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The Relationship Between Anxiety and Spirituality in Persons Undergoing Chemotherapy for Cancer by Cindy Tofthagen R.N., B.S.N. A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science Colle ge of Nursing University of South Florida Major Professor: Susan C. McMillan, Ph.D. A.R.N.P. Cecile A. Lengacher, Ph.D., R.N. Lois Gonzalez, Ph.D., A.R.N.P Date of Approval: April 5, 2006 Keywords: oncology, nursing, psycho social, psycho oncology, psychology Copyright 2006 Cindy Tofthagen
Dedication This is dedicated to my wonderful family. To my husband Todd, thank you for always believing in me and supporting my decision to continue my education. To my daughter Summer, thanks for helping me see the world through your eyes and for giving me someone to try to set an example for. To my mother, Naomi, thank you for providing lots of very practical help when I stretched myself too thin and for teaching me about what is truly valuable in life. To my father, Gary, thanks for always encouraging me to work hard and dream big. I am honored and blessed to have each of you in my life!
Acknowledgements I would like to express my appreciation to my employers and friends, Dr. Ron D. Schiff and Dr. Egberto Zayas for the many sacrifices made over the last few years so that I could pursue higher education and gainful employment simultaneously. I will always be grateful for your support. I am also thankful to all of my co workers, especially Bernadette Fowler, Lori Kelly, and Nelly Bell e I feel honored to work w ith each of you. Thanks for helping me get through this and still have a smile on my face! Thanks to all of the wonderful patients who participated in my study. Your courage inspires me on a daily basis. Thanks to my preceptors Leah Sisler, Pam Labadie, an d Melissa Carver for being wonderful role models. Melissa Leggatt, thanks for all of your help with my data! I dont know what I would have done without you! Thanks to Dr. Cecile Lengacher and Dr. Lois Gonzalez for being on my committee and for all of you r insight on anxiety and spirituality. A special thanks to Dr. Susan McMillan for all of your advice, encouragement, and research expertise over the last two years.
i Table of Contents List of Tables Abstract Chapter One Introduction Problem statement Research questions Definition of terms Significance to nursing Chapter Two Review of the Literature Anxiety Spirituality Summary Chapter Three Methods Setting and Sample Instruments State Trait Anxiety Inventory Reliability Validity The Functional Assessment of Chronic Illness Therapy Spiritual Well Being Scale Reliability Validity Demographic Data Form Procedures Data Analysis Chapter Four Results, Discussion and Conclusions Results Demographic Data State Trait Anxiety Spiritual Well Being Discussion Demographic Data State Trait Anxiety Spiritual Well Being Implications for Nursing Co nclusions Recommendations for Future Research iii iv 1 2 3 3 4 5 5 8 12 14 14 14 14 15 15 16 16 16 17 17 17 19 19 19 23 23 24 24 25 26 26 27 27
ii References 28 Appendices 30 Appendix A: State Anxiety Inventory 31 Appendix B: Trait Anxiety Inventory 32 Appendix C: FACIT Sp 12 (Version 4) 33 Appendix D: Demographic Data Form 34 Appendix E: Letter of Approval from Physician #1 36 Appendix F: Letter of Approval from Physician #2 37 Appendix F: Appendix G: Informed Consent 38
iii List of Tables Table 1. Frequency and Percent of Participants Living Conditions 19 Table 2. Frequency and Percent of Participants Demographic Characteristics 20 Table 3. Frequency and Percent of Participants Religion and Religious Involvement 21 Table 4. Frequency and Pe rcent of Subjects by Their Perceived Goal of Chemotherapy 22 Table 5. Frequency and Percent of Site of Original Disease 22 Table 6. Correlations of Spiritual Well Being and State and Trait Anxiety, and Religious Involvement 24
iv The Relationship Between Anxiety And Spirituality In Cancer Patients Undergoing Chemotherapy Cindy Tofthagen ABSTRACT Anxiety is a common problem for cancer patients, especially those who must receive chemotherapy. Anxiety may have a negative effect on quality of life, interrupting sleep, causing uncomfortable physical symptoms, and inhibiting sound decision making. This study examined the relations hip between spiritual well being and anxiety in patients on chemotherapy for cancer. The convenience sample consisted of 30 patients, 15 male and 15 female, receiving chemotherapy in a two physician private medical oncology practice in Southwest Florida. Patients completed the State Trait Anxiety Inventory and the Functional Assessment of Chronic Illness Therapy Spiritual Well Being Scale. Participants ranged in age from 31 to 88, with a mean age of 59.7 years. Almost 60% were getting chemotherap y with the goal of slowing down the growth of cancer(n=15) or relief of symptoms(n=2)and did not consider their cancer to be curable. Participants had been given an average of 15 chemotherapy treatments. Ninety percent were Catholic or non Catholic Christi an. Sixty percent were not heavily involved in organized religion.
v The results of this study show strong negative relationships between spiritual well being and both state anxiety (r= 0.463, p=0.010) and trait anxiety (r= 0.524, p=0.003). A strong posit ive relationship was found between level of involvement in organized religion and level of spiritual well being (r= 0.545, p=0.002). Trait anxiety was also significantly negatively associated with involvement in organized religion (r= 0.38, p=0.037). Al though the sample size was small and homogenous, the results support findings of previous studies. This study is important for nursing because it examines key aspects of psychological distress in cancer patients undergoing chemotherapy. Findings suggest th e need for evidence based studies focusing on designing appropriate assessment and pertinent interventions.
1 Chapter I Introduction Anxiety is a pervasive problem for people who are undergoing treatment for cancer. It is believed to be the most common form of psychological distress, occurring in up to 50% of cancer patients (Holland & Gooen Piels, 2000). A lack of attention to anxiety in research and in clinical practice has been recognized (Schmidt, 2003). In contrast, depression in cancer patients has been studied extensively, particularly at the end o f life. The concepts of depression and anxiety are often referred to as psychological distress, and studied as one entity. Although anxiety and depression often coexist, they are distinct phenomena, which can independently increase distress for patients (S chmidt, 2003). Anxiety, characterized by persistent fear, can be accompanied by hyper vigilance, poor concentration (Holland & Gooen Piels, 2000), nervousness, and agitation (Schmidt, 2003). When experienced as a normal response to a known or perceived t hreat, anxiety often dissipates when the threat is removed. In the case of someone diagnosed with cancer, the threat is often insidious and may continue after treatments are completed. Fear of recurrence of cancer and/or death can loom in a persons mind c ausing chronic anxiety and apprehension about the future. Anxiety in cancer patients can be related to frightening aspects of treatment or to the uncertainty of coping with a potentially life threatening diagnosis. People with preexisting anxiety disorders tend to experience exacerbations in their disorder when
2 confronted with a cancer diagnosis. Research shows that certain events result in increased vulnerability and susceptibility to increased anxiety such as discovering a new suspicious symptom; first be ing diagnosed; awaiting test results; beginning a new treatment; experiencing a change in treatment; ending treatment; having a treatment failure; being discharged from the hospital; learning the disease has progressed; experiencing stresses of survivorshi p; and facing the end of life (Holland & Gooen Piels, 2000) A cancer diagnosis often causes individuals to reexamine the meaning of their lives, their relationships with others, their relationship with the universe, and with their creator. Spiritual need s often go unaddressed by health care professionals, who have had little training in providing spiritual care and may not feel comfortable assuming that role (Allgar, Neal & Pascoe, 2003) Numerous studies validate that a strong sense of spiritual well bei ng in cancer patients is associated with better quality of life and less psychological distress (Bauer Wu & Farran, 2005; Chibnall, Videen, Duckro, & Miller, 2002; Krupski, et al., 2005; McClain, Rosenfeld, & Breitbart, 2003; Noguchi, et al., 2005). Resear ch suggests that because of the strong relationship between psychological and spiritual well being, these concepts should be referred to as psycho spiritual functioning (Bauer Wu & Farran, 2005). Problem Statement Although several studies have been condu cted to examine the relationship between spirituality and emotional distress in cancer patients, most of these studies have focused on the terminally ill (Chibnall, Videen, Duckro, & Miller, 2002; McClain, Rosenfeld, & Breitbart, 2003; McClain Jacobson, et al., 2004). Chemotherapy is reported to increase
3 the risk of anxiety related to fears about treatments, side effects, and uncertainty about the future (Schreier & Williams 2004). Some patients are able to find a great deal of comfort in their spirituality Conversely, patients may suffer from spiritual distress, questioning the meaning of life, and their relationships with God and with others. More research is needed to examine psycho spiritual aspects of cancer care. The purpose of this study was to explo re the relationship between anxiety and spirituality in persons with cancer. Research Questions The following research questions were addressed in this study: 1. Is there a significant relationship between spiritual well being and severity of state and tra it anxiety in persons with cancer receiving chemotherapy? 2. Are there significant relationships between anxiety in chemotherapy patients and their age, gender, marital status, education, involvement in organized religion, and what the patient believes the goal of treatment to be? 3. Are there significant relationships between spiritual well being in chemotherapy patients and their age, gender, marital status, education, involvement in organized religion, and what the patient believes the goal of treatment to be? Definitions of Terms For the purpose of this study the following terms are defined: Anxiety : a continuous state of tension with the expectation of disaster (Carroll Johnson, Gorman, & Bush, 1998, p.126). Spiritual well being : a sense of harmony wi th oneself and others, the world, and a perceived higher power (Ackley & Ladwig, 2002).
4 Spiritual distress : Disruption in life principles that creates a sense of disharmony with oneself or others, the world, or a perceived higher power (Ackley & Ladwig, 2002). Chemotherapy patient : A person with a cancer diagnosis who is being treated with antineoplastic medications for the purpose of prevention of recurrence, cure, disease control, or palliation of symptoms. Significance to Nursing Nurses are committed t o providing holistic care to patients. In order to provide holistic care to patients, nurses must recognize that anxiety causes patients a great deal of distress and that it is a nursing responsibility to treat it. Assessment of available spiritual support and ensuring patient access to sources of spiritual support are important topics for nursing. Methods of helping patients utilize their spirituality to find comfort, peace, and meaning in life should be explored. This study may shed light on whether the re is a strong relationship between spiritual well being and anxiety. If those people who have a higher degree of spiritual well being experience less anxiety, then assessing anxiety and spiritual well being will help nurses develop interventions to enhanc e quality of life in these patients.
5 Chapter II Review of the Literature This chapter reviews current empirical literature relevant to anxiety and spirituality in cancer patients. First is a review of the empirical literature pertaining to anxie ty in cancer patients, particularly those receiving chemotherapy. This is followed by a review of current studies focusing on spirituality in cancer patients, and ends with a summary of findings. Anxiety Several studies have examined anxiety in cancer pati ents. A study by Keller, et al. (2004) sought to determine the prevalence of anxiety and depression in 189 newly admitted patients scheduled for cancer surgery and to evaluate how accurate medical and nursing staff are in recognizing those who are experien cing psychological distress. Patients were evaluated prior to surgery using a psychiatric interview, the Hospital Anxiety and Depression Scale, and a nurse and physician evaluation. Results showed 28% of the patients in the study had a psychiatric diagnosi s. Physicians recognized significant distress in 77% of the severe cases. Nurses recognized significant distress in 75% of the severe cases. Unfortunately, the rate of referral for psychosocial support was only 40% of those with a DSM IV disorder and 31% o f those demonstrating high levels of psychological distress according to the Hospital Anxiety and Depression Scale (Keller, et al. 2004).
6 A prospective study reported by Iconomou, Mega, Koutras, Iconomou, and Kalofonos, (2004) examined the rates and clini cal course of emotional distress, cognitive impairment, and quality of life in cancer patients who had never received chemotherapy. This study evaluated 80 patients in Greece before the initiation of chemotherapy and again at the completion of chemotherapy Quality of life was evaluated by the European Organization for Research and Treatment of Cancer QLQ C30. Cognitive function was measured using the Folstein Mini Mental State Examination. The Hospital Anxiety and Depression Scale was used to assess psych ological distress. Results showed cognitive function was not affected by chemotherapy, type of cancer, or stage of disease. Quality of life parameters did not change significantly over time, except for fatigue, which was more severe at the end of treatment Of the patients surveyed, 31.25% had high levels of anxiety before the initiation of chemotherapy and 26.25% had high levels of anxiety at the end of chemotherapy, showing no significant difference. These results confirm that anxiety is a common symptom for patients receiving chemotherapy and remains at high levels throughout the course of treatment. A study examining anxiety and quality of life in 48 breast cancer patients receiving chemotherapy and radiation therapy was completed by Schreier and William s (2004). The participants were asked to participate in the study before starting chemotherapy or radiation. Telephone interviews were conducted at baseline, again at four weeks, 12 weeks, and after one year. Seventeen of the women had radiation and thirty one women had chemotherapy. The Ferrans and Powers Quality of Life Index was administered at the start of treatment and a year later to evaluate quality of life. Anxiety was assessed using the State Trait Anxiety Inventory. The results of this study indic ated that chemotherapy
7 patients experience more anxiety than radiation therapy patients. High anxiety levels were associated with decreased quality of life both at the start of treatment and at the one year mark. The study highlights the need to initiate nursing interventions to reduce anxiety at the beginning of chemotherapy (Schreier & Williams 2004). Another study examining anxiety in 250 cancer patients receiving chemotherapy was conducted by Tchekmedyian, Kallich, McDermott, Fayers, and Erder (2003). This study examined the relationship between changing levels of anxiety and depression with changes in fatigue levels in anemic lung cancer patients receiving platinum based chemotherapy. Patients were given darbepoetin alfa or a placebo. Anxiety and depr ession were evaluated using the Brief Symptom Inventory, depression and anxiety subscales. Fatigue was measured using the Functional Assessment of Cancer Therapy fatigue subscale. The study showed that as fatigue improved, there was corresponding improveme nt in levels of anxiety and depression. Results showed that darbepoetin alfa therapy is helpful for treatment of anemia and the associated fatigue in this group of patients. The placebo group demonstrated higher anxiety levels at the end of the study. By t reating the anemia, practitioners may see improvement in not only fatigue but in anxiety and depression as well. A randomized clinical trial of 227 women with breast cancer who received chemotherapy by Andersen and colleagues (2004), examined the effects o f a psychosocial intervention on psychological distress, social adjustment, health behaviors, adherence to the chemotherapy regimen, and immune assays. Patients were evaluated before and after four months of group therapy sessions. The sessions included tr aditional psychosocial elements as well as discussions on diet, exercise, smoking, and adherence to
8 treatment. The Profile of Mood States was used to assess anxiety, depression, anger, fatigue, and confusion. The Social Network Index and Perceived Social S upport Scales for Friends and Family were used to assess perceived social support. The Food Habits Questionnaire, Seven Day Exercise Recall of the Stanford Heart Disease Prevention Program, and a questionnaire related to smoking habits were used to assess health behaviors. Chemotherapy non adherence was documented. Functional status was evaluated using the Karnofsky Performance Status Scale. Blood tests were done before and after the intervention for immune assays. The results showed a significant reducti on in anxiety in the intervention group as well as improvement in perceived social support, dietary habits, and smoking. The intervention group was more adherent to the prescribed chemotherapy regimen. There was improvement in immune responses in the inter vention group Andersen, et al (2004). Spirituality Three studies were found that address spirituality among terminally ill cancer patients. A study by McClain, Rosenfeld, and Breitbart (2003) attempted to assess the relationship between spiritual well bei ng and end of life despair. One hundred sixty cancer patients with a life expectancy of three months or less were studied over an eighteen month period. This study examined whether spiritual well being was associated with depression, hopelessness, attitude s toward hastened death, functional support, and performance status. Instruments used in the study were Functional Assessment of Chronic Illness Therapy Spiritual Well Being Scale, Mini Mental State Examination, Hamilton Depression Rating Scale, Beck Hopel essness Scale, Schedule of Attitudes toward Hastened Death, Functional Social Support Questionnaire, Memorial Symptom
9 Assessment Scale, and Karnofsky Performance Rating Scale. Results showed that spiritual well being was strongly associated with less hopel essness, end of life despair, and suicidal ideation. Depression was highly associated with desire for hastened death in patients who experienced low spiritual well being but not for those who experienced high levels of spiritual well being. A subsequent s tudy by McClain Jacobson, et al. (2004) was conducted on 276 terminally ill cancer patients to determine whether a belief in the afterlife was associated with lower levels of end of life despair, anxiety, and depression. Patients were asked whether they believed in an afterlife, whether their beliefs about an afterlife were comforting, and whether their beliefs about an afterlife were distressing. Results showed that most patients (63.4%) reported belief in an afterlife, 17.0% reported no belief in the af terlife and 19.6% were unsure about their beliefs Spiritual well being was assessed with the Functional Assessment of Chronic Illness Therapy Spiritual Well being Scale. Depression was measured using the Hamilton Depression Rating Scale and Hospital Depr ession Scale. Anxiety was measured using the Hospital Anxiety Scale. Hopelessness was measured using the Beck Hopelessness Scale. Belief in an afterlife, spiritual well being and end of life despair in patients with advanced cancer were measured using the Schedule of Attitudes Toward Hastened Death. This study concluded that belief in an afterlife was associated with lower levels of hopelessness, suicidal ideation, and desire for hastened death but was not associated with anxiety or depression. A randomized controlled trial by Chibnall, Videen, Duckro, and Miller (2002) was completed to identify individual factors associated with death related anxiety and depression and to evaluate the effectiveness of support groups on the psychosocial and
10 spiritual well be ing of patients with life threatening conditions. Members of the intervention group attended monthly support groups for one year. Three hundred and fifty people with serious, life threatening medical conditions were invited to participate in the study. Par ticipants were randomly assigned to either an intervention group or a control group. Sixty seven patients completed the study. Out of those 67 patients who completed the study, 24% had a diagnosis of cancer. All participants were asked to complete a base line questionnaire packet including the State Trait Anxiety Inventory, the Beck Depression Inventory, the Spiritual Well Being Scale, the Illness Disability Index, the Perceived Social Support Inventory, and the Modified City of Hope Questionnaire, and the Death Anxiety and Death Depression Scales. The Illness Disability index measures illness related interference with function. The Modified City of Hope Questionnaire measured physical symptom severity, emotional and spiritual well being, perceived quality of personal relationships, medical and nursing care (Chibnall, Videen, Duckro, & Miller, 2002). This study revealed that higher levels of death distress were associated with more depressive symptoms, less spiritual well being, less perceived communication with their physician, and with living alone. Higher levels of death anxiety and death depression were correlated with lower levels of spiritual well being. The sample size was not large enough to evaluate differences between the intervention group and the control group (Chibnall, et al., 2002). A cross sectional study by Bauer Wu and Farran (2005) compared personal meaning in life, spirituality, stress, and psychological distress in breast cancer patients to a group of healthy patients. There were seventy eight women who participated in the study
11 ranging from 35 to 55 years of age. Most participants had a high socioeconomic status, were Caucasian, and married. Thirty nine were breast cancer survivors a nd thirty nine had no personal history of cancer or othe r chronic or life threatening illness (Bauer Wu & Farran, 2005). All participants completed questionnaires including three measures of personal meaning: the Personal Meaning Index; the Existential Vacuum, and the Ladder of Life Index at Present. One measu re of spirituality, the Index of Core Spiritual Experiences was used. Perceived stress was measured with the Perceived Stress Scale. Psychological distress was measured using the brief Profile of Mood States (Bauer Wu & Farran, 2005). The study concluded that there is a correlation between perceived meaning in life and spirituality. These elements have an inverse correlation with psychological distress and perceived stress. Another interesting finding was that personal meaning in life and spirituality were lower and psychological distress was higher in breast cancer survivors without children compared to breast cancer patients with children (Bauer Wu & Farran, 2005). A similar study by Krupski, et. al. (2005) was conducted on prostate cancer patients of lo w socioeconomic class to determine whether spirituality is associated with health related quality of life or psychosocial health. Health related quality of life was measured using the RAND Medical Outcomes Study Short Form 12 Item Health Survey, version 2. Anxiety was evaluated using an unnamed instrument validated in leukemia survivors. Emotional well being was assessed with the Medical Outcomes Study 5 item Mental Health Index. Symptom distress was measured using the Symptom Distress Scale. The Functional Assessment of Chronic Illness Therapy Spiritual Well Being scale was
12 utilized to evaluate spiritual well being. The study findings show that as spiritual well being increased, health related quality of life also improved. Spirituality was associated with higher levels of life satisfaction. Men who had lower levels of spiritual well being also had lower levels of psychological well being including increased anxiety and more symptom distress (Krupski, et al., 2005). A study of 298 adult cancer patients re ceiving radiation therapy was conducted in Japan by Noguchi, et al (2005). This study examined the possibilities of providing spiritual care based on Frankls existential analytical therapy. All participants completed the Japanese versions of the Function al Assessment of Chronic Illness Therapy Spiritual, the Purpose in Life test, the WHO subjective inventory, and the Hospital Anxiety and Depression Scale. The study confirmed that high levels of spiritual well being correlated with lower levels of anxiety and negative thinking (Noguchi, et al., 2005). Summary Numerous studies indicate that patients on chemotherapy experience high levels of anxiety (Iconomou, et al., 2004; Schreier & Williams, 2004; Tchekmedyian, et al., 2003; Andersen, et al., 2004). Psyc hological interventions are of benefit in reducing anxiety (Andersen, et al., 2004). High levels of anxiety in cancer patients have been associated with fatigue (Tchekmedyian, et al., 2003) and reduced quality of life (Schreier & Williams, 2004). Unfortu nately, health care professionals often fail to properly assess patients for anxiety and seldom make appropriate referrals for psychological treatment (Keller, et al). Two studies have concluded that high levels of spiritual well being correlate with less anxiety and negative thinking in cancer patients (Noguchi, et al., 2005; Krupski, et al
13 2005). Neither of these studies examined the relationship between anxiety and spiritual well being in patients receiving chemotherapy. Current research supports the id ea that spiritual well being results in decreased death anxiety among the terminally ill (Chibnall, et al., 2002). Knowing whether a relationship between anxiety and spiritual well being in cancer patients receiving chemotherapy exists is essential to the development of nursing interventions aimed at decreasing anxiety and increasing quality of life in this population.
14 Chapter III Methods The purpose of this study was to determine whether there was a significant relationship between anx iety and spiritual well being in cancer patients receiving chemotherapy. This chapter outlines the research methods. First the sample and setting are described. The instruments included in the study are then discussed. Third, data collection procedures are outlined, and finally, data analysis information is provided. Setting and Sample The sample consisted of 30 patients from an outpatient facility currently undergoing chemotherapy treatments. Sample size was estimated using power analytic techniques. With alpha set at .05 and power set at .80, a sample size of 30 would be needed to detect a moderate effect size. For inclusion in the study, patients had to be receiving chemotherapy for a known type of malignancy, be at least 18 years of age, and be able to s peak, read, and write English. Those who had a history of psychiatric illness were excluded. Instruments State Trait Anxiety Inventory The State Trait Anxiety Inventory (STAI) assesses both personal tendency toward anxiety, also known as trait anxiety, and current level of anxiety, referred to as state anxiety (Spielberger, 1983). This instrument was chosen because it allows for comparison between anxious personality characteristics and level of current anxiety.
15 There are a total of 40 multiple choice quest ions, 20 assessing trait anxiety and 20 assessing state anxiety. It is a four point Likert type scale, and possible answers to anxiety related questions include: 1 (not at all), 2 (somewhat), 3 (moderately so), and 4 (very much so). Scores range from 20 to 80 and higher scores correspond with higher anxiety levels. The questionnaire is written on a sixth grade reading level, is self administered, and takes less than 10 minutes to complete. Reliability Alpha coefficients range from 0.83 to 0.94 for the sta te anxiety subscale and are higher under stressful circumstances. The median alpha coefficient for trait anxiety is 0.90 (Spielberger, 1983). Validity Construct validity of the trait anxiety scale was determined by comparing scores of neuropsychiatric p atients, who tend to have high levels anxiety, to the scores of normal subjects. Of the 461 neuropsychiatric patients in the study, only one had trait anxiety scores within the normal range. The rest had elevated scores on the trait anxiety subscale (Spiel berger, 1983). Validity of the trait anxiety scale was also confirmed by comparing scores of people with character disorder, for whom the absence of anxiety is a defining characteristic, to normal scores. The character disorder patients had significantly l ower levels of trait anxiety. Construct validity of the state anxiety subscale was determined by comparing the scores of military recruits (N=1,964) entering highly stressful training programs to those of people in the same age group under non stressful c onditions. Scores on the state anxiety scale were much higher for the military recruits than for those under non stressful
16 conditions. Further validity of the state anxiety scale was determined by comparing scores of 977 college students during regular cla ss periods, during an exam, and after relaxation training. Scores were highest during the exam and lowest during the relaxation training (Spielberger, 1983). The Functional Assessment of Chronic Illness Therapy Spiritual Well Being Scale The Functional Ass essment of Chronic Illness Therapy Spiritual Well Being Scale (FACIT Sp 12) is a Likert type scale consisting of 12 multiple choice questions (Cella, n.d.). This instrument was chosen because it was specifically designed for use in oncology patients. The i nstrument is comprised of two subscales; one measures the role of faith in illness, and the other assesses peace and meaning in life (Peterman, Fitchett, Brady, Hernandez, & Cella, 2002). Possible responses to the 12 questions assessing spiritual well bein g include 0= not at all, 1= a little bit, 2= somewhat, 3= quite a bit, 4= very much. Higher scores indicate a higher degree of spiritual well being. Reliability Reliability was evaluated with internal consistency coefficients. The alpha coefficients were 0.87 for the entire scale, 0.81 for the meaning/peace subscale and 0.88 for the faith subscale (Peterman, Fitchett, Brady, Hernandez, & Cella, 2002). Validity Positive correlations between FACIT Sp and the Functional Assessment of Cancer Therapy General and the Profile of Mood States have evaluated validity of this instrument. The correlation between the role of faith in illness subscale and the peace and meaning in life subscale was 0.54 (p=0.0001) (Peterman, Fitchett, Brady, Hernandez, & Cella, 2002).
17 Demographic data form A demographic tool was developed for this study. The demographic tool included age, gender, cancer type, goal of chemotherapy, how many chemotherapy treatments the patient has received, marital status, who the patient lives with, in come level, educational level, religion, and degree of involvement in organized religious activities assessed on a 0 to 10 scale. Procedures Approval for the study was obtained from the physicians who own the practices where the study was conducted, Ron D Schiff, M.D., Ph.D. and Egberto Zayas, M.D. and from the University of South Florida Institutional Review Board. Expedited status was granted. The investigator was the nurse caring for the patients and thus identified patients meeting inclusion criteria when they came into the office to receive chemotherapy. The purpose of the study and requirements for the study were explained to patients coming into the office for chemotherapy, and their questions were answered. If they chose to participate in the study informed consent was obtained and each patient was given a copy of the consent form to keep. The questionnaires were completed by the patients while they were receiving their chemotherapy or while they were waiting. All data was confidential and stored i n a locked closet. Data Analysis Descriptive statistics were used to analyze the demographic data including frequencies and percentages, means, and standard deviations. Relationships between variables were assessed using the Pearson product moment correla tion coefficient. Data were analyzed using the Statistical Package for the Social Sciences. Levels of state and
18 trait anxiety were correlated with levels of spiritual well being to determine whether a relationship existed between the two. Levels of state and trait anxiety were correlated with demographic characteristics to determine whether a relationship exists between any of the demographic variables and increased levels of anxiety. Levels of spiritual well being were correlated with demographic charac teristics to determine whether a relationship exists between any of the demographic variables and overall levels of spiritual well being. Data were analyzed with the goal of shedding light on the following research questions: 1. Is there a significant rela tionship between spiritual well being and severity of state and trait anxiety in persons with cancer receiving chemotherapy? 2. Are there significant relationships between anxiety in chemotherapy patients and their age, gender, marital status, education, i nvolvement in organized religion, and what the patient believes the goal of treatment to be? 3. Are there significant relationships between spiritual well being in chemotherapy patients and their age, gender, marital status, education, involvement in organ ized religion, and what the patient believes the goal of treatment to be?
19 Chapter IV Results, Discussion and Conclusions This chapter presents the findings of the study. The results, discussion of the results and limitations, conclusions, and sug gestions for future research are discussed. Results Demographic data The sample consisted of 30 patients, 15 male and 15 female, ranging in age from 31 to 88 with a mean age of 59.7 (SD=13.4). Years of formal education ranged from 9 to 21 years with a mean of 14 years. Two thirds of the patients were married and lived with a spouse (n=20) (Table 1) and one third were unmarried (n=10) (Table 2). Number of previous chemotherapy treatments ranged from 0 to 50 with a mean of 15.63 (SD=15.0). The majority of pa tients had an annual household income of $50,000 or more per year (n=18) (Table 2). Table 1. Frequency and Percent of Participants Living Conditions Living Conditions Frequency a Percent _______________________________________________________________________ lives alone 5 16.7 lives with spouse 20 66.7 lives with family member 5 16.7 lives with friend 2 6.7 a Participants could choose multiple answers
20 Table 2. Frequency and Percent of Participants Demographic Characteristics Demographic Variable Frequency Percent _______________________________________________________________________ Gender Male 15 50.0 Female 15 50.0 Marital status Single 1 3.3 Married 20 66.7 Divorced 3 10.0 Separated 1 3.3 Widowed 5 16.7 Income Less than $25,000 5 16.7 $25,000 $49,999 6 20.7 $50,000 $74,999 9 30.0 More than $75,000 9 30.0 Missing Data 1 3.3 _______________________________________________________________________ Most of the participants were Caucasian (n=27) and non Catholic Christian (n=18) or Catholic (n=9). Ten percent of patients did not identify with any religion. Sixty percent rated their degree of involvement in organized religion on a scale of one to ten as a zero
21 (n=8), one (n=3), or two (n=7). Only 16.7% (n=5) were highly involved in organized religion, responding with a score between 8 and 10 (Table 3). Table 3. Frequency and P ercent of Participants Religion and Religious Involvement Frequency Percent _______________________________________________________________________ Religion Non Catholic Christian 18 60.0 Catholic 9 30.0 None 3 10.0 Involvement in organized religion on a scale of 0 to 10 a 0 8 2 6.7 1 3 10.0 2 7 23.3 3 4 13.3 4 1 3.3 5 0 0.0 6 2 6.7 7 0 0.0 8 2 6.7 9 1 3.3 10 2 6.7 ______________________________________________________________________ a Assessed on a 0 (no involvement) to 10 (highly involved) scale Most patients were unaware of the stage of their malignancy (n=19). Forty percent (n=12) believed that the goal of chemotherapy was cure or prevention of recurrence.
22 Almost sixty percent of the patients who responded to the question (n=17) believed the goal of chemotherapy was slowing down cancer growth (n=15) or relief of symptoms (n=2) (Table 4). Seven patients had lung cancer, six had colorectal cancer, six had breast cancer, three had prostate cancer, three had non Hodgkins lymphoma, two had multiple myeloma, and four had other solid tumors. Table 4. Frequency and Percent of Subjects by Their Perceived Goal of Chemotherapy Goal Frequency Percent________ Cure 5 16.7 Prevention of recurrence 7 23.3 Slowing down growth 15 50.0 Relief of symptoms 2 6.7 Missing 1 3.3 _______________________________________________________________________ Table 5. Frequency and Percent of Site of Original Disease Type of Cancer Frequency Percent____________ Lung 7 23.3 Colorectal 6 20.0 Breast 6 20.0 Non Hodgkins Lymphoma 3 10.0 Multiple My eloma 2 6.7 Anal Cancer 1 3.3 Bladder Cancer 1 3.3 Ovarian Cancer 1 3.3______________
23 State trait anxiety State and trait anxiety were assessed using the State Trait Anxiety Inventory. There w ere no significant differences in scores between men and women. The mean score on the state anxiety inventory was 35.5 for males (SD=13.9) and 35.3 for females (SD=11.4). The mean score on the trait anxiety inventory was 35.6 for males (SD=11.3) and 36.9 f or females (SD=9.7). No relationships were found between anxiety and age, marital status, level of education, or goal of treatment. Trait anxiety was significantly higher in people with a low degree of involvement in organized religion (r = 0.38, p =.037) State anxiety was also negatively associated with the degree of religious involvement (r = 0.35, p = 0.061), although the relationship was not considered statistically significant. Levels of state and trait anxiety were inversely related to levels of sp iritual well being. Spiritual well being Spiritual well being was measured using the Functional Assessment of Chronic Illness Therapy Spiritual Well Being Scale (FACIT Sp 12). No significant correlation was found between spiritual well being and age, m arital status, level of education, or goal of treatment. The mean score on the FACIT Sp 12 was 35.1 for males (SD=6.9) and 38.0 for females (SD=7.3). Levels of spiritual well being were associated with involvement in organized religion (r=0.545, p=0.002). Level of spiritual well being was negatively related to levels of both state and trait anxiety (Table 6).
24 Table 6. Correlations of Spiritual Well Being and State and Trait Anxiety, and Religious Involvement FACIT Sp 12 r p_______________ State Anxiety 0.463 0.010 Trait Anxiety 0.524 0.003 Involvement in organized religion 0.545 0.002 _______________________________________________________________________ Discussion Demographic data Participants were recruited from a two physician private practice usi ng a convenience sample. Data for the study were collected during the months of December 2005 through February 2006. The sample largely consisted of middle class, white, non Hispanic participants. All of the participants who professed a religion we re of the Christian faith and so the results cannot be generalized to people of other races, economic classes or faiths. The majority of participants had received numerous chemotherapy treatments and cure was no longer the goal of treatment. Anxiety levels in this population may differ from those who are new to chemotherapy or are in early stages of cancer treatment. Treatment related anxiety, disease related anxiety, and facing their own mortality are major sources of anxiety for cancer patients. Th ese issues that cancer patients must face, contribute to decreased feelings of well being and overall quality of life (Holland & Gooen Piels, 2000).
25 State trait anxiety The results of this study confirm that trait anxiety levels are lower among cance r patients receiving chemotherapy who have higher levels of spiritual well being. This means that the patients general tendency to be anxious was related to both their level of spiritual well being and their degree of religious involvement. Similar findin gs related to spiritual well being among radiation therapy patients (Noguchi, et al., 2005) and prostate cancer patients (Krupski, et al 2005) have been previously reported. Mean levels of state and trait anxiety were higher among unmarried people, but the differences were statistically insignificant. Only five of the 30 participants lived alone. This small sample size may account for why this study failed to confirm the findings of previous studies that support the idea that people who live alone ha ve higher levels of anxiety. No relationships were found between anxiety and age, gender, education, or what the patient believes the goal of treatment to be. The study found that anxiety levels were lower among participants who were more active in organized religion. Current research literature does not address this topic. Increased social support and feelings of connectedness with God and others found though group worship would be expected to help alleviate anxiety, and contribute to a better sen se of spiritual well being and better quality of life. Trait anxiety and spiritual well being were inversely correlated, and although a negative correlation between state anxiety and religious involvement was found, again, it was a statistically insig nificant finding. A larger sample size may have resulted in a statistically significant finding.
26 Spiritual well being There was no correlation between spiritual well being and age, education, or what the patient thought the goal of treatment was. Ag ain, more significant findings may have resulted from a larger sample size. Patients who were involved in organized religion had higher levels of spiritual well being than did those who were not involved in organized religion. Religious involvement and spi ritual well being, while different, are related concepts. The affirmation of ones spiritual beliefs and values, the focus on a relationship with God, and the opportunity to interact with others who share the same beliefs is a positive experience for many. Implications for nursing The findings of this study have several implications for nursing. Holistic care should be emphasized in oncology nursing education. Assessment of spiritual and psychological health and interventions to help support spiritual a nd psychological well being need to be incorporated into nursing curriculum. Nursing research focusing on the development of specific interventions to alleviate anxiety and support spiritual health are needed. Because the primary role of nurses is t hat of patient advocate and because nurses tend to have a holistic approach to care, nurses are ideally suited to address the complex physical, emotional, and spiritual needs of patients facing an illness that is potentially life limiting. Health care prof essionals from other disciplines have been slow to address the emotional and spiritual aspects of cancer treatment believing that it is outside of their realm. Many health care professionals are reticent to discuss issues such as fear of loss of control, f ear of pain and suffering, and fear of death and dying with patients because of their own personal fears and discomfort with the subject matter. These are areas where
27 nurses have expertise and where their input should be valued by other members of the heal th care team, who may not understand the complex needs of these patients including the need to be understood and to have their feelings and experiences validated. Conclusions Anxiety levels are higher among people with lower degrees of spiritual well being. Those who are involved in organized religion have higher levels of spiritual well being and lower levels of anxiety. No relationships between anxiety or spirituality and age, marital status, level of education, or goal of treatment were significant Findings suggest the need for evidence based studies focusing on designing appropriate assessment and pertinent interventions. Recommendations for future research Future studies should include a larger sample size and a more ethnically, economically and religiously diverse sample. More studies looking at nursing interventions that help support spiritual and psychological well being are needed. Studies are also needed to determine whether interventions designed to support spiritual well being would be usef ul in helping to alleviate anxiety and increase quality of life in this population.
28 References Ackley, B. J., & Ladwig, G. B. (2002). Nursing diagnosis handbook (2). St. Louis, Missouri. Mosby. Allgar, V. L., Neal, R. D., & Pascoe, S. W. (2003). Cancer patients consultation patterns in primary care and levels of psychological mordidity: findings from the health survey for England. Psycho Oncology 12, 736 740. Andersen, B. L., Farrar, W. B., Golden Kreutz, D. M., Glaser, R., Emery, C. F., Crespin, T. R., et al. (2004, Sept ember). Psychological, behavioral, and immune changes after a psychological intervention: a clinical trial. Journal of Clinical Oncology 22(17), 3570 3580. Bauer Wu, S., & Farran, C. J. (2005, June). Meaning in life and psycho spiritual functioning. Journal of Holistic Nursing 23(2), 172 190. Carroll Johnson, R. M., Gorman, L. M., & Bush, N. J. (Eds.). (1998). Psychosocial nursing care. Pittsburgh, PA: Oncology Nursing Press. Cella, D. (n.d.). The Functional Assessment of Chronic Ilness Therapy Spiritual Well Being Scale. Retrieved July 4, 2005, from http://facit.org Chibnall, J. T., Videen, S. D., Duckro, P. N., & Miller, D. K. (2002). Psychosocial spiritual correlates o f death distress in patients with life threatening medical conditions. Palliative Medicine 16, 331 338. Holland, J. C., & Gooen Piels, J. (2000). Principles of psycho oncology Retrieved June 15, 2004, from http://www.cancer.org Iconomou, G., Mega, V., Koutras, A., Iconomou, A. V., & Kalofonos, H. P. (2004). Prospective assessment of emotional distress, cognitive function, and quality of life in patients with cancer treated with chemo therapy. Cancer 101(2). Keller, M., Sommerfeldt, S., Fischer, C., Knight, L., Riesbeck, M., Lowe, B., et al. (2004). Recognition of distress and psychiatric morbidity in cancer patients: a multi method approach. Annals of Oncology 15, 1243 1249. Krupski, T. L., Kwan, L., Fink, A., Sonn, G. A., Maliski, S., & Litwin, M. S. (2005, in press). Spirituality influences health related quality of life in men with prostate cancer. Psycho oncology pp. 1 11.
29 McClain, C. S., Rosenfeld B., & Breitbart, W. (2003). Effect of spiritual well being on end of life despair in terminally ill cancer patients. The Lancet 361, 1603 1607. McClain Jacobson, C., Rosenfeld, B., Kosinski, A., Pessin, H., Cimino, J., & Breitbart, W. (20 04, September). Belief in an afterlife, spiritual well being and end of life despair in patients with advanced cancer. General Hospital Psychiatry, 26 (6), 484 486. Noguchi, W., Morita, S., Ohno, T., Aihara, O., Tsujuii, H., Shimozuma, K., e t al. (2005). Spiritual needs in cancer patients and spiritual care based on logotherapy. Supportive Care in Cancer online article, 1 12. Peterman, A. H., Fitchett, G., Brady, M. J., Hernandez, L., & Cella, D. (2002). Measuring spiritual well being in people with cancer: the Functional Assessment of Chronic Illness Therapy Spiritual Well Being Scale. Annals of Behavioral Medicine 24(1), 49 58. Schmidt, L. (2003). Anxiety: The most misunderstood element in end of life care. Retrieved from http://www.healthandage.com/Home/gm=20!gid2=2796 Schreier, A. M., & Williams, S. A. (2004, January). Anxiety and quality of life of women who receive radiation thera py or chemotherapy. Oncology Nursing Forum 31(1), 127 131. Spielberger, C. D. (1983). State trait anxiety inventory for adults form Y review set. Redwood City, CA: Mindgarden, Inc. Tchekmedyian, N. S., Kallich, J., McDermott, A., Fayers, P. & Erder, M. H. (2003, July). The relationship between psychologic distress and cancer related fatigue. Cancer 98(1), 198 203.
31 Appendix A: State Anxiety Inventory
32 Appendix B: Trait Anxiety Inventory
33 Appendix C: FACIT Sp 12 (Version 4)
34 Appendix D: Demographic Data Form 1. What is your current age? ______ 2. Which gender are you? (circle one) male/female 3. What type of cancer are you being treated for ( breast, colon, lymphoma, etc.)? _________________________ 4. What do you understand the goal of the chemotherapy is (check one answer below)? ___cure ___ prevention of recurrence ___s lowing down the growth of the cancer ___relief of symptoms ___not sure 5. How many chemotherapy treatments have you had, not including today? ________ 6. Who lives with you (check one or more answers below)? ___ I live alone. ___ I live with my spouse. __ I live with at least one family member who is not my spouse. ___ I live with a friend. ___ I live in a nursing home or assisted living facility. 7. Marital status (check one). ___single ___married ___ divorced ___ separated ___widowed 8. What is your annual household income (check one) ___less than 25,000 dollars per year ___ 25,000 49,999 dollars per year ___50,000 74,999 dollars per year ___more than 75,000 dollars per year 9. How many years of formal education have you completed? ________
35 exa mple: 12 = high school graduate, 14 = associate degree or technical school 16=baccalaureate degree 10. What is your race or ethnicity (check all that apply) ___American Indian/Alaskan Native ___Asian ___Black/African American ___Hispanic/Latino ___Native Hawaiian/Pacific Islander ___White/Caucasian ___Other or Unknown 11. What is your religion (check as many as apply)? ___none ___Jewish ___Islamic ___Buddhist ___Catholic ___ Christian (non Catholic) denomination________________ ___other, please describe ______________________ 12. On the scale below circle the number that corresponds with your degree of involvement in organized religious activities. no 0 1 2 3 4 5 6 7 8 9 10 very invo lvement involved
36 Appendix D: Letter of Approval from Physician #1
37 Appendix E: Letter of Approval from Physician #2
38 Appendix F: Informed Consent
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The relationship between anxiety and spirituality in persons undergoing chemotherapy for cancer
h [electronic resource] /
by Cindy Tofthagen.
[Tampa, Fla] :
b University of South Florida,
Thesis (M.A.)--University of South Florida, 2006.
Includes bibliographical references.
Text (Electronic thesis) in PDF format.
System requirements: World Wide Web browser and PDF reader.
Mode of access: World Wide Web.
Title from PDF of title page.
Document formatted into pages; contains 40 pages.
ABSTRACT: Anxiety is a common problem for cancer patients, especially those who must receive chemotherapy. Anxiety may have a negative effect on quality of life, interrupting sleep, causing uncomfortable physical symptoms, and inhibiting sound decision-making. This study examined the relationship between spiritual well-being and anxiety in patients on chemotherapy for cancer. The convenience sample consisted of 30 patients, 15 male and 15 female, receiving chemotherapy in a two physician private medical oncology practice in Southwest Florida. Patients completed the State-Trait Anxiety Inventory and the functional Assessment of Chronic Illness Therapy-Spiritual Well- Being Scale.Participants ranged in age from 31 to 88, with a mean age of 59.7 years. Almost 60% were getting chemotherapy with the goal of slowing down the growth of Cancer (n=15) or relief of symptoms(n=2) and did not consider their cancer to be curable. Participants had been given an average of 15 chemotherapy treatments. Ninety percentwere Catholic or non-Catholic Christian. Sixty percent were not heavily involved inorganized religion. The results of this study show strong negative relationships between spiritual well-being and both state anxiety (r= -0.463, p=0.010) and trait anxiety (r= -0.524,p=0.003). A strong positive relationship was found between level of involvement inorganized religion and level of spiritual well-being (r= 0.545, p=0.002). Trait anxiety wasalso significantly negatively associated with involvement in organized religion (r= -0.38,p=0.037). Although the sample size was small and homogenous, the results support findings of previous studies. This study is important for nursing because it examines key aspects of psychological distress in cancer patients undergoing chemotherapy. Findings suggest the need for evidence-based studies focusing on designing appropriate assessment and pertinent interventions.
Adviser: Susan C. Mcmillan, Ph.D.
t USF Electronic Theses and Dissertations.