- Email: [email protected]
The Emotional and Psychological Impact on Radiation Therapists of Treating Children
Journal of Medical Imaging and Radiation Sciences
Journal of Medical Imaging and Radiation Sciences 45 (2014) 276-282
Journal de l’imagerie médicale et des sciences de la radiation
www.elsevier.com/locate/jmir
Research Article
The Emotional and Psychological Impact on Radiation Therapists of Treating Children Brittany Smith, RT, BSc, Sandra Hamilton, RT, BSc and Laval J. Grimard, MD, FRCPC* Ottawa Hospital Radiation Medicine Program, The Ottawa Hospital, Ottawa, Ontario, Canada
ABSTRACT Purpose: The aim of this study was to determine the psychological effects and difficulties that radiation therapists (RTs) experience while treating paediatric patients. This study is intended to provide some information to assist RTs in their occupation and to complement the literature on this topic.
RESUM E Objet: L’etude visait a determiner les effets psychologiques et les difficultes que les radiotherapeutes experimentent lorsqu’ils traitent des patients en pediatrie. On tente ici de fournir de l’information pour aider les radiotherapeutes dans l’execution de leurs t^aches et pour alimenter la documentation sur le sujet.
Methods: A survey was conducted to capture data on the emotional effects and opinions of RTs at The Ottawa Hospital Regional Cancer Centre (TOHRCC) treating children with cancer. A questionnaire was created specifically for this study standardized to TOHRCC conditions and methods and inspired from the limited literature around this issue. The study converged on the reactions of RTs while children received radiation treatment at TOHRCC and the impact on their emotional state around this component of their practice. The questionnaire was distributed electronically via e-mail to all RTs within the Radiation Therapy Department at TOHRCC.
Methodologie: On a effectue un sondage pour recueillir des donnees sur les effets emotifs et les opinions des radiotherapeutes au Centre de cancerologie de l’H^opital d’Ottawa o u l’on traite des enfants atteints du cancer. On a redige un questionnaire expressement pour l’etude tenant compte des conditions et des methodes du Centre et inspire de la documentation sur le sujet, bien qu’elle soit limitee. L’etude portait sur les reactions des radiotherapeutes au moment o u les enfants du Centre recevaient leur traitement et sur les emotions eprouvees dans le cadre de cet aspect de leur pratique. Le questionnaire a ete diffuse par courriel a tous les radiotherapeutes du service de radiotherapie du Centre de cancerologie de l’H^opital d’Ottawa.
Results: This study involved 62 of 104 RTs employed at TOHRCC who completed the survey of 20 questions and submitted their responses. Due to the sample size, statistical correlations and links between variables were limited. The questionnaire was analysed based on the answers given by the RTs on the provided Likert scale for each question. The questionnaire showed that gender and age played no major role in the RTs’ ability to cope mentally. Half of the RTs had children themselves; and of these, 66% indicated that having children made it somehow more difficult to cope emotionally with paediatric patients. Seventy-five percent of all RTs indicated that the emotional state of parents or care givers of the affected children played a key role in the anxiety they felt during a child’s treatment. Eighty-one percent of RTs stated that treating children caused higher anxiety levels than treating adults. Finally, our survey suggests that time constraints play a large part in the RTs’ stress level during treatments. Conclusion: Overall, treating children did not cause much more distress than treating adults. Results from this survey were used to create a new tool describing the cognitive stages in children to help RTs treat paediatric patients in the future.
Resultats: Soixante-deux des 104 radiotherapeutes du Centre ont repondu au questionnaire comportant 20 questions. Etant donne la taille de l’echantillonnage, les correlations statistiques et les liens entre les variables etaient limites. L’analyse du questionnaire s’est effectuee en fonction des reponses des radiotherapeutes fournies d’apres une echelle Likert. Elle a permis de determiner que le sexe et l’^age n’avaient pas d’influence importante sur la capacite des radiotherapeutes a faire mentalement face a la situation. La moitie des radiotherapeutes avaient euxm^emes des enfants; et de ceux-ci, 66% ont indique que le fait d’avoir des enfants rendait quelque peu plus difficile de faire face a des patients en pediatrie. Soixante-quinze pour cent de tous les radiotherapeutes ont indique que l’etat emotif des parents ou des soignants des enfants malades jouaient un r^ole important sur l’anxiete qu’ils ressentaient durant le traitement d’un enfant. Quatre-vingt-un pour cent des radiotherapeutes ont declare que traiter des enfants etait plus anxiogene que traiter des adultes. Enfin, l’etude porte a croire que les
The author(s) have no financial disclosures or conflicts of interest to declare. * Corresponding author: Laval J. Grimard, MD, FRCPC, The Ottawa Hospital Cancer Center, Radiation Medicine Program, 501 Smyth Road, Ottawa, ON K1H 8L6. E-mail address: [email protected] (L.J. Grimard). 1939-8654/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jmir.2014.05.004
restrictions de temps jouent un grand r^ole sur le niveau de stress des radiotherapeutes durant les traitements. Conclusion: Dans l’ensemble, traiter des enfants ne cause pas beaucoup plus de stress que traiter des adultes. Les resultats de l’etude ont
servi a creer un nouvel outil qui decrit les stades cognitifs des enfants, dans le but d’aider les radiotherapeutes a traiter les patients en pediatrie.
Keywords: Pediatric; radiation therapists; emotional impact
Introduction The Canadian Cancer Society stated that, ‘‘Although childhood cancer is rare, it remains of significant public health importance’’ [1, 2]. There were 0.016% of the Canadian population aged newborn to 19 years of age reported to have cancer in 2008; 14% of these cases died from disease. Although rare, childhood cancer is the most common cause of death by disease in the age group of newborns through 14 years old. By 2013, the overall cure rate has improved to 75% of all paediatric cancers [2, 3]. With the current modalities of treatment available for cancer, radiation therapy remains an important form of treatment. Only a select group of Canadian radiotherapy centres treat children because of the comprehensive specialised care required. The Ottawa Hospital Regional Cancer Centre (TOHRCC) is one of the 17 radiotherapy centres in Canada that treat children with cancer. Within the time period of July 2006–January 2012, TOHRCC treated 196 paediatric patients, aged between 0 and 19 years old, with radiation therapy. Interacting and providing care for a child with cancer can be emotionally overwhelming, even more so when it comes to dealing with the imminent death of a child. The psychological fallout could be serious, with possible professional burnout and a high emotional burden. This study attempted to discover some new information on the emotional well-being of those therapists caring for children and answer the question, ‘‘is the radiation therapist emotionally impacted when treating children’’? According to the work from Figley [4], the very act of being compassionate and empathetic extracts a cost under most circumstances. In this therapist’s labour to view the world from the perspective of the suffering, does the therapist suffer? This is the perspective that this study followed to evaluate the initial and subsequent emotional effects of dealing with children receiving radiotherapy and their families [4, 5]. Does the rarity of paediatric cases affect professionals such as radiation therapists (RTs), who most often care for adults? Can they excel in the setup and treatment procedures and at the same time mentally prepare themselves to handle the emotionally complex paediatric cases? Paediatric radiotherapy cases, due to both the specifics of their cancer and the immobilization requirements, create more strategizing than adult radiotherapy cases. Metastases are thought to be present at diagnosis in approximately one-quarter of all childhood cancer cases. Many cases are palliative, and this can effect the emotions of the staff. In the Ottawa clinic, of the 389 paediatric courses treated, 60 were of palliative intent. The thought of young
children requiring such intense treatment of a palliative nature can have an impact on a therapists’ mental state. Emotional distress can also be brought on by the knowledge that the treatments are designed to enhance cancer cure but can also cause debilitating side effects. Childhood cancer survivors are known to have increased risk of physical, neurocognitive, and psychological health problems as a result of both the disease and the therapies received. Chemotherapy, radiation therapy, and surgery can all lead to significant acute and long-term morbidity in a child [1]. Finally, the treatment of children entails, at times, particularly distraught parents, adding to the complexity of emotional interactions at the time of treatment. This study explored the issues that can make it difficult to treat children in a radiation therapy department. The objective was to gain more information on this limited field and possibly attain some insight on how to improve the available emotional support for RTs while they are treating children. Past studies from Sweden and UK in oncology have suggested areas staff find most difficult, including: observing a child’s pain and suffering, caring for dying children, the event of a death, working with and supporting a patient’s family/parents, workload, lack of resources, and inadequate support from management [3, 6]. This survey’s intent was to gain not only an understanding of the emotional state of therapists before, during, and after the treatment of children but also to gain some new information that has not been documented in this area of radiation oncology. The questionnaire for this study was built and inspired by the methods of multiple other studies. The questionnaire of 20 questions is available in the appendix. Methods Ethics Ethics approval was required from the Ottawa Hospital, for clinical use within their General Hospital campus where the TOHRCC is located. Approval was also required from Laurentian University, because this study was conducted as a student research project in the Radiation Therapy program of Laurentian University. Laurentian ethics approval was given on November 8, 2012, and The Ottawa Hospital ethics approval was given on December 17, 2012. Design This investigation was done through a survey. The survey focused on the emotional impact that paediatric patients have
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on RTs. A questionnaire was created specifically for this study, standardized to The Ottawa Hospital Cancer Center conditions and procedures in terms of language and content; also in reference to a literature review of this topic. Questions were written using a Likert scale to quantify the impact on the RTs. Only descriptive statistics were used from the survey results. Limitations of the Study This study has major limitations which must be highlighted. This was an educational project with a short time span to complete. Consequently, a pilot project to validate the questionnaire was not possible. This shortcoming significantly limits the value of the survey. Some of the questions may have led to answering in a specific way or to omit answering the question altogether, as they were not formally validated. The questions were designed mostly by the first author and therefore are subject to some bias, this also may have influenced the results of the survey. The survey was completed in a single radiotherapy department, thus limiting inference from our results to RTs at large. The emotional and psychological impact on RTs in this survey may not be reflective of practice at other centres with different settings, such as a dedicated small team within a larger general adult practice. Participants Since this study focused on the mental health of RTs dealing with paediatrics, the TOHRCC RTs are the participants in this study. Utilizing an online survey generator, FluidSurveys*(trademark of Fluidware), the survey link was included within a message sent to all TOHRCC therapists via e-mail. Procedure There was a need to create a questionnaire for this study based on conditions at TOHRCC. This cancer centre has 12 treatment units and most children are treated on 2 units only. There are about 100 RTs and two-thirds have treated children. Although, there is a rotation of RTs in the different treatment units, not all RTs have had the opportunity to treat children. All the questions were geared to answer whether experience helps in the mental ability to cope with paediatric case information and the extent of the emotional impact to RTs’ mental health and well-beingdnot only in work, but also in their home life. Answers to some questions were created using a 5-point Likert scale. This method allowed quantification of these replies to determine the overall emotional responses. Other methods used were a ‘‘yes or no’’ and ‘‘true or false’’ response. This study required RTs to access the survey via e-mail. Because this survey was voluntary, there was no coercion or persuasion to participate. It was sent to the TOHRCC RTs’ individual e-mail accounts once ethics approval was obtained. Since all RTs at TOHRCC have access to these e-mails both 278
at home and at work, the therapists could do these surveys at a time most convenient to them. The survey opened from the time of ethics approval on 17 December 2012 to the closing date of March 10 2013. The survey allowed participants to go back to previously answered questions and change answers if deemed appropriate before submission of the questionnaire. The 20 questions addressed demographics, experience, and emotional and practical aspects that made treating children different than treating adults. The questions are shown in Appendix 1. Results The link to the electronic survey was sent to all RTs employed by TOHRCC on three separate occasions. The first e-mail was sent on January 14, 2013; the second was sent on January 24, 2013; and the final reminder e-mail was sent on February 4, 2013. The survey, however, remained open through to March 10, 2013. All data input by participants was concluded on February 6, 2013. There were 62 replies submitted, or two-thirds of the RTs working at TOHRCC. There were 21 males and 41 females with a median age of 33 and a mean of 37 (range, 21–62). Half had worked 6 years or less and a third had worked 10 years or more. The majority of radiation therapy staff (70%) stated that treating children has no impact on their perception of having children. However, 22% of respondents stated that treating children made them ‘‘more worried’’ about their children at home. Among the 32 RTs with children living at home, 21 (65%) felt that this made it harder, in terms of emotional stress, to treat children. The suggested causes of added difficulty in treating children were: the parents of the children for 47 RTs (75%), the age of the child treated for 33 RTs (52%), and the child’s behaviour for 31 RTs (49%). The setup difficulties (21%) and the lack of experience (11%) were not as much of a problem. A combination of age and experience for 27 RTs (44%) was considered instrumental in coping emotionally while treating children. For 41 RTs (72%), the treatment of children on a unit with an intense workload was considered either high (31 RTs) or very high (10 RTs) as a stressor in dealing with children. General anaesthesia did not influence the difficulties of treating children. While 48% felt that it made no difference, 39% felt that it was more difficult to treat the children awake, and 11% felt that it was more difficult to treat the children under general anaesthesia. The great majority felt that the operational issues with anesthesia were quite good. The majority of RTs (52%) did not feel that they were prepared to discuss questions of ‘‘life and death’’ with the parents and did not consider that they would be the appropriate person for such discussion. The responses from this question were meant to indirectly explore the preparedness of the RT staff to verbalize the questions concerning life and death with a young patient or their family. The responses
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demonstrated that the participants were not prepared to address this topic, nor inclined to consider that this type of encounter was appropriate and should instead fall under the domain of the primary care provider, the paediatric oncologist. Most RTs felt that treating children was rewarding. In comparison with treating adults, the majority stated that this had no impact in their job satisfaction (52%) and for many (38%), there was a higher level of satisfaction. When it came to palliative radiotherapy for children, there were 57 RTs who answered and 34 of these (60%) felt that this was harder emotionally than when treating children with curative intent. The influence of the parents in the daily treatment of children was explored. Although for 25 RTs the role and influence of the parents on daily treatments was either low or neutral, more than 37 RTs (60%) expressed some concern. There were 25 RTs (40%) who felt that the parents played a relatively small role in explaining and helping for the treatments while 29 RTs (47%) identified that parents contributed an important role. Ten RTs in the latter group expressed the impression that the parents made the delivery of radiotherapy more difficult. The RTs were divided on the presence of the parents in the bunker with 27 RTs (44%) expressing the least amount of personnel in the bunker was ideal and 26 RTs (42%) expressing the presence of parents was helpful. The time constraint, in comparison with treating adults, was identified as a stressor by 33 RTs (53%). While 50 RTs (80%) felt that, in comparison with adults, treating children caused more anxiety, 22 RTs yielded a higher satisfaction than when treating adults and only a small group of RTs (16%) expressed the opinion that extra psychosocial support would be warranted for their own emotional support while treating children. There were 17 RTs (27%) who expressed the desire to have more teaching on children’s cognitive development to better deal with children on radiotherapy. Discussion and Conclusions Although it is assumed by many that dealing with paediatric cancer patients is a stressful line of work, no qualitative data existed to support this assumption in radiation therapy. The questions of the survey ventured into the context of what the greatest impact is; whether from the concept of children dying or from the lack of resources that are considered needed during treatment itself. The survey also attempted to answer the question of how it truly affects the emotional well-being of the RTs on both their work and home life. This survey was able to acquire data from a high percentage of RT staff at TOHRCC. Considering the sample size of our survey, overall correlations and further statistical analysis limit our conclusions. Nonetheless, the survey indicated some interesting information. Both genders respond equally to the stresses of caring for paediatric patients. The RTs had an
average age of 37 years with a bimodal peak around 30 years and another around 50 years of age. The survey revealed that there was no relation between the age of the RT and their ability to cope mentally with paediatric patients. This did not correlate with the findings of the study done by Stenmarker et al [3]. Experience in a department with paediatrics did not seem to significantly affect mental stress. Fifty-two percent of RTs in the survey have children of their own. For two-thirds of these RTs, having children of their own influenced their emotional state when treating children. This finding suggests that staff with children could benefit from further access to aid or information while treating children. The survey explored the issue of parents and how RTs communicate with them in only a limited sense, and this issue requires more understanding. It seems, however, that each experience may be unique in the sense that what may be appropriate for some, may not be for others, like the presence of parents in the bunker. This complex interaction should be further studied. Fifty-two percent of respondents indicated that the job satisfaction they felt after paediatric patient treatment was the same as for adults, and 34% of RTs felt that it was higher. These findings correlated to the findings of the study conducted by Mukherjee et al [6]. Forty-three percent of participants suggested they would like some sort of additional emotional support. Considering that this survey was exploring the needs of the medical radiation therapist staff at the TOHRCC, the corollary was to develop some tools for emotional support and implement this type of intervention, as suggested by the responses. Impact to Practice: Recommendations This study introduced information in the field of radiation therapy that was not yet qualitatively known. Some information gained from the results of this survey indicates that the introduction of new coping mechanisms may aid the staff while treating paediatric patients. RT staff may need a different method of accessing information or emotional support while a paediatric patient is assigned to their designated treatment unit. Personnel who may be particularly in need of such intervention are: RTs with their own children and those treating a child with palliative intent. The role of parents and how RTs communicate with them should be the subject of further studies. The proposed recommendations to practice are to have an information sheet or protocol available to all RTs, including: A chart of paediatric cognitive stages and ways to determine the stage of the child on treatment (Table 1). A reference to the best ways for the RTs to communicate with a patient in each cognitive stage (Table 1). Information on how to contact psychosocial oncology support programs and suggested sites and locations that may aid an RT that is experiencing an excessive emotional response.
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Table 1 Children and Their Cognitive Stage: How to Communicate Stage (Age; y)
Characteristics
Ways to Communicate
Sensori-motor (birth–2 y)
Differentiates their own self from objects Recognises their self as the reason of action and begins with intentional actions Begin to realise that objects exist even when out of sight Learns to use language Learns to represent objects by images and words Still have trouble taking the view of others Classify objects using a single feature
With children in this stage, it is difficult to communicate and define things that will be happening. Try to keep explanations simple and minimal. (eg, ‘‘Mommy and daddy will wait for you outside, they are watching you, and will come in soon’’)
Preoperational (2–7 y)
When communicating with a child in this stage, link the things that you are talking about to something that they know and can relate to (eg, tell them that the treatment table is like a ride, let them see it in action). Be sure to direct information to them in a way they can understand, not to the parents. Be sure to detail what will happen while in the treatment room by using descriptions with lots of the use of the word ‘‘you’’ (eg, ‘‘you’ll be on our TV’’ or ‘‘you will be on our table, it’s like a ride, do you like rides?’’). If they are able, or talkative, ask them what they believe is going to happen during treatment, after some explanation, and then try to expand or add onto their belief; rather than using concepts that may confuse them. In this stage, the child is having a difficult time understanding that they have something wrong inside of them, therefore do not try to describe the treatment as anything to help their ‘‘booboo’’ or make them ‘‘feel better’’, because this will be confusing for them. In this stage, the child is very literal in their thinking. This means that everything that you do or say in the treatment room will be taken at face value. These children have a difficult time with figurative language. Simply say that they will be coming to visit for the next little while and that when they do it will be the same every day. If the child is having difficulty with the immobilization device, make the idea more concrete by stating that although you have to add it, the device will come off as soon as the treatment is done. If the child begins to question your reasoning, be sure to emphasise that there is a need to have this treatment, and to do it they must follow the instructions that you have told them. In this stage the child will be able to dispute the information that you are giving them; however, reasoning with them has become easier. The child may understand the reasoning, or the need for the treatment now; this may be the tool to be used if questioned by the child. If the child begins to have issues with the setup and starts to argue and question the information, simply resort to a simplified phrase to instruct them (eg, ‘‘you are sick, this treatment will help make you better, but to have it we must do it like this’’). Generally, most children in this group will already understand the reasoning for undergoing treatment, and will be prepared to do what you say is necessary. In this group of children there are many categories of cognitive ability, the three that we should focus on, including in our communication with the child are: Comprehensiondensuring the child understands the facts and ideas Applicationdensure the child knows all the rules, principles, and procedures and that they know how to use them Analysisdensure that when you are communicating the application information, break down the concepts into parts for better understanding
Concrete operational (7–11 y)
Think logically about objects and events Classifies objects using multiple features and can order them in series with single dimensions (eg, size)
Formal operational (11 y)
Can think logically about nonconcrete ideas and test theories systematically Becomes concerned about the possible, the future and ideological problems
Extra information
Parents of the patient: The results from this study show that parents, although helpful on the first treatment, can cause the most anxiety during the treatment of a child. It is advised that parent’s involvement in future treatments is the decision of the medical radiation therapists staff. If the parents are causing stress for the staff or becoming a distraction to the child, encourage them to remain in the waiting room. Be sure to explain to them the importance of your attention to the treatment and it would be best for the child if they waited in the waiting room. This should not cause an issue since this should be the parents’ main focus as well. For staff who want access to psychological aid: The links that follow will be dependent on the location of the clinic that chooses to use this format of information. The links should include ways for the staff to access external aid for emotional coping.
Please note that the age ranges given are only guidelines. Some children may have different cognitive development. Inspired from the works of Piaget The information above only includes the details that are felt to be most important to know for radiation therapists in their role of treating children. The following are the references used to make the table and contain further information on the stages and development of children [7–13]: Atherton, J. S. (2011). Learning and teaching; Piaget’s developmental theory.http://www.learningandteaching.info/learning/piaget.htm. EssortmentdYour source for knowledge. (2011) Child development: stages & how child learn. http://www.essortment.com/child-developmentstages-child-learn-50822.html. Piaget, J. (1977). Gruber, H. E. & Voneche, J. J. (Eds.), The essential Piaget. New York: Basic Book. Piaget, J. (2007). The Child’s conception of the world: a 20th century classic of child psychology (pp. 37–61). United States of America: Rowman & Littlefield. Satterly, D. (1987). ‘‘Piaget and education’’. In R. L. Gregory (Ed.), The Oxford companion to the mind. Oxford: Oxford University Press. Swift, J. (2012). Piaget’s stages of cognitive development. http://www.telacommunications.com/nutshell/stages.htm. Wood, D. (1998). How children think and learn (2nd ed.,). Oxford: Blackwell Publishing.
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Acknowledgements This project would not have been possible without the support of any of the following individuals from The Ottawa Hospital Cancer Centre: Clinical Coordinator: Jayne Belanger, MRT. Dr. Wayne Kendal, MD, FRCPC, Radiation Oncologist. Jamie Bahm, MRT. A big thank you to the aforementioned and also to all other radiation therapists at The Ottawa Hospital Cancer Center for being understanding and helpful during the research process.
[4] [5]
[6]
[7] [8] [9] [10]
References [1] Canadian Cancer Society (CCS)/National Cancer Institute of Canada (NCI). (2008). Canadian cancer statistics 2008. [2] Neal, A., & Hoskin, P. (2009). Clinical oncology; basics principles and practices, (4th ed.). London, England: Hodder Arnold publisher, Hachette UK. [3] Stenmarker, M., Palmerus, K., & Marky, I. (2009). Stress-resilience capacity of pediatric oncologists: a Swedish nationwide and
[11] [12] [13]
population-based study of motivation, emotional distress, and overall life satisfaction. Pediatric Blood Cancer 52, 503–509. Figley, C. R. (2002). Compassion fatigue: psychotherapists’ chronic lack of self care. Journal of Clinical Psychology 58(11), 1433–1441. Baker, J., & Kane, J. (2008). Compassion Fatigue in Pediatric Hospice and Palliative Care Providers. St Jude Children’s Research Hospital. Web presentation. Mukherjee, S., Beresford, B., Glaser, A., & Sloper, P. (2008). Burnout, psychiatric morbidity, and work-related sources of stress in paediatric oncology staff: a review of the literature. Psycho-Oncology 18, 1019–1028. AllPsychoONLINE. (2011). Examples of 5–Point Likert Scales. Atherton J S (2011) Learning and teaching; Piaget’s developmental theory. Piaget, J. (1977). In: H. E. Gruber & J. J. Voneche (Eds.), The essential Piaget. New York: Basic Book. Piaget, J. (2007). The Child’s conception of the world: a 20th century classic of child psychology (pp. 37–61). United States of America: Rowman & Littlefield. Satterly, D. (1987). Piaget and education. In R. L. Gregory (Ed.), The Oxford companion to the mind. Oxford: Oxford University Press. Swift, J. (2012). Piaget’s stages of cognitive development. Wood, D. (1998). How children think and learn, (2nd edition). Oxford: Wiley-Blackwell Publishing.
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Appendix 1: Survey Questionnaire 1. What gender are you? a) Male b) Female 2. How old are you? a) 20-29 b) 30-39 c) 40-49 d) 50þ 3. How many years have you been working with children in the radiation therapy department? a) 0-2 b) 3-5 c) 5-9 d) 10þ 4. Has dealing with paediatric cancer impacted your view on having children? a) yes b) makes me more worried about my current children c) no 5. Did you find that the concerns of working with children changed when you had children? a) yes-made it easier b) yes-made it harder c) no d) N/A (not applicable) 6. What is it in particular that makes it most difficult to deal with paediatrics? (choose any that apply) a) parents b) patients age c) behaviour d) setup for treatment e) lack of experience with paediatric setups f) N/A (not applicable) 7. Do you believe that age, or the amount of experience with paediatrics contributes more to the increase in your, or others, ability to handle the emotional impact of paediatrics? a) my age b) more experience c) both d) neither 8. Rate the emotional burden from the child patient on treatment when the daily workload is high on the following scale: 1(extremely high) / 2 / 3(neutral) / 4 / 5(not at all) / N/A 9. Does treating children make you question your perception of the ‘‘natural order of life’’? a) yes b) no c) I don’t have a belief in this principle 10. When dealing with paediatric cases, do you find it changes your view and attitude if they have been anesthetised? a) yes – it is more difficult with patients under general anaesthetic b) no – patients who are awake during treatment are more difficult c)no – there is no difference whether the child is apprehensive or asleep. 11. Do you find yourself prepared to discuss questions about life and death when dealing with palliative paediatric cases? a) yes b) no c) it depends 12. What is your overall self-satisfaction after treating children, compared to that felt after the adult treatments? 1(much higher) / 2 / 3(same) / 4 / 5(much lower)
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13. Does the idea of palliation in such a young group of patients make it more difficult for you to treat? a) Yes - palliative care is particularly difficult b) No – Any paediatric case is difficult c) Does not apply 14. During treatment, how much stress do you feel from the parents alone? 1(very high) / 2 / 3(neutral) / 4 / 5(very low) 15. When explaining the procedure and trying to set up the patient, how much aid do you find parents typically give as far as contribution to the team? 1(very high) / 2 / 3(neutral) / 4 / 5(make the setup more difficult) 16. On the following scale, how much more anxiety would you say that paediatrics cause compared to the adult oncology cases? 1(much higher) / 2 / 3(same) / 4 / 5(much lower) 17. When doing paediatric setups, what is the adequate amount of staff required to make the treatment go smoothly on a daily basis? a) 2 MRTs and the parents b) the regular amount of staff on the unit (2) plus a planner or a doctor c) more than a typical amount of MRTs d) least amount of people on the room as possible (2) 18. Do time constraints while dealing with children increase the anxiety of the situation? a) yes - the time constraint makes me more anxious and more aware of the duration of the treatment b) no – the time limit for paediatric treatments causes the same stress as a typical adult treatment setup c) no – time constraints have no effect on my anxiety 19. When treating a patient who requires general anaesthetic, rate the coordination of the procedure (i.e. Booking, Children Hospital staff, anaesthesiologist preparedness) on the following scale. 1 (not at all prepared) / 2 / 3(neutral) / 4 / 5 (very well prepared) / Unable to answer this question 20. Would access to psychosocial support, whether group or individual, aid in your emotional stability for the duration of a paediatric patients treatment? A) Yes – emotional support while treating children would be helpful b) Yes - getting aid to determine the psychological stage of development of the child would be helpful c) No
B. Smith et al./Journal of Medical Imaging and Radiation Sciences 45 (2014) 276-282
Journal of Medical Imaging and Radiation Sciences 45 (2014) 276-282
Journal de l’imagerie médicale et des sciences de la radiation
www.elsevier.com/locate/jmir
Research Article
The Emotional and Psychological Impact on Radiation Therapists of Treating Children Brittany Smith, RT, BSc, Sandra Hamilton, RT, BSc and Laval J. Grimard, MD, FRCPC* Ottawa Hospital Radiation Medicine Program, The Ottawa Hospital, Ottawa, Ontario, Canada
ABSTRACT Purpose: The aim of this study was to determine the psychological effects and difficulties that radiation therapists (RTs) experience while treating paediatric patients. This study is intended to provide some information to assist RTs in their occupation and to complement the literature on this topic.
RESUM E Objet: L’etude visait a determiner les effets psychologiques et les difficultes que les radiotherapeutes experimentent lorsqu’ils traitent des patients en pediatrie. On tente ici de fournir de l’information pour aider les radiotherapeutes dans l’execution de leurs t^aches et pour alimenter la documentation sur le sujet.
Methods: A survey was conducted to capture data on the emotional effects and opinions of RTs at The Ottawa Hospital Regional Cancer Centre (TOHRCC) treating children with cancer. A questionnaire was created specifically for this study standardized to TOHRCC conditions and methods and inspired from the limited literature around this issue. The study converged on the reactions of RTs while children received radiation treatment at TOHRCC and the impact on their emotional state around this component of their practice. The questionnaire was distributed electronically via e-mail to all RTs within the Radiation Therapy Department at TOHRCC.
Methodologie: On a effectue un sondage pour recueillir des donnees sur les effets emotifs et les opinions des radiotherapeutes au Centre de cancerologie de l’H^opital d’Ottawa o u l’on traite des enfants atteints du cancer. On a redige un questionnaire expressement pour l’etude tenant compte des conditions et des methodes du Centre et inspire de la documentation sur le sujet, bien qu’elle soit limitee. L’etude portait sur les reactions des radiotherapeutes au moment o u les enfants du Centre recevaient leur traitement et sur les emotions eprouvees dans le cadre de cet aspect de leur pratique. Le questionnaire a ete diffuse par courriel a tous les radiotherapeutes du service de radiotherapie du Centre de cancerologie de l’H^opital d’Ottawa.
Results: This study involved 62 of 104 RTs employed at TOHRCC who completed the survey of 20 questions and submitted their responses. Due to the sample size, statistical correlations and links between variables were limited. The questionnaire was analysed based on the answers given by the RTs on the provided Likert scale for each question. The questionnaire showed that gender and age played no major role in the RTs’ ability to cope mentally. Half of the RTs had children themselves; and of these, 66% indicated that having children made it somehow more difficult to cope emotionally with paediatric patients. Seventy-five percent of all RTs indicated that the emotional state of parents or care givers of the affected children played a key role in the anxiety they felt during a child’s treatment. Eighty-one percent of RTs stated that treating children caused higher anxiety levels than treating adults. Finally, our survey suggests that time constraints play a large part in the RTs’ stress level during treatments. Conclusion: Overall, treating children did not cause much more distress than treating adults. Results from this survey were used to create a new tool describing the cognitive stages in children to help RTs treat paediatric patients in the future.
Resultats: Soixante-deux des 104 radiotherapeutes du Centre ont repondu au questionnaire comportant 20 questions. Etant donne la taille de l’echantillonnage, les correlations statistiques et les liens entre les variables etaient limites. L’analyse du questionnaire s’est effectuee en fonction des reponses des radiotherapeutes fournies d’apres une echelle Likert. Elle a permis de determiner que le sexe et l’^age n’avaient pas d’influence importante sur la capacite des radiotherapeutes a faire mentalement face a la situation. La moitie des radiotherapeutes avaient euxm^emes des enfants; et de ceux-ci, 66% ont indique que le fait d’avoir des enfants rendait quelque peu plus difficile de faire face a des patients en pediatrie. Soixante-quinze pour cent de tous les radiotherapeutes ont indique que l’etat emotif des parents ou des soignants des enfants malades jouaient un r^ole important sur l’anxiete qu’ils ressentaient durant le traitement d’un enfant. Quatre-vingt-un pour cent des radiotherapeutes ont declare que traiter des enfants etait plus anxiogene que traiter des adultes. Enfin, l’etude porte a croire que les
The author(s) have no financial disclosures or conflicts of interest to declare. * Corresponding author: Laval J. Grimard, MD, FRCPC, The Ottawa Hospital Cancer Center, Radiation Medicine Program, 501 Smyth Road, Ottawa, ON K1H 8L6. E-mail address: [email protected] (L.J. Grimard). 1939-8654/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jmir.2014.05.004
restrictions de temps jouent un grand r^ole sur le niveau de stress des radiotherapeutes durant les traitements. Conclusion: Dans l’ensemble, traiter des enfants ne cause pas beaucoup plus de stress que traiter des adultes. Les resultats de l’etude ont
servi a creer un nouvel outil qui decrit les stades cognitifs des enfants, dans le but d’aider les radiotherapeutes a traiter les patients en pediatrie.
Keywords: Pediatric; radiation therapists; emotional impact
Introduction The Canadian Cancer Society stated that, ‘‘Although childhood cancer is rare, it remains of significant public health importance’’ [1, 2]. There were 0.016% of the Canadian population aged newborn to 19 years of age reported to have cancer in 2008; 14% of these cases died from disease. Although rare, childhood cancer is the most common cause of death by disease in the age group of newborns through 14 years old. By 2013, the overall cure rate has improved to 75% of all paediatric cancers [2, 3]. With the current modalities of treatment available for cancer, radiation therapy remains an important form of treatment. Only a select group of Canadian radiotherapy centres treat children because of the comprehensive specialised care required. The Ottawa Hospital Regional Cancer Centre (TOHRCC) is one of the 17 radiotherapy centres in Canada that treat children with cancer. Within the time period of July 2006–January 2012, TOHRCC treated 196 paediatric patients, aged between 0 and 19 years old, with radiation therapy. Interacting and providing care for a child with cancer can be emotionally overwhelming, even more so when it comes to dealing with the imminent death of a child. The psychological fallout could be serious, with possible professional burnout and a high emotional burden. This study attempted to discover some new information on the emotional well-being of those therapists caring for children and answer the question, ‘‘is the radiation therapist emotionally impacted when treating children’’? According to the work from Figley [4], the very act of being compassionate and empathetic extracts a cost under most circumstances. In this therapist’s labour to view the world from the perspective of the suffering, does the therapist suffer? This is the perspective that this study followed to evaluate the initial and subsequent emotional effects of dealing with children receiving radiotherapy and their families [4, 5]. Does the rarity of paediatric cases affect professionals such as radiation therapists (RTs), who most often care for adults? Can they excel in the setup and treatment procedures and at the same time mentally prepare themselves to handle the emotionally complex paediatric cases? Paediatric radiotherapy cases, due to both the specifics of their cancer and the immobilization requirements, create more strategizing than adult radiotherapy cases. Metastases are thought to be present at diagnosis in approximately one-quarter of all childhood cancer cases. Many cases are palliative, and this can effect the emotions of the staff. In the Ottawa clinic, of the 389 paediatric courses treated, 60 were of palliative intent. The thought of young
children requiring such intense treatment of a palliative nature can have an impact on a therapists’ mental state. Emotional distress can also be brought on by the knowledge that the treatments are designed to enhance cancer cure but can also cause debilitating side effects. Childhood cancer survivors are known to have increased risk of physical, neurocognitive, and psychological health problems as a result of both the disease and the therapies received. Chemotherapy, radiation therapy, and surgery can all lead to significant acute and long-term morbidity in a child [1]. Finally, the treatment of children entails, at times, particularly distraught parents, adding to the complexity of emotional interactions at the time of treatment. This study explored the issues that can make it difficult to treat children in a radiation therapy department. The objective was to gain more information on this limited field and possibly attain some insight on how to improve the available emotional support for RTs while they are treating children. Past studies from Sweden and UK in oncology have suggested areas staff find most difficult, including: observing a child’s pain and suffering, caring for dying children, the event of a death, working with and supporting a patient’s family/parents, workload, lack of resources, and inadequate support from management [3, 6]. This survey’s intent was to gain not only an understanding of the emotional state of therapists before, during, and after the treatment of children but also to gain some new information that has not been documented in this area of radiation oncology. The questionnaire for this study was built and inspired by the methods of multiple other studies. The questionnaire of 20 questions is available in the appendix. Methods Ethics Ethics approval was required from the Ottawa Hospital, for clinical use within their General Hospital campus where the TOHRCC is located. Approval was also required from Laurentian University, because this study was conducted as a student research project in the Radiation Therapy program of Laurentian University. Laurentian ethics approval was given on November 8, 2012, and The Ottawa Hospital ethics approval was given on December 17, 2012. Design This investigation was done through a survey. The survey focused on the emotional impact that paediatric patients have
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on RTs. A questionnaire was created specifically for this study, standardized to The Ottawa Hospital Cancer Center conditions and procedures in terms of language and content; also in reference to a literature review of this topic. Questions were written using a Likert scale to quantify the impact on the RTs. Only descriptive statistics were used from the survey results. Limitations of the Study This study has major limitations which must be highlighted. This was an educational project with a short time span to complete. Consequently, a pilot project to validate the questionnaire was not possible. This shortcoming significantly limits the value of the survey. Some of the questions may have led to answering in a specific way or to omit answering the question altogether, as they were not formally validated. The questions were designed mostly by the first author and therefore are subject to some bias, this also may have influenced the results of the survey. The survey was completed in a single radiotherapy department, thus limiting inference from our results to RTs at large. The emotional and psychological impact on RTs in this survey may not be reflective of practice at other centres with different settings, such as a dedicated small team within a larger general adult practice. Participants Since this study focused on the mental health of RTs dealing with paediatrics, the TOHRCC RTs are the participants in this study. Utilizing an online survey generator, FluidSurveys*(trademark of Fluidware), the survey link was included within a message sent to all TOHRCC therapists via e-mail. Procedure There was a need to create a questionnaire for this study based on conditions at TOHRCC. This cancer centre has 12 treatment units and most children are treated on 2 units only. There are about 100 RTs and two-thirds have treated children. Although, there is a rotation of RTs in the different treatment units, not all RTs have had the opportunity to treat children. All the questions were geared to answer whether experience helps in the mental ability to cope with paediatric case information and the extent of the emotional impact to RTs’ mental health and well-beingdnot only in work, but also in their home life. Answers to some questions were created using a 5-point Likert scale. This method allowed quantification of these replies to determine the overall emotional responses. Other methods used were a ‘‘yes or no’’ and ‘‘true or false’’ response. This study required RTs to access the survey via e-mail. Because this survey was voluntary, there was no coercion or persuasion to participate. It was sent to the TOHRCC RTs’ individual e-mail accounts once ethics approval was obtained. Since all RTs at TOHRCC have access to these e-mails both 278
at home and at work, the therapists could do these surveys at a time most convenient to them. The survey opened from the time of ethics approval on 17 December 2012 to the closing date of March 10 2013. The survey allowed participants to go back to previously answered questions and change answers if deemed appropriate before submission of the questionnaire. The 20 questions addressed demographics, experience, and emotional and practical aspects that made treating children different than treating adults. The questions are shown in Appendix 1. Results The link to the electronic survey was sent to all RTs employed by TOHRCC on three separate occasions. The first e-mail was sent on January 14, 2013; the second was sent on January 24, 2013; and the final reminder e-mail was sent on February 4, 2013. The survey, however, remained open through to March 10, 2013. All data input by participants was concluded on February 6, 2013. There were 62 replies submitted, or two-thirds of the RTs working at TOHRCC. There were 21 males and 41 females with a median age of 33 and a mean of 37 (range, 21–62). Half had worked 6 years or less and a third had worked 10 years or more. The majority of radiation therapy staff (70%) stated that treating children has no impact on their perception of having children. However, 22% of respondents stated that treating children made them ‘‘more worried’’ about their children at home. Among the 32 RTs with children living at home, 21 (65%) felt that this made it harder, in terms of emotional stress, to treat children. The suggested causes of added difficulty in treating children were: the parents of the children for 47 RTs (75%), the age of the child treated for 33 RTs (52%), and the child’s behaviour for 31 RTs (49%). The setup difficulties (21%) and the lack of experience (11%) were not as much of a problem. A combination of age and experience for 27 RTs (44%) was considered instrumental in coping emotionally while treating children. For 41 RTs (72%), the treatment of children on a unit with an intense workload was considered either high (31 RTs) or very high (10 RTs) as a stressor in dealing with children. General anaesthesia did not influence the difficulties of treating children. While 48% felt that it made no difference, 39% felt that it was more difficult to treat the children awake, and 11% felt that it was more difficult to treat the children under general anaesthesia. The great majority felt that the operational issues with anesthesia were quite good. The majority of RTs (52%) did not feel that they were prepared to discuss questions of ‘‘life and death’’ with the parents and did not consider that they would be the appropriate person for such discussion. The responses from this question were meant to indirectly explore the preparedness of the RT staff to verbalize the questions concerning life and death with a young patient or their family. The responses
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demonstrated that the participants were not prepared to address this topic, nor inclined to consider that this type of encounter was appropriate and should instead fall under the domain of the primary care provider, the paediatric oncologist. Most RTs felt that treating children was rewarding. In comparison with treating adults, the majority stated that this had no impact in their job satisfaction (52%) and for many (38%), there was a higher level of satisfaction. When it came to palliative radiotherapy for children, there were 57 RTs who answered and 34 of these (60%) felt that this was harder emotionally than when treating children with curative intent. The influence of the parents in the daily treatment of children was explored. Although for 25 RTs the role and influence of the parents on daily treatments was either low or neutral, more than 37 RTs (60%) expressed some concern. There were 25 RTs (40%) who felt that the parents played a relatively small role in explaining and helping for the treatments while 29 RTs (47%) identified that parents contributed an important role. Ten RTs in the latter group expressed the impression that the parents made the delivery of radiotherapy more difficult. The RTs were divided on the presence of the parents in the bunker with 27 RTs (44%) expressing the least amount of personnel in the bunker was ideal and 26 RTs (42%) expressing the presence of parents was helpful. The time constraint, in comparison with treating adults, was identified as a stressor by 33 RTs (53%). While 50 RTs (80%) felt that, in comparison with adults, treating children caused more anxiety, 22 RTs yielded a higher satisfaction than when treating adults and only a small group of RTs (16%) expressed the opinion that extra psychosocial support would be warranted for their own emotional support while treating children. There were 17 RTs (27%) who expressed the desire to have more teaching on children’s cognitive development to better deal with children on radiotherapy. Discussion and Conclusions Although it is assumed by many that dealing with paediatric cancer patients is a stressful line of work, no qualitative data existed to support this assumption in radiation therapy. The questions of the survey ventured into the context of what the greatest impact is; whether from the concept of children dying or from the lack of resources that are considered needed during treatment itself. The survey also attempted to answer the question of how it truly affects the emotional well-being of the RTs on both their work and home life. This survey was able to acquire data from a high percentage of RT staff at TOHRCC. Considering the sample size of our survey, overall correlations and further statistical analysis limit our conclusions. Nonetheless, the survey indicated some interesting information. Both genders respond equally to the stresses of caring for paediatric patients. The RTs had an
average age of 37 years with a bimodal peak around 30 years and another around 50 years of age. The survey revealed that there was no relation between the age of the RT and their ability to cope mentally with paediatric patients. This did not correlate with the findings of the study done by Stenmarker et al [3]. Experience in a department with paediatrics did not seem to significantly affect mental stress. Fifty-two percent of RTs in the survey have children of their own. For two-thirds of these RTs, having children of their own influenced their emotional state when treating children. This finding suggests that staff with children could benefit from further access to aid or information while treating children. The survey explored the issue of parents and how RTs communicate with them in only a limited sense, and this issue requires more understanding. It seems, however, that each experience may be unique in the sense that what may be appropriate for some, may not be for others, like the presence of parents in the bunker. This complex interaction should be further studied. Fifty-two percent of respondents indicated that the job satisfaction they felt after paediatric patient treatment was the same as for adults, and 34% of RTs felt that it was higher. These findings correlated to the findings of the study conducted by Mukherjee et al [6]. Forty-three percent of participants suggested they would like some sort of additional emotional support. Considering that this survey was exploring the needs of the medical radiation therapist staff at the TOHRCC, the corollary was to develop some tools for emotional support and implement this type of intervention, as suggested by the responses. Impact to Practice: Recommendations This study introduced information in the field of radiation therapy that was not yet qualitatively known. Some information gained from the results of this survey indicates that the introduction of new coping mechanisms may aid the staff while treating paediatric patients. RT staff may need a different method of accessing information or emotional support while a paediatric patient is assigned to their designated treatment unit. Personnel who may be particularly in need of such intervention are: RTs with their own children and those treating a child with palliative intent. The role of parents and how RTs communicate with them should be the subject of further studies. The proposed recommendations to practice are to have an information sheet or protocol available to all RTs, including: A chart of paediatric cognitive stages and ways to determine the stage of the child on treatment (Table 1). A reference to the best ways for the RTs to communicate with a patient in each cognitive stage (Table 1). Information on how to contact psychosocial oncology support programs and suggested sites and locations that may aid an RT that is experiencing an excessive emotional response.
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Table 1 Children and Their Cognitive Stage: How to Communicate Stage (Age; y)
Characteristics
Ways to Communicate
Sensori-motor (birth–2 y)
Differentiates their own self from objects Recognises their self as the reason of action and begins with intentional actions Begin to realise that objects exist even when out of sight Learns to use language Learns to represent objects by images and words Still have trouble taking the view of others Classify objects using a single feature
With children in this stage, it is difficult to communicate and define things that will be happening. Try to keep explanations simple and minimal. (eg, ‘‘Mommy and daddy will wait for you outside, they are watching you, and will come in soon’’)
Preoperational (2–7 y)
When communicating with a child in this stage, link the things that you are talking about to something that they know and can relate to (eg, tell them that the treatment table is like a ride, let them see it in action). Be sure to direct information to them in a way they can understand, not to the parents. Be sure to detail what will happen while in the treatment room by using descriptions with lots of the use of the word ‘‘you’’ (eg, ‘‘you’ll be on our TV’’ or ‘‘you will be on our table, it’s like a ride, do you like rides?’’). If they are able, or talkative, ask them what they believe is going to happen during treatment, after some explanation, and then try to expand or add onto their belief; rather than using concepts that may confuse them. In this stage, the child is having a difficult time understanding that they have something wrong inside of them, therefore do not try to describe the treatment as anything to help their ‘‘booboo’’ or make them ‘‘feel better’’, because this will be confusing for them. In this stage, the child is very literal in their thinking. This means that everything that you do or say in the treatment room will be taken at face value. These children have a difficult time with figurative language. Simply say that they will be coming to visit for the next little while and that when they do it will be the same every day. If the child is having difficulty with the immobilization device, make the idea more concrete by stating that although you have to add it, the device will come off as soon as the treatment is done. If the child begins to question your reasoning, be sure to emphasise that there is a need to have this treatment, and to do it they must follow the instructions that you have told them. In this stage the child will be able to dispute the information that you are giving them; however, reasoning with them has become easier. The child may understand the reasoning, or the need for the treatment now; this may be the tool to be used if questioned by the child. If the child begins to have issues with the setup and starts to argue and question the information, simply resort to a simplified phrase to instruct them (eg, ‘‘you are sick, this treatment will help make you better, but to have it we must do it like this’’). Generally, most children in this group will already understand the reasoning for undergoing treatment, and will be prepared to do what you say is necessary. In this group of children there are many categories of cognitive ability, the three that we should focus on, including in our communication with the child are: Comprehensiondensuring the child understands the facts and ideas Applicationdensure the child knows all the rules, principles, and procedures and that they know how to use them Analysisdensure that when you are communicating the application information, break down the concepts into parts for better understanding
Concrete operational (7–11 y)
Think logically about objects and events Classifies objects using multiple features and can order them in series with single dimensions (eg, size)
Formal operational (11 y)
Can think logically about nonconcrete ideas and test theories systematically Becomes concerned about the possible, the future and ideological problems
Extra information
Parents of the patient: The results from this study show that parents, although helpful on the first treatment, can cause the most anxiety during the treatment of a child. It is advised that parent’s involvement in future treatments is the decision of the medical radiation therapists staff. If the parents are causing stress for the staff or becoming a distraction to the child, encourage them to remain in the waiting room. Be sure to explain to them the importance of your attention to the treatment and it would be best for the child if they waited in the waiting room. This should not cause an issue since this should be the parents’ main focus as well. For staff who want access to psychological aid: The links that follow will be dependent on the location of the clinic that chooses to use this format of information. The links should include ways for the staff to access external aid for emotional coping.
Please note that the age ranges given are only guidelines. Some children may have different cognitive development. Inspired from the works of Piaget The information above only includes the details that are felt to be most important to know for radiation therapists in their role of treating children. The following are the references used to make the table and contain further information on the stages and development of children [7–13]: Atherton, J. S. (2011). Learning and teaching; Piaget’s developmental theory.http://www.learningandteaching.info/learning/piaget.htm. EssortmentdYour source for knowledge. (2011) Child development: stages & how child learn. http://www.essortment.com/child-developmentstages-child-learn-50822.html. Piaget, J. (1977). Gruber, H. E. & Voneche, J. J. (Eds.), The essential Piaget. New York: Basic Book. Piaget, J. (2007). The Child’s conception of the world: a 20th century classic of child psychology (pp. 37–61). United States of America: Rowman & Littlefield. Satterly, D. (1987). ‘‘Piaget and education’’. In R. L. Gregory (Ed.), The Oxford companion to the mind. Oxford: Oxford University Press. Swift, J. (2012). Piaget’s stages of cognitive development. http://www.telacommunications.com/nutshell/stages.htm. Wood, D. (1998). How children think and learn (2nd ed.,). Oxford: Blackwell Publishing.
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Acknowledgements This project would not have been possible without the support of any of the following individuals from The Ottawa Hospital Cancer Centre: Clinical Coordinator: Jayne Belanger, MRT. Dr. Wayne Kendal, MD, FRCPC, Radiation Oncologist. Jamie Bahm, MRT. A big thank you to the aforementioned and also to all other radiation therapists at The Ottawa Hospital Cancer Center for being understanding and helpful during the research process.
[4] [5]
[6]
[7] [8] [9] [10]
References [1] Canadian Cancer Society (CCS)/National Cancer Institute of Canada (NCI). (2008). Canadian cancer statistics 2008. [2] Neal, A., & Hoskin, P. (2009). Clinical oncology; basics principles and practices, (4th ed.). London, England: Hodder Arnold publisher, Hachette UK. [3] Stenmarker, M., Palmerus, K., & Marky, I. (2009). Stress-resilience capacity of pediatric oncologists: a Swedish nationwide and
[11] [12] [13]
population-based study of motivation, emotional distress, and overall life satisfaction. Pediatric Blood Cancer 52, 503–509. Figley, C. R. (2002). Compassion fatigue: psychotherapists’ chronic lack of self care. Journal of Clinical Psychology 58(11), 1433–1441. Baker, J., & Kane, J. (2008). Compassion Fatigue in Pediatric Hospice and Palliative Care Providers. St Jude Children’s Research Hospital. Web presentation. Mukherjee, S., Beresford, B., Glaser, A., & Sloper, P. (2008). Burnout, psychiatric morbidity, and work-related sources of stress in paediatric oncology staff: a review of the literature. Psycho-Oncology 18, 1019–1028. AllPsychoONLINE. (2011). Examples of 5–Point Likert Scales. Atherton J S (2011) Learning and teaching; Piaget’s developmental theory. Piaget, J. (1977). In: H. E. Gruber & J. J. Voneche (Eds.), The essential Piaget. New York: Basic Book. Piaget, J. (2007). The Child’s conception of the world: a 20th century classic of child psychology (pp. 37–61). United States of America: Rowman & Littlefield. Satterly, D. (1987). Piaget and education. In R. L. Gregory (Ed.), The Oxford companion to the mind. Oxford: Oxford University Press. Swift, J. (2012). Piaget’s stages of cognitive development. Wood, D. (1998). How children think and learn, (2nd edition). Oxford: Wiley-Blackwell Publishing.
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Appendix 1: Survey Questionnaire 1. What gender are you? a) Male b) Female 2. How old are you? a) 20-29 b) 30-39 c) 40-49 d) 50þ 3. How many years have you been working with children in the radiation therapy department? a) 0-2 b) 3-5 c) 5-9 d) 10þ 4. Has dealing with paediatric cancer impacted your view on having children? a) yes b) makes me more worried about my current children c) no 5. Did you find that the concerns of working with children changed when you had children? a) yes-made it easier b) yes-made it harder c) no d) N/A (not applicable) 6. What is it in particular that makes it most difficult to deal with paediatrics? (choose any that apply) a) parents b) patients age c) behaviour d) setup for treatment e) lack of experience with paediatric setups f) N/A (not applicable) 7. Do you believe that age, or the amount of experience with paediatrics contributes more to the increase in your, or others, ability to handle the emotional impact of paediatrics? a) my age b) more experience c) both d) neither 8. Rate the emotional burden from the child patient on treatment when the daily workload is high on the following scale: 1(extremely high) / 2 / 3(neutral) / 4 / 5(not at all) / N/A 9. Does treating children make you question your perception of the ‘‘natural order of life’’? a) yes b) no c) I don’t have a belief in this principle 10. When dealing with paediatric cases, do you find it changes your view and attitude if they have been anesthetised? a) yes – it is more difficult with patients under general anaesthetic b) no – patients who are awake during treatment are more difficult c)no – there is no difference whether the child is apprehensive or asleep. 11. Do you find yourself prepared to discuss questions about life and death when dealing with palliative paediatric cases? a) yes b) no c) it depends 12. What is your overall self-satisfaction after treating children, compared to that felt after the adult treatments? 1(much higher) / 2 / 3(same) / 4 / 5(much lower)
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13. Does the idea of palliation in such a young group of patients make it more difficult for you to treat? a) Yes - palliative care is particularly difficult b) No – Any paediatric case is difficult c) Does not apply 14. During treatment, how much stress do you feel from the parents alone? 1(very high) / 2 / 3(neutral) / 4 / 5(very low) 15. When explaining the procedure and trying to set up the patient, how much aid do you find parents typically give as far as contribution to the team? 1(very high) / 2 / 3(neutral) / 4 / 5(make the setup more difficult) 16. On the following scale, how much more anxiety would you say that paediatrics cause compared to the adult oncology cases? 1(much higher) / 2 / 3(same) / 4 / 5(much lower) 17. When doing paediatric setups, what is the adequate amount of staff required to make the treatment go smoothly on a daily basis? a) 2 MRTs and the parents b) the regular amount of staff on the unit (2) plus a planner or a doctor c) more than a typical amount of MRTs d) least amount of people on the room as possible (2) 18. Do time constraints while dealing with children increase the anxiety of the situation? a) yes - the time constraint makes me more anxious and more aware of the duration of the treatment b) no – the time limit for paediatric treatments causes the same stress as a typical adult treatment setup c) no – time constraints have no effect on my anxiety 19. When treating a patient who requires general anaesthetic, rate the coordination of the procedure (i.e. Booking, Children Hospital staff, anaesthesiologist preparedness) on the following scale. 1 (not at all prepared) / 2 / 3(neutral) / 4 / 5 (very well prepared) / Unable to answer this question 20. Would access to psychosocial support, whether group or individual, aid in your emotional stability for the duration of a paediatric patients treatment? A) Yes – emotional support while treating children would be helpful b) Yes - getting aid to determine the psychological stage of development of the child would be helpful c) No
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