Download Hope in Newly Diagnosed Cancer Patients

Vol. 46 No. 5 November 2013
Journal of Pain and Symptom Management
661
Original Article
Hope in Newly Diagnosed Cancer Patients
Wendy Duggleby, PhD, Sunita Ghosh, PhD, Dan Cooper, MDiv,
and Lynne Dwernychuk, MN
Faculty of Nursing (W.D.) and Faculty of Medicine and Dentistry (S.G.), University of Alberta,
Edmonton, Alberta; Regina Qu’Appelle Health Region (D.C.), Regina, Saskatchewan; and
Saskatchewan Cancer Agency (L.D.), Saskatoon, Saskatchewan, Canada
Abstract
Context. Hope is important to cancer patients as it helps them deal with their
diagnosis. Little is known about hope in newly diagnosed cancer patients.
Objectives. Based on the Transcending Possibilities conceptual model of hope,
the purpose of this study was to examine the relationship of hope with pain,
energy, and psychological and demographic characteristics in newly diagnosed
adult oncology outpatients.
Methods. Data from 310 New Patient Assessment Forms from cancer
outpatients’ health records were collected. Health records from the first six
months of 2009 were reviewed and data were collected on hope, energy, pain,
depression, anxiety, feeling overwhelmed, and demographic variables. A
generalized linear modeling approach was used to study the relationship of hope
scores with these variables. Hypothesized variables and variables that were
significant at the P ¼ 0.01 level from the univariate analysis were entered into the
multivariate model, with hope scores as the dependent variable.
Results. Hope scores were significantly negatively related to age (P ¼ 0.02).
More specifically, oncology patients who were 65 years of age or older had
significantly less hope than those under the age of 65 years (P ¼ 0.01). Gender
(P ¼ 0.009) also was a significant factor, with men having higher hope scores than
women. No other variables were significant.
Conclusion. Older adults comprise the majority of persons in Canada with
cancer. The lower hope scores found in this age group compared with their
younger counterparts underscore the importance of further research. This study
provides a foundation for future research in this important area for oncology
patients. J Pain Symptom Manage 2013;46:661e670. Ó 2013 U.S. Cancer Pain
Relief Committee. Published by Elsevier Inc. All rights reserved.
Key Words
Hope, newly diagnosed, cancer, outpatient, age
Introduction
Address correspondence to: Wendy Duggleby, PhD, Faculty of Nursing, University of Alberta, 3rd floor
ECHA, 11405, 87th Avenue, Edmonton, Alberta
T6G 1C9, Canada. E-mail: wendy.duggleby@
ualberta.ca
Accepted for publication: December 5, 2012.
Ó 2013 U.S. Cancer Pain Relief Committee.
Published by Elsevier Inc. All rights reserved.
In a recent literature review, Chi1 identified
hope as one of the single most important elements in the lives of patients struggling with
a cancer diagnosis. Hope helped them deal
with the distress and uncertainty of their
0885-3924/$ - see front matter
http://dx.doi.org/10.1016/j.jpainsymman.2012.12.004
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Duggleby et al.
diagnosis.2 The hope of oncology patients appears to be related to a variety of factors,
both physical (e.g., pain and energy levels)
and psychological (e.g., anxiety and depression).1 However, a limited number of studies
have examined the relationships among hope
and physical, psychological, and demographic
factors in oncology patients3 and very often
did not include those with low hope scores.4
Moreover, very few studies have been conducted with persons newly diagnosed with cancer.5
Hope, as a multidimensional and dynamic
construct, is influenced by multiple factors
and is defined as the possibility of a better future from an uncertain and difficult present.6
Identifying factors that influence the hope of
newly diagnosed cancer patients is of great importance as hopelessness is a risk factor for suicide,7 depression, and desire for hastened
death8 in cancer patients.
Examples of physical characteristics that may
influence hope include energy and pain levels.
Energy is considered as an attribute of hope,9
and lack of energy (fatigue) has been found to
be significantly related to hope.4,9e11 In a study
of 122 women with breast cancer, Lee9 reported
a significant negative relationship between
hope and overall perceived fatigue, in which increased fatigue was associated with decreased
hope. Similar findings occurred in a study of
51 patients with lung cancer4 and 85 patients
with advanced cancer.11 In a recent study of
182 newly diagnosed patients with various solid
tumors, fatigue duration and interference with
mood and relations with others were found to
be significantly associated with hope.10 Thus,
energy levels may influence levels of hope in
cancer patients.
Pain in lung cancer patients was found to be
related to hope,4 with more pain associated
with less hope. Moreover, more pain interference with daily life is inversely correlated
with levels of hope in cancer patients.12 In
a study of 226 cancer patients, Chen13 reported a relationship between the levels of
bearable pain intensity and hope; the higher
the tolerance (bearable pain), the higher
levels of hope. The cognitive dimension of
pain (meaning ascribed to pain) also was
significantly associated with hope, in which
higher hope scores were related to positive
meanings ascribed to pain. Pain intensity levels
were not significantly correlated. In a study of
Vol. 46 No. 5 November 2013
225 cancer patients with differing types of cancer, however, Utne et al.3 reported no statistically significant relationships between pain
intensity and hope. Thus, the influence of
pain on hope is not clear, and more research
is required to define this relationship.
Psychological factors such as anxiety and depression also have been found to be related to
hope.14,15 Oncology patients who are depressed and have higher levels of anxiety report less hope. In a study of 225 oncology
inpatients, subjects who did not report depression and anxiety had higher levels of hope
than those who reported having both.14 This
is similar to the findings of a study of 80 oncology inpatients, in which anxiety and depression were found to be significantly and
negatively correlated with hope scores.15
Therefore, anxiety and depression also may
be significant factors in the hope of newly diagnosed cancer outpatients.
Demographic characteristics of patients diagnosed with cancer have been found to be related to hope. In two studies of newly
diagnosed cancer patients, men were found to
have higher levels of hope than women, and
younger people and those who lived alone had
lower levels of hope than their older counterparts.16,17 In contrast, in a study of 85 patients
with advanced cancer and their caregivers,
younger subjects had more hope than their
older counterparts.11 In a study of newly diagnosed cancer patients, Ballard et al.16 found
those who were married had higher levels of
hope; this again indicates that social support
may be an important factor for hope. However,
several other studies with cancer patients have
found no relationships among demographic
variables and hope.3,15,18e20
Every year approximately 1000e1500 new
patients are admitted to the Saskatoon Cancer
Centre, one of two centers of the Saskatchewan Cancer Agency. A New Patient Assessment
Form was developed in 2000 at the agency, and
every new patient admitted to the outpatient
cancer center was asked to complete this
form. All newly diagnosed patients in Saskatchewan are admitted to the agency as outpatients. As such, those who are newly admitted
are newly diagnosed. The New Patient Assessment Form has 27 questions, which include
the Herth Hope Index (HHI), a pain intensity
scale and an energy level scale. A variety of
Vol. 46 No. 5 November 2013
Hope in Newly Diagnosed Cancer Patients
clinical, psychosocial, and demographic variables that may influence hope also are included. It appears that the types of questions
asked on this form are unique to the Saskatchewan Cancer Agency and are not part of other
Canadian cancer agencies’ assessment forms.
A retrospective health record study using this
information provided a unique opportunity
to study hope with a large sample of a variety
of oncology patients.
Conceptual Framework
The framework guiding this study was a conceptual model of hope entitled Transcending
Possibilities.21 This model was developed using
a metasynthesis approach of 22 qualitative
studies of persons with chronic illnesses (one
of which was cancer). In this model, hope is
conceptualized as situational and dynamic
based on multiple factors, such as symptoms
and physical and mental health. It also suggests that, as a situation changes (i.e., newly diagnosed with cancer), hope objects and
pathways change.
Study Aims
The purpose of this study was to examine
the relationship of hope with pain, energy,
and psychological and demographic characteristics in newly diagnosed Saskatchewan Cancer
Agency adult oncology outpatients.
The specific study aims were to:
1. Examine the relationship between hope
(HHI) and pain intensity and energy level
in newly diagnosed adult oncology
patients,
2. Examine the relationship between hope
(HHI) and anxiety, depression, and feeling overwhelmed in newly diagnosed
adult oncology outpatients, and
3. Examine the relationship between hope
(HHI) and demographic variables (age
and gender) in newly diagnosed adult oncology outpatients.
Methods
The study used a cross-sectional, retrospective, descriptive, correlational design based
on newly diagnosed oncology outpatients’
health records. This study received ethical
663
approval from the Alberta Cancer Research
Ethics Board and the University of Saskatchewan Research Ethics Committee. Operational
approval was obtained from the Saskatchewan
Cancer Agency.
Sample
Data from the health records of cancer patients (18 years of age and older) newly admitted to the Saskatoon Cancer Centre in the first
six months of 2009 (407) were collected. The
New Patient Assessment Form was revised in
2010 and did not thereafter include the questions from the HHI. Health record data from
the beginning of the year 2009 were collected
as they were the most recent and most complete health records with HHI data. A sample
size of 150 was needed to test the individual
predictors with a medium effect size on the dependent variable (HHI total score) with seven
independent variables (pain, energy, anxiety,
depression, overwhelmed, age, and gender),
with a power of 0.80.22(p. 173)
Measures
Table 1 lists the variables and measures collected from the health records. The main variables are described in the following:
Modified HHI. The HHI is a 12-item, fourpoint Likert scale that addresses three factors
of hope: temporality and future, positive readiness and expectancy, and interconnectedness.23 The HHI has been found to be
reliable (test-retest, r ¼ 0.091) and valid
(convergent validity, r ¼ 0.84; criterion,
r ¼ 0.092; and divergent, r ¼ 0.73).23 The
New Patient Assessment Form contained 12
questions from the HHI, but the responses
were in a binary format (yes or no) rather
than the four-point Likert scale. Before beginning the study, data from the principal investigator’s other studies on hope were used to
determine the reliability of a binary HHI vs.
a four-point Likert scale, using Pearson correlation coefficients. The binary scale had a reliability coefficient of r ¼ 0.73, P < 0.01,
compared with the four-point Likert scale.
This is similar to the range of construct validity
for the HHI.23 The modified HHI had a summative score, with the highest possible score
being 24, as it consisted of 12 questions with
a yes (scored as 2) or no response (scored
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Table 1
Variables and Measures
Variable Categories
Main
Clinical
Variables
Measures
Where
Hope
Pain
Energy
Type of cancer
HH1 Binary Scale (12 questions): yes ¼ 2 and no ¼ 1
Numeric Pain Intensity Scale: 1 (no pain) to 5 (lots of pain)
Numeric Energy Level Scale: 1 (lots of energy) to 5 (no energy)
Diagnosis
Stage of disease
Comorbidity
Stages IeIV
Any other health problems? List of problems to be checked
(diabetes, stroke, high blood pressure, headaches, heart
disease, seizures, and others): will be checked if yes. If not,
checked no (binary)
List of 20 symptoms to be checked if present. Binary response:
yes if checked and if not, checked no
List of five to be checked if they are a problem (poor appetite,
food tastes bad or lack of taste, weight gain, difficulty
swallowing, and recent weight loss). Binary response: yes if
checked and no if not
Is there anyone you are concerned about as a result of your
illness? yes or no and who
Since your illness, have you felt any of the following? anxious,
depressed, overwhelmed by emotions, or feelings about your
illness. Yes if checked and no if not checked (binary)
Years
Male or female
Married, single, divorced/separated, and widowed
Employed (yes or no) and type of work
Do you live alone? yes or no
Do you have difficulty caring for yourself? yes or no
Are you taking any medications? yes or no; list of prescription
and nonprescription drugs
Are you taking any complementary and/or herbal therapies?
yes or no, list
Do you have an advance health care directive? yes or no
Is there a history of cancer in your family? yes or no
Postal code
New Patient Assessment Form Question 19
New Patient Assessment Form Question 10
New Patient Assessment Form Question 4
Oncologist notes in patient health record and
New Patient Assessment Form Question 1
Oncologists notes in patient health record
New Patient Assessment Form Question 3
Other symptoms
Psychosocial
concern
Demographic
Complementary and/or herbal
therapies
Advance Health Care Directive
History of cancer
Rural or urban
New Patient Assessment Form Question 16
New Patient Assessment Form Question 17
Patient health record
Patient health record
New Patient Assessment
New Patient Assessment
New Patient Assessment
New Patient Assessment
New Patient Assessment
Form
Form
Form
Form
Form
Question
Question
Question
Question
Question
12
12
13
14
7
New Patient Assessment Form Question 8
New Patient Assessment Form Question 9
New Patient Assessment Form Question 25
Patient health record
Vol. 46 No. 5 November 2013
Age
Gender
Marital status
Occupation
Live alone
Caring for themselves
Medications
New Patient Assessment Form Question 12
Duggleby et al.
Problems with nutrition
New Patient Assessment Form Question 5
Vol. 46 No. 5 November 2013
Hope in Newly Diagnosed Cancer Patients
as 1). In regard to scoring, questions in the
HHI that were to be negatively scored also
were negatively scored in the modified HHI.
The Cronbach alpha for the modified HHI
in this study was r ¼ 0.69.
Energy Level. Newly diagnosed cancer patients
were asked to rate their energy level using a numerical rating scale (NRS) from 1 (lots of energy) to 5 (no energy); the higher the score
on the scale, the less energy reported by participants. NRSs for measuring intensity of fatigue/energy have established reliability and
validity and are used in cancer care.24
Pain Intensity. Pain rating scores were measured on an NRS from 1 (no pain) to 5 (lots of
pain); the higher the score on the scale, the
more pain was being experienced. NRSs have
been used extensively in measuring pain intensity in cancer patients. They have established reliability and validity and have better compliance
than other pain intensity rating scales.25
Psychological Variables. The New Patient Admission Form asks newly admitted cancer patients to identify if they are feeling anxious,
depressed, or overwhelmed, with a yes or no
answer.
Data Collection
Two registered nurses who were employees
of the Saskatchewan Cancer Agency were
trained in an orientation session to review
the health records of oncology patients. During data collection (May to September 2010),
meetings were held with the principal investigator and data collectors to discuss any issues
with data collection. Using a data collection
form developed by the research team and
data collectors, data were entered into an Excel spreadsheet. The first five entries were
cross-checked by each of the registered nurses
for accuracy and interrater reliability. Revisions
were made to the data collection form based
on the first five entries, and the interrater reliability was 99%. The data on the Excel spreadsheet were deidentified and sent to the
principal investigator on a monthly basis.
Statistical Analysis
Data were entered, cleaned, and analyzed
using SPSS version 19.0 for Windows software
665
(SPSS Inc., Chicago, IL). The stage of disease
was categorized using the Tumor, Node, and
Metastasis staging system, which is one of the
most widely used cancer staging systems.26 Descriptive statistics were used to describe demographic, physical, and psychosocial factors and
levels of hope in newly diagnosed oncology
outpatients. Means and SDs are reported for
the continuous variables, and frequency and
percentage are reported for the categorical
data.
The descriptive analysis of the data showed
that 26% of the data were missing for age, gender, difficulty caring for self, modified HHI total, cancer stage, energy level, pain rating, and
depression variables. There was no particular
pattern of missing data. For example, the patients who did not respond to the depression
question ranged in age from 18 to 92 years;
also, most of the missing information for depression was from patients who were not living
alone. The HHI total score for the patients
with missing information on depression was
minimum score of 1 and maximum of 22,
a mean score of 19.82; for those with complete
data, the mean score was 19.65 (minimum ¼ 1
and maximum ¼ 22). As there did not appear
to be any particular pattern of missing data, for
the purpose of analysis, we assumed missing
data were completely at random. To account
for the missing data, a multiple imputation
method developed by Rubin27 was used. Multiple imputation is a Monte Carlo technique in
which the missing values are replaced by
m > 1 simulated versions, where m is typically
less than 10; for the current analysis, m ¼ 5
was selected. Each of the simulated complete
data sets was analyzed by standard methods,
and the results were combined to produce estimates and CIs that incorporate missing data
uncertainty.
To determine the predictors of modified
HHI total score, variables were treated as continuous (i.e., age, pain rating, and energy
level) or categorical (i.e., difficulty caring for
self, gender, depression, and cancer stage).
The variables chosen as predictors to be entered into the univariate analysis were based
on a review of the literature. At the univariate
level, each of the variables described previously
was analyzed using a generalized linear model
(GLM) method, with modified HHI total as
the dependent variable.
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Duggleby et al.
GLM is an extension of the linear regression
method and provides the flexibility to handle
categorical, count, and continuous data as
the response variables.28 The GLM analysis
was performed on the original data set with
no imputation and on the five imputed data
sets. The results from the pooled parameter
analysis were used for reporting purposes. Variables significant at P < 0.10 at the univariate
level, and the variables chosen from the literature review, were entered in the multivariate
model. Variables entered into the multivariate
analysis were age, gender, pain and energy, depression, difficulty caring for self, and stage of
cancer. Variables that were significant in the
multivariate GLM at the P < 0.05 level were
considered factors that were associated with
the outcome variable of hope.
Results
Demographic Characteristics
A total of 407 health records were reviewed,
of which 98 (24%) were missing the New Patient Assessment Form. The demographic
characteristics of the remaining 311 outpatient
oncology patients are summarized in Table 2.
The mean age of the participants was 64.4
years (SD ¼ 14.2); 58.5% were male, 62.7%
were married, and 76.5% did not live alone.
The most common type of employment was
tradesperson (11.3%).
The most frequent types of reported cancer
were gastrointestinal/head and neck/pancreatic cancer (27.7%) and Stage 4 cancers
(23.8%). The most common comorbidity of
participants who reported other health problems was high blood pressure (94.8%).
Hope and Demographic Variables
A significant inverse relationship was found
between total hope scores and age (P ¼ 0.02)
(Table 3). As the patients’ mean age was 64.4
(SD ¼ 14.2) years, data were then categorized
into two groups: patients 65 years of age and
older and patients 64 years of age and younger.
Using Mann-Whitney U analysis to determine
differences between two groups, there was a
significant difference in total modified
HHI scores between the two age groups
(P ¼ 0.017). Those between 18 and 64 years
Vol. 46 No. 5 November 2013
Table 2
Demographic and Clinical Characteristics of
Newly Admitted Oncology Outpatients
Characteristic
Age
X
SD
Range
64.44
14.21
18e92
Characteristics
Gender
Female
Male
Missing
Location
Rural
Urban
Missing
Live alone
No
Yes
Missing
Marital status
Married
Single
Divorced/separated
Widowed
Missing
Employed
No
Yes
Retired
Missing
Employment (type of work)
Health care professional
Teacher/educator
Secretary/receptionist
Farmer
Tradesperson
Business owner/self-employed
Homemaker
Professional
Blue-collar worker
Missing
Type of cancer
Breast
Lung
Melanoma skin cancer
Hematological
Genitourinary þ prostate
GI/H þ N þ pancreatic
Other
Multiple causes
Missing
Stage of cancer
I
II
III
IV
Missing
n ¼ 311
%
129
182
0
41.5
58.5
0.0
147
162
2
47.3
52.1
0.6
238
68
5
76.5
21.9
1.6
195
24
26
50
16
62.7
7.7
8.4
16.1
5.1
120
119
52
20
38.6
38.3
16.7
6.4
13
15
3
28
35
14
4
20
20
159
4.2
4.8
1.0
9.0
11.3
4.5
1.3
6.4
6.4
51.1
12
18
1
30
23
86
62
13
66
3.9
5.8
0.3
9.6
7.4
27.7
19.9
4.2
21.2
63
42
70
74
62
20.3
13.5
22.5
23.8
19.9
Characteristics
Yes
No
Total
Yes Valid%
Comorbidity
Diabetes
Stroke
High blood pressure
Headaches
Heart disease
Seizures
41
15
110
21
31
0
6
6
6
5
6
6
47
21
116
26
37
6
87.2
71.4
94.8
80.8
83.7
0
GI/H þ N ¼ Gastrointestinal, Head and Neck.
Vol. 46 No. 5 November 2013
Hope in Newly Diagnosed Cancer Patients
667
Table 3
Univariate and Multivariate Analyses
Univariate
HHI-Dependent Variables
Clinical variables
Pain rating
Energy level
Cancer stage
Carcinoma in situ
I
II
III
IV (reference)
Demographic variables
Age
Difficulty caring for yourself
No
Yes (reference)
Gender
Males
Females (reference)
Psychosocial variables
Depressed
No
Yes (reference)
95% CI
B
SE
Lower
Upper
0.11
0.52
0.41
0.27
1.07
1.07
2.14
1.05
1.8
0
1.28
1.17
1.10
0.05
Multivariate
95% CI
P-value
B
SE
Lower
Upper
P-value
0.86
0.04
0.86
0.07a
0.56
0.76
1.01
1.54
2.56
3.78
1.43
2.25
0.58
0.62
0.36
1.24
0.27
4.65
3.35
4.05
0.09a
0.37
0.08a
1.10
1.29
1.55
0
2.32
2.06
1.85
4.179
5.34
5.18
3.730
2.75
2.084
0.63
0.53
0.40
0.15
0.08
0.02
0.002a
0.13
0.05
0.23
0.02
0.02b
1.51
0
0.63
2.74
0.27
0.02a
4.77
0
2.69
0.51
10.06
0.08
0.11
0
0.16
4.33
0.20
0.52
4.78
1.84
1.18
8.39
0.01b
5.24
0
2.34
0.65
9.83
0.02a
0
0.92
2.70
6.21
4.37
0.73
Significant at P < 0.01.
Significant at P < 0.05.
a
b
of age reported significantly higher hope
scores (mean ¼ 20.18; SD ¼ 2.7) than those
who were 65 years of age and older
(mean ¼ 18.95; SD ¼ 4.28).
Gender also was found to be significant at
the multivariate analysis level, with men having
higher hope scores than women (P ¼ 0.01).
Total modified HHI scores for men were on
average 19.69 (SD ¼ 3.74), and for women,
the mean modified HHI score was 18.59
(SD ¼ 3.26). No other demographic variables
were statistically significant.
Hope, Pain Rating, and Energy Level
Modified HHI mean scores were 18.6
(SD ¼ 3.7). In this study, the lowest modified
HHI binary score was 1.0 and the highest was
22.0. The mean energy level score was 3.1
(SD ¼ 0.9) (range 1e5). The mean pain rating
score was 2.8 (SD ¼ 1.1) (range 1e5).
No significant relationships were found between total hope scores and pain ratings
when analyzed by univariate analysis
(P ¼ 0.86) or multivariate analysis (P ¼ 0.56)
or between total hope and energy scores
when analyzed by univariate analysis (P ¼
0.07) and multivariate analysis (P ¼ 0.0.62)
(Table 3).
Hope and Psychological Variables
Most of the newly diagnosed cancer patients
reported feeling anxious (n ¼ 107; 96.4%), depressed (n ¼ 64; 91.4%), and overwhelmed
(n ¼ 83; 93.3%). Feeling depressed was significantly related to hope at the univariate
analysis level (P ¼ 0.03). However, at the multivariate analysis level, it was not significant
(P ¼ 0.73). Feeling anxious and overwhelmed
were not significantly related to hope.
Discussion
Age was a significant factor influencing
hope in our population of newly diagnosed
cancer outpatients. Our findings suggest that
hope decreases with age, with those aged 65
years and older reporting the least hope.
Hope is an important psychosocial resource
that older adults use to cope with life’s adversities.29 It has been found to be significantly
correlated with quality of life in cancer patients,30 with hopelessness associated with
feelings of despair and desire for hastened
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Duggleby et al.
death.8,31 Thus, it is important to understand
why older adults have lower hope scores than
their younger counterparts.
In a metasynthesis study on hope and older
persons with chronic illness, the authors concluded that hope in older adults changes in
its interaction with suffering from a lifethreatening illness.21 In our study, the finding
of lower hope scores in older adults newly diagnosed with cancer compared with younger
adults might be a function of the interaction
of hope and suffering in this population. The
diagnosis of cancer for older adults initiates
a time of great uncertainty and confrontation
of their mortality.32 Their life experience and
being closer to mortality may affect their initial
appraisal of their disease status. In older
adults, processes of hope include a cognitive
reappraisal and transcendence from their situation.21 As newly diagnosed cancer patients,
the transcendence process, which involves reflection, may not yet have had time to occur.
More research is needed to further explore
the reason why older adults have lower levels
of hope on admission to an outpatient cancer
facility.
Similar to the findings of two previous studies on hope,16,17 men were found to have significantly higher levels of hope than women.
Based on these studies, although we initially
did not find a significant difference, we entered gender into the multivariate analysis.
The significant results suggest that hope in
newly admitted cancer outpatients is significantly different for women than men. In a qualitative study of cancer and aging, the authors
concluded that there is a gendered discourse
on how people interpret cancer and aging.32
Women were often portrayed as having gone
through an exploratory journey and men
maintained a continuous sense of identity.
More research is needed to explore whether
there is a gendered discourse of hope in older
adults.
The stage of cancer was not a significant factor influencing hope in newly diagnosed cancer outpatients. This is similar to other
studies of hope and cancer. In a systematic literature review, Butt5 concluded that disease
stage did not appear to have an impact on
hope. In a study with 226 patients with varying
types of cancer, Chen13 also concluded that
stage of disease did not affect levels of hope.
Vol. 46 No. 5 November 2013
A study by Sanatani et al.33 found that those receiving curative chemotherapy had little difference in hope scores compared with those
receiving palliative treatment.
The relationship between hope and pain was
not significant. This was similar to the finding in
the study by Utne et al. of hospitalized oncology
patients.3 A simple descriptive scale to measure
pain was used, which does not reflect its multidimensional nature. Other studies have found significant relationships between hope and pain
interference12 and attribution of the meaning
of pain,13 suggesting that multidimensional
measures of pain may have different results.
Moreover, as suggested by the Transcending
Possibilities conceptual framework of hope,21
it may not be pain intensity alone that influences hope but rather the possibility of pain interfering with a person’s achievement of their
hope objects or goals. Thus, pain interference
measures may be a better measure than pain intensity in studying pain’s influence on hope.
This also may be the reason why energy levels
and hope were not significantly related. In
a study of newly diagnosed outpatients with
cancer, Shun et al.10 suggested that fatigue
duration and interference caused by fatigue
are inversely related to hope. These measures
are different than the energy level scale that
was used in our study and may account for the
differences in findings.
Although significant at the univariate level,
depression was not a significant factor influencing hope, when other variables were controlled for. In two studies that reported
a relationship between hope and anxiety and
depression in cancer patients,14,15 the analyses
were conducted at a univariate level without
controlling for other variables such as age. Furthermore, the scales used to measure anxiety
and depression either combined both concepts15 or the authors combined the anxiety
and depression group scores.14 However, other
studies have reported a significant relationship
among hopelessness, depression, and distress.8,31,34 Thus, more research is needed at
the multivariate level to understand the relationships between hope and psychological
variables.
Limitations
There were several limitations to this study
such as the study design, measures, and
Vol. 46 No. 5 November 2013
Hope in Newly Diagnosed Cancer Patients
missing data. The study was focused on newly
diagnosed oncology outpatients and was
cross-sectional in nature. A longitudinal study
of factors influencing hope may have different
findings at different times in the cancer journey. As this was a retrospective study, potentially significant variables influencing hope
suggested in the literature, such as relationships and spirituality,21 were not measured.
Retrospective health record reviews use data
that are collected for a different purpose
than the study. However, measures of pain
and energy that have well- established reliability and validity were used in the New Patient
Assessment Form. Although the modified measure of hope did have similar construct validity
with the original HHI and internal consistency,
the original measure of the HHI with a fourresponse choice rather than the modified
one would have added to the generalizability
of the study findings.
Health records data commonly have large
amounts of missing data, although missing
data are an issue in most clinical research.35
The most accurate data are actual data; however, as in the case of our study, it was important
to impute missing data using a robust method
rather than eliminating them.
In spite of its limitations, a retrospective
health records review allows access to data that
may not be accessible to prospective studies.36
For example, in our study, the data included
a wide range of hope scores compared with
other studies. Retrospective health record review data can serve as useful preliminary findings that assist researchers in planning more
complex prospective studies.36 Future prospective studies should examine the relationships of
hope in newly diagnosed cancer patients over
time and also incorporate measures of spirituality and relationships. Older adults comprise the
majority of persons with cancer in Canada,37
and given the complex construct of hope and
the essential nature of hope to older persons
with cancer, the findings of this study underscore the importance of further research to develop knowledge in this area.
Disclosures and Acknowledgments
Funding for this study was received from the
Nursing Research Chair in Aging and Quality
669
of Life, Faculty of Nursing, University of Alberta. The authors declare no conflicts of interest.
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