OPTIMISM, COPING, AND PSYCHOLOGICAL WELL-BEING

AHONG PEOPLE WITH ADVANCED LUNG CANCER

by

Lynn A. Coulter

Submitted in partial fulfillment of the requirements

for the degree of Haster of Nursing

Dalhousie University

Halifax, Nova Scotia

A u ~ u s ~ , 1999

Copyright by Lynn A. Coulter, 1999

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TABLE OF CONTENTS

TABLE OF C O N T E N T S w . w w w w . w w e w w w m w m w . w . e w w . w w w . . . a m . e w e w w

LIST OF TABLES..*.. ............................a.......

LIST OF FIGURES...w.w.ee ..............m................

ABSTRACTwwwmmw.... .......................m.............

ACKNOWLEDGEMENTS. .........*.........................m..

CHAPTER 1: Introduction.. .............................. ........................................... P u ~ ~ o s ~

Literature Review m............................... ........ Psychological Response to Lung Cancer

...................................... Coping

................... Coping and Personality ... Optimism ....................m...............

......................... Optimism and Coping

.................... Psychological Well-being

................. Influence of Other Variables

Gender ...............e.................. Age ....................................

Sumary ...e....................................... Theoretical Framework ............................ Research Questions ................................ Definitions ......................................

CHAPTER II: Hethodology ................................ Study Design. .m................................... Setting.. .........................................

iv

viii

X

xi

xii

1

2

2

3

11

13

18

20

26

40

40

42

46

4 7

53

53

55

55

55

Sample ......................................... 55

Sample Characteristics ........................ 56

.................... Demographic Variables 56

Illness and Treatment Characteristics. ... 59

Procedure for Data collection...^........^....^.... 62

Instruments ........................................ 63

..................... Demographic Questionnaire 63

................ Revised tife Orientation Test. 64

Validity .......................O........ 65 .............................. Reliability 67

Ways of Coping Questionnaire .................. 68

Validity ................................. 72 Reliability.. ........................... 74

..................... Profile of Hood States... 75

Validity ................................. 76

.............................. Reliability 77

Data Analysis ................................ . 78

............................. Ethical Considerations 80

......................... Protection of Rights. 80

Risks and Benefits ............................ 81

................................... CHAPTER III: Findings 82

................... Interna1 Consistency Reliability 82

Revised Life Orientation Test ................. 82

Ways of Coping Ouestionnaire ... ..........m...m 83

........................ Profile of Mood States 84

Data Analysis ................................... 87

............................. Coping Strategies

The Relationship Between Dispositional

Optimism and Coping Strategies ...............O The Relationship between Age. Gender. Coping

Strategies. Dispositional Optimism and

...................... Psychological Well-Being

CHAPTER IV: Discussion .................................. .................................. Coping Strategies

The Relationship Between ~ispositionaï Optimism

.............................. and Coping Strategies

The Relationship between Age. Gender. Coping

Strategies. Dispositional Optimism and

........................... Psychological Well-Being

CHAPTER V: Summary. Limitations and Implications ........ Summary ............................................ Limitations ........................................ Implications for Nursing Practice and Education ....

......................... Implications for Research.

............................ Implications for Theory

Conclusions.... .................................... APPENDICES

Appendix A (Letter of Introduction) ................ Appendix B (Introduction by Clinic Staff) .........

............................. Appendix C (Consent)..

Appendix D (Demographic Questionnaire) ............. ........................ Appendix E (Disease Data)..

Appendix F (IMT-R) ................................. 162

Appendix G ( W O C Q ) w ~ w ~ ~ w ~ ~ ~ w ~ ~ ~ ~ w w m w ~ ~ ~ ~ ~ ~ w ~ ~ w w ~ ~ w ~ m 164

Appendix H (POMS) ..........................m....... 170 Referen~es..........~.... ............................... 171

vii

LIST OF TABLES

Table

Demographic Characteristics of Study Participants . 58

. . . . . . . Illness and Treatment Characteristics 61

Cronbachrs Alpha for the Ways of Coping Subscales . 84

Cronbach's Alpha for the Profile of Hood States

Total Mood Disturbance Scale and Hood State

Subscales . . . . . . . . . . . . . . . . . . 8 5

categories of Stressots selected by People with Advanced or Inoperable Lung Cancer . . . . . O . . 88

Degree of Stress Experienced by People with

. . . . . . . . . Advanced or Inoperable Lung Cancer 89

Means, Standard Deviation, Range of Scores and

. . . . . Relative Scores for Ways of Coping Scales 90

Pearsonrs Product-Homent Correlation Coefficients

for Degree of Stress and Age w i t h L!!e Coping

S c a l e ~ . . . . . . . . ~ . . . . . . . . . . ~ ~ . . 9 2

Analysis of Variance for Mean Coping Scores and the

Type of Stressor Subgroups . . . . . . . . . m . . e 94

Total Mood Disturbance and Hood State Hean Scores,

Standard Deviation, Actual Range of Scores and

the Possible Range of Scores . . m . . . , . . . . . 98

viii

Table . Stepwise Multiple Regression of Age, Gender,

Optimism, Stressors, Degree of Stress and Seven

Coping Strategies with Total Mood Disturbance Score 100

Stepwise Multiple Regression of Age, Gender,

~ptimism, Stressors, Degree of Stress and Seven Coping

Strategies with Tension-Anxiety Mood State Score . 101

Stepwise Multiple Regression of Age, Gender,

Optimism, Stressors, Degree of Stress and Seven Coping

Strategies with Fatigue-Inertia Hood State Score . 102

~tepwise Multiple Regression of Age, Gender,

Optimism, Stressors, Degree of Stress and Seven

Coping Strategies with Depression-Dejection Mood State

S c o r e , . . . . . . . . . . . . . . . . . . . . 1 0 3

Stepwise Multiple Regression of Age, Gender,

optimism, Stressors, Degree of Stress and Seven Coping

Strategies with Anger-Hostility Mood State Score . 104

Stepwise Multiple Regression of Age, Gender,

Optimism, Stressors, Degree of Stress and Seven Coping

Strategies with Confusion-Bewilderment Mood State . 105

Stepwise Multiple Regression of Age, Gender,

Optimism, Stressors, Degree of Stress and Seven Coping

Strategies with Vigor-Activity Mood State . . . . 106

LIST OF FIGURES

Figure 1. Relationships of variables of interest in the

Lazarus and Folkman Framework . . . . . . . . . . . . . . 52

ABSTRACT

A descriptive multiple correlational design was used to examine the relationships between dispositional optimism, coping strategies, age, gender, and psychological well-being of people with advanced or inoperable primary lung cancer. The theoretical framework guiding this research was Lazarus and Folkman's theory of s t r e s s , appraisal and coping.

A convenience sample of 44 males and 20 females diagnosed within the previous year participated: the majority were Caucasian and married. Data was collected in an interview format during a clinic visit. Three questionnaires were administered; the Revised Life Orientation Test (dispositional optimism), the Ways of Coping Questionnaire (coping) and Profile of Hood States (psychological well-being). In completing the Ways of Coping Questionnaire participants indicated their greatest stressor and rated their degree of stress. Data analysis included descriptive statistics, correlational analysis, t-tests and multiple regression analysis.

Fear and uncertainty about the future was the most frequently identified stressful situation. Overall the degree of stress for most participants was moderate to very stressful. The coping strategy used most frequently was seeking social support; escape avoidance and accepting responsibility were the strategies used the least. Using multiple regression analysis 41 percent of the variance in psychological well-king was explained by the coping strategy escape-avoidance (17%), the degree of stress (12%) optimism (8%) and the coping strategy distancing(4%).

This study expands on previous research that has indicated that the use of optimism and avoidance coping strategies are significant factors in psychological well- being, with people with advanced or inoperable lung cancer. The findings from this study are valuable in determining which patients are at greater risk of psychological distress and as a basis for further research focusing on interventions to manage this life threatening illness.

ACKNOWLEDGEMENTS

I wish to thank the many groups and individuals who

supported and encouraged me in the completion of this

thesis. First to my principal advisor Dr. Barbara Doune-

Wamboldt, who not only provided me w i t h her knowledge and

expertise regarding the research process but who also

encouraged me with her belief in my ability to conduct this

research, thank you. 1 am also very grateful to my committee

members Dr. Lorna Butler and Dr. Katherine Bowen for their

patience, expertise and encouragement.

1 also extend my thanks to the Divisions of Nursing and

Thoracic Surgery of the QEII Health Sciences Centre and to

the Nova Scotia Research Satellite Centre of the NCIC

Sociobehavioural Cancer Research Network for their support.

Without this support the completion of this work would not

have been possible. 1 thank Karen Colwell, Valerie Powell,

and the nurses and physicians of the Nova Scotia Cancer

Centre for their assistance during recruitment and data

collection.

1 wish to express my appreciation to the nursing staff

of 6A for their understanding when my thesis work took me

away from my "real jobm and for their continued support of

my role. 1 am also grateful for the advice and encouragement

that 1 received from so many of my other nursing collegues

and friends. 1 would like to extend a special thank you to

Sandra Matheson and Anna Bates for listening and for sharing

xii

their experience with me.

To ay family and friends who endured, encouraged and

supported me through this seemingly unending endeavour 1 am

forever grateful. Finally and most importantly 1 thank my

daughter Laura for her patience, her understanding, and her

hugs .

xiii

Introduction

It is estimated that in Canada in 1998, over 20,000 new

cases of lung cancer will be diagnosed (National Cancer

Institute of Canada, 1998). Despite improving statistics for

many cancers, lung cancer continues to carry a dismal

prognosis with an overall five year sumival of

approximately 14 percent (Rosenow, 1993). For m a s t types of

lung cancer surgical therapy is the most effective and the

only potentially curative treatment: unfortunately this

option exists for only 20 to 25% of those diagnosed

(Shields, 1993). In most cases the cancer is too far

advanced at the time of diagnoses or other medical problems

render the patient inoperable (Murren & Buzaid, 1993).

Patients who receive this diagnosis are confronted with

a stressor which threatens their life. The negative impact

of lung cancer on psychological well-being has been well

documented (Weisman & Worden, 1976-1977; Benedict, 1989:

Ginsburg, Quint, Ginsburg, L MacKillop, 1995). Despite the

acknowledged distress caused by lung cancer little research

has been completed focusing on the factors influencing this

aspect of the disease and how people with lung cancer cope

with this distress.

A goal of nursing is to help people to cope effectively

2

with a life threatening illness such aslung cancer. There

is a need to determine how people with lung cancer cope,

what methods are used, what strategies are effective for

which patients and in which situations. Coping however is a

very complex and individual process, which despite extensive

research rernains poorly understood (Pearlin, 1991).

Purboçe

The purpose of this study was to examine the

relationships between the personality disposition of

optimism, the coping strategies used, the demographic

characteristics of age and gender and psychological well-

being of people with advanced or inoperable primary lung

cancer.

While the topic of lung cancer has received a great

deal of attention the vast majority of the literature has

focused on disease and treatment; relatively little has been

written regarding the psychological aspects of this illness.

This literature review includes the psychological responses

to lung cancer, an overview of coping, coping in relation to

personality, and more specifically in relation to the

personality disposition of optimism. The outcome of

psychological well-being as related to optimism and coping

strategies and the influence of the demographic variables

age and gender on coping are discussed.

A number of studies have attempted to determine the

individual's psychological response to lung cancer- The

variability and wide variety of reactions to a diagnosis of

lung cancer was demonstrated in a study by Ginsburg, Quint,

Ginsburg, and MacKillop (1995). Zn this descriptive study 52

patients with a new diagnosis (within 5 months) of lung

cancer underwent psychiatric evaluation, The majority of the

sample was male, married, and between 50 and 70 years of

age. Most were skilled or partly skilled workers and had

completed sonte high school education. Al1 were receiving

either radiation or chemotherapy in an ambulatory clinic

setting. Twenty five percent had small ce11 lung cancer and

75% had non-small ce11 lwrg cancer. Each patient was

interviewed by a psychiatrist using a standardized formal

diagnostic instrument based on the Diagnostic and

Statistical Manual of Mental Disorders, 3rd edition (DSM-

III) to assess anxiety, depression, alcohol use and tobacco

use. A less structured interview (but also based on DSM-III

criteria) was completed to determine the presence of an

adjustment disorder. At the time of the interview eight

patients were diagnosed as currently having a psychiatric

illness. While 20 demonstrated calm acceptance and five were

optimistic a wide variety of less positive reactions were

identifie& Most frequently sadness, thoughts of death,

insomnia, and loss of libido were reported, Seven had at

4

least on one occasion suicida1 ideation and seven were

abusing alcohol.

Benedict (1989) studied the incidence of suffering

associated with lung cancer. Suffering was defined as "a

negative affective state resulting from an event or

situation that is perceived to be physically painful,

uncornfortable, or psychologically distressingm. In this

descriptive study 30 patients (26 male and 4 female) were

interviewed. Both the incidence of suffering and the

physical, psychological, and interactional aspects of the

disease which were associated with suffering were reported,

Fifty percent of the sample reported Wery muchm suffering.

The greatest suffering was associated with disability, pain,

anxiety, changed activities, and weakness/fatigue, While 50

percent of the sample reported employment problems only 20

percent reported this to be a cause of suffering. The type

of lung cancer was not included as a variable but those with

and without metastatic disease were compared. No difference

was found in relation to the physical and interactional

aspects but those with metastatic disease reported

significantly more suffering related to the psychological

aspects, No significant differences were found in relation

to the type of treatment the patient had received,

Weisman and Worden (1976-1977) studied the emotional

distress of 120 patients with newly diagnosed cancer. Of

this sample 23, al1 white males, had a diagnosis of lung

5

cancer. In the lung cancer sample the mean age vas 58 years,

the majority (65%) were married. A11 patients were

interviewed by a social worker using open ended questions

following a recommended sequence. In addition to gathering

demographic and illness data the interview included areas of

stress and concerns; the interviewer classified coping

responses according to a list of coping behaviours and

indicated how the situation was resolved. The interviewer

also rated the patient on a four point scale with respect to

emotional and psychological distress called an Index of

Vulnerability scale. The patients also completed Profile of

Mood States, Minnesota Piultiphasic Personality Inventory and

a Thematic Apperception test. Initial interviews were

carried out near the time of diagnosis (within 10 days) and

again at four to s i x week intervals over a 3 month period.

In this study the patients with lung cancer were found to be

the most distressed. The results also indicated that for the

patients with lung cancer, vulnerability and mood

disturbance steadily increased during the first 100 days

following diagnosis. Generally it was found that patients

with high emotional distress were more pessimistic, had a

tendency to give up and expected little support.

This study highlighted the need to consider people with

different sites of cancer separately. The subsample of

patients with lung cancer is quite small and al1 male. The

question of variability among patients with lung cancer and

6

the factors influencing that variability is not addressed by

this study.

In addition to investigating the psychological response

to lung cancer attempts have been made to determine what

factors influence psychological adjustment. Cella et al.

(1987) studied the relationships among performance status,

extent of disease and psychological distress in 455 patients

with small ce11 lung cancer entered into one of three

clinical trials. Treatment was not considered to be a

variable as study data were collected prior to the

initiation of any treatment. This sample vas mostly male

( 7 0 % ) , married ( 7 5 % ) , and had at least a high school

education (82%). The mean age of the group vas 58.6 years.

Performance status was rated on a five level scale ranging

from no impairment (O) to bedridden (4). Psychological

distress was measured using the Profile of Hood States

(POMS); this inventory measures six mood or affective states

and also provides a reflection of total mood disturbance.

Age, gender, marital status and education were also

included. Of the study variables performance status and

gender showed a significant relationship with the total mood

disturbance score. Women and those with poorer performance

status had higher mood disturbance scores. The extent of the

disease became significant when performance status scores

were low. The researchers explain the gender difference

stating that healthy women also tend to repart greater mood

distress than healthy males.

Hopwood and Stephens (1995) assessed and compared

symptoms of 232 patients with small ce11 lung cancer (SCLC)

and a sample of 423 patients with non-small ce11 lung cancer

(NSCLC). In addition to differences in ce11 type the groups

also differed in terms of performance status with al1 the

non-small ce11 group having a good performance status and

over half of the small ce11 group having poor status. The

groups were similar in terms of age and gender, with a

median age of 65 years for the SCLC group and 66 years for

NSCLC. Sixty three percent of the SCLC group were male

compared to 79% of the NSCLC group. The symptoms were

assessed using the Rotterdam Symptom Checklist which was

described as measure of quality of life consisting of 30

symptoms in a number of domains including physical,

psychological and sexual. Symptoms were similar for the two

groups with the eight commonest being worry, anxious

feeling, tiredness, lack of energy, lack of appetite,

difficulty sleeping, shortness of breath, and cough. The

symptoms ranked as most severe were decreased sexual

interest, lack of energy and shortness of breath. As would

be expected the number of symptoms reported was greater with

worsening performance status. In the non-small ce11 group

females reported more psychological symptonrs than did the

males. Interestingly this difference was not found in the

small ce11 cancer group. Whether or not gender difference

8

disappears as performance status decreases is unknom.

Klemm (1994) using a descriptive correlational design

studied psychological adjustment in lung cancer in relation

to three variables; daily hassles, illness demands, and

social support in a sample of 60 patients with advanced

(stage 3 and 4) lung cancer. A convenience sample of 171

potential subjects were contacted by phone, 112 agreed to

participate, of the 112, 56 returned usable questionnaires.

In this sample the majority were white ( 8 3 . 9 % ) , male

( 6 2 . 5 % ) , and married (75%). The mean age was 60.3 years.

Demands of illness was measured using the Demands of Illness

Inventory which is a 125 item questionnaire with seven

subscales (physical symptoms, persona1 meaning of illness,

family functioning, social relationships, self-image,

monitoring symptoms, and treatment issues). Adjustment was

measured using the Patient Adjustment to Illness Scale - Self Report (PAIS-SR). This instrument also has seven

domains (healthcare orientation, vocational environment,

domestic environment, sexual relationships, extended family

relations, social environment, and psychological distress).

Overall subjects in this study had high social support, low

hassles, and moderately low demands of illness. The author

found of the variables only the demands of illness ta be

predictive of psychosocial adjustment. Race was also found

to be predictive of adjustment however the researcher

hypothesized that economic status which was not included as

9

a variable may better explain this relationship. The low

response rate in this study is not discussed; the

possibility that those who did not participate had too many

demands of illness and daily hassles to have time was not

explored.

Berckman and Austin (1993) investigated the

relationships among casual attribution, perceived control

and adjustment to lung cancer. The 61 subjects (41 male and

20 female) in this sample ranged in age from 36 to 80 years

with a mean of 60 years. Most were married, unemployed,

disabled or retired, and had less than high school

completion. The mean time since diagnosis was 23 months. A

combination of a structured interview with opened ended

questions and questionnaires were used. In relation to

casual attribution subjects were asked what they thought had

caused their cancer and what they thought causes cancer and

general. In addition they completed a questionnaire rating

the importance of 30 interna1 and external causal beliefs

and four items related to identifying responsibility for the

cause of the cancer. Perceived control was assessed by one

open ended question and 17 scaled items. Subjects were asked

to list al1 the ways in which they had control over the

course of their cancer, to rate the extent to which they

could control the course of their cancer and its recurrence,

and to rate the importance of 16 different ways of

perceiving control. Adjustment was measured using the

10

Psychosocial Adjustment to Illness scale.

Interestingly it was found that most patients indicated

that they thought that they were adjusting very well to

their illness. A significant relationship between perceived

control and adjustment was not found, however both internal

and external causal attributions were related to poor

adjustment. Those who attributed internal causation for

their cancer had low adjustment scores in terms of their

domestic and social environments and high psychological

distress. Those who attributed their cancer to external

causes also had low adjustment scores in their domestic

environment and high psychological distress but did have

better scores for sema1 adjustment,

The factors predicting psychological distress in

relation to a diagnosis of lung cancer have also been

studied in other cultures. Akechi, Kugaya, Okamura,

Nishiwaki, Yamawaki and Uchitomi (1998) studied the

influence of coping, social support, and demographic

variables on distress among 87 Japanese ambulatory lung

cancer patients. This sample consisted of 61 males and 26

fernales, The mean age was 62.4 years and most w e r e married.

Al1 types and stages of primary lung cancer were included.

Coping was measured using the Japanese version of the Mental

Adjustment to Cancer (HM) scale. This is a 40 item self-

rating scale consisting of 5 subscales which are the coping

styles. The utilization of confidants was the measure of

11

social support. Psychological distress was measured by the

Profile of Mood States (POnS). Multiple regression analysis

produced a mode1 explaining 52 percent of the variance in

the total mood disturbance score. The variables predicting

greater distress were female gender, living alone, no

children in the role of confidant, nurses as confidants and

helplessness/hopelessness as a coping style. The authors of

this study suggested that the finding thst having nurses as

confidants was a predictor of greater distress may have

simply indicated that those who were more distressed sought

support f rom nurses.

It is evident from the literature that lung cancer is

xesponsible for a great deal of psychological as well as

physical distress. Disease related variables such as type of

lung cancer, functional status, and extent of the disease

are important in terms of both physical and psychological

distress but do not provide a complete explanation of why

this distress is greater or less for some individuals. The

literature suggests that it is very likely the outcome of

many factors. The role coping plays in determining and

modifying the physical and psychological response to lung

cancer was considered in only one study in the literature

reviewed . CoPina

Coping has been defined by Lazarus and Folkman (1984)

as "constantly changing cognitive and behavioral efforts to

12

manage specific external and/or interna1 demands that are

appraised as taxing or exceeding the resources of the

personn ( p.141). This definition of coping or paraphrasing

of this definition is the most frequently cited in coping

literature in general (Latack & Havlovic, 1992) and in

nursing literature (Jalowiec, 1993)- A similar definition,

"coping is what one does about a perceived problem in order

to bring about relief, reward, quiescence, or equilibriumH,

was previously provided by Weisman and Worden (1976-1977).

This conceptualization of coping differs from the

traditional psychoanalytic view and from the commanly held

meaning of the word. Coping as part of this traditional

mode1 was viewed as superior to defense- Strategies in

response to stressful situations are considered inherently

good or bad and are not judged on outcome (Lazanis &

Folkman, 1984)-

In common usage the word coping is frequently used to

refer to outcome. For example to Say he or she "is coping"

usually implies that that person is managing the stressor at

least reasonably well. Both in the traditional models and in

common usage the term coping is positive, meaning the person

is managing or adapting well.

Coping according to Lazarus and Folkman (1984) is part

of the process that occurs in response to a stressful

situation. Not al1 coping will be effective in achieving the

desired outcome and not al1 situations are amenable to

13

change for the better. Strategies in and of themselves are

neither good or bad and can be judged only in t e m s of

effectiveness in producinq the desired outcome or at least a

tolerable one

Coping is influenced by a vast array of persona1 and

situational factors. The influence of personality, and

demographic variables are examined in relation to coping

strategies and outcome in the following sections.

C Q D ~ U m d P e t ; c o n u

Somerfield and Curbow (1992) in a review of

methodological and research issues in the study of coping

with cancer, conclude that personality variables may be

implicated in coping with cancer and may help predict the

use and effectiveness of various coping strategies-

While Lazarus and Folkman (1984) argue in favour of a

situational process approach to coping it is important to

note that they do not deny the importance of coping traits.

Lazarus (1993a) describes trait and process as two sides of

the same coin with both sides usually being relevant.

Lazarus (1993b), notes that some strategies such as thinking

positively tend to be stable across situations and depend on

personality.

Bolger (1990) studied the personality disposition of

neuroticism (defined as a broad dimension of personality

characterized by autonomie nervous system lability and a

tendency to experience negative emotions) in relation to

14

coping and outcomes of both psychological distress and

performance. The sample consisted of 50 (24 male and 26

female) college students taking the Medical College

Admissions Test (MCAT). The average age for the sample was

20.3 years. Measures included a 24 item neuroticism scale

from the Eysenck Personality Inventory, coping was measured

using the Ways of Coping scale and anxiety using a daily

diary containing three items from the Profile of Mood

States. Grade point averages (GPA) and the HCAT scores were

also obtained. Neuroticism was measured at time one, five

weeks prior to the exam, GPAs were also obtained at this

point along w i t h coping methods. Coping methods were again

assessed at time two which was 10 days prior to the exam and

also at time three, 17 days after the exam. Anxiety was

measured daily from 17 days prior to the exam until 17 days

following the exam. Controlling for preexisting anxiety

differences, neuroticism was associated with increases in

anxiety under stress. This difference was found to be

mediated by the greater use of the coping mode of wishful

thinking and self-blame. No difference in performance (exam

score) was found to be related to personality or coping

differences.

The complexity of personality in the understanding of

coping is evident in Bolger and Zuckerman (1995) proposed

framework for considering the different possible roles of

personality in the stress/coping process. Personality is

15

considered to have four possible influences on coping. No

affect, affects only coping choice, affects only coping

effectiveness or affects both. This framew~rk was used in a

study of 94 students. The personality trait studied was

neuroticism and the stressor was interpersonal conflicts.

In this study a relationship was found between the

personality trait and particular choice of coping

strategies. The high-neuroticism group engaged in more

planful problem solving, self-controlling, seeking social

support, and escape-avoidance strategies. The coping

strategies used were also related to different outcomes

based on the personality trait. For example with the high

neuroticism group the use of self-control coping in response

to conflicts resulted in greater depression the following

day. The reverse was true for the low-neuroticism group. In

this case it would appear that personality affects both

choice and effectiveness of the coping strategy. The

subjects of this study were college students and one would

assume generally healthy. However there have been a number

of studies supporting the concept of coping styles in the

cancer literature.

Monitoring and blunting styles were studied by Leman

et al (1990) among a convenience sample of 48 patient

receiving chemotherapy. In this quasi experimental study

patients were randomly assigned to either a treatment group

which received relaxation training or to a control group.

16

Coping style was measured using the Miller Behavioral Style

Scale, There was not a significant difference in the number

of subjects with each coping style between the experimental

or control group. While a num.ber of cancer tumor sites were

included the majority had either breast cancer (38%) or

lymphoma ( 2 5 % ) , 67 percent of the sample was female. As

expected, monitoring which is characterized by increased

vigilance under stress was associated with higher self-

reported anxiety and nausea, Blunting which is characterized

by distraction strategies was associated with less anxiety,

depression and nausea. Blunters in the experimental group

experienced significantly less anticipatory anxiety than

those in the control group, indicating that the relaxation

intervention did have an effect for this coping style, This

was not found among those with a monitoring style.

These coping dispositions were also considered in

relation to women at increased risk for ovarian cancer

(Schwartz, Leman, Miller, Daly & Hasny, 1995). In this

study of 103 women with at least one first degree relative

with ovarian cancer, monitoring was predictive of increased

perception of risk and of more intrusive thoughts.

Monitoring was indirectly related to psychological distress.

Three styles emerged in a qualitative study examining

patients adaption to cancer treatment (chemotherapy or

radiotherapy) (Lev, 1992). Forty-seven patients (21 male and

26 female) ranging in age from 19 to 87 years with a variety

17

different cancer diagnoses participated in the study. Two

these styles, npreparersn and nsuppressorn were telated

decreased emotional distress. The third, navoidersn, was

associated with increased emotional arousal.

Coping effectiveness in terms of adaptational outcomes

such as psychological and physical well-being is an

important consideration for nursing. It is evident that

certain strategies at least for certain individuals in

certain circumstances have better outcomes. The particular

characteristic of the individual, the situation and hou it

is appraised, and the coping strategies selected will al1

influence the outcome.

No research-has been completed that examines the

relationships of personality characteristics, coping

strategies and psychological well-being in people with lung

cancer. Studies involving people with cancer of a variety of

other types indicates that a relationship between optimism,

selection of coping strategies, and less psychological

distress znay exist. Research in the area of personality,

specifically the personality trait of optimism, is needed to

add to the understanding of different responses to lung

cancer. These relationships are expanded upon in the

following sections.

18

Ootimisw

Optimism, in the common usage of the word, is closely

linked to the concept of h o p and to possessing positive

attitude. A positive attitude, h o p and optimism have also

been linked in a role believed to foster healing and in cure

(Seigel, 1986; Cousins, 1991)- While these authors do not

disregard the value of medical care they believe that the

power of the mind exceeds that which is possible through

modern medicine.

Bruckbauer and Ward (1993) studied the public's

perception of a positive mental attitude ( P m ) and health

beliefs. In this sample of 167 mostly white and middle class

subjects the majority (71 percent) included themes of hope

and optimism in their meaning of Pm. The authots defined

optimism as a positive attitude about the present and hope

was referred to as a positive future orientation- In this

study PMA was believed to influence the prevention of

illness in general but not the prevention of cancer.

However the majority did believe that PMA influenced the

recovery from cancer.

Optimism was defined by the Merriam-Webster dictionary

(1989) as "an inclination to anticipate the best possible

outcome of action or eventm and hope "to desire with

expectation of fulfilmentn contrary to Bruckbauer and WardOs

definition both imply future orientation.

Hope and optimism have been considered related but not

19

identical concepts (Stubblefield, 1995). Lazarus (1991)

differentiates hope and optimism based on the degree of

confidence regarding outcome. When there is confidence that

things will work out positiveiy it is optimism not h o p

which is experienced. Scheier and C a r v e r (1985) provide a

similar view that optimism is not the h o p for a desirable

event but the expectation of its occurrence. It seem that

confidence in outcome is significant in differentiating the

two concepts. We know that we can h o p for anything but this

does not mean we are necessarily optimistic about the

outcome.

Scheier and Carver (1985, 1992) used the term

dispositional optimism to describe individuals who hold

positive expectations for success which are relatively

stable across time and context. Carver and Scheier8s

interest in optimism arose from their study of the process

involved in behavioral self regulation. An assumption

underlying Carver and Scheiergs mode1 of behavioral self

regulation is that expectancies influence action Le. if the

outcome or goal is believed to be attainable efforts will be

continued to achieve the goal no mattsr how difficult,

however if goals are not believed to be attainable then

efforts will stop and the individual will withdraw from the

goal. Therefore behaviour and expectancy are linked. When a

discrepancy exists between the current situation and the

goal, an assessment of the possibility of goal achievement

20

must be made, an optimist having a greater expectation of

success is more likely than a pessimist to view the goal as

attainable and therefore more likely to persist. This

expectation of success is also believed to result in

differences in affect with those who see their goal as being

attainable experiencing a more positive affect.

Carver and Scheier (1992) proposed that the optimist

and the pessimist would experience different outcomes and

that these differences are at least in part related to the

differences in strategies used by optimists and pessimists

to cope with stress.

Dispositional optimism as a general expectancy has been

defined by Scheier and Carver (1992) the tendency to

believe that one will generally experience good vs. bad

outcomes in lifen (p. 202). They developed a measure of this

characteristic called the Life Orientation Test (Scheier &

C a r v e r , 1985).

d Co-

Empirical support for the relationship between optimism

and specific coping strategies has b e n found with a number

of different populations; university students (Carver,

Scheier, & Weintraub, 1989; Scheier, Weintraub, & Carver,

1986; Chang, 1998), first year law students (Segerstrom,

Taylor, Kemeny 6 Fahey, 1998), patients recovering from

coronary artery bypass surgery (Scheier, Hatthews, Owens,

Hagovern, Lefebvre, Abbott & Carver, 1989; King, Rowe,

21

Kimble & Zerwic, 1998), participants in a cardiac

rehabilitation program (Shepperd, Haroto & Pbert, 1996),

people with cancer ( Friedman et al, 1992) and specifically

with breast cancer (Stanton 4 Snider, 1993; Carver et al,

1993). In these studies the method of measuring coping

varied, however the Life Orientation Test vas consistently

the measure of dispositional optimism.

Scheier, Weintraub, and Carver, (1986) carried out two

studies with university students to determine if the coping

strategies of optimists and pessimists differed. The first

study consisted of 181 male and 110 female students. Coping

strategies were assessed using the Ways of Coping Checklist

in relation to the most stressful event the student had

experienced in the previous two months. Through factor

analysis the Ways of Coping Checklist was reduced to seven

factors. Results showed optimism to be significantly

associated with four of the seven factors. Positive

associations were reported with problem focused coping (x =

. 2 2 , p < -01) and positive reinterpretation (x = -26, Q <

-01) when the situation was viewed as controllable and

acceptance/resignation (x = .33, Q < .001) in situations

which uncontrollable. A negative correlation was found with

distancing/denial strategies (r = 9.12, Q e . 0 5 ) . The use of

acceptance/resignation was somewhat unexpected, this is

explained somewhat by the fact that it was only significant

when the situation was felt to be uncontrollable. Another

22

unexpected finding was that seeking out of social support

was only significant among males.

While interesting and for the most part expected

results were produced by this study it should be noted that

the coping strategies used were based on student recall of

an event that occurred up to two months before, In addition

this study provided no indication of the effectiveness of

the strategies . More recently, Chang, (1998a) studied optimism,

appraisals, coping and adjustment among 253 male and 497

female predominantly white, freshmen students. Age range was

15 to 48 years with a mean of 19.7 years, Coping was

measured using the Coping Strategies Inventory (CSI) a 72

item self report inventory similar in format to the Ways of

Coping Checklist. The stressor was the first examination of

ar, introductory psychology course, al1 measures were in the

form of a take home survey given out on the day of the exam

and returned on the next class day. Results of this study

indicated that optimists used significantly more cognitive

restructuring strategies while pessimists used more wishful

thinking, self criticism and social withdrawal strategies in

coping with the examination. Regression analysis,

controlling for differences in sex and appraisal, indicated

that optimism was significant in explaining additional

amounts of the variance in predicting seven of the eight

coping strategies,

23

Segerstrom et al (1998) examined optimism in relation

to mood, coping and immune change in response to the stress

of being a student in first year law, Ninety students age 20

to 37 years (M = 23-9) participated, just over half were

white, most were single. Optimism was measured in the 2

weeks prior to law school orientation and coping, assessed

by the Coping Operations Preference Enquiry (COPE) was

measured at midsemester. In this study dispositional

optimism was significantly associated with the use of less

avoidance coping (r = 0.21, p < . 0 5 ) .

Scheier, et al. (1989) studied dispositional optimism,

coping strategies, physical recovery, mood, and post surgery

quality of life in 51 male patients undergoing coronary

artery bypass. The average age of the subjects was 48.5

years, most were married, employed full time and had high

school or less education. In this longitudinal study

assessment was carried out on three occasions, the day

before surgery, 6 to 8 days postoperatively and 6 months

postoperatively. Coping strategies were assessed prior to

surgery and in the early postoperative period. Unfortunately

coping strategies were not measured using a psychometrically

tested instrument. Pour questions were asked ta assess

coping strategies, 1) hou much thought they had given to

their symptoms, emotions and stay in hospital, 2) the extent

to which they had tried to ignore or not think about these

things, 3) the degree to which they had sought out

24

information relevant ta their operation and recovery, and 4)

the degree to which they had made plans and set goals for

recovery. Prior to surgery optimists were more likely ta be

making plans and setting goals for recovery and

postoperatively to report seeking information about

recovery. Optimists were less likely to report being helped

by not thinking about w h a t recovery would be like. These

results are similar to those previously cited in that

optimists tend to use more problem focused strategies and

fewer avoidance strategies.

King et al., (1998) also studied optimism, coping and

long term recovery following coronary artery surgery but the

participants in this study were 55 women. The mean age of

the participants was older than the males in the preceding

study (H = 62.2) but the samples were similar in terms of

race and martial status. In this study coping was measured

by the Ways of Coping Revised scale and by an interview

constructed specifically for patients having coronary artery

bypass graft surgery. The data collection times were 5 to 6

days p s t surgery, and at 1, 6, and 12 months. Optimism in

this study related to only the coping strategy escapism at

12 months,(r = 0.31, p < . 0 5 ) positive thinking at one week

(r = . 35 , p < .OS)and search for meaning at one month (r = - .29, p < - 0 5 ) .

The effects of optimism and coping have also b e n

studied among people with coronary artery disease (CAD)

25

participating in a cardiac rehabilitation program (Shepperd,

Maroto & P b e r t , 1996). The goal of this study was to

determine the relationship of dispositional optimism to

success at making health changes to lower risk factors

associated with CAD. This was a small study of 18 males and

4 females ranging in age from 40 to 80 years with a mean of

61. Dispositional optirnisi and coping as determined by the

COPE scale were assessed at the beginning of the

rehabilitation program. This study found very high

correlations between optimism and two styles of coping. A

positive correlation was determined between optimism and

problem-focused coping (r = -84, p ~ 0 0 0 1 ) and a negative

correlation with withdrawal strategies (r = 0.80, p <

.0001). Optimism was also associated with success in

lowering a number of the risk factors for CAD.

The relationship of optimism to particular strategies

was also demonstrated in a study of patients with cancer

(Friedman et al, 1992). The sample of 94 patients with

cancer of various sites, were recruited while waiting in

clinic for their follow up visit. The mean age for this

sample was 55 years, most were Caucasian (89%), married

(79%) and had on average 14 years of school. Coping was

measured using the Hoos Coping Scale. This is a 19 item

scale which classifies three methods of coping, active-

behavioral, active-cognitive and avoidance. In this study

the alpha for active-cognitive coping was unacceptably low

26

(.16) and therefore omitted from analysis. In response to

coping with the stress of cancer a positive relationship vas

found between optimism and active behaviour coping (x - 2 2 , p

< . 0 5 ) and a negative relationship with avoidance coping ( x

- , 43 , Q < .001).

The literature reviewed does provide support that there

are differences in the ways that optimist and pessimist cope

and a pattern of more problem focused coping and less

avoidance/withdrawal coping among optimist does emerge, It

is difficult, however to draw firm conclusions because of

the variety of measures used to assess coping. It should

also be noted that the correlations between optimism and the

coping strategies are for the most part quite 10%

vcholoaical Well - Re- A number of different outcomes have been studied in

relation to coping and dispositional optimism. tazarus and

Folkman (1984) identify three basic adaptational outcomes;

functioning in work and social living, morale or life

satisfaction, and somatic health. Morale and psychological

well being are presented as similar if not identical

concepts including dimensions of happiness, satisfaction and

subjective well-being. Morale is described as a background

affective state that is relatively enduring. Dispositional

optimism is also believed to influence the outcomes of

psychological and physical well-being, however an

independent relationship between optimism and physical well-

27

being, at least in terms of symptom reporting has not been

supported (Scheier, Carver & Bridges, 1994). Psychological

well-being is usually measured in terms of mood, affect or

depression scores. The outcome of psychological well being

is the focus of the following review.

Optimism and coping have both been studied in relation

to psychological well-being in a number of different

populations.

Chang (1998b) studied the role of dispositional

optimism as a moderator between perceived stress and

psychological well-being among university students enrolled

in a psychology course. The participants in this study were

predominantly white and ranged in age from 16 to 43 years (m

= 19.9). Perceived stress was measured by the Perceived

Stress scale (PSS) a 14 item self appraisal measure

reflecting the degree of perceived stress in the past month.

Psychological well-being was measured by the Satisfaction

With Life Scale (SWLS), a 5 item measure of global life

satisfaction and the Beck Depression Inventory (BDX), a 21

item self-report measure of depressive symptomatology. Based

on the results of hierarchical regression analyses this

study found that optimism accounted for a small but

significant additional variance over that accounted for by

perceived stress for both outcome measures; for depressive

symptoms, optimism accounted for an additional 3 percent and

for life satisfaction an additional 8 percent. Optimism

28

was also found to have a small but significant moderating

effect between perceived stress and psychological well-king

as measured in this study. Coping was not a variable in this

study . In a similar population, using the same outcome

measures for psychological well-being Chang (1998a),

examined the effect of appraisal and coping along with

dispositional optimism. Again dispositional optimism was

found to add significantly (10 percent of the variance) to

the prediction of psychological well-being beyond the

variance accounted for by appraisal and coping.

Optimism has also been examined in other cultures.

Sumi, (1997), investigated the role of optimism, social

support, and stress on psychological and physical well-king

in 176 Japanese female college students (H age = 18.7

years). The Life Orientation Test (LOT) was the measure of

optimism and psychological well-being was measured by the

depression and anxiety subscales of the Hopkins Symptoms

Checklist. Results of this study indicated that those rating

themselves higher on optimism also reported better well-

being regardless of perceived stress.

Carver and Gaines (1987) studied the role of optimism

and pessimism in postpartum depression. Seventy-five women

in their third trimester completed the LOT measure of

dispositional optimism and the Beck Depression Inventory

(BDI). The BDI was completed again at three weeks

postpartum, Controlling for prenatal depression levels a

significant negative relationship was found for optimism and

postpartum depression. Given that a number of very possibly

significant variables, such as the temperament of the

infant, were not measured or controlled the authors are

cautious in their conclusions.

A study conducted by Lauver and Tak (1995) examined the

relationships among optimism, delay in seeking care for

breast cancer symptoms, anxiety regarding symptoms and

expectations of positive outcomes of care seeking. One

hundred and thirty five women attending a clinic for

evaluation of breast cancer symptoms participated in the

study. Optimism was found to have a significant but indirect

effect on anxiety. This relationship was mediated through

expectations of care seeking (Le. optimism was positively

related to expectations of positive outcomes of seeking

care). optimism scores were also inversely related to delay

in care seeking but when occupational status was controlled

for, the relationship between less delay in seeking care for

breast cancer symptoms and optimism was not significant.

In the previously discussed study of men undergoing

coronary artery bypass surgery (Scheier, et al, 1989)

psychological well-being was measured in terms of

depression, anxiety, and hostility and through a measure of

quality of life. Optimists had significantly louer

presurgical hostility scores but no other difierences were

30

found in relation to mood. It should be noted that optimists

reported being more satisfied with medical care and with the

emotional support they received from friends. Quality of

life at 6 months was reported as significantly higher by

optimists, Unfortunately this variable had not b e n

previously measured, One would expect that quality of life

would also be significantly higher among optimist

preoperatively.

This study did find a positive relationship between

optimism and recovery. Optimists took significantly fewer

days post surgery to resume ambulation and were found to

have normalized their lives in a fewer number of weeks than

pessimists.

In the study by King et al (1998) of women having had

coronary artery surgery psychological well-being was

determined by the Bipolar Profile of Pfood States (POMS-BI)

and the Satisfaction with Life Scale. Optimism was measured

at one week post surgery and the measures of well-being were

completed at 1 week, 1,6 and 12 months post surgery.

Significant positive correlations were found between

optimism and positive mood and life satisfaction at al1

measurement points (r = - 3 4 - .Sb). Significant negative

correlations for negative mood were found at 1 and 12 months

(r = 0.42 and - 3 7 respectively).

A number of significant correlations, most in the low

to moderate range, between the various coping strategies and

31

outcome variables were found. The stronger of these

correlations included negative mood with escapism at 6 and

12 months (r = - 53 and -38 respectively, p < .Cl) and with

avoidance at 1 week (r = -29, p < - 0 5 ) , 1 month (r = .44, p

< -01) and 6 months (r = -39, p < .01) A significant

negative correlation vas also found between escapism and

life satisfaction at 6 months (r = - . 3 7 , p < .01).

The coping strategy search for meaning was negatively

correlated with positive mood at one week (r 0 . 2 7 , p < - 0 5 )

and with life satisfaction at one month (r = 9-31, p < . 0 5 ) ,

It was correlated also with negative mood at one and six

months (r = -41, p < .01).

The relationship of optimism and m o d disturbance among

people living with the life threatening illness of recurrent

ventricular dysrhythmia while awaiting implantation of an

interna1 cardioverter defibrillator has been investigated

(Dunbar, Jenkins, Hawthorne, & Porter, 1996)- Of the 101

participants in this study 84 were males and 17 female, most

were married and between the ages of 24 and 79 years (m =

34.1)- In this study optimism was found to have a

significant moderate negative correlation (r = -.40, p =

-001) with the mood disturbance score as measures by the

Profile of Mood States. Only the POMS total score was used

in this study- Coping as measured by the Jalowiec Coping

Scale was also a variable in this study. Only the evasive

and confrontive subscale were reportedm A moderate

32

significant association between the total mood disturbance

score and the evasive coping score (r = .44, p < .OS) was

determined. Optimism was not significantly correlated with

evasive coping. Results of multiple regression analyses

indicated that less dispositional optimism and the use of

evasive coping were significant predictors of greater mood

disturbance. Female se% was also a significant predictor of

greater distress in this study.

Taylor et al. (1992) studied the relationship of

optimism and distress in a group of 550 gay men at risk for

developing AIDS. Two groups were studied, those w h o were HIV

seropositive (238) and those who were HIV seronegative

(312). The sample was recruited from a cohort of men

participating in the Multicenter AIDS Cohort Study, a

multisite longitudinal research study. Optimism was assessed

using the LOT scale. A psychological distress score was

developed using both the Profile of Mood states and the Beck

Hopelessness scale. The appropriateness of using the later

scale is questionable as it has been referred to as both a

measure of hopelessness (Stoner, 1988) and as a measure of

pessimism (Beck, Weissman, Lester, & Trexler, 1974).

In this study hierarchical regression analysis was used

to examine the relationship between optimism and

psychological adjustment. Entered into the equation were

age, partner status HIV serotype and in the fourth step

optimism. This mode1 explained 35% of the variance in

33

psychological distress. Dispositional optimism was the only

significant predictor (M = - 3 4 , p < .OOOl).

The role of optimism in relation to psychological

distress has also been examined among patients with cancer

being evaluated for bone marrow transplantation (BHT)

(Baker, Marcellus, Zabora, Polland, & Jodrey, 1997). The 259

male and 179 female participants in this study were

predominantly white, married and between the ages of 18 and

65 (M = 40). Two measures of psychological status were used,

the Centre for Epidemiologic Studies - Depression cale (CES-D) and the Profile of Mood States (POMS). Optimism as

measured by LOT was significantly correlated with al1

psychological outcome measures. Al1 correlations were

negative with the exception of the P O M S vigor-activity

subscale. In multiple regression analyses with al1

independent variables entered (age, sex, social support,

family function, persona1 control, physical function and

optimism) optimism remained a significant predictor for al1

of the psychological distress outcomes except for POHS-

fatigue.

Dunkel-Schetter, Feinstein, Taylor, and Falke, (1992)

in a study of 603 people with a variety of types of cancer

examined coping strategies used in managing what was

referred to as the most stressful aspect their cancer.

Coping was assessed using the Ways of Coping Cancer Version.

Emotional state, as measured by POMS, was found to be to be

34

related to five patterns of coping. Less distress was

associated with coping strategies of social support,

focusing on the positive, and distancing; more distress was

reported with both cognitive and behavioral escape-

avoidance.

mile optimism was not a variable in the Dunkel-

Schetter, Feinstein, Taylor, and Falke, (1992) study

optimism has previously been positively associated with

focusing on the positive and negatively associated with

avoidance coping.

A relationship between optimism, coping strategies used

and psychological well-being has been demonstrated in two

studies of women with breast cancer. Stanton and Snider

(1993) conducted a longitudinal study comparing women who

underwent breast biopsy and received a benign diagnosis with

those receiving a cancer diagnosis. One hundred and forty

seven women who were referred for a breast biopsy agreed ta

participate. Of this sample 36 received a cancer diagnosis

and 111 a benign diagnosis. The two groups differed in terms

of age with al1 the cancer group k i n g age 40 or over,

therefore women in the benign group under forty were deleted

from the analysis. The majority of the women were white,

married and had a high schaol eduction. Data were collected

at three points in t h e ; 24 hours pre-biopsy, 24 hours

before surgery, and at 3 weeks following surgery for those

who received a cancer diagnosis. The group receiving a

3 5

benign diagnosis completed the questionnaires at time one.

Approximately one half of this group (n=20) vas selected to

complete the questionnaires at a time corresponding to time

two and the other half (n=27) at time three. Locus of

control, dispositional optimism, cognitive appraisal, coping

and mood were measured. The Ways of Coping Questionnaire was

the nieasure of coping used in this study. Dispositional

optimism was measured using the Life Orientation Test.

Pre-biopsy the groups did not differ on the variables

measured. Post diagnosis (time 2) results w e r e as expected,

women who received a cancer diagnosis were more tense,

depressed, angry, fatigued, confused and less vigorous. At

time 3 (post-surgery) women with the cancer diagnosis were

less vigorous and more fatigued but surprisingly the groups

did not differ on tension, depression, anger or confusion.

Regression analysis revealed that age, optimism,

threat, and coping were al1 significant in explaining the

variance in the negative mood scores pre-biopsy. More

distress was reported by women who were younger, less

optimistic, more threatened and engaged in more cognitive

avoidance coping. The mediation role of coping in the

relationship between optimism and negative mood was

supported for one coping strategy cognitive avoidance.

Optimism however did remain a significant unique predictor

of negative mood. It is of note that p s t biopsy and p s t

surgery optimism was not a significant predictor of vigor or

36

negative mood. The use of cognitive avoidance coping was a

significant predictor of negative mood and vigor both post

biopsy and post surgery.

In a prospective longitudinal investigation (Carver et

al,, 1993) of 59 women with stage I and II breast cancer the

personality disposition of optimism, coping and distress

were studied. The women in this study ranged in age from 33

to 72 years, most were married, were white and on average

had completed 14.15 years of education. Optimism was

measured at the initial interview using the Life Orientation

Test. Scores for this group tended toward the optimistic but

not to an extreme. Mood and coping were measured pre and

post surgery and at three, six and twelve months. Coping was

measured in this study by the Cope Scale (Carver et al.

1989). Copinq strategies of acceptance and use of humour

were found to be positively related to optimism. As with the

previously discussed finding among patients undergoing

coronary bypass surgery, optimism was associated in the pre-

surgery period with active coping and planning. As expected

negative correlations were found in relationship of optimism

to the coping strategies of denial and disengagement . The relationship of optimism and distress is much more

evident in this study. Optimism was negatively correlated

with distress at al1 measurement points, (pce and post

surgery and at 3, 6 and 12 month follow up). Controlling for

the level of distress at the prior assessment the

37

relationship of optimism to distress remained significant at

al1 points except p s t surgery, The role of coping as a

mediator between optimism and distress vas also examined in

this study at each measurement point while controlling for

the previous level of distress, Significant mediators

included the coping strategies of humour and acceptance at 6

months and behavioral disengagement at 12 months.

Lazarus and Folkman (1984) argue that the effectiveness

of a coping strategy may Vary depending on both the

situation and the stage of situation. There is some support

for this found in Carver et al (1993) study of women with

breast cancer, In this study the use of individual

strategies varied over the course of the study with some

rapidly declining and others gradually stabilizing, the use

of humour and religion proved to be the most stable.

The effects of both optimism and coping in relation to

psychological distress and well-being were studied among a

sample of 75 adults with advanced cancer (Miller, Manne,

Taylor, Keates 61 Dougherty, 1996)- The participants inthis

study (33 female and 42 males) were predominantly white and

between the ages of 35 and 75 years. Most had been diagnosed

with gastrointestinal tract cancer. ~uestionnaires were

completed on 3 occasions each 2 months apart. Optimism was

measured using the Life Orientation Test (LûT) and coping by

the Ways of Coping Questionnaire - Revised Version (WOC-R;

Folkman et al, 1986). In this study three of the coping

38

subscales (distancing, confrontive coping and self-control)

were excluded because of low interna1 consistency

coefficients, Psychological distress/well-being was measured

using the Mental Health Inventory (MHI). Correlational

analyses at both time 1 and time 3 indicated a significant

negative relationship between optimism and psychological

distress ( r = - 053 , and -061 respectively, p < ,005) and a

significant positive relationship with well-being (r = -69

and - 7 3 , respectively, p < , 0 0 5 ) . Among the coping

strategies escape-avoidance vas significantly related to

psychological distress at time 1 and t h e 3 (r = -43 and -61

respectively, p < .005). The negative relationship between

escape avoidance and well-being did not reach significance.

The only other coping strategy that vas significantly

related to outcome was accepting responsibility. This

occurred only at tirne 3, accepting responsibility was

inversely related to well-being (r = - -36) and was correlated in a positive direction with psychological

distress (r = .49).

Hierarchical regression analyses were conducted with

the time 3 distress and well-being scores as the dependent

variables. The independent variables entesed into each

equations were age, functional status, previous

distress/well-being scores, optimism and the coping

subscales escape-avoidance and accepting responsibility- In

the equation predicting distress 70 percent of the variance

39

was explained by the independent variables. Overall younger

age, louer functional status, less dispositional optimism

and greater use of escape-avoidance coping predicted greater

distress. Of this optimism accounted for 9 percent (p <.001)

of the variance and escape avoidance coping for 11 percent

(p <.OOOl). Sixty-six percent of the variance in well-being

was explained. In this case older age, better functional

status, more dispositional optimism and less use of

accepting responsibility predicted greater well-being. Of

this optimism accounted for 30 percent (p <.0001) of the

variance and accepting responsibility for 3 percent (p

c . 0 5 ) .

The literature reviewed is somewhat difficult to

interpret due to the differences in the coping measurement

scales used. While no conclusion can be drawn, there are a

nurnber of fairly consistent findings. There is some evidence

that at least in some situations optimists and pessimists

(as detemined by the Life Orientation Test) tend to use

different coping strategies in similar situations. In tenus

of psychological well-being optimists tend to have better

outcomes. Some coping strategies such as problem focused

coping, and positive focus/positive reframing tend to

consistently result in better psychological outcome (less

distress) while denial and avoidance produce greater

distress. While minimal there is some evidence that as

Carver and Scheier (1985, 1992) suggest it may be that the

relationship between optimism and more positive outcornes

occurs at least partially through their selection of coping

strategies. None of the çtudies reviewed, which examined the

relationships of optimism, coping and psychological well-

being, focused specifically on people with lung cancer.

Genaer

Until recent years lung cancer was a predominantly

male disease. However according to Canadian Cancer

Statistics (1998) lung cancer among women is the second most

common cancer and the leading cause of cancer death. Gender

differences have been noted in the psychological response to

lung cancer (Akechi et a1.,1998; Hopwood & Stephens, 1995;

Cella et al, 1987). With more women developing lung cancer

it is necessary to consider if gender plays a role in coping

strategy selection and effectiveness. Two questions seem to

be of importance in this issue. Are there gender differences

in coping and if so what are these differences?

Porter and Stone (1995) conducted a 20 day longitudinal

study of 79 middle-class community residing, married

couples. The average age for males in the study was 43 years

and 40 years for fernales. The couples completed daily

questionnaire booklets which included the most bothersome

event of the day, apptaisal, and coping assessment.

Differences were found in the content of the stressful

event, with women reporting more parenting and interpersonal

4 1

problems and men more work related and non-interpersonal

problems. However gender differences in the use of coping

strategies were minimal, leading to the suggestion that the

content of the problem was more influential in the selection

of coping responses than the gender of the individual. This

finding is consistent with the conclusion made by Lazarus

(1993b) that men and women show very similar coping patterns

when the type of stressful situation is the same.

These results differ from those of Ptacek, Smith, and

Zanas (1992) in a 21 day longitudinal study of 152 college

students (42 males and 110 females). The age range for this

sample was 18 to 46 with an average for males of 23 years

and 22 for females. Only 16 of the subjects were married.

The data collection format was similar to that used by

Porter and Stone (1995). In this sample bath men and women

reported the same content areas for stressful situations

however men reported using more problem-focused methods and

were more likely to use these as the first strategy applied.

Women used more coping strategies per event than men and

used social support more frequently than men. Thoits (1991)

also studying college students reported fairly similar

findings which provided some support for this stereotypical

picture . Stanton, Danoff-Burg, Cameron, and Ellis (1994) found

that the use of emotion focused coping may have very

different outcomes for men and women. In a sample of 83

42

female and 88 male undergraduate college students Stanton et

al. found that in situations of low-control men who used

emotional focused coping became more depressed over time

where as women became less depressed.

Dunkel-Schetter, Feinstein, Taylor, and Falke (1992)

in a sample of 603 people with cancer studied a number of

variables in relation to patterns of coping with stressor

related to the cancer. Gender was not found to be related to

the use of coping strategies.

Gender may play a role in the relationship between

optimism and selection of coping strategies. In a study of

university students optimism was positively associated with

seeking social support but this finding was gender (being

male) specific (Scheier, Weintraub C Carver, 1986)

Results from recent studies of the gender-coping issue

have illustrated that a clear understanding of the

relationship between gender and coping has not been

achieved. While gender does, at least in some samples, seem

to influence coping strategies and possibly psychological

outcomes the results are not conclusive and further research

is needed.

Aae

Lung cancer is generally a disease of middle 40-60 and

older 60+ age groups. As the roles and responsibilities of

these two age groups differ it is possible that age may also

influence coping. Whether or not coping changes with aging,

43

from young adulthod to old age is unclear (Lazarus &

Folkman, 1984). Age differences have been found in relation

to emotional response to a diagnosis of cancer (Edlund 61

Sneed, 1989). The sample in this study consisted of 44 males

and 89 females with a variety of cancer types. Age ranged

from 22 to 87 years. Four age groups were established; 21 to

49 years, 50 to 59 years, 60 to 69 years and 70 years and

older. In this sample socioeconomic status decreased with

increasing age. Coping strategies were not measured.

Distress was measured using the Brief Symptom Inventory

which focuses on emotional distress and the Health Insurance

Study General Well-Being Schedule which focuses on general

well being and mental health. Attitudes toward cancer were

measured by the Cancer Attitude Inventory. The oldest age

group was found to have the most negative attitudes about

cancer but also had significantly less psychological

distress on learning of the diagnosis.

In reviewing the literature Rook, Dooley, and Catalano

(1991) tentative concluded that age plays a modest role in

the choice of coping strategies. However in a study of

coping in young (18-34) middle ( 3 5 - 5 9 ) and older (60+ )

workers in relation to economic distress they found age was

significant not only in coping strategy selection but also

in terms of the emotional outcome of the strategy. For

example cutting expenses was associated with greater

depression in the the middle age gtoup but with less

44

depression in the younger group.

Folkman and Lazarus (1988a) also found differences in

age on the effect of coping on emotion. They compared the

findings of two studies. In one study, the younger sample,

the mean age of the women was 39.6 years and for the men

41.4 years. In the other study, the older sample, the mean

age of the women was 68.9 years and for the men 68.3 years.

Results indicated that positive reappraisal was associated

with decreased distress and increased positive feelings in

the younger group but with more worry/fear in the older

group. Confrontive coping was associated with increased

distress in the younger group and seeking social support

with increased positive emotions in the older group. These

results however must be viewed in light of a number of

limitations.

The samples used not only differed in age but also in

marital status, al1 the younger sample were married while

39% of the older group were single, divorced, or widowed.

Income was also significantly different with the median

family income for the younger sample being twice that of the

older sample. In addition to sample differences method also

differed. Coping was measured using the the Ways of Coping

Questionnaire however different versions and methods of

administration were used for the two samples. Emotions were

assessed by asking the subjects to indicate the extent to

which they experienced a number of different emotions

45

however again there were variations in the method used.

However a similar result was found in a sample of 77

patients with rheumatoid arthritis (Spitzer, Bar-Tal, &

Golander, 1995). In this study the mean age of the subjects

was 54.2 years. On average they had 10-3 years of formal

education. Coping was measured using a modified

questionnaire developed by Hoos et al. Three coping strategy

classifications were identified active cognitive coping,

active behavioral coping and avoidance coping. In this study

Active cognitive coping (strategies similar to positive

reappraisal) were was found to be more effective in reducing

psychological distress for the yowiger subjects than for the

older group.

The use of confrontive coping has produced varied

results. In the Folkman and Lazarus (1988a) study

confrontive coping vas associated with more distress in the

younger sample but had no effect in the older sample.

However in a sample of 59 long-term cancer survivors no age

differences were found in the use or effectiveness of

confrontive coping (Halstead & Fernsler, 1994). The age

range for this sample vas 21 to 82 years, most were female

and survivors of breast cancer (50.8%). The sample was

unusual in that most (61%) had at least college education

and were employed as professionals (57.8%). The sample was

divided into three group based on age; 21 to 40 years, 41 to

65 years and 66 to 82 years- The revised Jalowiec Coping

Scale was used to measure the use and effectiveness of

coping strategies. The elderly group perceived optimistic

(thinking positively), palliative (handling distress by

doing things to make one feel better) and supportant (using

supportive resources) strategies as most effective. Folkman

and Lazarus (1988a) also noted the use of social support

increased positive emotions in the older group.

Although limited, there does seem to be support for the

conclusion that the use of coping strategies varies w i t h

age. Coping must however be considered in the context of the

entire stress, appraisal, and coping process. Stressors,

appraisal of degree of stress, and coping resources must al1

be considered in future studies to clearly understand the

role of age in the selection of coping strategies and

influence on psychological outcome.

Lung cancer by its very nature as a life threatening

illness has a negative impact on psychological well-being.

The psychological distress resulting from a diagnosis of

lung cancer has been well documented. However coping with

the stressors resulting from this diagnosis has not been

examined. The selection of coping strategies and their

effectiveness is influenced by numerous factors. It has been

proposed that personality, specifically the personality

disposition of optimism, is one such factor. A number of

47

studies of differing populations both with and without a

specific illness have been completed which support the

relationships between optimism, coping strategy selection,

and psychological outcome. No studies examining these

relationships have been reported with regard to people with

lung cancer.

Age and gender have also been considered as possible

factors influencing the coping process. Research in both of

t h e s e areas has not provided a clear understanding of

whether the selection or effectiveness of coping strategies

is influenced by either age or gender. No research reporting

the effect of age or gender in relation to coping among

people with lung cancer was identified.

For nursing a better understanding of the influence of

optimism, age and gender on the selections of coping

strategies and the effectiveness of those strategies among

patients with lung cancer would enhance assessment, planning

and interventions.

Lazarus and Folkman's (1984) theory of stress and

coping was used to guide this study. This framework, which

has b e n frequently used in the study of the stress and

coping process in a variety of settings, provided a broad

framework encorpassing the concepts of stress, appraisal,

coping, person and environmental antecedents of stress and

4 8

coping, and short and long term adaptational outcornies

(p.306). Lazarus and Folkman (1984) describe their theory of

stress and coping as a transzctional process oriented model;

transactional because the person and environment are

constantly interacting and cbanging as a result of this

interaction. The person-environment relationship is viewed

as reciprocal and bidirectional. It is this constantly

changing process which was of interest in this study.

Psychological stress was defined as any person-

environment relationship which is appraised by the person as

taxing or exceeding resources and thereby endangering the

person's well being. Stress can therefore include a wide

variety of situations, appraisal is key in this process.

According to Lazarus and Folkman there are three types

of appraisal; primary, secondary, and reappraisal. Primary

appraisal is considered as a continuous cognitive process of

evaluating the meaning or significance of life situations.

In the primary appraisal process the situation may be

appraised as irrelevant, benign-positive or, stressful.

Stress appraisals are subclassified as harm or loss,

indicating that damage to self or social esteem has already

occurred, as a threat in which harm or loss are anticipated,

or as a challenge in that there is a potential for gain or

growth. Primary appraisal is influenced by persona1 factors

such as what is important and meaningful to the individual

(Le, values and beliefs).

4 9

Primary appraisal is also influenced by the

characteristics of the situation. Situational factors such

as novelty, predictability, and uncertainty al1 influence

the type of appraisal.

Secondary appraisal is the evaluation of what might or

can be done about the situation. Secondary appraisal depends

mainly on the coping resources available. Among these

resources Lazarus and Folkman include health and energy,

positive beliefs, problem-solving skills, social skills,

social support and material resources. While the role and

value of each of these resources is fairly evident, positive

beliefs require more explanation. Lazarus and Folkman (1984)

describe this category as beliefs which serve as a basis for

hope and which sustain coping in the most adverse

situations. Both primary and secondary appraisal influence

coping and in turn are influenced by coping.

Coping, as conceptualized by Lazarus and Folkman, is

viewed as a process. From this perspective coping has three

features. First the focus is on what the person actually

thinks or does, not on what the person usually does or would

do. Second the thought or action is considered in a specific

context i.e. what the person is coping with. Finally the

process is considered dynamic, with thoughts and actions

changing as the stressful situation unfolds.

Coping has two major functions, one is to manage or

change the stressful situation, termed problem-focused

50

coping and the other to regulate the emotional response to

the situation, termed emotion-focused coping.

Person and environmental antecedents of stress and

coping include personal values and beliefs, situational

factors, and factors identified as coping resources.

Conditions such as gender, age, socioeconomic status, and

personality traits, are often termed moderators (Folkman &

Lazarus, 1988a) and will also influence appraisal, coping

and outcome. Optimism when defined as a personality trait is

consider by Lazarus (1991) to be an antecedent variable and

as such probably influences appraisal and coping and may

influence emotional and adaptational outcome.

Coping is a mediator between stress and adaptational

outcome. Three basic and general types of outcomes are

identified; social functioning, subjective well-being and

somatic health.

In summary coping is one aspect of a framework of

stress, appraisal and adaptational outcome. Coping efforts

represent attempts to manage situations appraised as

stressful. The focus of these efforts is directed at either

managing or solving the problem, or regulating the emotional

response to the situation. Coping is viewed as a process

which changes during the situation on the basis of constant

appraisal and reappraisal. Coping thoughts and actions are

influenced by both situational and persona1 variables. The

effectiveness of coping is determined on the basis of

adaptational outcomes.

The proposed relationships of the variables of

interest are depicted in the Lazarus and Folkman framework

in Figure 1. The causal antecedents included were the person

variables of age, gender and degree of optimism, and the

situational factor of a diagnosis of advanced lung cancer.

The mediating processes of appraisal and coping strategies

w e r e considered to be influenced by the antecedent factors

and were also considered to influence each other. The final

variable of interest, the effect, was the psychological

outcome. The psychological outcome was considered to be

influenced by and in turn to influence appraisal and the use

of coping strategies.

A Causal Antecedents Mediating Processes

Ef f ects

Person variables including age, gender and optimism

Environmental factors including diagnosis of Lung Cancer

Appraisal Pr imary Secondary Reappraisal

Psychological

Coping Strategies

Outcome 1

e 1. Proposed relationships of the variables of

interest in the Lazarus and Folkman Framework of Stress,

Appraisal and Coping. Adapted from Lazarus and Folkman

( 1 9 8 4 ) .

Be-arcn oue.stiQns

What are the coping strategies used by people with

advanced or inoperable primary lung cancer*

What is the relationship between dispositional optimism

and the coping strategies used by people with advanced or

inoperable primary lung cancer.

mat is the relationship between age, gender,

dispositional optimism, coping strategies used and the

psychological well-being of people with advanced or

inoperable primary lung cancer.

A d v a n c e d a cancer was def ined for the purpose of

this study as any histologically confirmed diagnosis of non

small ce11 lung cancer which has been determined to be stage

III (mediastinal lymph node involvement),or stage IV

(distant metastases)(Luketich, Van Raemdonck 61 Ginsberg,

1993). A histologically confirmed diagnosis of small ce11

lung cancer of any stage - because of its aggressive nature and poor prognosis (Harvey 6 Beattie, 1994; Greco L

Hainsworth, 1994) - is also included in the definition of advanced lung cancer.

for the purpose of this study

was defined as any histologically confirmed diagnosis of

lung cancer which is determined to be advanced on the basis

of staging investigations or occurring in anyone who is

54

medically unfit for the operation (Murren & Buzaid, 1993).

In these situations the person is faced with the knowledge

that cure is unlikely, recurreiice is probable and sumival

tirne limited. . . . srtroml Ont- was defined "as the tendency to

believe that one will generally experience good vs. bad

outcomes in lifen (Scheier & Carver, 1992, p. 2 0 2 ) . ft w a s

measured using the Life Orientation Test (Scheier, Carver L

Bridges, 1992).

Co~inq was defined as *constantly changing cognitive

and behavioral efforts to manage specific external and/or

interna1 demands that are appraised as taxing or exceeding

the resources of the personn (Lazams and Folkman, 1984,

p.141). Coping was measured using the Ways of Coping

Questionnaire (Folkman & Lazarus, 1988b).

Psvcholoaical Weil - Be was defined as a subjective

feeling of emotional well-being. The Profile of Mood States

(McNair, Lorr & Droppleman, 1992) was used as the measure of

psychological well-being,

Chapter II

Hethodology

A descriptive multiple correlational design was used to

examine the relationships between the personality

disposition of optimism, the coping strategies used, the

demographic characteristics of age and gendet, and

psychological well-being of people with advanced or

inoperable primary lung cancer.

Settina

This study was conducted in a large tertiary care

health centre in Eastern Canada. This facility includes the

Nova Scotia Cancer Centre, Halifax Clinic, and serves as one

of two provincial referral centres for patients with lung

cancer.

SamDle

The population for this study was people with a

diagnosis of advanced or inoperable primary lung cancer.

This included any person with a diagnosis of primary lung

cancer who was determined to be medically unfit for

operation, or had stage three (involvement of mediastinal

lymph nodes)or stage four (metastatic) non-small ce11 lung

cancer, or small ce11 lung cancer of any stage. People

meeting this criteria who were between one month and one

year of diagnosis, able to speak and understand English, had

no known brain metastases, had no other cancer diagnosis

(with the exception of non-melanoma ce11 skin cancer and

cancer of the cervix insitu) within the pst five years, and

can give informed consent were asked to participate. People

who have had surgical resection of stage one or stage two

lung cancer may anticipate a better prognosis than those

with advanced disease and therefore were not included.

Patients with recurrent disease were also excluded as the

issues and impact of recurrent cancer differs from that of

the initial diagnosis (Mahon, Cella, & Donovan, 1990; Mahon,

1991).

Based on the technique of power analysis using the

parameters of a puer of 0 - 8 0 , effect size of 0.34 and

significance level of 0.05 for a two tailed test it was

determined that a sample of 64 patients was required for

this study (Kraemer & Thiemann, 1987)-

A convenience sample of sixty-four people participated

in the study, The age range was from 44 to 77 years (n =

61.34, a = 8.10). Forty-four (68.8%) of the participants

w e r e male and 20 (31.3%) female, Most of the participants

w e r e married or living with their common law spouse (11 = 48,

75%). Only 12 (18.8%) were living alone. Thirty-seven

57

(57.8%) were retired, 20 (31.3%) were on sick leave, 6

(9.4%) were unemployed and only 1 (1.6%) continued to work.

Sixty-two (96.9) of the participants were Caucasian; of the

two remaining one was Black and one was Asian.

Religious beliefs were considered to be important to

the majority of the participants. Twenty-one (32.8%)

believed religion had some importance, 10 (15.6%) rated it

as moderately important and 26 (40.6%) as very important.

Seven (10.9%) did not consider religion to be of importance

in their lives.

The majority of the participants were not well educated

in terms of fonnal education with only 22 percent (n = 14)

having high school or greater education. Of those, five

(7.8%) had obtain University or Post Graduate degrees.

Annual household incomes also tended to be low with 46.9

percent (n = 30) reporting less than $21,000. An additional

16(25%) reported incomes between $21,000 and $30,000, and 13

(20.4%) reported incomes greater than $30,000. Five (7.8%)

choose not to answer this question. The relative frequency

distributions for selected demographic variables are

presented in Table 1.

Table 1

. .. . . .

characteristic n E - -

Martial status

Married/commonlaw

Widowed

Separated/divorced

Single

Living arrangements

Spouse alone

Spouse & family

Alone

Adult children

Education

Junior high or less 32 50.0

Partial high school 18 28.1

High school diploma 5 7.8

Partial university 4 6.3

University degree 2 3.1

Post graduate degree 3 4.7

Household income

< $10,000 9 14.1

$10,000 - $20,000 21 32-8

$21,000 - $30,000 16 25.0

$31,000 - $40,000 6 9.4

$41,000 - $60,000 4 6.2

$61,000 O $100~000 1 1.6

> $100,000 2 3.1

NO response 5 7.8

59

ness and Treatm-t Ch--?

The time since diagnosis ranged from 4 to 51 weeks with

a median time of 12 weeks. Thirty-four (53.1%) of the

participants had received a diagnosis of non small ce11 lung

cancer and 30 (46.9%) a diagnosis of small ce11 lung cancer.

This reflects a greater percentage of participants with

small ce11 lung cancer than is consistent with the over al1

lung cancer population. For those participants w i t h non

small ce11 the majority were stage 3 (3a = 8, 12.5%; 3b =

17, 2 6 . 6 % ) , 2 were early stage (stage 1 or 2) but were

inoperable for other medical reasons and 7 (10,9%) had stage

4 disease. Of those with small ceIl lung cancer, 12 (18.8%)

had limited stage disease and 18 (28.1%) had extensive

stage.

Participants were asked to indicate if they were

experiencing cough, shortness of breath, pain, fatigue or

other symptoms they believed to be related to lung cancer or

its treatment. One or more symptoms were experienced by 62

(96.9%) of the participants. Fatigue was the most frequently

reported symptom (n = 47, 73 ,4%) . Of those who reported

fatigue, 40 indicated that it was severe enough to interfere

with their usual activities. Shortness of breath interfering

with usual activities was reported by 27 (42.2%), and cough

severe enough to interfere with usual activities was

reported by 10 (15.6%) of the participants. Pain was

reported by 25 (39.1%) of the participants. Twenty-four were

60

taking medication for pain yet 13 (20.3%) still indicated

that the pain was interfering with their usual activities.

Other symptoms reported by participants included leg

weakness, aching joints, decreased appetite, hoarseness,

sore throat, difficulty swallowing and nervousness.

The Eastern Cooperative Oncology Group / World Health

Organization (ECOG/WHO) performance status scale (Zubrod et

a1.,1960; Miller, Hoogstraten, Staquet, & Winkler, 1981) was

used as a self assessment of level of function, Most (n =

45, 70.3%) participants rated themselves at level 1

(restricted in strenuous activity but ambulatory and able to

carry out light work or pursue a sedentary occupation or who

are fully active but require analgesia). None of the

participants were level 4 (completely disabled) and only one

was level 3 (limited self-care).

Al1 of the participants in the study had received or

were currently receiving radiation or chemotherapy. Eight

(12.5 % ) had had surgery but were found to have advanced

disease at the time of the operation.

Table 2 provides the relative frequency distributions

for selected illness and treatment variables for the

participants.

Table 2

Illness and Treatwnt C h w e i c s of Studv P a r t i c m . .

IN = 6 4 1

Characteristic 11 e Symptoms

Fatigue 4 7

Dyspnea 44

Cough 4 2

Pain 25

Other 8

Pain medication used

None

Strong narcotic

Codeine

Tylenol/ASA

Performance status

Fully activity 5

Restricted in strenuous activity 45

Self care only 13

Limited self care 1

Chemotherapy

Currently receiving

No chemotherapy

Completed or between cycles

Radiation

Currently receiving 24

No radiation 23

Completed 17

62

P r o c e d u r d

Following approval by the Dalhousie University Faculty

of Graduate Studies Human Ethics Committee and the Research

Ethics Committee of the Queen Elizabeth II Health Sciences

Centre potential participants were identified from the

patient lists of the thoracic surgeons at the QEII Health

Sciences Centre and from those patients attending lung

oncology clinics at the Nova Scotia Cancer Centre, Halifax

site.

Patients who were identified as meeting the study

criteria were approached either by a letter from the

thoracic oncology group (Appendix A), or directly by their

primary QEII physician, or by a nurse or a physician

providing their care in the lung oncology clinic, The letter

from the thoracic oncology group included a brief

description of the study and a stamped, addressed return

envelope. Those who choose to reply could either request to

be contacted by the researcher and provided with more

information or indicate they are not interested. Those

approached directly by their physician or nurse were

provided with a brief description of the study (Appendix

B). Those who were willing to consider participation were

introduced to the researcher or to the research assistant.

The study was described and a time arranged for the

interview with those who were willing to participate,

Written consent was obtained.

63

Al1 interviews were conducted in a private area on the

hospital site with only the participant and interviewer

present. After a brief explanation about each

questionnaire, the questions were read to the participant

and their responses recorded on the appropriate forms. This

included demographic information and questionnaires

measuring optimism, coping strategies used and psychological

well being. The estimated time for completion was about 60

to 90 minutes. The actual time required ranged from 45 to 60

minutes, - In a brief interview demographic information including

martial status, cultural background, education, occupation

and income was obtained. The participants were asked to rate

the importance of religion in their life as this is often

identified as an important coping resource, Information

about the symptoms currently k i n g experienced and the

current use of narcotic medications was also included as

these may influence the individuals outlook and sense well-

being (Appendix D), Present physical status was assessed

using the Eastern Cooperative Oncology Group / World Health

Organization (ECOG/WHO) performance status scale (Zubrod et

a1.,1960; Miller, Hoogstraten, Staquet, f Winkler, 1981).

Length of time since diagnosis, lung cancer stage, ce11 type

64

and treatment was obtained from the health record (Appendix

E)

g n T e s t (LOT - RL The revised Life Orientation Test (L0T-R) (Appendix F)

was used to measure optimisme The original version of the

Life orientation Test was developed by Scheier and Carver

(1985) as a measure of the personality characteristic of

dispositional optimism or the generalized expectancy of good

rather than bad outcomes in life. This measure consists of

eight items plus four filler items.

This scale has been widely used to measure optimism in

a number of different populations; university students

(Carver, Scheier, & Weintraub, 1989; Scheier, Weintraub, &

C a r v e r , 1986), patients recovering from coronary artery

bypass surgery (Scheier et al, 1989), people with cancer

(Friedman et al, 1992) and specifically with breast cancer

(Stanton & Snider, 1993; Carver et al, 1993).

The scale is usually administered as a self report

questionnaire but has also been used in an interview design

(Carver et al, 1993). The tirne to complete the questionnaire

has not been reportede However given its brevity a

completion time of approximately 10 minutes for the

questionnaire administered in an interview was considered

reasonable.

The scale vas revised in 1994 (Scheier, Carver &

65

Bridges, 1994). Two items which did not refer specifically

to the expectancy of a positive outcome but instead could be

viewed as coping strategies were removed. Because both of

these item were worded positively one negatively worded item

was also removed and one new positive item added in order to

achieve a balance in the number of positive and negative

items. The final result is a scale with 10 items, three

positive, three negative and four filler items. Respondents

are asked to indicate their level of agreement with the

items on a five category Likert scale. Negatively worded

items are reversed prior to scoring. The responses are

summed to provided a score reflecting the degree of

optimism,(i.e. the higher the score the greater the

optimism) with a possible range of O to 24.

Valigitv.

The face validity of LOT and LOT-R is reported as high.

Items such as "In uncertain times, 1 usually expect the

best" and nif something can go wrong for me, it willn

reflect the commonly held view of the life outlook of the

optimist and pessimist.

The authors (Scheier, Carver, 6 Bridges, 1994) examined

the predictive validity of LOT in a sample of 4309

undergraduate univetsity students. In addition to LOT,

outcome measures of depression, physical symptoms, and

coping along with other predictor variables including

neuroticism, self-mastery, self-esteem, and trait anxiety

66

were examined. Significant correlations (p < - 0 5 ) were

reported for LOT with al1 the outcome variables supporting

the predicative validity of LOT. When the other predictor

variables (neuroticism, self-mastery, self-esteem, and trait

anxiety) were controlled for, the correlation between

optimism and three of the coping factors remained

significant supporting a degree of discriminant validity.

The validity of the Revised Life Orientation Test has

been examined by the authors (Scheier, Carver, & Bridges,

1994) in a study of 2,055 (622 women, 1394 men and 39 who

did not indicate gender) undergraduate college students.

Principle components factor analysis was conducted. Varimax

final rotation technique was used and the eigenvalue

criterion set at 1.0- A one-factor solution emerged

accounting for 48.1% of the variance. Al1 items loaded at

least - 5 8 on this one factor.

In addition to completing the revised LOT one or more

of the following questionnaires were completed; the Self-

Mastery Scale, tat te-Trait Anxiety Inventory, the Guilford-

Zimmerman Temperament Survey (a measure of neuroticism), the

Self-Esteem Scale and the Neuroticism Scale of the Eysenck

Personality Questionnaire. Correlations between the LOT-R

and the other scales including the original LOT were

determined to examine convergent and discriminant validity.

The authors describe the other scales as measuring

conceptually related concepts and consider the correlations

(with the exception of the high correlation with the

original scale) as modest indicating that while there is

conceptual and empirical overlap the other scales are

measuring other qualities in addition to optimism. The

correlations were al1 significant (p < .001) and ranged from

a low of 0.36 to a high of - ,53.

The original LOT has b e n criticized (Smith, Pope,

Rhodewalt & Poulton, 1989) as having limited convergent and

discriminant validity, correlating as well with measures of

neuroticism as with a second measure of optimism the

Generalized Expectancy for Success Scale (GESS). However as

the authors of the LOT scale note neuroticism is a

multifaceted construct which includes pessimism and

therefore is conceptually linked to optimism.

Acceptable interna1 consistency of the original LOT

scale has been reported. Scheier and Carver (1985) for a

sample of college students reported a CronbachOs alpha of

. 7 6 . Carver et al (1993) in a study of women with breast

cancer reported an alpha of .87. Interna1 consistency of the

revised scale has been reported only for a college student

sample, for this sample the Cronbach's alpha was . 78 .

A test-retest reliability coefficient of .79, over a 4

week interval, has b e n reported by Scheier and Carver

(1985) in a saraple of college students, In a sample of women

with breast cancer Carver et al (1993) reported a test-

68

retest reliability coefficient of ,74, over a one year

period. Test-retest stability has been examina for the

revised Life Orientation Test in four samples of college

students, Each sample vas retested at a different point,

Test-retest coefficients of -68 at 4 months, -60 at 12

months .56 at 24 months and -79 at 28 months were reported

(Scheier, Carver C Bridges, 1994) -

mvs of Co- O u e s t i m

The Ways of Coping Questionnaire (Folhan & Lazams,

1988b) was used as the measure of coping (Appendix G ) - The

Ways of Coping Questionnaire is a theoretically derived

measure based on the cognitive-phenomenological theory of

stress and coping of Lazarus and Folkman (1984). It was

designed to identify the thoughts and actions an individual

uses to cope with a specific stressful encounter. The

original version, the Ways of Coping Checklist, was a 67

item list of strategies to which the subject indicated with

a yes or no response whether or not they had used the

strategy to deal with a particular stressful event.

Although the Ways of Coping Questionnaire is a frequently

used measure of coping, cornparison is difficult because it

is often modified for the particular population-

The present scale, as provided with the Ways of Coping

Questionnaire Hanual (Folkman & Lazarus, 1988b), has 66

items and eight coping scales. Revisions to the original

scale included rewording or deleting unclear items, adding

69

new items based on the suggestions of subjects and changing

the response format to a 4-point Likert scale indicating the

frequency with which each item used.

The eight coping scales have been derived from factor

analysis based on a sample of 75 middle and upper-middle-

class white married couples having at least one child living

at home. Data was collected from husbands and wives

separately on 5 occasions. The data was analyzed using alpha

and principal factoring with oblique rotation resulting in

eight factors. The eight scales have been labelled and

described as follows:

ve con- - aggressive efforts to alter the situation and suggests some degree of

hostility and risk-taking.

Distancina - cognitive efforts to detach oneself and to minimize the significance of the situation.

Self - CO- - efforts to regulate one's feelings and actions.

S e e u s o c m s~ppo- - efforts to seek informational support, tangible support and

emotional support.

B c - Q t h g r-pansibllltv . . . - acknowledges one's own

role in the problem with a concomitant theme of

trying to put things right.

- wishful thinking and behavioral efforts to escape or avoid the problem.

ul Problem - deliberate problem- focused efforts to alter the situation, coupled

with an analytic approach to solving the problem.

- efforts to create positive meaning by focusing on persona1 growth, also has a

religious dimension. (Folkman & Lazarus, 1988b,

p.11)

The number of items in each scale varies from four to eight.

The Ways of Coping Questionnaire has been designed to

be answered in relation to a specific stressful event. The

authors advise that the exact method should be adapted to

fit the needs of the particular study. The method described

by Dunkel-Schetter, Feinstein, Taylor and Falke (1992) was

used this study. Dunkel-Schetter et al used the Ways of

Coping Questionnaire in a study of 603 people with cancer.

Because they were making a single assessment of coping

rather than repeated assessments they believed that asking

the subject to select a stressful episode would provide an

isolated and possibly unrepresentative instance of the

individuals coping response and that asking for a response

in relation to coping with cancer in general would be too

nonspecific. The following set of cancer-related stressors

were listed: fear and uncertainty about the future due to

cancer; limitations in physical ability, appearance, or life

style due to cancer; acute pain, symptoms, or discomfort

from illness or treatment; and problems with family or

71

friends related to cancer. Respondents were asked to choose

from this list which one had been most stressful for them

and to indicate on a scale of 1 (not stressful) to 5

(extremely stressful) hov stressful the problem had b e n

over the previous 6 months. The Ways of Coping Questionnaire

(revised for this study) vas completed in relation to the

stressor selected, Forty-one percent selected fear or

uncertainty about the future,

As a self-administered questionnaire the Ways of Coping

takes approximately 10 minutes to complete, Although usually

a self-administered questionnaire Folkman and Lazarus (1988)

reported that the Ways of Coping Questionnaire has been used

as an interview protocol. No time estimate for completion as

an interview protocol is reported- Approximately 30 minutes

or three time the self-administration time seemed to be a

reasonable estimate for completion in an interview format-

To complete the Ways of Coping Questionnaire the

participant, keeping the stressful situation in mind,

responds to each of the items in the questionnaire

indicating the degree to which the item was used on a 4-

point Likert scale where O indicates ndoes not apply or not

usedw, 1 indicates "used somewhatm, 2 indicates Wsed quite

a bitw and 3 indicates %sed a greet dealmm Of the 66 items

50 are included in the scoring.

In scoring the Ways of Coping Questionnaire raw scores,

mean raw scores and relative scores were determined. A raw

72

score was obtained by summing the subjects responses for the

items which comprised a particular scale. This provides a

summary of the extent to which each type of coping vas used.

This is the methoâ describe by Lazarus and Folkman (1988) as

being used in the majority of their research, however

because some scales have up to eight items and others have

only four the mean score for each scale was determined.

The relative score is described as an indicator of the

contribution of each scale relative to al1 the scales

combined. In this method the mean scores for the eight

scales are sumrned, the mean score for each scale is then

divided by the s u of the eight mean scores.

Validitv,

Folkman and Lazarus (1988b) describe both face and

construct validity for the Ways of Coping Questionnaire.

Evidence of face validity is based on the source of the

items included in the scale; the items are the strategies

described by individual as being used to cope with the

demands of a stressful situation.

Evidence of construct validity was supported by

research findings using the Ways of Coping Questionnaire

which were consistent with the theoretical predictions of

Lazarus and Folkman's theory of stress and coping.

specifically that coping consists of both problem and

emotion focused strategies and that coping is a process and

therefore changes as the context and demands of the

situation change.

The constmct validity however has been challenged

(Wineman, Durand, & McCulloch, 1994) on the basis of the

factor structure. These authors argue that the factors need

to be reproduced across studies in order to determine if the

structure is supported. In a secondary analysis of a random

sample of 690 individuals with multiple sclerosis or a

spinal cord injury it was found by these authors that the

eight factor mode1 developed with a community based

population did not adequately describe the present

population. Re-analysis of the factor structure revealed

three coping factors.

Studies of clinical populations with cancer have also

revealed differing factor structures. Hishel and Sorenson

(1993) in a study of women with gynecological cancer also

questioned the appropriateness of the factor structure due

to low internal consistency estimates. On reanalysis a seven

factor structure emerged, four within the problem coping

mode and three within the eaotion focused mode. ûunkel-

Schetter, Feinstein, Taylor, And Falke (1992) in a study of

coping among people with a variety of types of cancer

produced a five factor structure. They had however modified

the scale prior to use. Stanton and Snider (1993) in a

sample of women with breast cancer found the five scales

from the Dunkel-Schetter study to produce greater internal

consistency with this sample than the original scales from

74

the community sample. Prior to using the questionnaire they

had removed the seven items added or modified by Dunkel-

Schetter . Folkman and Lazarus (1988b) recognize the concern

related to the variability of the factor structure and while

they maintain that a good deal of convergence exists with

respect to several factors, this is not the case for all.

Test-retest reliability is not considered an

appropriate evaluation of the Ways of Coping Questionnaire.

Based on the definition of coping as a process variation is

expected

Reliability as determined by internal consistency has

been reported in the Ways of Coping Manual (Folkman &

Lazarus, 1988b) for the community based sample of 75 married

couple previously described. Cronbach's alpha coefficients

for the eight scales ranged from -61 to .79. However as

discussed the factor structure has not consistently yielded

adequate internal consistency with other populations. Alpha

ranged from -51 to -71 in a sample of people with multiple

sclerosis and spinal cord injury (Wineman, Durand &

Mcculloch, 1994) and from -49 to -79 among patients with

gynecological cancer (Mishel & Sorenson, 1993). Dunkel-

Schetter, Feinstein, Taylor, And Falke (1992) using a

modified the Ways of Coping Questionnaire reported alpha

coefficients of -74 to .86 with a five factor structure.

Stanton and Snidet (1993) using the same five factor

structure, but having removed the modified items reported

alphas of ranging from - 7 0 to - 8 4 for four of the five

factors. The factor labelled Behavioral Avoidance achieved

an alpha of only .51.

Profile of mod States

Psychological vell-being was measured using the Profile

of Mood States (McNair, Lorr & Droppleman, 1992) (Appendfx

H). The Profile of Mood States (POMS) vas developed as a

measure of mood or affective state in psychiatric

outpatients but has also been used extensively with non-

psychiatric populations. It is a factor analytically derived

inventory which measures six mood states, Tension-Anxiety:

Depression-Dejection: Anger-Hostility: Vigor-Activity;

Fatigue-Inertia; and Confusion-Bewilderment. The POnS has

also been used as a single global estimate of affective

state, providing a Total Mood Disturbance Score.

The POMS consists of 65 adjectives (such as tense,

unhappy, lively, sad) which are rated on a five point Likert

scale. The intensity modifiers for the scale are not at ail,

a little, moderately, quite a bit and extremely. The

participant indicates the degree of the feeling experienced

over the past week. When self-administered the scale takes

3-5 minutes to complete. WllS has b e n administered orally

to visually impaired athletes (Mastro, French & Hall, 1987

as cited in McNair, Lorr & Droppleman, 1992) in which case

76

it took approximately five minutes longer to complete.

The instrument is scored by suinming the the responses

for each of the adjectives which define the mood state. Two

items "relaxedm in the tension-anxiety scale and wefficient"

in the confusion scale are weighted negatively. To obtain

the Total Hood Disturbance score the scores for five of the

mood states are summed and the score for the Vigor scale is

then subtracted.

u t v .

The validity of the six mood factor structure has been

demonstrated by the authors of the scale through six

independent factor analytic studies. Five of these studies

involved psychiatrie outpatients and one male college

students.

The face validity of the items defining each of the

mood states is high. The authors of scale also cite seven

different areas of research as providing evidence of

predictive and constact validity. Included are: brief

psychotherapy studies; controlled outpatient drug trials;

cancer research; drug abuse and addiction research; studies

of response ta emotion-inducing conditions; research on

sports and athletes and studies of concurrent validity

coefficients (HcNair, Lorr & Droppleman, 1992). Profile of

Mood States was used as a measure of distress and

psychological well being in t w o previously discussed studies

of women with breast cancer (Carver et a1.,1993; Stanton &

77

Snider, 1994). In both studies distress following diagnosis

was measured over time and in relation to optimism and

coping strategies. As predicted distress varied in relation

to tirne, coping strategies utilized and the degree of

optimism.

Concurrent validity has been reported by the authors

(McNair, Lorr & Droppleman, 1992). Significant correlations

between POMS and the Hopkins Symptom Distress scales in a

sample of psychiatric outpatients were reported-

Significant correlations for the subscales were also

demonstrated. The Tension-anxiety scale was correlated with

the Taylor Manifest Anxiety Scale in a sample of psychiatric

outpatients (.80) dental patients (-51) and college males

(.36). The Depression subscale vas correlated with the Beck

Depression Scale (-61) in a sample of workers exposed to

organic solvents.

Peliabllltv. . .

The interna1 consistency of the POHS was examined by

the scale authors using the Kuder-Richardson formula (K-R20)

among 350 female (F) and 650 male (H) psychiatric

outpatients, The reliability coefficients as follow, were

acceptable for al1 factors: Tension-anxiety -92 (H), .90

(F); Depression-dejection -95 (H), .95 (F); Anger-hostility

. 9 2 (M), -93 (F); Vigor .89 (n), .87 (F); Fatigue .94 (H),

.93 (F); Confusion -87 (M), .84 (F). The Cronbach8s alpha

coefficients based on a sample of 2360 adults participating

78

in a smoking cessation research program was also reported.

T h e s e were also acceptable with al1 coefficients -90 or

above for both sexes with the exception of the confusion

scale which was .85 for females and -83 for males.

Test-retest stability for this instrument is moderate.

In the sample of psychiatrie outpatients Product-moment

correlations between POM score at the tirne of first visit

and again immediately prior to first treatment ( median 20

days, range 3 ta 110 days) were calculated. The stability

coefficients ranged from -65 for vigor to .74 for

depression, This was explained by expected fluctuation in

mood state and in this particular case by the impact that

finding a source of assistance would have on mood.

Data Analvfiis

Descriptive statistics were used to describe the sample

characteristics in terms of demographics, disease and

treatment data, Means, standard deviation, medians, range,

percents and frequencies were used.

The interna1 consistency reliability was calculated and

examined for each of the scales used with this sample.

Besearch Oues+ions

estion 1, What are the coping strategies used by

people with advanced or inoperable primary lung cancer?

Raw scores and mean raw scores for each coping category from

the Ways of Coping Questionnaire were determined, Relative

scores (percentages) indicating which coping categories were

79

used most were calculated. Descriptive statistics including

the range of scores for each category and the mean and

standard deviation were determined. Pearson's product-moment

correlation and t-tests were used to examine the

relationships of the scores for the degree of stress, age

and gender with the scores for the coping strategies.

ouestion 2 . What is the relationship between

dispositional optimism and the coping strategies utilized by

people with advanced and inoperable primary lung cancer?

Dispositional optimism was measured using the revised L i f e

Orientation Test (LOT-R). Higher scores indicated greater

optimism. Pearson product-moment correlation coefficient

(Pearson's r) was calculated to determine the strength and

direction of the relation between dispositional optimism

scores and the scores for each coping strategy category.

Puestion 3. What is the relationship between age,

gender, coping strategies used, dispositional optimism and

the psychological well-being of people with advanced or

inoperable primary lung cancer? Multiple regression

analysis was used to determine the relationship between the

independent variables of age, gender, the coping strategy

scores, the dispositional optimism score and the dependent

variable psychological well-being as measured by the Profile

of Mood States.

cal Cowideratiom

Protection of R&h&s

Only potential participant who indicated their

willingness to consider participation in the study were

approached by the investiqator. Willingness to consider

participation was ascertained by either: the potential

participant contacting the researcher directly after

receiving a letter inviting participation in the study from

the thoracic oncology group (Appendix A); or indicating

their willingness to consider participation to the physician

or nurse in the oncology clinic who had provided a brief

explanation of the study (Appendix B).

Informed consent was obtained prior to the time of the

interview (Appendix C ) . This included an explanation of the

purpose of the study and any possible risks and benefits.

Participants were informed: that participation vas voluntary

and would in no way influence their care; that they may

withdraw at any tirne; and that al1 information would remain

confidential.

Confidentiality was assured in the following manner.

Al1 data collection sheets (demographic, disease and

treatment data sheets, and questionnaires) were identified

using a numeric code, no names appeared on any data

collection sheets. Only one list of names with corresponding

code numbers was made which was secured in a locked file

cabinet.

~is)i<sf i t ~

There were no known risks or benefits related to

participation in this study. However, due to the subject

matter it was possible that some participants may find the

process emotionally distressing. A11 participants were

informed that they may stop the interview at any time. It

was also planned that if any indication of emotional

distress was noted the interview would be stopped and

emotional support provided. Once the individual had regained

their composure they would be given the option of continuing

the interview or concluding at that point.

It was also possible that the process may be beneficial

to the participant by providing an opportunity, which they

may not have previously had, to discuss their feelings. In

completing the Ways of Coping Questionnaire they may also

identify coping strategies which may prove beneficial for

them. Providing information which may be helpful to others

may also be perceived as a benefit to the participant. One

participant did indicate that the process was beneficial in

helping her to talk about her feelings.

Prior to data collection approval of the Dalhousie

University Faculty of Graduate Studies Human Ethics

Committee and the ~cientific and Ethical Review Committee of

the Queen Elizabeth II Health Sciences Centre was obtained.

CHAPTER 111

Findings

This chapter presents the analysis of the data

collected. The first section presents the analysis of the

internal consistency reliability for each of the three study

instruments. The second section presents the analysis of the

data pertaining to each of the three research questions.

terna) Consiwtencv . .

Three questionnaires were completed in an interview

format by the study participants. The Revised Life

Orientation Test (Scheier, Carver & Bridges, 1994) was the

measure of optimism, the Ways of Coping Questionnaire

(Folkman & Lazarus, 1988b) vas used as the measure of coping

and the Profile of Hood States (WcNair, torr 6 Droppleman,

1992) as the measure of psychological well-being. The

internal consistency reliability was determined for each

instrument using Cronbach's alpha.

Revised Life orientation T e f i t

The Revised Life Orientation Test is a 10 item scale

with three positive, three negative and four filler items.

Respondents were asked to indicate their level of agreement

with the items on a five category Likert scale. Negatively

worded items were reversed prior to scoring. The Cronbach's

alpha in this study was determined to be -83. This is a

higher internal consistency then reported by Scheier,

83

Carver, and Bridges (1994) for a college student sample, for

that sample the Cronbach's alpha was . 78 .

mvs - of Co- Oue-

The Ways of Coping Questionnaire (Folkman & Lazarus,

1988b), consists of 66 items, 50 of which are categorized in

eight coping scales: confrontive coping, distancing, self-

controlling, seeking social support, accepting

responsibility, escape-avoidance, planful problem solving

and positive reappraisal,

Item number 16, 1 slept more than usual, was removed

from the escape-avoidance subscale. This item, in this

population, was not considered to be an indication of

escape/avoidance but rather related to the fatigue often

experienced by people with lung cancer and as a side-effect

of the cancer treatment- Removal of this item resulted in an

increase of the alpha coefficient from -58 to -71.

The interna1 consistency reliability for each scale was

determined using Cronbach's alpha. The results are presented

in Table 3.

Table 3

C r o w h 8 s AlPha for me Wavs - of Co- Subsca)es (N - - I

Scale # of Items Coefficient Alpha

Confrontive

Distancing

Self-Controlling

Seeking Social Support

Accepting Responsibility

Escape-Avoidance

Planful Problem Solving

Positive Reappraisal

The low reliability coefficient of .40 for the

Confrontive Coping scale in this study indicated that this

scale was not reliable for this population and therefore was

not used in any further analysis,

Reliability coefficients previously reported by

Folkrnan and Lazarus (1988b) for the community based sample

of 75 married couples were generally higher than in this

study. Cronbach's alpha coefficients for the eight scales

ranged from .61 to .79. with the greatest differences being

noted for Confrontive coping ( . 7 0 ) and Self-Controlling

( - 7 0 ) .

Profile of MQod States

The Profile of Wood States (POnS) was developed as a

measure of mood or affective state. The POMS consists of 65

adjectives, 58 of which are categorized into s ix mood

states: Tension-Anxiety, Depression-Dejection, Anger-

Hostility, Vigor-Activity, Fatigue-Inertia and Confusion-

Bewilderment. The -13s has also been used as a single global

estimate of affective state, providing a Total Mood

Disturbance Score.

Reliability coefficients were determined for each Mood

State subscale and for the Total H o o d Disturbance scale. The

results and presented in Table 4.

Table 4

Cronbach's AlPna for The Profile of Mood States Tot- - - 1

Scale # of Items Coefficient Alpha

Total Mood Disturbance 58 .94

Mood State Subscales

The subscale alpha levels were somewhat less than those

reported by McNair, Lorr 6 Droppleman (1992), but al1 were

acceptable and indicated a mderate to high internal

consistency reliability for these scales with this

population. The alpha coefficient for the Total Hood

Disturbance scale of .94 indicated a high internai

consistency reliability for this scale. An alpha coefficient

was not previously reported for the Total Hood Disturbance

scale.

Sygl~aary

The internal consistency reliability was determined for

each of the scales used in this study- An acceptable

reliability (alpha - 8 3 ) was determined for the Revised Life

Orientation Test. The reliability coefficients for the

Ways of Coping scales: distancing ( . 6 0 ) , self-controlling

( . 6 0 ) , seeking social support (.71), accepting

responsibility ( . 6 0 ) , escape-avoidance (.71), planful

problem solving (.64) and positive reappraisal ( - 7 8 ) were

also acceptable. The alpha level determined for the

confrontive coping scale was only . 4 0 and not considered

acceptable, therefore this scale was not included in any

further analysis. The reliability coefficients for the

Profile of Moods States Total Mood Disturbance scale (-94)

and the six Mooà State subscales ( - 7 6 - . 9 0 ) were al1

acceptable and indicated moderate to high levels of internal

consistency for these scales.

- The following section presents the analyses of the data

in relation to each of the three research questions.

Co~ina Strate-

The first research question asked what are the coping

strategies used by people with advanced or inoperable lung

cancer? The Ways of Coping Questionnaire (Folkman &

Lazarus, 1988b) was used as the measure of coping in this

study. This questionnaire was designed to be answered in

relation t o a specific stressful event therefore

participants were asked to select from a list of four

potentially stressful situations or to describe the

situation which they fowrd most stressful. This method of

administration was described by Dunkel-Schetter, Feinstein,

Taylor and Falke (1992).

Frequencies and percents were determined to describe

the types of stressor and the degree of stress experienced

by the participants i n this study. (Tables 5 and 6).

88

Table 5

rres of Stressors Selected bv People w m c e d oz

Stressor n E

Fear and uncertainty 28 43.7

Other 13 20.3

Limitations in ability 10 15.6

Problems with family/friends 7 10.9

P a i n or symptoms 6 9.3

Fear and uncertainty about the future due to cancer was

the situation m o s t frequently selected ( n =28, 43.8%). In

t h e category labeled nothern thirteen (20.3%) participants

chose to describe their greatest stress- These situations

included concerns related to telling adult children about

the diagnosis, a spouse being diagnosed with cancer at the

same time, waiting for diagnosis, initial shock of

diagnosis, fear of being a burden, disappointment due to

t r e a t m e n t failure, and frustration with delays in treatment

and lack of information. The situations waiting for

diagnosis, initial shock of diagnosis, and fear of being a

burden seemed to correspond to the category fear and

uncertainty about the future. These situations were not

however re-coded as the participant believed that they

represented unique situations. Other situations did not

correspond to the categories provided- !Che stress of having

a spouse diagnosed with cancer at the same time clearly did

89

not fit the categories. Also identified was the stress

experienced in relation to delays in treatment and with lack

of information. Two participants could not identify a

specific stressor, and rated their degree of stress as none.

The majority of the participants rated the degree of

stress experienced in relation to the stressor as

'9noderately stressfulw (n = 17, 2 6 . 6 % ) , or "very stressfuln

(n = 25, 39.1%).

Table 6

ree of Stress

Ino-a C a n c e r -- - - --

Degree of Stress n 2

Not Stressful

Mildly Stressful

Moderately Stressful

Very Stressful

Extremely Stressful

Data from seven of the coping scales, from the Ways of

Coping Questionnaire, was analyzed. Raw, mean and relative

scores were calculated for each of the coping scales. As

some scales had up to eight items and others only four the

mean and relative score for each scale were used for the

purposes of cornparison. Relative scores indicate the

contribution of each scale relative to al1 the scales

combined. A high relative score for a coping scale means

the coping behaviours included were used more often than

other behaviours.

Using the mean individual scores the mean, standard

deviation, range of scores and relative scores for each of

the coping scales were determined, and are presented in

Table 7.

Table 7

n. R a n ) and Relative

Scores fPercex&a!aesl f n r W a v r a ofmhJ Scales (N - - 1 a

Scale Mean SR Range p ~

Seeking social support 1.71 .72 .33-3.0 25

Distancing 1.22 .64 00-2 , 5 18

self-controlling 1.10 .58 00-2.9 15

Planful problem solving 1.02 .61 00-2 . 5 14

Positive reappraisal 0.95 .72 00-2 . 6 12

Escape-avoidance O . 68 .51 00-2 . 1 9

Accepting responsibility 0.52 .60 00-2.5 6

'~elative percentage indicates contribution of scale

relative to al1 scales combined.

As presented in Table 7 the behaviours which comprise

the scale seeking social support w e r e used most often, those

included in the accepting responsibility scale were used the

least,

In order to determine if there were differences in the

use of coping strategies based on gender a StudentOs two

sample t-tests on the means for males and females for each

of the coping scales were performed. No statistically

significant differences were found.

It was also considered that age may influence the use

of coping strategies. The participants were divided into two

age groups: Group 1 = 40 - 59 years, n = 26; and Group 2 =

60 - 79 years = 38. Student8s two sample t-tests showed

no statistically significant differences between the age

groups for any of the coping scales.

Pearson's product-moment correlation was also used to

determine if any significant relationship existed between

age and any of the coping scales. Using this statistic a

negative low correlation was found between escape-avoidance

coping and age (r = 0.305 p =-01) for the ungrouped data

(Table 8 ) . Pearson's product-moment correlation was used to

determine if there were significant correlations between the

degree of stress perceived and each of the coping strategy

scales. There was a low, negative correlation between the

degree of stress, and the use of distancing strategies ( r =

-0.26 Q = 0.03) indicating that when more stress was

perceived fewer distancing strategies were usedm (Table 8).

92

Table 8

. . nt Correlat iclents for Degree

of Stress md Aue w th the Co s (N - 1 - -

Degree of Stress AQe

Seeking Social Support 0.22 0.12

Distancinq -0.26* -0.01

Planful Problem Solving 0.22 0. 07

Positive Reappraisal -0.04 -0.03

Escape-Avoidance -0.03 -0.30*

Accepting Responsibility -0.15 -0 . 10 *g < . 0 5 .

The correlations between the degree of stress and

seeking social support, and between the degree of stress and

planful problem solving approached significance (r = 0.22 p

= 0 . 0 7 ) .

To determine if the type of stress influenced the use

of coping strategies the sample was sorted by the stressful

situations which were identified by the participants. The

type of stressor subgroups were: fear and uncertainty about

the future due to cancer; limitations in physical ability,

appearance, or life style due to cancer; pain, symptoms, or

discornfort from illness or treatment; problems with family

or friends related to cancer, and other.

The means and relative scores were then calculated for

9 3

each group. The mean scores and standard deviations are

presented in Table 9. Seeking social support had the highest

mean and relative score in each of the groups except,

problems with family or friends. In the group which selected

problems with family and friends as their most stressful

situation the relative scores for distancing (20%) and self-

controlling (17%) were higher then for seeking social

support (15%).

With the data still grouped according to the stressful

situation a one-way analysis of variance (ANOVA) was

performed to determaine if there were statistically

significant differences between the groups for any of the

means of the coping scales. For this procedure the group

labelled other was coded as missing data because this group

consisted of several differing types of stressors.

Statistically significant differences were determined

between the groups for the coping scale escape-avoidance LE

(3.47) = 3.60; p = 0.0201). In order to determine which

groups had statistically significant differences Tukey8s

studentized range test was performed. The escape-avoidance

coping scale mean scores were found to be different between

the groups limitations in physical ability, appearance, or

life style due to cancer and tvo of the other groups, fear

and uncertainty about the future due to cancer, and problems

with family or friends related to cancer. In each case the

mean score for the escape avoidance category was lower when

the identified stressor was limitations in ability. The

r e s u l t s of the one-way ANOVA and the Tukey test are

presented in Table 9.

Table 9

ce for Me Scores

e of Stressor S-

Stressor Subgroups Pear and Limitations in Pain, Roblers Uncertainty ability S y i p t o u Parily/f riend n = 28 n =10 n = 6 n = 7

Copinq Strategies H SD LI SR LI Sr! CI SP P - - - - - - p p

Distancinq 1.36 0.59 1.02 0.74 0.86 0.27 1.66 0.75 2.55

Self -controlling 1.17 0.58 1.07 0.54 0.98 0.46 1.51 0.75 1.08

Seekinq Social Sueport 1.65 0.74 1.56 0.63 2.17 0.88 1.28 0.88 1.51

Accepting 0.66 0.71 0.25 0.31 0.13 0 .N 0.85 0.71 2.40 Respnsibility

Planf ul problei O.% 0.63 1.08 0.39 1.14 0.84 1.07 0.43 0.22 solving

Positive Reappraisal 1.03 0.74 0.73 0.78 0.81 0.76 1.20 0.66 0.75

Hote. Hem vith different subscripts differ significantly at p < .O5 in Wreyts studentized range test. *Q < .os.

SummarY

The stressful situation most frequently identified by

the participants of this study was fear and uncertainty

about the future (n =28, 43.7%). Thirteen (20.3%) choose not

to select from the provided list of stressful situations but

to describe their greatest stress relsted to their diagnosis

of lung cancer. Most of the participants rated the degree of

95

stress experienced as moderately or very stressful.

The mean and relative scores for the coping categories

indicated that the behaviours included in the seeking social

support scale were used most frequently. This was followed,

in order of decreasing scores, by distancing, self-

controlling, planful problem solving, positive reappraisal,

escape-avoidance and accepting responsibility.

Student8s two sample t-tests revealed no statistically

significant gender differences were found for the mean

coping category scores. Repeating the two sample t-test for

the sample divided into two age groups (Group 1 = 40 - 59 years, n = 26; and Group 2 = 60 - 79 years n = 38) no

statistically significant age group differences were found

for the coping category scores. However using Pearson's

product-moment correlation for the ungrouped data a low

negative correlation between escape-avoidance coping and age

(r = -JO5 p = A l ) was determined. Pearson's product-moment

correlation also indicated a low negative correlation

between the degree of stress and the coping category

distancing (x = -0.26, p = - 0 3 ) .

The group was then divided according to the type of

stressful situation. Seeking social support remained the

coping category with the highest mean and relative scores

for al1 groups except the group who selected 'problems with

family or friends' as their most stressful situation. For

this group the scores for distancing and self-controlling

were higher then for seeking social support.

One-way analysis of variance was performed to determine

if the means for the coping categories for the grouped data

differed according to the type of stressful situation. A

significant difference vas found for the coping category

escape avoidance (Table 9). Tukey's studentized range test

indicated that there were statistically significant

differences in the mean scores for the coping category

escape avoidance between the group limitations in physical

ability, appearance, or life style due to cancer and the

means of two other groups, fear and uncertainty about the

future due to cancer, and problems with family or friends

related to cancer (Table 9).

D m s i t i w O p t i a l s m Co- . . . .

Strateaies

The second research question asked what is the

relationship between dispositional optimism and the coping

strategies utilized by people with advanced and inoperable

primary lung cancer?

Dispositional optimism was measured in this study using

the Revised Life Orientation Test(L0T-R) (Scheier, C a r v e r &

Bridges, 1994).

The mean, standard deviation, median and range of

scores were determined. Using this scale, higher scores

indicated greater degrees of optimism. The mean optimism

97

score as determined by Life Orientation Test was 15-9 (SD =

5 - 3 ) , the median was 17 and the range of scores was 2 - 24. The mean and median scores indicate a moderate degree of

optimism.

Pearson's product-moment correlation coefficient was

calculated to determine the strength and direction of the

relationship between dispositional optimism and each of the

coping scales- None of these correlations proved to be

significant at alpha i -05- A low negative correlation

between escape avoidance coping and LOT-R approached

significance (x = 0.22, p = -07)-

relationship between age, gendet, coping strategies used,

dispositional optimism and the psychological well-being of

people with advanced or inoperable primary lung cancer?

The dependent variable psychological well-king was

measureà using the Profile of Mood States (McNair, Lorr 61

Droppleman, 1992). This instrument measures six mood states;

tension-anxiety, depression-dejection, anger-hostility,

vigor-activity, fatigue-inertia and confusion-bewilderment

and provides single global estimate of affective state, the

total mood disturbance score.

The mean, standard deviation, actual range of scores

and the potential range of scores for each mood state and

for total mood disturbance are presented in Table 10.

Table 10

S t a w d nevia- of Scores

Subscale Mean sr! Actual Potential

Range Range

Confusion-

bewilderment 6.92 4.98 00 - 22 00 - 28

Total mood disturbance 28.14 29.06 -20 - 117 - 3 2 - 200 Note. Higher mean scores indicate greater mood disturbance

with the exception of the vigor-activity scale.

Multiple regression analysis was used to determine the

relationship between the independent variables of age,

gender, coping strategies, type of stressor, degree of

stress and dispositional optimism and the dependent variable

psychological well-being. The type of stressor and the

degree of stress were included because of their relationship

to the coping strategies. Stepwise multiple regression was

first perfonned on the dependent variable total mood

disturbance using the independent variables of age, gender,

99

optimism as measured by the Life Orientation test the type

of stressor, the degree of stress and the seven coping

strategies determined by the Ways of Coping Questionnaire,

The type of stress was coded according to the five groups

identified from the Ways of Coping Questionnaire (fear and

uncertainty about the future due to cancer; limitations in

physical ability, appearance, or life style due to cancer;

pain, symptoms, or discornfort from illness or treatment;

problems with family or friends related to cancer, and

other). This analysis revealed a model with four independent

variables explaining 41% of the variance of the total mood

disturbance score 10.34, p = .0001)(Table 11)- The

independent variables that best predicted the total mood

disturbance score were the coping strategy escape-avoidance

which explained 17% of the variance, the degree of stress

which explained 12%, optirnisrni which explained 8% and the

coping strategy distancing which explained 4% of the

variance in the dependent variable. Distancinq and optimism

were inversely related to the total mood disturbance score.

Both fornard and backward variable selection procedures were

performed, al1 methods produced the same final model.

Table 11

- -- . - - - -- -

Variable Coefficient Standard A Ra s E

Error

Escape-

avoidance 26.41 6.48 0.17 0.17 12.60***

Degree of

stress 7.34 2.79 0.12 0.29 10.29**

Optimism -1.49 0.56 0.08 0.37 7.49**

This statistical procedure was repeated with each of

the mood states as the dependent variable. Stepwise multiple

multiple regression was next performed on the dependent

variable tension-anxiety mood state using the independent

variables of age, gender, optimism, type of stress, degree

of stress and the seven coping strategies. This analysis

revealed a mode1 with two independent variables explaining

25% of the variance of the tension-anxiety mood score a 9.97, p = .0002)(Table 12). The independent variables that

best predicted the tension-anxiety mood score were the

degree of stress explaining 13% of the variance and the

coping strategies escape-avoidance explaining 12% of the

variance.

- - - . - - - . - - -

Variable Coefficient Standard A R2 K E

Error

Degree of

stress

Escape-

avoidance

A stepwise multiple regression with the dependent

variable fatigue-inertia mood state and the independent

variables of age, gender, optimism, the type of stress, the

degree of stress and the seven coping strategies was

performed. This analysis revealed a mode1 with two

independent variables explaining 16% of the variance of the

fatigue-inertia mood score LE 5.71, p = ,0053) (Table 13).

The independent variables that best predicted the fatigue-

inertia mood score were optimism which explained 9% of the

variance, and the coping strategy self-controlling which

accounted for 7% of the variance in the dependent variable.

Optimism was inversely related to the fatigue-inertia mood

score.

102

Table 13 . .

$te&e M w l e Reureswaon of A-- Gender. ODtlmlsml

Stressorsa deglree of Stress and Seven Copina Stratedes with

F F - - - --

Variable Coefficient Standard A R2 le E

Error

Optimism -0.42 0.15 0.09 0.09 6.13*

Self - Controlling 3.10 1.40 0.07 0.16 4.90*

A stepwise multiple regression w i t h depression-

dejection mood state as the dependent variable and the

independent variables of age, gender, optimism, type of

stress, degree of stress and the seven coping strategies was

conducted. This analysis revealed a mode1 with t w o

independent variables explaining 29% of the variance of the

depression-dejection mood score (F 12.46, p = .0001)(Table

14). The independent variables that best predicted the

depression-dejection mood score were the coping strategy

escape-avoidance accounting for 20% of the variance and

optimism explaining 9% of the variance. Optimism was

inversely related to the depression-dejection maod score.

103

Table 14

Escape-

avoidance

Optimism

A stepwise multiple regression with the dependent

variable of anger-hostility mood state and the independent

variables of age, gender, optimism, type of stress, degree

of stress and the seven coping strategies was conducted.

This analysis revealed a mode1 with two independent

variables explaining 28% of the variance of the anger-

hostility mood score (F 11.09, p = -0001)(Table 15). The

independent variables that best predicted the anger-

hostility mood score were the coping strategy escape-

avoidance accounting for 14% of the variance and the degree

of stress accounting for 14% of the variance-

104

Table 15 . . on of A g e - Gender. O ~ t i m l s r a ,

tv Mood State Score (N - - 1 -

Variable Coefficient Standard 4 R2 E E

Error - - - - - - - - - - - -

Escape-

avoidance 4.33 1.20 0.14 0.14 10.44**

Degree of

stress 1.92 O. 56 0.14 0.28 11.58+*

A stepwise multiple regression with the dependent

variable of confusion-bewilderment mood state and the

independent variables of age, gender, optimism, type of

stress, degree of stress and the seven coping strategies was

conducted. This analysis revealed a mode1 with three

independent variables explaining 37% of the variance of the

confusion-bewilderment mood state score jF 11.80, p= .0001)

(Table 16). The independent variables that best predicted

the confusion-bewilderment mood state score were the coping

strategy escape-avoidance which explained 23% of the

variance, the coping strategy distancinq which explained 7%

and optimism which accounted for 5% of the variance in the

dependent variable. Distancing and optimism were inversely

related to the confusion-bewilderment mood state score.

105

Table 16

Ste~wise Multiple R- of Aue, G m r . Optlmlsm. and . .

Seven C o m a - Stratmies w i a m i o n - Bew-ent Mooa

State Score fBf - - 1

Variable Coefficient Standard A R2 E E

Error

Escape-

avoidance 5.46 1.14 0.24 0.24 19.55***

Distancinq -2.23 0.88 0.08 0.32 6 .92*

Optimism -0-22 0.10 0.05 0.37 5.14* *g < . 0 5 . ***Q < .O01

A stepwise multiple regression with the vigor-activity

mood state as the dependent variable and the independent

variables of age, gender, optimism, type of stress, degree

of stress and the seven coping strategies was conducted.

This analysis revealed a mode1 with three independent

variables explainhg 26% of the variance of the vigor-

activity mood score (F 7.18, p = .0003). The independent

variables that best predicted the vigor-activity mood score

were the degree of stress which accounted for 11% of the

variance, the type of stressor (pain, symptoms or

discomfort) which explained 8% of the variance and optimism

which accounted for 7% of the variance in the dependent

variable (Table 17). The degree of stress and the type of

stressor were inversely related to the vigor mood state-

- --

Variable Coefficient Standard A Rz E E

Error

Degree of

stress -2.03 O. 65 0.11 0.11 7.66*+

Stressor

pain/symptoms -5.93 2.41 0.08 0.19 6.28*

Summarv

Psychological well-being, the dependent variable for

the third research question was measured using the Profile

of Mood States (McNair, Lorr & Droppleman, 1992)- The total

rnood disturbance score and scores for s i x mood states were

determined. Multiple regression analysis was used to

determine the relationship between the selected independent

variables and dependent variable total mood disturbance.

Multiple regression was also used to examine the

relationships between the independent variables and each of

the mood states.

Forty-one percent of the variance of the total mood

disturbance score was explained. The independent variables

that best predicted the total moocf disturbance score were

107

the coping strategies escape-avoidance and distancing, the

degree of stress and dispositional optimism. Distancinq and

optimism were inversely related to the total mood

disturbance score.

Three of the independent variables were predominant in

the regression models; the coping strategy escape-

avoidance, dispositional optimism and the degree of

perceived stress. The coping strategy escape-avoidance was a

significant predictor of the variance in five of the models

total mood disturbance, tension-anxiety, depression-

dejection, anger-hostility, and confusion-bewilderment. It

was nat significant in explaining the variance in the models

for the dependent variables of fatigue-inertia or vigor-

activity . Dispositional optimism was a significant predictor in

total mood disturbance, confusion-bewilderment, vigor-

activity, fatigue-inertia and depression-dejection but not

in the tension-anxiety and the anger-hostility models.

Optimism was invetsely related to the dependent variable in

each of the models except for vigor-activity.

The degree of stress was a significant predictor in

four of the multiple regression models; total mood

disturbance, tension-anxiety, anger-hostility, and vigor-

activity but not in fatigue-inertia, depression-dejection or

confusion-betwilderment. The degree of stress was inversely

related in the mode1 predicting vigor-activity.

The score of the coping strategy distancinq was a

significant predictor in the models that used total m o o à

disturbance and confusion-bewilderment as the dependent

variables. Distancing was inversely related to the dependent

variable in both of these models. The the score of the

coping strategy self-controlling was a significant predictor

in the mode1 that used fatigue-inertia as the dependent

variable. The type of stressor (pain, symptoms, or

discornfort from illness or treatment) was a significant

predictor of the vigor-activity mood state score.

The independent variables of age, gender, and the

coping strategies seeking social support, planful problem

solving, accepting responsibility and positive reappraisal

did not enter any of the regression equations with entry

level alpha of 0 . 0 5 .

Discussion

This chapter presents the discussion of the findings

according to each research question.

g v Pe_oDlewitnulQper'tnor-rable

umLcmG= Consistent with the findings of Dunkel-Schetter,

Feinstein, Taylor and Falke (1992) fear and uncertainty

about the future due to cancer was the most frequently

identified stressful situation selected by the participants

in this sample. This was followed, in order of decreasing

frequency, by those who chose to describe their greatest

stressor, limitations in abilit.1 and life style, problems

with family or friends, and pain or symptoms. This pattern

of frequency reflected the fairly high performance status of

this sample. Most were limited only in strenuous activity

and al1 were ambulatory. With the progression of this

illness one would expect that limitations in ability, and

pain and symptoms may become the more prevalent stressors,

however at this particular phase of illness fear and

uncertainty about the future was predominant. It must also

be considered that being presented with a list of possible

stressors influenced the participants decision regarding

their greatest stressor. As would be expected among people

110

with advanced lung cancer the degree of perceived stress was

rated as moderate to very stressful by the majority of

participants. This level of stress was consistent with the

findings of Dunkel-Schetter et al. (1992) among patients

with a variety of types of cancer.

The coping strategies used by the participants in this

çample were detemined by the Ways of Coping Questionnaire

(Folkman & Lazarus, 1988b). Seven of the eight subscales

were used. Confrontive coping was excluded because of a low

reliability coefficient in this sample. Miller et al. (1996)

also found a low reliability for this subscale in a sample

of people with advanced cancer. The confrontive coping

subscale which was described as "aggressive efforts to alter

the situation and suggests some degree of hostility and

risk-takingw; this method may not be relevant for people

with advanced cancer. Miller et al. (1996) also excluded the

scales for the coping strategy distancing and self-

controlling due to low reliability coefficients.

Seeking social support was the coping category used

most by this sample of people with advanced lung cancer. On

average this coping category accounted for 25% of the total

coping effort and was the only category which was used to

at least some degree by al1 the participants. The use of

this strategy may be partially explained by the high

availability of support to this group. Al1 of the

participants in the study were being followed in the cancer

111

centre and had regular contact with the physicians and

nurses of the centre. Items in this scale such as Valking

to someone to find out more about the situationn, "getting

professional helpn, Valking to someone who could do

something concrete about the problemn seemed to tapthis

type of support. In addition the majority (81.2%) of the

participants were living with their spouse or other family

members which would also enhance the availability of social

support.

A consistent primary coping strategy among people with

cancer was not found in the literature reviewed. While the

current study found the coping strategy seeking social

support to be used most frequently, Miller et al. (1996) in

a study of people with advanced cancer found the coping

strategy positive reappraisal to be the strategy used most.

Caner et al. (1993) found that among women with early stage

breast cancer the use of the coping strategy acceptance was

significantly higher than the other scales used. In a

longitudinal study of women with breast cancer Stanton and

Snider (1993) found that the use of strategies varied with

tirne. Dunkel-Schetter et al. (1992) found distancinq coping

strategies to be most common. This lack of consistency

supports the view of Lazarus and Folkman (1984) that coping

is a dynamic and changing process.

Most of the coping strategies were used at least to

some extent by most of the participants. The one exception

112

was the coping strategy accepting responsibility. This

strategy had the lowest mean score and contributed only 6

percent to the total coping score. Twenty two (34.4%) of the

participants did not use any of the items on this scale. The

limited use of the coping strategy accepting responsibility

among people with advanced cancer was consistent with the

findings of Miller et al. (1996). The coping strategy

accepting responsibility was not included in any of the

other studies among people with cancer which were reviewed.

King, Roue, Kimble, and Zerwic (1998) found the use of the

strategy self blame to be moderate among women recovering

from heart surgery. The limited use of the accepting

responsibility strategy in this study may reflect that there

were only 4 items on the accepting responsibility scale

however it also must be considered that the items comprising

this scale may not have been selected because they were

viewed as negative (e.g. 1 criticized or lectured myself, 1

realized that 1 had brought the problem on myself). Given

the relationship between smoking and lung cancer the item

relating to bringing on the problem myself may have

triggered a denial response. The coping strategy accepting

responsibility may simply not be relevant in managing the

stress related to a diagnosis of lung cancer.

In assessing the relationship between the degree of

perceived stress and the use of specific coping strategies a

low negative correlation (r = -0.26 p = . 0 3 ) was determined

113

between the coping strategy distancing and the degree of

perceived stress indicating that those who perceived the

situation as most stressful used fewer distancing

strategies. It has been suggested that in relation to

psychological distress the coping strategy distancing, which

minimizes and distracts attention from the situation, may

not be needed at very low levels and may not be possible at

very high levels (Dunkel-Schetter et al., 1992). It may also

be that at high levels of perceived stress individuals are

unable to use distancing coping strategies. Dunkel-Schetter

et al. (1992) also examined the relationship between the

degree of perceived stress and the selection of coping

strategies finding that the degree of perceived stress was

associated with greater coping through seeking social

support, and the use of escape-avoidance coping strategies,

but not with the strategy distancing. The current study did

not find an association between the degree of perceived

stress and either of the coping strategies seeking social

support or escape-avoidance. The role of perceived stress in

the selection of coping strategies remains unclear.

To determine if the use of coping strategies varied

with the situation the sample was grouped according to the

situations identified as most stressful by the participants.

The ordering of the mean scores did Vary with the situation

in what seemed to be a logical manner. When the situation

identified as most stressful was related to fantily and

114

friends both the scores for the coping strategies distancing

and self-controlling were greater than the strategy seeking

social support. This may indicate that when the source of

social support was viewed to be the source of stress coping

strategies other than seeking social support were selected.

When the problem was limitations in ability or pain and

symptoms the coping strategy score for planful problem

solving was the second highest, however when the problem was

fear and uncertainty or problems with family and friends the

score for the coping strategy planful problem solving fell

to fifth. A one way analysis of variance performed on the

grouped data determined that for one coping strategy, escape

avoidance, the differences in the mean scores were

significant (r 3 , 4 7 = 3 . 6 0 ; p = 0.02). Further analysis

using Tukey's studentized range test indicated that the

coping strategy escape avoidance was used less when the

situation involved limitations in ability than when the

situation was either fear and uncertainty or problems with

family or friends. Participants may have found that as they

performed their daily activities they were constantly

reminded of of their physical limitations making avoidance

of this situation more difficult. Longitudinal studies among

women with breast cancer (Carver at al., 1993; Stanton &

Snider, 1993) have found that the use of coping strategies

varies over tirne. These studies did not specify the stressor

in more detail than coping with breast cancer but one would

115

expect the specific stressful aspects of the situation would

change over time supporting the concept that different

strategies were used to mange different stressors. This

variation in selection of coping strategies based on the

specific cancer related situation is consistent with the

view of Lazarus and Folkman (1984) that the process of

coping used varies with the significance and requirements of

the situation. Contrary to this view Dunkel-Schetter et al.

(1992) did not find the pattern of coping to Vary with the

stressful situation.

Gender differences in the use of coping strategies

suggesting that women use more emotion focused coping then

men have been fowid in a number of studies involving

university students (Chang, 1998a; Ptacek et al. 1992;

Thoits, 1991). Studies of adult cancer populations (Dunkel-

Schetter et al., 1992; Friedman et al., 1992) have not found

gender differences. Consistent with this finding this study

using two sample t-tests on the means for males and females

for each of the coping strategies found no gender

differences. It has been suggested that in similar

situations men and women use similar strategies (Porter h

Stone, 1995; Lazarus, 1993). Findings from this study

support this contention.

The possibility that age would influence the use of

coping strategies was explored. Younger age has been

associated with the greater use of seeking social support,

116

focusing on the positive and behavioral escape avoidance

(Dunkel-Schetter et al., 1992). In the present study a low

negative correlation (r = 0.30 p = -01) was determined for

escape avoidance coping and age indicating a decrease in the

use of this strategy with increasing age. To further

explore this the participants were grouped into two age

categories, (Group 1 = 40 - 59 years and Group II = 60 - 79 years) however no significant differences were detemined

based on Students t-tests. A plot of these data revealed

that this relationship did not become evident until in the

late 60 's explaining the lack of a significant relationship

when the group was divided at age 60. This plot also

revealed the existence of an outlier, one participant aged

74 who had the highest score on the escape avoidance

subscale. On further investigation this participant was one

of the feu participants with early stage cancer but was not

operable for other medical reasons, Removal of this

participants data set from analysis produced a much stronger

negative correlation between age and escape avoidance coping

(r = 9-41, p = -0008) but there still no significant

differences between the two age groups when the dividing

point was age 60, Changing the division point to age 65 did

demonstrate a difference in the age groups. Halstead (1994)

studying the coping strategies used by long term cancer

survivors found difierences in the coping strategies of the

middle aged (41-65 years) and the elderly (65-82 years). The

117

elderly group used more optimistic and palliative strategies

and the middle-aged more emotive strategies. No differences

were f o n d in the use of evasive strategies between the two

age groups, Why the elderly would be less likely to use

escape avoidance as a coping strategy is not clear- The

items in the escape avoidance scale focused on denial and

avoidance of the reality of the situation being managed- It

may be that the elderly appraise what is at stake in the

situation differently and as a result feel less need to

avoid or deny the situation (Edlund 6i Sneed, 1989). When the

stressful situation is related to a diagnosis of advanced

lung cancer the elderly may be better prepared to accept a

poor prognosis-

In summary, while the participants in this study tended

to use a variety of strategies, seeking social support was

the only strategy used by al1 the participants in al1

situations. This may simply reflect the availability of

social support to this particular sample. There did seem to

be variability in the use of the strategies depending on the

situation but for only the coping strategy escape-avoidance

was there a significant difference across the situations.

Escape avoidance coping was used significantly more by the

participants w h o identified their stressor as fear and

uncertainty, or problems with family and friends than those

participants w h o identified limitation in ability-

Distancing as a coping strategy was used less by those who

118

perceived greater stress. These findings support the theory

that primary appraisal of the situation influences the

selection of coping strategies. Gender was not significant

in the selection of coping strategies in this study

consistent with the concept that it is the situation not

gender that is more important in coping (Lazarus, 1993).

The role of age in the use of coping strategies among this

sample was less clear. Age seemed only to be of importance

in relation to the coping strategy escape avoidance with a

pattern indicating that this strategy was used less often by

the most elderly in the sample.

The ~ebtionçhiP between n-tlom . . . OP- and C o u

Strateaies.

Dispositional optimism has been defined by Scheier and

C a r v e r (1992) the tendency to believe that one will

generally experience good versus bad outcomes in lifem. In

this study optimism was measured using the revised Life

Orientation Test (LOT-R). The mean score was 15.9 (SD =

5 4 , this vas slightly higher than the mean score of 13.9

obtained among a large sample of college students (Chang,

1998a). Direct comparisons with other studies is not

possible as most have used the original version of the Life

Orientation Test, however the finding of higher optimism

scores among people with cancer compared with college

students is not an unusual finding (Miller et al., 1996;

119

C a n e r et al., 1993) but has not been consistent (Friedman

et al., 1992). Whether optimism is a consistent trait or

increases with age or when faced with a life threatening

illness is not clear. Age and optimism were not correlated

in this study.

Based on an assumption underlying the theory of

behavioral self regulation that expectancies influence

action Scheier and Carver (1985) theorize that when a

discrepancy between the current situation and a goal exists

an assessment of the possibility of goal achievement is

made, an optimist having greater expectations of success is

more likely to view the goal as attainable and therefore

more likely to persist and as a result experience better

outcorne. That optimists do experience better outcomes at

least in terms of psychological well-king has b e n

supported in a number of studies (Chang, 1998a; Segerstrom

et al., 1998; King et al., 1998; Dunbar et al., 1996;

Scheier, 1989; Taylor, et al., 1992; Baker et al- 1997;

Carver et al., 1993; Stanton t Snider, 1993; Miller et al.,

1996). Scheier, Weintraub and Carver (1986) also have

purposed that the differences experienced by an optimist and

a pessimist are related at least partially to the selection

of different coping strategies- Although the empirical

support for this contention is not as strong, a number of

studies have a found a relationship between optimism and the

uses of certain coping strategies (Scheier, Weintraub &

120

Carver, 1986; Friedman et a1,,1992; Shepperd et al., 1996;

Carver et al,, 1993; Chang, 1998a; King et al., 1998;

Segerstrom et al., 1 9 9 8 ) . The current study did not however

find this relationship. Although the relationship between

optimism and escape avoidance coping did approach

significance none of the relationships between optimism and

the seven coping strategies were significant.

Because of the theoretical and empirical support for

the existence of this relationship the lack of support found

in this study requires further exploration. A number of

possible explanations were considered.

Although a fairly consistent finding the strength of

the relationships reported have for the most part been low

to moderate. It is possible that the sample size of this

study was not sufficient to detect a relationship between

coping and optimism.

A second possibility considered was that the use of the

revised version of the Life Orientation Test in this study

may be the reason that no relationships were found between

optimism scores and the coping strategies. The Life

Orientation Test was revised (Scheier, Canter C Bridges,

1994) because two of the items on the original scale were in

fact items related ta coping by positive reinterpretation.

Despite the revision the original scale has remained in use

and with the exception of a study by Chang (1998s) al1 of

the studies reviewed used the original scale, Chang did

121

however find a relationship between a number of coping

strategies and optimism which weakens this arguaient.

It was also considered that relationship of optimism

and the use of specific coping strategies may be

situational, in some situations optimist and pessimist may

tend to use different strategies but this may not hold true

for al1 situations. A relationship between optimism and

coping may not have been found in this study because of the

method used in the measurement of coping. The participants

in this study were interviewed between one month and one

year of diagnoses and in responding to the coping

questionnaire were asked to identify a specific stressful

situation in relation to having a cancer diagnosis.

Therefore while the underlying theme vas a diagnosis of lung

cancer the participants were in fact dealing with a variety

of different stressors and were at different points along

the illness continuum. Longitudinal studies do provide some

support for this possibility that the relationship between

the level of dispositional optimism and the selection of

coping strategies is situational. Carver et al. (1993)in a

study among women who had surgery for breast cancer, found

significant associations between optimism and some

strategies over the course of a year but other strategies

were only significantly associated at some of the

measurement points. In a study of women recovering from

coronary artery bypass graft surgery King et al. (1998)

122

found fewer significant relationships and none thatwere

consistent across the study period-

This study did not find any significant relationships

between optimism and coping. While optimism may nothave the

same relationship to coping among people with lung cancer as

has been found in other studies a nuaaber of methodological

issues have b e n explored which could provided alternate

explanations,

The Relatio-p between hae, Strateaes,

Opti- gnd P s y c h o l a Well - beina,

The final research question explored the relationship

between the selected independent variables and the dependent

variable psychological well-being. Psychological' well-

being was measured using the Profile of Mood States ( P O M S ;

McNair, Lorr & Droppleman, 1992) which provides a total mood

disturbance score and scores for each of six mood states.

Higher scores indicate less well-king and greater distress

with the exception of one scale, the vigor-activity scale.

Consistent with the findings from previous studies among

people with lung cancer (Cella et al,, 1987) and breast

cancer (Carver et al., 1993; Stanton & Snider, 1993) the

participants in this study did not indicate high levels of

distress (total mood disturbance m = 28.1, possible range - 32 - 200). There were no significant differences between

the means based on gender in this group. The mean for the

123

male participants (m = 29.5) was actually slightly higher

than for the females (m = 25.0). Although no tests of

statistical significance were conducted the scores for this

population were not dissimilar from those of a large (n

=2360) sample of adults participating in a smoking cessation

program (mean total mood disturbance score for males was

2 7 . 2 and 33.4 for females, HcNair, torr C Droppleman, 1992).

The scores on the subscales were also similar to those of a

sample of womien following surgery for breast cancer (one

exception was on the confusion-bewilderment scale where the

mean for the breast cancer sample was 2.76 and for lung

cancer was 6.92)(Stanton & Snider, 1993). These findings

regarding mood disturbance do not support the finding that

people with lung cancer are more distressed (Weisman 6

Worden, 1976-77) or that women experience higher levels of

distress (Cella et a1.,1987; HcNair, Lorr & Droppleman,

1 9 9 2 ) .

Multiple regression analysis was used to further

explore the relationship between the independent variables

of interest; age, gender, optimism, and coping, with the

dependent variable psychological well-being. In addition two

other variables were included in the regression analysis,

the degree of stress and the type of situation. These

variables were included because in previous analysis they

did show some degree of relationship to coping and because

of their theoretical significance in relation to Lazarus and

124

Folkman's (1984) model of stress and coping. In this model

primary appraisal, the initial assessment of the situation,

is considered to be of importance in determining the use of

coping strategies. The situation, or what the individual is

coping with, and degree of stress produced by the situation

are important components of primary appraisal. Chang (1998a)

found that primary and secondary appraisal were both

significant in predicting coping strategies and the outcome

measures of life satisfaction and deprsssive symptoms.

The first regression analysis included the variables

age, gender, optimism, the type of stressor, the degree of

stress, and seven coping strategies regressed on the total

mood disturbance score. Forty-one percent of the variance of

the total mood disturbance score was explained. The

independent variables that best predicted the total mood

disturbance score were the coping strategies escape-

avoidance and distancing, the degree of stress and

dispositional optimism. The coping strategy distancing and

optimism were inversely related to the total mood

disturbance score. The amount of variance explained by

optimism was less than for escape avoidance. This may be

related to the outcome measure used (moad disturbance) as it

bas been suggested that optimism better predicts the

positive aspects of adjustment than the negative (Miller et

al., 1996). Multiple regression analysis was also used to

examine the relationships of the independent variables with

125

each of the six mood states. Three of the independent

variables were predominant in the regression models; the

coping strategy escape-avoidance, dispositional optimism and

the degree of perceived stress.

The relationship between the use of the coping

strategy escape-avoidance and psychological distress was

not surprising. Avoidance coping has been fond to be

significant in the prediction of greater psychological

distress in previous research (Stanton & Snider, 1993;

Segerstrom et al., 1998; King et al., 1998; Miller et al.,

1996; Carver et al., 1993; Dunkel-Schetter et al., 1992).

Escape-avoidance coping is an emotion focused strategy

directed at lessening emotional distress (Lazarus & Folkman,

1984) however it appears to have the opposite effect. Why

escape avoidance coping has this effect is not clear.

Several possibilities have been considered. Avoidance coping

may interfere with more effective or problem solving

actions, it may have a paradoxical effect and intensify the

thoughts being avoided, and it consumes considerable effort

(Stanton & Snider, 1993).

Examining the items included in this strategy provides

some insight as to why this strategy was not successful. The

escape avoidance strategy included elements of denial, nI

refused to believe that it had happenedu; wishful thinking,

nI hoped for a miraclem, NI wished that the situation would

go awayn, 1 had fantasies or wishes about how things might

126

turn outn; and active avoidance, "1 generally avoided king

with peoplen, "1 tried to make myself feel better by eating,

drinking, drugs etcon A11 avoid and deny the reality of the

situation, a reality that is constantly reinforced in this

population by the occurrence of symptoms, treatments and

doctors appointments.

Dispositional optimism was a significant predictor of

the variance in the score for total mood disturbance.

Previous research has linked optimism and psychological

we11-being/distress in a number of different populations

including university students, (Chang, 1998a; Segerstrom et

al., 1998), heart disease, (King et al., 1998; Dunbar et

al., 1996; Scheier, 1989) AIDS, (Taylor, et al., 1992)

cancer patients receiving bone marrow transplant, (Baker et

al. 1997) breast cancer,( Carver et al., 1993; Stanton 6

Snider, 1993) advanced cancer, (Miller et al., 1996). The

present research, in a population of people with advanced

lung cancer, supports this finding.

How optimism functions in promoting psychological well-

being has been the focus of some speculation. One theory

postulates that optimist and pessimist cope differently and

it is through the employment of different coping strategies

that different outcomes are experienced (scheier C Carver,

1985). While there has been some empirical support for this

theory, findings have not been consistent, and most have

found both a direct and indirect effect (Segerstrom et

127

a1.,1998; Chang, 1998a; King et al., 1998; Carver et al.,

1993). This study does not provide support for this

mechanism of action, as none of the relationships between

optimism and the coping strategies were significant;

although an inverse relationship between optimism and escape

avoidance did approach significance. ~lternative

explanations of the relationship between optimism and

psychological well-being have been considered. Taylor et al.

(1992) has suggested that optimism may also influence

psychological outcomes by influencing appraisal of the

situation. Optimism may act as a stress resistance resource

rather than a coping resource similar to Antonovsky's sense

of coherence (Antonovsky, 1993) or Kobasa's concept of

hardiness (Bowsher & Keep, 1995) or optimists may alter

their expectations to accommodate a new reality. Given this

possibility optimists who experience advanced lung cancer

may not hold unrealistic expectations for cure but may focus

on realistic expectations of symptom control and prolonging

survival.

Dispositional optimism was also significant in the

prediction of the mood states explaining a portion of the

variance in confusion-bewilderment, vigor-activity, fatigue-

inertia and depression-dejection. As expected optimism was

inversely related to the dependent variable in each of the

models except for vigor-activity. Optimism was not

significant in the tension-anxiety and the anger-hostility

128

models. This further analysis helps to clarify the role of

optimism in psychological well-being/distress. From this

analysis it does not appear that optimists have less

psychological distress because they are less anxious or

angry . That optimism explains a portion of the variance in the

predictions of greater vigor and less fatigue is somewhat

surprising given that these mood states reflect the physical

aspects of distress. A causal relationship between optimism

and the mood states can not be assumed. The relationships

between optimism and vigor and optimism and fatigue are

unclear, although we are considering optimism as a

dispositional trait, and therefore stable, one might

question if in fact it is those who feel greater vigor or

less fatigue who are more optimistic. The view of optimism

as a dispositional trait has been questioned elsewhere.

Miller et al. (1996) in a review of optimism scores from

different clinical populations reported higher scores among

certain populations and has suggested that optimism may

interact with specific stressors and be less of a stable

dispositional trait than previously believed.

The other significant predictors of the mood states

vigor-activity and fatigue-inertia are more in keeping with

this physical nature of these mood states. The type of

stressor being pain, syniptoms or discomfort and the degree

of perceived stress are the other significant predictors in

129

the model with vigor activity as the dependent variable. The

stress of living with pain and symptoms and the experience

of feeling stressed consume large amounts of energy and

therefore this negative relationship with vigor is not

unexpected.

Overall a greater portion of the variance was explained

in the vigor-activity model than in the fatigue-inertia

model but it should be kept in mind that vigor-activity and

fatigue-inertia are not simple opposite poles of the same

concept (McNair, Lorr & Droppleman, 1992). In addition to

optimism only one other variable was significant, the use of

the coping strategy self-controlling. This strategy is

defined as efforts to regulate ones feelings and actions.

These efforts included such items as tried to keep my

feelings to myselfu and Yrom interfering with other thingsn

and "1 kept other from knowing hou bad things weren. A l 1 of

these efforts would take considerable energy resulting in

increased fatigue.

The degree of perceived stress which was considered in

this study to be a component of primary appraisal vas a

significant predictor of the variance in the of total mood

disturbance score. The greater the perceived stress the

greater the mood disturbance. It was not an unexpected

finding that those who considered their situation most

stressful would experience the greatest psychological

distress. This relationship between primary appraisal and

130

psychological outcome is consistent with the stress and

coping theory of Lazarus and Folkman (1984)-

Also consistent with this theory is the possibility

that the relationship between the degree of perceived stress

and psychological distress was mediated by the coping

strategy distancing. In this study those who perceived their

situation as more stressful and those who used fewer

distancing coping strategies experienced greater distress- A

correlation between greater perceived stress and the use of

fewer distancing coping strategies was also found. These

findings support the possibility that the relationship

between perceived stress and psychological distress may have

been at least partially influenced by the use of fewer

distancing strategies.

Conflicting results regarding the relationship between

the coping strategy distancing and psychological distress

have been reported. Consistent with the findings of the

current study, the coping strategy distancing was reported

t o be associated with less emotional distress in a large

sample of people with varioiis type of cancer (Dunkel-

Schetter et al., 1992) however p s t hoc analysis in that

study revealed a curvilinear relationship with the coping

strategy being used most at moderate levels of distress. In

a sample of women with a diagnosis of breast cancer (Stanton

& Snider, 1993) distancing was not related to the

psychological outcome. Distancinq is defined as %ognitive

131

efforts to detach oneself and the minimize the significance

of the situation? Reviewing the items in this scale reveals

elements of acceptance aI went along with fate sometimes 1

just have bad luckn, positive reappraisal, lwked for the

silver lining, 1 tried to look on the bright aide of thingsn

and minimization, 1 made light of the situation; I refused

to get to serious about itn and didn't let it get to met

1 refused to think about it too muchm. It is worth noting

that some of the participants in this study had difficulty

with the last item stating that they didn't let it get to

them but it wasn't because they refused to think about it.

They implied that it had more to do with their own persona1

resolve not to give in. Using the distancing coping

strategy may be effective in reducing psychological distress

among people with lung cancer by providing respite from the

reality of their prognosis without the actual denial of its

existence.

The use of distancing as a coping strategy was also

found to be a significant predictor of the variance in the

mode1 with confusion-bewildement as the dependent variable.

It is of note that the designation of confusion-bewilderment

as a mood state has been questioned. It has been suggested

that the cognitive inefficiency represented by this scale

(confused, forgetful, unable to concentrate) may be a by

product of anxiety (McNair, Lorr & Droppleman, 1992) or

other negative emotions such as depression (i-e. the ability

132

to think clearly is cloudy by anxiety, depression or

conflicting emotions). However if confusion-bewilderment is

simply a result of anxiety or depression it would be

expected that the coping strategy distancing would also be

significant in predicting the scores of these mood states,

this was not the case, the coping strategy distancing was

not significant in preâicting the score of either the

tension-anxiety mood state or the depression-dejection mood

state.

Contrary to the findings that younger age (Carver et

a1.,1993; Miller et al., 1996; King et al., 199 Stanton &

Snider, 1993; Baker, 1997) and female gender (Chang, 1998a,

Dunbar et al., 1996; Akechi et al., 1998; Baker et al.,

1997) have b e n associated with greater distress,

specifically more tension and anger, neither age nor gender

were found to be significant in the prediction of total mood

disturbance or of any of the mood states examined in this

study. This is consistent with finding by Miller et al.

(1996) who reported no difference in gender in a sample of

people with advanced cancer.

The coping strategies seeking social support, planful

problem solving, accepting responsibility and positive

reappraisal were not significant predictors of the variance

in total mood disturbance or of any of the mood states in

this study. The findings of previous research involving

people with cancer has produced conflicting results. Miller

133

et al. (1996) found that less use of the coping strategy

accepting responsibility was associated with higher levels

of well-being but consistent with the findings of the

current study they did not find the strategies seeking

support, positive reappraisal of planful problem solving to

be associated with either well-being or distress. However

contrary to the finding of the current study other studies

( C a n e r et al., 1993; Stanton & Snider, 1993; Dunkel-

Schetter et a1.,1992) have found coping strategies involving

social support and positive reframing/focusing to be

significant predictor of psychological distress/well-being.

S_unimarv

Fear and uncertainty about the future was the

predominant stressful situation among this group of people

with advanced lung cancer. The degree of perceived stress

related to the stressful situation was rated as moderate to

high however for a feu participants it was reported as

extreme . Seeking social support was the coping strategy used

most often, this may reflect the level of support available

to the participants. The coping strategy of accepting

responsibility and escape avoidance were used least often.

Distancing, the second most frequently used strategy, was

negatively correlated with the degree of stress indicating

that it was more difficult to minimize the situation as

stress increased. Escape avoidance coping although used

134

infrequently by this sample, did Vary with the type of

stress and decreased in use with increasing age. The use of

the coping strategies self-controlling, positive reappraisal

and planful problem solving was moderate. Gender did not

influence the use of coping strategies in this study.

No relationships were found between dispositional optimism

and any of the coping strategies.

The main findings from the regression analysis, that

the use the escape avoidance coping strategy and less

dispositional optimism were significant in the prediction of

greater distress were as expected, and support the findings

from previous studies. Escape-avoidance coping may have been

unsuccessful in this sample of people with advanced lung

cancer because they are confronted with constant reminders

of their illness. Optimism which was not related to any of

the coping strategies was associated with less distress.

This study did not support the theory that optimists

experience better psychological outcomes because of the use

of different coping strategies.

The use of the coping strategy distancing and the

degree of perceived stress were found to be significant

predictors of the variance in psychological distress. The

use of the coping strategy distancing was also negatively

correlated with the degree of stress perceived. Those who

perceive a situation as very stressful and are unable to

distance themselves from it may experience greater

135

psychological distress.

The coping strategy self-controlling was found to be a

significant predictor of the variance in the mode1 with the

dependent variable as fatigue. The self-control coping

strategy was used to a moderate degree by the participants

in this study and included items which seemed to be focused

on the protection of others. These behaviours would take

considerable energy and perhaps contributed to feeling of

fatigue.

The stressful situations labelled pain, symptoms or

discomfort was a significant predictor in the variance of in

vigor-activity. When the most stressful situation associated

with lung cancer was pain, symptoms or discomfort less vigor

was reported. None of the other stressful situations

identified were significant predictors of the variance in

any of the mood states.

In this study neither age or gender, or the coping

strategies seeking social support, planful problem solving,

accepting responsibility or positive reappraisal were found

to be significant predictors of psychological distress.

CHAPTER V

Summary , Limitations and Implications

Sumniarv

Lung cancer is the leading cause of cancer death in

Canada (National Cancer Institute of Canada, 1998)- Despite

advances in cancer treatment the prognosis for those with

lung cancer remains poor. Surgery provides the best

possibility for survival, but most of those diagnosed with

lung cancer will have disease which is too advanced at the

tirne of diagnosis or, for other medical reasons, will not be

candidates for surgery. The negative impact of lung cancer

on psychological well being is recognized, however coping

with the stressors resulting from this diagnosis has

received little attention. The selection of coping

strategies and their effectiveness is influenced by numerous

factors. Relationships between optimism, coping strategy

selection, and psychological outcome were found in a number

of studies, however no studies examining these relationships

were reported with regard to people with lung cancer.

The purpose of this study was to examine the

relationships between the personality disposition of

optimism, coping strategies, the demographic characteristics

of age and gender and psychological well-being of people

with advanced or inoperable primary lung cancer,

The theoretical framework guiding this research vas the

137

Lazarus and Folkman (1984) theory of stress, appraisal and

coping. Dispositional optimism as conceptualized by Carver

and Scheier (1985) was incorporated in the framework as a

persona1 factor . This study vas conducted in a large tertiary care

health centre which serves as one of the provincial referral

centres for patients with lung cancer. Data w e r e collected

£rom 64 patients during a clinic visit which had been

scheduled for either treatment or follow up. Al1 the

participants in this study had been diagnosed with advanced

or inoperable primary small or non small ce11 lung cancer,

were between one month and one year of receiving that

diagnosis, and could speak and understand English. No one

with recurrent cancer, another recent cancer diagnosis or

brain metastases were included-

Data collection was conducted in a interview format.

Participants provided demographic information and responded

to three questionnaires, the L i f e Orientation Test - revised (Scheier, Carver & Bridges, 1994), the Ways of Coping

Questionnaire (Polkman d Lazarus, 1988b), and the Profile of

Hood States (HcNair, Lorr & Droppleman, 1992). Data

regarding disease and treatment were obtained form the

participants health record-

Three research questions were addressed. The study

findings related to each question are as follows:

1. What are the coping strategies used by people w i t h

138

advanced or inoperable primary lung cancer?

The coping strategies were measured using the Ways of

Coping Questionnaire (Folkman & Lazarus, 1988b).

Participants responded to this questionnaire by first

identifying the situation related to their diagnosis of lung

cancer which tbey had found most stressful and then

indicating on a scale of one to five the perceived degree of

stress. Fear and uncertainty about the future was the

situation most frequently identified. Most (65.7%) rated the

degree as moderate ta very stressful (rating 3 - 4). The

most used coping strategy was seeking social support

followed by distancing, self-controlling, planful problem

solving and positive reappraisal. Escape avoidance and

accepting responsibility were the strategies used the least.

T-test analysis revealed no gender differences in the use of

any of the strategies. Correlational analysis determined a

low negative correlation between the degree of stress and

the coping strategy distancing. The analyses based on age

produced conflicting results, t-tests with participants

grouped by age (Group 1 40-59, Group II 60 - 80) determined no differences however using Pearson's product-moment

correlation a low negative correlation vas determined for

escape avoidance coping and age. From a plot of these data

it appeared that the most elderly use escape-avoidance

coping strategies the least.

One-way analysis of variance was performed to determine

139

if the means for the coping categories for the data grouped

according to the type of stressful situation differed. There

were statistically significant differences in the mean

scores for the coping category escape avoidance between the

group 'limitations in ability', and the means of two other

groups ' fear and uncertainty' and 'problems with family or

friends related to cancer8.

2. What is the relationship between dispositional optimism

and the coping strategies utilized by people with advanced

and inoperable primary lung cancer?

Dispositional optimism was measured in this study using

the Revised Life Orientation Test(LOT-R) (Scheier, Carver &

Bridges, 1994). The mean optimism score as determined by

Life Orientation Test was 15.9 (SD = 5 . 3 ) , the median was 17

and the range of scores was 2 - 24. Pearson's product-moment

correlation coefficient was calculated to determine the

strength and direction of the relationship between

dispositional optimism and each of the coping scales. None

of these correlations proved to be significant at alpha < or

= . 0 5 .

3. What is the relationship between age, gender, coping

strategies used, dispositional optimism and the

psychological well-being of people with advanced or

inoperable primary lung cancer?

Psychological well-being, the dependent variable in the

third research question was measured using the Profile of

140

Mood States (McNair, Lorr & Droppleman, 1992). The Total

Mood Disturbance Score and scores for six mood states were

determined.

Multiple regression analysis was used to determine the

relationship between the independent variables of age,

gender, coping strategies, type of stressor, degree of

stress and dispositional optimism and the dependent variable

psychological well-being. The type of stressor and the

degree of stress were included because of their relationship

t o the coping strategies. The type of stress was coded

according to the five groups identified from the Ways of

Coping Questionnaire (fear and uncertainty about the future

due to cancer; limitations in physical ability, appearance,

or life style due to cancer; pain, symptoms, or discomfort

from illness or treatment; problems with family or friends

related to cancer and other). This analysis revealed a model

with four independent variables explaining 41% of the

variance of the total mood disturbance score LE 10.34, Q =

-0001). The independent variables that best predicted the

total mood disturbance score were the coping strategy

escape-avoidance (17%), the degree of stress (12%), optimism

(7%) and the coping strategy distancing (4%). Distancing and

optimism were inversely related to the total mood

disturbance score.

Multiple regression analyses was also used to determine

the relationship of the independent variables with each of

141

the mood states. This analysis produced the following

models: 25 percent of the variance in the tension-anxiety

mood state was explained by the variables the degree of

stress and the coping strategies escape-avoidance; 16

percent of the variance of the fatigue-inertia mood state

was explained by the variables optimism (inversely related)

and the coping strategy self-controlling; 29 percent of the

variance of the depression-dejection mood state was

explained by the coping strategy escape-avoidance and

optimism (inversely related); 28 percent of the variance of

the anger-hostility mood state was explained by the coping

strategy escape-avoidance and the degree of stress; 26

percent of the variance in the vigor-activity mood state was

explained by three variables the degree of stress (inversely

related), the type of stressor being pain, symptoms or

discornfort (inversely related), and optimism; and 37 percent

of the variance of the confusion-bewilderment mood state was

explained by the coping strategy escape avoidance,

distancing (inversely related) and optimism (inversely

related). Three of the independent variables were

predominant in the regression models; the coping strategy

escape-avoidance, dispositional optimism and the degree of

perceived stress. The independent variables of age, gender,

and the coping strategies seeking social support, planful

problem solving, accepting responsibility and positive

reappraisal did not enter any of the regression equations

with entry level alpha of 0.05.

t i o m

A number of factors limit the ability to generalize the

study findings- The sample was a small non-probability

convenience sample which may not be typical of the

population regarding the study variables. The sample was

restricted to only those people with advanced or inoperable

lung cancer so cannot be considered representative of the

entire lung cancer population or of other cancer

populations. The majority of the participants were Caucasian

and had little forma1 education limiting the ability to

generalize to other groups. The study was conducted in one

setting, an ambulatory cancer clinic, therefore the sample

was not representative of those who required hospitalization

or who were being followed in the community.

The Ways of Coping Questionnaire was ansvered in

relation to a situation which may have a occurred at any

time since diagnosis, therefore responses were based on the

participants recall of what they did or thought at that

time. In some cases the situation being recalled may have

occurred several months prior to the interview, cansequently

responses may not have reflected the actual thoughts and

behaviours that were used in the situation-

Al1 questionnaires were completed in an interview

format by a registered nurse. Participants may have tended

to give the responses which they considered to be most

socially desirable.

for N w a Practice and E a c a t l ~ n

Findings from this research add to the increasing body

of evidence indicating that less optimism and the use of

escape avoidance coping are related to psychological

distress. This knowledge could serve to enhance nurses

ability to recognize patients who are at greater risk for

psychological distress. Resources in the hospital, in the

clinic setting and in the community are limited and must be

used to best advantage. Nurses caring for patients with

advanced lung cancer sometimes experience difficulty in

deciding which patients may benefit most from resource

services. Knowledge which will help determine who is more

likely to experience greater distress may be of advantage in

allocating services,

Results from this study serve to reinforce the basic

nursing principle of the need for individual patient

assessment. While results did indicate that fear and

uncertainty about the future was frequently a major stressor

for many people with advanced lung canver it was not the

case for everyone. This highlights the need for nurses to

ask patients specifically what they are finding most

stressful in relation to their illness. In addition to

asking what was most stressful, participants in this study

were also asked to indicate how stressful they perceived the

situation to be, those who rated their degree of stress

higher w e r e found to have greater psychological distress.

Asking patients to indicate their degree of stress could be

easily added to the nursing assessment and may be valuable

in helping to determine which patients are likely to

experience greater psychological distress.

Contrary to a number of studies, findings from the

current study did not support that gender (being female) or

age (being younger) were significant in the prediction of

greater psychological distress. This finding emphasizes the

importance of individual assessment and cautions nurses not

to assume that those who are male or older are less

vulnerable to psychological distress.

Dispositional optimism was found, in previous research

and in the current study, to be significant in the

prediction of psychological distress. The use of the Life

orientation Test, as a scxeening tool for assessing the

dispositional optimism of patients in clinical practice has

been suggested (Miller et al., 1996). In the current study

the tool proved to be easy to administer and to score,

however prior to this tool becoming useful in clinical

practice further research is needed to determine at what

level optimism becomes clinical significant (i.e. how low of

an optirnisrni score would indicate the need for

intervention?). A forma1 evaluation of optimism with a

specific tool may not be needed, a question regarding

145

outlook on life included in the nursing assessment may

provide the necessary information.

While optimism was found in the current study, and in

previous research to be related to psychological well-king

interventions aimed at increasing psychological well-being

through increasing optimism have not been studied.

Interventions which are aimed at helping patients to focus

on achievable goals may improve the individualsO situational

optimism, however optimism defined as a dispositional trait

may not be amenable to change. Furthemore the relationship

between optimism and psychological well-being requires

greater clarification. This study did not find a

relationship between optimism and the selection of specific

coping strategies and therefore did not support the

contention that the relationship between optimism and

psychological well- k i n g is mediated by the selection of

coping strategies.

The finding that specific coping strategies are related

to psychological distress/well-being emphasises the need for

a more detailed evaluation of what individuals are doing to

cope with the stress of this illness. Findings indicates

that there is a need to differentiate the use of escape

avoidance strategies and those of distancing and that the

use of self controlling strategies may be associated with

greater fatigue. The assessment of coping strategies in

clinical practice requires further work. In talking with and

146

observing patients, nurses gather a great deal of

information about what the individual is coping with, and

what they are doing to manage the stress, much of this

information is neither recorded or shared with other health

professional or family members. Basic and continuing nursing

education is needed to increase nurses' understanding of the

stress and coping process and to assist nurses in developing

skills in recognizing the coping strategies which are being

used. Consistency in describing and labelling coping

strategies would be of great benefit in the process of

understanding and sharing information about coping

strategies. Questionnaires such as the Ways of Coping are

lengthy for patients to complete and are too time consuming

to score to have utility in clinical practice. Alternative

methods of assessment and documentation are needed.

This was not an interventional study and therefore

provides little guidance in terms of specific nursing

interventions. However the use of distancinq as a coping

strategy was found to be related to psychological well-being

for some patients, therefore interventions which support

this strategy may be of value. Such interventions as

ensuring flexible visiting policies, k i n g aware of the

individuals interests, engaging in non-illness related

conversations, and ensuring the availability of distraction

materials e.g. books, puzzles, television may help the

individual to distance themselves for a period of tirne. It

147

has not been determined if external interventions can alter

coping strategies or their effectiveness. Clearly further

research is needed to evaluate the effectiveness of specific

interventions.

Coping was studied in relation to a specific stressful

event determined by the participant. The present study

examined the variables of optimism and coping strategies and

their relationship to psychological distress at one point in

time. The individuals participating in this study were at

various stages in their illness and treatment. A

longitudinal study would provide valuable information about

the relationship between optimism and selected coping

strategies over the course of illness, helping to answer

questions about the stability of optimism, hou coping

strategies change, and would be beneficial in determining if

in individuals coping varies with the situation or if in

fact there are coping dispositions. A larger sample and

similar studies involving people with lung cancer at earlier

stages and those with recurrent disease is also needed.

Only the outcome of psychological well-being was

considered in this study. The role of optimism in relation

to other outcontes such as miortality (Schulz, Bookwala,

Knapp, Scheier,& Williamson, 1996) immune change,

(Segerstrom, Taylor, Kemeny, & Fahey, 1998) and success in

1 4 8

making health related change, (Shepperd, Haroto & P b e r t ,

1996) have been studied in other populations. These outcomes

are also of interest in the lung cancer population.

Especially relevant is the role of optimism in making health

changes such stopping smoking following surgery for lung

cancer.

The finding from this study did not indicate a

relationship between optimism and the coping strategies

used, this is contrary to to what a number of other studies

have found and therefore requires further exploration.

The role of age in the use of coping strategies was not

clear in this study. There was some indication that escape

avoidance coping was used less with increasing age. Given

the relationship of escape avoidance coping and

psychological distress, the effect of age requires further

study with a sample including sufficient of n&rs for

cornparison of age groups.

Interventional studies are needed. Johnson (1996) and

Johnson , Fieler, Wlasowicz, Mitchell, and Jones, (1997)

found that among pessimistic patients who were receiving

radiation therapy those who received information consisting

of concrete, objective descriptions of the experience were

less distressed. These studies involved patients with breast

and prostate cancer. Given the relationship of optimism and

psychological distress among patients with advanced lung

cancer found in the present study similar intementional

149

studies are warranted, Interventional studies examining ways

of altering escape avoidance strategies should also be

considered,

for Tbory

The theoretical framework guiding this research was

Lazarus and Folkman's (1984) theory of stress, appraisal and

coping. According to the framework appraisal and coping are

influenced by the antecedent factors, In this study the

casual antecedents were the person variables of age, gender

and the degree of optimism and the situational factor of a

diagnosis of advanced lung cancer. The outcome, the final

variable of interest was psychological well-being.

There was minimal evidence that the antecedent

variables of age, gender or the degree of optimism

influenced the selection of coping strategies. Only a iow

negative correlation between age and the coping strategy

escape avoidance indicated a relationship.

In the.Lazams and Folkmar, mode1 primary appraisal, the

initial assessment of the situation, is also considered to

be of importance in determining the use of coping

strategies. The situation, or what the individual is coping

with, and degree of stress produced by the situation are

important components of primary appraisal. In the current

study escape-avoidance coping was used significantly more by

the participants in some situations than in others and those

150

who perceived the situation to be more stressful used less

distancing coping strategies. These findings provide some

support for the theory that primary appraisal of the

situation influences the selection of coping strategies.

Also consistent with this model of stress and coping, the

current study found that the degree of perceived stress was

associated with the outcome of greater psychological

distress supporting a direct relationship between primary

appraisal and outcome.

Another major component of Lazarus and Folkman0s theory

of stress and coping is that coping does influence outcome.

Some support for the relationship between coping strategies

and psychological outcome was found. Three of the coping

strategies escape-avoidance, distancing and self-controlling

were significant in the prediction of psychological

distress.

The concept of dispositional optimism included in this

study was based on Carver and Scheier's (1985, 1992) model

of behavioral self regulation. An assumption underlying

this model is that expectancies influence action, therefore,

because optimism and pessimists have different expectations

it is presumed that they would use different coping

strategies. Finding from this study did not support this

assumption, no relationship was found between optimism and

any of the coping strategies.

Con-

In conclusion this study has contributed to the

understanding of optimism and coping as factors involved in

the psychological well-being of people with advanced lung

cancer. People with advanced or inoperable lung cancer face

a variety of stressors. Por many in a i s study dealing with

the fear and uncertainty about the future was the most

stressful. Although faced with a poor prognosis high levels

of distress w e r e not reported.

Seeking social support was the coping strategy used

most but was not significant in predicting any of the

psychological outcomes. No relationship was found between

optimism and any of the coping strategies. This study found

that those who perceived their situation as more stressful,

who were less optimistic, and who used more escape avoidance

and fewer distancing coping strategies were most distressed.

Age, gender and the coping strategies seeking social

support, positive reappraisal, planful problem solving and

accepting responsibility were not significant predictors in

the variance of the scores in psychological outcome.

This study expands the finding from previous research,

that optimism and avoidance coping are significant factors

in predicting the variance in the scores of psychological

well-being, to include a sample of people with advanced or

inoperable lung cancer. The findings from this study are

valuable to nurses in determining which patients are at

152

greater risk of psychological distress and as a basis for

further research focusing on interventions to reduce this

distress.

Appendix A

Letter of Introduction Dear :

The Thoracic Oncology group, of which your physician is a member, has agreed to assist with a research study being conducted by Lynn Coulter, a registered nurse who works with this group and is completing her Master's degree in Nursing a t Dalhousie University. The putpose of this study is to gain a better understanding of the different ways in which people with lung cancer manage the stress that this illness causes. You are invited to participate in this study. Participating in this study would involve one interview, which would take place on the same visit as your clinic appointment. You would be asked to answer some general questions about yourself and respond to questions from three questionnaires which the researcher would read to you. It will take about 60 to 90 minutes. Your decision to participate in this study is entirely your oun and ri11 not affect the care you are receiving at the meen Elizabeth Health Sciences Centre.

If you would like to leam more about this study please check the appropriate box below and return this letter in the attached envelope . Hs. Coulter will telephone you to explain the study and ask if you are willing to participate.

Thank you for your time and interest.

Sincerely,

Dr. D.C.G. Bethune

0 1 am interested in learning more about the research My telephone number is (902) .

[7 1 do not wish to participate because ( optional ) .

Verbal Introduction of Study to Potential Participants

A research study being conducted to gain a better

understanding of the different ways in which people with lung cancer manage the stress that this illness causes. This

study is king conducted by Lynn Coulter, a registered nurse

who works with your doctors and nurses and is completing her Master8s degree in Nursing at Dalhousie University- To

assist Ms. Coulter we are inviting you to participate in this study.

Participating in this study would involve answering

some general questions about yourself and responding to

questions from three questionnaires which the researcher will read to you. It will take about 60 to 90 minutes. Y o u r

decision to participate in this study is entirely your ani and vil1 not affect the care you are receiving at the Queen Elizabeth Health Sciences Centre,

If your are prepared to consider participating, 1: will

introduce you to Us- Coulter. She will provide you with an

outline of the study in sufficient detail to allow you to

make a decision about participation, Talking with her does

not mean you are consenting to participate in the study.

Consent Form

Study Title: Optimism, Coping, and Psychological Well-Being among People with Advanced Lung Cancer

Principal Investigator: Lynn Coulter, BN, RN Expanded Role Nurse Thoracic Surgery Haster of Nursing Candidate (902)473-7556

Research Supervisor:

Committee Hembers:

Barbara Downe-Wamboldt,PhD,RN Dalhousie University (902)494-2391

Lorna Butler, PhD, RN Queen Elizabeth II Health Sciences Centre

Katherine Bowen, PhD Department of Hathematics and Statistics Dalhousie University

Introduction

We invite you to take part in a research study at the Queen Elizabeth II Health Sciences Centre. You must understand several general principles that apply to everyone in our study. Taking part in the study is voluntary. The quality of your care will not be affected by whether you participate or not. Participating in the study may not benefit you, but we may learn things that will benefit others. You may withdraw from the study at any time without losing any benefits that you are entitled to. The study is described below. This description tells you about the risks, inconvenience, or discornfort which you may experience. You should discuss any questions you have about this study with the people who explain it to you.

Purpose of the Study

The purpose of this study is to learn about hou individuals with lung cancer manage the stress that this illness causes in their lives, Specifically this study will examine the relationships among the personality disposition of optimism (the persons outlook on life), the coping strategies ysed to manage the stress of lung cancer, age, gender, and the psychological well-being of people with lung cancer.

Why this Study is Being Ikne

Different individual have different outlooks on life and different ways of managing stress. What works for one person may not be helpful for another. The information from this study may help nurses and physicians to better assist the people they care for to manage the stressor of lung cancer.

Taking P a r t in the Study

Participating in this study involves one interview, This interview will be arranged at a time convenient for you during your visit to the clinic and will take about 60 to 90 minutes. You will be asked to answer some questions about yourself and to respond to questions from three questionnaires which the researcher will read to you. The questionnaires ask questions about your outlook on life, what you do when faced with a stressor, and how you are feeling emotionally. Information specific to the type, stage and treatment of your cancer will be obtained from your health record.

Risks and Benefits

The information you provide may not directly benefit you but may be used to assist others with cancer. There is no financial compensation for taking part in this study. There are no anticipated risks involved in your participation. Some people may find answering some questions upsetting if they have not talked about their experience or what they are feeling before taking part in this study. If this is upsetting for you and you would like to meet with a specialist vho helps people to cope with a cancer diagnosis a referral will be arranged for you.

voluntary participation

The decision to participate in this study is entirely your own. Your decision vil1 not affect the quality of care you

are presently receiving. If you do participate and wish to withdraw from the study or refuse ta answer any questions you may do so at any tirne.

Confidentiality

Information about you will not be identified. The persona1 information you provide, information obtained from your health record, and the questionnaires are coded w i t h a number that corresponds to your name which will be kept in a locked file available only to the researcher. Your name will not appear on any information sheet or questionnaire. The results of this study may be published in a health journal or presented at conferences. No individual will be identified in any writing or presentation. If you wish to be informed of the results, a summary of the findings vil1 be made available upon request.

Further Information About the Study

If you wish to ask further questions about the study or discuss your participation you may contact the study investiqators listed on the first page.

1 have read the erplanation about the mI Co- . . r>wvcholaWell- - Cancer study and have baan g i w a y e opportunity to discuss

e m

it and to ask questions. 1 hereby consent to take part in this study

Signature of Participant Date

Signature of Xnvestigator Date

Signature of Witness Date

Demographic Information

Stress and hou it is managed is influenced by many things. In order to better understand the role of 0th- possible influences please answer the following questions.

1. What is your age? years

2 . What is your gender? male , fernale . 3. What is your current marital status?

Married/common law , Single , Widowed I

Separated , Divorced . 4 . Who currently lives with you? (you may check more than one )

Live alone Spouse or partner ,-

Children Other family members

Friend or friends

5 . How important a role does your religion or religious beliefs play in your life?

None Some Moderate Vesy important

6. What is your cultural background?

White Black Asian Aboriginal

Other

7 . What is your approximate annual household income?

less than 10,000 10,000 - 20,000 21,000 - 30,000 31,000 - 40,000 41,000 - 60,000 61,000 - 100,ooo more than 100,000

8. What is or was (if retired) your usual occupation?

Are you currently working , on sick leave

unemployed , or retired 9. What is the amount of formal education you nad the

opportunity to complete?

seventh grade or less Grades eight or nine Some high schoal High school graduate Some college College/university graduate Post Graduate education

10a. Are you experiencing any of the following symptoms?

cough Yes no

shortness of breath

pain Yes no

fatigue/tiredness yes no

other

b. Are any of the following symptoms severe enough that they affect of limit your usual activities?

cough Yes no

shortness of breath

pain YeS no

fatigue/tiredness yes no other

11. Are you taking pain medication? yes no If yes name of medication you are taking.

Tylenol Tylenol w i t h Codeine Morphine or Dilaudid Other

12. Performance status (ECOG/WHO)

O = fully active, able to carry out al1 pre-disease activities without restriction and without aid of analgesia,

1 = restricted in strenuous activity but ambulatory and able to carry out light work or pursue a sedentary occupation. Patient who are fully active but require analgesia-

2 = ambulatory and capable of al1 self care but unable to carry out any work. Up and about more than fifty percent of waking hours.

3 = capable of only limited self care, confined to bed or chair more than fifty per cent of waking hours.

4 = completely disabled, Unable to carry out any self care and confined totally to bed or chair-

Thank you for completing this questionnaire-

Disease and Treatment Data from patients Health Record

1. Length of time since diagnoses.

2. Stage and Ce11 Type:

W S C f i C : squamous adenocarcinorna

large ce11 other

Stage T- N - site of metastasis

medically unfit

SCLC: Stage: limited extensive

3. Treatment:

Radiation

treatment plan

date started

currently receiving

date completed

Cheiotherapy

protocol

date started

currently receiving between cycle

date completed

Surgery-

date -woce-e

tation Test ~ e v u

INSTRUCTIONS:

Please be as honest and accurate as you can throughout. Try

not to le t your response to one statement influence your

response to other statements. There are no ucorrectu or

'5ncorrectW answers. Answer according to your own feelings,

rather than how you think "most peoplen would answer.

PLEASE LIS- BACH STA- -Y AND INDICATB H m

HUCH YOU AGRKB WITH T'HB S'TA-

#

1 . I n uncertain times. 1 usually expect the best . . . . O 1 2 3 4

2 . I t ' s e a s y f o r m e t o r e l a x . . . . . . . . . . . . . . O 1 2 3 4

3 . I f something can go wong f o r me it wil1 . . . . . . O 1 2 3 4

4 . I ' m always op t im is t i c about my f u tu re . . . . . . . . O 1 2 3 4

5 . 1 enjoy my f r iends a l o t . . . . . . . . . . . . . . O 1 2 3 4

6 . I t ' s important f o r me t o keep busy . . . . . . . . . O 1 2 3 4

7 . 1 hardly ever expect things t o go my way . . . . . . O 1 2 3 4

8 . 1 don't get upset too easi ly . . . . . . . . . . . . O 1 2 3 4

9 . 1 rarely count on good things happening t o me . . . . O 1 2 3 4

10 . 1 expect more good things t o happen t o me than bad . O 1 2 3 4

Reproduced w i t h permission

INSTRUCTIONS :

To respond to the statements in this questionnaire, you must

have a specific stressful situation in mind. Please take a

few moments and think about the iost stressful situation you

have experienced related to your illness.

Stressful Situation

By *stressfulW 1 mean a situation that was difficult or

troubling for you, either because you felt distressed or

because you had to use considerable effort to deal with the

situation*

The following is a list of situations which may have been or

are still stressful for you. Please tell me which, if any,

of the situation you find most stressful or you can tell me

about another situation related to your cancer which is more

Fear and uncertainty about the future due to cancer

Limitations in physical ability, appearance, or life style due to cancer

Pain, symptoms, or discomfort from illness or treatment

Problems with family or friends related to cancer.

How stressful is/was this situation for you:

1 = not stressful

2 = mildly stressful

3 = moderately stressful

4 = very stressful

5 = extremely stressful

As you respond to each of the following statements, keep

the stressful situation in mind. Remember there are no

"correctn or nincorrectm responses.

LISTEN TO EACH STATEMENT CAREFULLY AND INDICATE Tû WHAT

EXTENT YOU USED IT IN THE SITUATION:

O = DOES NOT APPLY OR NOT USED

1 = USED SOHEWHlrT

2 = USED QUITE A BIT

3 = USED A GREAT DEAL

1. 1 just concentrated on what 1 haâ to do next - the next step. . O 1 2 3

2. 1 tri& to analyze tbe problem in order to understand it better . . O 1 2 3

4. 1 felt that time would have made a différence - the oaly thing was to wait. . . . . . . . . . . . . . . . . . . . . . . . O 1 2 3

5 . 1 bargained or compromised to get something positive fromthe situation. . . . . . . . . . . . . . . . . . . . . . . . . . . . O 1 2 3

6. 1 did something that 1 didn't think would work, but at least I was dohg something. . . . . . . . . . . . . . . . . . O 1 2 3

7 . 1 tri4 to get the person responsible to change his or ber mindg O 1 2 3

8. 1 talked to someom to f ï d out more about the situation- . . . . O 1 2 3

9 . 1 criticized or lectured myself. . . . . . . . . . . . . . . . . . . . . O 1 2 3

10. I tried not to burn my bridges, but lave things open somewhat. O 1 2 3

I I . 1 hoped for a miracle. . . . . . . . . . . . . . . . . . . . . . . . . . O 1 2 3

12. 1 went dong witb tàte; sometimes 1 just have bad luck. . . . . . O 1 2 3

13. 1 went on as if nothiag had happened . . . . . . . . . . . . . . . . O 1 2 3

14. 1 tried to keep my feelings to ayself. . . . . . . . . . . . . . . . . O 1 2 3

15. 1 looked for the silver Iining, so to speak; 1 tried to look on the bright si& of things. . . . . . . . . . . . . O 1 2 3

17. 1 expressed anger to the person(s) wbo caused the problem. . . O 1 2 3

18.1acceptedsympathydundersraadiagfromsomeone. . . . . . O 1 2 3

19. 1 told myself things that helped me fœl better. . . . . . . . . . . O 1 2 3

20. 1 was inspired to do sometbiag creative about the problem. . . . O 1 2 3

Goontoocxtpage

Cowght 1988 by Consulhg Rycbologists h, Inc. Ail rights rtscrvbd WAYSP Fermissim Test

W e t

. . . . . . . . . . . . . . . . . . . . 21.1 tried to forget the whole thhg O 1 2 3

. . . . . . . . . . . . . . . . . . . . . . . . . 22.1 got professional help O 1 2 3

. . . . . . . . . . . . . . . . . . . . . 23.1 cbanged or grew as a prson O 1 2 3

24.1 waited to see what would happn befme &hg anything . . . . O 1 2 3

. . . . . . . . . . . . . 25.Iapologizedordidsomcthingtomakeup. O 1 2 3

. . . . . . . . . . . . . . . 26 . 1 made a pian of action and followed it O 1 2 3

27 . 1 accepted the aurt best thing to what 1 wanted . . . . . . . . . . O 1 2 3

. . . . . . . . . . . . . . . . . . . . . 28.1 let my feliags out somehow O 1 2 3

29 . 1 realid that 1 had brought the pmblem on myseif . . . . . . . . O 1 2 3

. . . . 3O.IcameoutoftheexperienceûettertbanwknIwentin. O 1 2 3

3 1 . 1 talked to someone who could do sotnethhg concrete about the problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . O 1 2 3

32 . 1 tried to get away h m it by restjng or taicing a vacation . . . O 1 2 3

33 . 1 aied to make myself feel beaa by eating. drinkïng. . . . . . . . . . . . . . smoking. using dnigs. or medicatim. etc O 1 2 3

34 . 1 took a big chance or did something very ridcy . . . . . . . . . . . . . . . . . . . . . . . . . . to solve the @lem O 1 2 3

. . . . . . . . 35 1 nied not to act too hastily or foliow my fim bunch O 1 2 3

. . . . . . . . . . . . . . . . . . . . . . . . . . . . 36.1 found new faith O 1 2 3

. . . . . . . . . . 37 . 1 maintained my pride ami kept a stiff upper lip O 1 2 3

. . . 39 . 1 changed so-g so that things wouid hm out all right O 1 2 3

. . . . . . . . . . . . . . . 40 . 1 generally avoided king witb people O 1 2 3

41 . 1 âidn't let it get to me; 1 refbsed to thialr too much about it . . O 1 2 3

Gooatoaextp8gc

Copyright 1988 by Consulting Psycbologiss Ress. Inc . AU r i g h ~ reserved WAYSP Pennissioiis Test

Booklet

. . . . . . . 42 . 1 asked advice fiom a relative or a F r i d 1 reqected 0

43 . 1 kept oibm h m knowing bow bad things were . . . . . . . . . O

44 . 1 made light of îbe situation; 1 refused to get too saious about it.0

. . . . . . . . . . . . 45.1 taiked to sotneone about bow 1 was feeling O

. . . . . . . . . 46 . I stood my gmunâ and fought for what 1 wanted O

. . . . . . . . . . . . . . . . . . . . . . 47 . 1 took it out on o t k -le O

48 . 1 drew on my ps t experience; 1 was io a similar situation before.0

49 . I knew what has to be done, so 1 doubled my efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . to rnake things work O

. . . . . . . . . . . . . . . 50 . 1 refused to believe that it had happened O

51 . 1 promwd myself thot things would be different next time . . . O

52 . 1 came up with a couple of different solutions to the pmblem . . O

53 . 1 accepted the situation since mthiag could be &ne . . . . . . . . 0

54 . 1 aied to keep my feelings about the problem from iaterfering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . with other things O

55 . 1 wished that 1 could change what had happened or how I feh . O

. . . . . . . . . . . . . . . . . 56 . I changed somethiag about rnyseîf- O

57 . 1 daydreamed or imagined a beüer time or place . . . . . . . . . . . . . . . . . . . . . . . . . . than the one I was in O

58 . I wished that the situation would go away or somebow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . beoverwith O

59 . 1 had fantasies or Msha about bow thiags rnight tum out . . . . O

6û.Iprayed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O

. . . . . . . . . . . . . . . . . . . . 6 1 . 1 prepared myself forthe! worsf 0

6 2 . 1 went o v a in my miad wbu 1 would say or & . . . . . . . . . . O

Go om to next page Copyright 1988 by Consulhg Psycbolo@üs b. Inc . Al1 rights reserved WAYSP Permissi- Test Boddet

63 . 1 thought about how a person 1 admire would hanâie this situation and used that as a model- . . . . . . . . . . . . . . . O 1 2 3

. . . . . 64 1 tried to see things from the other persun's point of view O 1 2 3

65 . 1 reminded myself how much worse things couid be. . . . . . . O 1 2 3

Copyright 1988 by Coasulting Rycbologists Ress. k . AU tights reserved WAYSP Permission Test

Bookle t

POMS Profile of Mood States

# Directions:

The following is a list of words that describe feelings

people have. Please listen carefully to each one and then

tell me which of the following best describes hou you have

been feeling during the past week including today.

O = Not at al1

1 = A little

3 = Quite a bit

4 = Extremely

Sample adjectives used in P O M S :

1. Friendly

16. On edge

30. Helpful

45. Desperate

63. Vigorous

Copyright 1971 EdITS/Educational and ~ndustrial Testing

Service.

Sample items reproduced w i t h permission.

References

Akechi, Tm, Kugaya, A., Okamura, H., Nishiwaki, Y., Yamawaki, S., 6 Uchitomi, Y. (1998). Predictive factors for psychological distress in ambulatory lung cancer patients. -e C-- 6. 281-286.

Antonovsky, A. (1993)- Complexity, conflict, chaos, . . coherence, coercion, and civility. Social Scimce Medicine, 37. 969-981.

Baker, F., Marcellus, D., Zabora, J., Polland, A., & Jodrey, D. (1997). Psychological distress among adult patients being evaluated for bone marrow transplantation.

tics, 38. 10-19.

Beck, A. T., Weissman, A., Lester, D., 6 Trexler, L. (1974). The measurement of pessimism: The hopelessness scale. do- of C-d n d w P s ~ l a q v . 42, . 861.865.

Benedict, S. (1989). The suffering associated with lung cancer. Cancer N , u, 34-40.

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