Carol Noll Hoskins

Breast cancer: Education, counseling, and adjustment among patients and partners: A randomized clinical trial

Background: Although various forms of psychoeducation and counseling interventions have been examined among patients with a variety of diagnoses, the unique contribution of phase-specific psychoeducation and telephone counseling (TC) to the ongoing process of adjustment has not been explored among patients with breast cancer and their partners. Objective: To conduct a randomized controlled clinical trial of phase-specific evidence-based psychoeducation and TC interventions to enhance emotional, physical, and social adjustments in patients with breast cancer and their partners. Methods: A purposive sample of 249 patient-partner dyads were assigned randomly to one of four groups: (a) control group receiving disease management (DM), (b) standardized psychoeducation (SE), (c) TC, or (d) standardized psychoeducation plus telephone counseling (SE + TC). Data were collected at baseline, diagnostic, postsurgery, adjuvant therapy, and ongoing recovery phases measuring emotional, physical, and social adjustments. Results: Patients showed poorer adjustment over time in the DM group relative to those receiving interventions on selected measures of emotional adjustment. All patients showed improvement over time in overall health and adjustment in social and vocational environments. Partners in all groups exhibited improvement over time for measures of adjustment in the social environment but no changes in psychological well-being or overall health. Partners in the TC group had poorer scores on physical symptoms compared with the SE + TC group and poorer vocational scores compared with the DM group. Discussion: Findings from this study provide preliminary support for the value of phase-specific SE and TC interventions to enhance selected adjustment outcomes for patients with breast cancer and their partners.

The effects of psychoeducation and telephone counseling on the adjustment of women with early-stage breast cancer

BACKGROUND Throughout the illness trajectory, women with breast cancer experience issues that are related to physical, emotional, and social adjustment. Despite a general consensus that state-of-the-art treatment for breast cancer should include educational and counseling interventions to reduce illness or treatment-related symptoms, there are few prospective, theoretically based, phase-specific randomized, controlled trials that have evaluated the effectiveness of such interventions in promoting adjustment. PURPOSE The aim of this study is to examine the physical, emotional, and social adjustment of women with early-stage breast cancer who received psychoeducation by videotapes, telephone counseling, or psychoeducation plus telephone counseling as interventions that address the specific needs of women during the diagnostic, postsurgery, adjuvant therapy, and ongoing recovery phases of breast cancer. DESIGN Primary data from a randomized controlled clinical trial. SETTING Three major medical centers and one community hospital in New York City. METHODS A total of 249 patients were randomly assigned to either the control group receiving usual care or to one of the three intervention groups. The interventions were administered at the diagnostic, postsurgery, adjuvant therapy, and ongoing recovery phases. Analyses were based on a mixed model analysis of variance. MAIN RESEARCH VARIABLES AND MEASUREMENT: Physical adjustment was measured by the side effects incidence and severity subscales of the Breast Cancer Treatment Response Inventory (BCTRI) and the overall health status score of the Self-Rated Health Subscale of the Multilevel Assessment Instrument. Emotional adjustment was measured using the psychological well-being subscale of the Profile of Adaptation to Life Clinical Scale and the side effect distress subscale of BCTRI. Social adjustment was measured by the domestic, vocational, and social environments subscales of the Psychosocial Adjustment to Illness Scale. FINDINGS Patients in all groups showed improvement over time in overall health, psychological well-being, and social adjustment. There were no significant group differences in physical adjustment, as measured by side effect incidence, severity, or overall health. There was poorer emotional adjustment over time in the usual care (control) group as compared to the intervention groups on the measure of side effect distress. For the telephone counseling group, there was a marked decline in psychological well-being from the adjuvant therapy phase through the ongoing recovery phase. There were no significant group differences in the dimensions of social adjustment. CONCLUSION The longitudinal design of this study has captured the dynamic process of adjustment to breast cancer, which in some aspects and at various phases has been different for the control and intervention groups. Although patients who received the study interventions improved in adjustment, the overall conclusion regarding physical, emotional, and social adjustment is that usual care, which was the standard of care for women in both the usual care (control) and intervention groups, supported their adjustment to breast cancer, with or without additional interventions. IMPLICATIONS FOR NURSING The results are important to evidence-based practice and the determination of the efficacy and cost-effectiveness of interventions in improving patient outcomes. There is a need to further examine adjustment issues that continue during the ongoing recovery phase. KEY POINTS Psychoeducation by videotapes and telephone counseling decreased side effect distress and side effect severity and increased psychological well-being during the adjuvant therapy phase. All patients in the control and intervention groups improved in adjustment. Adjustment issues are still present in the ongoing recovery phase.

PATTERNS OF ADJUSTMENT AMONG WOMEN WITH BREAST CANCER AND THEIR PARTNERS

Four inventories were completed by 128 women and 121 partners evaluating predictors of emotional and physical adjustment at six phases of experience with breast cancer. Emotional adjustment could be predicted by marital support, support from other adults, and role function. The relationships were significant at concurrent times, across contiguous times, and predicting from the 7- to 10-day postsurgical phase to both the 6-mo. and 1-yr. end points.

Medical factors and patterns of adjustment to breast cancer

Dimensions of emotional adjustment, perceived health status and role function were compared by three medical groups: breast conserving versus non‐breast conserving surgery; positive versus negative nodes; and post‐surgical adjuvant therapy. Intact data series were obtained at 7–10 days, at 1, 2, 3 and 6‐months, and 1 year post‐surgery for 93 women. The overall mean scores for measures of emotional adjustment, perceived health status, and role function did not differ significantly between breast‐conserving and non‐breast‐conserving groups. However, there was a significant change over time with both surgical groups showing improved adjustment. Although there were no statistically significant differences between the node status groups in mean scores on the adjustment variables, the overall patterns over time were analogous to that of the surgical groups. In comparing post‐surgical adjuvant therapy groups, significant differences in mean scores on the adjustment outcomes were noted mainly between the chemotherapy versus no adjuvant therapy groups at 3 and 6 months post‐surgery.

Level of activation, body temperature, and interpersonal conflict in family relationships.

The 24-hour variation in physiological and psychological functioning within the individual and interpersonal differences were investigated in relation to the nature of social interaction between individuals. Level of activation, body temperature, and interpersonal conflict were studied in a sample of 16 married couples for a period of six weekdays of routine activity. Homogeneity was a major factor in sample selection. Body temperature was measured every hour during the waking time by electronic thermometer, and level of activation was measured four times a day on alternate forms of a self-report adjective checklist. Interpersonal conflict, defined as perceived fulfillment of emotional and interaction needs, was measured in the morning and late day. The Interpersonal Conflict Scale with established validity was constructed for the study and had two alternate forms of equal reliability. An index of desynchrony between partners for both temperature and activation was calculated for each day of data collection by the following method: The deviation score from the overall six-day mean was determined for each measurement time for each spouse and for each variable. Absolute values of the differences between deviation scores were added to obtain an index of desynchrony in that variable for the day. A daily mean of interpersonal conflict scores for both partners was also calculated. The hypotheses that a desynchrony between partners in body temperature rhythm and in level of activation rhythm would be positively related to conflict were tested by the Pearson product moment correlation. Obtained coefficients were not significant at the .05 level.

The Breast Cancer Treatment Response Inventory: Development, Psychometric Testing, and Refinement for Use in Practice

PURPOSE/OBJECTIVES To describe the development, testing, and utility of the Breast Cancer Treatment Response Inventory (BCTRI), an instrument that captures the symptom experience of women with breast cancer. DATA SOURCES Journal articles and results of research studies used to establish BCTRI psychometric properties. DATA SYNTHESIS The tool is a valid and reliable method to determine and monitor numbers of symptoms, the severity of those symptoms, and the amount of distress experienced by patients. It is an easily and quickly employed assessment tool to guide and evaluate interventions. CONCLUSIONS The BCTRI has strong psychometric properties and is a valid and reliable instrument to measure symptom experience among populations of breast cancer survivors. IMPLICATIONS FOR NURSING Data collected using the BCTRI provide information that healthcare providers can use to target interventions toward symptoms that are most troublesome or distressful. The BCTRI can be used at meaningful points in treatment, recovery, and ongoing survivorship to explore the emerging concept of symptom experience in samples that reflect socioeconomically and ethnically diverse populations.

Measuring Perceived Dominance-Accommodation: Development of a Scale:

The assessment of family health includes both the stability and quality of relationships within the system. The probability of marital conflict is high when the needs of partners are either not met or the complementarity of psychosocial need fulfillment is rigid. A self-report instrument to measure dominance-accommodation was constructed by developing definitions of these behaviors and formulating 100 items to reflect the definitions. Data were collected from a convenience sample of 45 men and 74 women and appropriate statistical procedures were applied to determine preliminary estimates of reliability and validity. The Jackson Personality Research Form was used for study of construct validity. Two factors emerged; the item content in the first factor reflected the degree to which the need expressed by one person was different from the polar need expressed by the partner. The items in the second factor contained content indicative of equality and compromise in resolution of differences. Data were collected from a second convenience sample of 59 subjects using only the Dominance-Accommodation Scale. Again, a two-factor solution accounted for more of the variance than any other linear combination of items. The orientation of the first factor was communication, ability to be assertive, trust in the partners consideration, and resolution of differences. The second factor reflected a more rigid dominant-accommodative pattern of interaction.

CIRCADIAN RELATIONS AMONG LEVEL OF ACTIVATION, CONFLICT, AND BODY TEMPERATURE ASSESSED BY CHRONOBIOLOGIC SERIAL SECTION

One couple who had been living together for 2 yr. indicated level of activation and interpersonal conflict on self-report measures six times per day for a period of 35 days. Body temperatures were recorded rectally at a sampling interval of 2 min. throughout the 24-hour period by means of the Vitalog Thermolog-2 ambulatory monitor. The activation and conflict scales each consisted of three factors: general activation, deactivation sleep, and high activation and interaction need conflict, emotional need conflict and sexual need conflict. Rhythmometric analyses provided descriptive parameters of peak time (acrophase), over-all mean (mesor), and degree of excursion of the wave of the rhythm (amplitude) for each variable. Significant circadian rhythms in activation and temperature were noted for both partners and in the emotional component of conflict for the man. The general activation data indicated that the man was more of a morning person than the woman who was evening-oriented. Correlations between the activation and conflict factor scores varied in significance between partners. A significant relation was noted for the man between a decline in general activation and a decrease in interaction need conflict in the early and late parts of the day. For the woman, a decrease in the deactivation sleep state, occurring at mid-day, was related to an increase in both emotional and interaction need conflict.

Social Chronobiology: Circadian Activation Rhythms of Married Couples

16 couples who had been married about 8½ yr. indicated level of activation every 4 hr. on each of 6 days and twice each day completed the Interpersonal Conflict Scale. Body temperatures were recorded each hour. Analyses showed group rhythms in scores, individual rhythms in some scores. Use of this information in resolving conflict seems possible.

THE DOMINANCE-ACCOMMODATION SCALE: FURTHER STUDIES OF VALIDITY AND RELIABILITY

Further study of The Dominance-Accommodation Scale (Hoskins, 1986) in a sample of 78 couples supported the original structure of the scale. A first factor had a focus of self-referent accommodation that included an ability to be assertive, accounted for 13.2% of the variance, and had an alpha coefficient of .79. The second factor accounted for an additional 8.9% of the variance, had an alpha coefficient of .65, and reflected communication and flexibility. The theoretical premise for complementarity in interactive behaviors of dominance and accommodation was supported.