Fatigue associated with arthritis is a persistent and highly prevalent symptom occurring in up to 80% of patients with arthritis (Hootman et al., 2018), which significantly impacts patients' quality of life and interferes with their participation in usual daily routines (Kirwan et al., 2007). Fatigue is a debilitating symptom defined as lack of energy and motivation and inability to maintain a usual routine (Rosenthal et al., 2008). Despite its high prevalence and significant impact on patient health outcomes, effective methods for managing fatigue are limited. Medications targeting arthritis (e.g., inflammation medications) have little effect on fatigue (Katz, 2017). Instead, a number of physical activity/exercise interventions (e.g., pool-based therapy, dynamic strength training, yoga, low impact aerobics) have demonstrated a significant moderate effect on fatigue (Cramp et al., 2013). These exercise interventions, however, are resource intensive, requiring specially trained personnel, highly structured activities, and attendance at classes or a specified facility. Each of these requirements increases cost and barriers to wide implementation in health care settings. Most importantly, a critical weakness of these interventions is participants' lack of long-term engagement in and adherence to the program after the intervention is completed (Mayo et al., 2014). As a result, these interventions produce immediate benefits, but the benefits largely disappear at follow up. Therefore, an urgent need exists for interventions that require minimal professional guidance and are convenient and easy to access.
To address this need, our team developed a simple walking program of physical activity, facilitated by tablet-based cognitive behavioral strategies. Becoming consistent with walking requires minimal professional guidance and equipment and has been shown to yield significant reductions in fatigue (Bravata et al., 2007). To ensure patients' long-term engagement and adherence to a walking activity, we developed educational modules based on cognitive behavioral principles. The program was designed to promote long-term behavioral changes (e.g., long-term engagement and adherence to the intervention). This long-term behavioral change was achieved through the application of basic learning principles (Skinner, 1953), as well as identification of unhelpful thoughts and behaviors that reinforce avoidance of activity rather than engagement. Cognitive-behavioral therapy (CBT) has been used broadly in the management of rheumatic disease (Dures & Hewlett, 2012). With CBT, patients improve core self-management skills of problem solving and goal setting and enhance a sense of control of their illness and confidence that they can do something to make a difference (Lorig & Holman, 2003), resulting in patients' long-term engagement in and adherence to a simple walking activity.
To deliver CBT education effectively and efficiently to older adults, we adopted a mini-tablet computer as a platform. A tablet computer can store sizable educational materials and is easy to carry and convenient for retrieving content, making educational materials readily available whenever and wherever needed. Technology is becoming easier to use and more cost-effective for individual use. Technology adoption continues to increase among older adults, with one in four people older than 65 owning smart-phones and one half with broadband in their homes (Pew Research Center, 2017).
Nursing is challenged to develop innovative and effective interventions using these technologies to improve fatigue symptoms. Our team devised a pragmatic approach to apply off-the-shelf technology, cognitive behavioral–focused education, and a simple walking activity intervention to improve fatigue for those with arthritis. To the best of our knowledge, there is no fatigue management intervention that has physical activity in a tablet platform and a behavioral change approach as intervention components. Current physical activity–only interventions produced a significant moderate effect on fatigue, but the effect does not last long and largely disappears after intervention completion (Katz et al., 2018); behavioral change–only interventions yield a long-term effect, but the effect sizes are smaller compared to the physical activity–only interventions (Hewlett et al., 2011). Our tablet-based cognitive behavioral intervention (Tab-CBI) comprises two intervention components, CBT and tablet-based physical activity education to address the limitations of current interventions. The current article describes the development of the Tab-CBI application (app) and the results of the first phase of our user-centered evaluation process.
Development of the Tab-CBI
Nurse researchers, through collaboration with engineers, psychologists, and nurse practitioners, developed the Tab-CBI app. The Tab-CBI innovation is a tablet-based app that uses off-the-shelf technology and the principles of CBT to promote patients' engagement and adherence to a simple walking activity. The Tab-CBI is composed of four key components: (a) multimedia CBT education; (b) videoconferencing communication with a provider; (c) individualized goal setting; and (d) electronic data submission.
Over the course of approximately 10 months, nurse researchers partnered with engineers to manage the off-the-shelf hardware and software customization and app. Clinical and content experts on cognitive-behavioral approaches worked with the research team to create specific educational modules for the Tab-CBI. This section describes some of the major work to develop the Tab-CBI.
The research team selected the hardware for use in this study. Hardware selection was determined by the availability of off-the-shelf products easily accessible to the general population. The research team selected a mini-tablet (Samsung Galaxy Tab-A) as a platform for the Tab-CBI app (Figure 1). A mini-tablet is a practical device for participant use; it can store sizable educational materials and yet is easy to carry. Although compact in size for mobility, the tablet screen size is larger than a standard smartphone, providing a larger screen space to accommodate a larger font size for viewing the Tab-CBI content. The research team also selected an accelerometer, Fitbit™ wristband, to count steps and wirelessly sync with the tablet. We chose the Fitbit wristband because it has a simple visual display, is easy to operate, and has a relatively long battery life lasting up to 5 to 6 days without recharging. Most of all, it is accurate for tracking step counts of frail older adults with slow gait (Case et al., 2015).
Learning module for Week 1.
Key Components of the Tab-CBI
Multimedia CBT Education Modules. The education modules consist of task management and written and video education. For the project, our team used a commercial software app, Microsoft To-Do™, loaded onto each tablet to manage weekly study tasks. Participants were oriented to a checklist with the activities they were asked to do each week. These activities include taking self-assessment quizzes (to reinforce what they learn from the learning modules), using the educational materials for the week, or reviewing their weekly goal for walking. The team had access to the master account to update or interact with participants in real time. For example, at a weekly educational session, participants' walking goals were jointly set for the coming week (King, 1981). The investigator can update the tablet remotely to write the client's weekly walking goal in the task management section for the client to view immediately.
Educational information provided on the Tab-CBI was created in two formats to appeal to the learning needs of participants. For each of the topic areas covered in the study, a short video 3 to 5 minutes in length described the key points for each session. A script for the videos was drafted and reviewed by a research team to ensure that the CBT concepts were written using easy and simple terms for older adults. The videos were made using existing organizational cameras and equipment by the research team. After the prototype videos were created, they were uploaded to a private YouTube account so that only invited participants could view the recordings. The videos were organized into the weekly task list for viewing at the appropriate times. A written one-page “key points” summation was also provided to participants as an item in the task list. Video and written material were available to participants at any time on the tablet (Figure 1).
Individualized Goal Setting. An important feature of the Tab-CBI is the goal setting component. Older adults maintain physical activity to a larger extent when goals are set (Katz et al., 2018). In line with the cognitive-behavioral approach, one research team member works with participants to set SMART goals (Doran, 1981), which are specific, measurable, achievable, realistic, and time-based. Participants set a goal each week when meeting with the team member. This goal is then listed on the weekly to-do task list on the tablet (Figure 2).
Goal setting for Week 1 learning module.
Communication With a Provider Using a Videoconferencing Tool. A tablet with a videoconferencing tool is well-suited to meet the needs of older adults with fatigue who often have difficulties traveling to places outside the home for education. Videoconferencing improves patients' access to the intervention, while closely resembling face-to-face interactions between a patient and a clinician, making it an effective alternative to the traditional in-person education approach (Moffet et al., 2015; Peel et al., 2011). The tablets have been outfitted for safe, secure, and HIPPA compliant video-conferencing software for weekly education review and goal setting with the research team member.
Electronic Data Collection and Submission. An accelerometer is a simple and inexpensive means of monitoring patients' step counts. For the current study, we paired a unique accelerometer to its own dedicated tablet. Participants use the tablet to sync the accelerometer to it in their home. After syncing, they are able to see the step count on the larger tablet in real time and compare it to the goal they have set. The accounts for the accelerometers are managed by the team and available for data collection.
Study metrics, such as fatigue, quality of life, and pain, are measured at baseline and Weeks 4, 6, 8, and 10. The surveys are created using a web-based survey tool, Qualtrics™, and populated into each tablet, as each participant takes the surveys on the tablet. The results are stored on Qualtrics secure servers and can be accessed and managed by the research team to analyze data and generate reports.
The foundation of the education provided in the Tab-CBI is based on cognitive-behavioral principles. The key elements of this CBT approach invited participants to consider the function of their thoughts and behavior in relation to engaging in a simple walking program. The psychoeducation lessons focused on how avoidance behaviors are maintained and how avoidance is self-reinforcing (Bandura, 1969). Participants were also taught how to recognize unhelpful thoughts that also interfered with successful engagement in walking. Through the tablet-based program, participants were then taught simple strategies to overcome avoidance and increase motivation based on the basic principles of behavioral activation (Jacobson et al., 2001) and cognitive reappraisal (Beck, 2011).
Over the course of 3 months, nurse researchers met weekly with a psychologist with expertise in CBT. The topics and content for the CBT–based education modules were developed during these meetings. As the content began to be refined, the one-page weekly topic handouts and 3- to 5-minute videos were created for use in the study. The videos and one-page handouts were reviewed and refined for their appropriateness, accuracy, and relevance by three outside experts. The final education modules consist of four weekly topics and one booster session (Table 1).
Collaborative Cognitive-Behavioral Psychoeducational Topics
Evaluation of the Tab-CBI
To move the innovation to the next level of research, usability of the Tab-CBI must be evaluated with a user-centered approach. This approach consists of a series of steps: expert review, quality assurance, and testing of the innovation in focus groups and individually in the context of daily living with older adults with fatigue. The research team completed the expert review and quality assurance of the Tab-CBI, and these results are presented in herein. The remaining portions of the usability testing are currently in progress.
Once development of the Tab-CBI was completed, we obtained feedback on its content and usability from three experts—a CBT expert (psychiatric nurse practitioner), a clinical education specialist, and a geriatric activity specialist—and placed it in a spreadsheet for systematic review and decision making if feasible to change.
In general, the experts perceived that the Tab-CBI was engaging and user-friendly (i.e., easy to use and intuitive without lengthy comprehensive user training), and that it has potential to improve simple walking routines and alleviate fatigue. One expert said, “…[the Tab-CBI is] geared toward patients who want to be the ‘driver’ of their care….” All three experts pointed out its remote accessibility as a key benefit. One of the key features of the Tab-CBI is the video-conferencing tool when communicating with patients for education and follow up. Patients do not need to leave home for communication, eliminating geographical constraints, such as costs and time for transportation. Therefore, the Tab-CBI can be more accessible to populations in remote areas and other populations who have physical and/or functional impairments that may limit their ability to participate in treatments, such as the patients with arthritis in the current study.
Experts also made a number of comments for further improvement. Several key comments are on icon education, minimizing the number of clicks, and user training. First, training would need to focus on education for the major icons of the Tab-CBI. Second, the expert comments addressed the need to minimize the number of clicks to streamline progression through the software. Third, one expert said, “Telecommunication may be harder for them [older adults] using a tablet…. May need additional support first 1–2 weeks of study period.” Although the Tab-CBI is perceived as intuitive and easy to use, older adults aged ≥75 may have challenges using the tablet. They may not be familiar with tablets and require more than one session for training. The experts' comments were integrated into a revision of the Tab-CBI.
During the process of developing the Tab-CBI, several improvements and changes were made. Once the final product was ready to begin testing, it was crucial that all tablets were systematically reviewed to ensure that the content was in the correct format and the components were working as intended. The researchers used a detailed spreadsheet to verify the tablets were all uniform.
Developing an innovation to improve fatigue symptoms requires a team approach, a solid framework for organizing the innovation, and a systematic method of user-centered evaluation and revision. A team of experts was used to develop the Tab-CBI. Having a team approach, including the collaboration of engineers and psychologists, was valuable to maximize the use of the software and minimize extra steps when possible. It took approximately 10 months to assemble and test the app. Some strengths of this work are the pragmatic perspective of using off-the-shelf items in an innovative way. In addition, the time, effort, and money for developing a sophisticated and complex software can be reduced. A challenge of the innovation is that the off-the-shelf items, such as the software, were not configured exactly as researchers would have preferred. For example, reducing the number of clicks to start the videoconferencing would be helpful but is not a customizable feature of the software.
The Tab-CBI innovation is based on a cognitive-behavioral approach. CBT principles guided what education content was provided and the formats for the weekly sessions. CBT is well regarded in promoting self-management of chronic conditions, such as diabetes mellitus (Safren et al., 2014), depression (Ngai et al., 2015), fibromyalgia (van Koulil et al., 2011), and cancer-related fatigue (Sandler et al., 2017), but it has rarely been used in arthritis fatigue management. The cognitive-behavioral approach received positive comments in our expert review process. Our team collaborated with a CBT expert, which was vital in this portion of the innovation.
The evaluation process of the Tab-CBI took a significant portion of time to complete, but it is a necessary step in a technology development process. Ensuring the innovation is consistent (e.g., quality assurance) and provides value to participants is a good starting point. The expert feedback provided the team with an actionable list of changes. For example, based on experts' comments, clearer and more detailed user instruction materials were developed. In addition, the user training manual was revised, paying special attention to provide education regarding the major icons on the Tab-CBI. The team worked to minimize clicks and simplify the process of working through the screens. Attention was heightened to ensure participants aged ≥75 years were well represented in the next phase of usability testing. Through the expert feedback, our team was able to make changes to improve the product and the experience for participants.
To move the innovation to the next level of research, it is important to evaluate technology using a user-centered approach. The goal of user-centered usability testing is to develop technologies that end users perceive as easy, effective, and enjoyable, and that fit seamlessly into their daily routines, thus promoting acceptance and use of the technologies (Preece et al., 2015). The current article describes the innovation of the Tab-CBI and the first phase of evaluation, which focuses on quality assurance and expert review. The second phase of usability testing involves the engagement of the end users, older adults with fatigue, in focus groups in a laboratory setting and individually in the context of their daily living. The second phase of user-centered evaluation is currently underway. For a future study, our team plans to conduct a pilot study to examine the long-term effect of the Tab-CBI on step counts, fatigue, self-efficacy, and quality of life.
Application of technology to health-promoting activities of daily life continues to grow. Many apps are readily available and are in use in the public. Nurse clinicians who care for older adults are seeking technology that has been determined to be appropriate and meaningful to this population. However, most apps have not been tailored to older adults. Technological interventions focused on older adults must be evaluated for use by older adults. The current study adds to what is known regarding evaluation of a specific technological app, the Tab-CBI, using a user-centered approach. Nurse educators, clinicians, and researchers may find the user-centered approach helpful in developing and evaluating technological apps in the future.
The current article described the purpose and development process of an innovation, the Tab-CBI, for older adults with arthritis fatigue. Development of the innovation required a team approach, a solid framework for organizing the innovation, and a systematic method of user-centered evaluation and revision. Our approach was team-oriented, based on CBT principles, and employed user-centered evaluation of a technology. In this initial stage, the Tab-CBI has been shown to be a usable innovation for fatigue management in older adults with arthritis.
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Collaborative Cognitive-Behavioral Psychoeducational Topics
|Title||Intervention Time Frame||Key Points||Strategies||Goal Setting|
|Session 1: Introduction: Taking steps to take steps||Week 1||Cognitive behavioral approach: how thoughts and feelings can change how we act||Ways to change behavior; setting SMART goals||Mutually set|
|Session 2: Tell me what you think||Week 2||Thoughts can change how we feel||Simple ways to change our thoughts from unhelpful to helpful||Mutually set|
|Session 3: Walk it out||Week 3||Emotions can change how we behave||Ways to keep emotions from controlling behavior||Mutually set|
|Session 4: Wrapping up and moving forward||Week 4||How we think and feel affects our behavior||How thoughts and emotions can be helpful/unhelpful; SMART goals are helpful. Motivational interviewing techniques.||Mutually set|
|Session 5: Moving forward: A review||Week 6||How we think and feel affects our behavior||Committing to action–reviewing the strategies of the previous weeks.
Participant reflection of what is helpful/unhelpful.||Client driven|