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Strap is research not feature
[headline]
[standfirst] Julie Burton and Paddy Stevenson
Abstract
Aim The aim of this study was to determine if patients who had undergone treatment
and their carers perceived benefits from taking part in an art project facilitated by trained
artists.
Method Semi-structured interviews were conducted with five patients and three carers,
once treatment had been completed.
Findings Patients and carers felt apprehensive and fearful when attending a cancer
treatment centre for the first time. Participation in art not only improved the environment
but was relaxing and offered a sense of friendship, facilitated conversation and provided
distraction from treatment.
Conclusion Patients and their carers should be encouraged to consider participation in
art. If staff were supported to spend time engaged in these activities, it may help
facilitate therapeutic relationships with patients and carers.
Keywords
Art, carers, patients
end
In recent years, many UK hospitals have introduced the arts, in various forms, into their
public spaces. This followed the recommendations of the Attenborough Committee of
Inquiry into the Arts and Disabled People that new and redeveloped hospitals should
include provision for works of art and art activities (Attenborough 1985). The importance
of art and art projects to the wellbeing of all users of healthcare buildings, including
cancer patients, has since been recognised by Staricoff and Loppert (2003), and there
is consensus about the potential benefit of the use of art in cancer care. Most of the
published data focus on patients engaging in interventional art therapy and its use has
been evaluated in various areas of cancer care such as symptom control (Nainis et al
2006) or quality of life (Svensk et al 2009). In these studies quantifiable data were
collected through the administration of validated instruments, for example, the
Edmonton Symptom Assessment Scale (Chang et al 2000) and the European
Organization for Research and Treatment of Cancer QLQ-C30 questionnaire (Aaronson
et al 1993).
However, art therapy is not the only means of using art in cancer care to good effect.
Participation in creative art projects or ‘art-making’ (Reynolds and Prior 2006), may
provide perceived benefits for wellbeing, for cancer patients and their carers. In 2004
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Walsh et al used a quantitative approach to demonstrate anxiety and stress reduction in
carers of cancer patients when participating in creative arts. These kinds of activities
have positively contributed to the perceived wellbeing of women (Collie et al 2006) and
men (Reynolds and Prior 2006) with cancer. For these studies, phenomenology, where
participant views were collected through analysis of open-ended narratives and semistructured interviews, formed an accepted methodological approach.
The Northern Centre for Cancer Care (NCCC), formerly the Northern Centre for Cancer
Treatment, at the Freeman Hospital, Newcastle upon Tyne provides complex treatment
for patients in the north of England. More than 5,000 patients attend NCCC each year,
making it one of the largest cancer treatment centres in the UK. In 2000, the ‘room for
you’ hospital arts project began when a small team of artists were invited to the NCCC
chemotherapy day unit to take up residency in the main reception area. This was initially
a three-month pilot with the intention of enabling patients to be involved in producing,
discussing or enjoying art while having cancer treatment. The pilot project was extended
for a further eight months and was well received. Funding was sought and secured from
Charlie Bear for Cancer Care - Newcastle upon Tyne Hospitals NHS Foundation Trust,
Northern Rock Foundation and latterly the Heritage lottery fund [Q from? - added] for a
further two-year period and subsequently until 2011. In an attempt to gain greater
understanding of the value of the availability of art to patients and their carers, a survey
of 52 patients and carers was undertaken in early 2003 to ascertain the extent of use of
the facility and to obtain relevant feedback in comment form. The comments suggested
that users perceived a positive benefit from taking part in the art on offer. As a result, a
research study was undertaken to explore the perceived benefits of the use of art in
cancer care.
[crosshead] Aim The aim of this study was to determine if patients who had undergone
treatment and their carers perceived benefits from taking part in an art project facilitated
by trained artists.
[crosshead] Method
This is descriptive research which employed Thematic analysis as outlined by Coffey
and Atkinson (1996) to analyse the data. The objective of descriptive research is to
discover new facts about a situation, people activities or events, or the frequency with
which certain events occur (Carter, 2000, p 213). Neergaard et al 2009 portrays
descriptive research as a rich straight description of an experience or event and
supports its use when description of a phenomenon is desired. As relevant qualitative
data are limited, especially on carers, the researchers considered this method to be
appropriate while also offering some flexibility in eliciting individual perceptions from
each participant. This in turn would add data to the given subject and act as a platform
for future research.
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[Q The consultant editor feels that although the approach to data collection and analysis
are qualitative, the method, data collection and analysis are not phenomenological? –
Agree changed Please could you clarify? Could you provide some refs to support your
choice of method, particularly in relation to data collection and analysis? – done]
Patients scheduled to receive chemotherapy and radiotherapy are routinely invited to
take part in art projects held in the reception area of NCCC. Three trained artists and
three facilitators work as part of ‘room for you’ hospital arts to demonstrate and assist
patients and carers with participation in different forms of art work while awaiting cancer
treatment. Attendance for treatment at NCCC is usually daily for 20-30 days for
radiotherapy and once every two to three weeks for approximately four to six months for
chemotherapy. During this time, on each occasion they attend NCCC, there is an
opportunity for patients and carers to participate in the art on offer. This includes
working with textiles, mat making, silk painting, watercolour, calligraphy and felt making.
Other media are also on offer if requested.
The artists were asked to identify potential participants, either patients or carers of
patients receiving either chemotherapy or radiotherapy, from their regular participant
group, who were defined as those who had taken part in the art on offer at least four
times previously. Those identified through this purposive selection process were asked
for their permission to be approached by an oncology nurse researcher two to four
weeks after completion of treatment, at which point they were invited to participate in
the study. Six adult (≥18 years) participants were recruited in this way.
One semi-structured interview was conducted with each participant by an oncology
nurse researcher, which lasted up to one hour. Interviews were taped. Interview
questions based on the following areas included:











Purpose for visiting NCCC.
Description of feelings about coming to NCCC before arrival.
Description of feelings about coming to NCCC on arrival.
Exploration of the purpose for taking part in art.
Whether the art or the artists were intrusive.
Whether participation was enjoyable.
If the art was enjoyable, an exploration of all aspects of how and why it was
enjoyable.
Exploration of any negative feelings about participation.
Exploration of any positive feelings about participation.
Motivation to carry on with art work.
Any additional comments to help us in the future.
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The series of questions were derived from the comments received from the 2003
survey.
Exact wording and the order of questions varied depending on participants’ responses.
During the interview, if participants deviated to areas of conversation not included in the
interview questions, they were allowed to continue talking. The researchers were aware
that any exploration of feelings of individuals who have recent experience of cancer
therapy could potentially be distressing for the interviewee. Clifford (1997) suggests that
any proposed research should be critically and sensitively planned to ensure that no
additional suffering occurs. Therefore, support was offered initially by the oncology
nurse researcher then by Macmillan nurses or the NCCC clinical psychologist, as
appropriate.
The interviews were transcribed on completion, and were uploaded to the N6 qualitative
data analysis software package from QSR International. Coding was performed by
reading through the transcribed text and listening to the tapes to identify emerging
branch themes based on ideas and perceptions that were identified through interview.
Examples of actual interview statements included:
 ‘I thought clippy mats like, straight away threw me back to my childhood days when
we used to do that’ (patient 1). This was coded as the branch theme ‘reminiscence’.
[Q please acknowledge quotes as Patient 1 or Carer X etc? - added]
 ‘It was something you could converse about, rather than the weather’ (carer 7). This
was coded as the branch theme ‘conversation’. [Q please acknowledge quotes as
Patient 1 or Carer X etc? - added]
[Did another person (rater) check the coding to increase the reliability of the findings
and interpretation?- Yes added]
Two researchers independently reviewed the data. This process was repeated with the
six interviewees. If a previously identified branch theme emerged in a new interview, it
was coded using the same code that was originally identified. However, if a new branch
theme was identified, it was assigned a new branch theme code. As each interview was
coded and new branch themes emerged, each of the previous interviews was
systematically revisited to determine if newly identified branch themes had been missed
on initial coding. If a researcher discovered a theme not already identified this was
agreed by consensus. Consequently, all interviews were exhaustively coded.
The analysis plan was to interview six participants and to continue interviewing
additional sets of two participants until no new branch themes emerged. After
completion of coding the six interviews, it was apparent that new branch themes were
still emerging, so an additional two participants were recruited. By completion of coding
of the eighth interview, additional branch themes were no longer emerging, hence
saturation had been achieved and recruitment was therefore stopped.
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A list of the identified branch themes was created and related branch themes were
grouped together into trunk themes which were weighted by the number of times branch
themes were coded and the number of participants who mentioned that theme. If a
particular branch theme could not be grouped into an existing trunk theme then this
branch was labelled as a ‘single trunk theme’. In turn, all trunk themes were grouped
together into related trees.
[subhead] Ethical considerations The study was approved by the Newcastle and
North Tyneside research ethics committee. No more than 16 participants could be
recruited without additional approval from the research ethics committee. All participants
were given a study number to ensure anonymity. The transcriptions were stored in a
password locked computer and all interview tapes were destroyed on completion of
data analysis. Written informed consent was obtained and participants were free to
withdraw consent at any time. The study was conducted in 2006. [Q were participants
free to withdraw at any time? Were data stored in a secure cupboard? - added]
[Did you adopt a mixed methods approach as there are a number of figures: if not
could you include some more comments from patients in the findings as you say
it is a qualitative study? – this was not a mixed method approach the numbers
correspond only to the frequency patients mentioned the theme]
[crosshead] Findings
The eight adult participants included five patients and three carers. Three participants
had undergone chemotherapy and five had undergone radiotherapy. One participant
was male, and seven female. [Q could you state their ages? Unfortunately not but
protocol stated age over 18, therefore added adult ]
During coding of the interviews the tree themes were termed ‘baseline’ (before
involvement in art and before starting cancer treatment), ‘during cancer treatment’ and
‘on completion’ of cancer treatment. The researchers felt that this was a logical
approach to take when analysing the data as different themes and feelings emerged
when participants were describing their experiences before, during and at the end of
treatment. Seven trunk themes emerged: [Q should this be 7 trunk themes? Yes
added] ‘why participate?’; ‘baseline feelings’; ‘feelings’; ‘enjoyable aspects’;
‘single trunk themes’ – which represented different branch themes coded collectively
to a single trunk; ‘intention to continue’ and ‘surprised service offered’. Thirty nine
branch themes were identified and were in turn coded to the three tree themes.
The branch, trunk and tree structures for the three identified trees are shown in Figures
1, 2 and 3. Figure 1 illustrates the ‘baseline’ tree structure; Figure 2 illustrates the
‘during cancer treatment’ tree structure and Figure 3 illustrates the ‘on completion of
cancer treatment’ tree structure.
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Table 1 presents a selection of verbatim participant quotes and shows how these
quotes were interpreted and therefore coded. The quotes shown were ultimately coded
to all three identified tree themes [Q only 2 are shown in the table though: baseline
and during cancer treatment? added quote from completion].
The number of times each branch theme was coded and the number of participants who
mentioned that theme are presented for each of the three trees identified in Figures 4, 5
and 6. Figure 4 shows the branch theme distribution for the ‘baseline’ tree; Figure 5
shows the branch theme distribution for the ‘during cancer treatment’ tree and Figure 6
shows the branch theme distribution for the ‘on completion of cancer treatment’ tree.
At ‘baseline’ (Figure 4), the most commonly mentioned branch themes were
‘apprehension’ (mentioned eight times by six participants), ‘approached by artists’
(mentioned four times by three participants), ‘previous art experience’ (mentioned four
times by four participants) and ‘fear’ (mentioned three times by three participants).
Carer 7 - “We had sort of mixed feelings about attending the Cancer centre,
apprehension, tension, all worked up, that sort of thing because you don’t know what’s
going to happen”.
‘During cancer treatment’ (Figure 5), the most commonly mentioned branch themes
were ‘distraction’ (mentioned 17 times by seven participants), followed by ‘sense of
friendship’ (mentioned 14 times by seven participants), ‘relaxing’ (mentioned 12 times
by five participants), ‘improves environment’ (mentioned eight times by five participants)
and ‘conversation’ (mentioned eight times by six participants). Patient 6 -“ You could
negatively say that using art is a form of distraction in these circumstances and is a way
of denying what’s really going on. Lets go and play at rug making, don’t let’s think how
seriously ill we are and how we feel about what’s going on in our bodies at the moment.
So what did I feel ? Well, I was grateful for the distraction “.
‘On completion of cancer treatment’ (Figure 6), the most commonly mentioned branch
theme was ‘surprised service offered’ (mentioned three times by two participants).
Patient 3 – “Imagine having an art project years ago – almost unbelievable isn’t it”
The findings indicated overall that for most participants the main outcome measure of
perceived benefit was evident.
[crosshead] Discussion
The main limitation of this study is its use of patients and carers in the same study. The
research may have carried more weight if the study had concentrated on either patients
or carers. However, the findings add to the limited qualitative data on art participation in
cancer care. This study was exploratory in nature, however, the findings indicated that
patients and carers often feel apprehensive and fearful when attending a cancer
treatment centre for the first time. The findings showed that participation in the art
project not only improved the environment but was relaxing and offered a sense of
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friendship, facilitated conversation and provided distraction from treatment. On
completion of cancer treatment, it was clear that patients were surprised that this
service was offered, which suggests that it may not be sufficiently well communicated to
users of the NCCC that the art on offer is freely available to them.
When patients are waiting for cancer treatment general conversations take place. For
example, ‘what do you think about the weather’? or ‘did you see the football?’. However,
the use of art as a vehicle for encouraging patients and carers to share their feelings
and emotions through conversation and friendship may have broader beneficial
implications for their wellbeing. There was evidence of benefit for carers and patients.
Future studies should consider the emergent themes when crafting further questions
and sampling should include more men if possible.
[crosshead] Conclusion
Although more extensive work is needed to explore the findings of this research for
patients and carers undergoing treatment in other centres, the overall benefits gained
from participation in art projects while attending for cancer treatment should not be
ignored. Opportunities should be made for staff to inform NCCC users about the
availability of art for all, and to encourage patients and their carers, in a more formalised
way, to consider participation in the art on offer. Support could be given to enable staff
to spend time engaged in these activities, as it may help facilitate therapeutic
relationships with some patients and carers. Participation in art is also an opportunity for
patients and carers to influence the clinical hospital environment.
Find out more
Room for you hospital arts: www.roomforyou.org.uk/
Research funding
Charlie Bear for Cancer Care Charitable Fund; ResCUE Fund (cancer research clinical
trials unit charitable fund); Art Project 2000.
This article has been subject to double-blind review and checked using antiplagiarism
software. For author guidelines visit the Cancer Nursing Practice homepage at
www.cancernursingpractice.co.uk For related articles visit our online archive and search
using the keywords
Julie Burton is thyroid cancer clinical nurse specialist, Freeman Hospital, Newcastle
upon Tyne
Paddy Stevenson is National Institute for Health Research operations manager for
Newcastle biomedicine clinical research platforms, Royal Victoria Infirmary, Newcastle
upon Tyne
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References
Aaronson N, Ahmedzai S, Bergman B et al (1993) The European Organization for
Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in
international clinical trials in oncology. Journal of the National Cancer Institute. 85, 5,
365-376.
Attenborough R (1985) Arts and Disabled People: Report of a Committee of Inquiry
under the Chairmanship of Sir Richard Attenborough. Bedford Square Press, London.
Carter D.E (2000) Descriptive Research. In D.F.S Cormack ed 2000. The Research
Process in Nursing. Blackwell Science Ltd, London. Ch 18.
Chang V, Hwang S, Feuerman M (2000) Validation of the Edmonton Symptom
Assessment Scale. Cancer. 88, 9, 2164-2171.
Clifford C (1997) Nursing and Health Care Research. A Skills-based Introduction.
Second edition. Prentice Hall, London.
Coffey A, Atkinson P (1996) Making sense of Qualitative Data. Complementary
Research Strategies. Sage Publications. London. Ch.2.
Collie K, Bottorff J, Long B (2006) A narrative view of art therapy and art making by
women with breast cancer. Journal of Health Psychology. 11, 5, 761-775.
Nainis N, Paice J, Ratner J et al (2006) Relieving symptoms in cancer: innovative use
of art therapy. Journal of Pain and Symptom Management. 31, 2, 162-169.
Neergaard M A, Olesen F et al (2009) Qualitative description – the poor cousin of
health research ? BMC Medical Research Methodology. 9, 52.
Reynolds F, Prior S (2006) The role of art-making in identity maintenance: case
studies of people living with cancer. European Journal of Cancer Care. 15, 4, 333-341.
Staricoff R, Loppert S (2003) Integrating the arts into health care: can we affect clinical
outcomes? In Kirklin D, Richardson R (Eds) The Healing Environment. Without and
Within. Royal College of Physicians, London.
Svensk A, Oster I, Thyme K et al (2009) Art therapy improves experienced quality of
life among women undergoing treatment for breast cancer: a randomized controlled
study. European Journal of Cancer Care. 18, 1, 69-77.
Walsh S, Martin S, Schmidt L (2004) Testing the efficacy of a creative-arts
intervention with family caregivers of patients with cancer. Journal of Nursing
Scholarship. 36, 3, 214-219.
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Table 1 Selected verbatim quotes and their coding to branch and tree
themes
Participant Interview
question/The
me
Patient 1
Describe
how you felt
before
coming to
Northern
Centre for
Cancer
Care?
Verbatim quote
Patient 6
Was the
presence of
art or the
artists
intrusive?
‘My perception is that
everybody who comes
through those doors is in a
state of crisis, one way or
another. They may not feel
like I do but there is a crisis
going on in their life
somewhere. They may or
may not see the art, they may
not see the desk even, it
depends what their
preconceptions are. If you
push it then it could become
intrusive.’
How did you
come to
participate?
‘It wasn’t until I’d come back
really several times when I
thought, “Oh I’ve seen those
people before, what are they
doing?” and then my natural
curiosity got the better of me.’
Carer 2
Why was
participation
enjoyable?
Carer 2
Why was
participation
enjoyable?
‘We got to know people
through the art which is
something I hadn’t thought
would happen.’
‘My sister listens, enjoys
listening but she doesn’t want
to try. We found that on a
Thursday, which was one of
‘The first time I came I was a
little bit apprehensive and I
thought, you know, all these
sick people, it’s going to be a
place of doom and gloom and
low and behold it was quite
the opposite.’
Coded as
branch
theme(s)
 Doom.
 Gloom.
 Apprehensi
on.
Tree
theme
‘Baseline
’.

Curiosity. [Q ‘Baseline
’.
this is a
branch
theme for
baseline
not during
cancer
treatment?Agree]

Sense of
friendship.

Reminiscen
ce.
‘During
cancer
treatmen
t’.
‘During
cancer
treatmen
t’.
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Participant Interview
question/The
me
Patient 4
What was
the purpose
of taking part
in the art?
Patient 4
What was
the purpose
of taking part
in the art?
Carer 7
Was
participation
enjoyable?
Can you
describe
why?
Carer 2
Has it given
you the
motivation to
carry on with
art ?
Verbatim quote
Coded as
branch
theme(s)
our days, there was a
demonstration every week of
hooky mats and proggy mats
and all the craft things that
they make out of this, which is
something we used to make
as children, sitting round the
fire in the days of coal fires
and draughts.’
‘It did take the edge off a

really clinical environment.’
Tree
theme
Improves
environment
.
‘During
cancer
treatmen
t’.
‘You can communicate things
in that indirect way as well as
to other people, to my family
or friends. If they came and
looked at the painting you
know, rather than having to
talk about the detail of it all,
they can get a sort of way in
to how you are feeling.’
‘It calmed me. Yeah, it was so
relaxing it was really nice.’

Easier to
talk about
cancer.
‘During
cancer
treatmen
t’.

Relaxing.
‘During
cancer
treatmen
t’.
“It certainly has motivated me
to carry on but I haven’t had
the time”
“I will get back to it sooner or
later”

Intention to
continue art.
‘ On
completi
on of
cancer
treatmen
t’
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Figure 1 ‘Baseline’ tree structure
Branch themes







Balance between treatment and
outside life.
Altruism.
Approached by artists.
Curiosity.
Reminiscence.
Reputation previous art.
Previous art experience.
Trunk themes
Tree theme
Why participate?
Baseline.







Doom.
Gloom.
Sickness.
Contented.
Apprehension.
Fear.
Surrounded by sick people.
Baseline
feelings.
Fourteen branch themes were coded from eight interviews which gave rise to two trunk themes: ‘why
participate?’ and ‘baseline feelings’ to produce the ‘baseline’ tree.
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Figure 2 ‘During cancer treatment’ tree structure
Branch themes
Trunk themes




Nervous.
Anxiety.
Tense.
Feelings
.















Sense of comfort.
Rapport with artist.
Enjoy but don’t know why.
Conversation.
Fun to do.
Sense of friendship.
Helps visualise my cancer.
Conversation starter.
Feel better with artists around.
Achievement.
Camaraderie.
Soothing.
Relaxing.
Improves environment.
Creates interest.





Distraction.
More choice wanted.
Easier to talk about cancer.
Reminiscence.
Support.
Enjoyable
aspects.
Tree theme
During cancer
treatment.
Single trunk themes:
 Distraction.
 Negative aspects.
 Easier to talk.
 Reminiscence.
 Support.

Twenty three branch themes were coded from eight interviews which gave rise to three trunk
themes: ‘feelings’, ‘enjoyable aspects’ and ‘single trunk themes’ to produce the ‘during cancer
treatment’ tree.
Branch themes identified from eight interviews were coded to three trunk themes and ultimately
the tree theme of ‘during cancer treatment’.
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Figure 3 ‘On completion of cancer treatment’ tree structure
Branch themes

Tree theme
Trunk themes
Intention to
continue.
Intention to continue art.
On completion of cancer
treatment.

Surprised service
offered.
Surprised service offered.
Two branch themes were coded from eight interviews which gave rise to two trunk
themes: ‘intention to continue’ and ‘surprised service offered’ to produce the ‘on
completion of cancer treatment’ tree.
end
Figure 4 Branch theme distribution at ‘baseline’
Why participate
Baseline feelings
ACQua branch theme distribution at baseline
Surrounded by sick people
Fear
Apprehension
Contented
Sickness
Gloom
Doom
Previous art experience
Reputation previous art
Reminiscence
Curiosity
Approached by artists
Altruism
Balance between treatment and outside life
0
participants naming a theme
2
4
6
times theme mentioned
8
10
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Fourteen branch themes were coded from eight interviews which gave rise to two trunk
themes: ‘why participate?’ and ‘baseline feelings’ to produce the ‘baseline’ tree.
end
Feelings
Enjoyable Aspects
Single Trunk
Themes
Figure 5 Branch theme distribution ‘during cancer treatment’
Support
Reminiscence
Easier to talk
Negative aspects
Distraction
feel better with artists around
helps visulise my cancer
enjoy but don’t know why
creates interest
soothing
Rapport with artist
Sense of comfort
cameraderie
fun to do
improves enviroment
relaxing
achievement
conversation starter
conversation
sense of friendship
Tense
Nervous
Anxiety
0
5
participants naming a theme
10
15
20
times theme mentioned
Twenty three branch themes were coded from eight interviews which gave rise to three
trunk themes: ‘feelings’, ‘enjoyable aspects’ and ‘single trunk themes’ to produce the
‘during cancer treatment’ tree.
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Intention to continue
intention
to
continue
art
Surprised service
offered
Figure 6 Branch theme distribution ‘on completion of cancer
treatment’
surprised
service
offered
0
0.5
1
participants naming a theme
1.5
2
2.5
3
3.5
times theme mentioned
Two branch themes were coded from eight interviews which gave rise to two trunk
themes: ‘intention to continue’ and ‘surprised service offered’ to produce the ‘on
completion of cancer treatment’ tree.