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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 17  |  Issue : 1  |  Page : 36-46

Effect of energy conservation strategies on fatigue and daily living activities among patients with systemic lupus erythematosus


Department of Medical Surgical Nursing, Faculty of Nursing, Cairo University, Cairo, Egypt

Date of Submission13-Jul-2020
Date of Decision30-Jul-2020
Date of Acceptance05-Aug-2020
Date of Web Publication18-Nov-2020

Correspondence Address:
Eman S.A El Fadeel
Department of Medical Surgical Nursing, Faculty of Nursing, Cairo University, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_20_20

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  Abstract 


Background Systemic lupus erythematosus (SLE) is a chronic autoimmune disease, with a significant effect on function, daily living activities, work ability, and patients’ quality of life.
Aim To evaluate the effect of energy conservation strategies on fatigue and daily living activities among patients with SLE.
Research hypotheses H1: there will be a significant difference in the mean scores of fatigue among the study group that received energy conservation strategies compared with the control group that received routine hospital care. H2: there will be significant difference in the mean scores of daily living activities among the study group that received energy conservation strategies compared with the control group that received routine hospital care.
Design Pre–posttest nonequivalent control group quasi-experimental design was used.
Sample A convenient sample of 60 patients with SLE was recruited along 6 months, at one teaching hospital affiliated to Cairo University.
Tools Three tools were used to collect data: Structured Interview Questionnaire, Global Fatigue Index, and Barthel Index of Activities of Daily Living.
Results There was a statistically significant difference in the mean scores of fatigue as well as daily living activities among the study group that received energy conservation sessions when compared with the control group that received routine hospital care.
Conclusion Energy conservation strategies could be effective in decreasing fatigue level and improving the level of independence during practicing daily living activities.
Recommendation The energy conservation strategies should be applied for the patients with SLE in the early course of the disease to have a maximum benefit.

Keywords: daily living activities, energy conservation, fatigue, systemic lupus erythematosus


How to cite this article:
El Fadeel ES, El-Deen DS. Effect of energy conservation strategies on fatigue and daily living activities among patients with systemic lupus erythematosus. Egypt Nurs J 2020;17:36-46

How to cite this URL:
El Fadeel ES, El-Deen DS. Effect of energy conservation strategies on fatigue and daily living activities among patients with systemic lupus erythematosus. Egypt Nurs J [serial online] 2020 [cited 2020 Dec 3];17:36-46. Available from: http://www.enj.eg.net/text.asp?2020/17/1/36/300780




  Introduction Top


Systemic lupus erythematosus (SLE) is a systemic autoimmune rheumatic disease that can involve any organ, compromise health-related quality of life, and finally threaten life. In SLE, the body attacks its own tissues, leading to inflammation and eventual potential organ damage. SLE is defined as a relapsing/remitting condition in which there are episodes of flares followed by periods of remission. Onset is thought to occur when a predisposed individual encounters an environmental insult, such as an infection, or first pregnancy, which initiates an excessive and uncontrolled stimulation of the immune system, resulting in the activation of self‐reactive B and T cells (Kenny et al., 2019; Ertekin et al., 2020).

Fatigue is a frequent disabling issue in SLE. It renders many persons with SLE unable to perform various daily living activities owing to lack of efficiency and endurance (Mahieu et al., 2016). Fatigue is a general and sustained feeling of exhaustion or difficulty performing physical and mental activities for days to weeks, which is not resolved by rest. Fatigue negatively affects cognitive, physical, and emotional functions; daily living activities; participation; and quality of life. Despite its prevalence and the known negative effect of fatigue, no pharmacological or nonpharmacological interventions are recommended for managing fatigue or improving daily living activities in people with chronic disease. Therefore, an intervention to improve daily living activities, through fatigue management, is urgently needed (Kim et al., 2016; Elefante et al., 2020).

Energy conservation is yet a new approach to fatigue management that has also been associated with improvements in populations with chronic diseases, such as multiple sclerosis and cardiac disease. The theory behind energy conservation is that fatigue in chronic disease is exacerbated when an individual’s energy capacity exceeds their energy expenditure during daily living activities, which can consequently interfere with life participation (Farragher et al., 2019).

The objective of energy conservation is to afford everyday approaches through prioritizing, using efficient body postures and organizing the home environment to reduce energy expenditure during everyday life. Therefore, energy conservation may be well suited to meet the needs of people with SLE, as they have been found to have a reduced energy capacity compared with healthy populations, and must also expend extra energy on multiple health management tasks (Farragher et al., 2019). Energy conservation has six strategies, which include (a) balancing work and rest throughout the day; (b) lifestyle modifications to reduce energy expenditures; (c) proper body mechanics and using the body efficiently; (d) set priorities, as doing the most important thing first; (e) using assistive devices to conserve energy such as walker or wheel chair; and (f) modification of the environment (Sadeghi et al., 2016; Farragher et al., 2020).

Nurses have a great role in providing care for patients as they have frequent contact with the patients for periods of time through assessment, planning, teaching to improve quality of life, as well as decrease financial burden. Therefore, the nurse should use evidence-based new therapies in the plan for management; however, the resulting change in the treatment plan means that the role of nurses in handling patients with SLE will inevitably expand. Therefore, the aim of this study was to evaluate the effect of energy conservation strategies on fatigue and daily living activities among patients with SLE.

Significance of the Study

SLE has significant effect on daily living activities, function, work ability, and patients’ quality of life (Keramiotou et al., 2020). Fatigue is a very common and debilitating symptom in patients with SLE. Fatigue as well as inability to perform daily living activities negatively influences quality of life and impairs the ability to maintain gainful employment. It also leads to limitations (restrictions) in physical and psychological functions, family conflicts, social isolation, anxiety, depression, reduction in working ability and self-esteem, and an increase in financial problems (Azad et al., 2017). Energy conservation is an established rehabilitative approach that teaches individuals to use strategies to manage their energy expenditure during usual daily living activities (Farragher et al., 2020).

Energy conservation strategies are safe, noninvasive, pain free, easy to be learned, and has been demonstrated to be without adverse effects. Moreover, it enhances patients’ sense of control over their condition and improves quality of life, as well as is cost effective. Hence, it is an innovative idea to involve patients in their own plan of care to play a major role in relieving their distressing symptoms by using their own abilities. This in turn, encourages behavioral changes that can improve participation in daily living activities.


  Patients and methods Top


Aim of the study

The aim of this study was to evaluate the effect of energy conservation strategies on fatigue and daily living activities among patients with SLE.

Research hypotheses

H1: there will be a significant difference in the mean scores of fatigue among the study group that received energy conservation strategies compared with the control group that received routine hospital care.

H2: there will be a significant difference in the mean scores of daily living activities among the study group that received energy conservation strategies compared with the control group that received routine hospital care.

Setting

The current study was conducted at one of the teaching hospitals affiliated to Cairo University.

Sample

A convenient sample of 60 female adult patients who fulfilled the inclusion criteria was recruited over 6 months in the current study. Patients were equally and randomly divided into study and control groups (30 patients each). The following inclusion criteria were established: (a) diagnosed with SLE; (b) reported fatigue on Global Fatigue Index (GFI), with score more than 15; (c) able to communicate verbally and willing to participate in the study; and (d) aged more than 18 years. Exclusion criteria were (a) signs of an SLE exacerbation, (b) infections, (c) pregnancy, and (d) hypothyroidism and hyperthyroidism.

Data collection tools

Three tools were used to collect data. Content validity of the Arabic version tools was reviewed by a panel of experts at the Medical Surgical Nursing Department of Faculty of Nursing, Cairo University. The study tools were as follows:
  1. Structured Interview Questionnaire: it was developed by the researchers and include two parts: the first part included demographic data that covered personal data such as age and sex, and the second part included data pertinent to medical history such as duration of disease, associated chronic diseases, and family history.
  2. GFI: it was developed by Piperet al.(1989). It consisted of 15 items that assessed the level of fatigue and the degree to which fatigue has interfered with daily living activities. It has three subitems: the first three questions asked about the degree of fatigue, the second 11 questions asked about to what extent fatigue interfered with activities of daily living, and the last question asked about the overall level of fatigue over the past week. The GFI total score ranges from 4 to 50, with mild fatigue has a score from 5<20, moderate fatigue has a score of 20<35, and severe fatigue has a score of 35–50. The tool has excellent reliability, where Cronbach’s alpha=0.93(Bormannet al., 2001).
  3. Barthel Index of Activities of Daily Living (BIADL): it was developed by Collinet al.(1988). It is used to measure daily living activities in relation to personal care and mobility of the patient. It includes 10 items related to bowel, bladder, grooming, toilet use, mobility, feeding, transfer, dressing, stairs, and bathing. The total possible scores range from 0 to 20, with 0 refers to dependent, 1–12 refer to partially dependent, 13–16 refer to needs minimal help, and 17–20 refer to independent. Reliability of BIADL was alpha=0.92 (Hsuehet al., 2001).


Pilot study

A pilot study was performed on six patients. It assessed the study feasibility and applicability as well as clarity of the tools. The data attained from the pilot study were excluded from the study results.

Ethical consideration

Primary approval to conduct the proposed study was obtained from the Research and Ethics Committee of Faculty of Nursing, Cairo University. Moreover, an official permission was obtained from hospital/clinic administrators to conduct the study. Researchers emphasized that participation in the current study was voluntary. Confidentiality of the patients was ensured through the coding of all data. Additionally, the patients were informed that they could refuse or withdraw from the study at any time, and this would not affect their process of care.

Procedure

Once official permission is granted to proceed with the proposed study, the researchers started to collect data through three phases: in the preparatory phase, the study sample that met the inclusion criteria was recruited individually. Then, the researchers explained and clarified the nature and purpose of the current study and those who agreed to participate had been asked to sign a consent form. Then patients were divided equally and randomly into control and study groups, as the first patient recruited in the control group and the second patient included in the study group and so on. To have baseline data, the demographic and medical-related data form, GFI tool, and BIADL tool were filled out to assess the degree of fatigue and degree of independence for both groups.

At that time, the implementation phase started. The control group received the routine hospital care, whereas the study group received teaching sessions regarding energy conservation strategies as well as the routine hospital care. The study group received three teaching sessions, wherein six energy conservation strategies were explained in the first session in the initial interview (first week) and included techniques regarding how to apply the strategies, which were balancing work and rest throughout the day; lifestyle modifications to reduce energy expenditure; instructions regarding proper body mechanics and using the body efficiently; set priorities as doing the most important thing first; using assistive devices to conserve energy such as walker or wheel chair; and modification of the environment. The second and third sessions began in the second and third weeks and included revision for all the previous instructions given, and the researchers made sure that the patients were committed to practice energy conservation strategies during performing activities of daily livings. The first session took ∼45 min interrupted by breaks, and the other two sessions took ∼10–15 min. Additionally, each patient handed in an illustrative Arabic handout that was designed by the researchers. This Arabic handout included information related to the importance of energy conservation strategies and its techniques supported with illustrative photographs. Moreover, by the end of data collection phase, the control group was handed over the illustrative Arabic handout to apply principle of fairness.

Evaluation phase

During this phase, follow-up o both groups was done two times by the end of the fourth week and by the end of the sixth week using GFI and BIADL assessment tools.

Statistical design

The collected data were scored, tabulated, and analyzed by a personal computer using statistical package for the social science program, version 25 (Armank, New York, USA). Descriptive as well as inferential statistics were used to analyze the data pertinent to the study. Descriptive statistics including frequency distribution, means, and SD and inferential statistics as independent t test were utilized. Level of significance was adopted at P value less than or equal to 0.05.


  Results Top


Findings of the current study are presented in three sections as follows: (a) description of the study sample demographic and medical characteristics, (b) description of the fatigue level and status of daily living activities of the study and control groups along the study period, and (c) comparison of the mean scores of fatigue as well as daily living activities between study and control groups along the study period.

[Table 1] shows that regarding age, 50% of the study group and 43.3% of the control group had an age range from 30 to less than 40 years, followed by 40% of the study group and 36.7% of the control group that had an age range from 18 to less than 30 years. The mean age of participants in the study and control groups was 32.3±8.2 and 33.6±10.3 years, respectively.
Table 1 Frequency and percentage distribution of demographic data among the study and control groups (N=60)

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In relation to marital status, the results revealed that in the study group and control group, a higher percentages were married (73.3 and 60%, respectively). With reference to educational level, 36.7% of the study group and 30% of the control group could not read and write. Moreover, there were no statistically significant differences between study and control groups in relation to all demographic variables ([Figure 1]).
Figure 1 Percentage distribution regarding work status among the study and control groups (N=60).

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In relation to work status, 86.7% of both groups, study and control, did not work, whereas 10% of the study group and 3.3% of the control group worked and needed physical effort. Additionally, there was no statistically significant difference in relation to work status between the study and control groups (χ2=2.0, P=450) ([Figure 2]).
Figure 2 Percentage distribution regarding place of residence among the study and control groups (N=60).

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Regarding place of residence, 63.3% of the study group and 60% of the control group were from urban area. Moreover, there was no statistically significant difference between the study and control groups regarding place of residence (χ2=0.0704, P=0.812) ([Table 2]).
Table 2 Frequency and percentage distribution regarding medical-related data of study and control groups (N=60)

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With reference to duration of illness, 50% of the study group and 36.7% of the control group had SLE for less than 5 years, whereas 13.3% of the study group and 40% of the control group had SLE for equal or more than 15 years. In relation to comorbidities, 60% of the study group and 43.3% of the control group experienced hypertension, whereas 26.7% of the study group and 43.3% of the control group had no chronic illness history. Moreover, there were no statistically significant differences between the study and control groups regarding medical-related variables.

Concerning family history, [Figure 3] illustrates that 90% of the study group and 86.7% of the control group had no family history, with no statistically significant differences between both groups (χ2=0.1616, P=0.732).
Figure 3 Percentage distribution regarding family history among the study and control groups (N=60).

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Regarding total fatigue score, [Table 3] indicates that all patients either in control or study group experienced fatigue. With reference to the control group, the highest percentage of them complained of moderate fatigue (66.7%) at the baseline observation, as well as 70% at the end of the fourth week, and 66.7% at the end of the sixth week. On the contrary, regarding the study group, 73.3% of them reported moderate fatigue at the baseline observation, whereas the highest percentage of the group experienced mild fatigue (46.7 and 63.3%) by the end of the fourth week and sixth week, respectively, after implementing energy conservation strategies.
Table 3 Frequency and percentage distribution of total scores of fatigue among the study and control groups along the study period (N=60)

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[Table 4] shows that 73.3% of the study group and 66.7% of the control group needed minimal help at baseline reading in relation to activities of daily living, whereas at the end of the fourth week, 50% of the study group and 73.3% of the control group still needed minimal help. Moreover, at the end of the sixth week, 63.3% of the study group patients were independent, whereas 66.7% of the control group still needed minimal help.
Table 4 Frequency and percentage distribution of total score of daily living activities among the study and control groups along the study period (N=60)

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[Table 5] reveals that at the baseline reading, there was no statistically significant difference between the study and control groups (t test=0.036, P=0.971) in relation to total mean scores of fatigue. However, there was a statistically significant difference between the study and control groups after fourth week of implementing energy conservation strategies (t test=4.314, P=0.000), and after sixth week of implementing energy conservation strategies (t test=5.465, P=0.000).
Table 5 Comparison of fatigue total mean scores between control and study groups along the study period (N=60)

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[Table 6] illustrates that at the baseline reading, there was no statistically significant difference between the study and control groups (t test=0.214, P=0.832) in relation to total mean scores of activities of daily living. However, there was a statistically significant difference between the study and control groups after the fourth week of energy conservation strategies application (t test =3.518, P=0.001) and after the sixth week (t test =5.770, P=0.000).
Table 6 Comparison between control and study groups in relation to activities of daily living total mean scores along the study period (N=60)

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  Discussion Top


Fatigue is defined as a state of reduced ability to work after a period of mental or physical activity. It is one of the most common and disabling symptoms affecting more than 80% of patients with SLE, and associated with decreased functioning capacities as well as performing daily living activities. The objective of energy conservation strategies is, therefore, to provide practical strategies to reduce energy expenditure during daily living activities, minimize fatigue, and maximize life participation (Farragher et al., 2019). Therefore, the aim of the current study was to evaluate the effect of energy conservation strategies on fatigue and daily living activities among patients with SLE.

A discussion on the current study findings is presented in the following sequences: (a) participants’ demographic and medical background information and (b) the effectiveness of energy conservation strategies on fatigue level and daily living activities.

Participants’ demographic and medical background information

The current study revealed that most patients’ age was between 18 and less than 40 years, with mean age of 33±10.3 years for the study sample. These findings were congruent with Sokolova et al. (2019), who conducted a study on 133 patients entitled ‘Poor health-related quality of life (Hrqol) and fatigue are associated with a higher work productivity impairment in systemic lupus erythematosus (SLE) patients’ and revealed that the mean age of patients was 32.2±11.8 years. However, this finding is not consistent with Yu et al. (2020), who conducted a study entitled ‘Trends of hospital palliative care utilization and its associated factors among patients with systemic lupus erythematosus in the United States from 2005 to 2014’ and found that more than half of the study sample was older than 50 years. Moreover, other studies conducted by Gatto et al. (2020), Strand et al. (2019), and Cheung et al. (2019), all pointed out that the mean of age of such patients was 41.4, 42.8, and 44.8 years, respectively.

Concerning marital status, it was found that more than half of the patients were married. These findings were congruent with Delis (2019) and Keramiotou et al. (2020), as all noted that approximately two-thirds of the study sample was married. On the contrary, this finding does not agree with Azizoddin et al. (2019), who conduct a study on 105 patients entitled ‘Fatigue in systemic lupus: the role of disease activity and its correlates’ and found that approximately half of the study patients were not married.

Moreover, in relation to educational level, approximately one-third of the patients could not read and write, and approximately one-quarter had secondary school. These findings were congruent with the study of Gergianaki et al. (2019), who pointed out that more than one-third of their study sample had secondary school education. On the contrary, this finding does not agree with the study of Keramiotou et al. (2020), who concluded that the vast majority had secondary school education.

With reference to employment status, it was found that most patients were not working. These findings were relatively congruent with Martz et al. (2019), who conducted a survey in Atlanta entitled ‘Vicarious racism stress and disease activity: the black women’s experiences living with lupus (BeWELL) study’ and found that more than half of the study patients were not working. On the contrary, this finding does not agree with Azizoddin et al. (2019) and Twumasi et al. (2019), who found that the highest percentage of the patients were working part-time or full time.

Concerning the place of residence, more than half of the patients belonged to urban areas. This finding could be matched with Feng et al. (2019), who conducted a study on 201 patients entitled ‘Psychometric properties of fatigue severity scale in Chinese systemic lupus erythematosus patients’ and revealed that more than half of their patients belonged to urban areas. Another study agreed with the results of the current study done by Pimentel-Quiroz et al. (2019), who conducted a study entitled ‘Factors predictive of serious infections over time in systemic lupus erythematosus patients: data from a multi-ethnic, multi-national, Latin American lupus cohort’ and pointed out that a small percentage belonged to rural area.

In relation to disease duration, almost half of the study patients had SLE for less than 5 years, with mean of 8±7.1 years, and this was matched with the study findings obtained by Pereira et al. (2020) in a study entitled ‘Quality of life in patients with systemic lupus erythematosus: the mediator role of psychological morbidity and disease activity,’ which revealed that the mean duration of SLE was 7 years. However, the current finding was inconsistent with the finding of Jolly and Sehgal (2020), who conduct a study entitled ‘Despite the high rate of response to treatment, lupus nephritis standard of care is still associated with high incidence of chronic kidney disease: a retrospective longitudinal study, from three South-European cohorts of patients in follow-up since 2000’ and found that the mean disease duration among the study patients was 14 years.

Moreover, the current study noted that the higher percentage of patients had hypertension, which is consistent with Fasano et al. (2019), who conducted a study entitled ‘Prolonged remission is associated with a reduced risk of cardiovascular disease in patients with systemic lupus erythematosus: a GIRRCS (GruppoItalianoDi RicercaIn ReumatologiaClinicaE Sperimentale) study’ and revealed that a higher percentage of their studied patients had hypertension.

Regarding family history, the current study revealed that a vast majority of patients were not accompanied by family history. This finding matched with Mena-Vázquez et al. (2019) and Yavuz et al. (2019), who affirmed that a small percentage of patients had family history of SLE.

Moreover, there were no statistically significant differences between study and control groups in relation to demographic data as well as medical-related information, so homogeneity along the current research was maintained.

The effectiveness of energy conservation strategies on fatigue level and daily living activities

In relation to fatigue level, the current study revealed that approximately two-thirds of the study and control groups had moderate fatigue at the baseline observation. Regarding the control group, the highest percentage reported moderate fatigue level along the study period. However, among the study group, the level of fatigue decreased after implementing energy conservation strategies to reach about half of the group that reported mild fatigue by the end of the fourth week, and approximately two-thirds of them reported mild fatigue by the end of sixth week. Additionally, there was a statistically significant difference in the mean scores of fatigue among the study group that received energy conservation sessions compared with the control group that received routine hospital care by the end of the fourth week and sixth week of intervention. Therefore, the study results support the first research hypothesis.

This finding supports the effectiveness of using energy conservation strategies to reduce level of fatigue among patients with SLE. This result could be interpreted in the light of the fact that energy conservation strategies provide adequate time to rest and sleep that help to reduce fatigue, and also energy conservation strategies afford instructions regarding avoiding unnecessary motions, as well as using proper body mechanics that may lead to performing daily living activities with minimal effort. Moreover, energy conservation strategies enhance usage of assistive devices that reduce wastage and losses of energy. Generally, the energy conservation strategies intervention was acceptable and well tolerated, indicating that most patients found that the intervention was credible and helpful to design work stations and could be incorporated for proper lifestyles to reduce fatigue and promote a healthy life.

This study finding is similar to Farragher et al. (2020), who reported that energy management education among participants with chronic dialysis is effective in reducing fatigue in a study entitled ‘A proof-of-concept investigation of an energy management education program to improve fatigue and life participation in adults on chronic dialysis.’ Furthermore, a study conducted by Sadeghi et al. (2016) evaluated the effects of the energy conservation strategies on cancer-related fatigue and health-related lifestyle in persons with breast cancer who experienced fatigue and reported a significant reduction in the level of fatigue among elderly patients who implemented energy conservation strategies, and this supported the current study findings.

With reference to daily living activities, the current study evidenced that approximately two-thirds of both study and control groups needed minimal help during performing daily living activities at baseline reading. Interestingly, at the end of the fourth week after applying energy conservation strategies, approximately one-third of the study group reported independency during performing daily living activities, whereas approximately three-fourths of the control group still needed minimal help. Moreover, at the end of the sixth week after applying energy conservation strategies, about two-thirds of the study group was independent, whereas approximately two-thirds of the control group still needed minimal help. Additionally, there was a statistically significant difference in the mean scores of daily living activities among the study group that received energy conservation sessions compared with the control group that received routine hospital care by the end of the fourth week and sixth week of intervention. Therefore, the study results support the second research hypothesis.

This finding could be interpreted as that patients who applied energy conservation strategies were encouraged to learn how to schedule their tasks around their energy levels. Moreover, they learned to take short breaks; these short breaks allowed their mind to rest before focusing again. Moreover, energy conservation strategies reduce fatigue, which in turn encourage participation in everyday activities. The current study findings are congruent with the studies done by Caplan et al. (2016) and Kim et al. (2016), who supported that energy conservation strategies could be effective in reducing fatigue and enhancing engagement in daily living activities.

Overall, energy conservation strategies are easily applied, self-administered, cost-effective, safe, and effective in reducing fatigue as well as improving daily living activities. They help the patient to live independently and increase the level of self-confidence, which in turn, encourages behavioral changes that can improve participation in everyday activities.


  Conclusion Top


The results of the current study conclude that practicing energy conservation strategies could be effective in reducing the level of fatigue as well as improving daily living activities among patients with SLE. Moreover, the study results support the two research hypotheses.

Recommendations

As the energy conservation strategies had a significant effect on patient’s fatigue as well as performing daily living activities, so the following recommendations were concluded:
  1. It is suggested to apply the energy conservation strategies for the patients with SLE in the early course of the disease, so that the patients have a maximum benefit.
  2. Replication of the study should be done on a larger probability sample selected from different geographical areas in Egypt to obtain more generalized result.
  3. Further studies may be needed to determine the stability of the effect of the energy conservation strategies on the different medical diagnoses that are associated with fatigue and impairment in performing daily living activities.


Nursing implication

The current study highlights the importance of applying energy conservation strategies for patients with SLE, as the strategies reduce fatigue and improve daily living activities. Therefore, the nurses would have a pivotal role in implementing such strategies that might lead to decreased length of hospital stay, reduced risk of complications, and enhanced positive clinical consequences on patient and health care system. Moreover, this study might provide a practice framework for the future development of other nursing evidence-based practice in that regard.[32]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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