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JOURNAL OF PSICOPATHOLOGY

Abstract

Background

Any cancer diagnosis induces fear and shocking emotional experience accomplished by anxiety, depression and unpredictability, also by distress, too. The emotional effect of a cancer diagnosis and the rigidity of cancer treatment negatively impact on patients’ wellness. The present systematic review and meta-analysis aims to underline how nursing coaching improves QoL perceptions among cancer patients during their hospitalization.

Methods

This review was carried out thanks to the PRISMA methodology until the end of November 2023 through PubMed, Scopus, Web of Science and CINAHL databases. Researchers systematically collected all the most current available literature. The search terms and boolean operators used to combine key words were: “QoL” AND “hospitalization” AND “cancer patients” AND “nursing coaching”.

Results

Four manuscripts were selected in the present review: a manuscript belonged to the British Nursing Database and was a mixed-block-randomized study; one belonged to Scopus which was also in the PubMed, the same to WoS and to Medline and was a study protocol for a RCT and two manuscripts belonged to the PubMed database and were all RCTs.

Conclusion

Nursing coaching improves QoL perceptions in cancer patients during their hospitalization. Patients prefer in-person intervention than nurse-led ones and QoL perceptions seem to be improved. However, very few evidence are available in this issue, thus, further interventional studies will be performed in order to better address coaching nursing interventions during cancer patients’ hospitalization.

Introduction

Health coaching may represent a new approach in nowadays health care to ameliorate the management of chronic diseases1. Coaching aims to encourage individuals to reach their health outcomes and inspire them to evaluate their related choices, to make decisions, to identify challenges and ameliorate their health attitudes1,2, by improving positive emotional and opinion effects3 and maturing self-care4, in their own health goals5,6 and quality of life perceptions7.

Health-coaching requirement is focused on an individual-centered approach, in which a helping relationship is established between the coach and the coached and the development of health improvement and education ameliorates self-care7-9. Therefore, nursing and coaching supplying in a holistic care approach consider the person as a whole in which the interconnection among biological, social, psychological and spiritual dimensions seems to be essential10. However, coaching is not still recognized as a usual approach in the nursing care process1.

Nursing coaching interventions

Nursing and more specifically oncology nursing field have been recognized as stressful conditions, due their relationship-centered care provisions in a particular setting with high exposure to death, heavy workloads, and disputal relationship between nurses and patients due to the ambiguity in emotional and spiritual conditions, which increases stress circumstances for nurses and patients11-13. Oncology nurses support cancer patients to achieve their self-care requirements14.

Literature has defined that nursing coaching practices has been characterized by kindness meditation at ensuring satisfaction and empathy, both for nurses and patients11-14. On the other hand, these practices have assessed the effectiveness to patients, also associated with an effective communication15. Nursing coaching has been practiced within nursing as a process and tool to develop and support nurse leaders, leadership skills, reflective practices and performance goal settings and improved communication competencies ti identify developmental needs and promoted individuals to achieve high performance and workplace standards of practice, through reflections14,16, healthy eating behaviors17.

Materials and methods

Aim

The present systematic and meta analyses aims to assess how health coaching intervention impacts on anxiety and depression conditions among cancer patients.

Search strategy

This systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA)18. The protocol has been registered in PROSPERO with id no. CRD42024511225.

Search approach was performed combining keywords and MeSH expressions thanks to the Boolean operators, such as: “Anxiety”, “Cancer”, “Clinical Trial”, “Coach”, “Patient”, “Depression”, also included in the “Population-Intervention-Outcome” (PIO) arrangement (Tab. I).

Peer review and data extraction

Two authors (E.V. & L.M.) carried out the literature search using several online data bases, specifically: British Nursing Database, CINHAL, Embase, Nursing & Allied Health Database, PubMed, Scopus and Web of Science databases. The selection methodology was characterized according to selected review criteria, which included only clinical trials published in English language which assessed anxiety and depression conditions before and after the coaching intervention among cancer patients. References with an unclear abstract or insufficient information regarding our outcome were further excluded for this review. After that, all selected articles were uploaded in their full text versions and then, assessed more closely for their eligibility. Disagreements on the inclusion studies were solved by consulting the third researcher (R.L.) in order to reach an agreement for all the studies included in the present systematic and meta-analysis review. All studies were assessed according to their characteristics, including: author, year of publication, aim, design, sample size, setting, participants and their related: age, cancer stage, type of treatments performed, and outcome both in anxiety and depression will be appropriately assessed by the HADS19.

Records assessed

A total of 263 studies were found at the first step of our literature research (Fig. 1). Before screening, two articles were removed as identified as duplicate and other 265 were removed as they were not in compliance with our final outcome. After screening, a total of 12 eligible records were found. However, 9 out of these 12 clinical trials were excluded as they did not contain data for further meta-analysis assessment. Finally, the remaining 3 clinical trials were included in the present systematic review and meta-analysis (Fig. 1).

Interventions and outcomes

The present systematic review and meta-analysis embraced all interventional, randomized clinical trials, quasi-experimental studies, applying nursing coaching interventions and recording anxiety and depression conditions, as outcome. Specifically, anxiety and depression conditions were assessed thanks to the Hospital Anxiety and Depression Scale (HADS)20, before and after a coaching intervention in any cancer treatment, such as: surgery, chemotherapy, radiotherapy or endocrine therapy. The HADS included a total of 14 items, whose 7 items assessed anxiety condition (HADS-A) and 7 items quantified depression one (HADS-D)21. Each sub dimension varied from 0-21 and higher scores indicated a greater pathological condition level. Evidence suggested high reliability and validity of the scale for all the two sub dimensions investigated19.

Quality assessment and risk of bias

The quality assessment of all the selected studies was enhanced by considering their study designs and related levels of evidence according to the Evidence Based Nursing (EBN) approach22. The EBN methodology included a total of seven levels of evidence, ranging from I to VII, suggesting the weakest quality of study design, specifically:

  • Level I: Evidence from systematic reviews or meta-analysis of randomized control trials;
  • Level II: Evidence from well-designed randomized control trials;
  • Level III: Evidence from well-designed control trials that are not randomized;
  • Level IV: Evidence from case-control or cohort studies;
  • Level V: Evidence from systematic reviews of descriptive or qualitative studies;
  • Level VI: Evidence from a single descriptive or qualitative study;
  • Level VII: Evidence from expert opinions.

In the present systematic review, we included all studies belonging from I to III level of evidence.

Additionally, the funnel plot was adopted as a graphical method for the risk of publication bias, using a contour-enhanced funnel plot and performing Egger’s t-test23.

Data synthesis

Studies were assessed for quality as per protocol recommendations. The information retrieved from the final selected studies will be exposed using both a narrative approach and tables. Statistical analysis was performed using the R environment (version 4.2). For each study, the standardized mean difference (SMD) was calculated using Hedges’ g method23. To assess the consistency across studies, the I2 statistic was adopted with 25%, 50%, and 75% suggesting low, moderate, and high heterogeneity degrees, respectively. However, I2 should be presented and interpreted cautiously in small meta-analyses. For this reason, 95% confidence intervals (95% CI) were presented in addition to the point estimate. The χ2-based Q test was also applied to look for heterogeneity of effects among studies. A significant Q value (PQ < 0.05) suggested the presence of significant heterogeneity between studies. The τ2 statistic was also presented to check the variance of the true effects. Random effects meta-analysis with the Knapp-Hartung adjustment method (HKSJ) were implemented. Forest Plots were generated for each meta-analysis25. Publication bias was assessed using a contour-enhanced funnel plot and performing Egger’s t-test23.

Results

Data were pooled from 3 studies25-27 with 228 subjects. For each study, the two subscales relating to depression (HADS-D) and anxiety (HADS-A) were considered separately and two separate meta-analyses were carried out.

Table II showed all study characteristics, specifically: author(s) and year of publication, study design and level of evidence and coaching interventions improved compared with the usual care provided. For each study included in the present systematic review and meta-analysis the HADS scale was adopted and then, both anxiety and depression assessments were performed for control and experimental group, respectively. Therefore, coaching interventions and their related findings were explained according to anxiety and depression evaluations.

Study characteristics

In the Boxleitner et al. study25 patients enrolled in the experimental harm received a coaching guide in addition to the standardized meditation session, both once a week after the radiation treatments. The aim of a guided-coaching meditation was addressed to enhance relaxation with a sense of peace and calm in order to empower patients in self-management their anxious and depressed experiences along with their treatments. In this way the coaching supported a mindful approach which better help the participant to concentrate on the current moment. Different organized phases were weekly arranged at the coached visit during radiation treatment over 6 weeks. Each meeting started with engagement in communication through the meditation coach to reach a level of acceptable comfort before beginning the session. The participants were trained that there was no a right approach to practice the meditation. Conversely, there was specific information on mindful meditation, breathing and scanning of the body. However, no significant improvements were reported between the usual and experimental groups, both for anxiety (p = 0.631) and depression conditions (p = 0.272), too. Meditation with a coach required a guided meditation coach on team to supply the facility and weekly encountered with patients. Self-meditation only needed a meeting at the beginning of the self-meditation pathway to teach participants how to perform it25.

In the Nguyen et al. study26 the coaching intervention was performed through an informed summary of Revised Symptom Management Conceptual Model28 and the Individual and Family Self-Management Theory29 in order to recognize circumstances that impact on the symptom self-management approach27, specifically: knowledge and awareness to encourage people to empower in required symptom handling attitudes, competences, and supplies requested to improve skills. The coaching intervention consisted of three individualized psycho-training phases which encountered all the possible patients’ symptom perceptions and their related requirements and contextual factors30. The first in-person meeting provided a training session through a PowerPoint presentation to give all the necessary information and the improvement of self- symptom management schedules thanks to the Five Model of Self-Management Support31. Patients were asked to assess their specific outcomes in attitudes along with their worries on symptom handling and probable obstacles and approaches to bridge them. Findings suggested a significant amelioration in patients’ anxiety (p = 0.002) and depression (p≤0.0001) which in turn could improve coaching interventions as a helpful psychoeducational intervention26.

In the Wei et al.27 study usual care, consisting in in-person interviews supported by an informative brochure on healthy lifestyle, was added to Baduanjin exercise. Coaching Baduanjin intervention was supplied by a Qigong specialist, who the participants to correct their movements. The participants were also received a video support to improve daily practice for 5 times/week for 30-60 minutes during the 12-week exercise period. The Baduanjin sessions started with stretching exercises, breathing with inhalation and exhalation, and muscle relaxation exercises. Patients were monitored also at home, since they were invited to record all the exercises performed at home and also any difficulties encountered. Findings suggested significant improvements in anxiety levels (p < 0.05) and no correlation between depression score (p = 0.585)27.

Meta-analysis results for HADS-Anxiety (HADS-A)

The Cochrane Q-test revealed the presence of a significant heterogeneity between the studies (PQ = 0.033; tau2 = 0.14; I2 = 70.7%). Within this domain, we did not find any significant difference between experimental and control interventions (Fig. 2). The Funnel Plot suggested the absence of publication bias (Fig. 3), with Egger’s regression intercept confirmed this result (β = 11.64; 95% CI = [1.79; 21.48]; P = 0.259).

Meta-analysis results for HADS-Depression (HADS-D)

The Cochrane Q test showed a significant heterogeneity among studies (PQ < 0.001; tau2 = 0.377 and I2 = 86.7%). The Forest Plot did not find any evidence in favour of the experimental treatment (Fig. 4). The symmetry of the Funnel Plot (Fig. 5) indicated that no publication bias was present. This result was confirmed by Egger’s regression (β = 19.22; 95% CI = [9.97; 28.47]; P = 0.153), although, due to the low number of studies, the test did not have the statistical power to detect bias.

Discussion

The present systematic review and meta-analysis aimed to assess how health coaching intervention impacted on anxiety and depression conditions among cancer patients. Data were collected from 3 studies25-27 enrolling a total of 228 subjects. For each study, the two subscales relating to anxiety (HADS-A) and depression (HADS-D) were considered separately and two separate meta-analyses were carried out.

As regards the anxiety outcomes, our findings suggested any significant difference between experimental and control interventions and the Cochrane Q-test revealed the presence of a significant heterogeneity between the few studies collected (PQ = 0.033; tau2 = 0.14; I2 = 70.7%). However, nursing coaching intervention appears more promising to better improve anxiety outcome. However, also some of our findings were disagreed, since on the one hand no significant improvements were reported in the coaching treatment25, and, on the other one, there was a significant improvement in anxiety outcome thanks to the coaching intervention26,27. In this regard also the current literature was doubtful to clearly define the improvement in the coaching intervention and its related benefit in the anxiety outcome. As regards the depression outcome, the Forest Plot revealed no statistical significant evidence in favour of the coaching treatment. Although, due to the low number of studies, the test did not have the statistical power to detect bias and also to confirm improvements in depression outcome, too. In fact, the studies included in this review showed no significant improvements in the experimental group25,27. However, Nguyen et al.26 suggested a significant amelioration in patients’ depression treated with coaching interventions. In this regard, the Boxleitner et al. study25 showed that the individual self-reflection approach was similarly effective as the coaching induced meditation intervention in terms of improvement in the anxiety outcome. Additionally, this study also revealed that meditation with a self-approach could be an effective intervention among males thanks to their practicing at their convenience25. Even before the self-reflection approach, giving information before the meditational intervention seemed to be very important and helpful in order to clearly understand all the circumstances and benefits which are related to this reflective approach. Additionally, self-meditation represented a low-budget intervention which supplied information that could be helpful to decrease anxiety and depression during cancer patients’ experiences25. Previous studies suggested the effectiveness of reflection as a mediation for men living cancer. Klafke et al.31 showed that Australian men followed meditation as a coping approach during cancer treatment, while Victorson et al.32 suggested that mindfulness meditation was practicable, acceptable, and psychologically advantageous to patients suffering from prostate cancer. Meditation was often recognized as a secure approach without any adverse events. Besides the self-meditation intervention, psychoeducational ones seemed to have a positive effect in the anxiety decreasing, thanks to a wide range of related factors, such as: training program33,34, information35,36, counseling37,38 and helping approaches36,37. However, there was very few evidence which assisted health care professionals to integrate these strategies into their daily practices as several strategies adopted were supported by inconsistent findings across symptomatology assessments39. A suitable approach to manage symptomatology embraced a multiple intervention, by considering all symptoms within the patients enrolled37-39 by highlighting specific symptomatology in order to reduce or prevent the incidence of other related symptoms34,40-41. A recent systematic review42 focusing on nonpharmacological interventions recognized that interventions simultaneously assessing multiple related symptoms may provide a more warranting approach39 compared to interventions based on a specific symptom assessment and management34,40. Additionally, previous studies suggested that self-reported cognitive deficiency has been connected to scarce physical exercise and also mental well-being among cancer patients43. As highlighted in a longitudinal observational study, fatigue might play an important role in the association between physical activity and individual cognition44, which could also damage the degree of insomnia45. Song and Yu45, of note, this report showed that aerobic physical exercise could ameliorate the quality of sleep and decrease depression in elderly individuals with mild cognitive deficiency. Physical activity might influence perception by increasing the level of brain-obtained neurotrophic factor in plasma46, ameliorating metabolic role, and decreasing systemic inflammation45. Another clinical study47 also highlighted that quality of life (QoL) perceptions among patients practicing Baduanjin physical activity was better than the control group, both in terms of anxiety and depression outcomes.

However, according to the results of the present systematic review and meta-analysis, it seemed that the coaching intervention recorded no significant effects. However, it should consider the lack presence and their related heterogenity in the studies focused on this intervention and its related potential benefits on anxiety and depression conditions among cancer patients. Thus, for these reasons, we collected heterogeneous studies which did not highlight a significant improvement in the experimental group. Therefore, future real-world studies will be necessary to better assess coaching intervention and its related improvement in terms of anxiety and depression outcomes.

Funding

This research received no external funding.

Conflicts of interest statement

The authors declare no conflicts of interest.

Authors contributions

For research articles with several authors, a short paragraph specifying their individual contributions must be provided. The following statements should be used “Conceptualization, E.V. and M.M-J.; methodology, E.V.; software, L.M.; validation, E.V. and L.M.; formal analysis, L.M; investigation, E.V., L.M., A.R.; data curation, L.M.; writing—original draft preparation, E.V.; writing—review and editing, E.V.; visualization, E.V., K.A. and A.R.; supervision, E.V. K.A. and A.R. All authors have read and agreed to the published version of the manuscript.

Guidelines and standards statement

This manuscript was drafted according to PRISMA guideline, through the equator network: https://www.equator-network.org/.

Additional declaration

The authors affiliated to the IRCCS Istituto Tumori “Giovanni Paolo II”, Bari are responsible for the views expressed in this article, which do not necessarily represent the Institute.

Figures and tables

FIGURE 1. Literature research performed.

FIGURE 2. Forest Plot of HADS-A.

FIGURE 3. Funnel Plot of HADS-A.

FIGURE 4. Forest Plot of HADS-D.

FIGURE 5. Funnel Plot of HADS-D.

Population Cancer Patients
Intervention Coaching intervention
Outcome Anxiety and Depression ameliorations
TABLE I. The PIO tool for the present systematic review and meta-analysis.
Author(s) Publication years Study design Evidence level Setting Usual intervention Experimental Coaching intervention
Boxleitner et al. 201725 Randomized Clinical Trial Patients with head and neck cancer in radiotherapy treatment 20-minutes self-standardized meditation session 1/ week after radiation treatment Coach provided: Meditation Relaxation Peace and calm improvement Patients’ empowerment
II Level
Nguyen et al. 201826 Parallel-group single-blind pilot quasi-experimental trial Cancer patients undergoing chemotherapy treatment Verbal information on chemotherapy treatment, side effects, taking medications, routine health care advice, and follow-up Usual care and psychoeducational program: 1 face-to-face session and two phone sessions delivered by a nurse one week apart
III Level
Wei et al. 202227 Randomized Controlled Trial Patients with breast cancer receiving chemotherapy Face to-face interviews in accordance with a brochure to maintain patients’ usual healthy lifestyles. Usual care and Baduanjin intervention thanks to a Qigong specialist who on-site guided the participants and correct their movements, by providing a video demonstration to promote daily practice.
II Level
TABLE II. Coaching interventions in the selected studies and Anxiety and Depression related outcomes (n = 3).

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Authors

Elsa Vitale - Scientific Directorate, IRCCS Istituto Tumori “Giovanni Paolo II” Bari, Italy

Lorenza Maistrello - IRCCS San Camillo Hospital, Venice, Italy

Mohadeseh Motamed-Jahromi - Department of Public Health, School of Health, Fasa University of Medical Sciences, Fasa, Iran

Karen Avino - Integrative Nurse coach Academy, International Nurse Coaching Association, Miami, FL, USA

Alessandro Rizzo - S.S.D. C.O.r.O. Bed Management Presa in Carico, TDM, IRCCS Istituto Tumori “Giovanni Paolo II”, Bari, Italy

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How to Cite
[1]
Vitale, E., Maistrello, L., Motamed-Jahromi, M., Avino, K. and Rizzo, A. 2025. Effect of health coaching on anxiety and depression conditions among cancer patients: a systematic review and meta-analysis of randomized controlled trials. Journal of Psychopathology. 30, 4 (Feb. 2025). DOI:https://doi.org/10.36148/2284-0249-N549.
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