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UBC Theses and Dissertations

Preferences for intervention among cancer patients receiving radiotherapy for the first time Salton, Christine Ann 1986

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PREFERENCES  RECEIVING  FOR  INTERVENTION  AMONG CANCER  PATIENTS  RADIOTHERAPY  FOR  THE F I R S T  TIME  By Christine A.,  The U n i v e r s i t y  THESIS THE  Ann  Salton  of British  Columbia,  SUBMITTED IN PARTIAL F U L F I L L M E N T REQUIREMENTS MASTER  FOR  OF S C I E N C E  THE DEGREE IN  OF  NURSING  in THE  FACULTY  OF GRADUATE  School  We  accept to  THE  this  of  Nursing  thesis  the required  UNIVERSITY  OF  June (&) C h r i s t i n e  STUDIES  as  conforming  standard  BRITISH  COLUMBIA  1986  Ann S a l t o n ,  1986  1977 OF  In p r e s e n t i n g  t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of  requirements f o r an advanced degree a t the  the  University  o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make it  f r e e l y a v a i l a b l e f o r reference  and  study.  I further  agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying of t h i s t h e s i s f o r s c h o l a r l y purposes may department or by h i s or her  be granted by the head o f representatives.  my  It is  understood t h a t copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l gain  s h a l l not be allowed without my  permission.  Department o f  JflLjAAt^  The U n i v e r s i t y of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3  DE-6  (3/81)  written  ABSTRACT This describe  exploratory, health  receiving  care  d e s c r i p t i v e study  preferences  radiotherapy  f o r the f i r s t  the  r e l a t i o n s h i p between  and  patients'  was  t h e r e l a t i o n s h i p between  health A cancer  care  patients  Survey,  offered  from  In addition, variables  examined  anxiety  and  as their  Each  responses  the population  included  36 t o 79 y e a r s .  completed  cancer  From  medical  demographic Care  a clinical  was  o r an a f f e c t i v e  measured  to the State-Trait  situation  by t h e  Anxiety  Inventory(STAI) . In over  most  cognitive  interventions  demographic may  situations, patients  affective interventions  have  variables.  affected  was  preferred  cognitive  and t h e p r e f e r e n c e largely  Clinical  intervention  19  forced-choice  a cognitive  Anxiety  urban  the Health  presented  between  of  21 women a n d  collected relevant  item  a choice  newly-diagnosed  at a large  a seven-item  intervention.  subjects'  of forty  The sample  Patients  questionnaire.  nursing  was  to  patients  demographic  patients'  radiotherapy  the researcher  Preference  cancer  time.  preferences  selected  i n age from  information.  and  was  facility.  ranging  records,  care  sample  receiving  treatment  selected  designed  preferences.  convenience  patients  men  health  among  was  independent  s i t u a t i o n and preference.  for of timing  Patients'  anxiety for  levels  health  State  care  anxiety  cognitive  significantly  affected  interventions.  scores  Patients  preferred  affective  who  preferences had  rather  high than  interventions.  Incidental  findings  included  about  p a r t i c i p a t i o n i n the study  their  illness  Implications further  their  experiences f o r nursing  research  are  and  subjects' and  comments  attitudes  obtaining  toward  information.  p r a c t i c e and recommendatons f o r  discussed.  i i i  TABLE  OF  CONTENTS  Abstract Table List  i i  o f Contents  i v  o f Tables  v i i  Acknowledgements Chapter  1:  viii  INTRODUCTION  Overview  1  Background and S i g n i f i c a n c e Problem Purposes D e f i n i t i o n o f Terms Assumptions and L i m i t a t i o n s  2 5 6 6 8  Chapter  2:  REVIEW  OF R E L E V A N T L I T E R A T U R E  Introduction C o g n i t i v e I n t e r v e n t i o n s : P a t i e n t E d u c a t i o n .... A f f e c t i v e Interventions: Emotional Support.... Patient Preferences f o rHealth Care Intervention Anxiety Effects of anxiety Measurement o f a n x i e t y Summary Chapter  3:  4:  19 24 27 28 29  METHODOLOGY  Introduction Instruments and Instrument Development Demographic q u e s t i o n n a i r e Health Care Preference Survey S t a t e - T r a i t Anxiety Inventory Setting Subjects Human R i g h t s a n d E t h i c s Data C o l l e c t i o n Data A n a l y s i s Chapter  9 11 16  P R E S E N T A T I O N AND  Introduction S e c t i o n 1. T h e S a m p l e Age a n d s e x Marital status Educational levels Ethnicity i v  31 31 31 32 33 34 35 36 37 38  D I S C U S S I O N OF R E S U L T S 41 41 42 42 42 44  Occupation 44 Home r e g i o n 45 Performance s t a t u s 45 Disease s i t e 46 Number o f t r e a t m e n t s 47 Nature o f treatment 47 The s a m p l e a n d o t h e r p o p u l a t i o n s 48 S e c t i o n 2. T h e H e a l t h C a r e P r e f e r e n c e Survey..49 R e s p o n s e s t o t h e HCPS 49 Concurrent validity 56 S e c t i o n 3. T h e HCPS a n d D e m o g r a p h i c V a r i a b l e s . 5 7 Age 57 Sex 58 Marital status 59 Education 59 Ethnic origin 59 Occupation. .60 Home r e g i o n 61 Performance status 61 Disease s i t e 62 Number o f t r e a t m e n t s 62 Primary o r adjuvant treatment 62 S e c t i o n 4. HCPS S c o r e s a n d S T A I S c o r e s 63 C o r r e l a t i o n s between S-Anxiety and T-Anxiety s c a l e s 66 HCPS s c o r e s a n d S t a t e a n x i e t y s c o r e s 66 HCPS s c o r e s a n d T r a i t a n x i e t y s c o r e s 67 S e c t i o n 5. O t h e r F i n d i n g s 68 Introduction 68 Attitudes of subjects 69 Comments a b o u t t h e q u e s t i o n n a i r e s 70 Comments a b o u t i n f o r m a t i o n 71 Comments a b o u t i n f o r m a t i o n a n d sensory problems 72 Summary 73 Chapter  5:  SUMMARY, C O N C L U S I O N S , RECOMMENDATIONS  IMPLICATIONS  Summary Conclusions Implications f o r Nursing P r a c t i c e Recommendations f o r F u r t h e r Study BIBLIOGRAPHY  AND  77 82 83 85 87  v  APPENDICES Appendix  A.  Demographic Background  Questionnaire  and  Information  Appendix  B.  Health  Care  Preference  Appendix  C.  Letter  of  Appendix  D.  Patient Information  97 Survey  Introduction  vi  Sheet  100 107 110  LIST  OF  TABLES  Table I.  Page Distribution  of Subjects  by Age a n d  Sex II. III. IV. V. VI. VII. VIII.  43  Marital  Status  Educational  X. XI.  Levels  44  Occupation  45  Performance Disease Number  Status  46  Sites  47  of Radiotherapy  Intervention Choices Preference  IX.  43  Survey  o f HCPS  Concurrent  Items  Items  Validity  48  on t h e H e a l t h  f o r Individual  D i f f e r e n c e s Between Content  Treatments  with  Care  Items..50 52  R e s p o n s e s . . . . 54  Question  56  XII.  State  Scores  63  XIII.  Trait  Scores  64  vii  ACKNOWLEDGEMENTS I this it  would  thesis  would  like  dream  never  been  Barbara  energy,  efforts  He  whose  help  gave  s l e e p and l o v e t o s e e  process, Warren,  t o thank  I am  i n g u i d i n g me indebted  Sue R o t h w e l l  Dr Willman  committee critical  i n mid-stream. comments  the last  through the  t o D r . M.  and B e t t y  Johnson.  task  Barbara  Warren's  years  will  long  I  would  comments and  of chairing  and u n f l a g g i n g s u p p o r t  five  Willman,  f o r her insightful  accepting the d i f f i c u l t  over  supported  and without  completed.  o f h i s time,  their  research  for  have  ways  who  fulfilled.  For  like  Nod M i r h a d y ,  i n innumerable  unstintingly a  t o thank  my  thesis  enthusiasm,  o f my  thesis  be remembered  with  gratitude. I  would  radiotherapy and of  also staff  the patients their  time  like  t o thank  Dr. Jackson, t h e  a t t h e Cancer  who  participated  t o make t h i s  study  viii  C o n t r o l Agency and gave possible.  o f B.C.,  so generously  CHAPTER  1  INTRODUCTION Overview The  diagnosis  acknowledged for  t o be s t r e s s f u l  patients.  often  and t r e a t m e n t  Fear,  cancer  as a  emotional often  psychosocial  anxiety  the consequences  of the public  equally  posed  potent  threats  posed  Health  workers  have  with  patients. been The  primary  amelioration accompanies  other with  goal  hand,  of the emotional the diagnosis  i s to assist  emotional energy  distress.  and m a t e r i e l ,  choice  between  and  i s the  limited  the health effort  usually  of cancer.  The  on t h e  t o understand  and  cope  procedures  Although  serve  have  cognitive.  interventions,  also  1  these  d i s t r e s s which  of cancer.  Given  putting  study,  and u n f a m i l i a r  may  cancer  interventions  patients  i n the treatment aim, t h e l a t t e r  of  and t r e a t m e n t  complex  diagnostic  radiotherapy.  affective  of cognitive  the multiple,  primary  of this  of affective  are the  of interventions f o r  problems  i n two c a t e g o r i e s ,  objective  involved  a  the psychosocial  For the purposes  placed  primary  a choice  or  of  and above t h e  itself  by t h e  and chemotherapy  distress are  Over  by t h e d i s e a s e  surgery  dealing  experiences  perception  illness.  procedures, care  are generally  and e m o t i o n a l  life-threatening  threats  of cancer  to  not the  ameliorate  resources  of  care  worker  into  affective  time,  often or  faces  cognitive  i n t e r v e n t i o n s . The l i t e r a t u r e  much g u i d a n c e effective literature  f o r delivering  interventions.  a p p r o p r i a t e , t i m e l y and  Likewise, there i s l i t t l e  on w h i c h t y p e o f h e a l t h c a r e  p a t i e n t s themselves  does n o t p r o v i d e  intervention  prefer.  B a c k g r o u n d and S i g n i f i c a n c e A survey fear  i n t h e USA n o t e d  of cancer  higher than  holocaust or violent diagnosis of cancer generally experience 1976;  t h a t people  the threat of a nuclear  crimes  (Cantor,  1978).  e v o k e s many p o w e r f u l  a c k n o w l e d g e d t o be a v e r y (Gullo,  ranked t h e  d e s c r i b e s the anxiety response d i s r u p t i v e o f the emotional  e m o t i o n s and i s  anxiety-provoking  Cherico _ Shadick,  Blumberg, F l a h e r t y & Lewis,  The  1974; V e t t e s e ,  1980).  Cantor'<1978)  a s one o f t h e most  reactions t o cancer.  The a n x i e t y e v o k e d by t h e d i s e a s e c a n become t h e p r i m a r y e x p e r i e n c e o f t h e d i s e a s e . When t h i s h a p p e n s , a n x i e t y h a s n o t p r e p a r e d u s f o r a c t i o n , i t h a s p r o d u c e d an a p p r e h e n s i v e s e l f - a b s o r p t i o n t h a t obscures the very nature o f what t h r e a t e n s u s . ( p . 19) However, i t i s n o t j u s t a n x i e t y . Bond  (1982) f o u n d  t h e d i s e a s e w h i c h b r i n g s on  t h a t p a t i e n t s had s i g n i f i c a n t  l e v e l s o f a n x i e t y and d e p r e s s i o n a s a r e s u l t radiotherapy  as the primary  O v e r 50*s o f c a n c e r apy  mode o f  treatment.  patients will  a t some p o i n t i n t h e i r  illness  o f having  receive radiother-  (Sarna,  1981). A  c o n s e n s u s e x i s t s among h e a l t h c a r e w o r k e r s t h a t patients should  be g i v e n some f o r m 2  these  of preparatory  information  (Creech,  1975; Peck & B o l a n d ,  & Flaherty,  1980; B a t t l e s ,  1981; B o u c h a r d - K u r t z  Speese-Owen, 1981; C a s s i l e t h , Smith, has  1982).  the overall  ively  T h i s i n f o r m a t i o n may t a k e many f o r m s , b u t goal of helping the patient  c o p e w i t h t h e d i s e a s e and t r e a t m e n t  workers a r e l e g a l l y informed  consent,  disclosure  Rogers,  experience.  begins, health care  namely t h e c o m p l e t e risks,  treatment  and r e a s o n a b l e  b e n e f i t s and s i d e  (Rozovsky,  presented  t o enable  effectively treatment  i n f o r m a t i o n s h o u l d be  side effects of  w h i c h c a n o c c u r when t h e p a t i e n t A l l of this  i t (Bahnson, 1975).  g i v e n may n o t c o r r e s p o n d  of patients to  Information they a r e  w i t h what t h e y want o r n e e d .  Murphy, and Powers  h e a l t h c a r e workers d i f f e r learning  r e t u r n s home  i n f o r m a t i o n must be c a r e f u l l y  t o t h e n e e d s and a b i l i t i e s  comprehend  During the  and h i s f a m i l y t o  manage t h e p r e d i c t a b l e  (Webb, 1 9 7 9 ) . tailored  the patient  effects  1979; Magnet-  1980; O'Connor, 1981; S t o r c h , 1 9 8 2 ) .  course of radiotherapy, a d d i t i o n a l  Lauer,  to effect-  bound t o meet r e q u i r e m e n t s o f  of potential  of t h e proposed  &  H e i b e r g e r , March & S u t t o n -  Before a course o f treatment  of  1977; J o h n s o n  (1981) n o t e d  that  significantly  n e e d s and o f what c o n s t i t u t e s  information.  3  p a t i e n t s and  i n perceptions important  Several  a u t h o r s have o b s e r v e d t h a t  whatever s o u r c e i n t e r f e r e s with (Izard  & Tompkins,  1978).  I t i s not  research  has  particular, imparted  1966;  surprising, therefore,  retain l i t t l e  & Mood, 1982;  the  last  two  a u t h o r s who  particular,  social  promote t h e Bahnson  integrity.  feel  more c o m f o r t a b l e ,  create best  the  listening, identifying ion  or  is  (1975) i n  b e n e f i t s f o r cancer  l e s s a n x i o u s and  emotional care  patients. the  leas  a patient's  patient  emotionally  e f f e c t i s to  i n which  help  learning  A f f e c t i v e i n t e r v e n t i o n s may  encouraging the  with  same  A f f e c t i v e health  second, concurrent  f e a r s and  Israel  preparatory  p r o v i s i o n of  can  include  v e n t i l a t i o n of f e e l i n g s ,  concerns, teaching  r e l a x a t i o n t e c h n i q u e s and  aspects of  that  many o f t h e  Creech  emotional conditions  take place.  in  biological,  most d i r e c t e f f e c t i s t o h e l p  The  recent  I t i s t o cope  p r o v i s i o n of  a l s o recommend t h e  and  distressed.  that  (1975) and  i n t e r v e n t i o n s have two first  information  to a patient's  support to cancer p a t i e n t s .  The  that  1974).  of these t h r e a t s  information,  Pohl,  (Dodd, 1982a; Dodd & Mood, 1981;  Mcintosh,  and  from  information  cancer patients,  of the  Cancer poses t h r e a t s psychological  l e a r n i n g new  L a d e r & Marks, 1971;  documented t h a t  t o them  anxiety  life  t a l k i n g about  (Gordon,  4  stress  reductoutside  Friedenbergs,  Diller,  Hibbard,  Lucido,  1980).  Wolf, L e v i n s , L i p k i n s ,  Thus, h e a l t h c a r e p r a c t i t i o n e r s dilemma.  Are they  to focus t h e i r  Ezrachi &  a r e faced with  a  e f f o r t s on c o g n i t i v e  interventions or affective  i n t e r v e n t i o n s , o r b o t h ? Much  of  be s e e n  the l i t e r a t u r e ,  as w i l l  i n Chapter  mends a c o m p r e h e n s i v e i n t e r v e n t i o n p r o g r a m t o psychosocial  problems, b u t does l i t t l e  patients at greatest risk different  address  to identify  o r i n g r e a t e s t need o f t h e  kinds of i n t e r v e n t i o n .  order of the types  2, recom-  Does t h e c h r o n o l o g i c a l  o f i n t e r v e n t i o n make a d i f f e r e n c e ?  There a r e recommendations f o r a f f e c t i v e i n t e r v e n t i o n s (emotional the  support)  before  information i s provided, but  o p p o s i t e recommendation  literature little  concerning  i s a l s o made.  patient preferences  Furthermore, provides  very  i n f o r m a t i o n about whether p a t i e n t s p r e f e r  cognitive or affective  i n t e r v e n t i o n s o r what d e m o g r a p h i c  o r p s y c h o l o g i c a l f a c t o r s may a f f e c t  the preference.  Problem Little  i s known a b o u t p r e f e r e n c e s  patients f o r cognitive or a f f e c t i v e to  or during a course  affect to  these  add t o a v a i l a b l e  interventions prior  of radiotherapy  preferences.  Therefore,  knowledge i n t h e s e  5  of cancer  o r how a n x i e t y t h i s study areas.  may  seeks  Purposes The  study  i s designed  to f u l f i l l  the following  purposes: 1. To d e s c r i b e h e a l t h c a r e p r e f e r e n c e s , a s measured by the Health cancer first 2.  Care Preference  patients receiving  Survey  [HCPS], among  radiotherapy  f o r the  time.  To e x a m i n e t h e r e l a t i o n s h i p  between s e l e c t e d  d e m o g r a p h i c v a r i a b l e s and p a t i e n t s ' h e a l t h  care  preferences 3. To e x a m i n e t h e r e l a t i o n s h i p anxiety, Inventory  between p a t i e n t s '  a s measured by t h e S t a t e - T r a i t CSTAI3, and t h e i r  Anxiety  health care prefer-  ences . Definition Health  o f Terms  C a r e P r e f e r e n c e : The s e l e c t i o n  for  a c o g n i t i v e health care  affective  health care  the  o f t h e HCPS.  items  Cognitive the  of or preference  i n t e r v e n t i o n o r f o r an  i n t e r v e n t i o n as described i n  ( H e a l t h C a r e ) I n t e r v e n t i o n : i s d e f i n e d by items  o f t h e HCPS a s t h e p r o v i s i o n by a h e a l t h  c a r e worker o f f a c t s , ation of Affective items  information or the explan-  procedures.  ( H e a l t h C a r e ) I n t e r v e n t i o n : i s d e f i n e d by t h e o f t h e HCPS a s t h e p r o v i s i o n by a h e a l t h  worker o f e m o t i o n a l  support.  care  State Anxiety:  Defined  by S p i e l b e r g e r ,  (1977) f o r t h e  STAI a s : a t r a n s i t o r y emotional s t a t e or c o n d i t i o n o f t h e human o r g a n i s m t h a t v a r i e s i n i n t e n s i t y and f l u c t u a t e s o v e r t i m e . This condition i s c h a r a c t e r i z e d by s u b j e c t i v e c o n s c i o u s l y p e r c e i v e d f e e l i n g s o f t e n s i o n and a p p r e h e n s i o n , and a c t i v a t i o n o f t h e a u t o n o m i c n e r v o u s s y s t e m . L e v e l o f A - S t a t e s h o u l d be h i g h i n c i r c u m s t a n c e s t h a t a r e p e r c e i v e d by an i n d i v i d u a l t o be t h r e a t e n i n g , i r r e s p e c t i v e o f the o b j e c t i v e danger; A-State i n t e n s i t y should be low i n c i r c u m s t a n c e s i n w h i c h an e x i s t i n g d a n g e r i s n o t p e r c e i v e d a s t h r e a t e n i n g . ( p . 39)  Threat:  Defined  by S p i e l b e r g e r  (1977) a s :  an i n d i v i d u a l ' s i d i o s y n c r a t i c p e r c e p t i o n o f a p a r t i c u l a r s i t u a t i o n as p h y s i c a l l y or psychol o g i c a l l y dangerous. The a p p r a i s a l o f a s i t u a t i o n a s d a n g e r o u s o r t h r e a t e n i n g w i l l be d e t e r m i n e d , i n p a r t , by an i n d i v i d u a l ' s p e r s o n a l i t y d i s p o s i t i o n and p a s t experience with s i m i l a r s i t u a t i o n s . ( p . 30) Trait  anxiety:  Defined  by S p i e l b e r g e r ,  (1977) f o r t h e  STAI a s : relatively stable individual differences i n anxiety proneness, that i s , t o d i f f e r e n c e s i n t h e d i s p o s i t i o n t o p e r c e i v e a wide r a n g e o f s t i m u l u s s i t u a t i o n s as dangerous o r t h r e a t e n i n g and i n t h e t e n d e n c y t o r e s p o n d t o s u c h t h r e a t s with A-State r e a c t i o n s . A - T r a i t may a l s o be r e g a r d e d a s r e f l e c t i n g i n d i v i d u a l d i f f e r e n c e s i n t h e f r e q u e n c y and t h e i n t e n s i t y w i t h w h i c h A - S t a t e s have been m a n i f e s t e d i n t h e p a s t , and i n t h e p r o b a b i l i t y t h a t s u c h s t a t e s w i l l be e x p e r i e n c e d i n t h e f u t u r e . <p.39)  7  A s s u m p t i o n s and L i m i t a t i o n s There 1. B o t h  a r e f o u r major assumptions  affective  and c o g n i t i v e  components o f a c a n c e r  in this  study:  interventions are v i t a l  patient's radiotherapy  treatment. 2. A n x i e t y i s a common e m o t i o n a l d i a g n o s i s and t r e a t m e n t p a t i e n t s vary anxiety  to the  o f c a n c e r and  individual  i n t h e amount and e x t e n t o f t h e i r  response  3. Subjects w i l l  response  t o t h e d i s e a s e and  truthfully  treatment.  and a c c u r a t e l y r e s p o n d  the data-gathering  instruments.  4. The i n s t r u m e n t s u s e d  i n the study  on  a r e r e l i a b l e and  valid. The  major l i m i t a t i o n  o f the study  i s that the  sample p o p u l a t i o n r e p r e s e n t s o n l y a s m a l l s u b s e t o f a l l cancer  p a t i e n t s i n the Cancer  Columbia  C o n t r o l Agency o f B r i t i s h  CCCABC] c a t c h m e n t a r e a and t h e f i n d i n g s a r e  comparable o n l y t o those f o r s i m i l a r cancer  patients.  a  populations of  CHAPTER  2  REVIEW OF RELEVANT  LITERATURE  Introduction Cancer threats Cancer  p a t i e n t s c o p e w i t h many r e a l  i n the course of t h e i r i s often  (Quint,  and d e a t h  Cancer  1975).  threat  (Weisman & Worden,  survival  cancer according t o Holland  f u n c t i o n and m u t i l a t i o n  (1976) " . . . a r e s o m e t i m e s a s  & Heskel(1977),  radiotherapy, observed  modalities  i n medicine  and a p p r e h e n s i o n ,  "Few t h e r a p e u t i c  misunderstanding,  than t h e use o f i r r a d i a t i o n (p.744).  Many r e s e a r c h e r s  cancer p a t i e n t s r e c e i v i n g radiotherapy  experience high degrees sion  Rotman,  at patients  that  i n d u c e more  i n cancer treatment."  that  (p.264).  looking  undergoing  agree  a  but the treatments f o r  formidable as the d i s e a s e i t s e l f "  therapy  1976).  Not o n l y d o e s t h e d i s e a s e s i g n i f y  to individual  confusion  that  a connotation f o r individuals of fear,  1975).  Rogow, D e l e o n  sentence  I t i s not s u r p r i s i n g  prolonged pain, loss of bodily (Creech,  death  c a n c e r p a t i e n t s have a p r e d o m i n a n c e o f concerns  carries  imaginary  d i a g n o s i s and t r e a t m e n t .  a s an u n e x p e c t e d  1965; C r e e c h ,  newly d i a g n o s e d life  seen  and  (Peck & B o l a n d ,  of stress,  a n x i e t y and d e p r e s -  1977; Rotman e t a l . ,  Forester,  Kornfeld & Fleiss,  treatment  m o d a l i t i e s may e v o k e s i m i l a r  9  1978).  While  1977; other  emotional  cancer  responses, on  the focus  the concerns In  and treatment  frightening  i s seen  unknown  etiology.  "...the  disease  invasion"  and  Sontag  that  (p. 5 ) .  character  When c a n c e r  that  guilt,  self-pity the  a probable  cancer  commonly fears  may  reported  biological cancer workers  care  grief,  correspond During  emotional  workers  dread,  i s how  Friel  be a  shock,  bitterness,  (1984)  anger, and  to different  phases o f  surgery  treatment,  recognize  and  are alienation,  denial. t h e impact  dilemma  to intervene  10  (1981)  dysfunc-  and Blumberg  responses  The c l i n i c a l  best  shame  b y new a n d  of the  and p s y c h o l o g i c a l t h r e a t s confronted  patients.  secret  that the  would  including  o f m u t i l a t i o n , m o r t a l i t y and Health  i t enters,  arouses  Johnson  responses,  experience.  i tas  as a ruthless,  response  depression,  which  before  and treatments,  i n anxiety.  anxiety,  describes  patients are threatened  many e m o t i o n a l  and o f  i n p a t i e n t s and o t h e r s .  considered  cite  knock  of the disease  diagnostic tests  increase  aptly  f u r t h e r argues  unfamiliar  tional  have  f u t u r e s because t h e  experienced  the fear of contagion  be  by t h e  many p a t i e n t s  intractable  (1977)  Sontag  will  t h r e a t s posed  their  doesn't  an i l l n e s s  mysterious  real  as mysterious,  review  patients.  o f cancer,  f a n t a s i e s about  disease  ...  literature  of radiotherapy  a d d i t i o n t o the very  diagnosis  cancer  of this  by  f o rhealth  i n order  care  t o help the  patient  cope  with  the experience  treatment.  There  health  workers.  only or  care  i s a range  interventions  researcher  will  cognitive ences  selectivlely  Lazarus  (1977)  i n which  threatening  Patient  defines  an  (appraisal)  evoked,  and t h e c o g n i t i v e mediates  actions deal  or strategies  with  threatening  emotional (Weisman  cited  below,  have  ation  and t h e i r c h o i c e  found  that  produced  action  prefer-  anxiety.  intra-psychic a s i t u a t i o n as t o modify  certain  the  emotions a r e  of taking  direct  emotion.  patients  studied  The  employ  b y many  & Nygren,  to  patients'  researchers  1978;  A number  1984).  identified  of  need  Welch,  authors,  f o r inform-  of information-seeking  a s an  strategy.  (1983),  studying  uncertainty  great  cancer  1976; M i l l e r  1983; G o t a y ,  Pruyn  the  on  patient  a s an  t h e evoked  been  Pruyn,  coping  cognitive  s i t u a t i o n s and t h e subsequent  1981;  effective  process  that  d i s t r e s s have & Worden,  coping  of appraisal  (reduces)  as  Education  and t a k e s  In t h e process  by  study,  literature  individual recognizes  threat.  action  review  and t h e e f f e c t s o f  Interventions:  used  In t h i s chapter,  and a f f e c t i v e i n t e r v e n t i o n s ,  Cognitive  and  of this  c a n be c a t e g o r i z e d  be c o n s i d e r e d .  f o r intervention  process  of interventions  For the purposes  which  affective will  of the disease  stress  breast  due t o a during  cancer  lack  of  diagnosis  patients, information  and  treatment.  Seeking  information  strategy  to  Gotay advanced seeking  reduce  was  early-stage  much  described  for  on  the  the  first  that  patients  most  list. as  being the  (1976),  days  of  used  information-seeking  reduced  how  that  family  for  react  strategy  used  as  a  by  of  who  cancer, strategy.  cancer  patients  treatment,  have  the  for  found as  an  families  Welch  families  (1981),  of of  used  support  their  perceptions  the  in  effectively  basis and  by  i t came  information-seeking  patients  supportive cancer  information  interventions  substant-  anxiety  helped  coping.  to  and  cancer  interventions  Information-seeking  cited  action")  common  and  and  information-  patients  afraid  (1980) e x t e n s i v e l y  patients  guidelines  those  Nurses  among  early  patients  i t s treatment.  examining  found  Friedman on  and  interventions  patients, ially  teaching  disease  retrospectively nursing  strategy.  of  that  firm  studying  patients'  the  common  strategy  stage  most  coping  about  found  diagnosis  commonly  by  most  study  "taking  effective  interventions  the  common  Among  was  Worden  100  patients,  advanced  themselves  and  as  comparative  (after  the  information-seeking Weisman  a  second  patients  but  lower  in  cancer  the  cited  uncertainty.  (1984),  stage  (p.608),  was  was  by  surveyed in  to  12  order  health  identified  patients  family  cope  as with  the to  care the  literature construct  workers.  number  cancer.  one Mengel  (1982)  observed  employed the  that  by n u r s e s  resources  t h e most  t o help  common  patients  of the patients,  intervention cope  i s t o improve  generally  by  providing  information. There education the  i s little compared  majority  have  been  Johnson  published  nursing the  topics  aspect  latter groups,  American  view  o f cancer has been  t h e Oncology  Nurses'  Standards  f o r Cancer  Patient  education  i s seen  Although issue  of the nursing many  addressed  e d u c a t i on,  to information.  i n their  CONS] a n d  position  Practice  standards  t h e second  (1979).  patient. address the  i s specifically  I t reads:  The c l i e n t a n d f a m i l y p o s s e s s k n o w l e d g e about t h e d i s e a s e and therapy i n order t o a t t a i n self-management, p a r t i c i p a t i o n i n therapy, optimal l i v i n g and peaceful death, (p.4) In useful  t h e r a t i o n a l e f o r t h e above principles  standard  other  are laid out:  The r a t e a n d t h e l e v e l o f i n f o r m a t i o n p r o v i d e d t o a c l i e n t and f a m i l y i s determined 13  paper  and r e q u i r e d  o f the cancer  o f t h e t e n outcome  of patient  by two  Society  as a recognized care  and  practice.  substantiated  Nursing  1984).  patient  an i n t e g r a l  Nursing  and  education  (Green,  cancer  nursing  Association  Outcome  component  that  patient  care  patient  journals  found  cancer  i n cancer  on c a n c e r  i n nursing  (1981)  regarding  i n c r e a s i n g l y h a s become  recognizable The  t o other  of the articles  and Green  education  literature  by t h e i n d i v i d u a l ' s i n t e l l e c t u a l emotional resources. (p.4)  capacity  and  and: Securing adequate information p r e r e q u i s i t e to development of coping, (p.4) Johnson the  themes  formal  and  and  Blumberg  issues of  definition  of  (1984)  the  cancer  ONS  is a functional  i n c o r p o r a t e many standard  in their  patient education  of more  as:  a series of structured or non-structured experiences which are designed t o a s s i s t p a t i e n t s t o c o p e v o l u n t a r i l y w i t h t h e immedi a t e c r i s i s response to t h e i r diagnosis, with l o n g t e r m a d j u s t m e n t s and w i t h symptoms; g a i n needed i n f o r m a t i o n about s o u r c e s o f prevention, d i a g n o s i s , and c a r e ; and d e v e l o p needed s k i l l s , k n o w l e d g e , and a t t i t u d e s t o m a i n t a i n o r r e g a i n h e a l t h s t a t u s , ( p . 9) Patient patient  as  Bahnson,  education  the  focus  1975;  have  be  tailored  to  to  be  Johnson The  nizing fall  into  two  emotional.  and  easiest  to  and  specific  Shani,  &  of  broad The  the  A  education needs  Green,  of  which  1981;  describe. of  educational  programs  need  Watson,  Grover  &  to  order 1982;  Engstrom,  1984).  affect  of A  these  recog-  These  factors  ability-related i s the  patient's  educational 14  includes  learning.  c a t e g o r i e s ; one first  of  1966;  patients in  patient education  variety  individual  number  Pellegrini,  Blumberg,  factors  one  resources  &  process  the  1975).  (Johnson  McLellan,  with  a t t e n t i o n (Abrams,  stated that  the  effective  1982;  of  Creech,  researchers  Jones,  starts  most  and  clear-cut  intellectual experiences  are  factors and  which  c a n a f f e c t new  treatment  individual's treatment ability  (Friel,,  physical  to  comprehend  (Johnson  condition  cancer  to their  affect  their  patients, disease  emotion  ability  t o comprehend  cancer  the  lack  the  event  of perceptual  the  diagnostic  early  illness to  because that  (i.e.,  i s facilitated  when n u r s e s  the concerns  15  (Redman,  patients  anxiety  (p.123).  retaining phase  are a with  anxiety  information  i s  i s "... about  Williams information)  i n  of cancer, i s  of anxiety.  in this  that  the patient's  the subsequent  pay p r i o r i t y  and i s s u e s  Lewis,  the associations  and t r e a t m e n t level  res-  c a n be an  cancer  or orienting  learning  &  learning  of immobilizing  by t h e p a t i e n t ' s  learning  new  that  i t s occurrence"  that  that  and p r o c e s s  problem  maintains  experiences  adversely  Anxiety  can i n t e r f e r e with  One s o u r c e  before  can  Flaherty,  1984).  are so threatening  disabling.  impeded  and treatment  (1981) a r g u e s  teaching  Age  ability  of the emotional  (Blumberg,  which  Williams  special  1975).  affect a patient's  many  & Blumberg,  intense  1978).  (Bahnson,  1984).  learning  Johnson  and  intellectual  and t o p a r t i c i p a t e i n l e a r n i n g  ponses  1980;  The  to diagnosis  cancer  also  diagnosis  1981).  on h i s / h e r  about  & Blumberg,  For  adaptation  i n part  and knowledge  and  about  1981; B r a i n e r d ,  immediate  depends  learning  phase  attention  She  suggests  of the and  the patients  respond  perceive  as  important  before  "Once  patient  the  pressing  agenda  information Williams  (1982a)  any  formal  perceives  that  the  nurse  as  given  over  also  important, by  that  that  nurse  will as  that  visits  regards  regard  his  the  important"(p.127).  information  successive  found  he  teaching.  given was  information  by  nurses  retained.  was  and  Dodd  retained  when i t  reinforced periodically.  Affective  Interventions:  Authors taken and  two  of  often  The  first  a f f e c t i v e nursing in nursing  encompasses  for  the  intervention  form,  interventions.  textbooks.  i n v e s t i g a t i v e e f f o r t s to  affective  Support  affective interventions  recommendations  taken  includes  Emotional  discussing  approaches.  clinical  timing is  with  observed  reinforced  was  proceeding  The  theoretical  content  and  This  approach  second  approach  identify  s t r a t e g i e s and  have  appropriate  evaluate  their  effectiveness. Examples Kooser and  (1981)  Kooser  as  the  and  (1981)  additional such  of  approach  Yasko  (1982)  argue  that  emotional  the  first  diagnosis  They  recommend  a  including  both  cognitive  and  provide  should  be  any  used  guidance first  in  in  periods  range  as  below.  of  phases  of  high of  to  Marino  risk  their  interventions,  which high  and  require  a f f e c t i v e . However,  these  16  Marino  patients  treatment  illness.  not  discussed  cancer  support and  include  they  interventions  risk  phases.  do  Yasko provide before  <1982>  emotional they  effective nursing  of  feedback the  decrease  relaxation  anxiety  have  the  may  side  used  support  The  be  in  this  benefits  interventions,  There  late  earlier i t was  are  isolation.  few  They  cognitive  or  valid  reliable  and  other  of  is  other  verbalizgiven  initiate  area  for  and  there  oncology in  section  reducing  also  In  on  patients  Seeking  their  of  treatments.  that  was  use  although  with  with  seen  and  social a  mates  commonly at  both  affective interventions studied  interventions. research  the  disease.  of  usually  interventions  patients  i n the  and  the  studies  are  as  active  that,  information.  patients  stages  as  advocates  reports  (affective interventions)  and  support  affective  effects associated  for  facilitate  patient's  to  (1984)  She  discussed  strategy  to  patient  nurse  to  patients  f e e l i n g s , and  cancer  other  Cobb  f a m i l i e s sought  intervene  process.  techniques.  and  cognitive  early  from  anxiety.  (1984),  chosen  the  such  and  concerns.  coping  there  i n order emotional  thoughts  controlled studies  patients,  their  defines  nurses  (interventions)  and  Clinicians  Gotay  She  facilitate  cares  to  information  exploring  facilitate  no  radiotherapy  provide  which  necessary  are  support  behaviors  actions  to  that  coping.  listening,  ation  recommends  because  in combination  There of  i s not  a  in  with  lot  methodological  of  problems is  also  including  practitioner,  anecdotal  relative  and  cancer  to  Weisman  patients  differentiate the  when  efficacy  the  patients  is  of  et  of  on  researchers  a l .  an  and  a  of  treatment  and  referrals the  However,  the  decrease  in  and  term  studied  the  that  purely  the  cognitive to  identify  affective  in  cognitive  group.  "high  "at  counselling  support  They programs  risk"  3)  variety  over  and  cancer  time  from  Quinlan,  effectiveness  in  group  affect  benefits  Kohorn,  and  of  18  and the  review.  strat-  strat-  2)counselling towards  control  They  groups  psychosocial evidenced  about  the  manipulation  support.  a  The  intervention  disease which reported  experproblems.  a  more  rapid  experienced  both  short  interventions.  Latimer, a  evaluated  intervention  feelings  financial  intervention negative  of  environmental  and  and  literature  intervention  improvement  Cain,  and  interventions.  cohort  information,  and  long  of  and  developed  extensive  reactions  ienced  a  researcher  groups  emotional  (1980)  patient's  both  accepted from  -the  attempted  counselling  the  that  They  who  evaluated  Dprovision  included  success  affective  blanket  of  control  (1980) m a i n t a i n  them  affective  based  egies:  of  of  because  unknown.  Gordon variety  use  bias  the  i s unknown.  question  egies  of  effectiveness  interventions  and  lack  evaluations  Worden  risk"  possible  and  thematic  Schwartz  (1986)  counselling  model  with  gynecology  group  formats.  structured affective solving  thematic  Patient  i n t e r v e n t i o n s were  combined  with  a  less  Preferences assessment has of  concentrated  on  of  cognitive  perceptions  Women  i n the  psychosocial  f o r Health of  and  problem-  i n t e r v e n t i o n groups distress  often  health  on  first  been care  filtered workers.  patient preferences  researchers  about  their  Care  s i x months  had and  their  to  ask  disease,  activities  Intervention  p a t i e n t s ' need  cognitive interventions.  know  series  both  intervention  the  a  later.  The  of  consisted of  and  i n which  component.  year  program  individual  sessions  substantially one  The  p a t i e n t s i n both  of  Linehan what  the  daily  and  preference  through  the  Most  early  within  the  (1966)  research category  was  one  p a t i e n t s wanted  treatment  for  and  of  to  i t s effect  living.  They wanted s i m p l e a n s w e r s , and f e w e r m e d i c a l t e r m s . They wanted more e x p l a n a t i o n s o f what was d o n e t o t h e m a n d why; what t o e x p e c t after an o p e r a t i o n o r t r e a t m e n t ; more e x p l a n a t i o n o f nursing procedures, (p.1068) Dodge of  their  higher tial and  <1969),  their  surgical  their "kinds  study  c o g n i t i v e needs,  priority  to  in a  found  information  p h y s i c a l and p a t i e n t s were  hospital of  on  of  experience  information  that  patients' that  that  emotional  patients placed was  asked  they  felt  seen  as  survival.  interviewed and  perceptions  to  essenMedical  half-way prioritize  they  should  a  through the be  given  and t h e r e l a t i v e  receiving learned  various  that  receiving them  long-range  "Patients  cancer  were  patients  differed  differed  on t h e rank  In t h e i r  study,  ordering  identified  patients'  iences  would  concern,  a t home a n d w o r k ; be l i k e  Cassileth, studied period  a mixed after  completed  followed  during  Zupkis, sample  their  they  i n d i c a t e d , on a f i v e  much  they  amount,  type  information  Styles point  or disagreed  (good  news a n d / o r  presented  and 4)what  o f 256 c a n c e r  an I n f o r m a t i o n  agreed  their  diagnosis  t o them.  20  o f communi-  their  by 2 ) p l a n  diagnosis.  information  2)self-care at  issues  Sutton-Smith  first  of  and p a t i e n t s  assistance;  l e a r n i n g about  nurses  l e a r n i n g needs a s :  f r i e n d s and f a m i l i e s about  identified  3)self-care  with  enable  that  o f 20 g e n e r a l  and 3 ) p s y c h o s o c i a l  first  would  perceptions  nurses  home a n d w o r k ;  their  concerned  found  i n their  of financial  Patients  She  immediate and  (1981)  1)availability  with  which  f o rtheir  and Powers  needs.  cation  (p.504).  (p.509).  Murphy,  Nurses  attributed to  particularly  of information  learning  items.  they  of information"  realistically  lives"  Lauer, and  kinds  the kinds  to plan  importance  concerns.  diagnosis of care, their  exper-  and treatment. & March  (1980)  patients  i nt h e  The p a t i e n t s  Questionnaire  i n which  Likert-type scale,  with  as  statements  bad) and source The a u t h o r s  how  about t h e of  were  trying  to  determine  become care.  the  informed The  about  study  55.5),  degree  and  showed  was  for  active participation  better and  educated,  performance  and  for  as  for  preferred  age  increased  They  information  among  more  were  (the  recently  unrelated  also  to  medical median  detailed information  decreased.  those  status  patients  participate in their  desire  preference  which  that  age  increased  the  to  and  found  whites,  an  the  diagnosed.  to  information  and  Silberberg  Sex  preference. Levenson, (1981) at  a  20)  used  group  a of  Pfeifferbaum, more  through were  a  of  acquired.  setting.  to  answer  They  also  information  Many  (65?<) o f  more  information  personally  the  but  diagnosis  as  would  Sex  means by  said  have  and  they  or  they  been  ethnicity  wanted  diagnosis  did.  patients  wanted  more  contrast  to  findings of  the  the  i t  for  been they and  was  their  families.  more  but  -  have  did  did  11  would  not  feel  wanted  that  themselves  information  not time  Specifically,  information  had  helpful for  i n C a s s i l e t h ' s study,  and  for  (age  amount  which  i f they  looked  program  related to  asked  patients  patients  educational  themselves  42?s s a i d  families.  results,  for  the  They  pediatric  the  questions and  were  in a  After  knowledge  more  their  patients  multi-disciplinary  asked  source  r e t r o s p e c t i v e approach.  cancer  outpatient  Copeland  their  affect  for  the  since Hispanic parents.  C a s s i l e t h study,  the  In  most  recently  additional Few  diagnosed  information  researchers  information  to  doctor-patient content ferent  of  Abrams, clues to  to  how  discuss  Several  cancer  anticipatory ment  Bouchard-Kurtz  illness.  given or  suggest  source  information.  cancer  that and  Stromborg  &  anxiety  et  they  Adolescents source  a l . , 1981). received  treatment Wright, the  their  1984).  They  nurses  reassurance  rather  treatment.  Bullough  the  literature  than  r e f e r s to  22  he  wishes  (p.317).  patients  be  1981;  studies  of  1981).  have  learning--the identified  information  of  the  have  (Frank-  support  reported  about  their  indicated that  their  their  patients  knowledge  of  given  treat-  Williams,  have  to  "...the  (Marino,  provided  has  dif-  offers  often  their  and  according  physician  knowledge  (1981)  style  during  Ambulatory  their  from  with  the  and  of  giving  examining  diagnosis  1981;  number  primary  discussions  nursing  to  factor affecting  their  (Levenson  reported disease  as  prior  in a  that  how  that  of  (1969),  prognosis"  Speese-Owens,  patients  timing  patient or  educators  &  the  changes  the  little  decrease  view  Information,  and  to  at  argues  diagnosis  another  physicians  when  how  indicated of  looked  to  helpful.  p a t i e n t s . Abrams  information  i n order  Cancer  be  likely  personally  communication  the  much  his  less  communications,  of  should  as  have  cancer  patient  phases  were  the  and  disease  that,  teaching  and  although and  emotional cancer  supportive  patients  significant support. patients only  nurses  Bullough  between  actual  role  Dodd describe  cancer  preference  researcher  associated  with  demographic  study  was  that  t h e HCPS  hospital. might  variables that  [HCPS]  scores  was  over found  on t h e  One r e c o m m e n d a t i o n  23  Dodd  affected  no  Health  and t h e S t a t e - T r a i t  be t e s t e d  be  including  of control.  She a l s o  as a  outpatient  teaching  (cognitive)  options.  [STAI].  of  a n d no c l e a r p r e f e r e n c e  options  to  (supportive)  i n an  and l o c u s  r e l a t i o n s h i p between  Inventory  setting.  v a r i a b l e s which  demographic  Survey  and t h e  was d e f i n e d  f o r information,  f o r information  Preference  Anxiety  urban  discrep-  attempted  behavioral  several  factors, anxiety  (supportive)  significant  large  preference  f o r information  behavioral  Care  examined  to a  f o r type  was c o n d u c t e d  at a  no s i g n i f i c a n t  preferences shown  preferences  and  emotional  study,  f o r information  The study clinic  of  i n the clinical  f o r cognitive versus  radiotherapy  found  patients'  Preference  information.  of information  finding  i n an e x p l o r a t o r y  as  emotional  p r o f e s s i o n a l image play  breast  post-mastectomy  as a source  attributes this  nurses  (1985),  o f 139  some  nurses  or of  as a source  nurses  the nurses' that  information.  perceive  20% o f a sample  25% i d e n t i f i e d  ancy  o f nurses,  of information  described  support.  The  do n o t a l w a y s  sources  Only  functions  of her  in a variety of  settings and  to obtain  corroborative  data  on i t s  validity  reliability.  Anxiety Anxiety  as i t i s usually  emotional  state,  character  (Freud,  associated 1947;  with  Miller,  control  be  When  threat,  state  in  I t i s often (Mowrer,  and l o s s o f  1970).  (Krause,  have  I t c a n be  1961) o r by  demonstrated  (Mowrer,  1948).  1939).  arousal  i s out of proportion  perception  anxiety can when  i s a protective  I t can a c t i v a t e t h e organism  o f autonomic  1950).  that  Anxiety,  o r danger,  i t c a n be a p o w e r f u l  (Adler,  distort  as unpleasant  tension  & Gatchel,  reports,  response  (Miller,  anxiety  force  Davidson  by s t r e s s , t h r e a t  a high  common  of i t s physiological correlates (Barratt,  a learned  response  1973).  i sa  the related feelings of fear,  Psychologists  triggered  to  1936; Groen,  by v e r b a l  observation 1972).  subjectively perceived  1948) h e l p l e s s n e s s ,  (Greer,  assessed  understood  (Barratt,  t o t h e immediate  and p o t e n t i a l l y  I n many c i r c u m s t a n c e s ,  and impair  1972).  problem-solving  disruptive anxiety can (Scott,  1983). Anxiety multifaceted school  manner.  of psychology,  condition, 1936).  has not always  often  Later  been  F o r Freud anxiety  the result  theorists,  i n this  and t h e p s y c h o a n a l y t i c  was a p a t h o l o g i c a l  of childhood  working  24  understood  from  trauma  (Freud,  the responses o f  healthy  people  example,  described  distinguished  "normal  normal  anxiety."  anxiety  as  Horney, f o r being:  i m p l i c i t i n t h e human s i t u a t i o n o f c o n t i n g e n c y i n t h e f a c e o f d e a t h . . . . B u t what c h a r a c t e r i z e s anxiety i s the f e e l i n g of d i f f u s e n e s s and u n c e r t a i n t y and t h e experience o f h e l p l e s s n e s s toward t h e t h r e a t . Anxiety i s a reaction to a threat t o something belonging to the 'core o r essence' of the personality. I t i s a reaction t o a t h r e a t t o some v a l u e w h i c h t h e i n d i v i d u a l holds e s s e n t i a l t o h i s existence as a personality. (May, 1950, p.140) Rollo process  May  even  (1950)  further  carried the  "de-pathologizing"  and d e s c r i b e d  normal  anxiety  as:  t h a t r e a c t i o n which: (1) i s n o t d i s p r o p o r t i o n a t e t o t h e o b j e c t i v e t h r e a t ; (2) does n o t i n v o l v e r e p r e s s i o n o r o t h e r mechanisms o f i n t r a - p s y c h i c c o n f l i c t , and, as a c o r o l l a r y t o the s e c o n d p o i n t ; (3) does n o t r e q u i r e n e u r o t i c d e f e n c e m e c h a n i s m s f o r i t s management, b u t c a n be c o n f r o n t e d c o n s t r u c t i v e l y on t h e l e v e l o f c o n s c i o u s a w a r e n e s s o r c a n be relieved i f the objective situation i s a l t e r e d . ( p . 194) Psychologists have  described  "appraisal Averill,  interested  emotions  of threat"  such  1974),  appraisal  e n t a i l s symbolic,  uncertain  states.  criteria included: ogical  Krause  & Optin,  (3) molar  behaviour  intuition;  and  25  or  developed  that  other  which  (2) p h y s i o l -  (restlessness, (4) t a s k  &  a set of  reports;  (6) r e s p o n s e  on t h e  1966; L a z a r u s  "transitory anxiety"  d i s t o r t i o n s of speech);  clinical  as based  anticipatory  (1961)  he c a l l e d  of stress  e s p e c i a l l y when  (1) i n t r o s p e c t i v e v e r b a l  signs;  posture, (5)  f o r what  as anxiety  (Lazarus  1972; L a z a r u s ,  i n the study  body  performance; to stress.  Spielberger Krause's state  work  and  anxiety.  (1966)  as:  unitary, istic"  (1966,  Trait  anxiety  13).  State  transitory state  which  varies This  consciously  the  in  perceived  of  from  patients  ized and a  the  state  past  time"  subjective  and  apprehen-  anxiety  perception  as:  organism  by  tension  of  is  usually  threat  depending  experience  Johnson,  <1985) f o u n d  differ  in their  perceptions  examined  group  perceptions  Their of  of  disease  process.  Adjective  the  patients  hostility.  which  on  with  The  and  higher patients  of  that of  nurses  anxiety.  nurses  and  transient anxiety,  sample  population  was  at  different  List.  levels  used  The of  These  hospitaldepression  the  for in  of  a  their  Multiple  care-givers attributed  anxiety  themselves.  26  stages was  and  composed  r e c e i v i n g treatment  instrument  A f f e c t Check  the  for  patients  diagnoses  significantly did  of  individual  and  character-  recognized  and  variety  than  to  disposition  oncology  mixed  the  a  situations.  Husted  authors  theory,  or  Spielberger  f l u c t u a t e s over  f e e l i n g s of  threat,  be  i s characterized  individual  personality, similar  condition  by  from  differences in  can  and  on  anxiety  defined  condition  intensity  Spielberger's  result  differs  or  built  personality  anxiety  "...a  In  was  permanent  1977)  trait  "...stable individual  (p.  sion.  1976,  differentiated  relatively  <p.l3).  1972,  The  to  the  patients  researchers  found  a  negative  of  correlation  anxiety  .  While  interesting, results  are  There anxiety ing  a  Forester,  ledges ment  that  career when  of  most  a  information treatment. need  to  causes  tion  of  with  of  the  their  nature  Effects  of  According interferes She  to  emotion  She such  on  of  a  of  the  size.  subject  of  receiv-  Rotman,  et a l . ,  (1976)  acknow-  and  treat-  a l l phases  occurs  large  at  a  volume  and  process  in  the  time of  new  proposed  information  depending  the  sample  diagnosis of  report  are  patients  Vettese  that  can  on  be  patients one  their  of  percep-  information.  Welch-McCaffrey  the  q u a l i t y of  itself  lists as:  as  the  a  chronic  numerous  dependence  health  of  cancer  a l l phases for this  itself;  life-style  change  patient.  condition of  the  unsettling in  bio-  alterations;  p r o f e s s i o n a l s ; and  27  a  anxiety  pervasive  sources  diagnosis  condition;  (1985),  life  throughout  psychological on  the  that  small  1977;  disease  anxiety  anxiety  manifests  illness.  with  treatment  of  a  Anxiety  their  client  anxiety.  with  describes  which  period  grapple  the  study  i n cancer  Boland,  Simultaneously,  cope  the  literature  patient.  related to  and  of  anxiety-provoking  must  age  generalizability  a l . , 1978).  cancer  patients  &  initial  of  because  reaction  (Peck et  the  i s the  and  voluminous  common  client  results  questionable is a  as  the  validity  radiotherapy  1977;  the  the  with  treatments.  The  symptoms  behaviors Kneisel  and  of  signs  (1979)  anxiety to  divide  in  blood  breathing,  the  vomiting, urinary  constant  effects  tion,  lack  details,  of  and  Dodd priately  hands  diminished  feet  to  concluded  that  these  to  anxiety  Measurement  present  most time  the  nausea  and/or  fatigue, anorexia, disturbance);  of  lack  and  symptoms  are  many  of  Spielberger  studies  patients  inappro-  nervousness, and  of not  measure  tingling  of  chemotherapy. unlike  I t has  She  those  the  STAI  28  anxiety  theory,  used  been  used.  the on  StateGorsuch,  extensively.  comprehensive had  at  based  the  (Spielberger,  been a  of  questionnaire  [STAI3  published  i n which  to  anxiety.  Inventory  1984,  rumina-  researchers.  self-report  1970).  as  effects  Trait  Lushene,  initiative),  attention  numbness  State/Trait anxiety  and  of  cancer  Spielberger's Anxiety  diarrhea,  emotional  diminished  symptoms  commonly-used is a  rate,  headache,  that  side  by  three  productivity).  a t t r i b u t e d such insomnia,  and  difficulty  sleep  (1982b) o b s e r v e d  attributed  into  (forgetfulness, preoccupation,  and  The  of  heart  Wilson  chest,  concentration,  irritability,  objective  of  r e s t l e s s n e s s , and  intellectual  from  anxiety  (increased  palms,  and  of  tightness  state  frequency,  (irritability, and  pressure, sweaty  range  subjective conditions.  categories—physiological elevated  can  In  bibliography I t has  been  used  to assess  coronary  anxiety  disease,  injuries,  i n many  hypertension,  psychiatry,  surgery,  psychosomatic  conditions  used  a n d 80%  t h e STAI  later.  The s t u d i e s  decreasing 1978);  anticipatory 1982);  o f insomnia  from  identifying  participation determining  incidence  demographic  of pediatric  (Powazek,  Goff,  patterns  (Morris,  (Lawson,  Greer,  as:  (Baum  &  Jones,  treating  & Morrell,  1977);  patients  programs  1981);  patients to  identi-  (Bernay,  (Kin,  with  1981);  relationship  to  emotional  hospitalization  & Paulson,  of expression  i n 1979 o r  variables associated  screening  Schyving  have  situational  (Strnad,  o f s t r e s s and t h e i r  responses  ing  i n reducing  of radiotherapy  of cancer  areas  (Morrow  cord  studies  ( C a n n i c i , 1980);  procedures  i n breast  levels  such  as  gynecology,  published  patients  and v o m i t i n g  the psychology  1976);  the  included  such  spinal  cancer  were  i n mastectomy  nausea  arising  diabetes,  Fifteen  the use o f modelling  anxiety fying  .  areas  obstetrics,  o f these  have  anxiety  treatment  medical  o f anger  P e t t i n g a l e & Watson,  1978);  and  i n breast  identifycancer  1981).  Summary Cancer biological The  t o cope  disease  threaten  and p s y c h o l o g i c a l i n t e g r i t y  literature  helped the  and i t s treatments  indicates that with  brings  diagnosed  the anxiety  both of  individuals.  p a t i e n t s c a n be  and u n c e r t a i n t i e s t h a t  by t h e u s e o f a f f e c t i v e  29  the  and c o g n i t i v e  interventions. unanswered health they  care  how  nurses  cognitive  and  can  leaves  many  assess  questions  what  kinds  individual patients  interventions  which  to  familiarize  i t s treatments  or  a f f e c t i v e (supportive)  which  ment?  Both  anxiety. sionals  lack  of  valid  manage t h e i r  intervention issue  and  reliable  help  health  their  the  disease  interven-  internal  may  i s that  with  to  to  environreduce  care  information  Do  profes-  about  preferences.  to  solution  identify  interventions  taking  to  central  partial  designed  them  types  The  patients' A  help  them  of  prefer.  add  help  tions  care  to  literature  interventions  prefer  knowledge and  as  The  into  selected  demographic  designed  to  address  particular  group  nurses  be  can  of  helped  this  patients'  in a  account  to  the  variety  dilemma  preferences of  influence  of  problem  cancer to  as  30  health  and study  i t relates to  patients  intervene  studies  situations  anxiety This  in  for  clinical  characteristics. the  lies  in  more  the  hope  is a  that  effectively.  CHAPTER  3  METHODOLOGY This care  study  preferences  radiotherapy ence  care  between  cancer  f o rthe f i r s t  preferences;  patients' scores  their In  health  this  instruments the  study,  the  data  t o : a) d e s c r i b e patients  time;  the researcher  o f t h e sample  population,  analysis.  were  used  the Health Anxiety  i n t h e study:  Care  a  Preference  Inventory.  Each  will  detail.  questionnaire. a copy  Appendix  A, was o r i g i n a l l y  schedule  i n c l u d e s such  o f which  devised  demographic  i s presented i n  by Dodd and  <1982a).  treatment  as age, sex, m a r i t a l s t a t u s , e t h n i c  diagnosis,  disease  treatment,  performance  Karnofsky  describe the  Development  Questionnaire,  instrument,  variables  test  the setting f o r  and t h e data  and t h e S t a t e - T r a i t  This  will  the data,  following instruments  Demographic  anxiety  preferences.  process  i n some  the influ-  the relationship  on a s t a n d a r d i z e d  and Instrument  discussed  b) examine  v a r i a b l e s on p a t i e n t s '  the characteristics  Demographic  health  receiving  and c) examine  to collect  collection  The  Survey,  care  chapter, used  Instruments  be  among  o f s e l e c t e d demographic  health  and  was u n d e r t a k e n  site,  performance  radiation  status status  31  dosage,  a s measured scale,  also  group,  nature  of  on t h e included i n  The  Appendix  A, a n d n u m b e r  obtainable status, were  from  listing which  level  HCPS  (1982).  relevant  various  a  might  includes health  vention.  item  tool  during  worker  Each  typical  process?  questionnaire item  consists of  encounters  i s asked  that  of diagnosis  and  are offered;  i n t e r v e n t i o n on t h e p a r t  and t h e o t h e r ,  The s u b j e c t  the question:  interventions at  forced-choice  the course  by  clinically  and treatment  a l t e r n a t i v e responses  a cognitive  devised  f o r health  or cognitive  describing  a  t o answer  by t h e s u b j e c t .  have  Two  care  CHCPS].  B) was o r i g i n a l l y  i n the diagnosis  vignette  treatment.  for  affective  i s completed  patient  Survey  and assessment  i s a seven  clinical  neither of  H e r i n t e n t i o n was t o c r e a t e  want  sheet  available.  (see Appendix  points  survey  information  and o c c u p a t i o n ,  T h e HCPS was d e s i g n e d  Do p a t i e n t s  a l l  o r , as i n performance  a background  Preference  screening  educators.  that  Care  record  treatments,  In a d d i t i o n , t h e subjects  of education  was o t h e r w i s e  The  The  ratable.  t o complete  Health  Mood  the medical  directly  asked  of radiotherapy  of a  an a f f e c t i v e  to indicate a  one  interpreference  one o f t h e two. The  HCPS  was m o d i f i e d  Mood's p e r m i s s i o n consisted gender  by t h i s  and a s s i s t a n c e .  o f d e l e t i n g any s p e c i f i c  of the health  care  provider  32  researcher The  with  modifications  reference  to the  and rewording  Items  a  3,  4,  the  and 5 f o r c l a r i t y  items The  to  which  ion.  As t h e r e  range  from  interpreted  emotional  items,  indicating  Scores  one o f t h r e e  --an  information/education  option  helpful  The  STAI  feelings worry.  Avenue,  preference f o r  times  and f o r  depending  on t h e  i n t h e HCPS  i s a  the subject  of care  that  option,  he/she  Anxiety  Inventory  support  CSTAI].  by S p i e l b e r g e r t o  assess  t e n s i o n , n e r v o u s n e s s and  o f the Inventory  Alto,  would  treatment  an e m o t i o n a l  i s available  (Consulting Psychologists Press,  Palo  i s asked  option.  o f apprehension,  publisher  times,  was d e v e l o p e d  A copy  c a n be  i n a d d i t i o n t o the medical  and a s e l f - c a r e  State-Trait  a t some  types  most  affect-  choices f o r  overall  i n which  find  o f an  t h e extremes  Included  item  scores  i n t e r v e n t i o n s , or as a  a t other  chosen.  choices seven  a moderate  f o r information  validity  the possible  seven  between  i n t e r v e n t i o n and 1  a cognitive intervent-  indicating  as e i t h e r  items  choose  a r e seven  support  concurrent to  an a f f e c t i v e  or f o r affective  preference  specific  of  by a s s i g n i n g 0 t o a  describes  t o seven,  information.  cognitive  which  zero,  option,  i s scored  describes  the response  ive  The c o n t e n t  was n o t a l t e r e d . instrument  response  of expression.  California  33  94306).  from t h e  577  College  I t has been  used  extensively a  major  revision  The each.  since  and  then  how  he/she  score  to rate  i s asked  he/she  generally  level  t o each  of anxiety  anxiety.  feels  the range  reports  situation  cases,  older  much  subjects  under  A rating  that  mean  lower  whether with  to  numerical o f 1-4  o f 1 i n d i c a t e s a low of a high  State  adults  In  scores  medical  anxiety  of  20 t o 80. in a  anxiety  the Trait  mean  from  level  i s from  o f 31.79 t o 36.75.  have  stress,  A  score  working  mean  scale)  according  scale).  the weighted  have  o r diagnosed  higher  (State  20 s t a t e m e n t s  o f 32.20 t o 36.54 w h i l e  a r e i n the range  treatment,  now  of possible scores  scores  subjects  right  (Trait  statements  the statements  and 4 t h e presence  (1983)  non-stressful  from  response.  The range  Spielberger  to rate  feels  the other  i s constructed  assigned  1983).  c o n s i s t s o f 2 s c a l e s o f 20  The s u b j e c t t o how  i n 1964 a n d u n d e r w e n t  i n 1976 ( S p i e l b e r g e r ,  Inventory  according  in  i t s development  scores anxiety both  and or  surgical  reactions,  have  scores.  Setting The  study  outpatient Evans  patients for  place  radiotherapy  Clinic  CCCABC].  took  CAMEC3  This  the province  department  o f the Cancer  facility  monthly  i n Vancouver,  B.C. i n a n  o f t h e A. Control  t r e a t s over  400  Maxwell  Agency  radiotherapy  and i s t h e primary  radiotherapy  o f B.C.  a  I t serves  34  o f B.C.  center  heterogenous,  multicultural facility Yukon  urban  population  f o r the mainland  and Northwest  and  i s the  referral  of the province  as well  as the  Territories.  Subiect3 The  subjects  receiving previous ities  radiotherapy experience  with  according legal read to  not  the  2)  participate  with  5)  major  first The  first  which  of  six criteria  might  subjects during  approached  were  of health  was  cancer  modal-  to 3)  give able  physically  first  to surgery  anxiety  to  able  f o r the  6)  levels,  o r s t e r o i d s 7)  care  used  within  by  Dodd  preferences.  The  on t h e p r i n c i p l e  which  become  were their  the  second  side  after  the  by t h e  appointment  subjects  fraction  Potential  35  severe  i n person  or third  The  a small  more  that  data.  approached  t o t h e AMEC.  patients.  those  added  confound  represented  radiotherapy  affect  no  were s e l e c t e d  1) a b l e  4)  had  treatment.  of treatment,  referral  could  tranquilizers  effects  after  language  They  They  or adjunctive  criterion  researcher  as having  patients  treatment  treatment  seventh  The  cancer  radiotherapy  i n her study  week,  time.  receiving  o r minor  week  cancer  of surgery.  the English  on m e d i c a t i o n  first  other  diagnosed  as a primary  (1985)  were  to the following c r i t e r i a :  consent  i.e.,  study  f o r the f i r s t  the exception  and w r i t e  time  for this  who  were  of a l l possible  subjects  were  screened  and  rejected i f their  the  researcher's  one  or  more  refused two  to  either  them  out  of  appointments  availability  the  seven  participate did  so  discarded.  not  did  and/or  criteria.  i n the  complete  study  the  they  approached  February  1985  14,  and  the  period  40  results  from  subjects  had  were  to  treated  January  meet  (five)  questionnaires or  p a t i e n t s were  the  few  with  to  when  Four  during  failed a  that  radiotherapy  coincide  Only  incompletely hundred  not  and  filled be  with  14,  1985  to  obtained  for  the  study. The  sample  completely ience. or the  rejecting  invalid  study  larger  qualify  (Abdellah study  &  the  Phillips  the  Levine,  and  exist  describe  subjects.  a  is a  i t s aims  (1971)  are  the  comments  aimed  conclusions  to  conven-  at  confirming  the  or  discover  about  of  this  whether study the sort  that: If the d e f i n i t i o n of the problem emphasizes the context of discovery, a superior strategy ( t o a random sample) f o r a g i v e n p r o b l e m m i g h t be t o s e c u r e d e t a i l e d d a t a on a n o n - p r o b a b i l i t y sample. (p. 95)  Human  Rights  and  Ethics  36  of  them  i s , however,  preferences  said  nature  render  v a r i a b l e s under  and  has  This  nor  of  hypothesis,  1965).  between  random  sample  study,  some e x p e r i m e n t a l  relationships to  were  might  exploratory  and  i s neither  representative—it  If this  sample  population  of  an  The person at  subjects  during  their  t h e AMEC.  them  were  contacted  second  The purpose  and they  were  asked  informed  ion  (see Appendix  C) t h a t  The  subjects  given  were sheet  again  t h e next  Data  AMEC  day t o o b t a i n  subjects  completed  of places  home f o r  personally  written  voluntary.  patient  t o take  contacted  consent  and t o  department  The m a j o r i t y  after  completing  day.  In a l l cases,  naires  the questionnaires  including the waiting  radiotherapy  subjects).  their  rooms  and a t t h e i r  of the patients  radiotherapy  except  those  home, t h e r e s e a r c h e r  of the  homes ( t w o filled  treatment  who t o o k  was p r e s e n t  in a  them o u t  f o r the  the question-  while  t h e forms  completed. Many  subjects  clarify  With  experiences  a great  their  o f time  about  The r e s e a r c h e r  comments  37  and t r i e d  trying  to the r e -  the subjects  to the researcher  and f e e l i n g s .  to their  amount  responses  few e x c e p t i o n s ,  wanted t o t a l k  carefully  spent  and e x p l a i n  searcher. and  were  D>  of introduct-  was  and a  subject  Collection  variety  to  a letter  the letter  They  Each  to  the questionnaires.  The  were  appointment  was e x p l a i n e d  participation  (see Appendix  consideration.  clinic  o f t h e study  v e r b a l l y and through  their  complete  or third  to participate.  was  information  by t h e r e s e a r c h e r i n  were  eager  their  listened  t o answer  their  questions  where  compromising content  of  reported  all  the  incidental  personal  separate  sent  an  Data  Analysis  from  determine  of the  relationship on  overall  the  score  relationship  the  from  data  the  the  HCPS was  to  instruments. recorded  them  The  and  to  will  proper  so  and  preserve  names and  according  DThe health  several  basis.  without  be  removed the  addresses  that  they  were  could  HCPS s c o r e s  care  on  three  scored  to  preferences.  demographic an  scores to  the  HCPS was  examined 3)STAI  to  variables  2)The to  item-by-item  were  examined  ascertain their  and in  degree  association. The using  data  the  Lotus  Corporation, and  from  1-2-3  1983)  statistical the  variables  studied as  questionnaires (Copyright  computer  functions  calculate  sub-groups  the  means and  well  for as  be  results.  study.  subjects' of  so  questionnaires  Subjects'  the  of  the  a n a l y s i s proceeded  objectives  scores  identifiers  abstract  The  the  do  data.  coded  anonymity.  kept  to  d i s c u s s i o n s was  researcher  patients'  possible to  responses  these  as  The  i t was  of  program. the  standard  the  Lotus  whole  compiled  Development The  program  data were  deviations of sample  f o r a l l other  38  were  and  for  sorting used  to  the various  calculations.  of  The data  statistical  available  different nominal  in that  different  but  disease  called  ordinal of  information  not  sented as  use  of  the  shape  but  of  populations  they  could of  the  the  ordinal.  study  but  reduced the  included  ethnic  be  as  ranked  the  data  subjects  were  i n rank  repre-  STAI.  and  the  statistical  the  sample  data  arose  are  i s lost loss  treated  through  i s more  size  requirements, from  Fewer  made a b o u t  i n the  types  the  than  probabilities  relationships  different  39  be  such  the  the  to  of  the  distribution.  need  to  number  Some o f  be  on  resulting  situations  between  score  the  could  HCPS.  Some p o w e r  population  different  to  data  received or  a l l interval  tests,  i n v o l v e d and  given  collected  differences  or  were  different  nominal  because  this  out  of  to  of  to  collected  be  data  type  i n some e x t e r n a l m e a s u r e  assumptions  relationships  the  age,  the  the  occupation,  had  data  of  carried  f o r by  unwarrantable  of  assigned  on  assigned  data  subjects could  interval  independence  Five  the  rank  made o n  purposes  were  compensated the  be  or  treatments  non-parametric  and  of  home r e g i o n ,  education,  the  i f they of  could  differences  manipulations as  Many  Some e x a m p l e s  choices  known  For  i t was  value  rankable,  years  way(s)  in that  called  only  the  m a r i t a l s t a t u s . Other  number  be  no  site,  and  could  depended  on  they  groups.  group,  the  used  categories.  categories  sex,  and  tests  of  the  between  them.  examination data.  Each  situation Where  data  was  independent  carried than  two  samples  relationship;  several  4)  the c h i - square  at least  coefficient  sets  was  used  Where  one-way  1 8 4 - 1 9 3 ) was  used;  rankable,  (Hopkins  p  one o f t h e d a t a  classes  Kruskal-Wallis  1956 p were  different  1956  1956  p  could  and t h e o t h e r  U test  of  test  to find  Where  computed.  40  used;  as  two  the  the strength sets  was  1978, p  of  included  rankable,  of variance classes  t h e Spearman rank  and G l a s s ,  was  rankable,  both  more  f o r 'k'  treated  and t h e o t h e r analysis  was  included  175-179)  was  test for  104-111)  sets  be  1)  dichotomously  one o f t h e d a t a  5)  test:  the chi-square  (Siegel,  (Siegel,  samples  Mann- W h i t n e y  the  samples  one o f t h e d a t a  independent  sets  t o be examined,  categories,  3) Where  statistical  b e t w e e n two  o u t ; 2) Where  independent  the  for a different  a relationship  grouped two  called  (Siegel, of  data  correlation  117-119)  was  4  CHAPTER PRESENTATION  AND  DISCUSSION  OF  RESULTS  Int.roduct.ion The in  five  results  of  sections.  description  of  the The  the  sample.  includes  p r e s e n t a t i o n and  the  Health  relationships ence  Survey  Similarly, on  the  Other in  in Section  Inventory  1  - The  Forty  addition  4  the  In  separate  Care  items  and  responses  are  study  Survey  and  are  the  Preferthe  discussed.  and  described  3  Section  Health  2  Section  scores  State-Trait  and  presented  discussed. and  discussed  Sample  A l l were  receiving to  newly  themselves,  the  researcher  demographic  information  collected  from  data-gathering  their  s t a t u s as  cancer  f o r the  completed  marital status, education, performance  the  diagnosed  radiotherapy  instruments  home t o w n ,  sections  a s s o c i a t i o n s between  Preference  the  the  discussed  detailed  questions.  presented  the  sex,  on  on  the  scores  three  Survey.  o u t p a t i e n t s completed  instruments. were  and  and  5.  Section  who  Care  findings of  Section  scores  whole  next  discussion of  Preference  between a  research  v a r i a b l e s are  Health  Anxiety  Care  as  demographic  three  reported  section i s a  The  to  to  are  initial  correspond a  the  study  first  by the  the  time.  In  subjects  following  medical  ethnicity, measured  patients  records:  age,  occupation, on  the  Karnofsky  scale,  treatments,  and nature  again  that  ience  and were  population Age  both  the subjects constituted n o t chosen  of cancer  sample  was f r o m  I t should a sample  be  noted  o f conven-  p a t i e n t s i n B.C.  i n c l u d e d 1 9 men  a n d mode w e r e  younger  = 62.1),  b u t t h e medians  data  married.  who  were  Hen t e n d e d  somewhat  f o r t h e two g r o u p s  i s designated  The l a t t e r  than  with  the ratios a n d women.  the  sample  t o be  older  were  (M  similar  significant.  as married  and n o t  includes includes  separated  o r never  o f a l l o f t h e s u b j e c t s were  o f married A summary  i s shown  Educational  group  divorced,  one-half  men  median  64 y e a r s .  I.  status  More  schooling.  a mean o f 6 1 , a n d  status.  widowed,  Most  The age  on t h e age and s e x o f p a r t i c i p a n t s a r e  Marital now  with  was n o t s t a t i s t i c a l l y  i n Table  Marital  a n d 2 1 women.  (M - 5 9 . 7 ) a n d women  the difference  presented  and  of radiotherapy  t o be r e p r e s e n t a t i v e o f t h e  36 t o 79 y e a r s  t h e median  Complete  numbers  o f treatment.  somewhat  and  site,  and sex.  The range  disease  t o not married  those  married. married  similar f o r  o f sex and m a r i t a l s t a t u s f o r  i n Table I I .  levels.  o f t h e s u b j e c t s h a d 12 o r m o r e y e a r s o f The range  was f r o m  o f 9 a n d 12 y e a r s ,  42  8 t o 20 y e a r s respectively.  with  mode  Women h a d  Table  I  Dlatribution  Age  of Subiects  Men  35-39  2  40-44  2  45-49  0  by Age a n d Sex  Women  Total  0  2 1  3  2  50-54  1  2 1  2  55-59  2  4  6  60-64  3  6  9  65-69  6  70-74  1  75-79  2  1  7  5  6 1  19  3  21  40  Table I I Marital  Status  N o t Now Married Married  Total  Men  12  7  19  Women  12  9  21  Total  24  16  40  o f formal  education  slightly  more y e a r s  =  but the difference  11.32)  data  a r e summarized  was n o t s i g n i f i c a n t .  i n Table I I I .  43  <M = 1 1 . 9 0 v s M The  Table I I I Educational  Levels  Years of Education  Men  Women  Total  0-8  4  5  9  9-10  4  2  6  11-12  7  6  13  13-14  2  5  7  15 +  2  3  5  21  19  40  Ethnicity. Only  35  background into  two  o f t h e 40  on t h e i r  groups  admission  with  and those  grounds  the other  group  grounds.  There  patients  i n the  (n = 1 5 ) .  i n c l u d e d many  were  sample  = 20)  <n  group  The  ethnic  claiming a British  one group  the other  sheet.  an  those  forming  in  subjects indicated  no  Asian,  with  divided  background  other  back-  The p a t i e n t s i n c l u d e d  other  European  back-  African  or Latin  American  sample.  Occupation. The were  majority of the subjects indicated  retired  previously accountant, they  a t the time  held  a variety  teacher  of the study  although  of occupations  or rancher.  previously or currently 44  The  that  such  they as  occupations  practiced  were  they had  nurse, which  grouped  into  c a t e g o r i e s by  the researcher  summary o f o c c u p a t i o n a l  f o r convenience.  groupings  i s presented  The in  Table  IV. Table  IV  Occupation  Occupational  Group  n  Homemaker  12  Professional/managerial  10  Skilled  trades  9  Clerical  work  4  Farmer  4  Unskilled  manual l a b o r  1  Total  40 Home r e g i o n . For  assigned listed  on  statistical t o two their  g r o u p s b a s e d on charts.  s u b j e c t s from G r e a t e r second  convenience,  i n c l u d e d 22  The  the  s u b j e c t s were  t h e home  first  addresses  group i n c l u d e d  Vancouver urban area  from the  remainder of  and  18  the  British  Columbia. Performance s t a t u s . All score out  by  by  of the the  s u b j e c t s were a s s i g n e d  i n t e r v i e w e r f o l l o w i n g the  Karnofsky  and  Burchenol 45  a  performance  procedure  (1949) and  laid  confirmed  as  valid is  by Y a t e s , C h a l m e r and HcKegney  based  daily  (1980).  on t h e s u b j e c t ' s d e s c r i p t i o n  activities.  For inclusion  o f h i s o r her  i n the study, the  s u b j e c t s were r e q u i r e d t o be a m b u l a t o r y reasonably well keeping  with the a c t i v i t i e s  with that  requirement,  and c o p i n g  of daily  living.  In  a l l 40 s u b j e c t s s c o r e d  between 70 and 90 o u t o f 100 on t h e K a r n o f s k y shown i n T a b l e V.  The s c o r e  s c a l e as  The mean s c o r e was 79.8 w h i l e t h e  median and mode were 8 0 . Table V Performance Karnofsky Score  Status  Men  Women  Total  70  1  3  4  75  3  6  9  80  9  9  18  85  3  0  3  90  3  3  6  21  40  19 Disease s i t e .  The s u b j e c t s had a v a r i e t y convenience,  the several  grouped  broader  into  of disease s i t e s .  different  sites  For  have been  c a t e g o r i e s a s shown i n T a b l e V I .  46  T a b l e VI Diaeaae  Site  Site  GI/GU  n  Gyn & Breast  13  15  Skin  Head & Neck Other  6  3  3  Number o f t r e a t m e n t s . All first  o f t h e s u b j e c t s were i n t e r v i e w e d d u r i n g t h e  week o f t h e i r  radiotherapy treatments.  t h e s u b j e c t s were i n t e r v i e w e d b e f o r e t h e i r treatment;  the rest  first  had had between one and  radiotherapy treatments each.  Eight of  five  The mean number o f  t r e a t m e n t s was 2.8 w h i l e t h e median f o r t h e  entire  s a m p l e was 4.  The mean number o f t r e a t m e n t s was  for  t h a n f o r women a t 2.4  men  a t 3.1  difference  i s not s t a t i s t i c a l l y  i n f o r m a t i o n on t h e d i s t r i b u t i o n is  higher  although the  significant. o f numbers  Complete  of treatments  presented i n Table VII. Nature o f treatment. Radiotherapy  was t h e p r i m a r y mode o f t r e a t m e n t f o r  16 o f t h e s u b j e c t s ,  the only p r i o r  diagnostic biopsy.  F o r t h e r e m a i n i n g 24  radiotherapy  s u r g e r y h a v i n g been a  was an a d j u v a n t t r e a t m e n t  surgery.  47  subjects,  following  Table VII Number o f R a d i o t h e r a p y Number o f Treatments  Treatments  Hen  Women  Total  0  3  5  9  1  0  5  5  2  3  2  5  3  2  0  2  4  6  3  9  5  5  6  11  21  19  40  The s a m p l e and o t h e r p o p u l a t i o n s . For a v a r i e t y  o f reasons,  compare t h e s a m p l e d i r e c t l y patient  i t i s d i f f i c u l t to  with e i t h e r  population or the overall  population.  Although  t h e Cancer  the radiotherapy  cancer  patient  C o n t r o l Agency o f B.C.  s e e s a g r e a t many o f t h e p r o v i n c e ' s c a n c e r p a t i e n t s and collects  some d e m o g r a p h i c d a t a on e a c h  n e e d s and p u r p o s e s study.  patient  seen, i t s  a r e n o t t h e same a s t h o s e o f t h i s  The Agency d o e s n o t c o l l e c t  t h e same d e m o g r a p h i c  i n f o r m a t i o n on i t s p a t i e n t s a s h a s been c o l l e c t e d f o r t h i s study  or, at least,  along d i f f e r e n t  lines.  i torganizes the information What c a n be s a i d  sample r e p r e s e n t s a p p r o x i m a t e l y therapy  patients treated  10X o f t h e new  during the data 48  i s that the radio-  collection  period  ( 4 1 4 ) , a n d j u s t u n d e r 1% o f t h e p a t i e n t s  during  the last  Section  complete year  2 - The H e a l t h C a r e P r e f e r e n c e  The  When t h e number o f i n t e r v e n t i o n  summed t o y i e l d  out o f seven,  On t h e o t h e r hand, e a c h  intervention  choices i s that  r i g h t through the course o f i n d i v i d u a l item  a t a p a r t i c u l a r stage o f the diagno-  and t r e a t m e n t p r o c e s s , a n d t h e r e s u l t i s t h e n scores.  an i n t e r v e n t i o n  Each o f t h o s e s c o r e s  seven  i s an i n d i c a t i o n  preference a t a p a r t i c u l a r time or i n  with the d i s c u s s i o n , presented  may  f e e l i n g s towards a  a p a r t i c u l a r s i t u a t i o n . Before continuing  as  i n two  tendency t o choose t h e  taken as a t e s t o f t h e s u b j e c t ' s  different of  a general  intervention  treatment.  sis  an o v e r a l l s c o r e  represents  cognitive  given  Survey  ways, e a c h o f w h i c h y i e l d s i n t e r e s t i n g  information.  be  1985).  r e s p o n s e s t o t h e HCPS c a n be c o n s i d e r e d  different  score  (4729) (CCABC,  treated  i n Table  i t i s worth l o o k i n g  any f u r t h e r at the findings  VIII.  R e s p o n s e s t o t h e HCPS. When t h e r e s p o n s e s t o t h e HCPS a r e summed f o r a s i n g l e preference score, preferred the  the cognitive  mean s c o r e  these subjects  over the a f f e c t i v e i n t e r v e n t i o n ,  b e i n g 4.98 o u t o f 7.  been i n d i f f e r e n t t o t h e i n t e r v e n t i o n s preferred  overwhelmingly  an a f f e c t i v e i n t e r v e n t i o n ,  49  I f t h e s u b j e c t s had offered  o r had  t h e mean  score  w o u l d have been 3.5 o r l e e s . with  t h e median s c o r e 5 and t h e mode 4.  Table  VIII  Intervention the Health for  The s c o r e s r a n g e d f r o m 2-7  C h o i c e s on  Care Preference  Survey  I n d i v i d u a l Items Item  Intervention  1  2  All  3  4  5  Subjects  6  7  Total*  <N = 40)  Cognitive  17  28  38  20  32  29  35  199  Affective  23  12  2  20  8  11  5  81  Women  Only  <N = 21)  Cognitive  8  12  20  10  16  15  18  99  Affective  13  9  1  11  5  6  3  48  Men  Only  <N = 19)  Cognitive  9  16  18  10  16  14  17  100  Affective  10  3  1  9  3  5  2  33  a T o t a l p o s s i b l e c h o i c e s a r e 280, 147 a n d 133 f o r a l l s u b j e c t s , women and men r e s p e c t i v e l y . When a l l i t e m s for  were summed t h e r e were 199 c h o i c e s  c o g n i t i v e i n t e r v e n t i o n a n d 81 c h o i c e s made f o r t h e  affective  intervention.  Over t h e seven items  a v e r a g e s o u t t o 28.4 s u b j e c t s i n d i c a t i n g 50  this  a preference  for  t h e c o g n i t i v e i n t e r v e n t i o n on e a c h i t e m .  items  a r e examined one a t a t i m e ,  v a r i a t i o n s from  were v e r y  (1 and 4) t h e r e s p o n s e s intervention.  of response  proportion tion  t o two o f t h e i t e m s  responses.  F o r two o t h e r  two  was  statistically  a s e r i e s o f c h i - s q u a r e t e s t s was d o n e .  of subjects choosing  on any g i v e n  item  seven d i f f e r e n t matrix,  items  To d e t e r m i n e w h e t h e r t h e p a t t e r n  The  the cognitive interven-  was compared t o t h e p r o p o r t i o n  making t h e same c h o i c e on a l l t h e o t h e r As  (3 and  l e a n toward t h e a f f e c t i v e /  t o t h e v a r i a n t items  significant,  response  s t r o n g l y i n f o r m a t i o n - o r i e n t e d compared t o  t h e a v e r a g e o f t h e summed  support  interesting  t h a t h y p o t h e t i c a l average  p a t t e r n a p p e a r . The r e s p o n s e s 7)  some  When t h e  items  combined.  s c o r e s went i n t o making up t h e two by  t h e d e g r e e s o f f r e e d o m was s e t a t s i x .  The  r e s u l t s a r e shown i n T a b l e I X . I t e m s 1 and 3 a r e s t a t i s t i c a l l y l e a s t a t t h e .05 l e v e l  and i t e m 4 a p p r o a c h e s  i c a n c e a t t h e .10 l e v e l . r e s t l e s s or anxious  In item  patient prior  s u b j e c t s chose t h e a f f e c t i v e situation rather in two  they  than  significant at  1, w h i c h d e s c r i b e s a t o surgery, the  intervention.  wanted e m o t i o n a l  support  an c o g n i t i v e i n t e r v e n t i o n .  i t e m 3, t h a t t h e y  signif-  and  In that reassurance  When a d v i s e d , a s  ought t o have r a d i o t h e r a p y , a l l b u t  o f them c h o s e t h e c o g n i t i v e i n t e r v e n t i o n .  4, when r a d i o t h e r a p y  In item  was t o commence i n t h e n e a r f u t u r e , 51  they  were e q u a l l y d i v i d e d between t h e two o p t i o n s ,  although  that represents  a much l o w e r  proportion  choosing  c o g n i t i v e i n t e r v e n t i o n s t h a n t h e mean f o r a l l  items. Table  IX  D i f f e r e n c e s Between  Item  Items  0  1  2  Ratio**  17/23  28/12  X2c  18.52**  Items for the choices X2 w i t h  o f t h e Health Care Preference Survey r e p o r t e d e n t i r e s a m p l e (N = 4 0 ) . b R a t i o o f c o g n i t i v e to affective choices. The c r i t i c a l value f o r d f = 6 i s 12.6. * p i . l 0 . **pi.05  a  3  .026  4  38/2  5  20/20  6  32/8  12.99**10.08* 1.80  different  s u b j e c t s d i d respond t o d i f f e r e n t ways.  I n an e f f o r t  among t h e i t e m s , content,  the  subject,  ed,  type  affect  .05  6.13  each  clinical identity  item  items i n  features  was e x a m i n e d f o r s i m i l a r i t i e s  situation,  implied feeling  of the health care  state of  worker i n v o l v -  o f i n t e r v e n t i o n o f f e r e d and amount o f p e r s o n a l involved.  The o n l y  intervention choice  clinical item.  35/5  t o s e e whether t h e  d i f f e r e n c e c o u l d be a c c o u n t e d f o r by common  contact  29/11  c  The  in  7  context  i n any m e a n i n g f u l way was t h e  of the situation  I t i s interesting  completed  f a c t o r w h i c h seemed t o  presented  i n t h e HCPS  t o note t h a t the s u b j e c t s  the questionnaires 52  during  their  first  week o f  radiotherapy phase  treatment.  of their  phase.  Thus,  situations content  illness items  that  a r e shown  1958)  suggests  an anxious  care as  Johnson  difference  permission itself item  X.  realm.  In item  Surgery  o f treatment.  In  radiotherapy ambivalent  similar  advised  1984).  both  be  produce. a  In  certain made a n d  The p a t i e n t  of radiotherapy  seeks  prior prior  event,  they  may  f o r care.  view be I n many  to radiotherapy i s t o surgery.  made a n d t h e p a t i e n t s may  53  i s described  I f the subjects  preference  just  given  t o make a b e t t e r d e c i s i o n .  as a threatening  as t o their  The  the surgery  t o take  information.  future.  t o t h e one j u s t  been  & Dabbs J r . ,  1 a n d 3 may  i tw i l l  i s for  described  No d e c i s i o n h a s y e t b e e n  4, t h e e v e n t  the situation  preference  has been  and i s awaiting  i n order  i n t h e immediate  t o surgery can  Leventhal  items  to the  (Janis,  1 t h e p a t i e n t has already  b e made w i t h o u t  item  prior  1974; C o c h r a n ,  between  f o r surgery  information  ways,  just  (Johnson,  & Leventhal,  The  and t h e responses  f o rpatients; their  event  treatment  typical  The l i t e r a t u r e  3, t h e p a t i e n t h a s b e e n  cannot  have  items  and t h e d i a g n o s t i c r e s u l t s  course  out  i n the active  currently dealing with.  the period  i n wording  significant.  as  that  i n the affective  1971;  it  were  i n Table  a threatening  the diagnostic  3, 4, 5, 6 a n d 7 w e r e  they  time  had passed  and were  of the individual  items  be  They  feel  A l l decisions that  more  information  at that  reassurance. weakly  want  would  The s t a t i s t i c a l  positive  total.  point  be l e s s  association  e t a l . (19S0)  suggest  information, but the findings of the information.  suggest  that  ients'  timing  preferences  may  than  f o r item  f o r i n f o r m a t i o n a s compared  Cassileth  timing  helpful  4 i s  to the  that patients  do n o t s p e c i f y t h e  Responses  be a c r i t i c a l  i n this factor  study i n pat-  f o r cognitive or f o r affective  interventions. Table  X  Content  o f HCPS  Items  with  Responses.  Preference Clinical Situation  HCPS Item  for:  Cognitive/ Information  Affective/ Support  1  17  23  In hospital-unfamiliar diagnostic test  2  28  12  Recommendation f o r radiotherapy treatment  3  38  2  Prior to radiotherapy commencing  4  20  20  First  5  32  8  6  29  11  Family d i s c u s s i o n s about 7 radiotherapy treatments  35  5  Pre-surgery  evening  treatment  Concerns about s i d e effects of radiotherapy  54  Dodd  (1985) r a i s e s  the  reliability  Her  findings indicated  preferences Dodd  used  and t h e v a l i d i t y  f o r information  whether  results.  information  about  the consistency,  o f t h e HCPS  no s i g n i f i c a n t  the Coefficient  determine similar  questions  instrument.  differencesi n  among t h e s u b j e c t s  Alpha  different  test  halves  studied.  (Cronbach,  of the test  1951) t o yielded  Her a n a l y s i s y i e l d e d a s c o r e f o r  alpha  o f .20.  She r e p o r t e d  that:  Health Care Preference subscales' r e l i a b i l i t y c o e f f i c i e n t s were low and would r e n d e r this instrument suspect o f containing noncontributing items. A g e n e r a l r u l e i s t h a t any i n s t r u m e n t with an a l p h a l e v e l (Cronbach) l o w e r t h a n .6 i s o f q u e s t i o n a b l e v a l u e , (p.12) Dodd's u s e o f C r o n b a c h ' s summed  score  vention.  I f t h e HCPS  analysis, powerful seems or  i s equivalent  an i n d i c a t o r  should  that  Alpha  be c o n s i s t e n t over  time  associated  feeling  Thus, one  state.  preferences  time  takes  into  item-by-item may  n o t be a s  and v a l i d i t y .  care  provider or i s measuring affect-  be p i c k i n g up a p r e f e r e n c e  55  clinical  and r e l i a b l e  t h e element  Dodd  f o rinterventioni s  I f t h e HCPS  be a v a l i d  account  f o r inter-  and i n a l l c l i n i c a l  and i n a p a r t i c u l a r  t h e HCPS may  that the  f o r a c o g n i t i v e o r f o r an  i n t e r v e n t i o n , i t may  particular  result  the preference  regardless of health  ive  on an  of reliability  situations  patients'  assumes  t o a preference  i s examined  the Coefficient  t o assume  Alpha  at a  situation.  instrument i f  of timing.  Concurrent In a  addition  concurrent  Appendix  B)  your  doctor  find  most  which is  shown  to  the  validity "In or  HCPS,  item  general, nurse  helpful  one  Table  Validity.  would  Number  of  The option  were  the  choose?"  type to  A  to  options.(see given of  your  a  care  choice you  medical  summary  of  by  would  treatment,  the  responses  XI.  Validity  Question  subjects  majority  A,  includes  "I the  combination  of  proportion  approximately  E  Wallis  are  (corrected  want  then  =  A  B  C  D  E  25  0  11  1  3  subjects  chose  more  that  chose  reported  option  that  of  choosing  same a s  70?O  When t h e  separate  i s done  from  against  for ties) , a  i s achieved.  for  The  one  the  of  56  "Something  wanted  the  some  other  overall  score  subjects  choosing  the  and  the  one  information  rest ranked  significance  trend  information If  E,  they  and  subjects  the  information."  information  the  kept  test  the  subjects and  HCPS.(28/40  of  would  different,"  .10  i f you to  Response  and  five  responded  XI  Concurrent  the  subjects  with  in addition  you  i n Table  as  the  indicated  a  HCPS  level by  choices, is of  the  options  Kruskal scores of  these  about  p_ =  results  C  is  i n t h e same d i r e c t i o n  the  as noted  above--people  c o g n i t i v e i n t e r v e n t i o n o n t h e HCPS a l s o  option  A on t h e c o n c u r r e n t  Section  3  - A s s o c i a t i o n s Between  Demographic The  validity  question.  t h e HCPS a n d  Variables  ethnic origin,  occupation,  performance  status, disease  site,  and  versus  treatment  primary  determine  whether  comparison  for at  a relationship  this  study  demographics,  because  Personal  treatments,  examined t o  e x i s t e d between  on demographic study  of  region,  of  were  level  of  any o f  items.  preferences  originally  intended  between  preference  f o r information  s h e d i d n o t do a d e m o g r a p h i c Alpha  communication,  score April  to  look  analysis  o f t h e HCPS 4,  No  variables,  Dodd  o f t h e low Cronbach  Dodd,  number  and Dodd's<1985)  the relationship  home  or i t s individual  c a n b e made, b a s e d  information. While  and  J.  adjuvant  a n d t h e HCPS a s a w h o l e  between  choose  v a r i a b l e s o f age, sex, m a r i t a l s t a t u s ,  education,  them  choosing  (M.  1985).  Age. A the  Spearman's  summed  than  0.10.  slightly found  score  patients'  correlation  o n t h e HCPS g a v e  Cassileth  younger  that  rank  (median  a g e was a s i g n i f i c a n t  significant  I t does  f o r t h e sample  working  age and of  with  a  age o f 55.5 y e a r s ) , variable not appear  i n this  57  between  a correlation  e t a l . (1980),  sample  preferences.  done  study.  affecting t o be When t h e  less  sample  was d i v i d e d  together years  a l l those  i n t o approximate under  58 y e a r s ,  and a l l t h e others,  square icant  tested  against  a l l those  and those  individual  d i f f e r e n c e s were  t h i r d s by  groups  HCPS  grouping  over  66  were c h i -  items,  no  signif-  found.  Sex. Overall, intervention scores for test  i n this option  f o rdichotomous  ically  women.  t h e mean 4.7.  gave  the cognitive The range o f  was 5 . 2 . T h e r a n g e The Mann-Whitney  a U-score  o f 159 a n d a  o f -1.1. As t h e c r i t i c a l  situation  significant  i s 1.64, t h e r e  r e l a t i o n s h i p between  value f o r  i s no  statist-  sex and o v e r a l l  score.  compared  are significant  results  on an i t e m - b y - i t e m  vs. intervention choice  strongly  significant  cognitive  strongly  chose  for  item  this  ficult  result.  option.  information  and then  option leave.  58  testsf o r  gave one  2, women  slightly  The value This  preferred  whereas  o f X2 item  option  and p o s s i b l y c o n t r a d i c t o r y  The i n f o r m a t i o n  item  On i t e m  w a s 4 . 8 8 , p_ < - 0 3 .  t h e sexes a r e  Chi-square  f o reach  intervention only that  when  basis.  one t o i n t e r p r e t a s each  different ion.  groups  z-score  i n this  There  the  than  women w a s 2 - 7 a n d t h e mean  Z-scores  sex  men c h o s e  more o f t e n  f o r men was 3-7 w h i l e  corresponding  HCPS  study,  men  ( 1 , N_ = 4 0 )  i sa  dif-  i n c l u d e s two  types  has a nurse  of  interact-  present the  The a f f e c t i v e  option has  the  nurse  stay  provision absence  of information  o f someone e l s e  difference  f o r men  Marital No on  icant  = 195;  2 score  were  with  done  that  status  groups  be t h e  or the presence which  makes t h e  found  between  using  the  (married,  =.08).  using  a s s o c i a t i o n s were  accord  i n t h e room  a s s o c i a t i o n was  f o r dichotomous  comparisons  or comfort,  I t may  or  status.  significant  score  the patient.  o r women.  t h e HCPS a n d m a r i t a l  test (U  and comfort  of Cassileth  This et a l .  married)  item-by-item  chi-square  found.  Mann-Whitney  not  When  scores  tests  no  finding  signif-  i s in  (1980).  Education. Using different  chi-square educational  education,  11-12  significant analysis.  of less Ethnic The  = 15).  indicate  and  t h e summed  than  years  13 o r more found  completed  years,  on an  correlation  HCPS s c o r e  of  with  no  item-by-item of years  produced  a  of  correla-  origin. f o r ethnic  purposes Five  origin  to two—British  out of the forty  an e t h n i c  dichotomous  8-10  groups  0.10.  categories  statistical (n  years,  a s s o c i a t i o n was  with  f o r three  levels,  A Spearman's rank  education tion  tests  groups  background. was  done  59  with  were  reduced  (n = 20)  subjects  and  for Other  d i d not  A Mann-Whitney significant  test for  results  <U  score  =  264.5:  item-by-item  Z  score  =  1.74,  p_ <  .04).  a n a l y s i s shows  that  there  are  results  for  item  1  (p_ <  .03)  results  for  item  6  (p_ <  .06).  all  of  these  results  British  origin  icantly  less  support  option  on  the  items  summed  i s the  chose  often  of  almost  What  than  the  significant  direction.  others,  significant  is interesting  cognitive  often  score  mentioned  the  than  more  and  The  Subjects  of  intervention  or  chose  others,  HCPS o r  on  the  signif-  affective/-  whether the  about  measured  individual  above.  Occupation. A  Kruskal-Wallis  HCPS s c o r e s  for  five  test  found. for of  and  farmer.  While  this the  not  study,  A  p_ <  quite  for  the  .06  i t closely  homemaker  and  due  to  higher  to  chi-square to  be  a  test  for  reasonable  categories  Home  allow  occupations way  to  a and  collapse  together.  region.  60  trade,  significance  p_ <  approaches  category  small  of  the  categories.  too  skilled  level  reaching  ranked  categories--  professional/managerial were  comparing  homemaker,  difference i s possibly  scores  done  occupational  professional/managerial, clerical  was  .05  level  set  significance. the  lower  scores The valid there  was  Most  HCPS  for  the  numbers  in  each  item-by-item did  not  occupational  seem  A Mann-Whitney Vancouver  (18)  and  test  done  Elsewhere  difference  was  = 200.5;  Z  score  likewise  r e v e a l e d no  urban  rural  or  was  found =  between  .027)  The  (22).  No  these  two  the  and  categories  significant groups.  item-by-item  significant  background  with  score  analysis  relationship  preference  (U  between  an  for  intervention. Performance A  Spearman's  HCPS s c o r e s was  done  than 2  which  and  with  0.10.  (new  The  had  test  even 80,  in better by  value  to  sample  an  8  to  5.57  preference  remained  as  divided  and  above  physical  other  into  condition  N  = 40, scores  70  had  this  p_ <  .06).  below  while  relationship  80,  If  admitted  the  there  or i f  performance  indicated,  61  (score <  preferred  For  been  between  Table  intervention  ( s c o r e > 80)  scores  and  with  (see  with  relationship  result  80  subjects  the  As  a  item  80,  subjects with  and  done,  Karnofsky  more  study  was  less  to  been  beow  of  scores  corresponding  1 margin. (2,  ranked  status  yielded  was  affective/support condition  was  analysis  significance.  the  the  correlation  immediately)  thirds  equal  an  a  item-by-item  subjects i n poorer  information the  an  between  performance  being  approached  preferred  those  Karnofsky  variables,  below  correlation  result  diagnostic  approximately  80)  the  When  demographic  V).  rank  the  closely  scores  status.  to  the  status  results  may  have  reached  other  the critical  items.  None  level  o f the other  for this items  and p o s s i b l y  approached  significance. Disease A of  site.  Kruskal-Wallis test  t h e HCPS s c o r e s ,  GI/GU,  Gyn/Breast,  was d o n e  comparing  corrected for ties, Skin  and other  t h e ranks  of subjects  cancers.  with  The r e s u l t ,  with  a probability  o f p_ < . 0 5 5 , <H = 7 . 5 8 ; d f = 3 ) , w a s  that  subjects with  Skin  choose  revealed  or other  The  of  number  overall  scores  o f treatments  or adiuvant prior  t o item  mode o f t r e a t m e n t  who  test.  N  2  analysis  already  received at the  t o be r e l a t e d  d i dn o t a f f e c t  radiotherapy more  one-half  surgery  overall  way, i t w a s a f a c t o r  (new d i a g n o s t i c t e 3 t  the rest  to either  treatment.  surgery  wanted  Only  had had p r i o r  intervention;  with  o r t o any o f i t s items.  16 s u b j e c t s f o r whom  upcoming  those  differences.  i n any s i g n i f i c a n t  responses  than  likely to  treatments.  HCPS s c o r e  Although  more  The item-by-item  o f i n t e r v i e w d i d n o t seem  Primary  All  cancers.  no s i g n i f i c a n t  Number  the  were  the information intervention  Gyn/Breast,  time  cancers  = 4 0 ) = 1 3 . 9 , p_ < . 0 0 1 .  62  i n the  immediately).  was t h e p r i m a r y  information about t h e (12/24)  opted  chose  HCPS  o f those  subjects  for the information  the support  option.  X2 ( l ,  Section  4  - HCPS S c o r e s  The Inventory treatment. a  and  subjects  completed  2-5  after  days  Overall,  the  XII  33.13 and  and  XIII,  mean S t a t e not  32.86 the  and  Table  XII  State  Scores  they  State-Trait  had  the  begun  scores  Trait  As  scores;  were and  shown  s u b j e c t s had however,  the  Mean  Overall  40  33.13  10.99  Women  21  34.05  11.77  Men  19  32.11  of  Trait ages,  includes For  S-Anxiety,  10.34) and as  with  the  central mean  age  range  quartiles  scores  i n Table men  in  of  scores  Tables higher  difference  was  XII,  having  norms  of  (SD  50  the are  = 8.67).  men's and  63  f o r both  adults  from  f o r men  the  Dev  9.97  f o r working  f o r women 3 2 . 2 0  indicated  reversed  scores  including 2  Std  (1983) p r o v i d e s  anxiety  the  Out  Trait  slightly  N  and  low.  significant.  Group  Spielberger  Anxiety  radiotherapy  mean S t a t e  respectively.  female  statistically  Scores  the  anxiety  p o s s i b l e 20-80 p o i n t s ,  were  STAI  lower  to  State  at  a  69  which  study  variety  sample.  34.51  (SD  In  this  = study,  women's s c o r e s  and  women t h e  are  higher  Table  XIII  Trait  Scores  Group  N  Mean  Std  Overall  40  32.35  8.69  Women  21  32.86  8.97  Men  19  31.79  8.33  mean s c o r e . scores 31.79 and  for (SD  For men  =  of  33.86  7.78).  surgical low  41.33;  also  SD  If  =  the  threatening  as  the  theorized  (1977)  and  scores  higher  those  of  to  the  threat  others,  for  deviations general  women  of  is  men's  reversed.  medical  and  psychiatric complications 42.68;  SD  than  previous much  and  =  treatment  13.76,  in  Trait:  is a by  principal  Spielberger would  have  the  norms  for  this  study  studies. more  like  of  cancer  i n d i c a t e s and  one  f i n d i n g s of  STAI  =  and  mean  r e l a t i o n s h i p between  for  literature  anxiety  the  M  diagnosis  of  Thus,  no  reports  M  =  12.55).  perception as  norms  with  (State:  the  8.86)  standard  cites  patients 40's  and  Spielberger  (SD. =  Again,  women's s c o r e s  Spielberger  the  T-Anxiety,  Dev  The  cause  are  i f  of  (1966),  expected  the  State Lazarus  State  anxiety  the  age  group  are  not  consistent  subjects  have  neutrally stressed  64  as  involved. with  responded working  adults  than  like  patients  anxiety-provoking explanations  illness.  for  the  Spielberger's in  mean  scores  anxiety; only in  the  total  If  the  study might  somewhat  of  sample  the  case,  a  or  Another least  subjects  found  less  treatments.  of  with  or  may the  generally  anxiety.  up  of  raise  the  for  result  of  anxious  or  holds  that  considers older  one  quarter  mean  test  of  shows  anxiety that  treatments  i t i s number  Some p o s s i b i l i t i e s  65  number  have  of of  treatment.  f a c t o r , perhaps the  STAI,  scores are  at  c o r r e l a t i o n s were  whether  anxiety  is the  true  of  any  sample.  and  administration  In  either  anxiety  no  is  no  Trait  versus  the  quarter  score.  between  this  no  subjects  youngest  their  however,  are  possibility  a n t i c i p a t i o n and  some o t h e r  lowering  Trait  i s that  because  decline  the  the  correlation age  and  This  correlation  and  treatment  be  and  possible  steady  he  almost  score.  to  a  State  subjects  tendency  rank  State This  treatments  ted  the  Unfortunately,  between  It  mean  anxiety  the  are  started.  show  possible explanation  partly  several  i s maintained,  significant  Trait  both  making  the  Spearman's  are  data  oldest  trend  by  for  population  statistically State  age  sample,  offset  life-threatening  discrepancy.  the  lower  a  There  normative  with  however,  69.  with  and  had  associa-  the  effect  reported  discussed  in Section  5.  Correlations Spielberger higher  r =  between  .47.  those  nature  State  of r =  of Spielberger  and T r a i t  Spearman's  may  and State rank  scores  anxiety  anxiety  scores  ponding  to a significance level  give  correlation anxiety  tive/support  scores  a correlation  lower He  scores  true  The  i n this  study  findings physical  of  cancer.  scores. between t h e and t h e S t a t e  o f p_ <  .001.  subjects  This  very  with  higher  and p r e f e r r e d  affec-  intervention to the provision of  anxiety  (1983)  o f r = -.49 c o r r e s -  h a d l o w HCPS s c o r e s  was a l s o  be  Trait  the study's  f o r ties)  indicates that  The r e v e r s e State  (corrected  will  population.  c o r r e l a t i o n s done  HCPS  lower  and  by t h e d i a g n o s i s  overall  tion.  there  be due t o t h e more  implied  scales  .65 f o r t h e s e v e n  The d i f f e r e n c e between  HCPS s c o r e s  State  anxiety  h i s normative  State  of the threat  strong  that  danger s i t u a t i o n s .  correlation  which comprise  correlation  and  1972) r e p o r t s  i n physical  a median  samples  and T-Anxiety  i n s o c i a l - e v a l u a t i v e s i t u a t i o n s and  correlations  is  (1966,  S-Anxiety  c o r r e l a t i o n s between  anxiety  cites  between  i n that  preferred  the  informa-  subjects  with  information  intervention. In items  order  to get a better  contributed  grasp  of exactly  to the correlation,  square  t e s t s was d o n e .  thirds  corresponding  The sample  t o low, m i d d l e  66  which  a series of c h i -  was d i v i d e d and high  into  State  anxiety the  scores.  groups  cognitive/affective  Significant  results  a  very  4  (radiotherapy  (State to  These  close  score  only  their  split  between  icant  a s X2  (side  effects  group  chose  evenly  i n 2 days)  feelings.  while  The middle  2  p_ <  information  to  affective  option  o r was s p l i t  HCPS  scores  and T r a i t  Correlations  When t h e T r a i t  between  scores scores  thirds  were were  group  between  67  anxiety group  was  intermediate  immediately) had a anxiety  group  overwhelming  either  chose t h e  t h e two  options.  HCPS S c o r e s a n d t h e  not significant t o group  and c h i - s q u a r e  6  scores.  t h e summed  used  evenly  ( 2 , N = 40) = 8.65,  The lower  anxiety  talk  F o r item  an  i t e m s by an  anxiety  >  i s signif-  anxiety  occupied  .06.  on a l l t h r e e  the higher  Anxiety  the high  a s X2  b y a n 11  was a l m o s t  .002.  group  score  pattern  (new d i a g n o s t i c t e s t  ( 2 , N = 4 0 ) = 5 . 8 7 , p_ <  approximate  option  12 c h o s e  This  group  Item  Trait  F o r item  o f r a d i a t i o n ) a l l 12 o f t h e l o w  information  while  2.  (State  group  ( 2 , N = 40) = 12.66,  p_ <  margin  while  t h e two o p t i o n s .  i s significant  chose  group  The m i d d l e  item.  t h e low a n x i e t y  anxiety  This  2  f o r item  In the high  information  against  f o r i t e m s 4 and 6 and  result  position.  X  HCPS  the information  split.  .02.  tested  < 26) c h o s e  4 chose  about  then  f o r each  achieved  to significant  1 ratio.  33),  choice  were  starts  were  teats  (r =  -0.20).  t h e sample done  into  f o r the  individual  items,  no s i g n i f i c a n t  r e l a t i o n s h i p s were  found. Section  5  - Other  Findings  Introduction• In to  addition to the information  the study  researcher  questions,  with  other,  the subjects anecdotal,  comments  began  recorded  by t h e r e s e a r c h e r .  the  subjects'  first  t o present  comments  h a s t o do w i t h  towards second other  taking  section  used  in this  problems  comments  are collected  comments  represented. available topic.  o n how  these  ideas  were  i n four  parts.  The  The  the questionnaire part  of  spoke  about  their  and  four  section.  of this  68  these  from  not a l l subjects are information i s  commented  on a  given  i t i s p o s s i b l e t o rank  further.  this  information,  numerical  topics.  and  statements  section are derived  subjects  time,  study.  information-seeking  and t h e r e f o r e  many  on r e l a t e d  they  these  and d i s c u s s i o n o f  The t h i r d  own  i n part  absolute  A t t h e same  comments pursue  No  about  i n gathering  findings i n this  voluntary  patterns,  o r any o t h e r  of the subjects  physical  The  As  of the subjects'  and t h e i r  Many  information.  the attitude of the subjects  i s an e x a m i n a t i o n  behaviours.  the  A summary  i n the study.  information  i n response  presented  i s presented  c o n s i s t s o f comments forms  about  part  regular  gathered  Subsequent  studies  order may  Attitudes If from  there  this  eager  subiects.  i s any o v e r a l l  group  of cancer  to talk.  eagerness to  of  patients  v o l u n t e e r comments  to talk  about  F o r many  subjects,  experiences  during the diagnostic  reasons reason about wanted  illness.  their  illness.  t o have  who  The they  one-half Vancouver knew  were  their  biasing  they  with  o f a dilemma  bored  and were  locally  or unwilling  a s an  patients.  from  i n local  t o engage  69  more they  during opportun-  person.  i t was  responses, the  questions.  reason  and were  The  that  Where  f o rparticipation  and had p l e n t y o f time.  staying  common  f o r the researcher  the instrument  common  their  to learn  a knowledgeable  similar  their  phases  i n the study.  had r e c e i v e d  the patients'  most  and  first  and treatment  s u b j e c t s remarked  o f t h e s u b j e c t s were  few p e o p l e  unable  with  answered  second  was t h e i r  a n d saw t h e s t u d y  somewhat  without  researcher  that  period  i s a clinician  possible  These  discussions  presented  with  themselves  was t h e d e s i r e  information than  ity This  given  were  comprehensively  to participate  commonly  diagnostic  they  The s u b j e c t s v o l u n t e e r e d t h r e e  most  the  about  a t and examine  f o r wanting  more  impressed  this  t o look  their  gathered  t h e q u e s t i o n n a i r e s and  opportunity  of  t o be  i t i s that  T h e r e s e a r c h e r was  and w i l l i n g n e s s  experiences.  impression  areas  More  i n many  than  outside of  accommodation.  either  was  They  physically  activities  outside  of  their  treatments.  as  an o p p o r t u n i t y The  ion  third  was t h a t  what  saw p a r t i c i p a t i o n  to socialize  most  common  they  welcomed  had happened  t o them.  Comments The  amount  ( 1 9 8 5 ) who  constantly beginning trying  o f time  through  for participatto talk  about  took  longer  than t h e  according  work  t o complete the  alone)  i t took  t o t h e 7 items their  own  experiences.  t o Dodd  them  forty  because  seemed  and medical  that  they  a preference care  they  t o be  the hypothetical situations  a n d t o come up w i t h  to  p r e - d i a g n o s i s and They  the actual experiences  the nursing  cited  an o p p o r t u n i t y  situations,  t a l k e d about treatment  distraction.  (20 m i n u t e s  t o respond  t o compare  HCPS w i t h  reason  of the subjects  I n many  minutes  and as a  i n the study  the questionnaires.  had s u b j e c t s  instrument. sixty  about  majority  expected  on  They  that  they  on t h e  had gone  f o r care had  based  actually  received. The complete  subjects t h e STAI.  feeling-oriented describe their  divorce.  an even  F o r many  items  themselves  lives  previous  took  and t o t a l k  The o p p o r t u n i t y  o f time  an o p p o r t u n i t y about  illness,  illnesses  period  death  to talk  to  the changes i n of a  spouse,  o r s u r g e r i e s , changes  70  to  of the subjects, the  provided  i.e., their  major  longer  i n jobs,  out anxiety-related  feelings low  as  they  mean S t a t e Comments None o f  given  too  than  anxiety about  the  much  information  occurred  health to  to  they  individuals  as  feelings.  choose  think  their  own  them  had  or,  were  their more  not  ever  of  (according and  to  not  who  had  had  major  previous  surgeries  commented  that  information-seeking  a  cognitive/  their because their  subjects), of  staff  managing  illnesses  (coronary  bypass,  they  the  as  information,  how  convey  to  seek  i t to.  distress  information  These  and  hospitalization  a  question perhaps  that  to  they  get  about have  same  had of  i t from,  reported  This  or  done  value  strong  situation.  should  design.  who  and  had  the  subjects  anxiety  i n every  association that  study  i t out,  used  they  illness  from  original  of  often  serious  previous  or  more  capable  their  marked  with  Men  the  learned  for  overwhelmed  o v e r t l y express  reported  of  been  intervention  subjects  levels  they  accurately,  These  to  the  had  choice  previously.  who  that  workers.  affective  "senile"  surgeries)  patterns  or  care  did  did  undergone  cardiac  to  affairs.  Subjects who  the  I f they  might  volunteered  explain  preference  failure  contributed  information.  information  women t r i e d  have  scores.  subjects  from  information  may  very  and low  preferences was prior  been  such  a  illness  part  of  the  Comments  about  information  Some o f t h e i n t e r e s t ion  may  be a s s o c i a t e d  older  subjects.  often  had t r o u b l e  discovered they or  well.  print  o n t h e HCPS  Some o f t h e e l d e r l y  subjects  personnel  because  of hearing  subjects print,  reported  they  really  they  had s i g n e d .  care  personnel  of these  t o them  that,  because  could They  their  because they  think  given.  that  they  Neither were  both  reading  the  that  of the size  inability. both  they or something  vein,  forms  some  oral  that  the health  Clearly,  some  and  deficits.  In  a reluctance  to  or f o r clarification  of  n o r women w a n t e d  o l d and n o t capable  72  and  of the  the consent  reported  men  the  instruct-  medical  of sensory  f o r additional information  a t home  questionnaires  when  with  that  weren't  reluctant to tell  had d i f f i c u l t y  deficits,  aids  In a s i m i l a r  not read  were  glasses  and e x p l a i n e d  difficulties.  communications  information to  talked  they  remarked  reported  understanding  and expose  the subjects  written  ask  had t o read  that  researcher  had d i f f i c u l t y  t o them.  nursing  spite  hearing  aloud  had d i f f i c u l t y  The  reading  and t h e STAI  of the  reported  of the subjects "good"  sometimes  and t h e items  often  of  their  informat-  deficits  or hearing.  The s u b j e c t s  researcher  ions  the sensory  the batteries i n their  working small  many  problems.  f o r more  of the subjects  reading  when  had f o r g o t t e n  that  the  this  and d e s i r e  with  Many  and s e n s o r y  people  o f managing  their  own  affairs.  reluctance  t o pursue  unfamiliarity  with  information.  Often  navigating identify  Another  through  reason  correct  f o r some  information  h o s p i t a l sources subjects  appropriate  was  their  and c h a n n e l s o f  had g r e a t  the treatment  subjects'  difficulty  system  and c o u l d n o t  and a c c e s s i b l e sources  of  information. Summary In terms  this  chapter,  o f age, sex, m a r i t a l  ethnicity, disease nature  occupation,  site, of  a  difference  ual  levels,  performance  status,  treatments,  sample  and  may  pre-surgical  examined  When p r e s e n t e d ,  health  There  were  o n t h e HCPS,  workers, the  preferred the  significant  differences  to different  be a c c o u n t e d  f o r by t h e v a r i a t i o n i n  presented  For instance. patient.  the affective  i n the text  Item  option.  a t the treatment  73  HCPS  items.  of the  1 describes  The m a j o r i t y  with  and r e c e i v i n g a  care  overwhelmingly  item-by-item  of responses  situation  recommended  were  receiving information  option.  items.  chose  score.  in this  the pattern  clinical  educational  region,  i n t e r v e n t i o n from  information in  home  t o t h e HCPS  between  supportive subjects  status,  described i n  treatment.  a s a summed  choice  has been  number o f r a d i o t h e r a p y  Responses and  t h e sample  an  The  individ-  anxious  of the subjects  When r a d i o t h e r a p y of choice  i n Item  i s 3, 3 8 o u t  of  40 o f t h e s u b j e c t s  iation and  was f o u n d  HCPS  only  preference  for  information  demographic  and  nature  the  preference  Subjects  for  information  followed  were  origin  on Item  f a r more  scores  diagnosis  entirely  regardless of Ethnicity  t o be p r e d i c t i v e o f  on i s o l a t e d  items.  2 subjects  treatment  option for  whom  preferred  f o r whom  radiotherapy  were  lower  State  with  and treatment.  anxiety  likely  than  threatening Several  expected  lower  items  radiotherapy  higher  State  correlation  scores  to prefer  <p_ < . 0 0 1 ) .  individual  the literature  the potentially  negative  who s c o r e d  were  than  nature  explanations  scores  b u t none  satisfactory.  significant  Subjects  tion  below, t h e  subjects.  On I t e m  those  o f f e r e d f o r t h e lower  those  item  preferred t h e support  1.  than  considering  cancer  STAI  assoc-  surgery.  suggests  between  found  was t h e p r i m a r y  Anxiety  A  was c o n s t a n t ,  information  of British  information  is  No  validity  identified  d i f f e r e n c e s between  o f treatment  radiotherapy  are  the concurrent  two e x c e p t i o n s ,  the  of  between  information.  scores.  With  over  preferred  a n d t h e summed  on t h e S t a t e  anxiety  scores  o f t h e HCPS. 4 ) a n d when  74  Just  identified HCPS  score.  scale of the  the supportive  option  preferred  T h e same r e l a t i o n s h i p  (Item  was  held  prior  while informa-  f o r two  t o commencing  l e a r n i n g about t h e  side-effects anxiety more  of radiotherapy  score  (p_ <  group  .02)  than  (Item  6 ) , t h e lower  State  preferred information  significantly  d i d those  anxiety  with  higher  scores. In  the process  administering collected reported  of conducting  the study  a number  instruments,  of incidental  s e v e r a l reasons  including;  seeking  more  information  boredom,  and f i n d i n g  out  feelings  about  process. brought of  format.  Many  and  o f the items  about  slowed many  them to  their  of these  other  understand serious access  feelings.  for  themselves,  and  was  illnesses  about  which  forms  said  made  their by t h e  own  experiences process  but  provided  i t difficult for  and, i n other or properly  situations,  hear  Subjects  and  with  better able  and t o f i n d  75  content  Some o f t h e s u b j e c t s  o r s u r g e r i e s were  and use i n f o r m a t i o n  talk  the  about  talking-out  t o them.  to  instruments  about  their  study  treatment  prompted  findings.  the instruments  what  were  This  deficits  hospital  one  of the instruments  incidental  sensory  to read  read  to talk  the completion  revealed  i n the  and a n o t h e r  of the subjects  subjects  part  the diagnosis  items  The  an o p p o r t u n i t y  s o r t s o f comments;  t h e HCPS a n d S T A I  and  researcher  The a d m i n i s t r a t i o n o f t h e s t u d y o u t two  content  the  findings.  f o r taking  relieving their  interviews  previous to  appropriate  sources ience  for  had  information.  more  difficulty  Subjects in  76  without  that  exper-  information-seeking.  CHAPTER SUMMARY,  CONCLUSIONS,  This  study  preferences for  among  the f i r s t  measure  was  IMPLICATIONS,  designed  cancer  time.  of anxiety  were  An o v e r v i e w  this  followed  nursing  practice  AND  RECOMMENDATIONS  to describe  health  patients receiving  Several  preference. chapter  5  demographic  examined  effect  on  i s presented  by c o n c l u s i o n s ,  and recommendations  radiotherapy  v a r i a b l e s and a  f o r their  o f the study  care  in  i m p l i c a t i o n sf o r f o r research.  Summary A cope  review  with  indicates support There ions  the diagnosis that  a r e among  cancer  their  radiotherapy  demographic  Data  patients  who  were  coping kinds  disease emotional  strategies. of interventprior  o r on t h e e f f e c t  Agency  study  was  i n Vancouver,  the Health  collected  from  Care  Anxiety 40  to or  of anxiety  on  were  used  of relationships  77  undertaken B.C.  using  a  Preference Inventory  radiotherapy  the established criteria.  measures  direction  of their  as helpful  and t h e S t a t e - T r a i t  met  patients  and s e e k i n g  on what  exploratory  questionnaire,  [STAI].  and  Control  [HCPS],  statistical  common  cancer  f o ri n t e r v e n t i o n s .  descriptive  the Cancer  Survey  t h e most  literature  preference This  and treatment  patients perceive  their  o n how  information-seeking  i s little  during  at  of the literature  t o determine between  Nonparametric the extent  t h e summed  and  item-by-item  HCPS s c o r e s ,  the  of  measures The  sex,  study  site,  and  almost  age  range  the  sample  was  home r e g i o n ,  schooling ethnic  described  levels  with  German,  French  median  and  Vancouver  a  and  over  disease  8  of  to  and  the  20  <24)  of  those  who  were  The  of  of rest  who  came f r o m  35  included Subjects the  clerical  the  single  the  and  approximately  came f r o m  those  formal  backgrounds.  numbers  They  The  largest  20  an  of  study.  The  background.  sample  women w i t h  years  British,  European  The  one-half  years.  was  smaller  and  status,  men  age,  ethnicity,  p r o f e s s i o n a l s , members o f  workers.  area,  12  to  treatments.  time  from  of  other  and  between  the  sample  homemakers, trades  Just  at  indicated  agricultural divided  yrs.  ranged  i n the  who  included skilled  a  performance  d i v i d e d between  married  according  levels,  radiotherapy  36-79  was  group  subjects  of  equally  educational  evenly  Greater the  interior  of  province. Karnofsky with  were  than  the  able  living.  and  sample  from  variables  anxiety.  number  was  90  demographic  marital status, educational  occupation,  the  the  median  at  to  cope  with  Most  of  cancer they  performance  had  of  the  the  80  of  the  m o r e common  0  ranged  indicating  most  lung  received  scores  that  disease  found  to  radiotherapy  78  the  among  of  sites the  70  and  subjects  activities  were 5  between  daily  other  subjects  treatments  each was  (median  3).  the primary  prior  form  Survey  questionnaire. short  Each  i s asked  o r she would  intervention.  interventions  significantly strength .  The  intervention ion.  In item  radiotherapy In  this  chose  over  case,  Two  examined  and on an  items  were  a pre-surgical  3, t h e p a t i e n t i s t h e optimum the subjects  informa-  found  t o be  interven-  situation i n oranxious.  the affective/support  treatment  intervent-  advised  that  f o rh i s condition.  overwhelmingly  79  (mean  as regards the  as r e s t l e s s  has been  option.  from  item-by-  preferred  the cognitive/information  the information  situation,  f o r the information  i s described  face  and t h e  i n that  the others  (23 o f 40) c h o s e over  might  affective interventions  d i f f e r e n t from  1 presents  of a  o r an a f f e c t i v e  overwhelmingly  4.98 o u t o f 7 ) .  the patient  subjects  whether,  t o t h e HCPS w e r e  of the preference Item  choice  process  overall scores  Subjects  Care  o f t h e HCPS c o n s i s t s  a cognitive  Responses  tion  which  had had  f o r health  forced  and treatment  prefer  basis.  score  item  7-item  to indicate  item  summed  preferences  of a situation a patient  perspectives—as  tion  the rest  was c o l l e c t e d o n t h e H e a l t h  the diagnosis  subject  patient  [HCPS]--a  description  during  two  about  interventions  Preference  he  o f treatment;  radiotherapy  surgery. Information  care  F o r 16 o f t h e s u b j e c t s ,  (38 o u t o f 40)  Preference tion  appeared  demographic with  a  only  with  for  to  the  be  independent  variables.  preference  for  respect  to  described  themselves  preferred  affective  before other  upcoming  intervention  adjuvant  preferred strongly  the  more  prior  than  the  associated  Patients  but  who  descent  item  l--anxious  than  those  with  whom r a d i a t i o n was the  new  those  surgery.  of  intervention  strongly for  interven-  majority  British  preferred  information  information  diagnostic  f o r whom  Also  on  the  test  radiation  item  i n t e r v e n t i o n much  2,  was  men  more  women.  of  other  manual  as  measured  lower  than  studies Both  and  State  the  other  scores  of  The  anxiety as  well,  means f o r  Trait  the  anxiety,  favourably  with  in  on  and  were  80  for  are  data  in  presented  medical,  often mid  Trait  considering  indicate that  to  33.13  respectively. those  State  patients  normative  the  study  the  expected  studies  scores, are  by  i n which  psychiatric patients  anxiety  and  being  2--strange  situations.  and  means f o r  compare  of  were  surgical  State  as  Inventory  STAI  80.  items.  scores  results  the  selected  anxiety  stressful in  the than  The Anxiety  to  information  Patients  item  immediately—much an  the  treatment  on  the  Some v a r i a b l e s w e r e  surgery--more  mode o f  of  i n t e r v e n t i o n s on  backgrounds.  primary  cognitive/information  the  Trait  low  40's  and  These  healthy,  the  out  32.86 scores  unstressed  for  working  adults  totally  satisfactory  known  (State  although  State  scores  anxiety  items.  are  and  and  scores with  have  overall  found  they  preferred affective  from  health  The  scores  for  scores  a  and  over  personnel  between  support,  preference  holds  particularly  prior  to  on  lower  found  No  scores  and  is  State  between  f o r the  side  scores  that i s ,  interventions  with  information  the  individual  anxiety  those  State  between  several State  while  and  between  information  high  and  32.83).  HCPS s c o r e s ,  strongly for  radiotherapy  =  f o r the  high  p r e f e r r e d the  relationship  preference  low  M  HCPS s c o r e s  subjects  care  Trait  offered.  overall  were  anxiety  to  33.35,  a s s o c i a t i o n s were  score  Those  =  explanation  several  Significant anxiety  M  lower  intervention .  anxiety lower  score  State  and  a  anxiety  information  intervention  items  6  4  effects  and of  (just  radiotherapy,  respectively). Incidental researcher  when  data  collection.  that  they  order  to  had  easily.  the  because They  subjects  The  wanted  information  support  the  l e a r n more  Some o f the  f i n d i n g s were  stated  of  the  participate  about  elderly  they  volunteered  majority to  items  collected  their men  did that  not  i f they  81  than  express  comments  i n the  reported  the  subjects  disease  more o f t e n  by  and  that those their  expressed  during  reported  study  in  treatments. they  chose  describing feelings or  asked  for  support.,  health  "senile"  and i n c a p a b l e  Many  of the elderly  which  made  task.  reading  Often,  could  p r o f e s s i o n a l s might  workers  with  these  the elderly  they  considered affairs. for  reported  subjects  oral  because  deficits  that  of hearing were  could  accessible  of  an  stated  problems.  and they  reported  not read.  but could  sources  own  them  affairs. deficits  impossible that from  they health  Most  subjects  r e l u c t a n t t o acknowledge  of the patients  information  think  sensory  communications  They  " o l d " and n o t capable Many  their  the questionnaires  ask f o r a s s i s t a n c e  forms  of handling  subjects  not understand  care  and  care  signing  consent  d i d n o t want  of handling  expressed  not identify  them  their  a strong  t o be own need  appropriate  and  information.  Conclusions The  following  of  t h e study  1.  Patients  tions  tion  prefer  With  situations.  on t h e b a s i s  affective  Clinical  interven-  circumstance to affect  and t h e  the  preference.  a few e x c e p t i o n s ,  interventions  the preference  for  informa-  i s not r e l a t e d t o demographic  variables.  Some d e m o g r a p h i c  significant  predictors of desired  specific  be drawn  c o g n i t i v e over  o f t h e i n t e r v e n t i o n s appear  intervention 2.  may  results:  i n most  timing  conclusions  situations.  Just  or treatment  prior  82  variables are  interventions i n t o surgery  subjects  with  British  tion  more  often  Confronted patients  than  with  with  treatment than  backgrounds  chose  those  with  backgrounds.  a new d i a g n o s t i c t e s t  immediately,  more  as their  likely  who  had had p r i o r  situation,  men  tended  more  than  3.  Anxiety  preferred  4.  Given  about 5. or  P a t i e n t s who  on i t e m s  their  F o r any r e s e a r c h may  larger  faces  instrument  the cognitive option  had high  need  State  anxiety  scores  cognitive interventions  cancer  and  with  p a t i e n t s want  to talk  feelings.  an e l d e r l y  have sensory  may  type  I n t h e same  4 a n d 6.  experiences  one which  options  to the preference f o r  r a t h e r than  an o p p o r t u n i t y ,  instruments  be  i s related  affective  especially  information  surgery.  t o choose  mode o f  women.  level  intervention.  primary  to select  those  often  interven-  other  radiotherapy  were  the affective  patient population  deficits,  t o be m o d i f i e d  and t h e e f f e c t  standard  with,  f o r instance,  of alternate  administration (i.e.  reading  methods o f  aloud)  needs t o  evaluated.  Implications 1. care  Cancer  f o r Nursing  p a t i e n t s vary  interventions.  Practice i n their  Nurses  cannot  preference assume  preference  f o r information or support  assessment  will  diagnosis  and  remain  constant  treatment.  83  that  noted  through  f o r health a  i n one  a l l stages of  2.  Nurses  need  physiology  and treatments  effectively ences 3.  t o be k n o w l e d g e a b l e  intervene  f o r cognitive  In a s s e s s i n g  that  readiness high  patient safety  teaching  need  be  t o read  able may  have  ability  and  even  5.  Patients  oral  just  from  they  meet.  may  prefer  than  should  may  can prefer-  Patients  supportive  who  first  have  nursing  ones.  necessary  should  recognize  influence  informational  efforts  other  When  f o r patient b e made t o  t o understand  offered  when  signing  deficits patient  patients  which  may n o t  consents.  may  education  hinder materials  communication. indicated that but from  Nurses  should  t o them  want  teaching  that  care  their  team  they  not  professional  role  as  members  providing  information  f o r patients.  particularly  radiotherapy  as a treatment  84  information  health  recognize  indicated that a t the time  they  every  and comprehensive  Patients  deficits in  elderly  print  sensory  a multidisciplinary  information  f o r sensory  F o r example,  the small  nurses  consistent 6.  nurses  of anxiety  t o assess  patients.  of  needs,  i s absolutely  elderly  their  they  anxiety.  Nurses  They  before  the patients'  f o r learning.  rather  or comfort,  reduce 4.  level  levels  interventions  and s a t i s f y  the patho-  interventions.  and needs  anxiety  f o r cancer  learning  the patient's  about  modality.  was  wanted first  In the timing  of  patient, education  that  patient's  perhaps  desire  be h i g h  7.  As c a n c e r  and  experiences  nurses talk  need  with  patients with  t o plan  ate  variables  on  want  a knowledgeable f o r and p r o v i d e  overall  2.  sample  tended  tended  t o have  worker, to  interventions Further  were  than  those  studies  intervention.  choice,  specificity  might  significance. i n  and  option  professional  HCPS s c o r e s  while  indicating a preference f o r  likely  with  other  site—subjects  t o choose disease  t o pursue  cognitive sites.  the findings  i n relation to preference f o r  An e x p a n d e d  situations  demographic  the affective  overall  a r e needed  situation specificity  to investig-  status--patients  (c) Disease  more  be c a r r i e d o u t  approached  scores,  cancers  forced  concerns care  i n order  between  higher  with  clinical  may  opportunities  <b) O c c u p a t i o n — m a n a g e r i a l  interventions.  of  size  to prefer  affective  2.  their  health  should  <a) p e r f o r m a n c e  homemakers had l o w e r  skin  study  relationships  condition  subjects  aware  Study  a n d t h e HCPS w h i c h  include:  Item  to learn  to discuss  f o r Further  the several  poorer  t o be  patients.  a larger  These  need  time.  A replication of this  using  nurses  and m o t i v a t i o n  at that  Recommendations 1.  programs,  instrument,  and a L i k e r t better  test  of the preference  85  scale  including instead  the strength  more  of the and the  f o r intervention.  3.  Since  the  diagnosis  in  the  patient  research  are  most  of  to  process  effective  call  may  those  interventions  through  be  variable  a  critical  interventions,  identify  stages  at  different  and  intervention  educators  nursing  treatment  i s needed  treatment  what  and  of  acceptance  and  hensive  timing  which  the  relative  programs the  which  teachable  86  of  the  moment.  diagnosis  interventions  success take  further  of  compre-  advantage  of  BIBLIOGRAPHY A b d e l l a h , F. & L e v i n e , E. ( 1 9 6 5 ) . B e t t e r t h r o u g h n u r s i n g r e s e a r c h . New York: P u b l i s h i n g Company.  patient care Macmillan  A b r a m s , R. D. ( 1 9 6 6 ) . 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T e a c h i n g t h e c a n c e r p a t i e n t a n d f a m i l y how t o c o p e w i t h t h e d i a g n o s i s a n d chemotherapy. I n M. D o n o v a n ( E d . ) , C a n c e r c a r e : A g u i d e f o r p a t i e n t e d u c a t i o n ( p p . 1 2 3 - 1 3 6 ) . New York: Appleton-Century-Crofts. W i l s o n , H., & K n e i s e l , C. ( 1 9 7 9 ) . M e n l o P a r k , CA: A d d i s o n - W e s l e y  Psychiatric nursing. P u b l i s h i n g Company.  W o r d e n , J . & W e i s m a n , A. ( 1 9 8 0 ) . Do c a n c e r p a t i e n t s r e a l l y want c o u n s e l l i n g ? General Hospital P s y c h i a t r y . 2, 1 0 0 - 1 0 3 . Yasko, J . (1982). Care o f t h e p a t i e n t radiation therapy. Nursing C l i n i c s 1 7 ( 4 ) , 631-648.  receiving o f North America,  Y a t e s , J . , C h a l m e r , B., & M c K e g n e y , P. (1980). E v a l u a t i o n o f p a t i e n t s with advanced cancer u s i n g the K a r n o f s k y P e r f o r m a n c e S t a t u s S c a l e . C a n c e r , 45, 22202224.  96  APPENDIX Demographic  A  Questionnaire and  Background  Information  97  Demographic 1.  Subject  Code  No.  4.  Marital  Status  6.  Physician  7.  Medical  8.  Medications  9.  Cancer  Diagnoses  2.  Age  5.  E t h n i c Group  other  patient  i s  Questionnaire  than  3.  cancer  taking  Diagnosis  10.  Purpose  11.  Anatomical  12.  R a d i a t i o n Therapy  dosage  13.  Radiation therapy  i s : Primary  14.  Date  15.  Performance  of  of  Radiotherapy site  of  90-100 70-89  50-69  30-49 10-29 0  - Curative  radiation  Palliative  therapy  Adjunctive to  surgery  Interview status  at (  Grade  Sex  time use  of  interview with  grade  investigator  )  Scale F u l l y a c t i v e , a b l e t o c a r r y on a l l p r e d i s e a s e performance without restriction Restricted i n physically strenuous a c t i v i t y but a m b u l a t o r y and a b l e t o c a r r y o u t work o f a l i g h t and s e d e n t a r y n a t u r e , e.g. l i g h t housework o r o f f i c e work a m b u l a t o r y and c a p a b l e o f a l l s e l f - c a r e b u t u n a b l e t o c a r r y o u t any work a c t i v i t i e s . Up a n d a b o u t m o r e t h a n 50% o f waking h o u r s . C a p a b l e o f o n l y l i m i t e d s e l f c a r e , c o n f i n e d t o bed o r c h a i r more t h a n 50% o f w a k i n g h o u r s Completely disabled. C a n n o t c a r r y on any self care. T o t a l l y c o n f i n e d t o bed o r c h a i r . Dead  98  Code Background What  i s your  Please  circle  educational  occupation?  t h e number  below  that  describes  your  experience.  Elementary High  School  School  Vocational or  Information  Junior  1 2 3 4 5 6 7 8 9  10  11  12  13  School College  College Graduate or Professional  school  1 2  3  4  1 2  3  4  1 2  3  4  5  Note I t e m s 2 t h r o u g h 4 a n d 6 t h r o u g h 13 o n t h e p r e v i o u s page w i l l be c o m p l e t e d u s i n g t h e p a t i e n t ' s m e d i c a l r e c o r d . Items 5 a n d 15 w i l l b e a s k e d d i r e c t l y o f t h e p a t i e n t . A t no t i m e i s t h e p r e v i o u s page s e e n by t h e S u b j e c t .  99  APPENDIX Health  Care  B  Preference  Survey  and Concurrent  Validity  100  Question  Health  Care  Preference  \  Survey  The f o l l o w i n g i t e m s d e s c r i b e s i t u a t i o n s a p e r s o n might encounter while receiving health care treatment. For each s t o r y b e l o w , d e c i d e w h i c h o n e o f t h e two p o s s i b l e r e s p o n s e s w o u l d be c l o s e s t t o what you w o u l d do i f you were i n t h i s situation. Because these are e n t i r e l y p e r s o n a l p r e f e r e n c e s , t h e r e a r e NO " r i g h t " o r " w r o n g " answers. P l e a s e c i r c l e an answer f o r e a c h q u e s t i o n . Even i f you w o u l d p r e f e r a n o t h e r s o l u t i o n , p l e a s e c h o o s e t h e r e s p o n s e (A o r B) w h i c h m o s t c l o s e l y r e s e m b l e s w h a t y o u w o u l d choose yourself. Your answers a r e c o m p l e t e l y c o n f i d e n t i a l and will be u s e d f o r r e s e a r c h p u r p o s e s o n l y . Thank you f o r your assistance.  <1> You a r e i n t h e h o s p i t a l and s c h e d u l e d f o r s u r g e r y . The e v e n i n g b e f o r e s u r g e r y you f i n d y o u r s e l f f e e l i n g restless and p a c i n g t h e f l o o r . W h i c h do y o u t h i n k w o u l d be more h e l p f u l t o you: A. B.  To  have  a  nurse  come a n d  reassure  To v i e w a s l i d e - t a p e e x p l a i n i n g s u r g e r y w i l l be like?  you? what  the  day  of  <2> While you a r e s t i l l i n t h e h o s p i t a l your d o c t o r s t o p s b y t o t e l l y o u t h a t t h e r e ' s a new d i a g n o s t i c t e s t t h a t h e w a n t s y o u t o u n d e r g o . He h a d a r r a n g e d f o r y o u t o h a v e t h e t e s t done i m m e d i a t e l y . Y o u d o n ' t know w h a t i t w i l l b e like e x c e p t t h a t i t i n v o l v e s s o m e new k i n d o f m a c h i n e s a n d t a k e s about h a l f a day t o c o m p l e t e . Which o f t h e f o l l o w i n g two c h o i c e s w o u l d b e m o s t l i k e l y t o make y o u f e e l m o r e comfortable about undergoing the t e s t : A.  B.  H a v i n g a n u r s e accompany you t o t h e e x a m i n a t i o n when u n d e r g o i n g t h e t e s t , e x p l a i n e x a c t l y w h a t p r o c e d u r e w i l l be l i k e , and t h e n l e a v e . Having a nurse stay with the whole procedure?  you  and  comfort  you  the  during  <3> Y o u r d o c t o r h a s j u s t a d v i s e d y o u t h a t r a d i a t i o n t h e r a p y i s the b e s t form of treatment. F o r many p e o p l e t h i s i s a n upsetting time. Which o f t h e s e 2 r e s p o n s e s i s most like what you w o u l d do? A.  I would want feeling.  to  talk  B.  I would want t o f i n d t r e a t m e n t s w o u l d be  with  someone  about  what  out i n f o r m a t i o n about like.  101  I  what  was  the  (4) Y o u r d o c t o r has i n f o r m e d you t h a t y o u r s e r i e s o f r a d i a t i o n t r e a t m e n t s w i l l b e g i n i n two d a y s . You a r e t o r e p o r t t o t h e r a d i a t i o n t h e r a p y d e p a r t m e n t one hour e a r l y meet w i t h t h e n u r s e . Which n u r s e would you p r e f e r ? p r e f e r t o meet w i t h concerns or fears.  Nurse  A  to  discuss  to  A.  I would cares,  my  B.  I w o u l d p r e f e r t o meet w i t h N u r s e B t o t o u r t h e r a d i a t i o n u n i t and s e e what t h e p r o c e s s i n v o l v e s .  (5) You a r e a b o u t t o r e c e i v e y o u r f i r s t t r e a t m e n t . T h e r e are two t e c h n i c i a n s on t h e u n i t . You w i l l k e e p t h e same t e c h n i c i a n f o r your e n t i r e course of r a d i a t i o n therapy. Which t e c h n i c i a n would you p r e f e r t o g i v e y o u r t r e a t m e n t ? A.  T e c h n i c i a n A g r e e t s you warmly, e n c o u r a g e s you t o t a l k a b o u t any w o r r i e s you have, a s s u r e s you t h a t h e / s h e w i l l be r i g h t o u t s i d e t h e d o o r , and t h a t he/she can t a l k w i t h you t h r o u g h t h e i n t e r c o m s h o u l d you need him/her.  B.  T e c h n i c i a n B c a r e f u l l y e x p l a i n s how y o u w i l l need t o l i e on t h e t a b l e , where t h e m a c h i n e w i l l be p l a c e d what s o u n d s you w i l l h e a r , and t h a t h e / s h e w i l l answer any q u e s t i o n s you have.  <6) You h a v e b e e n w o r r y i n g a l o t l a t e l y . One o f t h e t h i n g s on y o u r mind has been t h e s t o r i e s y o u ' v e h e a r d a b o u t t h e side effects of radiation therapy. The n u r s e c a n h e l p i n s e v e r a l ways. W h i c h do you t h i n k w o u l d be more h e l p f u l f o r you? A.  The n u r s e c a n g i v e you p a m p h l e t s t h a t e x p l a i n t h e s i d e e f f e c t s o f r a d i a t i o n , a n d what y o u c a n do t o m i n i m i z e them.  B.  The n u r s e can t e a c h y o u r e l a x when y o u  you are  a technique worried.  that  can  help  (7) You h a v e s e n s e d t h a t t h e r e i s s o m e t h i n g m i s s i n g i n t h e d i s c u s s i o n s you have had w i t h y o u r f a m i l y a b o u t y o u r treatments. Would y o u r f a m i l y b e n e f i t more f r o m learning: A.  More  B.  How  details to  about  communicate  how more  102  the  treatments  openly?  work?  Concurrent In or  general,  nurse  helpful would A.  to  the  were  type  in addition  you I  as  i f you  Validity  to  given  of  your  care  Question a  choice  you  medical  would  C.  I  your  find  treatment,  doctor  most which  ONE  choose?  would  want  to  get  more  information  i l l n e s s o r my t r e a t m e n t , about t o me a n d w h a t I s h o u l d e x p e c t B.  by  would with when  want t o h a v e more s o m e o n e a b o u t how I get blue or sad  about  my  what's happening t o happen.  opportunity to talk I'm feeling, especially or angry.  I w o u l d w a n t t o know m o r e a b o u t w h a t I c a n do f o r m y s e l f s o t h a t I c a n r e l a x more e a s i l y , t a k e c a r e o f my m i n d a n d b o d y . D.  None  of  these.  E.  Something  different:  103  (please  explain)  and  APPENDIX Letter  of  C  Introduction  104  Letter  of  Introduction  Hello: My graduate part  name  student  o f my  ask  time  preferences  If  minutes. after Your and  confidential.  thesis The  this  about  we  will  to  kind  of  radiotherapy.  f o rhealth  be a b l e  which  study, will  care  t o make  I will  take  ask  about  to questions  15  y o u may  the questionnaires.  to the questionnaires a r e no i d e n t i f y i n g will  will  will  purposes.  105  only  be  names  be p o o l e d .  see the questionnaires  study  what  your  are useful  and t h e i n f o r m a t i o n  from  like  and u s e f u l .  completed  will  selected  f o r the  I would  regarding  i n future,  There  supervisors  results  Clinic.  be a v a i l a b l e t o r e s p o n d  responses  questionnaires  name h a s b e e n  to participate i n this  you have  I am  are receiving  i s to learn  two q u e s t i o n n a i r e s  I will  As  study.  meaningful  you agree  and a  Columbia.  thesis,  Your  Evans  f o r information  more  t o complete  a r e g i s t e r e d nurse  receiving radiotherapy  o f the study  so that,  who  time.  you see as necessary  explanations  have  patients  of patients  purpose  professionals  you  with  a t t h e A. M a x w e l l  information  I am  Master's  y o u t o p a r t i c i p a t e i n my The  Your  f o r my  f o rthe f i r s t  t h e group  first  work  a study  radiotherapy  Salton.  at the University of British  course  conducting  from  i s Chris  be used  anonymous on t h e Only  my  themselves. f o rscholarly  Your to  participation  participate  i s entirely  voluntary.  o r your  refusal  will  present  or future care  at this  facility.  respond  t o any q u e s t i o n  participation There  very  when  planning If  consent you.  Thank  my  study.  which  you have time  Y o u may  withdraw  your  refuse to  from  o r b e n e f i t s t o you f o r The i n f o r m a t i o n  care  explanations  letter  convenient  risks  to health  you d e c i d e  After  thank  in this  helpful  affect  consent  time.  a r e n o known  participating be  a t any  a n d y o u may  i n n o way  Your  to participate, summarizes  please  yourself. read  the information  i t we  can arrange  f o r you and I t o complete  you f o r t a k i n g  may  professionals i n the future  to patients like  signed  you p r o v i d e  t h e time  I have  given  mutually  the questionnaires.  t o read  you f o r c o n s i d e r i n g t h e p o s s i b i l i t y  a  the attached  this  letter  and  of participating i n  study.  Chris Master  Salton of Science  106  i n Nursing  Student  APPENDIX Patient  D  Information  107  Sheet  PATIENT The  i n v e s t i g a t o r ' s study  interventions  among  for  time.  the f i r s t If  will I  INFORMATION  I agree  patients  SHEET  examines who  preferences f o r  are receiving  to participate the following  meet t h e i n v e s t i g a t o r a t a m u t u a l l y  will  complete  minutes  each.  regarding  my  record.  some  questionnaires  medical  also  will  obtained  from  happen:  from  the  anonymous and c o n f i d e n t i a l .  I  t i m e and  take  obtain  h i s t o r y and treatment  A l linformation  will  convenient  which  The i n v e s t i g a t o r w i l l  radiotherapy  about  15  information my  medical  questionnaires  will  be kept  The r e s u l t s  will  used  f o r s c h o l a r l y p u b l i c a t i o n s and t h e i n v e s t i g a t o r ' s  be  thesis. I from  understand  participating  completing clinic  provide  relevant  receive  this  study  answered. further  a r e no r i s k s  study.  help  I  spend  not interfere  treatment.  will  o r b e n e f i t s t o me  The t i m e  will  information  with  I t i s hoped  health  to future  care cancer  my  that the  professionals patients  who  radiotherapy. that  a t any time  care  o r my  the study  understand  withdraw future  in this  appointments from  I  there  the questionnaire  results  will  that  my  participation  and t h i s  a t t h e A. M a x w e l l with I may  will Evans  not affect Clinic.  t h e i n v e s t i g a t o r a n d my contact  Ms.  Salton  questions.  108  i s voluntary.  at  my  I  present  I have  questions  or  discussed  have  i f I  may  been  have  

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