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European Journal of Oncology Nursingjournal homepage:www.elsevier.com/locate/ejon
Exercise: A positive feature on functioning in daily life during cancer
– Experiences from the Phys-Can study
, Birgitta Johanssonb,c
, Maria Carlssonc
, Karin Nordinc,d
, Sussanne Börjesona aDepartment of Oncology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
bDepartment of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden cDepartment of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden dDepartment of Public Health, Sport and Nutrition, University of Agder, Kristiansand, Norway
A R T I C L E I N F O Keywords: Neoplasms Activities Social participation Exercise Rehabilitation A B S T R A C T
Purpose: Impaired functioning due to cancer treatment is a challenge for daily life. Exercise during treatment can improve functioning. However, research describing experiences of how exercise aﬀects activities of daily life is limited. We aimed to explore how individuals with cancer receiving curative treatment and participating in an exercise intervention experienced their functioning in daily life.
Methods: Twenty-one participants were recruited from Phys-Can, an exercise intervention study. Semi-struc-tured interviews were conducted after the intervention hadﬁnished, and data was analysed using thematic analysis.
Results: Two main themes evolved:“Striving to maintain a normal life in a new context” and “Struggling with impairments from side eﬀects of cancer treatment”. The supervised group exercise proved popular, and parti-cipants reported positive eﬀects on physical and psychological functioning, as well as social and informative support from other participants. Participants struggled with impaired cognitive and physical functioning and exhaustion. They strove to maintain a normal life by adjusting their activities.
Conclusions: Perceived physical and psychological beneﬁts from exercise during cancer treatment suggest that exercise should be a part of cancer rehabilitation to facilitate activities and participation in daily life. Striving to maintain a normal life during cancer treatment is vital, and adjustments are needed to maintain activities and participation in daily life. Cancer nurses should motivate patients to engage in physical activity and encourage the introduction of exercise as part of their rehabilitation. They could also support patients in making adjust-ments to maintain functioning in daily life.
Impaired functioning due to the symptoms of cancer and cancer treatment is a challenge for daily life, and negatively aﬀects a person's health-related quality of life (HRQOL) (Appleton et al., 2015;Fleischer and Howell, 2017; Okamoto et al., 2012; Stuhlfauth et al., 2017). Functioning is an overall term for body functions, body structures, ac-tivities and participation (World Health Organization, 2013). According toWHO (2013), activities may be operationalized as domestic respon-sibilities, leisure, work and school, and participation as joining in com-munity activities and participating in society. The present study focuses on activities and participation, hereinafter referred to as functioning in daily life, in the context of cancer care, which few previous studies have done.
Social participation and activities of daily life often need to be ad-justed due to impaired functioning during treatment (Fleischer and Howell, 2017;Stuhlfauth et al., 2017).Ness et al. (2006)investigated recent and long-term cancer survivors and found that more than 50% were limited in terms of performing physical tasks that required muscle activity, such as bending, lifting or carrying, compared to 21% of the general population (Ness et al., 2006). More than 30% of the survivors also reported limitations in performing activities of daily life such as shopping and attending social events, compared to 13% of the general population. Up to 90% of those receiving cancer treatment report fa-tigue, a distressing symptom aﬀecting the ability to participate fully in activities due to exhaustion (Berger et al., 2015;Minton et al., 2013). Another common challenge with regard to functioning in daily life is impaired cognitive functioning aﬀecting learning, memory, speed of
Received 4 July 2019; Received in revised form 5 December 2019; Accepted 9 December 2019
∗Corresponding author. Department of Oncology and Department of Medical and Health Sciences, Linköping University, 581 83, Linköping, Sweden.
E-mail addresses:firstname.lastname@example.org(A.-K. Ax),email@example.com(B. Johansson),firstname.lastname@example.org(M. Carlsson), email@example.com(K. Nordin),firstname.lastname@example.org(S. Börjeson).
1462-3889/ © 2019 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
processing and concentration, which has a negative impact on partici-pation in social life (Bernstein et al., 2017;Meattini et al., 2017;Von Ah et al., 2013). Functioning in daily life can also be aﬀected by neuro-pathic symptoms, particularly numbness and tingling in the hands and feet (Tofthagen et al., 2011).
Exercise,a planned, structured and repetitive activity intended to maintain or improve physicalﬁtness (Caspersen et al., 1985), has been tested as an intervention to reduce side eﬀects of cancer treatment and thereby improve functioning in daily life, and is now recommended as an important part of the rehabilitation process (Fong et al., 2012; Furmaniak, 2016;Mishra et al., 2012;Ormel et al., 2017). Studies have shown that exercise can decrease fatigue, anxiety, depression, nausea and sleep disturbance, and has a positive eﬀect on physical functioning, role functioning, HRQOL and emotional wellbeing (Fong et al., 2012; Mishra et al., 2012;Schmitz et al., 2010). Unfortunately, many people reduce their physical activity levels during cancer treatment (Huy et al., 2012), increasing the risk of impaired functioning (Fong et al., 2012; Furmaniak, 2016;Hall-Alston, 2015). Although the beneﬁts of exercise are well documented, it has still not been explored whether functioning in daily life during cancer treatment can be facilitated by exercise.
Due to the signiﬁcant consequences of impaired functioning, as-sessments of functioning are an important area for cancer nurses when supporting and motivating patients during their rehabilitation process (Hauken, 2018). In order to develop and implement clinically relevant rehabilitation programmes, it is important to increase knowledge about how patients experience the eﬀects of exercise on their functioning in daily life and to examine the role exercise plays in their recovery. However there is limited research in this area. This study aimed to explore how individuals with cancer receiving curative treatment and participating in an exercise intervention experienced their functioning in daily life.
2. Method 2.1. Research ethics
The study was approved by the Regional Ethical Review Board in Uppsala, Sweden (ref. 2014-249). Informed consent was obtained from all individual participants included in the study.
A qualitative interview study using a semi-structured interview guide was conducted. Data was analysed using thematic analysis (Braun and Clarke, 2006).
The participants were recruited from the Phys-Can study, a Swedish multicentre randomized controlled trial evaluating the eﬀects of ex-ercise with high or low-to-moderate intensity on cancer-related fatigue (Berntsen et al., 2017). The Phys-Can study recruited participants from three university hospitals and included individuals≥18 years of age, diagnosed with breast cancer, colorectal cancer or prostate cancer, scheduled for curative chemotherapy and/or radiotherapy and/or en-docrine therapy. Participants were deemed to be eligible by a cancer specialist. Exclusion criteria were: individuals not able to perform basic activities of daily living, presenting with cognitive disorders or severe emotional instability, and suﬀering from other disabling co-morbid conditions that might contraindicate physical exercise (e.g. heart failure, chronic obstructive pulmonary disease, orthopaedic conditions or neurological disorders). (Berntsen et al., 2017). The intervention lasted for six months during cancer treatment and consisted of home-based monitored endurance training together with twice-weekly su-pervised resistance training at a gym with other participants. The ex-ercise programme was standardized and equal at all sites, and
physiotherapists were responsible for the design of the intervention. The participants had ended their primary curative treatment by the end of the intervention. A convenience sample of 22 individuals, presenting the three diagnoses, both sexes and various ages, were re-cruited from one of the three university hospitals in the Phys-Can study. They were asked at the end of the exercise intervention to participate in the present study; one declined. One participant interrupted the inter-vention for personal reasons a few weeks before it ended. Since this person had already been invited to participate, the person was included in this study (Table 1). During theﬁnal interviews, no new information was obtained from the interviewees’ and thus the data collection was closed.
The Phys-Can gym instructors identiﬁed potential participants to receive written information about the study. The gym instructors in-formed theﬁrst author (AA) in which candidates were positive towards receiving further information. AA subsequently phoned or emailed those who were interested in receiving further information, and if they were willing to participate a date and location for the interviews was agreed.
2.4.1. The interviews
To minimize recall bias, the interviews were conducted within one month of completing the exercise programme. They were conducted by AA between December 2016 and May 2017 in a room at the local hospital, the participants workplace, their home or a ﬁtness centre, according to the participant's wishes. A semi-structured interview guide (Table 2) was used, inﬂuenced by the questionnaire WHODAS 2.0 (World Health Organization, 2010), assessing domestic responsibilities, leisure, work, community activities and participation in social life. Two pilot interviews were conducted, which highlighted exercise to a greater extent than we expected. After a discussion within the research group, we chose to add aspects of the experiences of how exercise impacted upon daily life to the interview guide. Since the pilot inter-views covered the modiﬁed interview guide, we chose to include them in the analysis. The interviews lasted 25–73 min and were recorded on a digital recorder. The demographic characteristics of the participants (Table 1) were collected from medical records.
Demographic characteristics of the 21 participants.
Age, mean years (min–max) 57.5 (42–75) Sex
Cancer diagnosis and treatments Breast cancer, n = 15
Surgery (S), chemotherapy (CT) and radiotherapy (RT) 1 S, CT, RT and endocrine therapy (ET) 5
S, RT and ET 5 S and RT 1 S and ET 3 Colorectal cancer, n = 3 S and CT 3 Prostate cancer, n = 3 RT 2 RT and ET 1 Total 21
2.5. Data analysis
The interviews were transcribed verbatim by AA within a few days of each interview. Thematic analysis with an inductive approach was used (Braun and Clarke, 2006). The transcripts were read through within the research team, and several times by AA. All statements re-levant to the aim were extracted and the data were then organized into initial codes. All researchers were involved in this process, with AA taking main responsibility. The coding was data-driven. Data were or-ganized manually in Microsoft Word®, and initial codes with similar content were highlighted toﬁnd patterns. The next step was to abstract the codes to potential subthemes and themes using mind maps. To as-sess credibility and trustworthiness (Lincoln and Guba, 1986), all members of the research team employed peer debrieﬁng to discuss and collate the codes and gathered them together into potential subthemes and themes. The themes were then checked in relation to codes, data extracts and the entire data set by AA (Table 3). The subthemes and themes were processed and clariﬁed into fewer distinctive themes by all members of the research team. Finally, the research team deﬁned and labelled the subthemes and themes together.
Reﬂexivity refers to the subjective eﬀect that the researcher can have on the setting and the people being studied, the research ques-tions, data collection and its interpretation (Berger, 2015). Reﬂexivity is important in qualitative studies because there are so many ways in which researcher bias could aﬀect the study due to the researchers using themselves as instruments in the research process. The research team in this study consisted of four cancer nurses and one psychologist. AA has limited experience of qualitative research, but the other mem-bers of the research group are experienced researchers with compre-hensive knowledge of research conducted using qualitative method. All the researchers were involved in the Phys-Can study except MC. AA is a clinician researcher and had met some of the participants during the recruitment for the Phys-Can study, and two in connection with their chemotherapy, but not as their primary nurse. AA was also a doctoral student in the study, which might have discouraged the participants from expressing negative opinions about the intervention.
Two themes (“Struggling with impairments from side eﬀects of cancer treatment” and “Striving to maintain a normal life in a new context”) and six subthemes were generated from the data (Fig. 1). 3.1. Struggling with impairments from side eﬀects of cancer treatment
This theme describes the negative aspects of the participants' func-tioning in daily life. Acute and late side eﬀects of the treatment had a negative impact on participants’ daily life, and limited activity and restricted participation. Despite struggling with side eﬀects, the parti-cipants attended the exercise intervention and experienced positive eﬀects, and believed their functioning in daily life would have been even worse without the intervention.
3.2. Exhausted all the time
Participants experienced both physical and mental exhaustion, which could come on at any time, but mostly during the evening. This had a profound negative eﬀect on functioning in daily life. Experiences of being aﬀected either most of the time or on certain occasions were expressed.
“You can't work all day, or you get tired and you don't work more than a certain number of days in a row. The body says, now we're taking it easy to recover. This message has been very clear.” (P11)
The physical exhaustion had a negative impact on social life when participants were too tired to go out in the evening, and mental ex-haustion limited their participation in social life because social inter-action with others took a lot of eﬀort. Family life could be aﬀected by not having the capacity to be a parent or a partner. Work capacity could be aﬀected by not being able to work full time. However, participants said they thought they would be even more exhausted without the exercise intervention.
“Exercise has been a positive thing. Of course, I've been tired pretty much all the time, but how would I have been without exercising?” (P2) Table 2
Examples of questions in the interview guide.
Main questions Probing questions
What was your experience of performing household chores over the past six months? Diﬀerences compared to before illness
-If you had any diﬃculties, how have they aﬀected you? What sort of impact do you think it had on you? How did you feel?
What initiatives did you take to participate in diﬀerent activities? How did your health aﬀect your ability?
At home? Socially? Why? Can you tell me about your experiences of carrying out leisure activities compared to before your illness?
Can you tell me about your social life over the last six months? Can you tell me what your relationship with your family has been like?
Can you describe any everyday situations where you found that exercise has aﬀected you?
Examples of data analysis from data extract to themes.
Data extract Codes Sub-themes Themes
Your head is messed up, you feel stupid and you don't understand. I have enormous diﬃculty with concentration. (P8)
Diﬃcult to concentrate. Impaired cognitive functioning.
Struggling with impairments from side eﬀects of cancer treatment. We haven't had any dinner parties. Those close friends that we spent time
with have been kind, saying“Come over to ours and eat. It's important that we meet up, but you don't have to do everything– come here instead.” (p. 15)
Spending time with close friends, made easier by adjusting the activity.
Adjusting activities. Striving to maintain a normal life in a new context.
You might feel tired before, and then after exercising you feel really good and I notice that I have more strength in my body. You can see it, and I also feel that I'm physically stronger. (p. 18)
Exercise reduced tiredness and increased physical strength.
Exercise facilitated functioning in daily life.
Striving to maintain a normal life in a new context.
3.2.1. Impaired cognitive functioning
Participants experienced diﬃculties with concentration when per-forming activities that required them to focus. The ability to initiate activities such as creative work or to participate in social meetings was also limited.
“I've experienced social and mental tiredness all the time. I haven't been able to spend a long time with people, that's what has aﬀected me the most.” (P4)
When returning to work, they said that it was harder to stay focused and concentrate for a whole day, and their ability to handle stressful situations and multitask was reduced. Their memory was aﬀected during cancer treatment and participants described experiences of forgetting what task to do next, what had been agreed with others, or the names of things.
“I felt really mushy in the head. I couldn't concentrate on facts, so I felt that I didn't need to get it right now, so Iﬁled it away and didn't even think about it because it felt exhausting.” (P3)
3.2.2. Impaired physical functioning
Particularly after surgery, some participants stated that they were dependent on help from family and friends with household activities like cooking, cleaning and carrying groceries, because they found it hard to lift their arms or carry heavy weights. Experiences of neurolo-gical side eﬀects from the chemotherapy treatment causing tingling and numbness in the hands or feet reduced their functioning, so the parti-cipants dropped things or felt unstable when walking. However, the paraesthesia did not stop them from engaging in the exercise pro-gramme and other activities.
Cancer treatment could aﬀect their social life due to bodily changes. Participants with stoma and urinary urgency were limited in their ac-tivities because they were afraid of leakages in public places. Intimate relations with partners could cause feelings of discomfort in connection with revealing their naked body.
“I still don't look at myself in the mirror properly. I would never get changed in a locker room. I don't go to the swimming pool anymore. I don't want to show myself to my husband. This aﬀects me a lot. It aﬀects me more than anything else, I think.” (P5)
Participants receiving chemotherapy experienced a fear of catching infections, and this could limit their social life. Public places, such as public transport, social events and shopping malls, were avoided during busy hours. This fear could also aﬀect their family life, leading to greater isolation and less participation in activities than before.
“However, my husband and I didn't meet so many people. To begin with, I was afraid to spend time with people because I thought that with che-motherapy you're so susceptible to infections. Then it turned out that it wasn't so dangerous.” (P18)
3.3. Striving to maintain a normal life in a new context
This theme describes the positive aspects of the participants’ func-tioning in daily life. Due to changes in health conditions during and after cancer treatment, the participants have to adjust their daily life according to a new context. The participants strove to maintain a normal life and adjusted their activities and participation so they could maintain routines. The perceived beneﬁts from the exercise interven-tion encouraged them to maintain their activities and their participa-tion in daily life.
3.3.1. Exercise facilitated functioning in daily life
The exercise was an important part of the rehabilitation, and helped the participants to maintain their health and physical ﬁtness and to focus on things other than their cancer. The participants stated that they were proud to have carried out the physical tests that showed an improvement in their physical strength and endurance after partici-pating in the exercise intervention. The exercise helped them to struc-ture their day, whether they were on sick leave or retired. The exercise was helpful for maintaining an active life. By maintaining physical functioning during treatment, many experienced that they gained more capacity for other activities such as housekeeping and participating in leisure activities that were physically demanding. Participants also stated that the exercise improved their self-esteem because they were able to exercise in spite of impaired physical functioning and fatigue during their treatment. Being in a healthy environment such as the ﬁtness centre empowered their eﬀorts to improve their health.
“I think the exercise has helped me in every situation. I've managed to think positively and I've developed a body that can manage everyday life all the time. It's aﬀected me. You could see this in the test results. I'm much stronger now than I was before … and the exercise didn't take place in a hospital environment, it was at a public gym. I think that also helped me to feel healthier.” (P6)
The exercise also brought psychological beneﬁts. The participants stated that they had felt depressed, but after the exercise session they were calm and full of mental energy, happiness and a sense of psy-chological wellbeing.
“I've been healthier and stronger, both mentally and physically. I can manage, if I hadn't exercised like that I think it would have taken longer for me to get going physically. Now I've been active all the time. Exercise improves your mental health, I've really felt that.” (P14)
Side eﬀects from the treatment, such as joint pain and stiﬀness, were improved as were problems with pain in the shoulders and back before the diagnosis, which was helpful when returning to work and doing heavy lifting.
3.3.2. Social and informative support from the exercise group
Social life could be limited during treatment, and the exercise group provided a context for participation and meeting others in a similar Fig. 1. Thematic map with themes and subthemes.
“It's also been positive in a social way. We're a great group and have got to know each other. We talk, support and encourage each other. It's because you actually go there and hang out even when it feels quite challenging. Yes, it's important to meet others who understand what you're going through. You notice that, because it's much easier to talk to people who know.” (P1)
The participants experienced that the group was supportive and provided motivation to attend the scheduled exercise sessions at the gym. The gym instructors contributed to the perception that exercise is safe during treatment and they also encouraged the participants to engage in other activities.
“You get a bit scared of doing things, especially if you've had a wound after the operation. Having a professional to provide guidance and having a special exercise programme were positive things.” (P16) 3.3.3. Adjusting activities
The participants could continue with many household activities during treatment by making adjustments. Being on sick leave was helpful when adjusting activities to match their capacity.
“Weekdays have worked because I have a lot of time to myself during the day. Today I've done a little laundry and tomorrow I will vacuum a little. Thus, you can do some of these things every day at your own pace. I've been able to handle all that, so it's felt good to me.” (P6)
The participants said that they had maintained their social lives and had retained the ability both to support others and to stay in contact with friends and family, although sometimes less than before. Instead of meeting people, it was easier to remain in contact by email or phone. Increased free time during sick leave was perceived as facilitating participating in social life. Still, adjustments were made, and social activities were often carried out during the daytime due to fatigue.
“My social life has probably been quite similar, and I've probably also prioritized that. Like meeting people and not being withdrawn. On the other hand, we may have done it in a simpler way, not making dinner but sitting over a coﬀee or buying a pizza.” (P10)
Participants stated that they travelled less and stayed closer to home or went away for shorter periods than before. It was important to continue with activities such as singing in a choir or taking dance classes as part of the rehabilitation, even though adjustments including rests were needed.
Experiences of work ability diﬀered between participants. At the time of the interview, some had been working for months and others for just a few weeks. Returning to work was important as it contributed to being part of a social context and to ﬁnding continuity, and it also brought structure to daily life. However, due to fatigue and impaired cognitive functioning, adjustments were made to occupational tasks and many worked part time atﬁrst and changed their working hours if needed.
Being aﬀected by a serious disease like cancer causes changes in perspectives about what is important in life. Many participants started to prioritize themselves and meaningful things. Reduced working hours gave them more time for themselves. Being close to family and friends, as well as having more time to participate in activities, traveling and exercise, became more important.
The results from this study showed that people with cancer parti-cipating in an exercise intervention during treatment found that ex-ercise improved functioning in daily life during cancer treatment through improved physical and psychological functioning, reduced symptoms and by facilitating their return to work. Thus, exercise may
be of great value in reducing the negative experiences of cancer treat-ment and fostering a feeling of normality. The participants also stated that despite their exhaustion, they managed to exercise during cancer treatment and they maintained their physical activity level or even increased it, even though a reduction in physical activity level is common during treatment (Huy et al., 2012). This indicates that the cancer nurse plays an important role as part of a multi-professional rehabilitation team to promote exercise during cancer treatment as a means to improve health and functioning in daily life. Cancer nurses are required to establish an individual care plan for each cancer patient, in which the rehabilitation needs must be assessed (Brennan et al., 2014; Swedish Government Oﬃcial Reports, 2009).
Daily life during cancer treatment was a struggle for the participants due to the side eﬀects, as also seen in previous research (Bennion and Molassiotis, 2013;Mishra et al., 2012;Nilsson et al., 2013;Stuhlfauth et al., 2017). Despite side eﬀects, the participants strove to live a normal life and to maintain routines in their new context. Many had the capacity to continue with their activities; however, they had to make adjustments due to deteriorating health condition and impairments. In our study, many participants were on sick leave. Having more time to perform household activities and receiving support from friends and family were facilitating factors in maintaining functioning of daily life. This is consistent with previous research which shows that people with cancer have toﬁnd strategies for adjusting activities to compensate for their limitations (DeSanto-Madeya et al., 2007; Ness et al., 2006). However, ourﬁndings also indicate that exercise can facilitate func-tioning of daily life since participants experienced that the exercise improved their physical functions and decreased their exhaustion, and thereby facilitated activities of daily life during treatment.
The group exercise was another important factor that facilitated the participants' functioning in daily life. One positive aspect of partici-pating in the exercise intervention was being in a social context with others in the same situation, giving participants social and informative support from fellow patients, which included empathic understanding, information and increased motivation. The participants stated that the group exercise promoted their participation in daily life, and that it took the focus away from the cancer and improved their health. Previous research also shows the beneﬁts of exercising in a group, due to both motivating aspects and social support, complementing our re-sults (Backman et al., 2016;Segal et al., 2017). The participants in our study raised the importance of meeting others in the same situation, and that participating in group exercise may provide both physical beneﬁts and peer support. Similar results from another study showed that a combination of walking and talking not only brought physical beneﬁts but also encouraged everyday and cancer-related conversation (Ireland et al., 2018). The exercise intervention was also helpful when structuring the participants’ days during their cancer treatment, which is consistent with previous research (Backman et al., 2016;Midtgaard et al., 2015).
Participating in social life was important for the participants, and family and close friends were prioritized more than before, which is consistent with other research (Pinquart et al., 2009). However, parti-cipation could be restricted due to exhaustion, impaired cognitive functioning or fear of catching infection, similar to the results from another study (Fleischer and Howell, 2017). Despite their fear of in-fections, the participants chose to attend the group exercise sessions. Fear of infection might aﬀect participation in social activities during chemotherapy treatment, so it is important for cancer nurses and physicians to inform patients that the risk of catching infections from others is small, and that most infections during chemotherapy are caused by their own bacterialﬂora (Freifeld et al., 2011).
Returning to work after sick leave was also important for many of the participants, and exercise during cancer treatment was perceived to facilitate their return to work because it helped the participants to maintain their physical functioning. Other studies also show that ex-ercise during or after treatment can facilitate a return to work for
people with cancer (Groeneveld et al., 2013; Leensen et al., 2017). However, the participants in our study had not experienced any long-term eﬀect since they had only recently returned to work. The parti-cipants also stated that the work brought structure and continuity to daily life, but some were too frail to return to work, or they wanted to change occupation or work less, as also found in a previous study (Lilliehorn et al., 2013). Impaired cognitive functioning made it diﬃ-cult for the participants to return to work in our study, regardless of the cancer treatment they received. Theseﬁndings are also supported by other results; cancer-related cognitive impairment is a common side eﬀect of cancer treatment and can have a negative impact on quality of life, daily functioning and work capacity (Pendergrass et al., 2018).
This study has focused on functioning in daily life during cancer treatment. However, the participants also stated that their deteriorating health condition during cancer treatment caused limitations in activity and restrictions in participation. The negative experiences of cancer treatment constitute diﬀerent aspects of disability for which exercise may be an important intervention. Cancer nurses need to be aware of these potential hindering consequences of cancer treatment so they can identify them and take action to initiate adequate rehabilitation, in order to improve HRQOL outcome and patient experiences (Hauken, 2018;World Health Organization, 2013).
4.1. Strengths and limitations
This study contributes additional knowledge demonstrating the potential of exercise as a rehabilitation tool to improve functioning in daily life as a part of HRQOL during cancer treatment. As far as we know, no study has explored the experience of functioning in daily life while participating in an exercise intervention for as long as six months during cancer treatment. Our study also contributes by describing the experiences of individuals with various diagnoses, which is important since most previous research has focused on women with breast cancer. Our intention was to obtain a representative sample of participants, mirroring the three diﬀerent diagnoses groups included in the Phys-Can study. This was achieved except for males with colorectal cancer. Thus, as in the Phys-Can study (80% of the participants were women with breast cancer), the majority of the participants in our study were women with breast cancer (15/21), which might limit the transfer-ability of the ﬁndings. Further studies about the perceived value of exercise for functioning in daily life that include participants with a range of cancer diagnoses and a mix of sexes are needed. Phys-Can is a randomized controlled study, including individuals from three large hospitals in Sweden covering three regions with similar demographic populations. Since we do not expect to see diﬀerences between parti-cipants enrolled at the three university hospitals, we chose to include participants from one of the sites in the present study for convenience reasons. The participants in this study had voluntarily participated in an exercise intervention, and their experiences of the beneﬁts of ercise might have been inﬂuenced by a positive attitude towards ex-ercise.
Being involved as a researcher in the intervention study may have aﬀected how the data was interpreted. Personal bias is impossible to avoid in qualitative research (Tong et al., 2007), and the pre-under-standing within the research group will have inﬂuenced the interview questions and the interpretation of the data (Berger, 2015). However, one researcher had not been involved in the planning or implementa-tion of the Phys-Can study. Having experienced qualitative researchers within the group was an advantage during the data analysis process. 5. Conclusion
Exercise was perceived as being important for maintaining func-tioning in daily life during cancer treatment, and the group exercise provided important social and informative support from others in a similar situation. Struggling with side eﬀects of treatment which
aﬀected functioning in daily life made adjustments important in order to keep their daily life as normal as possible.
6. Implications for practice
The experienced advantages of participating in the exercise inter-vention in this study, together with similar results from other studies, indicate that exercise should be a natural part of cancer rehabilitation, and that healthcare staﬀ should recommend exercise during cancer treatment to improve functioning in daily life. It should be the re-sponsibility of the health care organisation to provide evidence-based information and to support exercise. Cancer nurses should motivate patients to maintain physical activity during treatment, in cooperation with the rest of the healthcare team and guided by physiotherapists. Cancer nurses should also include exercise during treatment as a part of the rehabilitation process and refer all patients with a need for ad-vanced exercise support to a physiotherapist. Since many patients need to adjust their activities and participation during cancer treatment, cancer nurses and the health care team can also help them toﬁnd strategies for making adjustments in daily life.
Declaration of competing interest
The authors declare they have no conﬂicts of interest. Acknowledgements
This work was supported by grants from the Department of Oncology, Linköping University Hospital, Sweden, Region Östergötland, Sweden, the Swedish Cancer Society and the Swedish Research Council.
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