- Email: [email protected]
Psychosocial aspects of neoplastic disease
PsychosocialAspects of Neoplastic Disease III. Group Support for the Oncology Nurse Peter M. Silberfarb, M.D. Professor of Psychiatry and Medicine, Dartmouth Medical School, and Chief, Cancer Psychiafy Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Hanover, New Hampshire
Associate
Unit,
Peter M. Levine, M.D. Clinical Assistant Professor of Psychiatry, Baylor College of Medicine and University of Texas, and Consultant, M.D. Anderson Hospital, Houston, Texas
Abstrack The attitudes of oncology nurses to job-related concepts were assessed by the Semantic Differential List prior to beginning and following six months of weekly 1.5 hour psychodynamically oriented support group sessions. These attitudes were compared to oncology nurses not in the group experienceduring the same time span. The oncology nurses who had completed the group experience had more negative attitude shifts to the job-pertinent concepts and also showed a greater amount of attitude change in the negative direction than those oncology nurses not in the group. These findings point to the importance of denial in cancer centerpersonnel and indicate that an educational model of group therapy may be more appropriate for this group of health professionals.
Many suggest that group support would be useful for cancer center personnel in order to lessen their sense of failure and discouragement in the face of the unrelenting stress of caring for cancer patients. This recommendation has been made even though little objective evidence exists that documents the effectiveness of group therapy for this population. It is very difficult, however, to objectively measure psychological changes in a clinical situation as variable as the cancer ward. This study attempts to do so by assessing attitude changes of cancer nurses
The authors wish to thank Anne-Marie Barron, R.N., MS. for her help in planning this project and acting as co-therapist; Dr. Gary J. Tucker for editorial advice; and Kit H. Shum, B.A. and Judith Brier, A.B. for statisti& assistance.
192 ISSN 0163-8343~192-0.25
before and after a six-month period of supportive group therapy.
Method The Mary Hitchcock Memorial Hospital, a 450-bed general hospital and component of the Dartmouth-Hitchcock Medical Center, admits all medical patients suffering from malignancy or suspect malignancy to one floor of the hospital. The nursing staff of this floor, in fact, comprises a team specializing in the care of cancer patients at all stages of disease. During the course of this study, the nursing staff, 41 in total, consisted of 18 registered nurses, 17 LPNs and 6 nursing assistants. The nursing schedule is divided into traditional 7~00 AM to 3:00 PM, 3:OOPM to 11:OO PM, and 11:OOPM to 7~00 AM shifts. For the duration of this study, all members of the nursing staff were female.
The Group Initially, several nurses expressed a desire for a support group to help them with the difficult task of caring for cancer patients. After approximately one month of publicity, 12 nurses indicated their willingness to join such a group. By their own choice and because of schedulng work shifts, they were divided into two separate groups of six nurses per group. Each group was led by co-therapists, a Generpl liospitpl Psychiatry 3,192~197,198O
@ Elswier North Holland, Inc., 1980 52 Vanderbilt Ave., New York, N.Y. 10017
Psychosocial Aspects of Neoplastic Disease
nurse specialist and a psychiatrist (PML), and met 1.5 hours each week for six months. The role of the co-therapists was that of facilitators. Although it was intended that the group format would follow a supportive psychodynamic model with the nurses being allowed to take the lead in discussion, only occasionally did the group become introspective with individuals, trying to understand their feelings in psychological terms. Most often, a specific nurse would bring a problem to the group and a discussion of how best to resolve the problem ensued. The facilitators offered feedback, clarified affect, and were gently interpretative. Clinical problems or work-related problems often were the topic for discussion, which frequently focused on the nurse’s feelings in the situation. The one rule followed by all group members was that there would be no discussion about content of the sessions with other nurses outside the group. it was the impression of the co-therapists and the group members that once the groups were in progress, there was not much interest in or curiosity about the group by nurses not in the group.
Evaluation Prior’to beginning the group, and at its conclusion six months later, all members of the oncology nursing staff were asked to complete the Semantic Differential List. This list consisted of 20 known concepts (Table 1) and 13 evaluative pairs of contrasting adjectives (Table 2). The 12 oncology nurses in the group plus 17 nongroup oncology nurses (controls) responded to this request. The Semantic Differential is a rating scale that measures reactions to a stimulus concept in response to contrasting adjectives. It has recently been used frequently in a medical environment, for example, to evaluate attitudes of family practitioners toward patients with psychiatric symptoms (1), measure the psychological impact of renal dialysis (2), and evaluate psychological responses of patients cured of advanced cancer (3). After reading the stimulus sentence, the participant selects a number on a graduated scale of 1 to 7 for each adjective which best characterizes how she feels about the concept. The concepts used in this study were formulated by the investigators and were felt to represent pertinent attitudes of the nursing staff in their work with cancer patients. The contrasting adjectives remained constant for each concept scored and were chosen from the evaluative adjective scales com-
Table 1. Concepts evaluated by means of contrasting adjectives 1. Providing nursing care for dying patient is: 2. The quality of the nursing care I provide is: 3. My emotional growth as a result of my working experience is: 4. My professional relationship with the physicians is: 5. My attitude toward myself as a nurse is: 6. My role as an oncology nurse is: 7. Providing nursing care for young cancer patients is: 8. My professional relationship with this oncology nursing staff is: 9. My attitude toward illness is: 10. My attitude toward myself as a person is: 11. My attitude toward death is: 12. Providing nursing care for a patient approximately my own age is: 13. My professional relationship with the psychiatryoncology team is: 14. Providing nursing care for cancer patients is: 15. My personal relationship with the oncology nursing staff is: 16. Providing nursing care for a middle aged cancer patient is: 17. My personal growth as a result of my working experience is: 18. My attitude toward cancer is: 19. Providing nursing care for an elderly cancer patient is: 20. My educational growth as a result of my working experience is:
piled by Osgood, Suci, and Tannenbaum (4). The concepts were also grouped into the following four categories, which reflect attitudes of the oncology nurse: 1. Attitude about oneself (concepts 2,5,6,10) 2. Attitude toward illness, death, and cancer (concepts 9,11,18) 3. Personal growth (concepts 3,17,20) 4. Professional relationships (concepts 4,8,13,15).
After conversion of all scale numbers 1 through 7 so that they ranged from positive to negative, averages were obtained for each concept by adding the score for adjective one and the score for adjective two, and so forth, and then dividing by 13. The neutral judgment of 4 was assigned if no scale was marked. The scores for each concept were obtained at the start of group therapy (“before”) and after six months, at the end of group therapy (“after”). By examining the difference between before and after 193
P. M. Silberfarb and P. M. Levine
Table 2. Contrasting adjectives which remained constant for each concept
1.Certain : uncertain 2. Positive : negative 3. Beneficial : harmful 4. Selfish : unselfish 5. Hopeful : hopeless 6. Complete : incomplete 7. Approving : disapproving 8. Meaningless : meaningful 9. Uncomfortable : comfortable 10.Honest : dishonest 11.Displeased : pleased 12.Unimportant : important 13.Rewarding : unrewarding
scores for both concepts and categories, an attitude change in either the positive or negative direction was identified.
S tutisticul Analysis An index of the amount of attitude change after the six-month period was measured by the following formula: d = -(d2 - dl)/(d2 + dl), where d is a percentage index of attitude change, dl is the premeasure, d2 is the post measure; the negative sign is added because the original scales use a greater number to indicate a more negative attitude. Thus a set of 20 percentages was obtained for each of the 29 nurses pertaining to the relative amount of attitude change as measured by the 20 concepts. However, because of the small sample size as compared with the number of dependent measures, a multivariate analysis of variance was not feasible. In order to circumvent this difficulty, the set of 20 measures was reduced to four by grouping them into the four different categories that reflect pertinent attitudes of the oncology nurse as noted previously. Then, for each of these four categories, an average index was obtained by taking the mean of the indices of attitude change for the constituent concepts. With the use of these four dependent measures, a multivariate analysis of variance was performed. Second, a multivariate discriminant analysis followed by classification by both Geisser’s Case 8 (5) and Eisenbeis and Avery’s Rule R:5.4 (6) was used to see if, on the basis of the 20 dependent measures (attitude change in the 20 concepts), the 12 nurses who had undergone group therapy could be reliably distinguished from the 17 who had not. Fi194
nally, in order to elicit the pattern of attitude change for the two groups, an independent two-tailed t-test was used to see if the amount of attitude change toward any of the 20 concepts was significantly different between the nurses who had undergone group therapy and those who had not.
Results Table 3 lists the demographic data for group and control nurses. The percent attitude change after group therapy for each of the 20 concepts is listed in Table 4. None of the t-tests was significant at the 0.05 level, although question 4 (“my professional relationship with physicians”) approached significance (P = 0.06) in that the group nurses had more of a negative response than controls. In fact, in 18 out of the 20 concepts, the nurses who had group therapy showed a negative attitude change, whereas controls did so in relation to only 11 concepts. When the two groups were compared relative to amount of attitude change, nurses who had been through the group experience showed less positive change (were more negative) in 14 out of the 20 concepts. The multivariate analysis of variance using the four average indices of attitude change did not achieve significance, f(4,24) =‘0.50. However, the disciminant analysis resulted in 96.55% accuracy; only one of the 29 nurses was misclassified. Even though the objective measures indicated attitude changes in the negative direction following group therapy, subjective verbalizations of the group nurses consistently were laudatory of the group experience. Nurses often expressed appreciation to the co-therapists and felt that the group experience was worthwhile. There was no evidence by patient or staff report that the group experience produced work or work-related difficulties such as poor patient care or strained interpersonal relationships. Employment absenteeism also was unchanged in the two groups during the study period. In an attempt to assess whether the negative attitude change influenced long-term employment, job turnover was measured. Two years after the study, only two of the 12 nurses in the group remained working on the oncology unit; eight left the area and two others transferred to other units in the hospital. Similar results, however, were found for the control nurses: five had transferred to other hospital units, seven had left the area, and only five remained working as oncology nurses.
Psychosocial
Aspects of Neoplastic Disease
Table 3. Demographic data Group (N = 12)
Age:
10-19 20-29 3039 4049 5059 Single Married Divorced Widow Protestant Catholic Other
Marital status:
Religion:
Practicing: Nonpracticing: Professional status:
Education:
Registered Licensed practical Nursing assistants High school
Diploma/School of Nursing College
0 11 0 1 0 10 1 1 0 5 6 1 8 4 10 2 0 1 4 7
Control (N = 17)
Total (N = 29)
0
0
11 2 2 2 6 9
22 2 3 2 16 10 2 1 14 12 3 15 14 15 9 5 12 5 12
1 1 9 6 2 7 10 5 7 5 11 1 5
Discussion Table 4. Percent of attitude change post
The enthusiasm for groups as the panacea for social and psychological discomfort is evident in the staff of cancer centers. Group process has been utilized
group therapy Mean for Question
group (%)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
0.35 -0.95 -2.93 -10.21 -3.96 -3.78 -0.02 -0.62 -3.43 2.03 -4.84 -1.67 -0.46 -1.27 -5.27 -6.18 -4.09 -1.76 -7.32 -4.91
Mean for control (%) -6.41 -1.61 0 0.11 -4.32 -3.74 0.15 -7.82 0.30 0.35 -2.10 1.36 -5.23 0.76 -2.72 -2.62 -0.47 1.38 -4.96 0.59
“Negative value indicates change for the worse.
(two-railed) 0.30 0.88 0.68 0.06 0.95 0.99 0.97 0.22 0.51 0.77 0.60 0.62 0.52 0.71 0.73 0.61 0.55 0.63 0.72 0.30
in training of oncology fellows (7, 8) and oncology nurses (9), but objective measures were not used in assessing outcome. Nevertheless, previous investigators have reported positive response on the part of the fellows and nurses to group therapy intervention. Wise (7) utilized group process in the training of
oncology fellows because it provided an efficient method of teaching psychological knowledge to physicians and nurses in a cancer center. His method used clinical problems as the focus of discussion and was, in effect, a liaison seminar, which permitted rotating staff and students to participate. Artiss and Levine (8) followed a more structured approach in their group process seminars for oncology fellows at the National Cancer Institute. Both studies appeared to be basically educative in nature, which may account for their uniformly positive results. Wise, for example, specifically states that his was not a psychotherapy group, in that there was no interpretation and leaders did not interpret group process. In addition, his group lasted only four months. 195
P. M. Silberfarb and P. M. Levine
Yano (9) followed an insight-oriented psychodynamic model but also utilized didactic sessions on pertinent topics such as mourning, anticipatory grief, and death and dying. He recommended group sessions of 1.5 hours per week for six months, the time frame followed in our study. Van Ostenberg (10) described therapy groups for hospital staff as an “effective means of promoting personal and professional growth,” but indicated he had little objective data to support his conclusion. Sainsbury and Milton (11) used weekly discussion groups to identify pertinent topics to clarify problems facing nurses on a cancer ward. Wodinsky (12) used a similar model for nurses on a leukemia service, while Janes and Weisz (13) did so on a cancer research ward. These reports utilized an education-discussion format and reported positive, albeit uncontrolled, responses from the participants. Galinsky and Schopler (14) reviewed the literature on casualties of the group experience and point out that participation in groups may be “as damaging to some individuals as it is beneficial to others.” Our results indicate that six months of supportive group therapy had a generally negative objective effect on the attitude of oncology nurses in relation to pertinent job-related concepts. However, nurses with group therapy expressed rather positive opinions about the group experience, which is inconsistent with the negative attitude changes measured by the Semantic Differential technique. Skewed selection may be an important factor, in that nurses who selected to have the group experience may have had prior negative feelings and participation in the group extended permission for expression of these negative feelings through consensual validation. In addition, the slightly older age and greater number of married participants in the control group may reflect a different population than the study group. However, the study group and controls were not distinguishable by length of employment or identifiable psychiatric stressors such as recent losses or history of psychiatric treatment. In view of the positive subjective responses of group members, the group may have facilitated discussion among participants with similar attitudes. These nurses had a more negative attitude following group, but they were not necessarily more troubled, and appreciated the chance for catharsis. Another more cynical possibility to explain the discordance between objective and subjective findings could be that the group members’ positive subjective response was an attempt to jus196
tify time investment during the six months of group therapy. The high job turnover for both the study group and the control group at follow-up two years later may reflect multiple factors such as low salaries, variable working conditions, and legitimate geographical moves not related to job stress. However, this rapid turnover of employment does serve to highlight the transient nature of oncology nursing and was not present on the general hospital nursing units. In view of the difficulty of objectively assessing attitude, the small sample size, and the fact that the group participants were selected on a voluntary basis, makes it difficult to consider our findings as conclusive. Instead, one should view this pilot study as a reason to hesitate before recommending blanket therapy of any kind for cancer center personnel. Just as Gottheil and his colleagues (15) recently pointed out the need for exercising caution and judgment in sharing information with cancer patients because “awareness” may not be beneficial for all, so should the same sensitivity be brought to bear on professionals working in cancer centers. It has been our observation that a “healthy” amount of denial is necessary for nurses and other professionals working in this environment. Negative attitude change is not necessarily bad and may even be indicative of personal growth, but the a priori view that “getting one’s feelings out” is always desirable should be tempered when dealing with cancer center personnel. Disrupting the delicate balance between “denial” and “reality” may have a deleterious effect on the psychic economy of some health professionals. Although there was no evidence that group experience produced any workrelated difficulties on the cancer floor, the frequent negative attitude change of group participants when compared with controls should give us reason to pause before extending the enthusiasm of the past decade for groups to health care professionals working in cancer centers. Even the attitudes that showed a positive change post group experience were less positive in magnitude than the control. It is stressful to care for cancer patients (16). This is apparent and is easily identified. What to do about the situation is another matter. Certainly, this study points to the need for more research into the effects of groups on cancer center personnel and the need for better methods and instruments to measure attitude change. However, other ways to relieve the sense of despair and entrapment experienced by cancer nurses should also be explored.
Psychosocial Aspects of Neoplastic Disease
These could take the form of clinical conferences, disposition conferences, or educational sessions. Bates and Moore (17), in their study of stress in hospital personnel, call for an administrative and educative approach to improve coping of this population. It is clear that further research in this important area is needed.
References 1. Werkman SL, Mallory L, Harris J: The common psychiatric problems in family practice. Psychosomatics 17:119-122, 1976 2. Clark R, Hailstone JD, Slade I’D: Psychological aspects of dialysis: A semantic differential study. Psycho1 Med 9:55-62, 1979 3. Kennedy BJ, Tellegen A, Kennedy S, Havemick N: Psychological response of patients cured of advanced cancer. Cancer 38:2184-2191, 1976 4. Osgood CE, Suci GJ, Tannenbaum PH: The Measurement of Meaning. Chicago, University of Illinois Press, 1971 5. Cooley WW, Lohnes PR: Multivariate Data Analysis. New York, Wiley, 1971 6. Eisenbeis RA, Avery RB: Discriminant Analysis and Classification Procedures. Lexington, Mass., Heath, 1972 7. Wise TN: Utilization of group process in training oncology fellows. Int J Group Psychother 27:105-111, 1977
8. Artiss K, Levine AS: Doctor-patient relationship in severe illness: A seminar for oncology fellows. N Engl J Med 288:1210-1214, 1973 9. Yano BS: What about us? J Practical Nurs 27~2838, 1977 10. Van Ostenberg DL: Therapy groups for staff and interns. Hosp Commun Psychiatry 24474475, 1973 11. Sainsbury MJ, Milton GW: The nurse in a cancer ward. Med J Austr 2:911-913, 1975 12. Wodinsky A: Psychiatric consultation with nurses on a leukemia service. Ment Hyg 48:282-287, 1964 13. Janes RG, Weisz AE: Psychiatric liaison with a cancer research center. Comp Psychiatry 11:336-345, 1970 14. Galinsky MJ, Schopler JH: Warning: Groups may be dangerous. Sot Work 2289-94, 1977 15. Gottheil E, McGum WC, Pollak 0: Awareness and disengagement in cancer patients. Am J Psychiatry 136:632X%, 1979 16. The Special Needs of the Oncology Nurse (editorial). J Practical Nurs 27~12, 1977 17. Bates EM, Moore BN: Stress in hospital personnel. Med J Austr 2:765-767, 1975
Direct reprint requests to:
Peter M. Silberfarb, M.D. Department of Psychiatry Dartmouth Medical School Hanover, NH 03755
197
Associate
Unit,
Peter M. Levine, M.D. Clinical Assistant Professor of Psychiatry, Baylor College of Medicine and University of Texas, and Consultant, M.D. Anderson Hospital, Houston, Texas
Abstrack The attitudes of oncology nurses to job-related concepts were assessed by the Semantic Differential List prior to beginning and following six months of weekly 1.5 hour psychodynamically oriented support group sessions. These attitudes were compared to oncology nurses not in the group experienceduring the same time span. The oncology nurses who had completed the group experience had more negative attitude shifts to the job-pertinent concepts and also showed a greater amount of attitude change in the negative direction than those oncology nurses not in the group. These findings point to the importance of denial in cancer centerpersonnel and indicate that an educational model of group therapy may be more appropriate for this group of health professionals.
Many suggest that group support would be useful for cancer center personnel in order to lessen their sense of failure and discouragement in the face of the unrelenting stress of caring for cancer patients. This recommendation has been made even though little objective evidence exists that documents the effectiveness of group therapy for this population. It is very difficult, however, to objectively measure psychological changes in a clinical situation as variable as the cancer ward. This study attempts to do so by assessing attitude changes of cancer nurses
The authors wish to thank Anne-Marie Barron, R.N., MS. for her help in planning this project and acting as co-therapist; Dr. Gary J. Tucker for editorial advice; and Kit H. Shum, B.A. and Judith Brier, A.B. for statisti& assistance.
192 ISSN 0163-8343~192-0.25
before and after a six-month period of supportive group therapy.
Method The Mary Hitchcock Memorial Hospital, a 450-bed general hospital and component of the Dartmouth-Hitchcock Medical Center, admits all medical patients suffering from malignancy or suspect malignancy to one floor of the hospital. The nursing staff of this floor, in fact, comprises a team specializing in the care of cancer patients at all stages of disease. During the course of this study, the nursing staff, 41 in total, consisted of 18 registered nurses, 17 LPNs and 6 nursing assistants. The nursing schedule is divided into traditional 7~00 AM to 3:00 PM, 3:OOPM to 11:OO PM, and 11:OOPM to 7~00 AM shifts. For the duration of this study, all members of the nursing staff were female.
The Group Initially, several nurses expressed a desire for a support group to help them with the difficult task of caring for cancer patients. After approximately one month of publicity, 12 nurses indicated their willingness to join such a group. By their own choice and because of schedulng work shifts, they were divided into two separate groups of six nurses per group. Each group was led by co-therapists, a Generpl liospitpl Psychiatry 3,192~197,198O
@ Elswier North Holland, Inc., 1980 52 Vanderbilt Ave., New York, N.Y. 10017
Psychosocial Aspects of Neoplastic Disease
nurse specialist and a psychiatrist (PML), and met 1.5 hours each week for six months. The role of the co-therapists was that of facilitators. Although it was intended that the group format would follow a supportive psychodynamic model with the nurses being allowed to take the lead in discussion, only occasionally did the group become introspective with individuals, trying to understand their feelings in psychological terms. Most often, a specific nurse would bring a problem to the group and a discussion of how best to resolve the problem ensued. The facilitators offered feedback, clarified affect, and were gently interpretative. Clinical problems or work-related problems often were the topic for discussion, which frequently focused on the nurse’s feelings in the situation. The one rule followed by all group members was that there would be no discussion about content of the sessions with other nurses outside the group. it was the impression of the co-therapists and the group members that once the groups were in progress, there was not much interest in or curiosity about the group by nurses not in the group.
Evaluation Prior’to beginning the group, and at its conclusion six months later, all members of the oncology nursing staff were asked to complete the Semantic Differential List. This list consisted of 20 known concepts (Table 1) and 13 evaluative pairs of contrasting adjectives (Table 2). The 12 oncology nurses in the group plus 17 nongroup oncology nurses (controls) responded to this request. The Semantic Differential is a rating scale that measures reactions to a stimulus concept in response to contrasting adjectives. It has recently been used frequently in a medical environment, for example, to evaluate attitudes of family practitioners toward patients with psychiatric symptoms (1), measure the psychological impact of renal dialysis (2), and evaluate psychological responses of patients cured of advanced cancer (3). After reading the stimulus sentence, the participant selects a number on a graduated scale of 1 to 7 for each adjective which best characterizes how she feels about the concept. The concepts used in this study were formulated by the investigators and were felt to represent pertinent attitudes of the nursing staff in their work with cancer patients. The contrasting adjectives remained constant for each concept scored and were chosen from the evaluative adjective scales com-
Table 1. Concepts evaluated by means of contrasting adjectives 1. Providing nursing care for dying patient is: 2. The quality of the nursing care I provide is: 3. My emotional growth as a result of my working experience is: 4. My professional relationship with the physicians is: 5. My attitude toward myself as a nurse is: 6. My role as an oncology nurse is: 7. Providing nursing care for young cancer patients is: 8. My professional relationship with this oncology nursing staff is: 9. My attitude toward illness is: 10. My attitude toward myself as a person is: 11. My attitude toward death is: 12. Providing nursing care for a patient approximately my own age is: 13. My professional relationship with the psychiatryoncology team is: 14. Providing nursing care for cancer patients is: 15. My personal relationship with the oncology nursing staff is: 16. Providing nursing care for a middle aged cancer patient is: 17. My personal growth as a result of my working experience is: 18. My attitude toward cancer is: 19. Providing nursing care for an elderly cancer patient is: 20. My educational growth as a result of my working experience is:
piled by Osgood, Suci, and Tannenbaum (4). The concepts were also grouped into the following four categories, which reflect attitudes of the oncology nurse: 1. Attitude about oneself (concepts 2,5,6,10) 2. Attitude toward illness, death, and cancer (concepts 9,11,18) 3. Personal growth (concepts 3,17,20) 4. Professional relationships (concepts 4,8,13,15).
After conversion of all scale numbers 1 through 7 so that they ranged from positive to negative, averages were obtained for each concept by adding the score for adjective one and the score for adjective two, and so forth, and then dividing by 13. The neutral judgment of 4 was assigned if no scale was marked. The scores for each concept were obtained at the start of group therapy (“before”) and after six months, at the end of group therapy (“after”). By examining the difference between before and after 193
P. M. Silberfarb and P. M. Levine
Table 2. Contrasting adjectives which remained constant for each concept
1.Certain : uncertain 2. Positive : negative 3. Beneficial : harmful 4. Selfish : unselfish 5. Hopeful : hopeless 6. Complete : incomplete 7. Approving : disapproving 8. Meaningless : meaningful 9. Uncomfortable : comfortable 10.Honest : dishonest 11.Displeased : pleased 12.Unimportant : important 13.Rewarding : unrewarding
scores for both concepts and categories, an attitude change in either the positive or negative direction was identified.
S tutisticul Analysis An index of the amount of attitude change after the six-month period was measured by the following formula: d = -(d2 - dl)/(d2 + dl), where d is a percentage index of attitude change, dl is the premeasure, d2 is the post measure; the negative sign is added because the original scales use a greater number to indicate a more negative attitude. Thus a set of 20 percentages was obtained for each of the 29 nurses pertaining to the relative amount of attitude change as measured by the 20 concepts. However, because of the small sample size as compared with the number of dependent measures, a multivariate analysis of variance was not feasible. In order to circumvent this difficulty, the set of 20 measures was reduced to four by grouping them into the four different categories that reflect pertinent attitudes of the oncology nurse as noted previously. Then, for each of these four categories, an average index was obtained by taking the mean of the indices of attitude change for the constituent concepts. With the use of these four dependent measures, a multivariate analysis of variance was performed. Second, a multivariate discriminant analysis followed by classification by both Geisser’s Case 8 (5) and Eisenbeis and Avery’s Rule R:5.4 (6) was used to see if, on the basis of the 20 dependent measures (attitude change in the 20 concepts), the 12 nurses who had undergone group therapy could be reliably distinguished from the 17 who had not. Fi194
nally, in order to elicit the pattern of attitude change for the two groups, an independent two-tailed t-test was used to see if the amount of attitude change toward any of the 20 concepts was significantly different between the nurses who had undergone group therapy and those who had not.
Results Table 3 lists the demographic data for group and control nurses. The percent attitude change after group therapy for each of the 20 concepts is listed in Table 4. None of the t-tests was significant at the 0.05 level, although question 4 (“my professional relationship with physicians”) approached significance (P = 0.06) in that the group nurses had more of a negative response than controls. In fact, in 18 out of the 20 concepts, the nurses who had group therapy showed a negative attitude change, whereas controls did so in relation to only 11 concepts. When the two groups were compared relative to amount of attitude change, nurses who had been through the group experience showed less positive change (were more negative) in 14 out of the 20 concepts. The multivariate analysis of variance using the four average indices of attitude change did not achieve significance, f(4,24) =‘0.50. However, the disciminant analysis resulted in 96.55% accuracy; only one of the 29 nurses was misclassified. Even though the objective measures indicated attitude changes in the negative direction following group therapy, subjective verbalizations of the group nurses consistently were laudatory of the group experience. Nurses often expressed appreciation to the co-therapists and felt that the group experience was worthwhile. There was no evidence by patient or staff report that the group experience produced work or work-related difficulties such as poor patient care or strained interpersonal relationships. Employment absenteeism also was unchanged in the two groups during the study period. In an attempt to assess whether the negative attitude change influenced long-term employment, job turnover was measured. Two years after the study, only two of the 12 nurses in the group remained working on the oncology unit; eight left the area and two others transferred to other units in the hospital. Similar results, however, were found for the control nurses: five had transferred to other hospital units, seven had left the area, and only five remained working as oncology nurses.
Psychosocial
Aspects of Neoplastic Disease
Table 3. Demographic data Group (N = 12)
Age:
10-19 20-29 3039 4049 5059 Single Married Divorced Widow Protestant Catholic Other
Marital status:
Religion:
Practicing: Nonpracticing: Professional status:
Education:
Registered Licensed practical Nursing assistants High school
Diploma/School of Nursing College
0 11 0 1 0 10 1 1 0 5 6 1 8 4 10 2 0 1 4 7
Control (N = 17)
Total (N = 29)
0
0
11 2 2 2 6 9
22 2 3 2 16 10 2 1 14 12 3 15 14 15 9 5 12 5 12
1 1 9 6 2 7 10 5 7 5 11 1 5
Discussion Table 4. Percent of attitude change post
The enthusiasm for groups as the panacea for social and psychological discomfort is evident in the staff of cancer centers. Group process has been utilized
group therapy Mean for Question
group (%)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
0.35 -0.95 -2.93 -10.21 -3.96 -3.78 -0.02 -0.62 -3.43 2.03 -4.84 -1.67 -0.46 -1.27 -5.27 -6.18 -4.09 -1.76 -7.32 -4.91
Mean for control (%) -6.41 -1.61 0 0.11 -4.32 -3.74 0.15 -7.82 0.30 0.35 -2.10 1.36 -5.23 0.76 -2.72 -2.62 -0.47 1.38 -4.96 0.59
“Negative value indicates change for the worse.
(two-railed) 0.30 0.88 0.68 0.06 0.95 0.99 0.97 0.22 0.51 0.77 0.60 0.62 0.52 0.71 0.73 0.61 0.55 0.63 0.72 0.30
in training of oncology fellows (7, 8) and oncology nurses (9), but objective measures were not used in assessing outcome. Nevertheless, previous investigators have reported positive response on the part of the fellows and nurses to group therapy intervention. Wise (7) utilized group process in the training of
oncology fellows because it provided an efficient method of teaching psychological knowledge to physicians and nurses in a cancer center. His method used clinical problems as the focus of discussion and was, in effect, a liaison seminar, which permitted rotating staff and students to participate. Artiss and Levine (8) followed a more structured approach in their group process seminars for oncology fellows at the National Cancer Institute. Both studies appeared to be basically educative in nature, which may account for their uniformly positive results. Wise, for example, specifically states that his was not a psychotherapy group, in that there was no interpretation and leaders did not interpret group process. In addition, his group lasted only four months. 195
P. M. Silberfarb and P. M. Levine
Yano (9) followed an insight-oriented psychodynamic model but also utilized didactic sessions on pertinent topics such as mourning, anticipatory grief, and death and dying. He recommended group sessions of 1.5 hours per week for six months, the time frame followed in our study. Van Ostenberg (10) described therapy groups for hospital staff as an “effective means of promoting personal and professional growth,” but indicated he had little objective data to support his conclusion. Sainsbury and Milton (11) used weekly discussion groups to identify pertinent topics to clarify problems facing nurses on a cancer ward. Wodinsky (12) used a similar model for nurses on a leukemia service, while Janes and Weisz (13) did so on a cancer research ward. These reports utilized an education-discussion format and reported positive, albeit uncontrolled, responses from the participants. Galinsky and Schopler (14) reviewed the literature on casualties of the group experience and point out that participation in groups may be “as damaging to some individuals as it is beneficial to others.” Our results indicate that six months of supportive group therapy had a generally negative objective effect on the attitude of oncology nurses in relation to pertinent job-related concepts. However, nurses with group therapy expressed rather positive opinions about the group experience, which is inconsistent with the negative attitude changes measured by the Semantic Differential technique. Skewed selection may be an important factor, in that nurses who selected to have the group experience may have had prior negative feelings and participation in the group extended permission for expression of these negative feelings through consensual validation. In addition, the slightly older age and greater number of married participants in the control group may reflect a different population than the study group. However, the study group and controls were not distinguishable by length of employment or identifiable psychiatric stressors such as recent losses or history of psychiatric treatment. In view of the positive subjective responses of group members, the group may have facilitated discussion among participants with similar attitudes. These nurses had a more negative attitude following group, but they were not necessarily more troubled, and appreciated the chance for catharsis. Another more cynical possibility to explain the discordance between objective and subjective findings could be that the group members’ positive subjective response was an attempt to jus196
tify time investment during the six months of group therapy. The high job turnover for both the study group and the control group at follow-up two years later may reflect multiple factors such as low salaries, variable working conditions, and legitimate geographical moves not related to job stress. However, this rapid turnover of employment does serve to highlight the transient nature of oncology nursing and was not present on the general hospital nursing units. In view of the difficulty of objectively assessing attitude, the small sample size, and the fact that the group participants were selected on a voluntary basis, makes it difficult to consider our findings as conclusive. Instead, one should view this pilot study as a reason to hesitate before recommending blanket therapy of any kind for cancer center personnel. Just as Gottheil and his colleagues (15) recently pointed out the need for exercising caution and judgment in sharing information with cancer patients because “awareness” may not be beneficial for all, so should the same sensitivity be brought to bear on professionals working in cancer centers. It has been our observation that a “healthy” amount of denial is necessary for nurses and other professionals working in this environment. Negative attitude change is not necessarily bad and may even be indicative of personal growth, but the a priori view that “getting one’s feelings out” is always desirable should be tempered when dealing with cancer center personnel. Disrupting the delicate balance between “denial” and “reality” may have a deleterious effect on the psychic economy of some health professionals. Although there was no evidence that group experience produced any workrelated difficulties on the cancer floor, the frequent negative attitude change of group participants when compared with controls should give us reason to pause before extending the enthusiasm of the past decade for groups to health care professionals working in cancer centers. Even the attitudes that showed a positive change post group experience were less positive in magnitude than the control. It is stressful to care for cancer patients (16). This is apparent and is easily identified. What to do about the situation is another matter. Certainly, this study points to the need for more research into the effects of groups on cancer center personnel and the need for better methods and instruments to measure attitude change. However, other ways to relieve the sense of despair and entrapment experienced by cancer nurses should also be explored.
Psychosocial Aspects of Neoplastic Disease
These could take the form of clinical conferences, disposition conferences, or educational sessions. Bates and Moore (17), in their study of stress in hospital personnel, call for an administrative and educative approach to improve coping of this population. It is clear that further research in this important area is needed.
References 1. Werkman SL, Mallory L, Harris J: The common psychiatric problems in family practice. Psychosomatics 17:119-122, 1976 2. Clark R, Hailstone JD, Slade I’D: Psychological aspects of dialysis: A semantic differential study. Psycho1 Med 9:55-62, 1979 3. Kennedy BJ, Tellegen A, Kennedy S, Havemick N: Psychological response of patients cured of advanced cancer. Cancer 38:2184-2191, 1976 4. Osgood CE, Suci GJ, Tannenbaum PH: The Measurement of Meaning. Chicago, University of Illinois Press, 1971 5. Cooley WW, Lohnes PR: Multivariate Data Analysis. New York, Wiley, 1971 6. Eisenbeis RA, Avery RB: Discriminant Analysis and Classification Procedures. Lexington, Mass., Heath, 1972 7. Wise TN: Utilization of group process in training oncology fellows. Int J Group Psychother 27:105-111, 1977
8. Artiss K, Levine AS: Doctor-patient relationship in severe illness: A seminar for oncology fellows. N Engl J Med 288:1210-1214, 1973 9. Yano BS: What about us? J Practical Nurs 27~2838, 1977 10. Van Ostenberg DL: Therapy groups for staff and interns. Hosp Commun Psychiatry 24474475, 1973 11. Sainsbury MJ, Milton GW: The nurse in a cancer ward. Med J Austr 2:911-913, 1975 12. Wodinsky A: Psychiatric consultation with nurses on a leukemia service. Ment Hyg 48:282-287, 1964 13. Janes RG, Weisz AE: Psychiatric liaison with a cancer research center. Comp Psychiatry 11:336-345, 1970 14. Galinsky MJ, Schopler JH: Warning: Groups may be dangerous. Sot Work 2289-94, 1977 15. Gottheil E, McGum WC, Pollak 0: Awareness and disengagement in cancer patients. Am J Psychiatry 136:632X%, 1979 16. The Special Needs of the Oncology Nurse (editorial). J Practical Nurs 27~12, 1977 17. Bates EM, Moore BN: Stress in hospital personnel. Med J Austr 2:765-767, 1975
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Peter M. Silberfarb, M.D. Department of Psychiatry Dartmouth Medical School Hanover, NH 03755
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