In response to: Jorgensen R. (2006) A phenomenological study of fatigue in patients with primary biliary cirrhosis. Journal of Advanced Nursing55(6), 689–697.


Discussion of fatigue concept results

As a practicing endoscopic nurse, the topic of biliary disease and fatigue symptomatology is of interest. Primary biliary cirrhosis represents a chronic progressive disease state and disabling conditions which have a negative impact on the client and family members. Typically, nurses relate to people with this illness during a hospitalization or a procedural event. Jorgensen's choice of qualitative method (interpretive-phenomenological approach) describes the personal client experiences of these disabling symptoms and life consequences (Byrne 2001). Currently, effective medical treatments for primary biliary cirrhosis are limited. Alleviation of clients’ physical and psychological symptoms necessitate effective nursing interventions. Empathy, caring, sensitivity, emotional and physical nursing presence improve client care and decrease the severity of fatigue symptoms (Jorgensen 2006). Effective nursing care promotes increased self-worth, decreased anxiety and hope for the future.

The theme of ‘unreliable body’ describes a whole body experience of weakness, decreased stamina, cognitive awareness of physical limitations and resulting grief reactions to the loss of previously enjoyed activities (Jorgensen 2006). Jorgensen compares the five fatigue themes and symptoms to the chronic fatigue concept. Another related concept to the unreliable body theme is the middle range theory of chronic sorrow (Eakes et al. 1998). The sustained, overwhelming and recurrent state of client's exhaustion with primary biliary cirrhosis relates to the chronic sorrow theory. The chronic sorrow theory includes the client's awareness of past lifestyle and perceptual loss of previous health status (Eakes et al. 1998). A client with disabling fatigue symptoms and the progressive disease course of primary biliary cirrhosis has similar characteristics of chronic loss and sorrow. Also, the emotional consequences of dysphoria, inadequacy, frustration, anger, fear, helplessness compare closely to the chronic sorrow theory emotional responses (Eakes et al. 1998, Jorgensen 2006).

Alteration of cognitive and affective functioning in fatigued clients as reported by the author of this JAN paper suggests potential depressive symptoms. Social withdrawal, emotional apathy and absence, feeling disconnected to family and friends and low activity motivation are depressive symptoms noted by Jorgensen (2006). Critical assessment, diagnosis, effective nursing interventions and on-going client evaluation is necessary. I concur with Jorgensen that the possibility of subclinical or overt depression may occur in clients diagnosed with primary biliary cirrhosis. The intent of this article is to propose clear communication and recognition of clients’ fatigue experiences. Elaboration and discussion of effective nursing interventions for depressive symptoms are outside the scope and intent of Jorgensen's article.

On reflection of these potentially depressive symptoms, it is clear that effective nursing interventions for chronically fatigued clients are needed. Brown and Shirley (2006) describe subthreshold depressive conditions. These low-level depressive states exhibit a wide range of symptoms including fatigue, weight gain, slowed thinking and sleep disturbances. Due to personal perception and symptom interpretation, the severity of fatigue symptoms is variably reported. Women are notable for increased depression problems. One intervention suggested by Brown and Shirley is the Light, Exercise, Vitamin Intervention Therapy (LEVITY) programme. Given decreased nutritional status, increased fatigue levels, and potential depression, the combination of daily oral supplements, walking exercises and exposure to natural outdoor light improve the emotional mood and decrease depressive symptoms. Additionally, Brown and Shirley describe concept linkage of increased serotonin activity to decreased symptoms of depression and anxiety, improved cognitive and affective processing, elevated energy levels, and a reduction in carbohydrate craving and overeating. The LEVITY programme represents a low-cost and easily implemented alternative intervention for fatigued, depressed and chronically ill clients.

The size of the sample in Jorgensen's study was small, involving just eight participants, and the author acknowledges the need for more research ‘to further understanding of patients’ experiences of fatigue in chronic liver disease…and other conditions’ (p. 695). Fu et al. (2001) presented additional definitions of fatigue characteristics as measured by self-reported tools (the revised Piper fatigue scale and the Schwartz measurement of fatigue scale) in a study involving 182 healthy women. The standardization of fatigue terminology and improved effective nursing interventions are the explicit goals of Fu et al. The identified fatigue characteristics of healthy women combined with Jorgensen's descriptions result in an expanded conceptualization of fatigue. This extended fatigue description benefits nursing identification and practice interventions. Suggested use of interpretive-phenomenological and self-reported tool approaches are needed to validate this expanded conceptualization. Also, evaluation of sociocultural and transcultural factors enhance the generalization and application of the fatigue concept to other population groups.

Jorgensen's article provides an interesting and important contribution to the understanding of the concept of fatigue in clients with primary biliary cirrhosis. I plan to share this article and current findings with my gastroenterology colleagues.