PE among patients with cancer during their treatment and the role of oncology nurses, Okechukwu (2021) investigated the value of oncology nurses in promoting PE among patients through raising their awareness of the physiological processes underlying the advantageous effects of exercise therapy⁴⁰.

McFarland et al. (2021) used the 2016 NCCN guidelines to treat CRF, which highlighted PE interventions as an effective method to treat CRF among patients with cancer during and after treatment. The role of oncology nurses in using the NCCN guidelines during patient visits has had encouraging and optimistic outcomes. The nurse’s role in promoting PE among patients with cancer through education and other modalities is important as it will also enhance patients’ QOL. Therefore, nurses should follow structured guidelines when providing PE advice to patient⁴².

Okechukwu (2021) asserted that educating patients was a major role of oncology nurses that needs to be implemented during patient visits. Therefore, nurses must be aware of specific exercise recommendations and follow-up with patients before, during, and after cancer treatment⁴².

Furthermore, Bourmaud et al. (2017) noted that nurses are in a favorable position as they have sufficient opportunities to deliver information. Therefore, it is important to initiate and promote oncology nurses’ role in oncology departments to ensure patients receive proper education and monitoring through their treatment and management of their post cancer treatment symptoms such as CRF⁴³.

1.5 Oncology Nurses’ Knowledge Regarding Physical Exercise

A study by Nadler et al. (2017) reported that approximately 80% of nurses were not aware of any exercise guidelines for patients with cancer. This indicated that nurses were not able to fulfil their role of promoting PE to patients because of their low knowledge regarding exercise therapy. This indicated there is a need to promote nurses’ role to come over this gap⁴⁴.

Shing (2017) conducted a cross sectional study involving 115 oncology nurses. That study found that 52% of those nurses reported they were involved in exercise therapy counseling, but 78% of those nurses had a belief that PE moderately reduced CRF among patients with breast cancer. Moreover, that study found that when nurses used a clear structure such as the “Get up and Get moving” campaign, which was created by the oncology nursing society (ONS) in 2016⁴⁶, during their role implementation, there was positive motivation between nurses and patients during PE therapy. Finally, a recent study by McCourt et al. (2021) reported similar findings, with nearly 48.6% of nurses having poor understanding about their role and the benefits of PE for patients with cancer, despite stating that they were routinely giving PE advice to patients⁴⁷.

Nurses are in a prominent position to increase PE rates among patients through sharing their knowledge about the crucial role of PE for patients undergoing cancer during treatment. Therefore, assessing their knowledge appears to be necessary for to enhance PE in oncology organizations^29,30.

In total, 111 oncology nurses completed a survey to assess their knowledge and attitudes, but their observed behavior indicated they had inadequate knowledge about PE. Another quantitative survey reported that regardless of the identified benefits of PE in relieving the effect of cancer treatments, oncology nurses did not usually recommend exercise for their patients because of their lack of knowledge. That study found that approximately 80% of those nurses were not aware of any exercise guidelines for patients with cancer. Another cross-sectional study that assessed oncology nurses’ knowledge regarding the benefits of PE found that 46% of nurses had insufficient knowledge when promoting PE for patients. Factors associated with recognizing insufficient knowledge about PE were being younger, having a lower level of education, and using oncology guidelines less often^30,44,48.

During therapy, patients are in close and constant contact with their nurses, who are expected to recommend PE and encourage patients to engage in PE during their daily routine. A major reason why patients had low adherence to PE was reported to be the lack of knowledge among oncology nurses regarding the benefits of PE for patients with cancer during treatment⁴⁹.

Similarly, Haussmann et al. (2018) conducted a quantitative study that demonstrated PE had positive effects on patients’ QOL and CRF. However, despite these apparent benefits, only 25%–40% of patients with cancer adhered to PE advice. The value of evaluating nurses’ knowledge about the benefits of PE has been defined. Likewise, McCourt et al. (2021) assessed oncology nurses’ knowledge about PE guideline recommendations through an online survey that included questions on PE for patients with cancer. Nearly 48.6% of nurses had poor knowledge, although they stated that they were routinely promoting PE to their patients. Those findings also showed that nurses were unfamiliar with the suggested guidelines. This highlighted a gap in international and local literature regarding oncology nurses’ knowledge about the benefits of PE for patients with cancer⁵¹.

1.6 Oncology Nurses’ Training and Education Needs

Regarding Physical Exercise:

When verifying the importance of PE for patients with cancer during treatment, Okechukwu (2021) emphasized barriers to implementing PE in this population, including the absence of education and lack of proper resources⁴². Therefore, advanced training on PE must be implemented for oncology nurses, including specific exercise recommendations and follow-ups before, during, and after cancer treatment to ensure patients receive the correct education and instructions.

The importance of including structured training programs in oncology organizations for nurses has been well documented. Importantly, if oncology nurses increase their PE expertise and take opportunities to regularly publicize PE, they can increase patients’ PE levels and improve their health^29,30. Shing (2017) suggested that difficulties associated with PE promotion facing nurses may be addressed through educational programs. In particular, that study suggested using the “Get up and Get moving” campaign created by the ONS in 2016 as a reference for nurse education⁵².

2 MATERIALS AND METHODS:

2.1 Research Paradigm:

Nieswiadomy and Bailey (2018) described the research paradigm as a philosophical worldview or conventional beliefs about nature and reality that create decisions and procedures. Therefore, the research paradigm refers to the beliefs that the researcher will bring to an investigation⁵³.

The positivist paradigm is a view that assumes that truth exists autonomously of human behaviour and mind, which requires the researcher to be impartial when gathering quantifiable objective and visible data. A positivist paradigm is best suited for quantitative research as it allows objective examination of the study variables⁵³.Therefore, a positivist paradigm was used for the present research.

In the literature reviewed for this study, 20 of 32 quantitative studies used the positivism paradigm with successful research outcomes. Therefore, the aim and objective of this study assessing oncology nurses’ level of knowledge about the benefits of PE for oncology patients could only be achieved using a quantitative approach. The chosen quantitative method with data collected using a self-report questionnaire could successfully meet the study aim and objective and answer the research question.

2.2 Research Method:

A quantitative research approach is a type of research method that concentrates on the collection of numerical data⁵⁴. This study used quantitative research method to collect and analyze data to answer the research question. A quantitative approach was deemed the most suitable method for this study as it allowed analysis of participants’ demographic characteristics and detection of patterns in the findings, rather than merely identifying these characteristics, and explaining their implications.

2.3 Research Design:

A research design is the plan that sets out the methods used to obtain the required information⁵⁵. A cross-sectional descriptive research design is a commonly used design, especially in studies where data are collected with self-report surveys⁵⁶. Therefore, the present research used a cross-sectional design to assess participants’ knowledge and associated factors, with data collected in an online survey. This design allowed this study to be conducted in a reasonably short timeframe and within a limited budget. In addition, it allowed effective collection of baseline information about the study population.

2.4 Population and Sampling:

Convenience sampling is a common method of sampling that is often used in research involving residents and hospitals. This sampling methods is inexpensive, and not as time consuming as other sampling approaches⁵⁷. This study used convenience sampling to select the study sample.

Approximately 324 oncology nurses were working in the inpatient and outpatient units in the study setting. The required sample size was calculated after considering the necessary effect size to give strength to the study findings. The final sample was drawn from the population that met the inclusion and exclusion criteria. The sample size was calculated using a sample calculator with a 5% margin of error and 95% confidence level; this indicated that 177 participants were needed for this study. The primary advantage of this sampling method was that it was inexpensive and did not take a large amount of time.

2.5 Inclusion Criteria:

This study targeted registered oncology nurses who worked in the center under study. The inclusion criteria were registered oncology nurses who worked in inpatient and outpatient units irrespective of their years of working experience, gender, age, level of education, nationality, and position.

3 RESULT:

SPSS software was used for the present analyses. Descriptive and inferential tests were performed using

t-tests and ANOVA (parametric testing).

3.1 Response Rate:

The Survey Monkey link to the study questionnaire was shared with 324 nurses from the studied oncology center. In total, 185 questionnaires were completed and submitted, which gave a response rate of 57%.

3.2 Demographic Characteristics:

Descriptive statistics (e.g., frequency and percentage) were used to describe the study variables. The sample comprised 185 oncology nurses. Most participants were female (n=130, 70.3%). The mean age was 29.9 years and those aged 20–30 years represented the dominant group (n=119, 64.3%) (Table 1). Two-thirds of the sample were non-Bahraini nurses (n=123, 66.5%). Most participants held a bachelor’s degree (n=170, 91.9%).

Table 1: Participants’ demographic characteristics (N=185)

Variable	Category	Frequency	Percentage (%)
Gender	Male	55	29.7
Gender	Female	130	70.3
Age, Years	20-30	119	64.3
	31-40	59	31.9
	≥41	7	3.8
Education	Diploma	7	3.8
	Bachelor’s degree	170	91.9
	Master’s degree	8	4.3
Nationality	Bahraini	62	33.5
Nationality	Non- Bahraini	123	66.5

3.3 Work Experience and Previous Training Related to Physical Exercise:

This section describes participants’ work experience and previous training related to PE for patients with cancer which is summarized in table 2. Descriptive statistics (e.g., frequency and percentage) were used to describe the study variables. Most participants reported they had overall work experience as a nurse of 1–10 years (n=161, 87%) with mean of 6.4 years. In addition, most participants reported they had 1–4 years of work experience in the oncology field (n=166, 89.7%) with mean of 2.4 years.

Most participants reported that they had received training on the benefits of PE for patients with cancer (n=123, 66.5%). More participants had received information regarding exercise prescription for patients with cancer compared with those that had not received such information. Nearly three-quarters of the sample did not have any knowledge about the ACSM or ONS exercise guidelines (n=130, 70.3%). Just over half of the participants reported that they had prior knowledge about exercise prescription for patients with cancer (n=102, 55.1%), and slightly more than half indicated they had access to resources to educate patients about PE (n=102, 55.1%) (Table 3).

3.4 Knowledge:

This section sought to answer the research question by examining participants’ level of knowledge about PE for patients with cancer (expressed descriptively) for each of the 10 knowledge items and as an overall score out of 10 points. Finally, the reliability of the instrument used to assess participants’ knowledge is demonstrated.

3.4.1 Knowledge About Physical Exercise:

Descriptive statistics (e.g., frequency and percentage) were used to evaluate participants’ responses to each of the 10 knowledge items. Overall, participants had a low level of knowledge regarding PE for oncology patients as only 42.2% of the answers to the 10 items were correct. The difference between the proportion of correct and incorrect answers was statistically significant (pooled frequency 1070, 57.8%, p<0.0001) according to chi-square test (X2=43.3, df=1, p<0.0001). The item that had the highest percentage of correct responses was “Main benefit of prescribing exercise to patients with cancer,” as 120 (64.9%) participants gave the correct answer. However, the item with the fewest correct answers was “Examples of moderate exercise” (n=35, 18.9%).

3.7 Association between Knowledge and Years of Work Experience (General/ Oncology Nursing):

A weak, positive, and statistically significant correlation between participant’s length of clinical experience and their knowledge about PE for oncology patients (r=0.274, p<0.0001). Overall, as participants’ experience (in years) increased, their level of knowledge increased. This relationship was modeled with simple linear regression that returned a statistically significant model (F=14.8, df=1, p<0.0001). According to this analysis, as participant’s experience increased by 1 year, their knowledge increased by 0.3 points. The length of work experience had a small effect on participants’ knowledge as shown by the small effect size (r2=0.07). Figure 2 presents a scatter plot displaying the relationship between years of work experience and participants’ level of knowledge.

Figure 2: Relationship between participants’ level of knowledge and years of work experience (N=185).

Second, the relationship between participant’s years of experience as an oncology nurse showed a weak, positive, and statistically significant correlation with their knowledge about PE for oncology patients (r=0.201, p=0.006). As participants’ experience (in years) increased, their level of knowledge increased. This relationship was modeled with simple linear regression that returned a statistically significant model (F=7.6, df=1, p=0.006). According to this analysis, as participants’ experience in oncology increased by 1 year, their knowledge increased by 0.2 points. The length of work experience in oncology had a small effect of participants’ knowledge as reflected by the small effect size (r2=0.035). Figure 3 presents a scatter plot of the relationship between years of work experience as an oncology nurse and participants’ level of knowledge.

Figure 3: Relationship between participants’ level of knowledge and years of work experience in oncology (N=85).

3.8 Association Between level of Knowledge and Previous Training:

Participants who reported that they had received training on the role of PE for patients with cancer had significantly higher knowledge scores than their counterparts who did not have the same training (4.5±1.8, p=0.020). Surprisingly, those who reported that they did not have access to resources to educate patients about PE had significantly higher knowledge scores than those had access to such resources (4.5±1.8, p=0.045). There were no significant associations for the remaining items in the knowledge scale (Table 9).

Table 9: Participants’ level of knowledge and prior training (N=185)

Question	Category	Knowledge score (Mean ± SD)
Training on the role of physical exercise for patients with cancer	Yes	4.5 ±1.8
	No	3.7±2
	p-value	0.020*
Information received regarding prescribing exercise for patients with cancer	Yes	4.4±1.9
	No	4.1±1.9
	p-value	0.331
Knowledge about ACSM or ONS exercise guidelines	Yes	4.2±1.9
	No	4.2±1.9
	p-value	0.940
Prior knowledge about exercise prescription for patients with cancer	Yes	4.2±1.9
	No	4.2±1.9
	p-value	0.997
Access to resources to educate patients about physical exercise	Yes	3.9±2
	No	4.5±1.8
	p-value	0.045*

Finally, chi-square tests were used to explore associations between levels of knowledge and prior training, and participants’ demographic variables (years of experience, gender, age, nationality, and level of education). K-mean cluster analysis was used to examine the current level of knowledge among oncology nurses in regard to the benefits of PE for patients with cancer.

3.9 Previous Training on Physical Exercise:

Participants were divided into two groups based on their responses to the survey question regarding previous training (group “YES” that had received training and group “NO” that had not received previous training). There were significant differences in the level of knowledge for participants who reported that they had received training on the role of PE for patients with cancer (p<0.0001) and those who did not have prior knowledge about the ACSM or ONS exercise guidelines (p<0.0001) (Table 10).

Table 10: P-values for participants with previous training on PE (N=185)

Question	p-value
Training on the role of physical exercise for patients with cancer	<0.0001*
Information received regarding prescribing exercise for patients with cancer	0.272
Knowledge about ACSM or ONS exercise guidelines	<0.0001
Prior knowledge about exercise prescription for patients with cancer	0.217
Access to resources to educate patients about physical exercise	0.217

*Statistically significant differences with a chi- square test of goodness of fit at alpha 0.0.

Overall, the results revealed that there was low level of knowledge regarding the benefits of PE for oncology patients among participating nurses as only 42.2% of the responses to the 10 knowledge questions were correct. There was a statistically significant association between prior training and participants’ knowledge level. There was also a weak positive correlation between participants’ length of clinical experience in oncology and their level of knowledge regarding PE for oncology patients. However, none of the participants’ demographic characteristics were significantly associated with their level of knowledge. The results are discussed in more detail and in relation to extant literature in the Discussion chapter.

4 DISCUSSION:

4.1 Nurses’ Knowledge About Physical Exercise:

The limited knowledge among oncology providers (i.e., nurses) regarding the presence and practical aspects of implementing PE guidelines was identified by Nadler et al. (2017) as the most substantial barrier to providing patient education on the benefits of PE. That study showed that 42% of participating nurses were able to correctly identify PE guidelines⁴⁴.

The present study revealed that only 42.2% of the participating oncology nurses were able to correctly answer the 10 questions related to the benefits of PE for patients with cancer. This result suggested that nurses had a low level of knowledge regarding the benefits of PE for patients with cancer.

Nurses’ low level of knowledge as found in the present study was also consistent with the study by van Veen et al. (2017) that indicated 46% oncology nurses had insufficient knowledge about the benefits of PE for patients with cancer. That study found that the factors underlying insufficient knowledge among nurses were young age and poor education⁴⁸.

In the present study, the item covering the main benefit of prescribing exercise for patients with cancer had the most correct responses (64.9%). However, participants showed inadequate knowledge (18.9%) when they were asked to give examples of moderate exercise. This highlighted a gap in nursing practice at the study hospital, as nurses were not able to identify PE examples despite being aware of the benefits of prescribing PE for their patients. Burdick et al. (2015) also highlighted the lack of suitable knowledge about current recommendations and PE guidelines, such as the time (minutes) needed for PE per week and the proper exercise type for each patient⁵⁸

Furthermore, the present study found that nearly three-quarters of participants were unaware of the ACSM or ONS exercise guidelines (n=130, 70.3% vs. 29.7%). Nadler et al. (2017) also indicated that 48% of participants reported that they did not know about Canada’s Physical Activity Guidelines, and 69% were not aware of any exercise guidelines at all⁴⁴.

McCourt et al. (2021) showed that 72 of 156 professionals (mostly oncology nurses) were aware of PE guidelines, although 33% (n=64) were not aware of any guidelines. The most frequently cited barriers for nurses to adhere to or facilitate the use of guidelines included their lack of knowledge about the presence of guidelines, work pressure, lack of training, lack of resources, and motivational setting^59,60

4.2 Factors Influencing Knowledge:

A recent study by Pueyo-Garrigues et al. (2022) identified several factors that may influence an individual’s level of knowledge, such as the absence of education or training during their career advancement, shortages of time and high workloads, years of working experience, and younger age. In the present study, factors that were linked with participant’s level of knowledge were their years of experience, age, gender, education level, and previous education or training, although some of these associations were not significant⁶¹. Similarly, Parajuli and Hupcey (2021) and Sharour (2020) noted that factors that may influence oncology nurses’ level of knowledge included demographic aspects, educational level, years of working experience, previous education or training, level of adherence to the guidelines, and the current clinical location^62,63.

In terms of participants’ gender, 130(70.3%) participants in this study were female (N=185 participants in total). This finding was inconsistent with other studies such as those by Wake et al. (2021) which showed the opposite as male nurses had higher knowledge by 3.09 points than females (54.7% of the study participants were female)⁶⁴.

The mean age of participants in the present study was 29.9 years and the majority (64.3%) were aged 20–30 years. This study found that the knowledge score appeared to increase as participants’ age increased; however, this linear relationship did not reach statistical significance (p=0.173). Similarly, Tamang et al. (2020) found a higher percentage of sufficient knowledge among nurses aged 50+ years (85.7%), which was linked with their positive attitude to gaining more knowledge and more years of work experience.

Moreover, the majority of participants in the present study held a bachelor’s degree (n=170, 91.9%). However, the association between knowledge and higher education (e.g., master’s degree) was not significant (p=0.387). Gigli et al. (2020) and Tamang et al. (2020) found that nurses with higher certification showed greater knowledge when compared with noncertified nurses (p<0.05). However, nurses with specialist certification had significantly better knowledge compared with those without specialist certification^65,66.

In the present study, there was a weak, positive, and statistically significant correlation between participants’ length of clinical experience and their knowledge about PE for oncology patients compared with others. In that study, 90.1% of the nurses had >13 years of work experience, but only 22.1% of those nurses had training; these nurses showed more positive attitudes and better knowledge compared with those who had not received training. Tamang et al. (2020) found that nurses with more than 5 years of work experience (84%) had a higher level of knowledge than those with less experience⁶⁶.

In the present study, two-thirds of nurses in the study sample were non-Bahraini (n=123, 66.5%). Although they formed the biggest portion of the study sample, there was no association between participants’ nationality and their level of knowledge (p=0.060). This finding was inconsistent with Ou et al. (2020) who found participants’ ethnicity was an independent influencing variable for knowledge, as nurses with Han ethnicity had higher knowledge than other ethnicities. Furthermore, Almutairi, Adlan and Nasim (2017) found that mean knowledge scores varied between 4.76 and 5.42 based on participants’ country of birth where they received their education.

In terms of previous training about the role of PE for patients with cancer, 66.5% of the participants in the present study had received training on PE; these participants scored significantly higher on the knowledge scale (p=0.020). Tamang et al. (2020) and Admass et al. (2020) showed similar results whereby participants who had received training (81.4%) had higher knowledge scores than those who did not receive any previous training^66,67.

Participants in the present study who reported that they had previously received information about prescribing exercise for patients with cancer were more knowledgeable than those who stated the opposite; however, the difference was not statistically significant (54.6% vs. 45.4%). Kyei-Frimpong et al. (2021) evaluated the plan of pre and post education sessions on study participants’ confidence during exercise prescription in clinical practice. They found that after the information was delivered to participants, there were substantial increases in participants’ confidence when prescribing exercise (p<0.05,89%). Conversely, Kleemann et al. (2020) found that 92% of their study participants did not receive any formal training or information about exercise prescription.

Most participants in the present study had general work experience of 1–10 years (87%) with a mean of 6.4 years. In addition, most participants had 1–4 years of work experience in the oncology field (89.7%) with mean of 2.4 years. In other words, as participants’ experience (in years) increased, their level of knowledge increased. van Veen et al. (2017) considered years of work experience as a dependent variable along with participants’ age, education level, gender, and specialty⁴⁸. Their study did not link years of experience with knowledge among oncology nurses as the collected data were nationwide from a diverse group of oncology nurses with various education experiences and different years of work experience. Pühringer (2017) and Jang, Kim and Kim (2016) found an association between years of working experience and the level of knowledge. Nurses with more than 25 years working experience were more likely to have no difficulties in promoting PE to their patients.

Previous studies made recommendations to address this practice gap. For example, Okechukwu (2021) suggested developing a hospital-based training system to promote oncology nurses’ level of knowledge about PE⁴². While, Alderman et al. (2020) highlighted the need for a training program for oncology nurses to improve QOL and overall well-being among patients with cancer³⁰. This study showed that participants’ gender, years of working experience, and level of education were linked with participant’s level of knowledge about PE. However, participants’ other demographic characteristics were not associated with their level of knowledge.

4.3 Impact of Training:

The lack of sufficient knowledge to deliver PE was highlighted as an obstacle. Teaching and training opportunities have been observed to have various positive consequences for learners, such as development in clinical practice, self-confidence, enthusiasm, and problem solving⁶⁹.

The present study showed that most participants reported that they had received training and received information in regard prescribing PE for patients with cancer (66.5%). The difference between participants that had received information to others (54.6% vs 45.4%) was not statistically significant. Despite this finding, only 42.2% of the participants were able to correctly answer the 10 questions related to the benefits of PE for cancer patients. The difference between the percentages of correct and incorrect answers was statistically significant (p=0.0001). Oppositely, van Veen et al. (2017) study participants reported insufficient knowledge level on PE for cancer patients 46% due to low education and training in this regard 95%.⁴⁸

Alderman et al. (2020) reported that 40%–59% of their study participants (oncology nurses) were not providing any PE recommendations to their patients which indicates an insufficient level of knowledge among participants although they played a crucial role in improving patients’ health outcomes. However, the effect of education on knowledge has not been fully investigated, which highlights the need for additional research to explore the association between knowledge and education.

In regard to prior knowledge about exercise prescription for cancer patients, over half of the participants in the present study reported that they had prior knowledge (55.1%). Anderson (2018) study results offered opportunity for enhancement of the level of knowledge among oncology nurses⁷⁰. 12/14 participants showed significant progress in their level of knowledge at post-test after receiving information compared with the same group pre-test. This indicated that an insufficient level of knowledge among nurses was associated with a lack of information and training, which impacted their quality of care.

Therefore, oncology nurses (6.8% of the study participants) showed a lack of training or management on exercise instruction, insufficient education materials for patients, and an inability to promote PE to patients as they had not received prior information. Pühringer (2017) and Keogh et al. (2017) indicated that oncology nurses were considerably more likely to cite low level of knowledge depending on their organization placement and their years of working experience^71,72.

Nearly three-quarters of the sample in the present study did not have any knowledge about the ACSM or ONS exercise guidelines (70.3 vs. 29.7%). This response rate was comparable with Williams et al. (2015), who reported that 36% of their participants were oblivious of any standard of living guidelines and 51% did not know of any current PE guidelines for patients with cancer⁷³.

In addition, Shimizu et al. (2021) found that 48.6% of participants were unaware of the relevant PE guidelines (the Japanese Association of Cancer Rehabilitation guideline). However, participants who reported being educated on the PE recommendations had better knowledge than other participants. Therefore, to facilitate implementation and use of those guidelines, that study highlighted various factors such as the importance of guideline accessibility at the facility, circulation of the revised guidelines to all healthcare workers and providing education or training programs on PE.

More than half of the participants in the present study reported that they had access to resources to educate patients on PE (55.1%). The relationship between access to resources and patients’ health outcomes was discussed by Alderman et al. (2020)³⁰, who found only 32% of oncology nurses were aware on how to access PE resources to educate their patients. Mina et al. (2018) also showed the importance of offering oncology nurses an access point to resources for cancer-specific exercise programs.⁷⁵

CONCLUSION:

This research recommends several strategies to enhance CRF and improve patients’ QOL:

Fatigue Assessment Scale: Implement a scale like the ECOG-PS to identify training gaps and ensure appropriate interventions.

Nurse Training: Provide targeted training on the benefits of PE for cancer patients and the impact of CRF on QOL.

Encourage Teamwork: Foster collaboration among nurses to promote knowledge exchange on PE.

Educational Program: Develop an evidence- based, online educational program to improve understanding of PE’s benefits, especially during the COVID-19 pandemic.

Specialist Collaboration: Work with physiotherapy trainers to create a simple PE program for cancer patients that physicians can refer to.

The use of Survey Monkey for data collection poses a risk of information bias, as participants might have accessed PE information while completing the survey. The instrument’s reliability was low (0.44), affecting internal validity. Convenience sampling, while facilitating recruitment, limits generalizability and may introduce bias, as more interested individuals may have participated.

Additionally, modifying an existing assessment tool due to a lack of suitable options could impact validity, despite efforts to ensure clarity.

Participants in this study displayed a low overall knowledge of the benefits of PE for cancer patients.

Their knowledge levels were not significantly influenced by demographic factors such as gender, though females showed slightly higher scores.

Knowledge appeared to increase with age, but this was not statistically significant.

In contrast, education and prior training programs significantly impacted knowledge levels; participants who received prior training scored higher. Additionally, there was a weak but significant correlation between years of clinical experience in oncology and knowledge about PE, indicating that increased experience correlates with greater knowledge. The findings should be interpreted considering the study’s limitations. Based

on the results, implications for nursing practice, education, and management were discussed, along with recommendations for further research and PE training for oncology nurses.

CONFLICT OF INTEREST:

The research project has no funds or conflicts of interest.

ACKNOWLEDGMENTS:

Acknowledgment I would like to thank the following people; without whom I would not have been able to complete this research. I wish to convey my grateful thanks to RCSI Bahrain University, especially to Dr Husain Ali Nasaif, my academic supervisor whose insight and knowledge into the subject matter drove me through this research. Special Thanks to my colleagues at radiation oncology unit, my family and not forgetting my friends for all the support, patience, and encouragement you have shown me through this research. This thesis is dedicated to the memory of my beloved brother Mohammed Faraj, whose love, battle with cancer, and unwavering belief in me fueled my journey. His spirit lives on in these pages.

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Received on 13.03.2025 Revised on 27.06.2025

Accepted on 09.07.2025 Published on 18.08.2025

Available online from August 30, 2025

A and V Pub Int. J. of Nursing and Med. Res. 2025;4(3):111-125.

DOI: 10.52711/ijnmr.2025.23

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.

Items	Yes		No
Items	n (%)		n (%)
Training on the role of physical exercise for patients with cancer	123	(66.5)	62	(33.5)
Information received regarding prescribing exercise for patients with cancer	101	(54.6)	84	(45.4)
Knowledge of ACSM or ONS exercise guidelines	55	(29.7)	130	(70.3)
Prior knowledge about exercise prescription for patients with cancer	102	(55.1)	83	(44.9)
Access to resources to educate patients about physical exercise	83	(44.9)	102	(55.1)

Item	Incorrect n (%)		Correct n (%)
Percentage of cancer patients experience fatigue during their treatment	130	(70.3)	55	(29.7)
Main benefit of prescribing exercise to patients with cancer	65	(35.1)	120	(64.9)
How Often Should Patients with Cancer exercise during treatment	104	(56.2)	81	(43.8)
When is it safe for patients with Cancer to exercise	67	(36.2)	118	(63.8)
High- risk patients who should be medically cleared and supervised during exercise	102	(55.1)	83	(44.9)
Moderate exercise	78	(42.2)	107	(57.8)
Examples of moderate exercise	150	(81.1)	35	(18.9)
Moderate- risk patients which should be medically cleared before and supervised during exercise.	127	(68.6)	58	(31.4)
Organizations recommend physical exercise for cancer survivors in both active treatment and during the survivorship phase of cancer care	147	(79.5)	38	(20.5)
The indication of score of 10 on the Rate of perceived Exertion Scale	100	(54.1)	85	(45.9)
Pooled frequency (%)	1070 (57.8)		780 (42.2)
p-value	<0.0001*

Mean	Median	St. Deviation	Minimum	Maximum	Range	95%Cl
4.2	4	1.9	0	9	9	3.9-4.5

Group	n (%)	Mean	St. Dev.	Minimum	Maximum
Low knowledge	71 (38.5)	2.9	0.8	0	3
Average knowledge	88(47.5)	4.9	0.7	4	6
High knowledge	26 (14)	7.2	0.5	7	9

Scale	No items	Kuder-Richardson index	Interpretation
Knowledge scale	10	0.44	Suboptimal reliability

Variable	Category	Knowledge score (Mean ±SD)
Gender	Male	3.8±1.7
	Female	4.4±1.9
	p-value	0.066*
Age, years	20-30	4±2
	31-40	4.5±1.8
	≥41	4.9±0.7
	p-value	0.173**
Education	Diploma	4.3±1.5
	Bachelor’s degree	4.2±1.9
	Master’s degree	5.1±1.4
	p-value	0.387**
Nationality	Bahraini	3.8±1.8
	Non-Bahraini	4.4±1.9
	p-value	0.060*