THE DEVELOPMENT OF INTERVENTION MEMORY- EXECUTIVE FUNCTION EXERCISE FOR BREAST
II. METHOD
This publication describe the development of an intervention package in the form of exercise in memory-executive functions and modules as a tool for assistance.
Modules consist of nurses and survivors’ modules. The reference for the development of intervention package and modules is the development step according to Borg &
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Gall (1983) as described in table 1. This The researchers used this development step to achieve the objective of this research.
The theory adopted has 7 (seven) steps. Steps of potential problems and data collection were skipped because they were done in the previous step. The mass production stage has not yet been undertaken because mass testing has not yet been carried out. In general, the steps used were step 3 to 9.
The MEFE intervention package and its modules were developed based on the analysis of literature reviews and previous research, including on the function of verbal learning and memory as well as the executive function of breast cancer survivors in Indonesia by Syarif et al. (2019). Next, an expert consultation will be conducted. Components developed include the form of intervention, standard operational procedures for intervention, learning materials summarized in modules, workbooks, checklists and documentation formats.
The validity test of the MEFE intervention package and its modules was carried out by expert consultation. This validity test consists of content and construct validity tests. The content validity and construct of the MEFE intervention package and its modules have been prepared using the scientific perspectives of experts whose scientific fields are relevant to this topic. Expert consultation is carried out with experts who are experienced in the area of structured intervention package and survivors of breast cancer. There are five experts who contributed to this research. The selected expert has an understanding and experience in treating cancer patients. The experts also played a role in the validation of the intervention guide modules, both the nurse module and the survivor module.
Table 8.1 Development Step of Intervention Package Step Description
1 Identification of potential problems 2 Data collection
3 Design of intervention package and modules 4 Validation of design intervention and modules 5 Revision of intervention design and modules 6 Trial of intervention package and modules 7 Revision of intervention package and modules 8 Trial of the intervention package and modules 9 Final revision of the intervention package and modules.
10 The mass production
The process of developing the MEFE intervention package and its modules applies the ethical principles of research in humans. All processes were carried out after passing the medical research ethics test from the Research Ethics Commission of Faculty of Nursing Universitas Indonesia and the Health Research Ethics Commission from Dharmais National Cancer Hospital (DNCH), Jakarta. All parties involved have
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obtained research explanations, stated their agreement, and signed informed consent before engaging in this process.
III. RESULTS
Design of Intervention Packages and Modules
This stage begins by examining the theory of unpleasant symptoms and conceptual models of chemotherapy-related changes in cognitive function (CRCCF) to develop interventions. Both theories explain that chemobrain is a multiple symptom and is influenced by various factors. The scope of intervention must also include management to deal with the various symptoms that arise. Based on the analysis of research Syarif et al. (2019) concerning the function of verbal learning and memory as well as executive functions in survivors of breast cancer in Indonesia, the structured package of interventions emphasizes modifiable conditions, including stress management and improving sleep quality.
Literature studies are also conducted on material related to nursing interventions to improve cognitive abilities in survivors of breast cancer with chemobrain. Some of the interventions carried out in chemobrain are compiling a detailed daily list, carrying out activities that challenge the brain, exercise, socialize, and improve sleep quality.
So the components included in the intervention package are optimization of adaptation strategies, brain stimulation, and sports optimization. At this stage, the components of the MEFE intervention package are; 1). Stress management, 2). Improving sleep quality, 3). Optimization of adaptation strategies, 4). Brain stimulation, and 5). Sports optimization. The form of intervention formulated is then distributed in the structure of the intervention package in the form of meeting sessions. The structure of the intervention package consists of eight (8) sessions, with each session lasting for 45–60 minutes, and without any daily assignments.
Validation of Design Interventions and Modules
Validation of the intervention package and modules was carried out through expert consultation. Before the expert consultation is carried out, the modules are first reviewed by a mental health specialist nurse. Experts who assessed the intervention package and module consisted of five experts in the fields of oncology nursing and mental health nursing. All experts have completed doctoral education and have long experience in the area. In the final stages of expert consultation, the experts stated their agreement to implement the intervention package that had been prepared.
The experts provided input for the perfection and suitability of the intervention package as written in the expert consultation report, including: focusing the intervention package on more relevant factors, changing the number of sessions to four sessions, using simple and easy to understand language, using pictures original that is appropriate and interesting, and utilizing cognitive stimulation exercises, such
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as puzzles, sudoku, and crosswords as daily tasks, and conducts training for nurses with appropriate criteria.
Revised Design of Intervention Packages and Modules
Revisions were made according to the input and direction of the experts at the time of the consultation. After making revisions based on expert consultation, the executive function exercise intervention package consists of four sessions; 1). Education and deep breathing relaxation exercises, 2). Exercise for guided stress inoculation and imagination, 3). Educate healthy sleep habits and self-talk, and 4). Educate safety sports and self-talk. In addition, the intervention is accompanied by several kinds of cognitive exercise games which are performed one item per day, such as puzzles, crosswords, and sudoku.
Trial the Intervention Package
Trials at this stage are carried out by two methods, including trials in nurses in the laboratory and readability test for breast cancer survivors. The modules that have been prepared are also read by populations in accordance with research respondents, namely breast cancer patients with chemotherapy. Readability test was conducted on 10 breast cancer patients who received chemotherapy at Dharmais Hospital, Jakarta. Respondents gave an assessment of the contents of the intervention module provided in accordance with their understanding and physical condition. In addition, respondents also gave their assessment of the difficulty of crossword puzzles, sudoku difficulties, understanding of language, pictures, font sizes, and the ease of the module to carry. Broadly speaking, the difficulty level of the crossword is 4.1 (range 1–10;
point 10 indicates the most difficult); the difficulty level of sudoku is 5.6 (1–10; point 10 indicates the most difficult); 100% answered that the language used could be understood; 100% respond that the font size can be read clearly, and 80% answer the module is easy to carry.
Trials in the laboratory setting were carried out by three assessors from medical surgery nursing specialist students, specialty oncology nursing. The assessor provides suggestions on the modules compiled which includes; the attractiveness of the module, the pictures, the clarity of the message conveyed, the suitability of the material with the target population, the language used, the validity of the references, the power of persuasion, and the ease of intervening.
Revised Intervention Packages and Modules
The revised package of interventions and modules is based on input from nurses and survivors of breast cancer. Based on the rating of the survivors, the crossword and sudoku are changed to an easier level. Based on the judgment of the nurse, the layout of the drawing is improved and the survivors used in the module.
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Trial of Intervention Packages and Modules
Trials at this stage were carried out on the appropriate respondents, namely breast cancer survivors. This trial was conducted simultaneously during training for nurses of Dharmais hospital. Some nurses demonstrated educational techniques and guided survivors in the intervention packages they had prepared. Survivors who conducted the trial stated that they were very happy with the package of interventions they had prepared, especially in carrying out guided imagery and playing puzzles.
Revised Intervention Packages and Modules
Revision at this stage is done based on input from nurses. So the final version of the intervention package consists of four sessions, one session per week, and is accompanied by daily tasks in the form of crosswords, puzzles, and sudoku.
IV. DISCUSSION
The development phase of intervention includes various processes that are initiated from the synthesis of concepts to trials in the relevant population. Memory-executive function exercise intervention (MEFE) package is a combination intervention package consisting of education, stress inoculation training, self-talk, guided imagery, and cognitive exercise; puzzle, sudoku, and crossword. This intervention package aims to help survivors of post-chemotherapy breast cancer to have a positive adaptation to the chemobrain experienced, including minimal stress, improved memory and executive functions, and increased participation in activities in the community. The selection of these types of interventions was based on literature review, previous research, and the results of the research stage of problem identification.
One of many things a research must fulfill is the element of novelty or findings from a study. Research can be said to be true if researchers find elements of new findings so that they can contribute both to science and to life. According to Sukardi (2006), the novelty of research consists of three types, namely invention, improvement, and refutation. The novelty of this research is to develop a method or a package of interventions for memory and executive function exercises, which are arranged through a scientific method and have been tested for validity. The scientific method used in the preparation of this intervention package is a synthesis of the results of literature studies and previous research. Then, test the validity and reliability. Validity test consists of content and construct validity. The content and construct validity test was developed from the scientific perspective of the experts. At the end of the expert consultation phase, the experts stated that the package of interventions and modules compiled was feasible to be applied.
Other specificities of this intervention package are shown in different components, products, and country contexts. Previous research has never used stress management, which consists of stress inoculation exercises and guided imagination as a major component in their research. Stress inoculation exercise is a type of cognitive
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behavior therapy. The product in the form of modules for nurses and patients in this study explains that chemobrain management is also the first product in Indonesia.
Then, the intervention package as it has been arranged has never been done before by researchers in Indonesia.
The main characteristic of this intervention package lies in its component of intervention. One selection of intervention components is based on factors that influence cognitive function. This principle is consistent with the contents of the TOUS theory which explained that nursing interventions that are arranged for survivors of breast cancer with chemobrain must consider its influencing factors (Smith & Liehr, 2014). Based on the research of Syarif et al. (2019), factors that influence memory function after logistic regression analysis are sleep quality and stress. Also according to a logistic regression analysis, it is found that factors that influence executive function include age, duration of education, respondent categories, menopausal status, hemoglobin levels, and stress. The intervention package provides a focus on modifiable factors that can be changed through nursing intervention. Stress affects memory and executive functions. Hence, a large portion of this intervention package revolves around stress management.
The selection of components in this intervention package is different from previous studies. A research done by Ferguson et al. (2007) focused on memory exercise.
Interventions given to respondents include giving instructions about recognizing memory disorders in themselves, progressive muscle relaxation, scheduling activities, and learning many compensation strategies. Meanwhile Kesler et al. (2013) focused on improving executive functioning. The intervention consisted of various games, including switching games, mental rotation games, n-back memory games, spatial sequencing memory games, word stem completion games, route planning, and rule- based puzzle solving. All of these exercises included visual stimuli that required motor responses.
A research about psychology training program by Weis, Poppelreuter & Bartsch (2011) consisted of two types of interventions that focused on improving function of attention and memory. The first group of respondents acquired interventions that were more focused on real life situations and compensation strategies they used directly in daily life. The second group underwent computer-based intervention and was supervised by a therapist. Schuurs & Green (2013) conducted a study which was a cognitive rehabilitation of various types of cancer and various treatment modalities that were carried out on a group basis. The intervention consisted of psychoeducation, training to strengthen memory and attention, compensation strategies, emotional adjustment, and self-care. The team explained that the novelty of their study lies in its group-based research characteristic that was involving survivors of various types of cancer diagnoses and their treatment modalities. Cherrier et al. (2013) also carried out cognitive rehabilitation in various types of cancer. The content of the intervention consisted of assistance for memory, meditation, and practice skills for memory.
However, the team did not provide a clear picture of the details of the interventions provided.
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One theory that underlies the selection of this intervention package is the theory of unpleasant symptoms (TOUS). The selection of this theory is based on its suitability with the conditions of the population being studied. The application of this theory has been widely studied, especially in cancer survivors and patients who are still receiving treatment. This population is the most studied population (Smith & Liehr, 2014).
Specifically, Myers (2009) has made an explanation related to cognitive disorders experienced by cancer patients who received chemotherapy using TOUS.
TOUS helps highlight the important aspects of symptoms experienced and potential strategies for symptom management that are not conveyed by other specific symptom models (Smith & Liehr, 2014) which aim to increase understanding and assist nursing research and practice (Lenz, 2018). For example, the TOUS emphasizes the importance of multivariable assessments of the symptoms experienced and possible factors that influence them, as well as providing a rational and framework for applying a biopsychosocial approach. TOUS suggests that multiple management strategies are needed to be applied simultaneously, carried out in the form of factors that influence symptoms (Smith & Liehr, 2014). This principle has been applied by the compilers of the intervention packages and modules, where one of the considerations for the preparation of the intervention packages is the factors that influence chemobrain, which are obtained at the problem identification stage.
TOUS is very valuable, because TOUS is intended to integrate information about the complexity and interactive nature of the symptoms experienced (Cooley, 2000).
The symptoms experienced are the heart of nursing services, so that whatever is done for the patient and with the patient must be based on the symptoms experienced (Lenz, 2018). Some experts encourage nurses to design interventions by including multiple dimensions of symptoms and the interactive nature of symptoms, influencing factors, and consequences, which make clients more specific (Smith & Liehr, 2014). The treatment plan must include the experience of short-term and long-term symptoms and ways of monitoring, and should include instructions to encourage patient doing self-monitoring and self-care (Lenz, 2018).
Education provided to respondents about chemobrain management, healthy sleep behavior, stress management, and exercise aims to increase the knowledge of breast cancer survivors, so that the expected behavioral changes in adapting to chemobrain are more easily achieved. In accordance with the statement of Notoatmodjo (2014), that health education is the right approach in increasing knowledge and attitudes towards health. Furthermore, good knowledge will help promote better behavior.
Stress inoculation training is a type of cognitive therapy that is designed to help a person adapt well to stress. This exercise aims to increase one’s resistance to stress and prepare it to provide a more effective response when experiencing stress (Lehrer, Woolfolk, & Sime, 2007). In the implementation of this intervention package, the stress inoculation exercise consists of the education and application phases. Nurses explore respondents’ concept of thinking about stress, then teach various skills to deal with stressful situations in the future (Robson & Manacapilli, 2014). In implementation phase, self-talk is the chosen strategy to practice adaptability towards stress. It is also in
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accordance with the emphasis given by Meichenbaum on the modification of cognitive behavior that is concentrated on how to modify self-talk (Lehrer, Woolfolk, & Sime, 2007). In addition, stress inoculation training and self-talk can help conceptualization and reframing stress that can support clients to develop new perspectives in order to cope with stress.
In the cognitive stimulation exercise component, the module maker chooses puzzles, sudoku, and crosswords. The choice of this type of game certainly has several theoretic and practical reasons. The types of interventions chosen have been adjusted to review the literature and the results of the problem identification phase of the research, where most of the respondents in the research phase were breast cancer survivors. According to Brown, Edwards & Buckley (2015), puzzles and crosswords are a type of intervention performed on survivors of breast cancer with chemobrain to reduce cognitive complaints or maintain their function.
The selection of the type of game is considered superior because it has been adapted to the needs and conditions of postchemotherapy breast cancer survivors in Indonesia. Puzzle games, sudoku, and crosswords are simple and easy to find games, but are very useful for exercising or maintaining cognitive functions.The module makers hope that survivors can still do these exercises with easier access to the types of games, after the research has been completed. Some research that has been done on respondents with chemobrain generally uses digital games, for example through smartphones. In this intervention package, the module maker uses paper. The consideration used was the respondent’s statement at the time of the intervention trial which said that they felt more comfortable using paper than a smartphone for several reasons, one of which was not causing headaches. Module makers also choose puzzles with motifs that are preferred by women, such as dolls, cinderella, and dream girl. This was chosen to increase the interest of the survivors in participating in the intervention package. This game has also been facilitated in the module, so that survivors can do it easily at home.
Another advantage of this intervention package lies in the modules used. The MEFE intervention package module consists of two modules, the nurse module and the survivor module. Survivors’ modules are arranged based on the needs of survivors, use language that is easy to understand, illustrated with original and interesting pictures, and consists of information and worksheets. An interesting picture will increase the interest of the survivors to read and follow the modules that have been made. The nurse module is arranged according to the nurse’s needs to guide the survivors in implementing the intervention package. The nurse module has easy-to-understand language, interesting pictures, a schedule of survivors’ activities, and a wider narrative than those of the survivors.
The module is made in two colors for the cover and its contents. The first type is cream colored (light brown) on the cover and contents. While the second module has a pink cover, and white on the inside. Brown is one of the colors that contain elements of the earth. This color dominance will give the impression of warm, comfortable and safe. Psychologically, the color brown will give a strong and reliable impression.