Tailoring traditional interviewing techniques for qualitative research with seriously ill patients about the end-of-life: a primer

Conducting qualitative interviews with seriously ill individuals about end-of-life issues is challenging for interviewers seeking to understand the problems, processes, and experiences individuals undergo when faced with death and dying. Although all qualitative interviewers face issues of building trust and obtaining answers to their research questions, these issues are exacerbated for interviewers of end-of-life issues due to the challenges of debilitated participants, sensitive subject matter, and heightened emotionalism. The purpose of this article is to offer field-tested techniques to tailor basic interviewing practices for discussions of end-of-life issues with seriously ill individuals. Use of tailored techniques facilitates the comfort of both interviewer and participant and enhances the probability of obtaining complete and accurate data, which in turn can improve the effectiveness of subsequent programs, policies, and clinical practice based on research findings.

Analyzing symptom management trials: the value of both intention-to-treat and per-protocol approaches

PURPOSE/OBJECTIVES

Two analytical approaches are described for a randomized trial testing interventions for symptom management.

DESIGN

To compare an intention-to-treat with a perprotocol approach.

SETTING

Patients were accrued from six cancer centers.

SAMPLE

94 men and 140 women with solid tumors were accrued.

METHODS

An intention-to-treat approach (as randomized) and per-protocol analyses (at least one symptom reaching threshold and one follow-up intervention) were compared. The analysis determines how each approach affects results. A two-arm, six-contact, eight-week trial was implemented. In one arm, nurses followed a cognitive behavioral protocol. In the second arm, a non-nurse coach referred patients to a symptom management guide.

MAIN RESEARCH VARIABLES

Trial arm; summed severity scores; interference-based severity categories at intake, 10 weeks, and 16 weeks; site; and stage of cancer.

FINDINGS

Each arm produced a reduction in severity at 10 and 16 weeks with no differences between arms. In the per-protocol analyses, symptoms reported at the first contact required more time to resolve. Older patients exposed to the nurse arm resolved in fewer contacts.

CONCLUSIONS

The intention-to-treat analyses indicated that both arms were successful but offered few insights into how symptoms or patients influenced severity. Per-protocol analyses (intervention and dose), when, and which strategies affected symptoms.

IMPLICATIONS FOR NURSING

Each analytical strategy serves a purpose. Intention-to-treat defines the success of a trial. Per-protocol analyses allow nurses to pose clinical questions about response and dose of the intervention. Nurses should participate in analyses of interventions to understand the conditions where interventions are successful.

Factors related to the use of dietary supplements by cancer survivors

OBJECTIVES

Estimates of the use of complementary and alternative medicine (CAM) among cancer survivors vary widely. Dietary supplements are an important CAM therapy to examine because of their potential to interact with conventional cancer therapies. We estimated the prevalence of dietary supplement use in a population-based sample of cancer survivors of the 10 most common cancers and examined potential correlates of use.

DESIGN AND SUBJECTS

This cross-sectional analysis included participants from the American Cancer Society's longitudinal Study of Cancer Survivors-I recruited in Connecticut who completed self-administered baseline and supplemental questionnaires. Using univariate and multivariate logistic regression, we examined demographic, clinical, and psychosocial predictors of dietary supplement use after cancer diagnosis.

RESULTS

Of the 827 cancer survivors, 573 (69.3%) reported using dietary supplements after their cancer diagnosis. Female gender [odds ratio (OR) = 1.72, 95% confidence interval (CI) = 1.25-2.36] and higher-education levels (OR = 5.44, 95% CI = 2.98-9.93) were significantly associated with supplement use. Common reasons for using dietary supplements included "something they could do to help themselves" (56.2%) and "to boost their immune system" (51.1%). Most survivors (82.4%) informed their physician of their supplement use. Patients obtained information from a variety of sources including physicians, friends or family, and magazines or books.

CONCLUSIONS

Use of dietary supplements after cancer diagnosis was quite common among this population-based sample of cancer survivors. Although gender and education were associated with use, it is important that clinicians discuss supplement use with all cancer survivors.

Using Generalized Estimating Equations to Analyze Longitudinal Data in Nursing Research

Although use of GEE has become widespread for analyzing longitudinal data in many fields, much research in nursing still uses only the traditional statistical methods. This article illustrates use of GEE, using a data set describing symptoms of women with gynecological cancers, with eight data collection times across a period of 6 months. Three research questions are analyzed: (a) Did number of symptoms in women with gynecological cancer change within 6 months after surgery? (b) Did individual symptom (e.g., pain) in women with gynecological cancers change within 6 months after surgery? (c) Were psychosocial and disease variables (age, cancer site, new diagnosis or recurrence, treatment, emotional distress, and use of symptom management toolkit) associated with individual symptoms (e.g., fatigue) in women with gynecological cancers? For each research question, SAS code and explanation of SAS instructions are described in detail. Missing data and time intervals for longitudinal studies are also discussed.

Depression screening using the Patient Health Questionnaire-9 administered on a touch screen computer

OBJECTIVE

To (1) evaluate the feasibility of touch screen depression screening in cancer patients using the Patient Health Questionnaire-9 (PHQ-9), (2) evaluate the construct validity of the PHQ-9 using the touch screen modality, and (3) examine the prevalence and severity of depression using this screening modality.

METHODS

The PHQ-9 was placed in a web-based survey within a study of the clinical impact of computerized symptom and quality of life screening. Patients in medical oncology, radiation oncology, and hematopoietic stem cell transplantation (HSCT) clinics used the program on a touch screen computer in waiting rooms prior to therapy (T1) and during therapy (T2). Responses of depressed mood or anhedonia (PHQ-2 cardinal depression symptoms) triggered additional items. PHQ-9 scores were provided to the oncology team in real time.

RESULTS

Among 342 patients enrolled, 33 (9.6%) at T1 and 69 (20.2%) at T2 triggered the full PHQ-9 by endorsing at least one cardinal symptom. Feasibility was high, with at least 97% completing the PHQ-2 and at least 96% completing the PHQ-9 when triggered and a mean completion time of about 2 min. The PHQ-9 had good construct validity. Medical oncology patients had the highest percent of positive screens (12.9%) at T1, while HSCT patients had the highest percent (30.5%) at T2. Using this method, 21 (6.1%) at T1 and 54 (15.8%) at T2 of the total sample had moderate to severe depression.

CONCLUSIONS

The PHQ-9 administered on a touch screen computer is feasible and provides valid depression data in a diverse cancer population.

Coping and acceptance: the greatest challenge for veterans with intestinal stomas

OBJECTIVE

Intestinal stomas (ostomies) create challenges for veterans. The goal of this qualitative analysis was to understand better patients' perspectives regarding their greatest challenge.

METHODS

Ostomates at three Veterans Affairs locations were surveyed using the modified City of Hope Quality of Life-Ostomy questionnaire that contained an open-ended request for respondents to describe their greatest challenge. The response rate was 51% (239 of 467); 68% (163 of 239) completed the open-ended item. Content analysis was performed by an experienced qualitative research team.

RESULTS

Coping and acceptance were the most commonly addressed themes. The most frequently expressed issues and advice were related to a need for positive thinking and insight regarding adjustment over time. Coping strategies included the use of humor, recognition of positive changes resulting from the stoma, and normalization of life with an ostomy.

CONCLUSIONS

Coping and acceptance are common themes described by veterans with an intestinal stoma. Health-care providers can assist veterans by utilizing ostomate self-management strategies, experience, and advice.

Couples and cancer: feasibility of brief instruction in massage and touch therapy to build caregiver efficacy

This study examined the feasibility of brief instruction in massage and touch therapy for caregivers ("partners") to provide comfort to cancer patients. Fifty partners and 49 patients participated. A longitudinal, within-subjects, repeated measures, control and intervention phases design used self-report instruments to assess feasibility via change in frequency, duration, partner-perceived self-efficacy, and patient-perceived helpfulness over a 90-day follow-up. Exploratory data were collected on psychosocial and quality of life variables. Focus groups provided qualitative data. A structured 6-hour workshop taught basic manual techniques for comfort and relaxation, followed by home practice. Significant increases in frequency (1.2 vs 2.7 times per week) and duration (4.7 vs 12.2 minutes) of massage, both p < .001, were sustained through the 3-month follow-up. Partners' perceived self-efficacy in massage and patients' ratings of its helpfulness more than doubled. Classification tree analysis found caregiver burden, relationship quality, and frequency and duration of practice to predict individual responses. Inhibitions about touch in cancer caregiving may lead to unnecessary physical and emotional distancing at a time when patients need touch the most. Brief instruction may be a feasible intervention to increase caregiver efficacy, patient satisfaction, quality of life, and quality of the relationship.

Cervical cancer: patterns of long-term survival

PURPOSE/OBJECTIVES

To describe the quality of life (QOL) experienced by long-term survivors of cervical cancer and the factors that promoted their adaptation.

DESIGN

Qualitative.

SETTING

Homes and offices in the northeastern United States.

SAMPLE

19 women diagnosed with cervical cancer from 1975-1995.

METHODS

Semistructured interviews were tape recorded. Interviewers asked the participants questions regarding their cancer experience, recovery, and long-term survival. Qualitative content analysis was used to identify themes that characterized participants' accounts. Participants varied in regard to how the themes were manifested in their accounts.

MAIN RESEARCH VARIABLES

Meaning, impact on identity, impact on QOL, coping strategies, and future expectations.

FINDINGS

Three distinct patterns of response emerged from participants' accounts of long-term survivorship with cervical cancer. Women categorized in the "moving on" pattern described their cancer as a difficult period taking place in the past, women in the "renewed appreciation of life" pattern focused on the positive outcomes of their cancer experience, and women in the "ongoing struggles" pattern emphasized the continuing negative outcomes of their cancer experience. Despite their overall distinctness, some common qualities in the patterns emerged, including the shock of the diagnosis, the pivotal role of healthcare providers, and the importance of support from family and friends.

CONCLUSIONS

Cervical cancer survival, for most of the study participants, brought with it some degree of long-term complications, with differences in reported QOL attributed to an ability or choice to reframe the cervical cancer experience.

IMPLICATIONS FOR NURSING

QOL and depression measures alone do not uncover embedded meanings of women's experiences with longterm survivorship. Clinicians can use a variety of interview probes and evidence-based psychosocial and educational approaches to assist the target population in the journey. Findings suggest that nurses play a key role in responding to cervical cancer survivors' unique experiences with illness and recovery.

Effects of a nursing intervention on quality of life outcomes in post-surgical women with gynecological cancers

OBJECTIVE

Women with gynecological cancers have reported poor health-related quality of life (QOL), with complex physical and psychological needs post-surgery and during chemotherapy treatment. There are no studies reporting interventions addressing these needs post-hospital discharge in this population.

METHODS

Patients were randomized into two groups. The intervention group received 6 months of specialized care by an Advanced Practice Nurse (APN); in addition, women with high distress were evaluated and monitored by a psychiatric consultation-liaison nurse (PCLN). The attention control group was assisted with symptom management by a research assistant. The effects of the 6-month intervention were evaluated using self-report questionnaires at baseline (24-48 h after surgery), 1, 3, and 6 months post- surgery. QOL assessments included the Center for Epidemiological Studies-Depression Scale , the ambiguity subscale of the Mishel Uncertainty in Illness Scale , the Symptom Distress Scale, and the Short-Form Health Survey (SF-12). The sample for the longitudinal analysis included 123 who completed QOL outcome measures across three occasions post-surgery.

RESULTS

The APN intervention resulted in significantly less uncertainty than the attention control intervention 6 months after surgery. When the sub-group who received the APN plus PCLN intervention was compared with the total attention control group, the sub-group had significantly less uncertainty, less symptom distress, and better SF-12 mental and physical QOL over time.

CONCLUSION

Nurse tailored interventions that target both physical and psychological aspects of QOL in women recovering from cancer surgery and undergoing chemotherapy produce stronger outcomes than interventions that target solely one QOL aspect.

Managing symptoms among patients with breast cancer during chemotherapy: results of a two-arm behavioral trial

PURPOSE

In this study, we compare symptom response and times to response among patients with breast cancer who were assigned to either a cognitive behavioral Nurse-Administered Symptom Management intervention or an Automated Telephone Symptom Management (ATSM) intervention.

PATIENTS AND METHODS

Patients with breast cancer were identified from a larger trial. Baseline equivalence existed between arms, and there was no differential attrition by arm. Anchor-based definition of response using mild, moderate, and severe categories of symptom severity were used. Responses and times to response for 15 symptoms were investigated in relation to trial arm, comorbid conditions, treatment protocols, and metastatic versus localized disease.

RESULTS

The ATSM arm was more effective among patents with metastatic disease. Compared with patients receiving combination chemotherapy protocols, those treated with single agents had greater response and shorter time to response.

CONCLUSION

An educational information intervention delivered via an automated voice response system that assesses symptoms and refers patients to a Symptom Management Guide is more effective than a complex cognitive behavioral approach in terms of producing greater symptom responses in shorter time intervals among patients with metastatic disease.

Health status and adaptation among long-term cervical cancer survivors

OBJECTIVES

This study assesses health and adaptation among long-term survivors of cervical cancer. Little research has been published on women who have survived over ten years after diagnosis of this disease. Both clinicians and patients can benefit from increased information on the likelihood of chronic and late effects of cervical cancer across the life course of survivors.

MATERIALS AND METHODS

The investigators interviewed 208 individuals six years or more post-invasive cervical cancer diagnosis from the Connecticut Tumor Registry. Cervical cancer survivors were compared with women from the general population interviewed in the Connecticut Behavioral Risk Factor Survey (BRFS). Measures of health status and adaptation were compared across successive categories of survival time, including self-assessment of general health according to an item from the MOS-36, days of ill health in past month, and days in past month in which activity was limited by physical or mental health.

RESULTS

No differences were detected in self-reported general health status between cervical cancer survivors and BRFS controls. But cervical cancer survivors more often reported days of illness and days in which their activities were limited by illness during the month prior to interview. No differences were detected in employment, marital status, or health insurance coverage. No statistically significant differences were detected across survival time categories.

CONCLUSIONS

A high level of adaptation appears to prevail among cervical cancer survivors. Late effects on health status are not evident. However, the possibility that specific subgroups may experience particularly severe challenges should not be ignored and future research should help identify these subgroups.

Sexuality and sexual function in long-term survivors of cervical cancer

OBJECTIVES

The study reported here assesses sexuality and sexual functioning among women treated for invasive cervical cancer over broad portions of the life cycle. Hysterectomy and oophorectomy, two widespread interventions in invasive cervical cancer, have potentially important effects on a woman's self-image and sexuality.

METHODS

The investigation focused on women aged 29-69 with histories of invasive cervical cancer (n = 179) from the Connecticut Tumor Registry, 6-29 years postdiagnosis. Logistic regression analysis was used to assess the relative impact of time since cervical cancer diagnosis and treatment received, adjusting for age and social and economic background. Sexuality, sexual function, and potential correlates were assessed using the Sexual Adjustment Scale, the MOS-36, and the Center for Epidemiological Studies-Depression Scale (CES-D).

RESULTS

Strong majorities of women in the study indicated that they were sexually active (81.1%) and both desired (81.4%) and enjoyed (90.9%) sexual activity. Neither time since cervical cancer diagnosis nor age significantly affected sexuality or sexual function. Women with hysterectomies (with or without oophorectomy) less often reported lack of interest in (odds ratio [OR] 0.36, p < 0.05) and lack of desire for (OR 0.26, p < 0.05) sexual activity than women who had not had hysterectomies. Among women with hysterectomies, those with oophorectomies had a greater risk (OR 21.1, p < 0.05) of not enjoying sex but did not differ otherwise from those without oophorectomies.

CONCLUSIONS

These findings suggest that cervical cancer survivors generally have a positive attitude toward sexuality and engage in satisfying sexual activity.

Quality of life among women after surgery for ovarian cancer

OBJECTIVES

Difficulties with diagnosis and aggressive, long-term treatment may result in lower quality of life (QOL), including high levels of anxiety, depression, and uncertainty, greater symptom distress, and lower overall QOL among women with ovarian cancer. The purpose of this study was to describe demographic, clinical, and other risk factors associated with compromised QOL among women who have undergone surgery for ovarian malignancies.

METHODS

Subjects were recruited to participate in a clinical trial that tested a specialized nursing intervention addressing psychological and physical care among women post-surgical for ovarian cancer. QOL was measured using five standardized self-report measures: the State-Trait Anxiety Scale (SAS), the Center for Epidemiological Studies Depression Scale (CES-D), the Mishel Uncertainty in Illness Scale (MUIS), the Symptom Distress Scale (SDS), and the Short-Form Health Survey (SF-12). Baseline data were collected while women were hospitalized following surgery.

RESULTS

The sample (n=145) included women with ovarian cancer (58%) and other cancers metastasized to the ovaries and abdomen (42%). Mean scores on the measures were consistent with or higher than previously reported means for similar populations. Women reporting the lowest QOL were more likely to be younger, more educated, and have early stage disease.

SIGNIFICANCE OF RESULTS

Women who have undergone surgery for ovarian malignancies have psychological needs that are often considered secondary to physical needs. Interventions should include routine screening for distress and referral to appropriate psychological and social services, thereby facilitating quality cancer care.

Homecare referrals and 12-week outcomes following surgery for cancer

PURPOSE/OBJECTIVES

To determine characteristics of patients undergoing cancer surgery who do and do not receive homecare referral after hospitalization, relative to poor discharge outcomes.

DESIGN

Secondary analysis of a randomized clinical trial.

SETTING

Urban, academic cancer center in the northeastern United States.

SAMPLE

375 patients 60 years and older and admitted for solid tumor cancer surgery.

METHODS

Stepwise, multiple logistic regression using patient characteristics related to homecare referrals or those related to poor discharge outcomes.

MAIN RESEARCH VARIABLES

Homecare referral and poor discharge outcome.

FINDINGS

Patients 70 years or older, single, hospitalized for a week or more for a late-stage cancer, with greater than four comorbid conditions, and discharged with more than four daily activity impairments, depressive symptoms, and a need for skilled nursing care were more likely to require home care. Patients not referred to home care who received adjuvant cancer therapies were about three times more likely to have poor discharge outcomes.

CONCLUSIONS

Patients who were referred for home care had characteristics similar to medical or surgical patients documented in the literature. However, younger patients with lengthy hospital stays and recipients of adjuvant cancer therapy did poorly after discharge and may benefit from home care.

IMPLICATIONS FOR NURSING

Certain characteristics, such as age, single marital status, depression, and cognition, should trigger further assessment of patients' needs after discharge, including anticipating needs of patients who will receive adjuvant therapies.

Models of inter-institutional collaboration to build research capacity for reducing health disparities

Health disparities are inequities in the health of different groups of people that may lead to needless pain, suffering, and premature death. The Yale-Howard Partnership Center on Reducing Health Disparities by Self and Family Management is part of a federally-funded initiative to foster the development of partnerships among researchers, faculty, and students at minority-serving institutions and research-intensive institutions. The goal of the initiative is to maximize the resources available to each of the partnering institutions. The purpose of this article is to describe the models of research collaboration that have emerged from the Yale-Howard Partnership Center on Reducing Health Disparities by Self and Family Management.

A Dimensional Analysis of the Concept: Good Death of a Child With Cancer

The death of a child is painful to all witnesses, but the experience varies among individuals, and differing perspectives lead to a variety of definitions for a good death. This analysis is undertaken to clarify the dimensions involved in a good death of a child with cancer and to examine them from 3 perspectives: the dying child, the child's family, and the health care providers.

Establishing mild, moderate, and severe scores for cancer-related symptoms: how consistent and clinically meaningful are interference-based severity cut-points?

Methods are presented to separate 16 frequently occurring cancer symptoms measured on 10-point symptom severity rating scales into mild, moderate, and severe categories that are clinically interpretable and significant for use in oncology practice settings. At their initial intervention contact, 588 solid tumor cancer patients undergoing chemotherapy reported severity on a standard 11-point rating scale for 16 symptoms. All reporting a one or higher were asked to rate on an 11-point scale how much the symptom interfered with enjoyment of life, relationship with others, general daily activities, and emotions. Factor analysis revealed that these items tapped into the same dimension, and the items were summed to form an interference scale. Cut-points for mild, moderate, and severe categories of symptom severity were defined by comparing the differences in interference scores corresponding to each successive increases in severity for each symptom. The cut-points differed among symptoms. Pain, fatigue, weakness, cough, difficulty remembering, and depression had lower cut-points for each category compared to other symptoms. Cut-points for each symptom were not related to site or stage of cancer, age, or gender but were associated with a global depression measure. Cut-points were related to limitations in physical function, suggesting differences in the quality of patients' lives. The resulting cut-points summarize severity ratings into clinically significant and useful categories that clinicians can use to assess symptoms in their practices.

Pain attitudes and knowledge among RNs, pharmacists, and physicians on an inpatient oncology service

Patients with cancer often experience pain, yet studies continue to document inadequate and inappropriate assessment and management of cancer-related pain. This study aimed to evaluate the attitudes and knowledge of inpatient oncology healthcare providers toward pain management by surveying nurses, pharmacists, and physicians working on the inpatient oncology units at an academic medical center. Healthcare providers generally reported positive attitudes toward pain management but were deficient in their knowledge of pain management. The authors suggest that pharmacists become more integral members of palliative care teams and actively participate in rounds. A need exists for educational programs in pain management for healthcare providers, especially for those who do not routinely care for patients with cancer.

Range and severity of symptoms over time among older adults with chronic obstructive pulmonary disease and heart failure

BACKGROUND

Symptoms are a central component of health status; however, little is known about the full range and trajectory of symptoms experienced by persons with chronic diseases other than cancer.

METHODS

Observational cohort study with interviews performed at least every 4 months for up to 2 years among community-dwelling persons 60 years or older with chronic obstructive pulmonary disease (COPD) or heart failure (HF). Seven symptoms rated as absent, mild, moderate, or severe were assessed at each interview.

RESULTS

Among the 79 participants with COPD, at least 50% reported shortness of breath, physical discomfort, fatigue, and problems with appetite and anxiety. Among the 59 participants with HF, at least 50% reported physical discomfort, fatigue, and problems with appetite at both their initial and final interviews. Both disease-specific and non-disease-specific symptoms increased in severity over time. The prevalence of individual symptoms did not differ according to whether the participants lived or died.

CONCLUSIONS

As a potentially modifiable contributor to poor health status, the high symptom burden among older persons with COPD and HF represents a large unmet need for improved symptom assessment and treatment. This need may not be met by current disease management guidelines, which focus on a small number of symptoms except for patients at the end of life.

Psychometric properties of the Male Urogenital Distress Inventory (MUDI) and Male Urinary Symptom Impact Questionnaire (MUSIQ) in patients following radical prostatectomy

INTRODUCTION

Research instruments can be used to assess the impact of lower urinary tract symptoms on health-related quality of life. Evaluating the reliability, validity, and sensitivity of two of these instruments provides evidence concerning their readiness for use in research and clinical settings.

OBJECTIVE

The researchers evaluated psychometric properties of the Male Urogenital Distress Inventory and Male Urinary Symptom Impact Questionnaire in men suffering from lower urinary tract symptoms following radical prostatectomy.

METHOD

The internal consistency reliability, concurrent validity, construct validity, and sensitivity of both instruments were evaluated in a cohort of men who participated in a larger study of nursing's impact on quality of life post-prostatectomy.

RESULTS

The reliability, validity, and sensitivity of both instruments were supported in this population.

CONCLUSIONS

Initial support is provided for use of the instruments to measure the effect of interventions for lower urinary tract symptoms and urine leakage on health-related quality of life during the first 6 months of recovery from radical prostatectomy; however, further research with a larger and more diverse sample is needed prior to using the instruments in clinical settings.