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Running head: MEASUREMENT OF STRESS IN THE ONCOLOGY POPULATION
Measurement of Stress in the Oncology Population
An Integrative Review
Merlessa Rosacina
Nursing Science II
Dr. Mary O’Keefe
March 26, 2015
1
MEASUREMENT OF STRESS IN THE ONCOLOGY POPULATION
2
Introduction
The purpose of this integrative literature review is to identify the best, consistent
measurement method for assessing stress in oncology patients. Stress is an occurrence in
everyday life and is a phenomenon spanning across all generations, ages, and genders.
According to the American Psychological Association (2012), a healthy stress level is considered
a score of 3.6 on a 10 point scale, but Americans report a mean stress level of 4.9 in the Stress in
America survey. Thirty-two percent of individuals value the importance of discussing stress
management with their healthcare providers, yet only 17% report these conversations actually
happening often (The American Psychological Association, 2012). Clinicians and patients have
open conversations on physical health complications and the same regard needs to be given to
psychological complications. This author works at a cancer facility where patients voice
recurrent psychological concerns including fear of death, financial woes, loss of independence,
and embarrassment, all of which impact stress levels. Levels of stress vary depending on
specific stressors and situation. Consistent assessment and monitoring of stress prevents
progression into higher levels and adverse physical symptoms caused by stress, and inhibits
extended periods of stress known to cause further health complications. The articles used in this
integrative review were guided with the following question: What are current methods used to
assess stress in the oncology field?
Search Strategy
The review was conducted through a Summons search via The University of Texas’
Moody Medical Library website. Boolean operators are used to expand or restrict a search (Polit
& Beck, 2014, p. 2). Delimiters used in this review include “psychological”, “distress”, and
MEASUREMENT OF STRESS IN THE ONCOLOGY POPULATION
3
“cancer.” Articles are taken from CINAHL, PubMed, PubMed and Psychological Abstracts
through the Summons search. CINAHL is a nursing based databases that includes more than 1
million records, and PubMed is considered the premiere source for bibliographic coverage that
contains more than 21 million records (Polit & Beck, 2014, p. 122). The original search
contained articles no older than 2004 to include the most current studies, but included few older,
significant articles. This integrative review relies on primary sources to maintain objectivity and
tentativeness. The search was difficult because the majority of the articles resulted were
secondary sources, which I excluded to remain unbiased. Nonresearch references that do not
show evidence in solving research problems are excluded. The search originally yielded 17,405
results, but due to exclusion criteria, only 13 were used.
Summary of Research Findings
The table below presents the 13 articles used in tabular format. Each research study was
reviewed and broken down to summarize its study purpose, sample size, design, findings,
instruments, strengths, and weaknesses.
Running head: MEASUREMENT OF STRESS IN THE ONCOLOGY POPULATION
Author/
s
Title
Journal
Date
(yr/vol/
iss)
Kugaya,
A.,
Akechi,
T.,
Okuyama
, T.,
Nakano,
T.,
Mikami,
I.,
Okamura
, H.,
Uchitomi
, Y.
Prevalen
ce,
Predictiv
e
Factors,
and
Screenin
g for
Psycholo
gic
Distress
in
Patients
with
Newly
Diagnose
d Head
and Neck
Cancer
Cancer,
Volume
88, Issue
12
11/20/2
000
Researc
h
Questio
n
Design
&
Metho
d
Does the
detection
of
psycholog
ic distress
in the
pretreatm
ent period
improve
the
patient’s
adaptatio
n to the
treatment
or
rehabilita
tion?
Crosssectiona
l study
Population
Sample
Data
Collection/
(Size, Type)
Instrumen
ts
107 patients
diagnosed
with head
and neck
cancer free
from
cognitive
impairment
Sociodemog
raphic data
and medical
data
obtained
from
subjects,
medical
records, and
physicians.
Interview to
assess social
support.
The Hospital
Anxiety and
Depression
Scale
(HADS) for
measuring
psychologica
l distress
measured
anxiety and
depression.
Analysis
Finding
s
4
Strengt
hs
Limitatio
ns
Conclusi
on
Implicati
ons
(Take
home
message)
Intergrou
p
comparis
on using
the chi
square
test,
Fisher
exact test,
unpaired
Student’s
t TEST,
and
variance
analysis.
Of 107
subjects,
18 had an
adjustme
nt
disorder
or major
depressio
n.
Thirtysix, 7,
and 35
met
criteria
for
alcohol
depende
nce,
alcohol
abuse,
and
nicotine
depende
nce.
Older
adults
living
alone
showed
significan
tly higher
score of
psycholo
gic
distress.
Good
sample
size.
Appropr
iate
methods
.
No other
group or
population
to compare
results
with.
HADS is a
good
measurem
ent to
track
psychologi
cal
distress in
cancer
patients.
Head and
neck
cancer
patients
who have
advanced
disease or
live alone
should be
assessed
so that
psychologi
cal
distress
can be
detected
and
interventio
n made.
MEASUREMENT OF STRESS IN THE ONCOLOGY POPULATION
Author/
s
Title
Journal
Date
(yr/vol/
iss)
de Haes,
J., van
Knippen
berg, F.,
Neijt,
J.P.
Measuri
ng
psycholo
gical and
physical
distress
in cancer
patients:
structure
and
applicati
on of the
Rotterda
m
Sympto
m
Checklist
British
Journal
of
Cancer
Volume
62
1990
Researc
h
Questio
n
Design
&
Metho
d
Is the
Rotterda
m
Symptom
Checklist
a reliable
method in
measurin
g
psycholog
ical and
physical
distress in
cancer
patients?
Crosssectiona
l study
Random
ised
control
trial
Population
Sample
Data
Collection/
(Size, Type)
Instrumen
ts
RSCL
stability
investigated
in 3 studies:
The
Rotterdam
Symptom
Checklist
95 female
cancer
patients
visiting an
outpatient
clinic
56 patients
participating
in a
randomised
control trial
comparing
two
chemotherap
y regimens
for the
treatment of
advanced
ovarian
cancer
20 cancer
patients
compared the
quality of life
with 611
patients of
‘normal’
controls.
5
Analysis
Finding
s
Strengt
hs
Limitatio
ns
Conclusi
on
Implicati
ons
(Take
home
message)
Principal
compone
nt
analysis
in all 3
studies.
Subscales
in the
RSCL
were
developed
on the
factors
identified.
Good
sample
size.
Allows 3
groups
of
compari
son.
Lack of
prior
studies
related to
the RSCL.
Reliability
of the
scale
constructe
d on the
basis of
the results
was
consistentl
y high,
and can be
used as a
basis for
future
studies.
The RSCL
shows
promising
potential
in
measuring
psychologi
cal
distress in
oncology
patients.
MEASUREMENT OF STRESS IN THE ONCOLOGY POPULATION
Author/
s
Title
Journal
Date
(yr/vol/
iss)
Jacobsen
, P.B.,
Donovan
, K.A.,
Trask,
P.C.,
Fleishma
n, S.B.,
Zabora,
J., Baker,
F.,
Holland,
J.C.
Screenin
g for
Psycholo
gic
Distress
in
Ambulat
ory
Cancer
Patients
Cancer,
Volume
103,
Issue 7
02/22/2
005
Researc
h
Questio
n
Design
&
Metho
d
Determin
e whether
the
singleitem
Distress
Thermom
eter (DT)
compared
favourabl
y with
longer
measures
currently
used to
screen for
distress.
Crosssectiona
l study
Population
Sample
Data
Collection/
(Size, Type)
Instrumen
ts
380 cancer
patients
recruited
from 5
different
cancer
hospitals, 18
years or
older,
diagnosed
with cancer,
scheduled for
an outpatient
appointment,
able to
understand
English and
informed
consent
Self-report
questionnair
e
The Distress
Thermomete
r
The Hospital
Anxiety &
Depression
Scale
6
Analysis
Strengt
hs
Limitatio
ns
Conclusi
on
Implicati
ons
(Take
home
message)
Receiver
operating
characteri
stic
Curve
analyses
Chi
square
analyses
t tests
Brief
Symptom
Inventory
Finding
s
DT
scores
yielded
good
overall
accuracy
in
comparis
on to the
HADS
and BSI
cutoff
score.
Patients
had a DT
scores of
greater
than or
equal or
4 are
more
likely to
be
women,
poorer
performa
nce
status,
report
practical,
family,
emotiona
l, and
physical
problem,
compare
Good
sample
size.
Appropr
iate
method
of data
collectio
n.
Limited
previous
research on
the
effectivene
ss of DT.
Limited
racial
diversity
Crosscultural
differences,
a previous
study was
done in
Japan that
yielded
different
results
The
singleitem DT
compares
favourably
with
longer
measures
used to
screen for
distress.
Further
research is
needed to
support
this
considerin
g the
limited
studies
regarding
the DT
tool.
The DT
tool helps
identify
patients
with a
range of
problem
that were
likely to
reflect
psychologi
c distress.
MEASUREMENT OF STRESS IN THE ONCOLOGY POPULATION
Author/
s
Title
Journal
Date
(yr/vol/
iss)
Researc
h
Questio
n
Design
&
Metho
d
Population
Sample
Data
Collection/
(Size, Type)
Instrumen
ts
7
Analysis
Finding
s
Strengt
hs
Limitatio
ns
Conclusi
on
Implicati
ons
(Take
home
message)
d with
patients
who have
DT
scores
<4.
Bleiker,
E.,
Pouwer,
F., van
der
Ploeg,
H., Leer
J., Ader,
H.
Psycholo
gical
distress
two years
after
diagnosis
of breast
cancer:
frequenc
y and
predictio
n
Patient
and
Educatio
n
Counsell
ing,
Volume
40, Issue
3
06/200
0
Investigat
e the
frequency
of high
stress
levels of
psycholog
ical
distress in
women
with early
stage
breast
cancer
almost
two years
after
diagnosis
and
identify
characteri
stics
associate
with longterm
distress.
Crosssectiona
l study
244 women
with a
histological
diagnosis of
breast cancer
treated with a
mastectomy
or breast
conserving
surgery, no
previous
neoplasms,
younger than
75 years of
age, and
knowledge of
the Dutch
language
Questionnai
re during the
period of
radiotherapy
, and again
after 1 and a
½ years
after the
first
assessment.
Holmes and
Rahe
Readjustme
nt Rating
Scale
Social
Experience
Checklist
SelfAssessment
Questionnai
re-Nijmegen
Impact of
Event Scale
Descriptiv
e
statistics
Explorati
ve
analyses
Pearson’s
and
Spearman
’s
correlatio
nal
methods
Confirmat
ive
multiple
regressio
n analysis
Sixteen
percent
of the
women
reported
a high
level of
psycholo
gical
distress.
Large
sample
size.
No
compariso
n group.
Two
part
analyses
method
Cultural
barrier.
This is a
good,
thorough
study. It
was done
in a Dutch
setting,
and may
need cross
cultural
studies in
the future
for further
support.
Patients
with early
diagnosis
and good
prognosis
still
experience
high levels
of stress
and need
active
screening.
MEASUREMENT OF STRESS IN THE ONCOLOGY POPULATION
Author/
s
Title
Journal
Date
(yr/vol/
iss)
Hoffman
, B.,
Zevon,
M.,
D’Arrigo,
M.,
Cecchini,
T.
Screenin
g for
Distress
in
Cancer
Patients:
The
NCCN
RapidScreenin
g
Measure
PscyhoOncolog
y, Issue
13
03/03/2
004
Researc
h
Questio
n
Design
&
Metho
d
Population
Sample
Data
Collection/
(Size, Type)
Instrumen
ts
The goal
of this
study is to
examine
the
psychome
tric
properties
of the
NCCN
DMSM
and
explore
its
psychome
tric
relationsh
ip to a
widely
used and
validated
measure
of stress.
Crosssectiona
l study
68 outpatient
cancer
patients
Distress
Managemen
t Measure
27 males, 41
females
Distress
Thermomete
r
60 White, 3
Hispanic, 3
AfricanAmerican, 1
Asian, 1 other
44 married,
10 single, 11
divorced/sep
arated, 3
widowed
Mean age
53.7 years of
age, age
range 17 to 90
Diagnosed an
average of
15.1 months
prior to
participation
14 breast
cancer, 11
lymphoma, 9
colon cancer,
10 leukemia,
20 other
cancers, 4
Distress
domain
checklists
Brief
Symptom
Inventory
Global
Severity
Index
8
Analysis
Finding
s
Strengt
hs
Limitatio
ns
Conclusi
on
Implicati
ons
(Take
home
message)
Receiveroperating
characteri
stic
curves
Internal
consisten
cy
coefficien
t Alphas
The
DMSM
has
moderate
ability to
detect
distress
identified
by the
BSI and
BSI-18.
Good
sample
size.
Mostly
Caucasian
– limits the
generizabil
ity.
There’s no
single
cutoff score
maximizes
sensitivity
and
specificity
for DMSM.
Lower
cutoff
scores risk
overidentifying
distressed
individuals
, while
higher
score
cutoffs risk
missing
truly
distressed
individuals
.
The NCCN
Distress
Managem
ent
Screening
Measure is
an
efficient,
nonthreat
ening
method
for the
rapid
screening
and
identificati
on of
distress
experience
d by
cancer
patients.
Further
research is
needed
with this
tool.
MEASUREMENT OF STRESS IN THE ONCOLOGY POPULATION
Author/
s
Title
Journal
Date
(yr/vol/
iss)
Researc
h
Questio
n
Design
&
Metho
d
Population
Sample
Data
Collection/
(Size, Type)
Instrumen
ts
9
Analysis
Finding
s
Strengt
hs
Limitatio
ns
Conclusi
on
Implicati
ons
(Take
home
message)
with
uncertain
diagnosis
Strong,
V.,
Waters,
R.,
Hibberd,
C., Rush,
R.,
Cargill,
A.,
Storey,
D.,
Walker,
J., Wall,
L.,
Fallon,
M.,
Sharpe,
M.
Emotion
al
Distress
in
Cancer
Patients:
The
Edinburg
h Cancer
Centre
Sympto
m Study
British
Journal
of
Cancer,
Volume
96
02/20/2
007
Measure
the
prevalenc
e of
clinically
significan
t
emotional
distress
and to
determine
its
demograp
hic and
clinical
associatio
ns in a
large
sample of
outpatien
ts with a
variety of
cancer
types
attending
a regional
cancer
centre.
Crosssectiona
l study
3071
outpatient
cancer
patients
above the age
of 18
Hospital
Anxiety and
Depression
Scale
Confident
ial
Interval
Cutoff
measure
ments
Nearly a
quarter
of the
sample
had
clinically
significan
t
emotiona
l distress.
Large
sample
size.
All
outpatient
clinics
were not
measured,
underestim
ating the
prevalence
of
emotional
distress.
Definition
of clinically
significant
emotional
distress is
based on a
self-rated
questionna
ire and
excludes
patients
experienci
ng
transient
distress.
The study
has a great
sample
size, but
has a lot of
missing
informatio
n and
needs to
be more
developed.
The
population
with the
highest
distress
score
include
being
female,
having
active
disease,
and an age
of less
than 65.
Knowing
this,
special
attention
is needed
for this
population
.
MEASUREMENT OF STRESS IN THE ONCOLOGY POPULATION
Author/
s
Title
Journal
Date
(yr/vol/
iss)
Keller,
M.,
Sommerf
eldt, S.,
Fischer,
C.,
Knight,
L.,
Riesbeck,
M.,
Lowe, B.,
Herfarth,
C.,
Lehnert,
T.
Ozalp,
E.,
Cankurta
ran, E.,
Soygur,
H.,
Geyik, P.,
Jacobsen
, P.
Recognit
ion of
distress
and
psychiatr
ic
morbidit
y in
cancer
patients:
a multimethod
approach
Screenin
g for
psycholo
gical
distress
in
Turkish
cancer
patients
Annals
of
Oncolog
y,
Volume
15,
Issues 8
PsychoOncolog
y,
Volume
16, Issue
4
04/08/2
004
08/16/2
006
Researc
h
Questio
n
Design
&
Metho
d
Explore
how
distressed
patients
can be
identified
in a
specific
setting in
order to
provide
appropria
te
support.
Crosssectiona
l study
Aim is to
investigat
e distress
impact on
oncology
patients
in Turkey
and
determine
optimal
cut-off
score on
the
Distress
Crosssectiona
l study
Population
Sample
Data
Collection/
(Size, Type)
Instrumen
ts
189
consecutively
recruited
cancer
patients upon
admission to
surgical
oncology
wards
Diagnostic
psychiatric
interview
182 cancer
patient in
Ankara
Oncology
Education
And Research
Hospital
10
Analysis
Distress
Thermomete
r
The Problem
List
The
European
Organizatio
n for
Strengt
hs
Limitatio
ns
Conclusi
on
Implicati
ons
(Take
home
message)
Multilevel
approach
Hospital
Anxiety and
Depression
Scale
Questionnai
re
Finding
s
Descriptiv
e
Statistics
Seventyseven
percent
of
patients
with a
psychiatr
ic
disorder
were
properly
identified
by
physician
s. Nurse
identified
75%
correctly.
Good
sample
size.
Scores on
DT were
moderate
ly
correlate
d to the
HADS
and
EORTC
concludi
ng its
acceptabi
lity
Allows
quantita
tive
predicti
ons to
be
made.
Quick
process.
Limited
sensitivity
and
specifity to
psychologi
cal
morbidity
Limited
resource,
unable to
conduct a
diagnostic
interview
with all
patients
A good
study, but
needs
more
informatio
n
regarding
morbidity.
The study
did not
effectively
support
that
aspect.
Further
training is
needed to
improve
communic
ation and
diagnostic
skills of
nurses and
doctors.
The study
needs
further
research
since it is
the first
step for
quick
distress
screening
in Turkey.
More
informatio
n needs to
Statisticall
y effective
studies
still need
further
process for
real-life
results.
No other
group
tested for
compariso
n.
Not
generalizab
le to
outpatients
.
Majority is
of low
socioecono
mic status
and
education
level.
Questionna
MEASUREMENT OF STRESS IN THE ONCOLOGY POPULATION
Author/
s
Title
Journal
Date
(yr/vol/
iss)
Researc
h
Questio
n
Design
&
Metho
d
Population
Sample
Data
Collection/
(Size, Type)
Instrumen
ts
Thermom
eter for
identifyin
g
clinically
significan
t distress
by
comparin
g DT’S
performa
nce with
existing
screening
methods.
Grassi,
L.,
Johansen
, C.,
Annunzi
ata, M.,
Capovilla
, E.,
Constant
ini, A.,
Gritti, P.,
Torta, R.,
Bellani,
M.
Screenin
g for
distress
in cancer
patients
Cancer,
Volume
119,
Issue 9
05/1/20
13
The
objective
of this
study is to
examine
the
validity
and
acceptanc
e of the
DT in a
large
saple of
Italian
patients
with
cancer.
11
Analysis
Finding
s
Strengt
hs
Limitatio
ns
Conclusi
on
Implicati
ons
(Take
home
message)
Research
and
Treatment
of Cancer
Quality of
Life
Questionnai
re
criterion
validity.
ires may
have been
manipulate
d.
Sample
size needs
to be
greater for
the test to
be valid.
be
obtained
about the
patients’
psychosoci
al
activities.
Not cross
validated
in different
sample of
patients.
Crosssectiona
l study
1108
outpatients
with cancer
were
recruited
from 38
representativ
e oncology
center in Italy
Distress
Thermomete
r, The
Problem
List, The
Hospital
Anxiety and
Depression
Scale, Brief
Symptom
Inventory,
Visual
Analog Scale
Descriptiv
e
Analysis,
Pearson r
correlatio
n tests,
chisquare
test,
Student t
tests,
analyses
of
variance
DT cutoff
scores
greater
than or
equal to
4 and
greater
than or
equal to
5 had
optimal
sensitivit
y and
specificit
y relative
to HADS
and BSI
cutoff
scores for
Good
sample
size.
Quick
data
collectio
n.
Precise,
quantita
tive, and
numeric
al data.
Generaliza
bility to
cancer
patients
with poor
outlook
should be
examined.
Restricted
research on
effectivene
ss of DT.
The
majority of
cancer sites
test
included
The study
needs
further
developme
nt of the
DT tools,
but shows
promising
trends on
identifying
patients
with risk
of
psychologi
cal
distress.
The DT
thermome
ter is
commonly
used to
assess
psychologi
cal
distress in
cancer
patients,
but needs
further
developme
nt for
reliability
especially
for such a
MEASUREMENT OF STRESS IN THE ONCOLOGY POPULATION
Author/
s
Title
Journal
(yr/vol/
iss)
Date
Researc
h
Questio
n
Design
&
Metho
d
Population
Sample
Data
Collection/
(Size, Type)
Instrumen
ts
12
Analysis
Finding
s
Strengt
hs
Limitatio
ns
Conclusi
on
Implicati
ons
(Take
home
message)
general
caseness
and more
severe
psycholo
gical
distress.
Patients
with
greater
than or
equal to
4 on the
DT are
more
likely to
be
women, a
history of
psycholo
gical
problem,
report
more
stressful
events in
the last
year, and
currently
have
more
family,
emotiona
l, and
physical
problem
related to
GI and
breast
cancer, and
did not
compare to
other
cancer
sites.
Methodolo
gy could be
improved.
Further
history
regarding
previous
psychiatric
issues need
to be
studied.
Treatment
algorithms
need
developme
nt.
common
tool in use.
MEASUREMENT OF STRESS IN THE ONCOLOGY POPULATION
Author/
s
Title
Journal
Date
(yr/vol/
iss)
Researc
h
Questio
n
Design
&
Metho
d
Population
Sample
Data
Collection/
(Size, Type)
Instrumen
ts
13
Analysis
Finding
s
Strengt
hs
Limitatio
ns
Conclusi
on
Implicati
ons
(Take
home
message)
cancer or
treatmen
t.
Knobf,
M.,
MajorCampos,
M.,
Chagpar,
A.,
Seigerma
n, A.,
Mccorkle
, R.
Promoti
ng
quality
breast
cancer
care:
Psychoso
cial
distress
screenin
g
Palliative
and
Supporti
ve Care,
Volume
12, Issue
1
02/2014
The
purpose is
to
evaluate
the
feasibility
of
implemen
ting
psychosoc
ial
distress
screening
in the
Breast
Center at
Smilow
Cancer
Hospital
at Yale
New
Haven.
Crosssectiona
l study
88 breast
oncology
patients
NCCN
Distress
Thermomete
r
The Problem
List
Descriptiv
e analysis
The new
patients
screened
in
surgical
oncology
reported
higher
average
distress
scores
compare
d to
patients
in
medical
oncology.
A greater
number
of
patients
in
medical
oncology
reported
scores
greater
than 4
compare
d to the
new
patients
Theory
based
study.
Appropr
iate
method.
Quick
data
collectio
n.
Able to
translate
to other
studies.
Limited to
the surgical
breast
oncology
patients.
This is a
good,
thorough
study
predicting
psychologi
cal
distress.
Nurse led
psychosoci
al
screening
is feasible.
Proper
psychosoci
al
screening
is an
important
quality
indicator
of patientcentred
care.
MEASUREMENT OF STRESS IN THE ONCOLOGY POPULATION
Author/
s
Title
Journal
Date
(yr/vol/
iss)
Researc
h
Questio
n
Design
&
Metho
d
Population
Sample
Data
Collection/
(Size, Type)
Instrumen
ts
14
Analysis
Finding
s
Strengt
hs
Limitatio
ns
Conclusi
on
Implicati
ons
(Take
home
message)
screen in
surgery.
Denters,
M.,
Deuteko
m, M.,
EssinkBot, M.,
Bossuyt,
P.,
Fockens,
P.,
Dekker,
E.
FIT
falsepositives
in
colorecta
l cancer
screenin
g
experien
ce
psycholo
gical
distress
up to 6
weeks
after
colonosc
opy
Supporti
ve Care
in
Cancer,
Volume
21, Issue
10
06/01/2
013
Explore
the
difference
s in
psycholog
ical
effects
crosssectionall
y after
receipt of
the
invitation
in all
invites
and
longitudi
nally in
participan
ts with a
positive
FIT
result.
Crosssectiona
l study
3828 of
average risk
persons
between the
ages of 50 to
74
The
Psychologica
l
Consequenc
es
Questionnai
re
Data was
analysed
by point
and time.
The
primary
analysis
focused
on the
PCQ total
score;
additional
analyses
were done
for the
PCQ
emotional
, physical,
and social
subscores
.
Mean
total,
physical,
and
social
PCQ
scores
had
decrease
d
significan
tly
between
the first
question
naire and
the precolonosc
opy one,
but
scores on
the
emotiona
l subscale
did not.
In falsepositives,
mean
total,
physical,
and
emotiona
l PCQ
Large
sample
size.
Relatively
low
response
rate among
nonpartici
pants,
making it
difficult to
generalize
scores.
Bias
cannot be
excluded –
people
experienci
ng high
levels of
stress were
more likely
to return
the
questionna
ire.
No other
group for
compariso
n.
A good
study that
reveals
how
testing can
induce
psychologi
cal stress.
There is
difficulty
in using
questionn
aires
where
participan
ts do not
readily
answer if
they feel
the study
does not
apply to
them.
Studies
that invite
participan
ts for test
screening
can cause
psychologi
cal
distress in
invitees.
MEASUREMENT OF STRESS IN THE ONCOLOGY POPULATION
Author/
s
Title
Journal
(yr/vol/
iss)
Date
Researc
h
Questio
n
Design
&
Metho
d
Population
Sample
Data
Collection/
(Size, Type)
Instrumen
ts
15
Analysis
Finding
s
Strengt
hs
Limitatio
ns
Conclusi
on
Implicati
ons
(Take
home
message)
scores
decrease
d
significan
tly, while
in truepositives,
a
significan
t
decrease
in mean
emotiona
l PCQ
score was
observed.
Running head: MEASUREMENT OF STRESS IN THE ONCOLOGY POPULATION
16
Research Synthesis
Operationally, the Distress Thermometer categorizes stress in 3 different levels.
A level from 0 to 4 indicates stress being controlled, a 5 to 7 indicates experiencing stress
levels that effect daily living, and a score of 8 to 10 indicates a high level of stress that
requires medical attention. The Brief Symptom Inventory Scale is an 18-item
questionnaire designed to examine distress in the last week through 3 subscales—
somatization, anxiety, and depression (Grassi et al., 2013). Each item is rated on a Likert
scale ranging from 0 (not at all) to 4 (extreme stress). A total distress score is derived by
summing all items. Other tools used to measure stress include the Hospital Anxiety and
Depression, Global Inventory Scale, etc. Regardless of the tool used, stress proves to be
a subjective phenomenon and quantitatively measuring continues to be difficult. Studies
in the review used different cutoff scores according to previous studies using the same
tool.
This makes standardizing significance of stress levels challenging. Using a
standardized cutoff score for future studies can further support clinical significance and
make it easier to compare scores. Most studies in the integrative review used a crosssectional study design. Populations include patients during hospital admissions and
outpatient visits. The integrative review focused on cancer patient’s level of stress. The
studies framework are appropriate.
Further Research
There are implications for further research associated with the integrative review.
A potential research area include exploring how distal, cognitive, behavioral, and genetic
risk factors affect stress levels during development. Can the incidence of stress be
predicted by identifying biological predictors and markers? According to Strong et al.
MEASUREMENT OF STRESS IN THE ONCOLOGY POPULATION
17
(2007), the population with the highest distress score within their study are female,
having active disease, and younger than 65. Comparing stress levels with populations
falling in different categories can highlight whether risk factors are significant in
predicting high levels of stress. Another area of potential research include investigating
the reliability of stress measurement tools. Most studies in the integrative literature
review noted the need for reliability and validity testing of the established instruments.
Comparing established stress measurement tools with full narratives can be a means of
testing data.
Summary
The integrative review yielded common measurement tools such as the Distress
Thermometer, Brief Symptom Inventory, HADS and GSI. The integrative review
highlights the need for further research to support validity and reliability of established
measurement tools. This brings up the question which tool is best for assessing stress.
Properly determining the presence and level of stress, and the best frequency of
assessment, is what these studies aimed to show. Regardless of the differing scores and
tools, the all agree with the importance of psychological stress screening and its
integration to a practice standard.
MEASUREMENT OF STRESS IN THE ONCOLOGY POPULATION
18
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