OPTIMISM, COPING, AND PSYCHOLOGICAL WELL-BEING
AHONG PEOPLE WITH ADVANCED LUNG CANCER
by
Lynn A. Coulter
Submitted in partial fulfillment of the requirements
for the degree of Haster of Nursing
Dalhousie University
Halifax, Nova Scotia
A u ~ u s ~ , 1999
Copyright by Lynn A. Coulter, 1999
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TABLE OF CONTENTS
TABLE OF C O N T E N T S w . w w w w . w w e w w w m w m w . w . e w w . w w w . . . a m . e w e w w
LIST OF TABLES..*.. ............................a.......
LIST OF FIGURES...w.w.ee ..............m................
ABSTRACTwwwmmw.... .......................m.............
ACKNOWLEDGEMENTS. .........*.........................m..
CHAPTER 1: Introduction.. .............................. ........................................... P u ~ ~ o s ~
Literature Review m............................... ........ Psychological Response to Lung Cancer
...................................... Coping
................... Coping and Personality ... Optimism ....................m...............
......................... Optimism and Coping
.................... Psychological Well-being
................. Influence of Other Variables
Gender ...............e.................. Age ....................................
Sumary ...e....................................... Theoretical Framework ............................ Research Questions ................................ Definitions ......................................
CHAPTER II: Hethodology ................................ Study Design. .m................................... Setting.. .........................................
iv
viii
X
xi
xii
1
2
2
3
11
13
18
20
26
40
40
42
46
4 7
53
53
55
55
55
Sample ......................................... 55
Sample Characteristics ........................ 56
.................... Demographic Variables 56
Illness and Treatment Characteristics. ... 59
Procedure for Data collection...^........^....^.... 62
Instruments ........................................ 63
..................... Demographic Questionnaire 63
................ Revised tife Orientation Test. 64
Validity .......................O........ 65 .............................. Reliability 67
Ways of Coping Questionnaire .................. 68
Validity ................................. 72 Reliability.. ........................... 74
..................... Profile of Hood States... 75
Validity ................................. 76
.............................. Reliability 77
Data Analysis ................................ . 78
............................. Ethical Considerations 80
......................... Protection of Rights. 80
Risks and Benefits ............................ 81
................................... CHAPTER III: Findings 82
................... Interna1 Consistency Reliability 82
Revised Life Orientation Test ................. 82
Ways of Coping Ouestionnaire ... ..........m...m 83
........................ Profile of Mood States 84
Data Analysis ................................... 87
............................. Coping Strategies
The Relationship Between Dispositional
Optimism and Coping Strategies ...............O The Relationship between Age. Gender. Coping
Strategies. Dispositional Optimism and
...................... Psychological Well-Being
CHAPTER IV: Discussion .................................. .................................. Coping Strategies
The Relationship Between ~ispositionaï Optimism
.............................. and Coping Strategies
The Relationship between Age. Gender. Coping
Strategies. Dispositional Optimism and
........................... Psychological Well-Being
CHAPTER V: Summary. Limitations and Implications ........ Summary ............................................ Limitations ........................................ Implications for Nursing Practice and Education ....
......................... Implications for Research.
............................ Implications for Theory
Conclusions.... .................................... APPENDICES
Appendix A (Letter of Introduction) ................ Appendix B (Introduction by Clinic Staff) .........
............................. Appendix C (Consent)..
Appendix D (Demographic Questionnaire) ............. ........................ Appendix E (Disease Data)..
Appendix F (IMT-R) ................................. 162
Appendix G ( W O C Q ) w ~ w ~ ~ w ~ ~ ~ w ~ ~ ~ ~ w w m w ~ ~ ~ ~ ~ ~ w ~ ~ w w ~ ~ w ~ m 164
Appendix H (POMS) ..........................m....... 170 Referen~es..........~.... ............................... 171
vii
LIST OF TABLES
Table
Demographic Characteristics of Study Participants . 58
. . . . . . . Illness and Treatment Characteristics 61
Cronbachrs Alpha for the Ways of Coping Subscales . 84
Cronbach's Alpha for the Profile of Hood States
Total Mood Disturbance Scale and Hood State
Subscales . . . . . . . . . . . . . . . . . . 8 5
categories of Stressots selected by People with Advanced or Inoperable Lung Cancer . . . . . O . . 88
Degree of Stress Experienced by People with
. . . . . . . . . Advanced or Inoperable Lung Cancer 89
Means, Standard Deviation, Range of Scores and
. . . . . Relative Scores for Ways of Coping Scales 90
Pearsonrs Product-Homent Correlation Coefficients
for Degree of Stress and Age w i t h L!!e Coping
S c a l e ~ . . . . . . . . ~ . . . . . . . . . . ~ ~ . . 9 2
Analysis of Variance for Mean Coping Scores and the
Type of Stressor Subgroups . . . . . . . . . m . . e 94
Total Mood Disturbance and Hood State Hean Scores,
Standard Deviation, Actual Range of Scores and
the Possible Range of Scores . . m . . . , . . . . . 98
viii
Table . Stepwise Multiple Regression of Age, Gender,
Optimism, Stressors, Degree of Stress and Seven
Coping Strategies with Total Mood Disturbance Score 100
Stepwise Multiple Regression of Age, Gender,
~ptimism, Stressors, Degree of Stress and Seven Coping
Strategies with Tension-Anxiety Mood State Score . 101
Stepwise Multiple Regression of Age, Gender,
Optimism, Stressors, Degree of Stress and Seven Coping
Strategies with Fatigue-Inertia Hood State Score . 102
~tepwise Multiple Regression of Age, Gender,
Optimism, Stressors, Degree of Stress and Seven
Coping Strategies with Depression-Dejection Mood State
S c o r e , . . . . . . . . . . . . . . . . . . . . 1 0 3
Stepwise Multiple Regression of Age, Gender,
optimism, Stressors, Degree of Stress and Seven Coping
Strategies with Anger-Hostility Mood State Score . 104
Stepwise Multiple Regression of Age, Gender,
Optimism, Stressors, Degree of Stress and Seven Coping
Strategies with Confusion-Bewilderment Mood State . 105
Stepwise Multiple Regression of Age, Gender,
Optimism, Stressors, Degree of Stress and Seven Coping
Strategies with Vigor-Activity Mood State . . . . 106
LIST OF FIGURES
Figure 1. Relationships of variables of interest in the
Lazarus and Folkman Framework . . . . . . . . . . . . . . 52
ABSTRACT
A descriptive multiple correlational design was used to examine the relationships between dispositional optimism, coping strategies, age, gender, and psychological well-being of people with advanced or inoperable primary lung cancer. The theoretical framework guiding this research was Lazarus and Folkman's theory of s t r e s s , appraisal and coping.
A convenience sample of 44 males and 20 females diagnosed within the previous year participated: the majority were Caucasian and married. Data was collected in an interview format during a clinic visit. Three questionnaires were administered; the Revised Life Orientation Test (dispositional optimism), the Ways of Coping Questionnaire (coping) and Profile of Hood States (psychological well-being). In completing the Ways of Coping Questionnaire participants indicated their greatest stressor and rated their degree of stress. Data analysis included descriptive statistics, correlational analysis, t-tests and multiple regression analysis.
Fear and uncertainty about the future was the most frequently identified stressful situation. Overall the degree of stress for most participants was moderate to very stressful. The coping strategy used most frequently was seeking social support; escape avoidance and accepting responsibility were the strategies used the least. Using multiple regression analysis 41 percent of the variance in psychological well-king was explained by the coping strategy escape-avoidance (17%), the degree of stress (12%) optimism (8%) and the coping strategy distancing(4%).
This study expands on previous research that has indicated that the use of optimism and avoidance coping strategies are significant factors in psychological well- being, with people with advanced or inoperable lung cancer. The findings from this study are valuable in determining which patients are at greater risk of psychological distress and as a basis for further research focusing on interventions to manage this life threatening illness.
ACKNOWLEDGEMENTS
I wish to thank the many groups and individuals who
supported and encouraged me in the completion of this
thesis. First to my principal advisor Dr. Barbara Doune-
Wamboldt, who not only provided me w i t h her knowledge and
expertise regarding the research process but who also
encouraged me with her belief in my ability to conduct this
research, thank you. 1 am also very grateful to my committee
members Dr. Lorna Butler and Dr. Katherine Bowen for their
patience, expertise and encouragement.
1 also extend my thanks to the Divisions of Nursing and
Thoracic Surgery of the QEII Health Sciences Centre and to
the Nova Scotia Research Satellite Centre of the NCIC
Sociobehavioural Cancer Research Network for their support.
Without this support the completion of this work would not
have been possible. 1 thank Karen Colwell, Valerie Powell,
and the nurses and physicians of the Nova Scotia Cancer
Centre for their assistance during recruitment and data
collection.
1 wish to express my appreciation to the nursing staff
of 6A for their understanding when my thesis work took me
away from my "real jobm and for their continued support of
my role. 1 am also grateful for the advice and encouragement
that 1 received from so many of my other nursing collegues
and friends. 1 would like to extend a special thank you to
Sandra Matheson and Anna Bates for listening and for sharing
xii
their experience with me.
To ay family and friends who endured, encouraged and
supported me through this seemingly unending endeavour 1 am
forever grateful. Finally and most importantly 1 thank my
daughter Laura for her patience, her understanding, and her
hugs .
xiii
Introduction
It is estimated that in Canada in 1998, over 20,000 new
cases of lung cancer will be diagnosed (National Cancer
Institute of Canada, 1998). Despite improving statistics for
many cancers, lung cancer continues to carry a dismal
prognosis with an overall five year sumival of
approximately 14 percent (Rosenow, 1993). For m a s t types of
lung cancer surgical therapy is the most effective and the
only potentially curative treatment: unfortunately this
option exists for only 20 to 25% of those diagnosed
(Shields, 1993). In most cases the cancer is too far
advanced at the time of diagnoses or other medical problems
render the patient inoperable (Murren & Buzaid, 1993).
Patients who receive this diagnosis are confronted with
a stressor which threatens their life. The negative impact
of lung cancer on psychological well-being has been well
documented (Weisman & Worden, 1976-1977; Benedict, 1989:
Ginsburg, Quint, Ginsburg, L MacKillop, 1995). Despite the
acknowledged distress caused by lung cancer little research
has been completed focusing on the factors influencing this
aspect of the disease and how people with lung cancer cope
with this distress.
A goal of nursing is to help people to cope effectively
2
with a life threatening illness such aslung cancer. There
is a need to determine how people with lung cancer cope,
what methods are used, what strategies are effective for
which patients and in which situations. Coping however is a
very complex and individual process, which despite extensive
research rernains poorly understood (Pearlin, 1991).
Purboçe
The purpose of this study was to examine the
relationships between the personality disposition of
optimism, the coping strategies used, the demographic
characteristics of age and gender and psychological well-
being of people with advanced or inoperable primary lung
cancer.
While the topic of lung cancer has received a great
deal of attention the vast majority of the literature has
focused on disease and treatment; relatively little has been
written regarding the psychological aspects of this illness.
This literature review includes the psychological responses
to lung cancer, an overview of coping, coping in relation to
personality, and more specifically in relation to the
personality disposition of optimism. The outcome of
psychological well-being as related to optimism and coping
strategies and the influence of the demographic variables
age and gender on coping are discussed.
A number of studies have attempted to determine the
individual's psychological response to lung cancer- The
variability and wide variety of reactions to a diagnosis of
lung cancer was demonstrated in a study by Ginsburg, Quint,
Ginsburg, and MacKillop (1995). Zn this descriptive study 52
patients with a new diagnosis (within 5 months) of lung
cancer underwent psychiatric evaluation, The majority of the
sample was male, married, and between 50 and 70 years of
age. Most were skilled or partly skilled workers and had
completed sonte high school education. Al1 were receiving
either radiation or chemotherapy in an ambulatory clinic
setting. Twenty five percent had small ce11 lung cancer and
75% had non-small ce11 lwrg cancer. Each patient was
interviewed by a psychiatrist using a standardized formal
diagnostic instrument based on the Diagnostic and
Statistical Manual of Mental Disorders, 3rd edition (DSM-
III) to assess anxiety, depression, alcohol use and tobacco
use. A less structured interview (but also based on DSM-III
criteria) was completed to determine the presence of an
adjustment disorder. At the time of the interview eight
patients were diagnosed as currently having a psychiatric
illness. While 20 demonstrated calm acceptance and five were
optimistic a wide variety of less positive reactions were
identifie& Most frequently sadness, thoughts of death,
insomnia, and loss of libido were reported, Seven had at
4
least on one occasion suicida1 ideation and seven were
abusing alcohol.
Benedict (1989) studied the incidence of suffering
associated with lung cancer. Suffering was defined as "a
negative affective state resulting from an event or
situation that is perceived to be physically painful,
uncornfortable, or psychologically distressingm. In this
descriptive study 30 patients (26 male and 4 female) were
interviewed. Both the incidence of suffering and the
physical, psychological, and interactional aspects of the
disease which were associated with suffering were reported,
Fifty percent of the sample reported Wery muchm suffering.
The greatest suffering was associated with disability, pain,
anxiety, changed activities, and weakness/fatigue, While 50
percent of the sample reported employment problems only 20
percent reported this to be a cause of suffering. The type
of lung cancer was not included as a variable but those with
and without metastatic disease were compared. No difference
was found in relation to the physical and interactional
aspects but those with metastatic disease reported
significantly more suffering related to the psychological
aspects, No significant differences were found in relation
to the type of treatment the patient had received,
Weisman and Worden (1976-1977) studied the emotional
distress of 120 patients with newly diagnosed cancer. Of
this sample 23, al1 white males, had a diagnosis of lung
5
cancer. In the lung cancer sample the mean age vas 58 years,
the majority (65%) were married. A11 patients were
interviewed by a social worker using open ended questions
following a recommended sequence. In addition to gathering
demographic and illness data the interview included areas of
stress and concerns; the interviewer classified coping
responses according to a list of coping behaviours and
indicated how the situation was resolved. The interviewer
also rated the patient on a four point scale with respect to
emotional and psychological distress called an Index of
Vulnerability scale. The patients also completed Profile of
Mood States, Minnesota Piultiphasic Personality Inventory and
a Thematic Apperception test. Initial interviews were
carried out near the time of diagnosis (within 10 days) and
again at four to s i x week intervals over a 3 month period.
In this study the patients with lung cancer were found to be
the most distressed. The results also indicated that for the
patients with lung cancer, vulnerability and mood
disturbance steadily increased during the first 100 days
following diagnosis. Generally it was found that patients
with high emotional distress were more pessimistic, had a
tendency to give up and expected little support.
This study highlighted the need to consider people with
different sites of cancer separately. The subsample of
patients with lung cancer is quite small and al1 male. The
question of variability among patients with lung cancer and
6
the factors influencing that variability is not addressed by
this study.
In addition to investigating the psychological response
to lung cancer attempts have been made to determine what
factors influence psychological adjustment. Cella et al.
(1987) studied the relationships among performance status,
extent of disease and psychological distress in 455 patients
with small ce11 lung cancer entered into one of three
clinical trials. Treatment was not considered to be a
variable as study data were collected prior to the
initiation of any treatment. This sample vas mostly male
( 7 0 % ) , married ( 7 5 % ) , and had at least a high school
education (82%). The mean age of the group vas 58.6 years.
Performance status was rated on a five level scale ranging
from no impairment (O) to bedridden (4). Psychological
distress was measured using the Profile of Hood States
(POMS); this inventory measures six mood or affective states
and also provides a reflection of total mood disturbance.
Age, gender, marital status and education were also
included. Of the study variables performance status and
gender showed a significant relationship with the total mood
disturbance score. Women and those with poorer performance
status had higher mood disturbance scores. The extent of the
disease became significant when performance status scores
were low. The researchers explain the gender difference
stating that healthy women also tend to repart greater mood
distress than healthy males.
Hopwood and Stephens (1995) assessed and compared
symptoms of 232 patients with small ce11 lung cancer (SCLC)
and a sample of 423 patients with non-small ce11 lung cancer
(NSCLC). In addition to differences in ce11 type the groups
also differed in terms of performance status with al1 the
non-small ce11 group having a good performance status and
over half of the small ce11 group having poor status. The
groups were similar in terms of age and gender, with a
median age of 65 years for the SCLC group and 66 years for
NSCLC. Sixty three percent of the SCLC group were male
compared to 79% of the NSCLC group. The symptoms were
assessed using the Rotterdam Symptom Checklist which was
described as measure of quality of life consisting of 30
symptoms in a number of domains including physical,
psychological and sexual. Symptoms were similar for the two
groups with the eight commonest being worry, anxious
feeling, tiredness, lack of energy, lack of appetite,
difficulty sleeping, shortness of breath, and cough. The
symptoms ranked as most severe were decreased sexual
interest, lack of energy and shortness of breath. As would
be expected the number of symptoms reported was greater with
worsening performance status. In the non-small ce11 group
females reported more psychological symptonrs than did the
males. Interestingly this difference was not found in the
small ce11 cancer group. Whether or not gender difference
8
disappears as performance status decreases is unknom.
Klemm (1994) using a descriptive correlational design
studied psychological adjustment in lung cancer in relation
to three variables; daily hassles, illness demands, and
social support in a sample of 60 patients with advanced
(stage 3 and 4) lung cancer. A convenience sample of 171
potential subjects were contacted by phone, 112 agreed to
participate, of the 112, 56 returned usable questionnaires.
In this sample the majority were white ( 8 3 . 9 % ) , male
( 6 2 . 5 % ) , and married (75%). The mean age was 60.3 years.
Demands of illness was measured using the Demands of Illness
Inventory which is a 125 item questionnaire with seven
subscales (physical symptoms, persona1 meaning of illness,
family functioning, social relationships, self-image,
monitoring symptoms, and treatment issues). Adjustment was
measured using the Patient Adjustment to Illness Scale - Self Report (PAIS-SR). This instrument also has seven
domains (healthcare orientation, vocational environment,
domestic environment, sexual relationships, extended family
relations, social environment, and psychological distress).
Overall subjects in this study had high social support, low
hassles, and moderately low demands of illness. The author
found of the variables only the demands of illness ta be
predictive of psychosocial adjustment. Race was also found
to be predictive of adjustment however the researcher
hypothesized that economic status which was not included as
9
a variable may better explain this relationship. The low
response rate in this study is not discussed; the
possibility that those who did not participate had too many
demands of illness and daily hassles to have time was not
explored.
Berckman and Austin (1993) investigated the
relationships among casual attribution, perceived control
and adjustment to lung cancer. The 61 subjects (41 male and
20 female) in this sample ranged in age from 36 to 80 years
with a mean of 60 years. Most were married, unemployed,
disabled or retired, and had less than high school
completion. The mean time since diagnosis was 23 months. A
combination of a structured interview with opened ended
questions and questionnaires were used. In relation to
casual attribution subjects were asked what they thought had
caused their cancer and what they thought causes cancer and
general. In addition they completed a questionnaire rating
the importance of 30 interna1 and external causal beliefs
and four items related to identifying responsibility for the
cause of the cancer. Perceived control was assessed by one
open ended question and 17 scaled items. Subjects were asked
to list al1 the ways in which they had control over the
course of their cancer, to rate the extent to which they
could control the course of their cancer and its recurrence,
and to rate the importance of 16 different ways of
perceiving control. Adjustment was measured using the
10
Psychosocial Adjustment to Illness scale.
Interestingly it was found that most patients indicated
that they thought that they were adjusting very well to
their illness. A significant relationship between perceived
control and adjustment was not found, however both internal
and external causal attributions were related to poor
adjustment. Those who attributed internal causation for
their cancer had low adjustment scores in terms of their
domestic and social environments and high psychological
distress. Those who attributed their cancer to external
causes also had low adjustment scores in their domestic
environment and high psychological distress but did have
better scores for sema1 adjustment,
The factors predicting psychological distress in
relation to a diagnosis of lung cancer have also been
studied in other cultures. Akechi, Kugaya, Okamura,
Nishiwaki, Yamawaki and Uchitomi (1998) studied the
influence of coping, social support, and demographic
variables on distress among 87 Japanese ambulatory lung
cancer patients. This sample consisted of 61 males and 26
fernales, The mean age was 62.4 years and most w e r e married.
Al1 types and stages of primary lung cancer were included.
Coping was measured using the Japanese version of the Mental
Adjustment to Cancer (HM) scale. This is a 40 item self-
rating scale consisting of 5 subscales which are the coping
styles. The utilization of confidants was the measure of
11
social support. Psychological distress was measured by the
Profile of Mood States (POnS). Multiple regression analysis
produced a mode1 explaining 52 percent of the variance in
the total mood disturbance score. The variables predicting
greater distress were female gender, living alone, no
children in the role of confidant, nurses as confidants and
helplessness/hopelessness as a coping style. The authors of
this study suggested that the finding thst having nurses as
confidants was a predictor of greater distress may have
simply indicated that those who were more distressed sought
support f rom nurses.
It is evident from the literature that lung cancer is
xesponsible for a great deal of psychological as well as
physical distress. Disease related variables such as type of
lung cancer, functional status, and extent of the disease
are important in terms of both physical and psychological
distress but do not provide a complete explanation of why
this distress is greater or less for some individuals. The
literature suggests that it is very likely the outcome of
many factors. The role coping plays in determining and
modifying the physical and psychological response to lung
cancer was considered in only one study in the literature
reviewed . CoPina
Coping has been defined by Lazarus and Folkman (1984)
as "constantly changing cognitive and behavioral efforts to
12
manage specific external and/or interna1 demands that are
appraised as taxing or exceeding the resources of the
personn ( p.141). This definition of coping or paraphrasing
of this definition is the most frequently cited in coping
literature in general (Latack & Havlovic, 1992) and in
nursing literature (Jalowiec, 1993)- A similar definition,
"coping is what one does about a perceived problem in order
to bring about relief, reward, quiescence, or equilibriumH,
was previously provided by Weisman and Worden (1976-1977).
This conceptualization of coping differs from the
traditional psychoanalytic view and from the commanly held
meaning of the word. Coping as part of this traditional
mode1 was viewed as superior to defense- Strategies in
response to stressful situations are considered inherently
good or bad and are not judged on outcome (Lazanis &
Folkman, 1984)-
In common usage the word coping is frequently used to
refer to outcome. For example to Say he or she "is coping"
usually implies that that person is managing the stressor at
least reasonably well. Both in the traditional models and in
common usage the term coping is positive, meaning the person
is managing or adapting well.
Coping according to Lazarus and Folkman (1984) is part
of the process that occurs in response to a stressful
situation. Not al1 coping will be effective in achieving the
desired outcome and not al1 situations are amenable to
13
change for the better. Strategies in and of themselves are
neither good or bad and can be judged only in t e m s of
effectiveness in producinq the desired outcome or at least a
tolerable one
Coping is influenced by a vast array of persona1 and
situational factors. The influence of personality, and
demographic variables are examined in relation to coping
strategies and outcome in the following sections.
C Q D ~ U m d P e t ; c o n u
Somerfield and Curbow (1992) in a review of
methodological and research issues in the study of coping
with cancer, conclude that personality variables may be
implicated in coping with cancer and may help predict the
use and effectiveness of various coping strategies-
While Lazarus and Folkman (1984) argue in favour of a
situational process approach to coping it is important to
note that they do not deny the importance of coping traits.
Lazarus (1993a) describes trait and process as two sides of
the same coin with both sides usually being relevant.
Lazarus (1993b), notes that some strategies such as thinking
positively tend to be stable across situations and depend on
personality.
Bolger (1990) studied the personality disposition of
neuroticism (defined as a broad dimension of personality
characterized by autonomie nervous system lability and a
tendency to experience negative emotions) in relation to
14
coping and outcomes of both psychological distress and
performance. The sample consisted of 50 (24 male and 26
female) college students taking the Medical College
Admissions Test (MCAT). The average age for the sample was
20.3 years. Measures included a 24 item neuroticism scale
from the Eysenck Personality Inventory, coping was measured
using the Ways of Coping scale and anxiety using a daily
diary containing three items from the Profile of Mood
States. Grade point averages (GPA) and the HCAT scores were
also obtained. Neuroticism was measured at time one, five
weeks prior to the exam, GPAs were also obtained at this
point along w i t h coping methods. Coping methods were again
assessed at time two which was 10 days prior to the exam and
also at time three, 17 days after the exam. Anxiety was
measured daily from 17 days prior to the exam until 17 days
following the exam. Controlling for preexisting anxiety
differences, neuroticism was associated with increases in
anxiety under stress. This difference was found to be
mediated by the greater use of the coping mode of wishful
thinking and self-blame. No difference in performance (exam
score) was found to be related to personality or coping
differences.
The complexity of personality in the understanding of
coping is evident in Bolger and Zuckerman (1995) proposed
framework for considering the different possible roles of
personality in the stress/coping process. Personality is
15
considered to have four possible influences on coping. No
affect, affects only coping choice, affects only coping
effectiveness or affects both. This framew~rk was used in a
study of 94 students. The personality trait studied was
neuroticism and the stressor was interpersonal conflicts.
In this study a relationship was found between the
personality trait and particular choice of coping
strategies. The high-neuroticism group engaged in more
planful problem solving, self-controlling, seeking social
support, and escape-avoidance strategies. The coping
strategies used were also related to different outcomes
based on the personality trait. For example with the high
neuroticism group the use of self-control coping in response
to conflicts resulted in greater depression the following
day. The reverse was true for the low-neuroticism group. In
this case it would appear that personality affects both
choice and effectiveness of the coping strategy. The
subjects of this study were college students and one would
assume generally healthy. However there have been a number
of studies supporting the concept of coping styles in the
cancer literature.
Monitoring and blunting styles were studied by Leman
et al (1990) among a convenience sample of 48 patient
receiving chemotherapy. In this quasi experimental study
patients were randomly assigned to either a treatment group
which received relaxation training or to a control group.
16
Coping style was measured using the Miller Behavioral Style
Scale, There was not a significant difference in the number
of subjects with each coping style between the experimental
or control group. While a num.ber of cancer tumor sites were
included the majority had either breast cancer (38%) or
lymphoma ( 2 5 % ) , 67 percent of the sample was female. As
expected, monitoring which is characterized by increased
vigilance under stress was associated with higher self-
reported anxiety and nausea, Blunting which is characterized
by distraction strategies was associated with less anxiety,
depression and nausea. Blunters in the experimental group
experienced significantly less anticipatory anxiety than
those in the control group, indicating that the relaxation
intervention did have an effect for this coping style, This
was not found among those with a monitoring style.
These coping dispositions were also considered in
relation to women at increased risk for ovarian cancer
(Schwartz, Leman, Miller, Daly & Hasny, 1995). In this
study of 103 women with at least one first degree relative
with ovarian cancer, monitoring was predictive of increased
perception of risk and of more intrusive thoughts.
Monitoring was indirectly related to psychological distress.
Three styles emerged in a qualitative study examining
patients adaption to cancer treatment (chemotherapy or
radiotherapy) (Lev, 1992). Forty-seven patients (21 male and
26 female) ranging in age from 19 to 87 years with a variety
17
different cancer diagnoses participated in the study. Two
these styles, npreparersn and nsuppressorn were telated
decreased emotional distress. The third, navoidersn, was
associated with increased emotional arousal.
Coping effectiveness in terms of adaptational outcomes
such as psychological and physical well-being is an
important consideration for nursing. It is evident that
certain strategies at least for certain individuals in
certain circumstances have better outcomes. The particular
characteristic of the individual, the situation and hou it
is appraised, and the coping strategies selected will al1
influence the outcome.
No research-has been completed that examines the
relationships of personality characteristics, coping
strategies and psychological well-being in people with lung
cancer. Studies involving people with cancer of a variety of
other types indicates that a relationship between optimism,
selection of coping strategies, and less psychological
distress znay exist. Research in the area of personality,
specifically the personality trait of optimism, is needed to
add to the understanding of different responses to lung
cancer. These relationships are expanded upon in the
following sections.
18
Ootimisw
Optimism, in the common usage of the word, is closely
linked to the concept of h o p and to possessing positive
attitude. A positive attitude, h o p and optimism have also
been linked in a role believed to foster healing and in cure
(Seigel, 1986; Cousins, 1991)- While these authors do not
disregard the value of medical care they believe that the
power of the mind exceeds that which is possible through
modern medicine.
Bruckbauer and Ward (1993) studied the public's
perception of a positive mental attitude ( P m ) and health
beliefs. In this sample of 167 mostly white and middle class
subjects the majority (71 percent) included themes of hope
and optimism in their meaning of Pm. The authots defined
optimism as a positive attitude about the present and hope
was referred to as a positive future orientation- In this
study PMA was believed to influence the prevention of
illness in general but not the prevention of cancer.
However the majority did believe that PMA influenced the
recovery from cancer.
Optimism was defined by the Merriam-Webster dictionary
(1989) as "an inclination to anticipate the best possible
outcome of action or eventm and hope "to desire with
expectation of fulfilmentn contrary to Bruckbauer and WardOs
definition both imply future orientation.
Hope and optimism have been considered related but not
19
identical concepts (Stubblefield, 1995). Lazarus (1991)
differentiates hope and optimism based on the degree of
confidence regarding outcome. When there is confidence that
things will work out positiveiy it is optimism not h o p
which is experienced. Scheier and C a r v e r (1985) provide a
similar view that optimism is not the h o p for a desirable
event but the expectation of its occurrence. It seem that
confidence in outcome is significant in differentiating the
two concepts. We know that we can h o p for anything but this
does not mean we are necessarily optimistic about the
outcome.
Scheier and Carver (1985, 1992) used the term
dispositional optimism to describe individuals who hold
positive expectations for success which are relatively
stable across time and context. Carver and Scheier8s
interest in optimism arose from their study of the process
involved in behavioral self regulation. An assumption
underlying Carver and Scheiergs mode1 of behavioral self
regulation is that expectancies influence action Le. if the
outcome or goal is believed to be attainable efforts will be
continued to achieve the goal no mattsr how difficult,
however if goals are not believed to be attainable then
efforts will stop and the individual will withdraw from the
goal. Therefore behaviour and expectancy are linked. When a
discrepancy exists between the current situation and the
goal, an assessment of the possibility of goal achievement
20
must be made, an optimist having a greater expectation of
success is more likely than a pessimist to view the goal as
attainable and therefore more likely to persist. This
expectation of success is also believed to result in
differences in affect with those who see their goal as being
attainable experiencing a more positive affect.
Carver and Scheier (1992) proposed that the optimist
and the pessimist would experience different outcomes and
that these differences are at least in part related to the
differences in strategies used by optimists and pessimists
to cope with stress.
Dispositional optimism as a general expectancy has been
defined by Scheier and Carver (1992) the tendency to
believe that one will generally experience good vs. bad
outcomes in lifen (p. 202). They developed a measure of this
characteristic called the Life Orientation Test (Scheier &
C a r v e r , 1985).
d Co-
Empirical support for the relationship between optimism
and specific coping strategies has b e n found with a number
of different populations; university students (Carver,
Scheier, & Weintraub, 1989; Scheier, Weintraub, & Carver,
1986; Chang, 1998), first year law students (Segerstrom,
Taylor, Kemeny 6 Fahey, 1998), patients recovering from
coronary artery bypass surgery (Scheier, Hatthews, Owens,
Hagovern, Lefebvre, Abbott & Carver, 1989; King, Rowe,
21
Kimble & Zerwic, 1998), participants in a cardiac
rehabilitation program (Shepperd, Haroto & Pbert, 1996),
people with cancer ( Friedman et al, 1992) and specifically
with breast cancer (Stanton 4 Snider, 1993; Carver et al,
1993). In these studies the method of measuring coping
varied, however the Life Orientation Test vas consistently
the measure of dispositional optimism.
Scheier, Weintraub, and Carver, (1986) carried out two
studies with university students to determine if the coping
strategies of optimists and pessimists differed. The first
study consisted of 181 male and 110 female students. Coping
strategies were assessed using the Ways of Coping Checklist
in relation to the most stressful event the student had
experienced in the previous two months. Through factor
analysis the Ways of Coping Checklist was reduced to seven
factors. Results showed optimism to be significantly
associated with four of the seven factors. Positive
associations were reported with problem focused coping (x =
. 2 2 , p < -01) and positive reinterpretation (x = -26, Q <
-01) when the situation was viewed as controllable and
acceptance/resignation (x = .33, Q < .001) in situations
which uncontrollable. A negative correlation was found with
distancing/denial strategies (r = 9.12, Q e . 0 5 ) . The use of
acceptance/resignation was somewhat unexpected, this is
explained somewhat by the fact that it was only significant
when the situation was felt to be uncontrollable. Another
22
unexpected finding was that seeking out of social support
was only significant among males.
While interesting and for the most part expected
results were produced by this study it should be noted that
the coping strategies used were based on student recall of
an event that occurred up to two months before, In addition
this study provided no indication of the effectiveness of
the strategies . More recently, Chang, (1998a) studied optimism,
appraisals, coping and adjustment among 253 male and 497
female predominantly white, freshmen students. Age range was
15 to 48 years with a mean of 19.7 years, Coping was
measured using the Coping Strategies Inventory (CSI) a 72
item self report inventory similar in format to the Ways of
Coping Checklist. The stressor was the first examination of
ar, introductory psychology course, al1 measures were in the
form of a take home survey given out on the day of the exam
and returned on the next class day. Results of this study
indicated that optimists used significantly more cognitive
restructuring strategies while pessimists used more wishful
thinking, self criticism and social withdrawal strategies in
coping with the examination. Regression analysis,
controlling for differences in sex and appraisal, indicated
that optimism was significant in explaining additional
amounts of the variance in predicting seven of the eight
coping strategies,
23
Segerstrom et al (1998) examined optimism in relation
to mood, coping and immune change in response to the stress
of being a student in first year law, Ninety students age 20
to 37 years (M = 23-9) participated, just over half were
white, most were single. Optimism was measured in the 2
weeks prior to law school orientation and coping, assessed
by the Coping Operations Preference Enquiry (COPE) was
measured at midsemester. In this study dispositional
optimism was significantly associated with the use of less
avoidance coping (r = 0.21, p < . 0 5 ) .
Scheier, et al. (1989) studied dispositional optimism,
coping strategies, physical recovery, mood, and post surgery
quality of life in 51 male patients undergoing coronary
artery bypass. The average age of the subjects was 48.5
years, most were married, employed full time and had high
school or less education. In this longitudinal study
assessment was carried out on three occasions, the day
before surgery, 6 to 8 days postoperatively and 6 months
postoperatively. Coping strategies were assessed prior to
surgery and in the early postoperative period. Unfortunately
coping strategies were not measured using a psychometrically
tested instrument. Pour questions were asked ta assess
coping strategies, 1) hou much thought they had given to
their symptoms, emotions and stay in hospital, 2) the extent
to which they had tried to ignore or not think about these
things, 3) the degree to which they had sought out
24
information relevant ta their operation and recovery, and 4)
the degree to which they had made plans and set goals for
recovery. Prior to surgery optimists were more likely ta be
making plans and setting goals for recovery and
postoperatively to report seeking information about
recovery. Optimists were less likely to report being helped
by not thinking about w h a t recovery would be like. These
results are similar to those previously cited in that
optimists tend to use more problem focused strategies and
fewer avoidance strategies.
King et al., (1998) also studied optimism, coping and
long term recovery following coronary artery surgery but the
participants in this study were 55 women. The mean age of
the participants was older than the males in the preceding
study (H = 62.2) but the samples were similar in terms of
race and martial status. In this study coping was measured
by the Ways of Coping Revised scale and by an interview
constructed specifically for patients having coronary artery
bypass graft surgery. The data collection times were 5 to 6
days p s t surgery, and at 1, 6, and 12 months. Optimism in
this study related to only the coping strategy escapism at
12 months,(r = 0.31, p < . 0 5 ) positive thinking at one week
(r = . 35 , p < .OS)and search for meaning at one month (r = - .29, p < - 0 5 ) .
The effects of optimism and coping have also b e n
studied among people with coronary artery disease (CAD)
25
participating in a cardiac rehabilitation program (Shepperd,
Maroto & P b e r t , 1996). The goal of this study was to
determine the relationship of dispositional optimism to
success at making health changes to lower risk factors
associated with CAD. This was a small study of 18 males and
4 females ranging in age from 40 to 80 years with a mean of
61. Dispositional optirnisi and coping as determined by the
COPE scale were assessed at the beginning of the
rehabilitation program. This study found very high
correlations between optimism and two styles of coping. A
positive correlation was determined between optimism and
problem-focused coping (r = -84, p ~ 0 0 0 1 ) and a negative
correlation with withdrawal strategies (r = 0.80, p <
.0001). Optimism was also associated with success in
lowering a number of the risk factors for CAD.
The relationship of optimism to particular strategies
was also demonstrated in a study of patients with cancer
(Friedman et al, 1992). The sample of 94 patients with
cancer of various sites, were recruited while waiting in
clinic for their follow up visit. The mean age for this
sample was 55 years, most were Caucasian (89%), married
(79%) and had on average 14 years of school. Coping was
measured using the Hoos Coping Scale. This is a 19 item
scale which classifies three methods of coping, active-
behavioral, active-cognitive and avoidance. In this study
the alpha for active-cognitive coping was unacceptably low
26
(.16) and therefore omitted from analysis. In response to
coping with the stress of cancer a positive relationship vas
found between optimism and active behaviour coping (x - 2 2 , p
< . 0 5 ) and a negative relationship with avoidance coping ( x
- , 43 , Q < .001).
The literature reviewed does provide support that there
are differences in the ways that optimist and pessimist cope
and a pattern of more problem focused coping and less
avoidance/withdrawal coping among optimist does emerge, It
is difficult, however to draw firm conclusions because of
the variety of measures used to assess coping. It should
also be noted that the correlations between optimism and the
coping strategies are for the most part quite 10%
vcholoaical Well - Re- A number of different outcomes have been studied in
relation to coping and dispositional optimism. tazarus and
Folkman (1984) identify three basic adaptational outcomes;
functioning in work and social living, morale or life
satisfaction, and somatic health. Morale and psychological
well being are presented as similar if not identical
concepts including dimensions of happiness, satisfaction and
subjective well-being. Morale is described as a background
affective state that is relatively enduring. Dispositional
optimism is also believed to influence the outcomes of
psychological and physical well-being, however an
independent relationship between optimism and physical well-
27
being, at least in terms of symptom reporting has not been
supported (Scheier, Carver & Bridges, 1994). Psychological
well-being is usually measured in terms of mood, affect or
depression scores. The outcome of psychological well being
is the focus of the following review.
Optimism and coping have both been studied in relation
to psychological well-being in a number of different
populations.
Chang (1998b) studied the role of dispositional
optimism as a moderator between perceived stress and
psychological well-being among university students enrolled
in a psychology course. The participants in this study were
predominantly white and ranged in age from 16 to 43 years (m
= 19.9). Perceived stress was measured by the Perceived
Stress scale (PSS) a 14 item self appraisal measure
reflecting the degree of perceived stress in the past month.
Psychological well-being was measured by the Satisfaction
With Life Scale (SWLS), a 5 item measure of global life
satisfaction and the Beck Depression Inventory (BDX), a 21
item self-report measure of depressive symptomatology. Based
on the results of hierarchical regression analyses this
study found that optimism accounted for a small but
significant additional variance over that accounted for by
perceived stress for both outcome measures; for depressive
symptoms, optimism accounted for an additional 3 percent and
for life satisfaction an additional 8 percent. Optimism
28
was also found to have a small but significant moderating
effect between perceived stress and psychological well-king
as measured in this study. Coping was not a variable in this
study . In a similar population, using the same outcome
measures for psychological well-being Chang (1998a),
examined the effect of appraisal and coping along with
dispositional optimism. Again dispositional optimism was
found to add significantly (10 percent of the variance) to
the prediction of psychological well-being beyond the
variance accounted for by appraisal and coping.
Optimism has also been examined in other cultures.
Sumi, (1997), investigated the role of optimism, social
support, and stress on psychological and physical well-king
in 176 Japanese female college students (H age = 18.7
years). The Life Orientation Test (LOT) was the measure of
optimism and psychological well-being was measured by the
depression and anxiety subscales of the Hopkins Symptoms
Checklist. Results of this study indicated that those rating
themselves higher on optimism also reported better well-
being regardless of perceived stress.
Carver and Gaines (1987) studied the role of optimism
and pessimism in postpartum depression. Seventy-five women
in their third trimester completed the LOT measure of
dispositional optimism and the Beck Depression Inventory
(BDI). The BDI was completed again at three weeks
postpartum, Controlling for prenatal depression levels a
significant negative relationship was found for optimism and
postpartum depression. Given that a number of very possibly
significant variables, such as the temperament of the
infant, were not measured or controlled the authors are
cautious in their conclusions.
A study conducted by Lauver and Tak (1995) examined the
relationships among optimism, delay in seeking care for
breast cancer symptoms, anxiety regarding symptoms and
expectations of positive outcomes of care seeking. One
hundred and thirty five women attending a clinic for
evaluation of breast cancer symptoms participated in the
study. Optimism was found to have a significant but indirect
effect on anxiety. This relationship was mediated through
expectations of care seeking (Le. optimism was positively
related to expectations of positive outcomes of seeking
care). optimism scores were also inversely related to delay
in care seeking but when occupational status was controlled
for, the relationship between less delay in seeking care for
breast cancer symptoms and optimism was not significant.
In the previously discussed study of men undergoing
coronary artery bypass surgery (Scheier, et al, 1989)
psychological well-being was measured in terms of
depression, anxiety, and hostility and through a measure of
quality of life. Optimists had significantly louer
presurgical hostility scores but no other difierences were
30
found in relation to mood. It should be noted that optimists
reported being more satisfied with medical care and with the
emotional support they received from friends. Quality of
life at 6 months was reported as significantly higher by
optimists, Unfortunately this variable had not b e n
previously measured, One would expect that quality of life
would also be significantly higher among optimist
preoperatively.
This study did find a positive relationship between
optimism and recovery. Optimists took significantly fewer
days post surgery to resume ambulation and were found to
have normalized their lives in a fewer number of weeks than
pessimists.
In the study by King et al (1998) of women having had
coronary artery surgery psychological well-being was
determined by the Bipolar Profile of Pfood States (POMS-BI)
and the Satisfaction with Life Scale. Optimism was measured
at one week post surgery and the measures of well-being were
completed at 1 week, 1,6 and 12 months post surgery.
Significant positive correlations were found between
optimism and positive mood and life satisfaction at al1
measurement points (r = - 3 4 - .Sb). Significant negative
correlations for negative mood were found at 1 and 12 months
(r = 0.42 and - 3 7 respectively).
A number of significant correlations, most in the low
to moderate range, between the various coping strategies and
31
outcome variables were found. The stronger of these
correlations included negative mood with escapism at 6 and
12 months (r = - 53 and -38 respectively, p < .Cl) and with
avoidance at 1 week (r = -29, p < - 0 5 ) , 1 month (r = .44, p
< -01) and 6 months (r = -39, p < .01) A significant
negative correlation vas also found between escapism and
life satisfaction at 6 months (r = - . 3 7 , p < .01).
The coping strategy search for meaning was negatively
correlated with positive mood at one week (r 0 . 2 7 , p < - 0 5 )
and with life satisfaction at one month (r = 9-31, p < . 0 5 ) ,
It was correlated also with negative mood at one and six
months (r = -41, p < .01).
The relationship of optimism and m o d disturbance among
people living with the life threatening illness of recurrent
ventricular dysrhythmia while awaiting implantation of an
interna1 cardioverter defibrillator has been investigated
(Dunbar, Jenkins, Hawthorne, & Porter, 1996)- Of the 101
participants in this study 84 were males and 17 female, most
were married and between the ages of 24 and 79 years (m =
34.1)- In this study optimism was found to have a
significant moderate negative correlation (r = -.40, p =
-001) with the mood disturbance score as measures by the
Profile of Mood States. Only the POMS total score was used
in this study- Coping as measured by the Jalowiec Coping
Scale was also a variable in this study. Only the evasive
and confrontive subscale were reportedm A moderate
32
significant association between the total mood disturbance
score and the evasive coping score (r = .44, p < .OS) was
determined. Optimism was not significantly correlated with
evasive coping. Results of multiple regression analyses
indicated that less dispositional optimism and the use of
evasive coping were significant predictors of greater mood
disturbance. Female se% was also a significant predictor of
greater distress in this study.
Taylor et al. (1992) studied the relationship of
optimism and distress in a group of 550 gay men at risk for
developing AIDS. Two groups were studied, those w h o were HIV
seropositive (238) and those who were HIV seronegative
(312). The sample was recruited from a cohort of men
participating in the Multicenter AIDS Cohort Study, a
multisite longitudinal research study. Optimism was assessed
using the LOT scale. A psychological distress score was
developed using both the Profile of Mood states and the Beck
Hopelessness scale. The appropriateness of using the later
scale is questionable as it has been referred to as both a
measure of hopelessness (Stoner, 1988) and as a measure of
pessimism (Beck, Weissman, Lester, & Trexler, 1974).
In this study hierarchical regression analysis was used
to examine the relationship between optimism and
psychological adjustment. Entered into the equation were
age, partner status HIV serotype and in the fourth step
optimism. This mode1 explained 35% of the variance in
33
psychological distress. Dispositional optimism was the only
significant predictor (M = - 3 4 , p < .OOOl).
The role of optimism in relation to psychological
distress has also been examined among patients with cancer
being evaluated for bone marrow transplantation (BHT)
(Baker, Marcellus, Zabora, Polland, & Jodrey, 1997). The 259
male and 179 female participants in this study were
predominantly white, married and between the ages of 18 and
65 (M = 40). Two measures of psychological status were used,
the Centre for Epidemiologic Studies - Depression cale (CES-D) and the Profile of Mood States (POMS). Optimism as
measured by LOT was significantly correlated with al1
psychological outcome measures. Al1 correlations were
negative with the exception of the P O M S vigor-activity
subscale. In multiple regression analyses with al1
independent variables entered (age, sex, social support,
family function, persona1 control, physical function and
optimism) optimism remained a significant predictor for al1
of the psychological distress outcomes except for POHS-
fatigue.
Dunkel-Schetter, Feinstein, Taylor, and Falke, (1992)
in a study of 603 people with a variety of types of cancer
examined coping strategies used in managing what was
referred to as the most stressful aspect their cancer.
Coping was assessed using the Ways of Coping Cancer Version.
Emotional state, as measured by POMS, was found to be to be
34
related to five patterns of coping. Less distress was
associated with coping strategies of social support,
focusing on the positive, and distancing; more distress was
reported with both cognitive and behavioral escape-
avoidance.
mile optimism was not a variable in the Dunkel-
Schetter, Feinstein, Taylor, and Falke, (1992) study
optimism has previously been positively associated with
focusing on the positive and negatively associated with
avoidance coping.
A relationship between optimism, coping strategies used
and psychological well-being has been demonstrated in two
studies of women with breast cancer. Stanton and Snider
(1993) conducted a longitudinal study comparing women who
underwent breast biopsy and received a benign diagnosis with
those receiving a cancer diagnosis. One hundred and forty
seven women who were referred for a breast biopsy agreed ta
participate. Of this sample 36 received a cancer diagnosis
and 111 a benign diagnosis. The two groups differed in terms
of age with al1 the cancer group k i n g age 40 or over,
therefore women in the benign group under forty were deleted
from the analysis. The majority of the women were white,
married and had a high schaol eduction. Data were collected
at three points in t h e ; 24 hours pre-biopsy, 24 hours
before surgery, and at 3 weeks following surgery for those
who received a cancer diagnosis. The group receiving a
3 5
benign diagnosis completed the questionnaires at time one.
Approximately one half of this group (n=20) vas selected to
complete the questionnaires at a time corresponding to time
two and the other half (n=27) at time three. Locus of
control, dispositional optimism, cognitive appraisal, coping
and mood were measured. The Ways of Coping Questionnaire was
the nieasure of coping used in this study. Dispositional
optimism was measured using the Life Orientation Test.
Pre-biopsy the groups did not differ on the variables
measured. Post diagnosis (time 2) results w e r e as expected,
women who received a cancer diagnosis were more tense,
depressed, angry, fatigued, confused and less vigorous. At
time 3 (post-surgery) women with the cancer diagnosis were
less vigorous and more fatigued but surprisingly the groups
did not differ on tension, depression, anger or confusion.
Regression analysis revealed that age, optimism,
threat, and coping were al1 significant in explaining the
variance in the negative mood scores pre-biopsy. More
distress was reported by women who were younger, less
optimistic, more threatened and engaged in more cognitive
avoidance coping. The mediation role of coping in the
relationship between optimism and negative mood was
supported for one coping strategy cognitive avoidance.
Optimism however did remain a significant unique predictor
of negative mood. It is of note that p s t biopsy and p s t
surgery optimism was not a significant predictor of vigor or
36
negative mood. The use of cognitive avoidance coping was a
significant predictor of negative mood and vigor both post
biopsy and post surgery.
In a prospective longitudinal investigation (Carver et
al,, 1993) of 59 women with stage I and II breast cancer the
personality disposition of optimism, coping and distress
were studied. The women in this study ranged in age from 33
to 72 years, most were married, were white and on average
had completed 14.15 years of education. Optimism was
measured at the initial interview using the Life Orientation
Test. Scores for this group tended toward the optimistic but
not to an extreme. Mood and coping were measured pre and
post surgery and at three, six and twelve months. Coping was
measured in this study by the Cope Scale (Carver et al.
1989). Copinq strategies of acceptance and use of humour
were found to be positively related to optimism. As with the
previously discussed finding among patients undergoing
coronary bypass surgery, optimism was associated in the pre-
surgery period with active coping and planning. As expected
negative correlations were found in relationship of optimism
to the coping strategies of denial and disengagement . The relationship of optimism and distress is much more
evident in this study. Optimism was negatively correlated
with distress at al1 measurement points, (pce and post
surgery and at 3, 6 and 12 month follow up). Controlling for
the level of distress at the prior assessment the
37
relationship of optimism to distress remained significant at
al1 points except p s t surgery, The role of coping as a
mediator between optimism and distress vas also examined in
this study at each measurement point while controlling for
the previous level of distress, Significant mediators
included the coping strategies of humour and acceptance at 6
months and behavioral disengagement at 12 months.
Lazarus and Folkman (1984) argue that the effectiveness
of a coping strategy may Vary depending on both the
situation and the stage of situation. There is some support
for this found in Carver et al (1993) study of women with
breast cancer, In this study the use of individual
strategies varied over the course of the study with some
rapidly declining and others gradually stabilizing, the use
of humour and religion proved to be the most stable.
The effects of both optimism and coping in relation to
psychological distress and well-being were studied among a
sample of 75 adults with advanced cancer (Miller, Manne,
Taylor, Keates 61 Dougherty, 1996)- The participants inthis
study (33 female and 42 males) were predominantly white and
between the ages of 35 and 75 years. Most had been diagnosed
with gastrointestinal tract cancer. ~uestionnaires were
completed on 3 occasions each 2 months apart. Optimism was
measured using the Life Orientation Test (LûT) and coping by
the Ways of Coping Questionnaire - Revised Version (WOC-R;
Folkman et al, 1986). In this study three of the coping
38
subscales (distancing, confrontive coping and self-control)
were excluded because of low interna1 consistency
coefficients, Psychological distress/well-being was measured
using the Mental Health Inventory (MHI). Correlational
analyses at both time 1 and time 3 indicated a significant
negative relationship between optimism and psychological
distress ( r = - 053 , and -061 respectively, p < ,005) and a
significant positive relationship with well-being (r = -69
and - 7 3 , respectively, p < , 0 0 5 ) . Among the coping
strategies escape-avoidance vas significantly related to
psychological distress at time 1 and t h e 3 (r = -43 and -61
respectively, p < .005). The negative relationship between
escape avoidance and well-being did not reach significance.
The only other coping strategy that vas significantly
related to outcome was accepting responsibility. This
occurred only at tirne 3, accepting responsibility was
inversely related to well-being (r = - -36) and was correlated in a positive direction with psychological
distress (r = .49).
Hierarchical regression analyses were conducted with
the time 3 distress and well-being scores as the dependent
variables. The independent variables entesed into each
equations were age, functional status, previous
distress/well-being scores, optimism and the coping
subscales escape-avoidance and accepting responsibility- In
the equation predicting distress 70 percent of the variance
39
was explained by the independent variables. Overall younger
age, louer functional status, less dispositional optimism
and greater use of escape-avoidance coping predicted greater
distress. Of this optimism accounted for 9 percent (p <.001)
of the variance and escape avoidance coping for 11 percent
(p <.OOOl). Sixty-six percent of the variance in well-being
was explained. In this case older age, better functional
status, more dispositional optimism and less use of
accepting responsibility predicted greater well-being. Of
this optimism accounted for 30 percent (p <.0001) of the
variance and accepting responsibility for 3 percent (p
c . 0 5 ) .
The literature reviewed is somewhat difficult to
interpret due to the differences in the coping measurement
scales used. While no conclusion can be drawn, there are a
nurnber of fairly consistent findings. There is some evidence
that at least in some situations optimists and pessimists
(as detemined by the Life Orientation Test) tend to use
different coping strategies in similar situations. In tenus
of psychological well-being optimists tend to have better
outcomes. Some coping strategies such as problem focused
coping, and positive focus/positive reframing tend to
consistently result in better psychological outcome (less
distress) while denial and avoidance produce greater
distress. While minimal there is some evidence that as
Carver and Scheier (1985, 1992) suggest it may be that the
relationship between optimism and more positive outcornes
occurs at least partially through their selection of coping
strategies. None of the çtudies reviewed, which examined the
relationships of optimism, coping and psychological well-
being, focused specifically on people with lung cancer.
Genaer
Until recent years lung cancer was a predominantly
male disease. However according to Canadian Cancer
Statistics (1998) lung cancer among women is the second most
common cancer and the leading cause of cancer death. Gender
differences have been noted in the psychological response to
lung cancer (Akechi et a1.,1998; Hopwood & Stephens, 1995;
Cella et al, 1987). With more women developing lung cancer
it is necessary to consider if gender plays a role in coping
strategy selection and effectiveness. Two questions seem to
be of importance in this issue. Are there gender differences
in coping and if so what are these differences?
Porter and Stone (1995) conducted a 20 day longitudinal
study of 79 middle-class community residing, married
couples. The average age for males in the study was 43 years
and 40 years for fernales. The couples completed daily
questionnaire booklets which included the most bothersome
event of the day, apptaisal, and coping assessment.
Differences were found in the content of the stressful
event, with women reporting more parenting and interpersonal
4 1
problems and men more work related and non-interpersonal
problems. However gender differences in the use of coping
strategies were minimal, leading to the suggestion that the
content of the problem was more influential in the selection
of coping responses than the gender of the individual. This
finding is consistent with the conclusion made by Lazarus
(1993b) that men and women show very similar coping patterns
when the type of stressful situation is the same.
These results differ from those of Ptacek, Smith, and
Zanas (1992) in a 21 day longitudinal study of 152 college
students (42 males and 110 females). The age range for this
sample was 18 to 46 with an average for males of 23 years
and 22 for females. Only 16 of the subjects were married.
The data collection format was similar to that used by
Porter and Stone (1995). In this sample bath men and women
reported the same content areas for stressful situations
however men reported using more problem-focused methods and
were more likely to use these as the first strategy applied.
Women used more coping strategies per event than men and
used social support more frequently than men. Thoits (1991)
also studying college students reported fairly similar
findings which provided some support for this stereotypical
picture . Stanton, Danoff-Burg, Cameron, and Ellis (1994) found
that the use of emotion focused coping may have very
different outcomes for men and women. In a sample of 83
42
female and 88 male undergraduate college students Stanton et
al. found that in situations of low-control men who used
emotional focused coping became more depressed over time
where as women became less depressed.
Dunkel-Schetter, Feinstein, Taylor, and Falke (1992)
in a sample of 603 people with cancer studied a number of
variables in relation to patterns of coping with stressor
related to the cancer. Gender was not found to be related to
the use of coping strategies.
Gender may play a role in the relationship between
optimism and selection of coping strategies. In a study of
university students optimism was positively associated with
seeking social support but this finding was gender (being
male) specific (Scheier, Weintraub C Carver, 1986)
Results from recent studies of the gender-coping issue
have illustrated that a clear understanding of the
relationship between gender and coping has not been
achieved. While gender does, at least in some samples, seem
to influence coping strategies and possibly psychological
outcomes the results are not conclusive and further research
is needed.
Aae
Lung cancer is generally a disease of middle 40-60 and
older 60+ age groups. As the roles and responsibilities of
these two age groups differ it is possible that age may also
influence coping. Whether or not coping changes with aging,
43
from young adulthod to old age is unclear (Lazarus &
Folkman, 1984). Age differences have been found in relation
to emotional response to a diagnosis of cancer (Edlund 61
Sneed, 1989). The sample in this study consisted of 44 males
and 89 females with a variety of cancer types. Age ranged
from 22 to 87 years. Four age groups were established; 21 to
49 years, 50 to 59 years, 60 to 69 years and 70 years and
older. In this sample socioeconomic status decreased with
increasing age. Coping strategies were not measured.
Distress was measured using the Brief Symptom Inventory
which focuses on emotional distress and the Health Insurance
Study General Well-Being Schedule which focuses on general
well being and mental health. Attitudes toward cancer were
measured by the Cancer Attitude Inventory. The oldest age
group was found to have the most negative attitudes about
cancer but also had significantly less psychological
distress on learning of the diagnosis.
In reviewing the literature Rook, Dooley, and Catalano
(1991) tentative concluded that age plays a modest role in
the choice of coping strategies. However in a study of
coping in young (18-34) middle ( 3 5 - 5 9 ) and older (60+ )
workers in relation to economic distress they found age was
significant not only in coping strategy selection but also
in terms of the emotional outcome of the strategy. For
example cutting expenses was associated with greater
depression in the the middle age gtoup but with less
44
depression in the younger group.
Folkman and Lazarus (1988a) also found differences in
age on the effect of coping on emotion. They compared the
findings of two studies. In one study, the younger sample,
the mean age of the women was 39.6 years and for the men
41.4 years. In the other study, the older sample, the mean
age of the women was 68.9 years and for the men 68.3 years.
Results indicated that positive reappraisal was associated
with decreased distress and increased positive feelings in
the younger group but with more worry/fear in the older
group. Confrontive coping was associated with increased
distress in the younger group and seeking social support
with increased positive emotions in the older group. These
results however must be viewed in light of a number of
limitations.
The samples used not only differed in age but also in
marital status, al1 the younger sample were married while
39% of the older group were single, divorced, or widowed.
Income was also significantly different with the median
family income for the younger sample being twice that of the
older sample. In addition to sample differences method also
differed. Coping was measured using the the Ways of Coping
Questionnaire however different versions and methods of
administration were used for the two samples. Emotions were
assessed by asking the subjects to indicate the extent to
which they experienced a number of different emotions
45
however again there were variations in the method used.
However a similar result was found in a sample of 77
patients with rheumatoid arthritis (Spitzer, Bar-Tal, &
Golander, 1995). In this study the mean age of the subjects
was 54.2 years. On average they had 10-3 years of formal
education. Coping was measured using a modified
questionnaire developed by Hoos et al. Three coping strategy
classifications were identified active cognitive coping,
active behavioral coping and avoidance coping. In this study
Active cognitive coping (strategies similar to positive
reappraisal) were was found to be more effective in reducing
psychological distress for the yowiger subjects than for the
older group.
The use of confrontive coping has produced varied
results. In the Folkman and Lazarus (1988a) study
confrontive coping vas associated with more distress in the
younger sample but had no effect in the older sample.
However in a sample of 59 long-term cancer survivors no age
differences were found in the use or effectiveness of
confrontive coping (Halstead & Fernsler, 1994). The age
range for this sample vas 21 to 82 years, most were female
and survivors of breast cancer (50.8%). The sample was
unusual in that most (61%) had at least college education
and were employed as professionals (57.8%). The sample was
divided into three group based on age; 21 to 40 years, 41 to
65 years and 66 to 82 years- The revised Jalowiec Coping
Scale was used to measure the use and effectiveness of
coping strategies. The elderly group perceived optimistic
(thinking positively), palliative (handling distress by
doing things to make one feel better) and supportant (using
supportive resources) strategies as most effective. Folkman
and Lazarus (1988a) also noted the use of social support
increased positive emotions in the older group.
Although limited, there does seem to be support for the
conclusion that the use of coping strategies varies w i t h
age. Coping must however be considered in the context of the
entire stress, appraisal, and coping process. Stressors,
appraisal of degree of stress, and coping resources must al1
be considered in future studies to clearly understand the
role of age in the selection of coping strategies and
influence on psychological outcome.
Lung cancer by its very nature as a life threatening
illness has a negative impact on psychological well-being.
The psychological distress resulting from a diagnosis of
lung cancer has been well documented. However coping with
the stressors resulting from this diagnosis has not been
examined. The selection of coping strategies and their
effectiveness is influenced by numerous factors. It has been
proposed that personality, specifically the personality
disposition of optimism, is one such factor. A number of
47
studies of differing populations both with and without a
specific illness have been completed which support the
relationships between optimism, coping strategy selection,
and psychological outcome. No studies examining these
relationships have been reported with regard to people with
lung cancer.
Age and gender have also been considered as possible
factors influencing the coping process. Research in both of
t h e s e areas has not provided a clear understanding of
whether the selection or effectiveness of coping strategies
is influenced by either age or gender. No research reporting
the effect of age or gender in relation to coping among
people with lung cancer was identified.
For nursing a better understanding of the influence of
optimism, age and gender on the selections of coping
strategies and the effectiveness of those strategies among
patients with lung cancer would enhance assessment, planning
and interventions.
Lazarus and Folkman's (1984) theory of stress and
coping was used to guide this study. This framework, which
has b e n frequently used in the study of the stress and
coping process in a variety of settings, provided a broad
framework encorpassing the concepts of stress, appraisal,
coping, person and environmental antecedents of stress and
4 8
coping, and short and long term adaptational outcornies
(p.306). Lazarus and Folkman (1984) describe their theory of
stress and coping as a transzctional process oriented model;
transactional because the person and environment are
constantly interacting and cbanging as a result of this
interaction. The person-environment relationship is viewed
as reciprocal and bidirectional. It is this constantly
changing process which was of interest in this study.
Psychological stress was defined as any person-
environment relationship which is appraised by the person as
taxing or exceeding resources and thereby endangering the
person's well being. Stress can therefore include a wide
variety of situations, appraisal is key in this process.
According to Lazarus and Folkman there are three types
of appraisal; primary, secondary, and reappraisal. Primary
appraisal is considered as a continuous cognitive process of
evaluating the meaning or significance of life situations.
In the primary appraisal process the situation may be
appraised as irrelevant, benign-positive or, stressful.
Stress appraisals are subclassified as harm or loss,
indicating that damage to self or social esteem has already
occurred, as a threat in which harm or loss are anticipated,
or as a challenge in that there is a potential for gain or
growth. Primary appraisal is influenced by persona1 factors
such as what is important and meaningful to the individual
(Le, values and beliefs).
4 9
Primary appraisal is also influenced by the
characteristics of the situation. Situational factors such
as novelty, predictability, and uncertainty al1 influence
the type of appraisal.
Secondary appraisal is the evaluation of what might or
can be done about the situation. Secondary appraisal depends
mainly on the coping resources available. Among these
resources Lazarus and Folkman include health and energy,
positive beliefs, problem-solving skills, social skills,
social support and material resources. While the role and
value of each of these resources is fairly evident, positive
beliefs require more explanation. Lazarus and Folkman (1984)
describe this category as beliefs which serve as a basis for
hope and which sustain coping in the most adverse
situations. Both primary and secondary appraisal influence
coping and in turn are influenced by coping.
Coping, as conceptualized by Lazarus and Folkman, is
viewed as a process. From this perspective coping has three
features. First the focus is on what the person actually
thinks or does, not on what the person usually does or would
do. Second the thought or action is considered in a specific
context i.e. what the person is coping with. Finally the
process is considered dynamic, with thoughts and actions
changing as the stressful situation unfolds.
Coping has two major functions, one is to manage or
change the stressful situation, termed problem-focused
50
coping and the other to regulate the emotional response to
the situation, termed emotion-focused coping.
Person and environmental antecedents of stress and
coping include personal values and beliefs, situational
factors, and factors identified as coping resources.
Conditions such as gender, age, socioeconomic status, and
personality traits, are often termed moderators (Folkman &
Lazarus, 1988a) and will also influence appraisal, coping
and outcome. Optimism when defined as a personality trait is
consider by Lazarus (1991) to be an antecedent variable and
as such probably influences appraisal and coping and may
influence emotional and adaptational outcome.
Coping is a mediator between stress and adaptational
outcome. Three basic and general types of outcomes are
identified; social functioning, subjective well-being and
somatic health.
In summary coping is one aspect of a framework of
stress, appraisal and adaptational outcome. Coping efforts
represent attempts to manage situations appraised as
stressful. The focus of these efforts is directed at either
managing or solving the problem, or regulating the emotional
response to the situation. Coping is viewed as a process
which changes during the situation on the basis of constant
appraisal and reappraisal. Coping thoughts and actions are
influenced by both situational and persona1 variables. The
effectiveness of coping is determined on the basis of
adaptational outcomes.
The proposed relationships of the variables of
interest are depicted in the Lazarus and Folkman framework
in Figure 1. The causal antecedents included were the person
variables of age, gender and degree of optimism, and the
situational factor of a diagnosis of advanced lung cancer.
The mediating processes of appraisal and coping strategies
w e r e considered to be influenced by the antecedent factors
and were also considered to influence each other. The final
variable of interest, the effect, was the psychological
outcome. The psychological outcome was considered to be
influenced by and in turn to influence appraisal and the use
of coping strategies.
A Causal Antecedents Mediating Processes
Ef f ects
Person variables including age, gender and optimism
Environmental factors including diagnosis of Lung Cancer
Appraisal Pr imary Secondary Reappraisal
Psychological
Coping Strategies
Outcome 1
e 1. Proposed relationships of the variables of
interest in the Lazarus and Folkman Framework of Stress,
Appraisal and Coping. Adapted from Lazarus and Folkman
( 1 9 8 4 ) .
Be-arcn oue.stiQns
What are the coping strategies used by people with
advanced or inoperable primary lung cancer*
What is the relationship between dispositional optimism
and the coping strategies used by people with advanced or
inoperable primary lung cancer.
mat is the relationship between age, gender,
dispositional optimism, coping strategies used and the
psychological well-being of people with advanced or
inoperable primary lung cancer.
A d v a n c e d a cancer was def ined for the purpose of
this study as any histologically confirmed diagnosis of non
small ce11 lung cancer which has been determined to be stage
III (mediastinal lymph node involvement),or stage IV
(distant metastases)(Luketich, Van Raemdonck 61 Ginsberg,
1993). A histologically confirmed diagnosis of small ce11
lung cancer of any stage - because of its aggressive nature and poor prognosis (Harvey 6 Beattie, 1994; Greco L
Hainsworth, 1994) - is also included in the definition of advanced lung cancer.
for the purpose of this study
was defined as any histologically confirmed diagnosis of
lung cancer which is determined to be advanced on the basis
of staging investigations or occurring in anyone who is
54
medically unfit for the operation (Murren & Buzaid, 1993).
In these situations the person is faced with the knowledge
that cure is unlikely, recurreiice is probable and sumival
tirne limited. . . . srtroml Ont- was defined "as the tendency to
believe that one will generally experience good vs. bad
outcomes in lifen (Scheier & Carver, 1992, p. 2 0 2 ) . ft w a s
measured using the Life Orientation Test (Scheier, Carver L
Bridges, 1992).
Co~inq was defined as *constantly changing cognitive
and behavioral efforts to manage specific external and/or
interna1 demands that are appraised as taxing or exceeding
the resources of the personn (Lazams and Folkman, 1984,
p.141). Coping was measured using the Ways of Coping
Questionnaire (Folkman & Lazarus, 1988b).
Psvcholoaical Weil - Be was defined as a subjective
feeling of emotional well-being. The Profile of Mood States
(McNair, Lorr & Droppleman, 1992) was used as the measure of
psychological well-being,
Chapter II
Hethodology
A descriptive multiple correlational design was used to
examine the relationships between the personality
disposition of optimism, the coping strategies used, the
demographic characteristics of age and gendet, and
psychological well-being of people with advanced or
inoperable primary lung cancer.
Settina
This study was conducted in a large tertiary care
health centre in Eastern Canada. This facility includes the
Nova Scotia Cancer Centre, Halifax Clinic, and serves as one
of two provincial referral centres for patients with lung
cancer.
SamDle
The population for this study was people with a
diagnosis of advanced or inoperable primary lung cancer.
This included any person with a diagnosis of primary lung
cancer who was determined to be medically unfit for
operation, or had stage three (involvement of mediastinal
lymph nodes)or stage four (metastatic) non-small ce11 lung
cancer, or small ce11 lung cancer of any stage. People
meeting this criteria who were between one month and one
year of diagnosis, able to speak and understand English, had
no known brain metastases, had no other cancer diagnosis
(with the exception of non-melanoma ce11 skin cancer and
cancer of the cervix insitu) within the pst five years, and
can give informed consent were asked to participate. People
who have had surgical resection of stage one or stage two
lung cancer may anticipate a better prognosis than those
with advanced disease and therefore were not included.
Patients with recurrent disease were also excluded as the
issues and impact of recurrent cancer differs from that of
the initial diagnosis (Mahon, Cella, & Donovan, 1990; Mahon,
1991).
Based on the technique of power analysis using the
parameters of a puer of 0 - 8 0 , effect size of 0.34 and
significance level of 0.05 for a two tailed test it was
determined that a sample of 64 patients was required for
this study (Kraemer & Thiemann, 1987)-
A convenience sample of sixty-four people participated
in the study, The age range was from 44 to 77 years (n =
61.34, a = 8.10). Forty-four (68.8%) of the participants
w e r e male and 20 (31.3%) female, Most of the participants
w e r e married or living with their common law spouse (11 = 48,
75%). Only 12 (18.8%) were living alone. Thirty-seven
57
(57.8%) were retired, 20 (31.3%) were on sick leave, 6
(9.4%) were unemployed and only 1 (1.6%) continued to work.
Sixty-two (96.9) of the participants were Caucasian; of the
two remaining one was Black and one was Asian.
Religious beliefs were considered to be important to
the majority of the participants. Twenty-one (32.8%)
believed religion had some importance, 10 (15.6%) rated it
as moderately important and 26 (40.6%) as very important.
Seven (10.9%) did not consider religion to be of importance
in their lives.
The majority of the participants were not well educated
in terms of fonnal education with only 22 percent (n = 14)
having high school or greater education. Of those, five
(7.8%) had obtain University or Post Graduate degrees.
Annual household incomes also tended to be low with 46.9
percent (n = 30) reporting less than $21,000. An additional
16(25%) reported incomes between $21,000 and $30,000, and 13
(20.4%) reported incomes greater than $30,000. Five (7.8%)
choose not to answer this question. The relative frequency
distributions for selected demographic variables are
presented in Table 1.
Table 1
. .. . . .
characteristic n E - -
Martial status
Married/commonlaw
Widowed
Separated/divorced
Single
Living arrangements
Spouse alone
Spouse & family
Alone
Adult children
Education
Junior high or less 32 50.0
Partial high school 18 28.1
High school diploma 5 7.8
Partial university 4 6.3
University degree 2 3.1
Post graduate degree 3 4.7
Household income
< $10,000 9 14.1
$10,000 - $20,000 21 32-8
$21,000 - $30,000 16 25.0
$31,000 - $40,000 6 9.4
$41,000 - $60,000 4 6.2
$61,000 O $100~000 1 1.6
> $100,000 2 3.1
NO response 5 7.8
59
ness and Treatm-t Ch--?
The time since diagnosis ranged from 4 to 51 weeks with
a median time of 12 weeks. Thirty-four (53.1%) of the
participants had received a diagnosis of non small ce11 lung
cancer and 30 (46.9%) a diagnosis of small ce11 lung cancer.
This reflects a greater percentage of participants with
small ce11 lung cancer than is consistent with the over al1
lung cancer population. For those participants w i t h non
small ce11 the majority were stage 3 (3a = 8, 12.5%; 3b =
17, 2 6 . 6 % ) , 2 were early stage (stage 1 or 2) but were
inoperable for other medical reasons and 7 (10,9%) had stage
4 disease. Of those with small ceIl lung cancer, 12 (18.8%)
had limited stage disease and 18 (28.1%) had extensive
stage.
Participants were asked to indicate if they were
experiencing cough, shortness of breath, pain, fatigue or
other symptoms they believed to be related to lung cancer or
its treatment. One or more symptoms were experienced by 62
(96.9%) of the participants. Fatigue was the most frequently
reported symptom (n = 47, 73 ,4%) . Of those who reported
fatigue, 40 indicated that it was severe enough to interfere
with their usual activities. Shortness of breath interfering
with usual activities was reported by 27 (42.2%), and cough
severe enough to interfere with usual activities was
reported by 10 (15.6%) of the participants. Pain was
reported by 25 (39.1%) of the participants. Twenty-four were
60
taking medication for pain yet 13 (20.3%) still indicated
that the pain was interfering with their usual activities.
Other symptoms reported by participants included leg
weakness, aching joints, decreased appetite, hoarseness,
sore throat, difficulty swallowing and nervousness.
The Eastern Cooperative Oncology Group / World Health
Organization (ECOG/WHO) performance status scale (Zubrod et
a1.,1960; Miller, Hoogstraten, Staquet, & Winkler, 1981) was
used as a self assessment of level of function, Most (n =
45, 70.3%) participants rated themselves at level 1
(restricted in strenuous activity but ambulatory and able to
carry out light work or pursue a sedentary occupation or who
are fully active but require analgesia). None of the
participants were level 4 (completely disabled) and only one
was level 3 (limited self-care).
Al1 of the participants in the study had received or
were currently receiving radiation or chemotherapy. Eight
(12.5 % ) had had surgery but were found to have advanced
disease at the time of the operation.
Table 2 provides the relative frequency distributions
for selected illness and treatment variables for the
participants.
Table 2
Illness and Treatwnt C h w e i c s of Studv P a r t i c m . .
IN = 6 4 1
Characteristic 11 e Symptoms
Fatigue 4 7
Dyspnea 44
Cough 4 2
Pain 25
Other 8
Pain medication used
None
Strong narcotic
Codeine
Tylenol/ASA
Performance status
Fully activity 5
Restricted in strenuous activity 45
Self care only 13
Limited self care 1
Chemotherapy
Currently receiving
No chemotherapy
Completed or between cycles
Radiation
Currently receiving 24
No radiation 23
Completed 17
62
P r o c e d u r d
Following approval by the Dalhousie University Faculty
of Graduate Studies Human Ethics Committee and the Research
Ethics Committee of the Queen Elizabeth II Health Sciences
Centre potential participants were identified from the
patient lists of the thoracic surgeons at the QEII Health
Sciences Centre and from those patients attending lung
oncology clinics at the Nova Scotia Cancer Centre, Halifax
site.
Patients who were identified as meeting the study
criteria were approached either by a letter from the
thoracic oncology group (Appendix A), or directly by their
primary QEII physician, or by a nurse or a physician
providing their care in the lung oncology clinic, The letter
from the thoracic oncology group included a brief
description of the study and a stamped, addressed return
envelope. Those who choose to reply could either request to
be contacted by the researcher and provided with more
information or indicate they are not interested. Those
approached directly by their physician or nurse were
provided with a brief description of the study (Appendix
B). Those who were willing to consider participation were
introduced to the researcher or to the research assistant.
The study was described and a time arranged for the
interview with those who were willing to participate,
Written consent was obtained.
63
Al1 interviews were conducted in a private area on the
hospital site with only the participant and interviewer
present. After a brief explanation about each
questionnaire, the questions were read to the participant
and their responses recorded on the appropriate forms. This
included demographic information and questionnaires
measuring optimism, coping strategies used and psychological
well being. The estimated time for completion was about 60
to 90 minutes. The actual time required ranged from 45 to 60
minutes, - In a brief interview demographic information including
martial status, cultural background, education, occupation
and income was obtained. The participants were asked to rate
the importance of religion in their life as this is often
identified as an important coping resource, Information
about the symptoms currently k i n g experienced and the
current use of narcotic medications was also included as
these may influence the individuals outlook and sense well-
being (Appendix D), Present physical status was assessed
using the Eastern Cooperative Oncology Group / World Health
Organization (ECOG/WHO) performance status scale (Zubrod et
a1.,1960; Miller, Hoogstraten, Staquet, f Winkler, 1981).
Length of time since diagnosis, lung cancer stage, ce11 type
64
and treatment was obtained from the health record (Appendix
E)
g n T e s t (LOT - RL The revised Life Orientation Test (L0T-R) (Appendix F)
was used to measure optimisme The original version of the
Life orientation Test was developed by Scheier and Carver
(1985) as a measure of the personality characteristic of
dispositional optimism or the generalized expectancy of good
rather than bad outcomes in life. This measure consists of
eight items plus four filler items.
This scale has been widely used to measure optimism in
a number of different populations; university students
(Carver, Scheier, & Weintraub, 1989; Scheier, Weintraub, &
C a r v e r , 1986), patients recovering from coronary artery
bypass surgery (Scheier et al, 1989), people with cancer
(Friedman et al, 1992) and specifically with breast cancer
(Stanton & Snider, 1993; Carver et al, 1993).
The scale is usually administered as a self report
questionnaire but has also been used in an interview design
(Carver et al, 1993). The tirne to complete the questionnaire
has not been reportede However given its brevity a
completion time of approximately 10 minutes for the
questionnaire administered in an interview was considered
reasonable.
The scale vas revised in 1994 (Scheier, Carver &
65
Bridges, 1994). Two items which did not refer specifically
to the expectancy of a positive outcome but instead could be
viewed as coping strategies were removed. Because both of
these item were worded positively one negatively worded item
was also removed and one new positive item added in order to
achieve a balance in the number of positive and negative
items. The final result is a scale with 10 items, three
positive, three negative and four filler items. Respondents
are asked to indicate their level of agreement with the
items on a five category Likert scale. Negatively worded
items are reversed prior to scoring. The responses are
summed to provided a score reflecting the degree of
optimism,(i.e. the higher the score the greater the
optimism) with a possible range of O to 24.
Valigitv.
The face validity of LOT and LOT-R is reported as high.
Items such as "In uncertain times, 1 usually expect the
best" and nif something can go wrong for me, it willn
reflect the commonly held view of the life outlook of the
optimist and pessimist.
The authors (Scheier, Carver, 6 Bridges, 1994) examined
the predictive validity of LOT in a sample of 4309
undergraduate univetsity students. In addition to LOT,
outcome measures of depression, physical symptoms, and
coping along with other predictor variables including
neuroticism, self-mastery, self-esteem, and trait anxiety
66
were examined. Significant correlations (p < - 0 5 ) were
reported for LOT with al1 the outcome variables supporting
the predicative validity of LOT. When the other predictor
variables (neuroticism, self-mastery, self-esteem, and trait
anxiety) were controlled for, the correlation between
optimism and three of the coping factors remained
significant supporting a degree of discriminant validity.
The validity of the Revised Life Orientation Test has
been examined by the authors (Scheier, Carver, & Bridges,
1994) in a study of 2,055 (622 women, 1394 men and 39 who
did not indicate gender) undergraduate college students.
Principle components factor analysis was conducted. Varimax
final rotation technique was used and the eigenvalue
criterion set at 1.0- A one-factor solution emerged
accounting for 48.1% of the variance. Al1 items loaded at
least - 5 8 on this one factor.
In addition to completing the revised LOT one or more
of the following questionnaires were completed; the Self-
Mastery Scale, tat te-Trait Anxiety Inventory, the Guilford-
Zimmerman Temperament Survey (a measure of neuroticism), the
Self-Esteem Scale and the Neuroticism Scale of the Eysenck
Personality Questionnaire. Correlations between the LOT-R
and the other scales including the original LOT were
determined to examine convergent and discriminant validity.
The authors describe the other scales as measuring
conceptually related concepts and consider the correlations
(with the exception of the high correlation with the
original scale) as modest indicating that while there is
conceptual and empirical overlap the other scales are
measuring other qualities in addition to optimism. The
correlations were al1 significant (p < .001) and ranged from
a low of 0.36 to a high of - ,53.
The original LOT has b e n criticized (Smith, Pope,
Rhodewalt & Poulton, 1989) as having limited convergent and
discriminant validity, correlating as well with measures of
neuroticism as with a second measure of optimism the
Generalized Expectancy for Success Scale (GESS). However as
the authors of the LOT scale note neuroticism is a
multifaceted construct which includes pessimism and
therefore is conceptually linked to optimism.
Acceptable interna1 consistency of the original LOT
scale has been reported. Scheier and Carver (1985) for a
sample of college students reported a CronbachOs alpha of
. 7 6 . Carver et al (1993) in a study of women with breast
cancer reported an alpha of .87. Interna1 consistency of the
revised scale has been reported only for a college student
sample, for this sample the Cronbach's alpha was . 78 .
A test-retest reliability coefficient of .79, over a 4
week interval, has b e n reported by Scheier and Carver
(1985) in a saraple of college students, In a sample of women
with breast cancer Carver et al (1993) reported a test-
68
retest reliability coefficient of ,74, over a one year
period. Test-retest stability has been examina for the
revised Life Orientation Test in four samples of college
students, Each sample vas retested at a different point,
Test-retest coefficients of -68 at 4 months, -60 at 12
months .56 at 24 months and -79 at 28 months were reported
(Scheier, Carver C Bridges, 1994) -
mvs of Co- O u e s t i m
The Ways of Coping Questionnaire (Folhan & Lazams,
1988b) was used as the measure of coping (Appendix G ) - The
Ways of Coping Questionnaire is a theoretically derived
measure based on the cognitive-phenomenological theory of
stress and coping of Lazarus and Folkman (1984). It was
designed to identify the thoughts and actions an individual
uses to cope with a specific stressful encounter. The
original version, the Ways of Coping Checklist, was a 67
item list of strategies to which the subject indicated with
a yes or no response whether or not they had used the
strategy to deal with a particular stressful event.
Although the Ways of Coping Questionnaire is a frequently
used measure of coping, cornparison is difficult because it
is often modified for the particular population-
The present scale, as provided with the Ways of Coping
Questionnaire Hanual (Folkman & Lazarus, 1988b), has 66
items and eight coping scales. Revisions to the original
scale included rewording or deleting unclear items, adding
69
new items based on the suggestions of subjects and changing
the response format to a 4-point Likert scale indicating the
frequency with which each item used.
The eight coping scales have been derived from factor
analysis based on a sample of 75 middle and upper-middle-
class white married couples having at least one child living
at home. Data was collected from husbands and wives
separately on 5 occasions. The data was analyzed using alpha
and principal factoring with oblique rotation resulting in
eight factors. The eight scales have been labelled and
described as follows:
ve con- - aggressive efforts to alter the situation and suggests some degree of
hostility and risk-taking.
Distancina - cognitive efforts to detach oneself and to minimize the significance of the situation.
Self - CO- - efforts to regulate one's feelings and actions.
S e e u s o c m s~ppo- - efforts to seek informational support, tangible support and
emotional support.
B c - Q t h g r-pansibllltv . . . - acknowledges one's own
role in the problem with a concomitant theme of
trying to put things right.
- wishful thinking and behavioral efforts to escape or avoid the problem.
ul Problem - deliberate problem- focused efforts to alter the situation, coupled
with an analytic approach to solving the problem.
- efforts to create positive meaning by focusing on persona1 growth, also has a
religious dimension. (Folkman & Lazarus, 1988b,
p.11)
The number of items in each scale varies from four to eight.
The Ways of Coping Questionnaire has been designed to
be answered in relation to a specific stressful event. The
authors advise that the exact method should be adapted to
fit the needs of the particular study. The method described
by Dunkel-Schetter, Feinstein, Taylor and Falke (1992) was
used this study. Dunkel-Schetter et al used the Ways of
Coping Questionnaire in a study of 603 people with cancer.
Because they were making a single assessment of coping
rather than repeated assessments they believed that asking
the subject to select a stressful episode would provide an
isolated and possibly unrepresentative instance of the
individuals coping response and that asking for a response
in relation to coping with cancer in general would be too
nonspecific. The following set of cancer-related stressors
were listed: fear and uncertainty about the future due to
cancer; limitations in physical ability, appearance, or life
style due to cancer; acute pain, symptoms, or discomfort
from illness or treatment; and problems with family or
71
friends related to cancer. Respondents were asked to choose
from this list which one had been most stressful for them
and to indicate on a scale of 1 (not stressful) to 5
(extremely stressful) hov stressful the problem had b e n
over the previous 6 months. The Ways of Coping Questionnaire
(revised for this study) vas completed in relation to the
stressor selected, Forty-one percent selected fear or
uncertainty about the future,
As a self-administered questionnaire the Ways of Coping
takes approximately 10 minutes to complete, Although usually
a self-administered questionnaire Folkman and Lazarus (1988)
reported that the Ways of Coping Questionnaire has been used
as an interview protocol. No time estimate for completion as
an interview protocol is reported- Approximately 30 minutes
or three time the self-administration time seemed to be a
reasonable estimate for completion in an interview format-
To complete the Ways of Coping Questionnaire the
participant, keeping the stressful situation in mind,
responds to each of the items in the questionnaire
indicating the degree to which the item was used on a 4-
point Likert scale where O indicates ndoes not apply or not
usedw, 1 indicates "used somewhatm, 2 indicates Wsed quite
a bitw and 3 indicates %sed a greet dealmm Of the 66 items
50 are included in the scoring.
In scoring the Ways of Coping Questionnaire raw scores,
mean raw scores and relative scores were determined. A raw
72
score was obtained by summing the subjects responses for the
items which comprised a particular scale. This provides a
summary of the extent to which each type of coping vas used.
This is the methoâ describe by Lazarus and Folkman (1988) as
being used in the majority of their research, however
because some scales have up to eight items and others have
only four the mean score for each scale was determined.
The relative score is described as an indicator of the
contribution of each scale relative to al1 the scales
combined. In this method the mean scores for the eight
scales are sumrned, the mean score for each scale is then
divided by the s u of the eight mean scores.
Validitv,
Folkman and Lazarus (1988b) describe both face and
construct validity for the Ways of Coping Questionnaire.
Evidence of face validity is based on the source of the
items included in the scale; the items are the strategies
described by individual as being used to cope with the
demands of a stressful situation.
Evidence of construct validity was supported by
research findings using the Ways of Coping Questionnaire
which were consistent with the theoretical predictions of
Lazarus and Folkman's theory of stress and coping.
specifically that coping consists of both problem and
emotion focused strategies and that coping is a process and
therefore changes as the context and demands of the
situation change.
The constmct validity however has been challenged
(Wineman, Durand, & McCulloch, 1994) on the basis of the
factor structure. These authors argue that the factors need
to be reproduced across studies in order to determine if the
structure is supported. In a secondary analysis of a random
sample of 690 individuals with multiple sclerosis or a
spinal cord injury it was found by these authors that the
eight factor mode1 developed with a community based
population did not adequately describe the present
population. Re-analysis of the factor structure revealed
three coping factors.
Studies of clinical populations with cancer have also
revealed differing factor structures. Hishel and Sorenson
(1993) in a study of women with gynecological cancer also
questioned the appropriateness of the factor structure due
to low internal consistency estimates. On reanalysis a seven
factor structure emerged, four within the problem coping
mode and three within the eaotion focused mode. ûunkel-
Schetter, Feinstein, Taylor, And Falke (1992) in a study of
coping among people with a variety of types of cancer
produced a five factor structure. They had however modified
the scale prior to use. Stanton and Snider (1993) in a
sample of women with breast cancer found the five scales
from the Dunkel-Schetter study to produce greater internal
consistency with this sample than the original scales from
74
the community sample. Prior to using the questionnaire they
had removed the seven items added or modified by Dunkel-
Schetter . Folkman and Lazarus (1988b) recognize the concern
related to the variability of the factor structure and while
they maintain that a good deal of convergence exists with
respect to several factors, this is not the case for all.
Test-retest reliability is not considered an
appropriate evaluation of the Ways of Coping Questionnaire.
Based on the definition of coping as a process variation is
expected
Reliability as determined by internal consistency has
been reported in the Ways of Coping Manual (Folkman &
Lazarus, 1988b) for the community based sample of 75 married
couple previously described. Cronbach's alpha coefficients
for the eight scales ranged from -61 to .79. However as
discussed the factor structure has not consistently yielded
adequate internal consistency with other populations. Alpha
ranged from -51 to -71 in a sample of people with multiple
sclerosis and spinal cord injury (Wineman, Durand &
Mcculloch, 1994) and from -49 to -79 among patients with
gynecological cancer (Mishel & Sorenson, 1993). Dunkel-
Schetter, Feinstein, Taylor, And Falke (1992) using a
modified the Ways of Coping Questionnaire reported alpha
coefficients of -74 to .86 with a five factor structure.
Stanton and Snidet (1993) using the same five factor
structure, but having removed the modified items reported
alphas of ranging from - 7 0 to - 8 4 for four of the five
factors. The factor labelled Behavioral Avoidance achieved
an alpha of only .51.
Profile of mod States
Psychological vell-being was measured using the Profile
of Mood States (McNair, Lorr & Droppleman, 1992) (Appendfx
H). The Profile of Mood States (POMS) vas developed as a
measure of mood or affective state in psychiatric
outpatients but has also been used extensively with non-
psychiatric populations. It is a factor analytically derived
inventory which measures six mood states, Tension-Anxiety:
Depression-Dejection: Anger-Hostility: Vigor-Activity;
Fatigue-Inertia; and Confusion-Bewilderment. The POnS has
also been used as a single global estimate of affective
state, providing a Total Mood Disturbance Score.
The POMS consists of 65 adjectives (such as tense,
unhappy, lively, sad) which are rated on a five point Likert
scale. The intensity modifiers for the scale are not at ail,
a little, moderately, quite a bit and extremely. The
participant indicates the degree of the feeling experienced
over the past week. When self-administered the scale takes
3-5 minutes to complete. WllS has b e n administered orally
to visually impaired athletes (Mastro, French & Hall, 1987
as cited in McNair, Lorr & Droppleman, 1992) in which case
76
it took approximately five minutes longer to complete.
The instrument is scored by suinming the the responses
for each of the adjectives which define the mood state. Two
items "relaxedm in the tension-anxiety scale and wefficient"
in the confusion scale are weighted negatively. To obtain
the Total Hood Disturbance score the scores for five of the
mood states are summed and the score for the Vigor scale is
then subtracted.
u t v .
The validity of the six mood factor structure has been
demonstrated by the authors of the scale through six
independent factor analytic studies. Five of these studies
involved psychiatrie outpatients and one male college
students.
The face validity of the items defining each of the
mood states is high. The authors of scale also cite seven
different areas of research as providing evidence of
predictive and constact validity. Included are: brief
psychotherapy studies; controlled outpatient drug trials;
cancer research; drug abuse and addiction research; studies
of response ta emotion-inducing conditions; research on
sports and athletes and studies of concurrent validity
coefficients (HcNair, Lorr & Droppleman, 1992). Profile of
Mood States was used as a measure of distress and
psychological well being in t w o previously discussed studies
of women with breast cancer (Carver et a1.,1993; Stanton &
77
Snider, 1994). In both studies distress following diagnosis
was measured over time and in relation to optimism and
coping strategies. As predicted distress varied in relation
to tirne, coping strategies utilized and the degree of
optimism.
Concurrent validity has been reported by the authors
(McNair, Lorr & Droppleman, 1992). Significant correlations
between POMS and the Hopkins Symptom Distress scales in a
sample of psychiatric outpatients were reported-
Significant correlations for the subscales were also
demonstrated. The Tension-anxiety scale was correlated with
the Taylor Manifest Anxiety Scale in a sample of psychiatric
outpatients (.80) dental patients (-51) and college males
(.36). The Depression subscale vas correlated with the Beck
Depression Scale (-61) in a sample of workers exposed to
organic solvents.
Peliabllltv. . .
The interna1 consistency of the POHS was examined by
the scale authors using the Kuder-Richardson formula (K-R20)
among 350 female (F) and 650 male (H) psychiatric
outpatients, The reliability coefficients as follow, were
acceptable for al1 factors: Tension-anxiety -92 (H), .90
(F); Depression-dejection -95 (H), .95 (F); Anger-hostility
. 9 2 (M), -93 (F); Vigor .89 (n), .87 (F); Fatigue .94 (H),
.93 (F); Confusion -87 (M), .84 (F). The Cronbach8s alpha
coefficients based on a sample of 2360 adults participating
78
in a smoking cessation research program was also reported.
T h e s e were also acceptable with al1 coefficients -90 or
above for both sexes with the exception of the confusion
scale which was .85 for females and -83 for males.
Test-retest stability for this instrument is moderate.
In the sample of psychiatrie outpatients Product-moment
correlations between POM score at the tirne of first visit
and again immediately prior to first treatment ( median 20
days, range 3 ta 110 days) were calculated. The stability
coefficients ranged from -65 for vigor to .74 for
depression, This was explained by expected fluctuation in
mood state and in this particular case by the impact that
finding a source of assistance would have on mood.
Data Analvfiis
Descriptive statistics were used to describe the sample
characteristics in terms of demographics, disease and
treatment data, Means, standard deviation, medians, range,
percents and frequencies were used.
The interna1 consistency reliability was calculated and
examined for each of the scales used with this sample.
Besearch Oues+ions
estion 1, What are the coping strategies used by
people with advanced or inoperable primary lung cancer?
Raw scores and mean raw scores for each coping category from
the Ways of Coping Questionnaire were determined, Relative
scores (percentages) indicating which coping categories were
79
used most were calculated. Descriptive statistics including
the range of scores for each category and the mean and
standard deviation were determined. Pearson's product-moment
correlation and t-tests were used to examine the
relationships of the scores for the degree of stress, age
and gender with the scores for the coping strategies.
ouestion 2 . What is the relationship between
dispositional optimism and the coping strategies utilized by
people with advanced and inoperable primary lung cancer?
Dispositional optimism was measured using the revised L i f e
Orientation Test (LOT-R). Higher scores indicated greater
optimism. Pearson product-moment correlation coefficient
(Pearson's r) was calculated to determine the strength and
direction of the relation between dispositional optimism
scores and the scores for each coping strategy category.
Puestion 3. What is the relationship between age,
gender, coping strategies used, dispositional optimism and
the psychological well-being of people with advanced or
inoperable primary lung cancer? Multiple regression
analysis was used to determine the relationship between the
independent variables of age, gender, the coping strategy
scores, the dispositional optimism score and the dependent
variable psychological well-being as measured by the Profile
of Mood States.
cal Cowideratiom
Protection of R&h&s
Only potential participant who indicated their
willingness to consider participation in the study were
approached by the investiqator. Willingness to consider
participation was ascertained by either: the potential
participant contacting the researcher directly after
receiving a letter inviting participation in the study from
the thoracic oncology group (Appendix A); or indicating
their willingness to consider participation to the physician
or nurse in the oncology clinic who had provided a brief
explanation of the study (Appendix B).
Informed consent was obtained prior to the time of the
interview (Appendix C ) . This included an explanation of the
purpose of the study and any possible risks and benefits.
Participants were informed: that participation vas voluntary
and would in no way influence their care; that they may
withdraw at any tirne; and that al1 information would remain
confidential.
Confidentiality was assured in the following manner.
Al1 data collection sheets (demographic, disease and
treatment data sheets, and questionnaires) were identified
using a numeric code, no names appeared on any data
collection sheets. Only one list of names with corresponding
code numbers was made which was secured in a locked file
cabinet.
~is)i<sf i t ~
There were no known risks or benefits related to
participation in this study. However, due to the subject
matter it was possible that some participants may find the
process emotionally distressing. A11 participants were
informed that they may stop the interview at any time. It
was also planned that if any indication of emotional
distress was noted the interview would be stopped and
emotional support provided. Once the individual had regained
their composure they would be given the option of continuing
the interview or concluding at that point.
It was also possible that the process may be beneficial
to the participant by providing an opportunity, which they
may not have previously had, to discuss their feelings. In
completing the Ways of Coping Questionnaire they may also
identify coping strategies which may prove beneficial for
them. Providing information which may be helpful to others
may also be perceived as a benefit to the participant. One
participant did indicate that the process was beneficial in
helping her to talk about her feelings.
Prior to data collection approval of the Dalhousie
University Faculty of Graduate Studies Human Ethics
Committee and the ~cientific and Ethical Review Committee of
the Queen Elizabeth II Health Sciences Centre was obtained.
CHAPTER 111
Findings
This chapter presents the analysis of the data
collected. The first section presents the analysis of the
internal consistency reliability for each of the three study
instruments. The second section presents the analysis of the
data pertaining to each of the three research questions.
terna) Consiwtencv . .
Three questionnaires were completed in an interview
format by the study participants. The Revised Life
Orientation Test (Scheier, Carver & Bridges, 1994) was the
measure of optimism, the Ways of Coping Questionnaire
(Folkman & Lazarus, 1988b) vas used as the measure of coping
and the Profile of Hood States (WcNair, torr 6 Droppleman,
1992) as the measure of psychological well-being. The
internal consistency reliability was determined for each
instrument using Cronbach's alpha.
Revised Life orientation T e f i t
The Revised Life Orientation Test is a 10 item scale
with three positive, three negative and four filler items.
Respondents were asked to indicate their level of agreement
with the items on a five category Likert scale. Negatively
worded items were reversed prior to scoring. The Cronbach's
alpha in this study was determined to be -83. This is a
higher internal consistency then reported by Scheier,
83
Carver, and Bridges (1994) for a college student sample, for
that sample the Cronbach's alpha was . 78 .
mvs - of Co- Oue-
The Ways of Coping Questionnaire (Folkman & Lazarus,
1988b), consists of 66 items, 50 of which are categorized in
eight coping scales: confrontive coping, distancing, self-
controlling, seeking social support, accepting
responsibility, escape-avoidance, planful problem solving
and positive reappraisal,
Item number 16, 1 slept more than usual, was removed
from the escape-avoidance subscale. This item, in this
population, was not considered to be an indication of
escape/avoidance but rather related to the fatigue often
experienced by people with lung cancer and as a side-effect
of the cancer treatment- Removal of this item resulted in an
increase of the alpha coefficient from -58 to -71.
The interna1 consistency reliability for each scale was
determined using Cronbach's alpha. The results are presented
in Table 3.
Table 3
C r o w h 8 s AlPha for me Wavs - of Co- Subsca)es (N - - I
Scale # of Items Coefficient Alpha
Confrontive
Distancing
Self-Controlling
Seeking Social Support
Accepting Responsibility
Escape-Avoidance
Planful Problem Solving
Positive Reappraisal
The low reliability coefficient of .40 for the
Confrontive Coping scale in this study indicated that this
scale was not reliable for this population and therefore was
not used in any further analysis,
Reliability coefficients previously reported by
Folkrnan and Lazarus (1988b) for the community based sample
of 75 married couples were generally higher than in this
study. Cronbach's alpha coefficients for the eight scales
ranged from .61 to .79. with the greatest differences being
noted for Confrontive coping ( . 7 0 ) and Self-Controlling
( - 7 0 ) .
Profile of MQod States
The Profile of Wood States (POnS) was developed as a
measure of mood or affective state. The POMS consists of 65
adjectives, 58 of which are categorized into s ix mood
states: Tension-Anxiety, Depression-Dejection, Anger-
Hostility, Vigor-Activity, Fatigue-Inertia and Confusion-
Bewilderment. The -13s has also been used as a single global
estimate of affective state, providing a Total Mood
Disturbance Score.
Reliability coefficients were determined for each Mood
State subscale and for the Total H o o d Disturbance scale. The
results and presented in Table 4.
Table 4
Cronbach's AlPna for The Profile of Mood States Tot- - - 1
Scale # of Items Coefficient Alpha
Total Mood Disturbance 58 .94
Mood State Subscales
The subscale alpha levels were somewhat less than those
reported by McNair, Lorr 6 Droppleman (1992), but al1 were
acceptable and indicated a mderate to high internal
consistency reliability for these scales with this
population. The alpha coefficient for the Total Hood
Disturbance scale of .94 indicated a high internai
consistency reliability for this scale. An alpha coefficient
was not previously reported for the Total Hood Disturbance
scale.
Sygl~aary
The internal consistency reliability was determined for
each of the scales used in this study- An acceptable
reliability (alpha - 8 3 ) was determined for the Revised Life
Orientation Test. The reliability coefficients for the
Ways of Coping scales: distancing ( . 6 0 ) , self-controlling
( . 6 0 ) , seeking social support (.71), accepting
responsibility ( . 6 0 ) , escape-avoidance (.71), planful
problem solving (.64) and positive reappraisal ( - 7 8 ) were
also acceptable. The alpha level determined for the
confrontive coping scale was only . 4 0 and not considered
acceptable, therefore this scale was not included in any
further analysis. The reliability coefficients for the
Profile of Moods States Total Mood Disturbance scale (-94)
and the six Mooà State subscales ( - 7 6 - . 9 0 ) were al1
acceptable and indicated moderate to high levels of internal
consistency for these scales.
- The following section presents the analyses of the data
in relation to each of the three research questions.
Co~ina Strate-
The first research question asked what are the coping
strategies used by people with advanced or inoperable lung
cancer? The Ways of Coping Questionnaire (Folkman &
Lazarus, 1988b) was used as the measure of coping in this
study. This questionnaire was designed to be answered in
relation t o a specific stressful event therefore
participants were asked to select from a list of four
potentially stressful situations or to describe the
situation which they fowrd most stressful. This method of
administration was described by Dunkel-Schetter, Feinstein,
Taylor and Falke (1992).
Frequencies and percents were determined to describe
the types of stressor and the degree of stress experienced
by the participants i n this study. (Tables 5 and 6).
88
Table 5
rres of Stressors Selected bv People w m c e d oz
Stressor n E
Fear and uncertainty 28 43.7
Other 13 20.3
Limitations in ability 10 15.6
Problems with family/friends 7 10.9
P a i n or symptoms 6 9.3
Fear and uncertainty about the future due to cancer was
the situation m o s t frequently selected ( n =28, 43.8%). In
t h e category labeled nothern thirteen (20.3%) participants
chose to describe their greatest stress- These situations
included concerns related to telling adult children about
the diagnosis, a spouse being diagnosed with cancer at the
same time, waiting for diagnosis, initial shock of
diagnosis, fear of being a burden, disappointment due to
t r e a t m e n t failure, and frustration with delays in treatment
and lack of information. The situations waiting for
diagnosis, initial shock of diagnosis, and fear of being a
burden seemed to correspond to the category fear and
uncertainty about the future. These situations were not
however re-coded as the participant believed that they
represented unique situations. Other situations did not
correspond to the categories provided- !Che stress of having
a spouse diagnosed with cancer at the same time clearly did
89
not fit the categories. Also identified was the stress
experienced in relation to delays in treatment and with lack
of information. Two participants could not identify a
specific stressor, and rated their degree of stress as none.
The majority of the participants rated the degree of
stress experienced in relation to the stressor as
'9noderately stressfulw (n = 17, 2 6 . 6 % ) , or "very stressfuln
(n = 25, 39.1%).
Table 6
ree of Stress
Ino-a C a n c e r -- - - --
Degree of Stress n 2
Not Stressful
Mildly Stressful
Moderately Stressful
Very Stressful
Extremely Stressful
Data from seven of the coping scales, from the Ways of
Coping Questionnaire, was analyzed. Raw, mean and relative
scores were calculated for each of the coping scales. As
some scales had up to eight items and others only four the
mean and relative score for each scale were used for the
purposes of cornparison. Relative scores indicate the
contribution of each scale relative to al1 the scales
combined. A high relative score for a coping scale means
the coping behaviours included were used more often than
other behaviours.
Using the mean individual scores the mean, standard
deviation, range of scores and relative scores for each of
the coping scales were determined, and are presented in
Table 7.
Table 7
n. R a n ) and Relative
Scores fPercex&a!aesl f n r W a v r a ofmhJ Scales (N - - 1 a
Scale Mean SR Range p ~
Seeking social support 1.71 .72 .33-3.0 25
Distancing 1.22 .64 00-2 , 5 18
self-controlling 1.10 .58 00-2.9 15
Planful problem solving 1.02 .61 00-2 . 5 14
Positive reappraisal 0.95 .72 00-2 . 6 12
Escape-avoidance O . 68 .51 00-2 . 1 9
Accepting responsibility 0.52 .60 00-2.5 6
'~elative percentage indicates contribution of scale
relative to al1 scales combined.
As presented in Table 7 the behaviours which comprise
the scale seeking social support w e r e used most often, those
included in the accepting responsibility scale were used the
least,
In order to determine if there were differences in the
use of coping strategies based on gender a StudentOs two
sample t-tests on the means for males and females for each
of the coping scales were performed. No statistically
significant differences were found.
It was also considered that age may influence the use
of coping strategies. The participants were divided into two
age groups: Group 1 = 40 - 59 years, n = 26; and Group 2 =
60 - 79 years = 38. Student8s two sample t-tests showed
no statistically significant differences between the age
groups for any of the coping scales.
Pearson's product-moment correlation was also used to
determine if any significant relationship existed between
age and any of the coping scales. Using this statistic a
negative low correlation was found between escape-avoidance
coping and age (r = 0.305 p =-01) for the ungrouped data
(Table 8 ) . Pearson's product-moment correlation was used to
determine if there were significant correlations between the
degree of stress perceived and each of the coping strategy
scales. There was a low, negative correlation between the
degree of stress, and the use of distancing strategies ( r =
-0.26 Q = 0.03) indicating that when more stress was
perceived fewer distancing strategies were usedm (Table 8).
92
Table 8
. . nt Correlat iclents for Degree
of Stress md Aue w th the Co s (N - 1 - -
Degree of Stress AQe
Seeking Social Support 0.22 0.12
Distancinq -0.26* -0.01
Planful Problem Solving 0.22 0. 07
Positive Reappraisal -0.04 -0.03
Escape-Avoidance -0.03 -0.30*
Accepting Responsibility -0.15 -0 . 10 *g < . 0 5 .
The correlations between the degree of stress and
seeking social support, and between the degree of stress and
planful problem solving approached significance (r = 0.22 p
= 0 . 0 7 ) .
To determine if the type of stress influenced the use
of coping strategies the sample was sorted by the stressful
situations which were identified by the participants. The
type of stressor subgroups were: fear and uncertainty about
the future due to cancer; limitations in physical ability,
appearance, or life style due to cancer; pain, symptoms, or
discornfort from illness or treatment; problems with family
or friends related to cancer, and other.
The means and relative scores were then calculated for
9 3
each group. The mean scores and standard deviations are
presented in Table 9. Seeking social support had the highest
mean and relative score in each of the groups except,
problems with family or friends. In the group which selected
problems with family and friends as their most stressful
situation the relative scores for distancing (20%) and self-
controlling (17%) were higher then for seeking social
support (15%).
With the data still grouped according to the stressful
situation a one-way analysis of variance (ANOVA) was
performed to determaine if there were statistically
significant differences between the groups for any of the
means of the coping scales. For this procedure the group
labelled other was coded as missing data because this group
consisted of several differing types of stressors.
Statistically significant differences were determined
between the groups for the coping scale escape-avoidance LE
(3.47) = 3.60; p = 0.0201). In order to determine which
groups had statistically significant differences Tukey8s
studentized range test was performed. The escape-avoidance
coping scale mean scores were found to be different between
the groups limitations in physical ability, appearance, or
life style due to cancer and tvo of the other groups, fear
and uncertainty about the future due to cancer, and problems
with family or friends related to cancer. In each case the
mean score for the escape avoidance category was lower when
the identified stressor was limitations in ability. The
r e s u l t s of the one-way ANOVA and the Tukey test are
presented in Table 9.
Table 9
ce for Me Scores
e of Stressor S-
Stressor Subgroups Pear and Limitations in Pain, Roblers Uncertainty ability S y i p t o u Parily/f riend n = 28 n =10 n = 6 n = 7
Copinq Strategies H SD LI SR LI Sr! CI SP P - - - - - - p p
Distancinq 1.36 0.59 1.02 0.74 0.86 0.27 1.66 0.75 2.55
Self -controlling 1.17 0.58 1.07 0.54 0.98 0.46 1.51 0.75 1.08
Seekinq Social Sueport 1.65 0.74 1.56 0.63 2.17 0.88 1.28 0.88 1.51
Accepting 0.66 0.71 0.25 0.31 0.13 0 .N 0.85 0.71 2.40 Respnsibility
Planf ul problei O.% 0.63 1.08 0.39 1.14 0.84 1.07 0.43 0.22 solving
Positive Reappraisal 1.03 0.74 0.73 0.78 0.81 0.76 1.20 0.66 0.75
Hote. Hem vith different subscripts differ significantly at p < .O5 in Wreyts studentized range test. *Q < .os.
SummarY
The stressful situation most frequently identified by
the participants of this study was fear and uncertainty
about the future (n =28, 43.7%). Thirteen (20.3%) choose not
to select from the provided list of stressful situations but
to describe their greatest stress relsted to their diagnosis
of lung cancer. Most of the participants rated the degree of
95
stress experienced as moderately or very stressful.
The mean and relative scores for the coping categories
indicated that the behaviours included in the seeking social
support scale were used most frequently. This was followed,
in order of decreasing scores, by distancing, self-
controlling, planful problem solving, positive reappraisal,
escape-avoidance and accepting responsibility.
Student8s two sample t-tests revealed no statistically
significant gender differences were found for the mean
coping category scores. Repeating the two sample t-test for
the sample divided into two age groups (Group 1 = 40 - 59 years, n = 26; and Group 2 = 60 - 79 years n = 38) no
statistically significant age group differences were found
for the coping category scores. However using Pearson's
product-moment correlation for the ungrouped data a low
negative correlation between escape-avoidance coping and age
(r = -JO5 p = A l ) was determined. Pearson's product-moment
correlation also indicated a low negative correlation
between the degree of stress and the coping category
distancing (x = -0.26, p = - 0 3 ) .
The group was then divided according to the type of
stressful situation. Seeking social support remained the
coping category with the highest mean and relative scores
for al1 groups except the group who selected 'problems with
family or friends' as their most stressful situation. For
this group the scores for distancing and self-controlling
were higher then for seeking social support.
One-way analysis of variance was performed to determine
if the means for the coping categories for the grouped data
differed according to the type of stressful situation. A
significant difference vas found for the coping category
escape avoidance (Table 9). Tukey's studentized range test
indicated that there were statistically significant
differences in the mean scores for the coping category
escape avoidance between the group limitations in physical
ability, appearance, or life style due to cancer and the
means of two other groups, fear and uncertainty about the
future due to cancer, and problems with family or friends
related to cancer (Table 9).
D m s i t i w O p t i a l s m Co- . . . .
Strateaies
The second research question asked what is the
relationship between dispositional optimism and the coping
strategies utilized by people with advanced and inoperable
primary lung cancer?
Dispositional optimism was measured in this study using
the Revised Life Orientation Test(L0T-R) (Scheier, C a r v e r &
Bridges, 1994).
The mean, standard deviation, median and range of
scores were determined. Using this scale, higher scores
indicated greater degrees of optimism. The mean optimism
97
score as determined by Life Orientation Test was 15-9 (SD =
5 - 3 ) , the median was 17 and the range of scores was 2 - 24. The mean and median scores indicate a moderate degree of
optimism.
Pearson's product-moment correlation coefficient was
calculated to determine the strength and direction of the
relationship between dispositional optimism and each of the
coping scales- None of these correlations proved to be
significant at alpha i -05- A low negative correlation
between escape avoidance coping and LOT-R approached
significance (x = 0.22, p = -07)-
relationship between age, gendet, coping strategies used,
dispositional optimism and the psychological well-being of
people with advanced or inoperable primary lung cancer?
The dependent variable psychological well-king was
measureà using the Profile of Mood States (McNair, Lorr 61
Droppleman, 1992). This instrument measures six mood states;
tension-anxiety, depression-dejection, anger-hostility,
vigor-activity, fatigue-inertia and confusion-bewilderment
and provides single global estimate of affective state, the
total mood disturbance score.
The mean, standard deviation, actual range of scores
and the potential range of scores for each mood state and
for total mood disturbance are presented in Table 10.
Table 10
S t a w d nevia- of Scores
Subscale Mean sr! Actual Potential
Range Range
Confusion-
bewilderment 6.92 4.98 00 - 22 00 - 28
Total mood disturbance 28.14 29.06 -20 - 117 - 3 2 - 200 Note. Higher mean scores indicate greater mood disturbance
with the exception of the vigor-activity scale.
Multiple regression analysis was used to determine the
relationship between the independent variables of age,
gender, coping strategies, type of stressor, degree of
stress and dispositional optimism and the dependent variable
psychological well-being. The type of stressor and the
degree of stress were included because of their relationship
to the coping strategies. Stepwise multiple regression was
first perfonned on the dependent variable total mood
disturbance using the independent variables of age, gender,
99
optimism as measured by the Life Orientation test the type
of stressor, the degree of stress and the seven coping
strategies determined by the Ways of Coping Questionnaire,
The type of stress was coded according to the five groups
identified from the Ways of Coping Questionnaire (fear and
uncertainty about the future due to cancer; limitations in
physical ability, appearance, or life style due to cancer;
pain, symptoms, or discornfort from illness or treatment;
problems with family or friends related to cancer, and
other). This analysis revealed a model with four independent
variables explaining 41% of the variance of the total mood
disturbance score 10.34, p = .0001)(Table 11)- The
independent variables that best predicted the total mood
disturbance score were the coping strategy escape-avoidance
which explained 17% of the variance, the degree of stress
which explained 12%, optirnisrni which explained 8% and the
coping strategy distancing which explained 4% of the
variance in the dependent variable. Distancinq and optimism
were inversely related to the total mood disturbance score.
Both fornard and backward variable selection procedures were
performed, al1 methods produced the same final model.
Table 11
- -- . - - - -- -
Variable Coefficient Standard A Ra s E
Error
Escape-
avoidance 26.41 6.48 0.17 0.17 12.60***
Degree of
stress 7.34 2.79 0.12 0.29 10.29**
Optimism -1.49 0.56 0.08 0.37 7.49**
This statistical procedure was repeated with each of
the mood states as the dependent variable. Stepwise multiple
multiple regression was next performed on the dependent
variable tension-anxiety mood state using the independent
variables of age, gender, optimism, type of stress, degree
of stress and the seven coping strategies. This analysis
revealed a mode1 with two independent variables explaining
25% of the variance of the tension-anxiety mood score a 9.97, p = .0002)(Table 12). The independent variables that
best predicted the tension-anxiety mood score were the
degree of stress explaining 13% of the variance and the
coping strategies escape-avoidance explaining 12% of the
variance.
- - - . - - - . - - -
Variable Coefficient Standard A R2 K E
Error
Degree of
stress
Escape-
avoidance
A stepwise multiple regression with the dependent
variable fatigue-inertia mood state and the independent
variables of age, gender, optimism, the type of stress, the
degree of stress and the seven coping strategies was
performed. This analysis revealed a mode1 with two
independent variables explaining 16% of the variance of the
fatigue-inertia mood score LE 5.71, p = ,0053) (Table 13).
The independent variables that best predicted the fatigue-
inertia mood score were optimism which explained 9% of the
variance, and the coping strategy self-controlling which
accounted for 7% of the variance in the dependent variable.
Optimism was inversely related to the fatigue-inertia mood
score.
102
Table 13 . .
$te&e M w l e Reureswaon of A-- Gender. ODtlmlsml
Stressorsa deglree of Stress and Seven Copina Stratedes with
F F - - - --
Variable Coefficient Standard A R2 le E
Error
Optimism -0.42 0.15 0.09 0.09 6.13*
Self - Controlling 3.10 1.40 0.07 0.16 4.90*
A stepwise multiple regression w i t h depression-
dejection mood state as the dependent variable and the
independent variables of age, gender, optimism, type of
stress, degree of stress and the seven coping strategies was
conducted. This analysis revealed a mode1 with t w o
independent variables explaining 29% of the variance of the
depression-dejection mood score (F 12.46, p = .0001)(Table
14). The independent variables that best predicted the
depression-dejection mood score were the coping strategy
escape-avoidance accounting for 20% of the variance and
optimism explaining 9% of the variance. Optimism was
inversely related to the depression-dejection maod score.
103
Table 14
Escape-
avoidance
Optimism
A stepwise multiple regression with the dependent
variable of anger-hostility mood state and the independent
variables of age, gender, optimism, type of stress, degree
of stress and the seven coping strategies was conducted.
This analysis revealed a mode1 with two independent
variables explaining 28% of the variance of the anger-
hostility mood score (F 11.09, p = -0001)(Table 15). The
independent variables that best predicted the anger-
hostility mood score were the coping strategy escape-
avoidance accounting for 14% of the variance and the degree
of stress accounting for 14% of the variance-
104
Table 15 . . on of A g e - Gender. O ~ t i m l s r a ,
tv Mood State Score (N - - 1 -
Variable Coefficient Standard 4 R2 E E
Error - - - - - - - - - - - -
Escape-
avoidance 4.33 1.20 0.14 0.14 10.44**
Degree of
stress 1.92 O. 56 0.14 0.28 11.58+*
A stepwise multiple regression with the dependent
variable of confusion-bewilderment mood state and the
independent variables of age, gender, optimism, type of
stress, degree of stress and the seven coping strategies was
conducted. This analysis revealed a mode1 with three
independent variables explaining 37% of the variance of the
confusion-bewilderment mood state score jF 11.80, p= .0001)
(Table 16). The independent variables that best predicted
the confusion-bewilderment mood state score were the coping
strategy escape-avoidance which explained 23% of the
variance, the coping strategy distancinq which explained 7%
and optimism which accounted for 5% of the variance in the
dependent variable. Distancing and optimism were inversely
related to the confusion-bewilderment mood state score.
105
Table 16
Ste~wise Multiple R- of Aue, G m r . Optlmlsm. and . .
Seven C o m a - Stratmies w i a m i o n - Bew-ent Mooa
State Score fBf - - 1
Variable Coefficient Standard A R2 E E
Error
Escape-
avoidance 5.46 1.14 0.24 0.24 19.55***
Distancinq -2.23 0.88 0.08 0.32 6 .92*
Optimism -0-22 0.10 0.05 0.37 5.14* *g < . 0 5 . ***Q < .O01
A stepwise multiple regression with the vigor-activity
mood state as the dependent variable and the independent
variables of age, gender, optimism, type of stress, degree
of stress and the seven coping strategies was conducted.
This analysis revealed a mode1 with three independent
variables explainhg 26% of the variance of the vigor-
activity mood score (F 7.18, p = .0003). The independent
variables that best predicted the vigor-activity mood score
were the degree of stress which accounted for 11% of the
variance, the type of stressor (pain, symptoms or
discomfort) which explained 8% of the variance and optimism
which accounted for 7% of the variance in the dependent
variable (Table 17). The degree of stress and the type of
stressor were inversely related to the vigor mood state-
- --
Variable Coefficient Standard A Rz E E
Error
Degree of
stress -2.03 O. 65 0.11 0.11 7.66*+
Stressor
pain/symptoms -5.93 2.41 0.08 0.19 6.28*
Summarv
Psychological well-being, the dependent variable for
the third research question was measured using the Profile
of Mood States (McNair, Lorr & Droppleman, 1992)- The total
rnood disturbance score and scores for s i x mood states were
determined. Multiple regression analysis was used to
determine the relationship between the selected independent
variables and dependent variable total mood disturbance.
Multiple regression was also used to examine the
relationships between the independent variables and each of
the mood states.
Forty-one percent of the variance of the total mood
disturbance score was explained. The independent variables
that best predicted the total moocf disturbance score were
107
the coping strategies escape-avoidance and distancing, the
degree of stress and dispositional optimism. Distancinq and
optimism were inversely related to the total mood
disturbance score.
Three of the independent variables were predominant in
the regression models; the coping strategy escape-
avoidance, dispositional optimism and the degree of
perceived stress. The coping strategy escape-avoidance was a
significant predictor of the variance in five of the models
total mood disturbance, tension-anxiety, depression-
dejection, anger-hostility, and confusion-bewilderment. It
was nat significant in explaining the variance in the models
for the dependent variables of fatigue-inertia or vigor-
activity . Dispositional optimism was a significant predictor in
total mood disturbance, confusion-bewilderment, vigor-
activity, fatigue-inertia and depression-dejection but not
in the tension-anxiety and the anger-hostility models.
Optimism was invetsely related to the dependent variable in
each of the models except for vigor-activity.
The degree of stress was a significant predictor in
four of the multiple regression models; total mood
disturbance, tension-anxiety, anger-hostility, and vigor-
activity but not in fatigue-inertia, depression-dejection or
confusion-betwilderment. The degree of stress was inversely
related in the mode1 predicting vigor-activity.
The score of the coping strategy distancinq was a
significant predictor in the models that used total m o o à
disturbance and confusion-bewilderment as the dependent
variables. Distancing was inversely related to the dependent
variable in both of these models. The the score of the
coping strategy self-controlling was a significant predictor
in the mode1 that used fatigue-inertia as the dependent
variable. The type of stressor (pain, symptoms, or
discornfort from illness or treatment) was a significant
predictor of the vigor-activity mood state score.
The independent variables of age, gender, and the
coping strategies seeking social support, planful problem
solving, accepting responsibility and positive reappraisal
did not enter any of the regression equations with entry
level alpha of 0 . 0 5 .
Discussion
This chapter presents the discussion of the findings
according to each research question.
g v Pe_oDlewitnulQper'tnor-rable
umLcmG= Consistent with the findings of Dunkel-Schetter,
Feinstein, Taylor and Falke (1992) fear and uncertainty
about the future due to cancer was the most frequently
identified stressful situation selected by the participants
in this sample. This was followed, in order of decreasing
frequency, by those who chose to describe their greatest
stressor, limitations in abilit.1 and life style, problems
with family or friends, and pain or symptoms. This pattern
of frequency reflected the fairly high performance status of
this sample. Most were limited only in strenuous activity
and al1 were ambulatory. With the progression of this
illness one would expect that limitations in ability, and
pain and symptoms may become the more prevalent stressors,
however at this particular phase of illness fear and
uncertainty about the future was predominant. It must also
be considered that being presented with a list of possible
stressors influenced the participants decision regarding
their greatest stressor. As would be expected among people
110
with advanced lung cancer the degree of perceived stress was
rated as moderate to very stressful by the majority of
participants. This level of stress was consistent with the
findings of Dunkel-Schetter et al. (1992) among patients
with a variety of types of cancer.
The coping strategies used by the participants in this
çample were detemined by the Ways of Coping Questionnaire
(Folkman & Lazarus, 1988b). Seven of the eight subscales
were used. Confrontive coping was excluded because of a low
reliability coefficient in this sample. Miller et al. (1996)
also found a low reliability for this subscale in a sample
of people with advanced cancer. The confrontive coping
subscale which was described as "aggressive efforts to alter
the situation and suggests some degree of hostility and
risk-takingw; this method may not be relevant for people
with advanced cancer. Miller et al. (1996) also excluded the
scales for the coping strategy distancing and self-
controlling due to low reliability coefficients.
Seeking social support was the coping category used
most by this sample of people with advanced lung cancer. On
average this coping category accounted for 25% of the total
coping effort and was the only category which was used to
at least some degree by al1 the participants. The use of
this strategy may be partially explained by the high
availability of support to this group. Al1 of the
participants in the study were being followed in the cancer
111
centre and had regular contact with the physicians and
nurses of the centre. Items in this scale such as Valking
to someone to find out more about the situationn, "getting
professional helpn, Valking to someone who could do
something concrete about the problemn seemed to tapthis
type of support. In addition the majority (81.2%) of the
participants were living with their spouse or other family
members which would also enhance the availability of social
support.
A consistent primary coping strategy among people with
cancer was not found in the literature reviewed. While the
current study found the coping strategy seeking social
support to be used most frequently, Miller et al. (1996) in
a study of people with advanced cancer found the coping
strategy positive reappraisal to be the strategy used most.
Caner et al. (1993) found that among women with early stage
breast cancer the use of the coping strategy acceptance was
significantly higher than the other scales used. In a
longitudinal study of women with breast cancer Stanton and
Snider (1993) found that the use of strategies varied with
tirne. Dunkel-Schetter et al. (1992) found distancinq coping
strategies to be most common. This lack of consistency
supports the view of Lazarus and Folkman (1984) that coping
is a dynamic and changing process.
Most of the coping strategies were used at least to
some extent by most of the participants. The one exception
112
was the coping strategy accepting responsibility. This
strategy had the lowest mean score and contributed only 6
percent to the total coping score. Twenty two (34.4%) of the
participants did not use any of the items on this scale. The
limited use of the coping strategy accepting responsibility
among people with advanced cancer was consistent with the
findings of Miller et al. (1996). The coping strategy
accepting responsibility was not included in any of the
other studies among people with cancer which were reviewed.
King, Roue, Kimble, and Zerwic (1998) found the use of the
strategy self blame to be moderate among women recovering
from heart surgery. The limited use of the accepting
responsibility strategy in this study may reflect that there
were only 4 items on the accepting responsibility scale
however it also must be considered that the items comprising
this scale may not have been selected because they were
viewed as negative (e.g. 1 criticized or lectured myself, 1
realized that 1 had brought the problem on myself). Given
the relationship between smoking and lung cancer the item
relating to bringing on the problem myself may have
triggered a denial response. The coping strategy accepting
responsibility may simply not be relevant in managing the
stress related to a diagnosis of lung cancer.
In assessing the relationship between the degree of
perceived stress and the use of specific coping strategies a
low negative correlation (r = -0.26 p = . 0 3 ) was determined
113
between the coping strategy distancing and the degree of
perceived stress indicating that those who perceived the
situation as most stressful used fewer distancing
strategies. It has been suggested that in relation to
psychological distress the coping strategy distancing, which
minimizes and distracts attention from the situation, may
not be needed at very low levels and may not be possible at
very high levels (Dunkel-Schetter et al., 1992). It may also
be that at high levels of perceived stress individuals are
unable to use distancing coping strategies. Dunkel-Schetter
et al. (1992) also examined the relationship between the
degree of perceived stress and the selection of coping
strategies finding that the degree of perceived stress was
associated with greater coping through seeking social
support, and the use of escape-avoidance coping strategies,
but not with the strategy distancing. The current study did
not find an association between the degree of perceived
stress and either of the coping strategies seeking social
support or escape-avoidance. The role of perceived stress in
the selection of coping strategies remains unclear.
To determine if the use of coping strategies varied
with the situation the sample was grouped according to the
situations identified as most stressful by the participants.
The ordering of the mean scores did Vary with the situation
in what seemed to be a logical manner. When the situation
identified as most stressful was related to fantily and
114
friends both the scores for the coping strategies distancing
and self-controlling were greater than the strategy seeking
social support. This may indicate that when the source of
social support was viewed to be the source of stress coping
strategies other than seeking social support were selected.
When the problem was limitations in ability or pain and
symptoms the coping strategy score for planful problem
solving was the second highest, however when the problem was
fear and uncertainty or problems with family and friends the
score for the coping strategy planful problem solving fell
to fifth. A one way analysis of variance performed on the
grouped data determined that for one coping strategy, escape
avoidance, the differences in the mean scores were
significant (r 3 , 4 7 = 3 . 6 0 ; p = 0.02). Further analysis
using Tukey's studentized range test indicated that the
coping strategy escape avoidance was used less when the
situation involved limitations in ability than when the
situation was either fear and uncertainty or problems with
family or friends. Participants may have found that as they
performed their daily activities they were constantly
reminded of of their physical limitations making avoidance
of this situation more difficult. Longitudinal studies among
women with breast cancer (Carver at al., 1993; Stanton &
Snider, 1993) have found that the use of coping strategies
varies over tirne. These studies did not specify the stressor
in more detail than coping with breast cancer but one would
115
expect the specific stressful aspects of the situation would
change over time supporting the concept that different
strategies were used to mange different stressors. This
variation in selection of coping strategies based on the
specific cancer related situation is consistent with the
view of Lazarus and Folkman (1984) that the process of
coping used varies with the significance and requirements of
the situation. Contrary to this view Dunkel-Schetter et al.
(1992) did not find the pattern of coping to Vary with the
stressful situation.
Gender differences in the use of coping strategies
suggesting that women use more emotion focused coping then
men have been fowid in a number of studies involving
university students (Chang, 1998a; Ptacek et al. 1992;
Thoits, 1991). Studies of adult cancer populations (Dunkel-
Schetter et al., 1992; Friedman et al., 1992) have not found
gender differences. Consistent with this finding this study
using two sample t-tests on the means for males and females
for each of the coping strategies found no gender
differences. It has been suggested that in similar
situations men and women use similar strategies (Porter h
Stone, 1995; Lazarus, 1993). Findings from this study
support this contention.
The possibility that age would influence the use of
coping strategies was explored. Younger age has been
associated with the greater use of seeking social support,
116
focusing on the positive and behavioral escape avoidance
(Dunkel-Schetter et al., 1992). In the present study a low
negative correlation (r = 0.30 p = -01) was determined for
escape avoidance coping and age indicating a decrease in the
use of this strategy with increasing age. To further
explore this the participants were grouped into two age
categories, (Group 1 = 40 - 59 years and Group II = 60 - 79 years) however no significant differences were detemined
based on Students t-tests. A plot of these data revealed
that this relationship did not become evident until in the
late 60 's explaining the lack of a significant relationship
when the group was divided at age 60. This plot also
revealed the existence of an outlier, one participant aged
74 who had the highest score on the escape avoidance
subscale. On further investigation this participant was one
of the feu participants with early stage cancer but was not
operable for other medical reasons, Removal of this
participants data set from analysis produced a much stronger
negative correlation between age and escape avoidance coping
(r = 9-41, p = -0008) but there still no significant
differences between the two age groups when the dividing
point was age 60, Changing the division point to age 65 did
demonstrate a difference in the age groups. Halstead (1994)
studying the coping strategies used by long term cancer
survivors found difierences in the coping strategies of the
middle aged (41-65 years) and the elderly (65-82 years). The
117
elderly group used more optimistic and palliative strategies
and the middle-aged more emotive strategies. No differences
were f o n d in the use of evasive strategies between the two
age groups, Why the elderly would be less likely to use
escape avoidance as a coping strategy is not clear- The
items in the escape avoidance scale focused on denial and
avoidance of the reality of the situation being managed- It
may be that the elderly appraise what is at stake in the
situation differently and as a result feel less need to
avoid or deny the situation (Edlund 6i Sneed, 1989). When the
stressful situation is related to a diagnosis of advanced
lung cancer the elderly may be better prepared to accept a
poor prognosis-
In summary, while the participants in this study tended
to use a variety of strategies, seeking social support was
the only strategy used by al1 the participants in al1
situations. This may simply reflect the availability of
social support to this particular sample. There did seem to
be variability in the use of the strategies depending on the
situation but for only the coping strategy escape-avoidance
was there a significant difference across the situations.
Escape avoidance coping was used significantly more by the
participants w h o identified their stressor as fear and
uncertainty, or problems with family and friends than those
participants w h o identified limitation in ability-
Distancing as a coping strategy was used less by those who
118
perceived greater stress. These findings support the theory
that primary appraisal of the situation influences the
selection of coping strategies. Gender was not significant
in the selection of coping strategies in this study
consistent with the concept that it is the situation not
gender that is more important in coping (Lazarus, 1993).
The role of age in the use of coping strategies among this
sample was less clear. Age seemed only to be of importance
in relation to the coping strategy escape avoidance with a
pattern indicating that this strategy was used less often by
the most elderly in the sample.
The ~ebtionçhiP between n-tlom . . . OP- and C o u
Strateaies.
Dispositional optimism has been defined by Scheier and
C a r v e r (1992) the tendency to believe that one will
generally experience good versus bad outcomes in lifem. In
this study optimism was measured using the revised Life
Orientation Test (LOT-R). The mean score was 15.9 (SD =
5 4 , this vas slightly higher than the mean score of 13.9
obtained among a large sample of college students (Chang,
1998a). Direct comparisons with other studies is not
possible as most have used the original version of the Life
Orientation Test, however the finding of higher optimism
scores among people with cancer compared with college
students is not an unusual finding (Miller et al., 1996;
119
C a n e r et al., 1993) but has not been consistent (Friedman
et al., 1992). Whether optimism is a consistent trait or
increases with age or when faced with a life threatening
illness is not clear. Age and optimism were not correlated
in this study.
Based on an assumption underlying the theory of
behavioral self regulation that expectancies influence
action Scheier and Carver (1985) theorize that when a
discrepancy between the current situation and a goal exists
an assessment of the possibility of goal achievement is
made, an optimist having greater expectations of success is
more likely to view the goal as attainable and therefore
more likely to persist and as a result experience better
outcorne. That optimists do experience better outcomes at
least in terms of psychological well-king has b e n
supported in a number of studies (Chang, 1998a; Segerstrom
et al., 1998; King et al., 1998; Dunbar et al., 1996;
Scheier, 1989; Taylor, et al., 1992; Baker et al- 1997;
Carver et al., 1993; Stanton t Snider, 1993; Miller et al.,
1996). Scheier, Weintraub and Carver (1986) also have
purposed that the differences experienced by an optimist and
a pessimist are related at least partially to the selection
of different coping strategies- Although the empirical
support for this contention is not as strong, a number of
studies have a found a relationship between optimism and the
uses of certain coping strategies (Scheier, Weintraub &
120
Carver, 1986; Friedman et a1,,1992; Shepperd et al., 1996;
Carver et al,, 1993; Chang, 1998a; King et al., 1998;
Segerstrom et al., 1 9 9 8 ) . The current study did not however
find this relationship. Although the relationship between
optimism and escape avoidance coping did approach
significance none of the relationships between optimism and
the seven coping strategies were significant.
Because of the theoretical and empirical support for
the existence of this relationship the lack of support found
in this study requires further exploration. A number of
possible explanations were considered.
Although a fairly consistent finding the strength of
the relationships reported have for the most part been low
to moderate. It is possible that the sample size of this
study was not sufficient to detect a relationship between
coping and optimism.
A second possibility considered was that the use of the
revised version of the Life Orientation Test in this study
may be the reason that no relationships were found between
optimism scores and the coping strategies. The Life
Orientation Test was revised (Scheier, Canter C Bridges,
1994) because two of the items on the original scale were in
fact items related ta coping by positive reinterpretation.
Despite the revision the original scale has remained in use
and with the exception of a study by Chang (1998s) al1 of
the studies reviewed used the original scale, Chang did
121
however find a relationship between a number of coping
strategies and optimism which weakens this arguaient.
It was also considered that relationship of optimism
and the use of specific coping strategies may be
situational, in some situations optimist and pessimist may
tend to use different strategies but this may not hold true
for al1 situations. A relationship between optimism and
coping may not have been found in this study because of the
method used in the measurement of coping. The participants
in this study were interviewed between one month and one
year of diagnoses and in responding to the coping
questionnaire were asked to identify a specific stressful
situation in relation to having a cancer diagnosis.
Therefore while the underlying theme vas a diagnosis of lung
cancer the participants were in fact dealing with a variety
of different stressors and were at different points along
the illness continuum. Longitudinal studies do provide some
support for this possibility that the relationship between
the level of dispositional optimism and the selection of
coping strategies is situational. Carver et al. (1993)in a
study among women who had surgery for breast cancer, found
significant associations between optimism and some
strategies over the course of a year but other strategies
were only significantly associated at some of the
measurement points. In a study of women recovering from
coronary artery bypass graft surgery King et al. (1998)
122
found fewer significant relationships and none thatwere
consistent across the study period-
This study did not find any significant relationships
between optimism and coping. While optimism may nothave the
same relationship to coping among people with lung cancer as
has been found in other studies a nuaaber of methodological
issues have b e n explored which could provided alternate
explanations,
The Relatio-p between hae, Strateaes,
Opti- gnd P s y c h o l a Well - beina,
The final research question explored the relationship
between the selected independent variables and the dependent
variable psychological well-being. Psychological' well-
being was measured using the Profile of Mood States ( P O M S ;
McNair, Lorr & Droppleman, 1992) which provides a total mood
disturbance score and scores for each of six mood states.
Higher scores indicate less well-king and greater distress
with the exception of one scale, the vigor-activity scale.
Consistent with the findings from previous studies among
people with lung cancer (Cella et al,, 1987) and breast
cancer (Carver et al., 1993; Stanton & Snider, 1993) the
participants in this study did not indicate high levels of
distress (total mood disturbance m = 28.1, possible range - 32 - 200). There were no significant differences between
the means based on gender in this group. The mean for the
123
male participants (m = 29.5) was actually slightly higher
than for the females (m = 25.0). Although no tests of
statistical significance were conducted the scores for this
population were not dissimilar from those of a large (n
=2360) sample of adults participating in a smoking cessation
program (mean total mood disturbance score for males was
2 7 . 2 and 33.4 for females, HcNair, torr C Droppleman, 1992).
The scores on the subscales were also similar to those of a
sample of womien following surgery for breast cancer (one
exception was on the confusion-bewilderment scale where the
mean for the breast cancer sample was 2.76 and for lung
cancer was 6.92)(Stanton & Snider, 1993). These findings
regarding mood disturbance do not support the finding that
people with lung cancer are more distressed (Weisman 6
Worden, 1976-77) or that women experience higher levels of
distress (Cella et a1.,1987; HcNair, Lorr & Droppleman,
1 9 9 2 ) .
Multiple regression analysis was used to further
explore the relationship between the independent variables
of interest; age, gender, optimism, and coping, with the
dependent variable psychological well-being. In addition two
other variables were included in the regression analysis,
the degree of stress and the type of situation. These
variables were included because in previous analysis they
did show some degree of relationship to coping and because
of their theoretical significance in relation to Lazarus and
124
Folkman's (1984) model of stress and coping. In this model
primary appraisal, the initial assessment of the situation,
is considered to be of importance in determining the use of
coping strategies. The situation, or what the individual is
coping with, and degree of stress produced by the situation
are important components of primary appraisal. Chang (1998a)
found that primary and secondary appraisal were both
significant in predicting coping strategies and the outcome
measures of life satisfaction and deprsssive symptoms.
The first regression analysis included the variables
age, gender, optimism, the type of stressor, the degree of
stress, and seven coping strategies regressed on the total
mood disturbance score. Forty-one percent of the variance of
the total mood disturbance score was explained. The
independent variables that best predicted the total mood
disturbance score were the coping strategies escape-
avoidance and distancing, the degree of stress and
dispositional optimism. The coping strategy distancing and
optimism were inversely related to the total mood
disturbance score. The amount of variance explained by
optimism was less than for escape avoidance. This may be
related to the outcome measure used (moad disturbance) as it
bas been suggested that optimism better predicts the
positive aspects of adjustment than the negative (Miller et
al., 1996). Multiple regression analysis was also used to
examine the relationships of the independent variables with
125
each of the six mood states. Three of the independent
variables were predominant in the regression models; the
coping strategy escape-avoidance, dispositional optimism and
the degree of perceived stress.
The relationship between the use of the coping
strategy escape-avoidance and psychological distress was
not surprising. Avoidance coping has been fond to be
significant in the prediction of greater psychological
distress in previous research (Stanton & Snider, 1993;
Segerstrom et al., 1998; King et al., 1998; Miller et al.,
1996; Carver et al., 1993; Dunkel-Schetter et al., 1992).
Escape-avoidance coping is an emotion focused strategy
directed at lessening emotional distress (Lazarus & Folkman,
1984) however it appears to have the opposite effect. Why
escape avoidance coping has this effect is not clear.
Several possibilities have been considered. Avoidance coping
may interfere with more effective or problem solving
actions, it may have a paradoxical effect and intensify the
thoughts being avoided, and it consumes considerable effort
(Stanton & Snider, 1993).
Examining the items included in this strategy provides
some insight as to why this strategy was not successful. The
escape avoidance strategy included elements of denial, nI
refused to believe that it had happenedu; wishful thinking,
nI hoped for a miraclem, NI wished that the situation would
go awayn, 1 had fantasies or wishes about how things might
126
turn outn; and active avoidance, "1 generally avoided king
with peoplen, "1 tried to make myself feel better by eating,
drinking, drugs etcon A11 avoid and deny the reality of the
situation, a reality that is constantly reinforced in this
population by the occurrence of symptoms, treatments and
doctors appointments.
Dispositional optimism was a significant predictor of
the variance in the score for total mood disturbance.
Previous research has linked optimism and psychological
we11-being/distress in a number of different populations
including university students, (Chang, 1998a; Segerstrom et
al., 1998), heart disease, (King et al., 1998; Dunbar et
al., 1996; Scheier, 1989) AIDS, (Taylor, et al., 1992)
cancer patients receiving bone marrow transplant, (Baker et
al. 1997) breast cancer,( Carver et al., 1993; Stanton 6
Snider, 1993) advanced cancer, (Miller et al., 1996). The
present research, in a population of people with advanced
lung cancer, supports this finding.
How optimism functions in promoting psychological well-
being has been the focus of some speculation. One theory
postulates that optimist and pessimist cope differently and
it is through the employment of different coping strategies
that different outcomes are experienced (scheier C Carver,
1985). While there has been some empirical support for this
theory, findings have not been consistent, and most have
found both a direct and indirect effect (Segerstrom et
127
a1.,1998; Chang, 1998a; King et al., 1998; Carver et al.,
1993). This study does not provide support for this
mechanism of action, as none of the relationships between
optimism and the coping strategies were significant;
although an inverse relationship between optimism and escape
avoidance did approach significance. ~lternative
explanations of the relationship between optimism and
psychological well-being have been considered. Taylor et al.
(1992) has suggested that optimism may also influence
psychological outcomes by influencing appraisal of the
situation. Optimism may act as a stress resistance resource
rather than a coping resource similar to Antonovsky's sense
of coherence (Antonovsky, 1993) or Kobasa's concept of
hardiness (Bowsher & Keep, 1995) or optimists may alter
their expectations to accommodate a new reality. Given this
possibility optimists who experience advanced lung cancer
may not hold unrealistic expectations for cure but may focus
on realistic expectations of symptom control and prolonging
survival.
Dispositional optimism was also significant in the
prediction of the mood states explaining a portion of the
variance in confusion-bewilderment, vigor-activity, fatigue-
inertia and depression-dejection. As expected optimism was
inversely related to the dependent variable in each of the
models except for vigor-activity. Optimism was not
significant in the tension-anxiety and the anger-hostility
128
models. This further analysis helps to clarify the role of
optimism in psychological well-being/distress. From this
analysis it does not appear that optimists have less
psychological distress because they are less anxious or
angry . That optimism explains a portion of the variance in the
predictions of greater vigor and less fatigue is somewhat
surprising given that these mood states reflect the physical
aspects of distress. A causal relationship between optimism
and the mood states can not be assumed. The relationships
between optimism and vigor and optimism and fatigue are
unclear, although we are considering optimism as a
dispositional trait, and therefore stable, one might
question if in fact it is those who feel greater vigor or
less fatigue who are more optimistic. The view of optimism
as a dispositional trait has been questioned elsewhere.
Miller et al. (1996) in a review of optimism scores from
different clinical populations reported higher scores among
certain populations and has suggested that optimism may
interact with specific stressors and be less of a stable
dispositional trait than previously believed.
The other significant predictors of the mood states
vigor-activity and fatigue-inertia are more in keeping with
this physical nature of these mood states. The type of
stressor being pain, syniptoms or discomfort and the degree
of perceived stress are the other significant predictors in
129
the model with vigor activity as the dependent variable. The
stress of living with pain and symptoms and the experience
of feeling stressed consume large amounts of energy and
therefore this negative relationship with vigor is not
unexpected.
Overall a greater portion of the variance was explained
in the vigor-activity model than in the fatigue-inertia
model but it should be kept in mind that vigor-activity and
fatigue-inertia are not simple opposite poles of the same
concept (McNair, Lorr & Droppleman, 1992). In addition to
optimism only one other variable was significant, the use of
the coping strategy self-controlling. This strategy is
defined as efforts to regulate ones feelings and actions.
These efforts included such items as tried to keep my
feelings to myselfu and Yrom interfering with other thingsn
and "1 kept other from knowing hou bad things weren. A l 1 of
these efforts would take considerable energy resulting in
increased fatigue.
The degree of perceived stress which was considered in
this study to be a component of primary appraisal vas a
significant predictor of the variance in the of total mood
disturbance score. The greater the perceived stress the
greater the mood disturbance. It was not an unexpected
finding that those who considered their situation most
stressful would experience the greatest psychological
distress. This relationship between primary appraisal and
130
psychological outcome is consistent with the stress and
coping theory of Lazarus and Folkman (1984)-
Also consistent with this theory is the possibility
that the relationship between the degree of perceived stress
and psychological distress was mediated by the coping
strategy distancing. In this study those who perceived their
situation as more stressful and those who used fewer
distancing coping strategies experienced greater distress- A
correlation between greater perceived stress and the use of
fewer distancing coping strategies was also found. These
findings support the possibility that the relationship
between perceived stress and psychological distress may have
been at least partially influenced by the use of fewer
distancing strategies.
Conflicting results regarding the relationship between
the coping strategy distancing and psychological distress
have been reported. Consistent with the findings of the
current study, the coping strategy distancing was reported
t o be associated with less emotional distress in a large
sample of people with varioiis type of cancer (Dunkel-
Schetter et al., 1992) however p s t hoc analysis in that
study revealed a curvilinear relationship with the coping
strategy being used most at moderate levels of distress. In
a sample of women with a diagnosis of breast cancer (Stanton
& Snider, 1993) distancing was not related to the
psychological outcome. Distancinq is defined as %ognitive
131
efforts to detach oneself and the minimize the significance
of the situation? Reviewing the items in this scale reveals
elements of acceptance aI went along with fate sometimes 1
just have bad luckn, positive reappraisal, lwked for the
silver lining, 1 tried to look on the bright aide of thingsn
and minimization, 1 made light of the situation; I refused
to get to serious about itn and didn't let it get to met
1 refused to think about it too muchm. It is worth noting
that some of the participants in this study had difficulty
with the last item stating that they didn't let it get to
them but it wasn't because they refused to think about it.
They implied that it had more to do with their own persona1
resolve not to give in. Using the distancing coping
strategy may be effective in reducing psychological distress
among people with lung cancer by providing respite from the
reality of their prognosis without the actual denial of its
existence.
The use of distancing as a coping strategy was also
found to be a significant predictor of the variance in the
mode1 with confusion-bewildement as the dependent variable.
It is of note that the designation of confusion-bewilderment
as a mood state has been questioned. It has been suggested
that the cognitive inefficiency represented by this scale
(confused, forgetful, unable to concentrate) may be a by
product of anxiety (McNair, Lorr & Droppleman, 1992) or
other negative emotions such as depression (i-e. the ability
132
to think clearly is cloudy by anxiety, depression or
conflicting emotions). However if confusion-bewilderment is
simply a result of anxiety or depression it would be
expected that the coping strategy distancing would also be
significant in predicting the scores of these mood states,
this was not the case, the coping strategy distancing was
not significant in preâicting the score of either the
tension-anxiety mood state or the depression-dejection mood
state.
Contrary to the findings that younger age (Carver et
a1.,1993; Miller et al., 1996; King et al., 199 Stanton &
Snider, 1993; Baker, 1997) and female gender (Chang, 1998a,
Dunbar et al., 1996; Akechi et al., 1998; Baker et al.,
1997) have b e n associated with greater distress,
specifically more tension and anger, neither age nor gender
were found to be significant in the prediction of total mood
disturbance or of any of the mood states examined in this
study. This is consistent with finding by Miller et al.
(1996) who reported no difference in gender in a sample of
people with advanced cancer.
The coping strategies seeking social support, planful
problem solving, accepting responsibility and positive
reappraisal were not significant predictors of the variance
in total mood disturbance or of any of the mood states in
this study. The findings of previous research involving
people with cancer has produced conflicting results. Miller
133
et al. (1996) found that less use of the coping strategy
accepting responsibility was associated with higher levels
of well-being but consistent with the findings of the
current study they did not find the strategies seeking
support, positive reappraisal of planful problem solving to
be associated with either well-being or distress. However
contrary to the finding of the current study other studies
( C a n e r et al., 1993; Stanton & Snider, 1993; Dunkel-
Schetter et a1.,1992) have found coping strategies involving
social support and positive reframing/focusing to be
significant predictor of psychological distress/well-being.
S_unimarv
Fear and uncertainty about the future was the
predominant stressful situation among this group of people
with advanced lung cancer. The degree of perceived stress
related to the stressful situation was rated as moderate to
high however for a feu participants it was reported as
extreme . Seeking social support was the coping strategy used
most often, this may reflect the level of support available
to the participants. The coping strategy of accepting
responsibility and escape avoidance were used least often.
Distancing, the second most frequently used strategy, was
negatively correlated with the degree of stress indicating
that it was more difficult to minimize the situation as
stress increased. Escape avoidance coping although used
134
infrequently by this sample, did Vary with the type of
stress and decreased in use with increasing age. The use of
the coping strategies self-controlling, positive reappraisal
and planful problem solving was moderate. Gender did not
influence the use of coping strategies in this study.
No relationships were found between dispositional optimism
and any of the coping strategies.
The main findings from the regression analysis, that
the use the escape avoidance coping strategy and less
dispositional optimism were significant in the prediction of
greater distress were as expected, and support the findings
from previous studies. Escape-avoidance coping may have been
unsuccessful in this sample of people with advanced lung
cancer because they are confronted with constant reminders
of their illness. Optimism which was not related to any of
the coping strategies was associated with less distress.
This study did not support the theory that optimists
experience better psychological outcomes because of the use
of different coping strategies.
The use of the coping strategy distancing and the
degree of perceived stress were found to be significant
predictors of the variance in psychological distress. The
use of the coping strategy distancing was also negatively
correlated with the degree of stress perceived. Those who
perceive a situation as very stressful and are unable to
distance themselves from it may experience greater
135
psychological distress.
The coping strategy self-controlling was found to be a
significant predictor of the variance in the mode1 with the
dependent variable as fatigue. The self-control coping
strategy was used to a moderate degree by the participants
in this study and included items which seemed to be focused
on the protection of others. These behaviours would take
considerable energy and perhaps contributed to feeling of
fatigue.
The stressful situations labelled pain, symptoms or
discomfort was a significant predictor in the variance of in
vigor-activity. When the most stressful situation associated
with lung cancer was pain, symptoms or discomfort less vigor
was reported. None of the other stressful situations
identified were significant predictors of the variance in
any of the mood states.
In this study neither age or gender, or the coping
strategies seeking social support, planful problem solving,
accepting responsibility or positive reappraisal were found
to be significant predictors of psychological distress.
CHAPTER V
Summary , Limitations and Implications
Sumniarv
Lung cancer is the leading cause of cancer death in
Canada (National Cancer Institute of Canada, 1998)- Despite
advances in cancer treatment the prognosis for those with
lung cancer remains poor. Surgery provides the best
possibility for survival, but most of those diagnosed with
lung cancer will have disease which is too advanced at the
tirne of diagnosis or, for other medical reasons, will not be
candidates for surgery. The negative impact of lung cancer
on psychological well being is recognized, however coping
with the stressors resulting from this diagnosis has
received little attention. The selection of coping
strategies and their effectiveness is influenced by numerous
factors. Relationships between optimism, coping strategy
selection, and psychological outcome were found in a number
of studies, however no studies examining these relationships
were reported with regard to people with lung cancer.
The purpose of this study was to examine the
relationships between the personality disposition of
optimism, coping strategies, the demographic characteristics
of age and gender and psychological well-being of people
with advanced or inoperable primary lung cancer,
The theoretical framework guiding this research vas the
137
Lazarus and Folkman (1984) theory of stress, appraisal and
coping. Dispositional optimism as conceptualized by Carver
and Scheier (1985) was incorporated in the framework as a
persona1 factor . This study vas conducted in a large tertiary care
health centre which serves as one of the provincial referral
centres for patients with lung cancer. Data w e r e collected
£rom 64 patients during a clinic visit which had been
scheduled for either treatment or follow up. Al1 the
participants in this study had been diagnosed with advanced
or inoperable primary small or non small ce11 lung cancer,
were between one month and one year of receiving that
diagnosis, and could speak and understand English. No one
with recurrent cancer, another recent cancer diagnosis or
brain metastases were included-
Data collection was conducted in a interview format.
Participants provided demographic information and responded
to three questionnaires, the L i f e Orientation Test - revised (Scheier, Carver & Bridges, 1994), the Ways of Coping
Questionnaire (Polkman d Lazarus, 1988b), and the Profile of
Hood States (HcNair, Lorr & Droppleman, 1992). Data
regarding disease and treatment were obtained form the
participants health record-
Three research questions were addressed. The study
findings related to each question are as follows:
1. What are the coping strategies used by people w i t h
138
advanced or inoperable primary lung cancer?
The coping strategies were measured using the Ways of
Coping Questionnaire (Folkman & Lazarus, 1988b).
Participants responded to this questionnaire by first
identifying the situation related to their diagnosis of lung
cancer which tbey had found most stressful and then
indicating on a scale of one to five the perceived degree of
stress. Fear and uncertainty about the future was the
situation most frequently identified. Most (65.7%) rated the
degree as moderate ta very stressful (rating 3 - 4). The
most used coping strategy was seeking social support
followed by distancing, self-controlling, planful problem
solving and positive reappraisal. Escape avoidance and
accepting responsibility were the strategies used the least.
T-test analysis revealed no gender differences in the use of
any of the strategies. Correlational analysis determined a
low negative correlation between the degree of stress and
the coping strategy distancing. The analyses based on age
produced conflicting results, t-tests with participants
grouped by age (Group 1 40-59, Group II 60 - 80) determined no differences however using Pearson's product-moment
correlation a low negative correlation vas determined for
escape avoidance coping and age. From a plot of these data
it appeared that the most elderly use escape-avoidance
coping strategies the least.
One-way analysis of variance was performed to determine
139
if the means for the coping categories for the data grouped
according to the type of stressful situation differed. There
were statistically significant differences in the mean
scores for the coping category escape avoidance between the
group 'limitations in ability', and the means of two other
groups ' fear and uncertainty' and 'problems with family or
friends related to cancer8.
2. What is the relationship between dispositional optimism
and the coping strategies utilized by people with advanced
and inoperable primary lung cancer?
Dispositional optimism was measured in this study using
the Revised Life Orientation Test(LOT-R) (Scheier, Carver &
Bridges, 1994). The mean optimism score as determined by
Life Orientation Test was 15.9 (SD = 5 . 3 ) , the median was 17
and the range of scores was 2 - 24. Pearson's product-moment
correlation coefficient was calculated to determine the
strength and direction of the relationship between
dispositional optimism and each of the coping scales. None
of these correlations proved to be significant at alpha < or
= . 0 5 .
3. What is the relationship between age, gender, coping
strategies used, dispositional optimism and the
psychological well-being of people with advanced or
inoperable primary lung cancer?
Psychological well-being, the dependent variable in the
third research question was measured using the Profile of
140
Mood States (McNair, Lorr & Droppleman, 1992). The Total
Mood Disturbance Score and scores for six mood states were
determined.
Multiple regression analysis was used to determine the
relationship between the independent variables of age,
gender, coping strategies, type of stressor, degree of
stress and dispositional optimism and the dependent variable
psychological well-being. The type of stressor and the
degree of stress were included because of their relationship
t o the coping strategies. The type of stress was coded
according to the five groups identified from the Ways of
Coping Questionnaire (fear and uncertainty about the future
due to cancer; limitations in physical ability, appearance,
or life style due to cancer; pain, symptoms, or discomfort
from illness or treatment; problems with family or friends
related to cancer and other). This analysis revealed a model
with four independent variables explaining 41% of the
variance of the total mood disturbance score LE 10.34, Q =
-0001). The independent variables that best predicted the
total mood disturbance score were the coping strategy
escape-avoidance (17%), the degree of stress (12%), optimism
(7%) and the coping strategy distancing (4%). Distancing and
optimism were inversely related to the total mood
disturbance score.
Multiple regression analyses was also used to determine
the relationship of the independent variables with each of
141
the mood states. This analysis produced the following
models: 25 percent of the variance in the tension-anxiety
mood state was explained by the variables the degree of
stress and the coping strategies escape-avoidance; 16
percent of the variance of the fatigue-inertia mood state
was explained by the variables optimism (inversely related)
and the coping strategy self-controlling; 29 percent of the
variance of the depression-dejection mood state was
explained by the coping strategy escape-avoidance and
optimism (inversely related); 28 percent of the variance of
the anger-hostility mood state was explained by the coping
strategy escape-avoidance and the degree of stress; 26
percent of the variance in the vigor-activity mood state was
explained by three variables the degree of stress (inversely
related), the type of stressor being pain, symptoms or
discornfort (inversely related), and optimism; and 37 percent
of the variance of the confusion-bewilderment mood state was
explained by the coping strategy escape avoidance,
distancing (inversely related) and optimism (inversely
related). Three of the independent variables were
predominant in the regression models; the coping strategy
escape-avoidance, dispositional optimism and the degree of
perceived stress. The independent variables of age, gender,
and the coping strategies seeking social support, planful
problem solving, accepting responsibility and positive
reappraisal did not enter any of the regression equations
with entry level alpha of 0.05.
t i o m
A number of factors limit the ability to generalize the
study findings- The sample was a small non-probability
convenience sample which may not be typical of the
population regarding the study variables. The sample was
restricted to only those people with advanced or inoperable
lung cancer so cannot be considered representative of the
entire lung cancer population or of other cancer
populations. The majority of the participants were Caucasian
and had little forma1 education limiting the ability to
generalize to other groups. The study was conducted in one
setting, an ambulatory cancer clinic, therefore the sample
was not representative of those who required hospitalization
or who were being followed in the community.
The Ways of Coping Questionnaire was ansvered in
relation to a situation which may have a occurred at any
time since diagnosis, therefore responses were based on the
participants recall of what they did or thought at that
time. In some cases the situation being recalled may have
occurred several months prior to the interview, cansequently
responses may not have reflected the actual thoughts and
behaviours that were used in the situation-
Al1 questionnaires were completed in an interview
format by a registered nurse. Participants may have tended
to give the responses which they considered to be most
socially desirable.
for N w a Practice and E a c a t l ~ n
Findings from this research add to the increasing body
of evidence indicating that less optimism and the use of
escape avoidance coping are related to psychological
distress. This knowledge could serve to enhance nurses
ability to recognize patients who are at greater risk for
psychological distress. Resources in the hospital, in the
clinic setting and in the community are limited and must be
used to best advantage. Nurses caring for patients with
advanced lung cancer sometimes experience difficulty in
deciding which patients may benefit most from resource
services. Knowledge which will help determine who is more
likely to experience greater distress may be of advantage in
allocating services,
Results from this study serve to reinforce the basic
nursing principle of the need for individual patient
assessment. While results did indicate that fear and
uncertainty about the future was frequently a major stressor
for many people with advanced lung canver it was not the
case for everyone. This highlights the need for nurses to
ask patients specifically what they are finding most
stressful in relation to their illness. In addition to
asking what was most stressful, participants in this study
were also asked to indicate how stressful they perceived the
situation to be, those who rated their degree of stress
higher w e r e found to have greater psychological distress.
Asking patients to indicate their degree of stress could be
easily added to the nursing assessment and may be valuable
in helping to determine which patients are likely to
experience greater psychological distress.
Contrary to a number of studies, findings from the
current study did not support that gender (being female) or
age (being younger) were significant in the prediction of
greater psychological distress. This finding emphasizes the
importance of individual assessment and cautions nurses not
to assume that those who are male or older are less
vulnerable to psychological distress.
Dispositional optimism was found, in previous research
and in the current study, to be significant in the
prediction of psychological distress. The use of the Life
orientation Test, as a scxeening tool for assessing the
dispositional optimism of patients in clinical practice has
been suggested (Miller et al., 1996). In the current study
the tool proved to be easy to administer and to score,
however prior to this tool becoming useful in clinical
practice further research is needed to determine at what
level optimism becomes clinical significant (i.e. how low of
an optirnisrni score would indicate the need for
intervention?). A forma1 evaluation of optimism with a
specific tool may not be needed, a question regarding
145
outlook on life included in the nursing assessment may
provide the necessary information.
While optimism was found in the current study, and in
previous research to be related to psychological well-king
interventions aimed at increasing psychological well-being
through increasing optimism have not been studied.
Interventions which are aimed at helping patients to focus
on achievable goals may improve the individualsO situational
optimism, however optimism defined as a dispositional trait
may not be amenable to change. Furthemore the relationship
between optimism and psychological well-being requires
greater clarification. This study did not find a
relationship between optimism and the selection of specific
coping strategies and therefore did not support the
contention that the relationship between optimism and
psychological well- k i n g is mediated by the selection of
coping strategies.
The finding that specific coping strategies are related
to psychological distress/well-being emphasises the need for
a more detailed evaluation of what individuals are doing to
cope with the stress of this illness. Findings indicates
that there is a need to differentiate the use of escape
avoidance strategies and those of distancing and that the
use of self controlling strategies may be associated with
greater fatigue. The assessment of coping strategies in
clinical practice requires further work. In talking with and
146
observing patients, nurses gather a great deal of
information about what the individual is coping with, and
what they are doing to manage the stress, much of this
information is neither recorded or shared with other health
professional or family members. Basic and continuing nursing
education is needed to increase nurses' understanding of the
stress and coping process and to assist nurses in developing
skills in recognizing the coping strategies which are being
used. Consistency in describing and labelling coping
strategies would be of great benefit in the process of
understanding and sharing information about coping
strategies. Questionnaires such as the Ways of Coping are
lengthy for patients to complete and are too time consuming
to score to have utility in clinical practice. Alternative
methods of assessment and documentation are needed.
This was not an interventional study and therefore
provides little guidance in terms of specific nursing
interventions. However the use of distancinq as a coping
strategy was found to be related to psychological well-being
for some patients, therefore interventions which support
this strategy may be of value. Such interventions as
ensuring flexible visiting policies, k i n g aware of the
individuals interests, engaging in non-illness related
conversations, and ensuring the availability of distraction
materials e.g. books, puzzles, television may help the
individual to distance themselves for a period of tirne. It
147
has not been determined if external interventions can alter
coping strategies or their effectiveness. Clearly further
research is needed to evaluate the effectiveness of specific
interventions.
Coping was studied in relation to a specific stressful
event determined by the participant. The present study
examined the variables of optimism and coping strategies and
their relationship to psychological distress at one point in
time. The individuals participating in this study were at
various stages in their illness and treatment. A
longitudinal study would provide valuable information about
the relationship between optimism and selected coping
strategies over the course of illness, helping to answer
questions about the stability of optimism, hou coping
strategies change, and would be beneficial in determining if
in individuals coping varies with the situation or if in
fact there are coping dispositions. A larger sample and
similar studies involving people with lung cancer at earlier
stages and those with recurrent disease is also needed.
Only the outcome of psychological well-being was
considered in this study. The role of optimism in relation
to other outcontes such as miortality (Schulz, Bookwala,
Knapp, Scheier,& Williamson, 1996) immune change,
(Segerstrom, Taylor, Kemeny, & Fahey, 1998) and success in
1 4 8
making health related change, (Shepperd, Haroto & P b e r t ,
1996) have been studied in other populations. These outcomes
are also of interest in the lung cancer population.
Especially relevant is the role of optimism in making health
changes such stopping smoking following surgery for lung
cancer.
The finding from this study did not indicate a
relationship between optimism and the coping strategies
used, this is contrary to to what a number of other studies
have found and therefore requires further exploration.
The role of age in the use of coping strategies was not
clear in this study. There was some indication that escape
avoidance coping was used less with increasing age. Given
the relationship of escape avoidance coping and
psychological distress, the effect of age requires further
study with a sample including sufficient of n&rs for
cornparison of age groups.
Interventional studies are needed. Johnson (1996) and
Johnson , Fieler, Wlasowicz, Mitchell, and Jones, (1997)
found that among pessimistic patients who were receiving
radiation therapy those who received information consisting
of concrete, objective descriptions of the experience were
less distressed. These studies involved patients with breast
and prostate cancer. Given the relationship of optimism and
psychological distress among patients with advanced lung
cancer found in the present study similar intementional
149
studies are warranted, Interventional studies examining ways
of altering escape avoidance strategies should also be
considered,
for Tbory
The theoretical framework guiding this research was
Lazarus and Folkman's (1984) theory of stress, appraisal and
coping. According to the framework appraisal and coping are
influenced by the antecedent factors, In this study the
casual antecedents were the person variables of age, gender
and the degree of optimism and the situational factor of a
diagnosis of advanced lung cancer. The outcome, the final
variable of interest was psychological well-being.
There was minimal evidence that the antecedent
variables of age, gender or the degree of optimism
influenced the selection of coping strategies. Only a iow
negative correlation between age and the coping strategy
escape avoidance indicated a relationship.
In the.Lazams and Folkmar, mode1 primary appraisal, the
initial assessment of the situation, is also considered to
be of importance in determining the use of coping
strategies. The situation, or what the individual is coping
with, and degree of stress produced by the situation are
important components of primary appraisal. In the current
study escape-avoidance coping was used significantly more by
the participants in some situations than in others and those
150
who perceived the situation to be more stressful used less
distancing coping strategies. These findings provide some
support for the theory that primary appraisal of the
situation influences the selection of coping strategies.
Also consistent with this model of stress and coping, the
current study found that the degree of perceived stress was
associated with the outcome of greater psychological
distress supporting a direct relationship between primary
appraisal and outcome.
Another major component of Lazarus and Folkman0s theory
of stress and coping is that coping does influence outcome.
Some support for the relationship between coping strategies
and psychological outcome was found. Three of the coping
strategies escape-avoidance, distancing and self-controlling
were significant in the prediction of psychological
distress.
The concept of dispositional optimism included in this
study was based on Carver and Scheier's (1985, 1992) model
of behavioral self regulation. An assumption underlying
this model is that expectancies influence action, therefore,
because optimism and pessimists have different expectations
it is presumed that they would use different coping
strategies. Finding from this study did not support this
assumption, no relationship was found between optimism and
any of the coping strategies.
Con-
In conclusion this study has contributed to the
understanding of optimism and coping as factors involved in
the psychological well-being of people with advanced lung
cancer. People with advanced or inoperable lung cancer face
a variety of stressors. Por many in a i s study dealing with
the fear and uncertainty about the future was the most
stressful. Although faced with a poor prognosis high levels
of distress w e r e not reported.
Seeking social support was the coping strategy used
most but was not significant in predicting any of the
psychological outcomes. No relationship was found between
optimism and any of the coping strategies. This study found
that those who perceived their situation as more stressful,
who were less optimistic, and who used more escape avoidance
and fewer distancing coping strategies were most distressed.
Age, gender and the coping strategies seeking social
support, positive reappraisal, planful problem solving and
accepting responsibility were not significant predictors in
the variance of the scores in psychological outcome.
This study expands the finding from previous research,
that optimism and avoidance coping are significant factors
in predicting the variance in the scores of psychological
well-being, to include a sample of people with advanced or
inoperable lung cancer. The findings from this study are
valuable to nurses in determining which patients are at
152
greater risk of psychological distress and as a basis for
further research focusing on interventions to reduce this
distress.
Appendix A
Letter of Introduction Dear :
The Thoracic Oncology group, of which your physician is a member, has agreed to assist with a research study being conducted by Lynn Coulter, a registered nurse who works with this group and is completing her Master's degree in Nursing a t Dalhousie University. The putpose of this study is to gain a better understanding of the different ways in which people with lung cancer manage the stress that this illness causes. You are invited to participate in this study. Participating in this study would involve one interview, which would take place on the same visit as your clinic appointment. You would be asked to answer some general questions about yourself and respond to questions from three questionnaires which the researcher would read to you. It will take about 60 to 90 minutes. Your decision to participate in this study is entirely your oun and ri11 not affect the care you are receiving at the meen Elizabeth Health Sciences Centre.
If you would like to leam more about this study please check the appropriate box below and return this letter in the attached envelope . Hs. Coulter will telephone you to explain the study and ask if you are willing to participate.
Thank you for your time and interest.
Sincerely,
Dr. D.C.G. Bethune
0 1 am interested in learning more about the research My telephone number is (902) .
[7 1 do not wish to participate because ( optional ) .
Verbal Introduction of Study to Potential Participants
A research study being conducted to gain a better
understanding of the different ways in which people with lung cancer manage the stress that this illness causes. This
study is king conducted by Lynn Coulter, a registered nurse
who works with your doctors and nurses and is completing her Master8s degree in Nursing at Dalhousie University- To
assist Ms. Coulter we are inviting you to participate in this study.
Participating in this study would involve answering
some general questions about yourself and responding to
questions from three questionnaires which the researcher will read to you. It will take about 60 to 90 minutes. Y o u r
decision to participate in this study is entirely your ani and vil1 not affect the care you are receiving at the Queen Elizabeth Health Sciences Centre,
If your are prepared to consider participating, 1: will
introduce you to Us- Coulter. She will provide you with an
outline of the study in sufficient detail to allow you to
make a decision about participation, Talking with her does
not mean you are consenting to participate in the study.
Consent Form
Study Title: Optimism, Coping, and Psychological Well-Being among People with Advanced Lung Cancer
Principal Investigator: Lynn Coulter, BN, RN Expanded Role Nurse Thoracic Surgery Haster of Nursing Candidate (902)473-7556
Research Supervisor:
Committee Hembers:
Barbara Downe-Wamboldt,PhD,RN Dalhousie University (902)494-2391
Lorna Butler, PhD, RN Queen Elizabeth II Health Sciences Centre
Katherine Bowen, PhD Department of Hathematics and Statistics Dalhousie University
Introduction
We invite you to take part in a research study at the Queen Elizabeth II Health Sciences Centre. You must understand several general principles that apply to everyone in our study. Taking part in the study is voluntary. The quality of your care will not be affected by whether you participate or not. Participating in the study may not benefit you, but we may learn things that will benefit others. You may withdraw from the study at any time without losing any benefits that you are entitled to. The study is described below. This description tells you about the risks, inconvenience, or discornfort which you may experience. You should discuss any questions you have about this study with the people who explain it to you.
Purpose of the Study
The purpose of this study is to learn about hou individuals with lung cancer manage the stress that this illness causes in their lives, Specifically this study will examine the relationships among the personality disposition of optimism (the persons outlook on life), the coping strategies ysed to manage the stress of lung cancer, age, gender, and the psychological well-being of people with lung cancer.
Why this Study is Being Ikne
Different individual have different outlooks on life and different ways of managing stress. What works for one person may not be helpful for another. The information from this study may help nurses and physicians to better assist the people they care for to manage the stressor of lung cancer.
Taking P a r t in the Study
Participating in this study involves one interview, This interview will be arranged at a time convenient for you during your visit to the clinic and will take about 60 to 90 minutes. You will be asked to answer some questions about yourself and to respond to questions from three questionnaires which the researcher will read to you. The questionnaires ask questions about your outlook on life, what you do when faced with a stressor, and how you are feeling emotionally. Information specific to the type, stage and treatment of your cancer will be obtained from your health record.
Risks and Benefits
The information you provide may not directly benefit you but may be used to assist others with cancer. There is no financial compensation for taking part in this study. There are no anticipated risks involved in your participation. Some people may find answering some questions upsetting if they have not talked about their experience or what they are feeling before taking part in this study. If this is upsetting for you and you would like to meet with a specialist vho helps people to cope with a cancer diagnosis a referral will be arranged for you.
voluntary participation
The decision to participate in this study is entirely your own. Your decision vil1 not affect the quality of care you
are presently receiving. If you do participate and wish to withdraw from the study or refuse ta answer any questions you may do so at any tirne.
Confidentiality
Information about you will not be identified. The persona1 information you provide, information obtained from your health record, and the questionnaires are coded w i t h a number that corresponds to your name which will be kept in a locked file available only to the researcher. Your name will not appear on any information sheet or questionnaire. The results of this study may be published in a health journal or presented at conferences. No individual will be identified in any writing or presentation. If you wish to be informed of the results, a summary of the findings vil1 be made available upon request.
Further Information About the Study
If you wish to ask further questions about the study or discuss your participation you may contact the study investiqators listed on the first page.
1 have read the erplanation about the mI Co- . . r>wvcholaWell- - Cancer study and have baan g i w a y e opportunity to discuss
e m
it and to ask questions. 1 hereby consent to take part in this study
Signature of Participant Date
Signature of Xnvestigator Date
Signature of Witness Date
Demographic Information
Stress and hou it is managed is influenced by many things. In order to better understand the role of 0th- possible influences please answer the following questions.
1. What is your age? years
2 . What is your gender? male , fernale . 3. What is your current marital status?
Married/common law , Single , Widowed I
Separated , Divorced . 4 . Who currently lives with you? (you may check more than one )
Live alone Spouse or partner ,-
Children Other family members
Friend or friends
5 . How important a role does your religion or religious beliefs play in your life?
None Some Moderate Vesy important
6. What is your cultural background?
White Black Asian Aboriginal
Other
7 . What is your approximate annual household income?
less than 10,000 10,000 - 20,000 21,000 - 30,000 31,000 - 40,000 41,000 - 60,000 61,000 - 100,ooo more than 100,000
8. What is or was (if retired) your usual occupation?
Are you currently working , on sick leave
unemployed , or retired 9. What is the amount of formal education you nad the
opportunity to complete?
seventh grade or less Grades eight or nine Some high schoal High school graduate Some college College/university graduate Post Graduate education
10a. Are you experiencing any of the following symptoms?
cough Yes no
shortness of breath
pain Yes no
fatigue/tiredness yes no
other
b. Are any of the following symptoms severe enough that they affect of limit your usual activities?
cough Yes no
shortness of breath
pain YeS no
fatigue/tiredness yes no other
11. Are you taking pain medication? yes no If yes name of medication you are taking.
Tylenol Tylenol w i t h Codeine Morphine or Dilaudid Other
12. Performance status (ECOG/WHO)
O = fully active, able to carry out al1 pre-disease activities without restriction and without aid of analgesia,
1 = restricted in strenuous activity but ambulatory and able to carry out light work or pursue a sedentary occupation. Patient who are fully active but require analgesia-
2 = ambulatory and capable of al1 self care but unable to carry out any work. Up and about more than fifty percent of waking hours.
3 = capable of only limited self care, confined to bed or chair more than fifty per cent of waking hours.
4 = completely disabled, Unable to carry out any self care and confined totally to bed or chair-
Thank you for completing this questionnaire-
Disease and Treatment Data from patients Health Record
1. Length of time since diagnoses.
2. Stage and Ce11 Type:
W S C f i C : squamous adenocarcinorna
large ce11 other
Stage T- N - site of metastasis
medically unfit
SCLC: Stage: limited extensive
3. Treatment:
Radiation
treatment plan
date started
currently receiving
date completed
Cheiotherapy
protocol
date started
currently receiving between cycle
date completed
Surgery-
date -woce-e
tation Test ~ e v u
INSTRUCTIONS:
Please be as honest and accurate as you can throughout. Try
not to le t your response to one statement influence your
response to other statements. There are no ucorrectu or
'5ncorrectW answers. Answer according to your own feelings,
rather than how you think "most peoplen would answer.
PLEASE LIS- BACH STA- -Y AND INDICATB H m
HUCH YOU AGRKB WITH T'HB S'TA-
#
1 . I n uncertain times. 1 usually expect the best . . . . O 1 2 3 4
2 . I t ' s e a s y f o r m e t o r e l a x . . . . . . . . . . . . . . O 1 2 3 4
3 . I f something can go wong f o r me it wil1 . . . . . . O 1 2 3 4
4 . I ' m always op t im is t i c about my f u tu re . . . . . . . . O 1 2 3 4
5 . 1 enjoy my f r iends a l o t . . . . . . . . . . . . . . O 1 2 3 4
6 . I t ' s important f o r me t o keep busy . . . . . . . . . O 1 2 3 4
7 . 1 hardly ever expect things t o go my way . . . . . . O 1 2 3 4
8 . 1 don't get upset too easi ly . . . . . . . . . . . . O 1 2 3 4
9 . 1 rarely count on good things happening t o me . . . . O 1 2 3 4
10 . 1 expect more good things t o happen t o me than bad . O 1 2 3 4
Reproduced w i t h permission
INSTRUCTIONS :
To respond to the statements in this questionnaire, you must
have a specific stressful situation in mind. Please take a
few moments and think about the iost stressful situation you
have experienced related to your illness.
Stressful Situation
By *stressfulW 1 mean a situation that was difficult or
troubling for you, either because you felt distressed or
because you had to use considerable effort to deal with the
situation*
The following is a list of situations which may have been or
are still stressful for you. Please tell me which, if any,
of the situation you find most stressful or you can tell me
about another situation related to your cancer which is more
Fear and uncertainty about the future due to cancer
Limitations in physical ability, appearance, or life style due to cancer
Pain, symptoms, or discomfort from illness or treatment
Problems with family or friends related to cancer.
How stressful is/was this situation for you:
1 = not stressful
2 = mildly stressful
3 = moderately stressful
4 = very stressful
5 = extremely stressful
As you respond to each of the following statements, keep
the stressful situation in mind. Remember there are no
"correctn or nincorrectm responses.
LISTEN TO EACH STATEMENT CAREFULLY AND INDICATE Tû WHAT
EXTENT YOU USED IT IN THE SITUATION:
O = DOES NOT APPLY OR NOT USED
1 = USED SOHEWHlrT
2 = USED QUITE A BIT
3 = USED A GREAT DEAL
1. 1 just concentrated on what 1 haâ to do next - the next step. . O 1 2 3
2. 1 tri& to analyze tbe problem in order to understand it better . . O 1 2 3
4. 1 felt that time would have made a différence - the oaly thing was to wait. . . . . . . . . . . . . . . . . . . . . . . . O 1 2 3
5 . 1 bargained or compromised to get something positive fromthe situation. . . . . . . . . . . . . . . . . . . . . . . . . . . . O 1 2 3
6. 1 did something that 1 didn't think would work, but at least I was dohg something. . . . . . . . . . . . . . . . . . O 1 2 3
7 . 1 tri4 to get the person responsible to change his or ber mindg O 1 2 3
8. 1 talked to someom to f ï d out more about the situation- . . . . O 1 2 3
9 . 1 criticized or lectured myself. . . . . . . . . . . . . . . . . . . . . O 1 2 3
10. I tried not to burn my bridges, but lave things open somewhat. O 1 2 3
I I . 1 hoped for a miracle. . . . . . . . . . . . . . . . . . . . . . . . . . O 1 2 3
12. 1 went dong witb tàte; sometimes 1 just have bad luck. . . . . . O 1 2 3
13. 1 went on as if nothiag had happened . . . . . . . . . . . . . . . . O 1 2 3
14. 1 tried to keep my feelings to ayself. . . . . . . . . . . . . . . . . O 1 2 3
15. 1 looked for the silver Iining, so to speak; 1 tried to look on the bright si& of things. . . . . . . . . . . . . O 1 2 3
17. 1 expressed anger to the person(s) wbo caused the problem. . . O 1 2 3
18.1acceptedsympathydundersraadiagfromsomeone. . . . . . O 1 2 3
19. 1 told myself things that helped me fœl better. . . . . . . . . . . O 1 2 3
20. 1 was inspired to do sometbiag creative about the problem. . . . O 1 2 3
Goontoocxtpage
Cowght 1988 by Consulhg Rycbologists h, Inc. Ail rights rtscrvbd WAYSP Fermissim Test
W e t
. . . . . . . . . . . . . . . . . . . . 21.1 tried to forget the whole thhg O 1 2 3
. . . . . . . . . . . . . . . . . . . . . . . . . 22.1 got professional help O 1 2 3
. . . . . . . . . . . . . . . . . . . . . 23.1 cbanged or grew as a prson O 1 2 3
24.1 waited to see what would happn befme &hg anything . . . . O 1 2 3
. . . . . . . . . . . . . 25.Iapologizedordidsomcthingtomakeup. O 1 2 3
. . . . . . . . . . . . . . . 26 . 1 made a pian of action and followed it O 1 2 3
27 . 1 accepted the aurt best thing to what 1 wanted . . . . . . . . . . O 1 2 3
. . . . . . . . . . . . . . . . . . . . . 28.1 let my feliags out somehow O 1 2 3
29 . 1 realid that 1 had brought the pmblem on myseif . . . . . . . . O 1 2 3
. . . . 3O.IcameoutoftheexperienceûettertbanwknIwentin. O 1 2 3
3 1 . 1 talked to someone who could do sotnethhg concrete about the problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . O 1 2 3
32 . 1 tried to get away h m it by restjng or taicing a vacation . . . O 1 2 3
33 . 1 aied to make myself feel beaa by eating. drinkïng. . . . . . . . . . . . . . smoking. using dnigs. or medicatim. etc O 1 2 3
34 . 1 took a big chance or did something very ridcy . . . . . . . . . . . . . . . . . . . . . . . . . . to solve the @lem O 1 2 3
. . . . . . . . 35 1 nied not to act too hastily or foliow my fim bunch O 1 2 3
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 36.1 found new faith O 1 2 3
. . . . . . . . . . 37 . 1 maintained my pride ami kept a stiff upper lip O 1 2 3
. . . 39 . 1 changed so-g so that things wouid hm out all right O 1 2 3
. . . . . . . . . . . . . . . 40 . 1 generally avoided king witb people O 1 2 3
41 . 1 âidn't let it get to me; 1 refbsed to thialr too much about it . . O 1 2 3
Gooatoaextp8gc
Copyright 1988 by Consulting Psycbologiss Ress. Inc . AU r i g h ~ reserved WAYSP Pennissioiis Test
Booklet
. . . . . . . 42 . 1 asked advice fiom a relative or a F r i d 1 reqected 0
43 . 1 kept oibm h m knowing bow bad things were . . . . . . . . . O
44 . 1 made light of îbe situation; 1 refused to get too saious about it.0
. . . . . . . . . . . . 45.1 taiked to sotneone about bow 1 was feeling O
. . . . . . . . . 46 . I stood my gmunâ and fought for what 1 wanted O
. . . . . . . . . . . . . . . . . . . . . . 47 . 1 took it out on o t k -le O
48 . 1 drew on my ps t experience; 1 was io a similar situation before.0
49 . I knew what has to be done, so 1 doubled my efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . to rnake things work O
. . . . . . . . . . . . . . . 50 . 1 refused to believe that it had happened O
51 . 1 promwd myself thot things would be different next time . . . O
52 . 1 came up with a couple of different solutions to the pmblem . . O
53 . 1 accepted the situation since mthiag could be &ne . . . . . . . . 0
54 . 1 aied to keep my feelings about the problem from iaterfering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . with other things O
55 . 1 wished that 1 could change what had happened or how I feh . O
. . . . . . . . . . . . . . . . . 56 . I changed somethiag about rnyseîf- O
57 . 1 daydreamed or imagined a beüer time or place . . . . . . . . . . . . . . . . . . . . . . . . . . than the one I was in O
58 . I wished that the situation would go away or somebow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . beoverwith O
59 . 1 had fantasies or Msha about bow thiags rnight tum out . . . . O
6û.Iprayed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O
. . . . . . . . . . . . . . . . . . . . 6 1 . 1 prepared myself forthe! worsf 0
6 2 . 1 went o v a in my miad wbu 1 would say or & . . . . . . . . . . O
Go om to next page Copyright 1988 by Consulhg Psycbolo@üs b. Inc . Al1 rights reserved WAYSP Permissi- Test Boddet
63 . 1 thought about how a person 1 admire would hanâie this situation and used that as a model- . . . . . . . . . . . . . . . O 1 2 3
. . . . . 64 1 tried to see things from the other persun's point of view O 1 2 3
65 . 1 reminded myself how much worse things couid be. . . . . . . O 1 2 3
Copyright 1988 by Coasulting Rycbologists Ress. k . AU tights reserved WAYSP Permission Test
Bookle t
POMS Profile of Mood States
# Directions:
The following is a list of words that describe feelings
people have. Please listen carefully to each one and then
tell me which of the following best describes hou you have
been feeling during the past week including today.
O = Not at al1
1 = A little
3 = Quite a bit
4 = Extremely
Sample adjectives used in P O M S :
1. Friendly
16. On edge
30. Helpful
45. Desperate
63. Vigorous
Copyright 1971 EdITS/Educational and ~ndustrial Testing
Service.
Sample items reproduced w i t h permission.
References
Akechi, Tm, Kugaya, A., Okamura, H., Nishiwaki, Y., Yamawaki, S., 6 Uchitomi, Y. (1998). Predictive factors for psychological distress in ambulatory lung cancer patients. -e C-- 6. 281-286.
Antonovsky, A. (1993)- Complexity, conflict, chaos, . . coherence, coercion, and civility. Social Scimce Medicine, 37. 969-981.
Baker, F., Marcellus, D., Zabora, J., Polland, A., & Jodrey, D. (1997). Psychological distress among adult patients being evaluated for bone marrow transplantation.
tics, 38. 10-19.
Beck, A. T., Weissman, A., Lester, D., 6 Trexler, L. (1974). The measurement of pessimism: The hopelessness scale. do- of C-d n d w P s ~ l a q v . 42, . 861.865.
Benedict, S. (1989). The suffering associated with lung cancer. Cancer N , u, 34-40.
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