Evidence Based Nursing Research: Yoga in Cancer

This paper critically evaluates the effectiveness of yoga in improving the quality of life in adult patients with cancer. It discusses the rationale behind exploring yoga as a clinical practice, the research background and PICOT question, the search strategy used to find evidence-based research, and the critical appraisal of a selected randomized controlled trial. The paper concludes by discussing the dissemination of findings into clinical practice and the need for further research.

Running head: EVIDENCE BASED NURSING RESEARCH: YOGA AND CANCER
EVIDENCE BASED NURSING RESEARCH: EFFECT OF YOGA IN IMPROVING
QUALITY OF LIFE IN CANCER PATIENTS
Name of the Student:
Name of the University:
Author note:

1EVIDENCE BASED NURSING RESEARCH: YOGA IN CANCER
Part 1: Introduction
As per the Standards of Practice postulated by the Nursing and Midwifery Council
(NMC), Registered Nurses are obliged to deliver patient care interventions, assessment
procedures and health educational materials which are ‘evidence-based’ or compliant with the
best and highest standards of evidence and research (NMC, 2015). ‘Evidence-based practice’
(EBP) is the name given to clinical practices, interventions and procedure which have developed
and are followed based on valid and significant scientific research. Engaging in extensive EBP
assists nurses to deliver interventions which are valid, pose the lowest risk and have been
researched to induce beneficial patient healthcare outcomes in the future (Horntvedt, Nordsteien,
Fermann & Severinsson, 2018).
Thus, considering the same, the following paper will comprise of critically evaluating the
effectiveness of a clinical practice which can improve the quality of life of adult patients, with
the help of screening and appraising an evidence-based research. The clinical practice upon
which an evidence based research will be selected is the ‘effectiveness of yoga in improving the
quality of life in adult patients with cancer.’
Part 2: Research Background and PICOT
Rationale
‘Psychosocial morbidity’ is the condition characterized by loss of psychological and
social wellbeing in individuals as a result of chronic illness, sickness, diseases and injuries.
Psychosocial morbidity is a frequent occurrence in patients who are well aware of the severity of
their disease and illness condition. It is thus common to find cancer patients encountering
psychosocial morbidity after experiencing chemotherapy, surgical and radiotherapy interventions

2EVIDENCE BASED NURSING RESEARCH: YOGA IN CANCER
resulting in frequent reporting of feelings of anxiety, depression, loss of ability to work and
dysfunction in social engagement (Caruso, Nanni, Riba, Sabato & Grassi, 2017). The adverse
metabolic consequences and associated loss in quality of life are major contributors to loss of
psychological and emotional wellbeing after cancer, which is why, cancer patients have been
evidenced to demonstrate an eagerness to regain their previous sense of empowerment, control
and responsibility over their own personal lives, their mindset and decision-making and the lives
of their loved ones and families (Matthews, Grunfeld & Turner, 2017).
With this respect, it has been evidenced that a growing number of cancer patients are
expressing an interest towards alternative and complementary therapeutic based interventions,
due to their ability to induce relaxation, spiritual wellbeing and mindfulness. Traditional
psychosocial and behavioural therapeutic interventions such as group therapy or cognitive
behavioural therapy (CBT), have been evidenced to enhance a sense of sharing, problem solving,
reasoning, support, a sense of responsibility and control, which in turn, contribute to reduced
feelings of distress and psychosocial morbidity and improved coping, mood, adjustment and
vigour in cancer patients (Eyigor, Uslu, Apaydın, Caramat & Yesil, 2018). However, despite
these benefits, such traditional psychosocial interventions do not consider factors like spiritual
wellbeing and enhancement of skills of self-awareness and mindfulness. While additional
interventions like physical exercise have also been evidence to yield improved physical as well
as psychological outcomes simultaneously, the presence of cancer related fatigue and the
debilitating physiological effects of radio or chemotherapy, imply that the effectiveness of
exercise is greatly subjective as per cancer patients’ current health and disease status
(Raghavendra Mohan Rao et al., 2017).

3EVIDENCE BASED NURSING RESEARCH: YOGA IN CANCER
Yoga is a complimentary, body and mind based therapy, which has originated in India
and rapidly gained popularity in Western countries. Yoga has been traditional considered as a
beneficial therapy in ancient Indian cultures, for the treatment of a number of health conditions
which are largely associated with psychological distress and morbidity like hypertension,
asthma, diabetes, anxiety, cardiovascular diseases, cancer and musculoskeletal diseases. With the
help of a range of postural and breathing exercises (such as ‘asanas’), yoga has been evidenced
to improve breathing regulation, induce calmness and physical as well as psychological
wellbeing (Amritanshu et al., 2017). Such factors contribute extensively in improving an
individual’s skills of mindfulness, sense of awareness as well as self-control. Such skills have
been evidenced to alter perceptions towards internal and external stimuli, induce improved sense
of self-control and lower reactivity to situation perceived as stressful, challenging and
threatening to individuals. For this reason, yoga can be considered as an efficient intervention
which can improve the quality of life in cancer patients who encounter psychosocial morbidity
and perceptions of threat regarding their illness, especially after critical treatment (Danhauer,
Addington, Sohl, Chaoul & Cohen, 2017). Thus, the prevalence of psychosocial morbidity in
cancer patients, the limitations of traditional psychosocial therapy and the beneficial impacts of
yoga form the rationale and motivation behind the exploration of yoga as an effective clinical
practice for the purpose of quality of life improvement in cancer patients.
PICOT Grid
No clinical research and underlying question can be formed without a structured ‘PICO’
format, which comprises of components like: Population, Intervention, Comparison and
Outcome. A PICO question is a structure and systematic format via which a researchable, valid
and answerable question can be developed. A PICO question, due to its specific components,

4EVIDENCE BASED NURSING RESEARCH: YOGA IN CANCER
eased the process of article screening and research evaluation for the researcher (Loversidge,
2016). Thus, the following PICO grid (Table 1), assisted in the development of the research
topic: ‘The effectiveness of yoga as a clinical practice for the purpose of improving the quality of
life among adult patients with cancer’.
Table 1: PICO Grid
PICOT Components Research Components
Population Adult Patients
Interventions Yoga
Comparison Convention psychosocial interventions like:
group therapy, counselling, CBT
Outcome Improved quality of life, improved moved
Search Strategy
For the purpose of obtained an evidence based research paper, an electronic search
strategy was performed by screening databases as MEDLINE and Cumulative Index to Nursing
and Allied Health (CINAHL), due to the vast repertoire of nursing, medical and clinical journals
these databases specialize. Each component of the advanced search terms were accumulated with
keywords compliant to the research question and in quotations for enhancing the article search
process, such as ‘cancer’, ‘yoga’, ‘quality of life’ and ‘cancer patients’. For the purpose of
improving the search strategy, alternative meanings and synonyms were used by the
incorporation of ‘Medical Subject Headings’ (MeSH) terms. Lastly, Boolean operators were
incorporated within the search terms and keywords in order ensure that the search yielded higher
number of findings (Appendix 1) (McGowan et al., 2016).
Articles were selected by following an inclusion and exclusion criteria (Appendix 2),
where studies published since last 5 years (2016 to 2020) and comprising of adult patients and
focusing upon primary research with only yoga as the experimental intervention were included.

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Studies irrelevant to the research question and comprising of pediatric cancer patients or clinical
practices comprising of yoga implemented in combination with another intervention as an
experimental procedure were excluded (Adorno, Garbee & Marix, 2016). The final search results
have been summarized in the table below (Table 2). Lastly, the randomized controlled trial
(RCT) performed by Rao et al., (2017), exploring the effectiveness of yoga for the purpose of
improving toxicity, mood and quality of life in patients with breast cancer was selected. An RCT
was chosen since it is considered as the most valid, significant and trustworthy research
methodology in the hierarchy of evidence.
Table 2: Search Results
Database Results Abstracts Full Articles
MEDLINE 10 5 2
CINAHL 20 9 3
Total 30 14 5
Part 3: Critical Appraisal
Strengths and Limitations
For the purpose of critically appraising the strengths and limitations the checklist for
RCT developed by the Critical Appraisal Skills Programme (CASP, 2020) due to the
comprehensive nature of questions which prove to be useful in evaluating the trustworthiness,
validity and significance of a selected research (Appendix 3).
Upon close examination, it can be observed that the RCT by Rao et al., (2017), clearly
specified that the research question was focused upon breast cancer patients treated with a yoga
program as an intervention, after encountering surgical, radio and chemotherapy. The outcomes
measured were clearly specified to be based on quality of life (QOL), mood, depression and

6EVIDENCE BASED NURSING RESEARCH: YOGA IN CANCER
toxicity after comparison with a patient group receiving comparative treatment of convention
supportive counseling therapy (Rao et al., 2017). This implies that the RCT by Rao et al., (2017)
was based on a clearly and easily identifiable focused issue which can be considered as a key
strength since it eases research understanding and identification by readers (Buccheri & Sharifi,
2017).
Upon critically reviewing the RCT by Rao et al., (2017), it can be observed that after
obtaining consent, participating patients were allocated randomly to intervention groups
receiving yoga program and supportive group therapy by generation of numbers via an
individual with no role in the research whatsoever, which were then placed in opaque envelopes
for selection. This implies that the authors adhered to true randomization during assignment of
treatment interventions to patients – a strength reflecting unbiased methodology with
commendable internal validity. The lack of information on blinding of allocation sequence by
researchers however raises doubts in validity and thus can be considered a key limitation. There
was no information concerning premature and sudden conclusion of the RCT and all patients in
both groups were evidenced to be accounted for the research conclusion – thus implying the
absence of any loss in statistical power or disparities between experimental and control groups
(Rao et al., 2017; van der Velden et al., 2016).
However, there is no information whatsoever regarding the blinding of patients,
researchers and health workers (Rao et al., 2017). Rather, Rao et al., (2017), clearly mention that
patients were educated concerning the trial prior to implementation. This raises serious doubts on
the validity of the research and evidences a risk of biasedness by health workers and resultant
poor methodological quality of the results. However, groups were evidenced to be similar in
terms of age, health condition, sex and social class prior to the implementation of the trial since

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the authors clearly mentioned the adherence to a stringent inclusion and exclusion criteria of
patient demographics, cancer stage and treatment – thus reflective of commendable internal
validity (Rao et al., 2017; Heydari & Hajiabadi, 2016). Further, the RCT by Rao et al., (2017)
also evidences that both groups received equal treatment considering that the authors have
mentioned that medication history, demographic data, clinical data and investigative information
were obtained from all participants prior to randomization (Heydari & Hajiabadi, 2016).
The effect of treatment was found to be extensive considering the comprehensive range
of outcomes measured, mainly the primary outcome of QOL, depression, anxiety and common
toxicity. Specifying the primary outcome in the research title and background itself can be
considered as key strengths in terms of research comprehensiveness (McKibben & Silvia,
2016).). Results indicated that patients encountering yoga practice as compared to conventional
treatment experienced a decrease in depression by 7.74 and 7.25 points, anxiety by 4.72 and 7.7
points, distress by 7.19 and 13.11 points, symptoms of treatment by 2.34 and 2.97 points,
symptom severity by 6.43 and 8.83 points and improvements in quality of life by 31.2 and 23.9
points, respectively. Adoption of a 95% confidence interval indicates that the results were
precise for 95% of the participating population (Rao et al., 2017).
Despite the commendable precision of results, the fact that the inclusion criteria
compromised only of Stage II breast cancer female patients hinder the applicability of the results
in scenarios comprising of diverse cancer patients (Rao et al., 2017). While a wide range of
clinically effective outcomes were considered, the inclusion of subjective patient perceptions
regarding their experiences in yoga could have provided a more detailed insight into patient
compliance. Considering the adverse consequences of cancer related fatigue, inability of cancer
patients to engage in physiological activity and risk of injury – inclusion of supervised yoga

8EVIDENCE BASED NURSING RESEARCH: YOGA IN CANCER
practice is advisable to ensure harm minimization in patients (Blystad, Rortveit, Gjerde, Muleta,
& Moland, 2018).
Clinical Practice & Patient Experience Quality
These findings have been evidenced to be disseminated into clinical practice by three
interventions: educational, pre-preparation and counseling phases (Rao et al., 2017). For the
purpose of motivating patients towards health behavior change, Rao et al., (2017) evidences the
need to first educate patients on the benefits of yoga using didactic sessions along with
incorporation of a post-implementation counseling session for the purpose of acquiring patient
feedback. Dissemination of interventions which contribute to positive patient experiences
comprise of inclusion of patients in yoga sessions comprising of breathing and postural exercises
which relax the supine and induce calming as well as stimulating effects (Rao et al., 2017).
Summary and Conclusion
Thus, the following paper provides an extensively yet elaborate discussion on the key
components of a search strategy, PICO and critical appraisal of evidence based research for the
purpose of exploring the effectiveness of yoga in improving the quality of life patients suffering
from cancer. To conclude, the findings evidenced by the selected RCT provide commendable
information on the effectiveness of yoga in EBP. However, adherence to blinding and inclusion
of a more heterogeneous patient populations could have assisted in overcoming limitations in
research validity and applicability.

9EVIDENCE BASED NURSING RESEARCH: YOGA IN CANCER
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13EVIDENCE BASED NURSING RESEARCH: YOGA IN CANCER
Appendices
Appendix 1: Key Search Terms
Population AND Intervention AND Comparison AND Outcome
cancer OR
cancer
patients
OR adult
cancer*
yoga OR
yoga therapy
OR yoga
practice OR
yoga
program*
Cognitive
behavioural
therapy OR
counselling
OR group
therapy*
Quality of
lie OR
depression
OR anxiety
OR stress*
Appendix 2: Inclusion and Exclusion Criteria
Inclusion Exclusion Rationale
1. Published within 2016
to 2020
2. Published in English
3. Comprising of adult
patients
4. Comprising of only
yoga as an
experimental
intervention
5. Comprising of
traditional
psychosocial
interventions as
control interventions
1. Not only published
within 2016 to 2020
2. Published in foreign
languages
3. Comprising of elderly
or paediatric patients
4. Comprising of yoga
combined with
another practice as an
intervention
5. Not comprising of
traditional
psychosocial
interventions as
control.
1. To ensure inclusion of
current information.
2. To prevent issues in
translation.
3. To comply with the
field of adult nursing.
4. To ensure relevance to
PICO and prevent
confounders
5. To ensure relevance to
PICO
Appendix 3: CASP Checklist for RCT
Checklist Question Answer
Did the trial address a clearly focused issue? Yes
Was the assignment of patients to treatments
randomised?
Yes
Were all of the patients who entered the trial
properly accounted for at its conclusion?
Yes
Were patients, health workers and study
personnel ‘blind’ to treatment?
Can’t tell
Were the groups similar at the start of the trial Yes

14EVIDENCE BASED NURSING RESEARCH: YOGA IN CANCER
Aside from the experimental intervention,
were the groups treated equally?
Yes
How large was the treatment effect? Multiple outcomes measured
How precise was the estimate of the treatment
effect?
95% Confidence interval
Can the results be applied to the local
population, or in your context?
No
Were all clinically important outcomes
considered
Cant’ tell
Are the benefits worth the harms and costs? Yes, but with supervision