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JHNXXX10.1177/0898010114526951Journal of Holistic NursingBenefits of a Hospital-Based Complementary Therapies Center / Williams et al.
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An Oasis in the Hospital The Perceived Benefits of a Cancer Support Center in a Hospital Setting Offering Complementary Therapies Anne M. Williams, PhD, MSc, BSc (Hons), RN Edith Cowan University SolarisCare Foundation Sir Charles Gairdner Hospital
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Journal of Holistic Nursing American Holistic Nurses Association Volume 32 Number 4 December 2014 250–260 © The Author(s) 2014 10.1177/0898010114526951 http://jhn.sagepub.com
Caroline E. Bulsara, PhD, GradDipEdSt, BA Notre Dame University Brightwater Care Group Edith Cowan University
David J. L. Joske, MBBS, FRACP, FRCPA Sir Charles Gairdner Hospital SolarisCare Foundation University of Western Australia
Anna S. Petterson, PhD, MA, BA, AHTR SolarisCare Foundation Edith Cowan University
Anna K. Nowak, PhD, MBBS, FRACP Sir Charles Gairdner Hospital University of Western Australia
Kellie S. Bennett, PhD, Mpsych, DipEd University of Western Australia
Aims:The aim of this study was to explore and describe the experiences of persons attending a cancer support center, providing emotional support to cancer patients through self-selected complementary therapies offered free of charge through qualified volunteer therapists. A grounded theory methodology was used. Sources of data were 16 semistructured interviews with persons attending the center. Interviews were digitally recorded and transcribed verbatim. Analysis was conducted using the constant comparative method. Findings: The overarching theme that emerged in this study was the benefits attributed to attendance at the cancer support center. The center was described as an “oasis” in the hospital, and three aspects relating to this were identified: (a) facilitating comfort, (b) increasing personal control, and (c) helping make sense of the cancer experience. Conclusion: A drop-in center offering complementary therapies appeared to enable coping with the diagnosis and treatment of cancer by facilitating comfort and increasing perceptions of personal control. The center also helped some participants to make sense of their experience with cancer. This research has provided a unique insight into the ongoing emotional needs of cancer patients, and directions for further development and research into the provision of holistic care for patients within a hospital setting. Keywords: psychological well-being; cancer patients; empowerment; psychosocial; clinical/focus area
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Benefits of a Hospital-Based Complementary Therapies Center / Williams et al. 251
Introduction Psychological distress is commonly found in patients admitted to hospital with a variety of diagnoses (Fincher, Shaw, & Ramelet, 2012; Kristofferzon, Lindqvist, & Nilsson, 2010; Lam, Chan, & Lam, 2010). Patients with a diagnosis of cancer are a population for which emotional difficulties are well acknowledged (Lavdaniti, Barbas, Fratzana, & Zyga, 2012; Lehto, 2011; Paul et al., 2012). These difficulties relate to the life-threatening nature of cancer, together with the physical symptoms and treatment side effects (Lasheen, Walsh, Sarhill, & Davis, 2010; LeGrand & Walsh, 2010; Soltow, Given, & Given, 2010). Psychological distress may be compounded by a sense of a loss of control and disempowerment during the active treatment phase, linked to perceptions of limited choices regarding medical care and decisions (Chang, Li, & Liu, 2004; Mok & Martinson, 2000). Given the busy pace of the hospital and often rushed nature of physician consults, there is evidence that doctors sometimes have difficulty in assessing and effectively addressing the emotional needs of patients (Butow, Brown, Cogar, Tattersall, & Dunn, 2002; Pollak et al., 2007). The provision of emotional care within an institutional setting would seem crucial for patients dealing with life-threatening diseases, such as cancer, yet few institutional approaches currently exist to address these issues. In 2001, a cancer support center offering complementary therapies was created at an acute care public hospital in Perth, Western Australia. The center (now named SolarisCare) was the initiative of a hematologist (David Joske) who had a vision for “integrative medicine,” providing both physical and emotional care to patients with cancer. Integrative medicine refers to complementary therapies that are provided to patients within the acute care hospital setting, in addition to standard treatment and care.
Persons with a diagnosis of cancer self-refer to the center where volunteer professional therapists provide complementary therapies free of charge. Patients are able to make bookings for a choice of therapies; or just use the facilities provided in the center, which include a comfortable seating area, availability of hot drinks, and access to reading materials. “Meet and greet” volunteers are provided to help visitors to the center feel welcome. Therapists are assessed for having undertaken a recognized training course in the selected therapy, a minimum of 12 months experience providing the selected therapy, and a probationary period volunteering as a meet and greet person at the center before assuming the role of therapist. The drop-in center was designed to provide psychosocial care to patients with cancer through the provision of a communal welcoming environment, information resources, and the opportunity to participate in either group-based or individual complementary therapies. A number of strategies are used to ensure that the therapies delivered in the center are safe (Williams, Bulsara & Petterson, 2013). For example, all of therapies included in the center are selected on a “does no harm” basis and appraisal on their level of evidence (Joske, Rao, & Kristjanson, 2006). The therapies offered are mostly touch-based and energy therapies (e.g., massage, Reiki, pranic healing) or noninterventional mind-body–based therapies (e.g., yoga, qigong, meditation). Counseling is also provided by trained counselors. The center was established in 2005 as a charitable organization under the name of the “SolarisCare Foundation” (http://solariscare.org.au). A total of 2,798 persons received therapies at this center during 2012. This is a novel initiative as the use of complementary medicine embedded within the acute care hospital setting is limited (DiGianni, Garber, & Winter, 2002). Quality of life outcomes and symptom control for people receiving treatment at the SolarisCare
Authors’ Note: We would like to thank all of the participants in this study for sharing their experiences so willingly and honestly. We acknowledge the following individuals for their support and contribution to the project: Dr. Lyndall Steed, Mr. David Edwards, and Ms. Trish Williams. This project was funded by the New Independent Researcher Infrastructure Support Award, Department of Health Western Australia; Curtin University; and the SolarisCare Foundation. AMW, CB, DJ, AP, and AN were involved with the study conception/design; AMW carried out the data collection/analysis; AMW, CB, DJ, AP, AN, and KB participated in the drafting of the manuscript and critical revisions for important intellectual content. This study was approved by the Sir Charles Gairdner Hospital Human Research Ethics Committee, Reference No. RD-10-08. Please address correspondence to Anne M. Williams, Edith Cowan University, Building 21, 270 Joondalup Drive, Joondalup, Western Australia 6027, Australia; e-mail: [email protected].
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center were recorded between 2002 and 2008. During that time, data were collected on more than 1,000 patients and 200 carers. These data showed that the majority (77%) of patients were female and outpatients (82%), with a mean age of 55 years. A small proportion of the sample was undergoing concurrent chemotherapy (12%) or radiotherapy (17%) and had previously had surgery for cancer (28%). The center was found to treat more patients with breast cancer (45%) than any other type of cancer. Improved scores on a symptom distress scale were demonstrated consistently when measured over six supervised complementary treatments. A statistically significant 14% reduction in symptom distress over six treatments was identified (p < .001; Joske, Petterson, & Phillips, 2009). This research supports that the therapies generally produce positive results for patients and do no harm (Joske et al., 2006; Joske, Popescu, Kristjanson, Wallis, & Oliver, 2005). This article describes a study undertaken to explore the experiences of patients attending the SolarisCare center.
Method Aims The aim of this study was to explore and describe from the perspective of persons diagnosed with cancer, experiences of attending the SolarisCare center. SolarisCare is a cancer support center offering complementary therapies, located in an acute care hospital setting in Perth, Western Australia. The method of grounded theory was used. This is a systematic qualitative research method that employs an interpretative approach and can be used in theory development (Moore, 2009). There are three major approaches to grounded theory in current use: Classic, Straussian, and Constructivist (Hunter, Murphy, Grealish, Casey, & Keady, 2011). This study used the Classic approach, which stems from the original work of Glaser and Strauss (1967) using comparative analysis. When using this approach, conceptual categories are systematically developed through coding and staggered analysis (Glaser & Strauss, 1967). Ethical approval was provided by an institutional review board at the hospital in which the center is located, as well as Curtin University.
Participants All persons attending the center during the study period were given a leaflet with a lay summary of the study. Persons willing to participate recorded basic demographic information about themselves as well as their contact details, and left this in a sealed box. Purposive sampling was used initially to select suitable participants to represent a range of experiences, according to factors such as gender, age, type of cancer, type of mainstream treatment for cancer, and type of complementary therapies accessed. All participants were older than 18 years and fluent in spoken English. Theoretical sampling directed the subsequent selection of participants to ensure that theoretical saturation of categories was achieved. The trustworthiness and rigor of the research were addressed using a number of strategies, including the use of member checks. Three patients currently attending the SolarisCare center were asked to review the findings of this current study and comment on whether the description made sense in terms of their own experiences. All three patients validated the findings. Some minor changes were made based on this feedback. Potential participants were contacted and interviews were arranged at a convenient time and place. Participants provided written informed consent. Semistructured interviews were conducted by the first investigator (AMW), and some demographic information was also collected. Questions such as “Can you tell me about your experiences with the SolarisCare center?” and “What therapies have you used at the SolarisCare center?” (prompt: helpful/not helpful) guided the data collection. Interviews were digitally recorded and transcribed verbatim. Sixteen persons diagnosed with cancer and attending the drop-in center participated in interviews. There were 3 male and 13 female participants, with the majority being between 32 and 64 years. Most participants were married/defacto. Different cancer diagnoses were included, but several had brain, blood, or breast cancer. Most participants were between diagnosis and 2 years, but the sample included 2 participants who were over 5 years since diagnosis. More than half the sample had other health conditions, did not need help with activities of daily living, and had assistance available to them from family and friends. Some patients were still receiving treatment for their cancers, whereas
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Benefits of a Hospital-Based Complementary Therapies Center / Williams et al. 253 Table 1. Demographic Profile of Participants (N = 16) Characteristic
N (%)
Age, years 1 (6) 21-31 32-42 3 (19) 43-53 8 (50) 54-64 3 (19) ≥65 1 (6) Gender Male 3 (19) Female 13 (81) Marital status Married/defacto 10 (63) Separated/divorced 5 (31) Widowed 1 (6) Type of cancer Brain 4 (25) Blood 4 (25) Breast 5 (31) Lung 1 (6) Pancreas 1 (6) Skin 1 (6) Length of time since diagnosis ≤6 months 3 (19) 6 months-1 year 6 (38) 1-2 years 3 (19) 2-4 years 2 (13) ≥5 years 2 (13) Other health conditions Yes 9 (56) No 7 (44) Needing help with activities daily living Yes 4 (25) No 12 (75) Assistance of family and friends available if needed Yes 15 (94) No 1 (6) Chemotherapy Yes 6 (38) No 10 (63) Radiotherapy 7 (44) Yes No 9 (56) Home location Metropolitan 12 (75) Rural 2 (13) Outside WA 2 (13)
others had completed their treatment. The majority of participants lived in the metropolitan area, but rural participants were included (see Table 1).
Table 2. Complementary Therapies Experienced by Participants at the Cancer Support Center Acupuncture Art therapy Bowen Breath for health Chi breathing Counseling Guided imagery Healing touch
Kinsiology Massage Meditation Pranic healing Qigong Reflexology Reiki
Data analysis Data were analyzed using the constant comparative method of analysis (Glaser & Strauss, 1967). Seventeen categories were identified that described various aspects relating to a diagnosis of cancer and attendance at the center. In addition, 15 different descriptions of therapies experienced were categorized (see Table 2). This article describes a descriptive rather than theoretical level of analysis. It focuses on the overarching theme, which described the perceived positive outcomes related to attendance at the center.
Results The prominent theme that emerged from the analysis of these data was the benefits attributed to attending the SolarisCare center. The center was likened to an oasis in the hospital; it was seen as a very special, luxurious place that was valued: “I just think this is something from heaven” (P05). It was said to be a place of comfort and a haven within an unpleasant busy environment: It’s a wonderful little oasis in the center of a very busy hospital . . . you can have a cup of tea . . . and the lounges are lovely and everyone’s very pleasant and . . . it’s wonderful . . . you can relax . . . in such . . . a busy bustling place. Once you go through that door . . . it’s very, very pleasant. (P03) The moment I walked in I thought, “Gee this has got a tranquility and serenity about it and it’s an oasis” . . . it’s just the feeling of calm that you get in there, away from the hustle and bustle of the hospital . . . not the clinical environment . . . You’re not being processed. (P07)
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Figure 1. An Oasis in the Hospital: The Perceived Benefits of a Cancer Support Center
Data from each of the 16 participants interviewed reflected this perception. Three personally positive aspects relating to the cancer support center were identified: (a) facilitating comfort, (b) increasing personal control, and (c) helping make sense of the cancer experience (see Figure 1). These will now be described.
Facilitating Comfort Attendance at the cancer support center was said to facilitate comfort, both emotional and physical. The experience was different to that of the general hospital environment: “Because so much of the stuff they do at hospital is painful or you have to wait in crummy waiting rooms or you get bad results . . .” (P14). Emotionally, the cancer support center was described as a much-needed sanctuary that focused on the emotional needs of cancer patients—needs that were not attended generally to within the hospital environment: It was like I guess a heart, a place for your heart in the hospital . . . Because so much of the other stuff in . . . the hospital . . . is about your body, not so much your mind . . . But I mean . . . your heart is
going through this cancer treatment as well . . . And so to be able to go to a place that . . . can deal with sort of supporting and nurturing you, it can be really beneficial I think. (P14)
Participants described how they felt valued in the center, how they appreciated having some extra attention focused on them: “All this extra attention. It does make you feel . . . like you’re somebody and you’re special . . . you’ve got value which is a basic need of everybody you know” (P01). Another participant said, It starts from when I walk in the door of Solaris. That’s when I start feeling cosseted and cared for and yes, I just walk out of there feeling like that. Relaxed, like all my cares have gone away for a while. Happy, sort of dreamy and that’s how I feel. (P05)
Comfort was said to be facilitated by a feeling of being at home at the cancer support center: “It’s more homely . . . it’s just somewhere you can go and you can feel as comfortable as you can in a place you don’t want to be” (P14); “The minute you walk in the door at Solaris, you just feel really welcome because
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Benefits of a Hospital-Based Complementary Therapies Center / Williams et al. 255
the people there are so nice. They can’t do enough for you . . . So immediately I feel at home” (P05). The center was said to be perceived as a safe place, where patients felt comfortable to talk frankly and sometimes cry: “It’s nice to be able to have some of that stress released in a safe place” (P14). One participant gave a very vivid example of how she felt that the cancer support center had facilitated emotional comfort for her:
Thursday, but then it actually gave me enough power to give me a boost for the rest of the day” (P09). There was also a perception for some participants that their pain had been reduced: “You’re floating and you’re calm and that heart stops racing. The pain doesn’t feel as heavy. You’ve shared it with someone” (P12).
I think there would be a very hard ball inside of me, which is chronic leukemia and all the anxiety that would be bound around it and that would be sitting somewhere inside me because I wouldn’t share all of that with anyone else . . . Because I wouldn’t unload it, I wouldn’t burden anyone else with all of that. But that hard ball of probably anxiety, chronic leukemia, fears, and tears would all be rolled up in that ball and it would be somewhere hidden inside my chest. Nobody else would know it was there, but I would know it was there and I would be trying to deal with it and break it down. But I wouldn’t be able to. I can’t do it by myself . . . but that’s probably the size of a pea now because of what I’ve got from Solaris and hopefully I’ll make it disappear. I don’t know if I will. (P05)
All of the study participants had experienced feelings of reduced personal control to varying degrees, in relation to their cancer diagnosis; “And how scared I was when I found out that I had the [cancer] because it was out of my control . . .” (P05). These feelings were manifested as emotional discomforts (e.g., self-reported feelings of anxiety and distress) and were exacerbated and caused in some instances by the presence of physical discomforts. It was apparent that the cancer support center enabled patients to increase their personal control by being more proactive in their health care. Participants described how empowered they felt by attending the center. It was their choice to attend and something they did voluntarily to help themselves feel better:
The center also provided a sense of community for some participants, which was especially important for patients living away from home to receive treatment at the hospital. Patients said that they talked to each other while waiting in the lounge and found this aspect supportive. In some cases, it provided them with the opportunity to support others. The facilitation of emotional comfort was evident through the use of words such as “calm,” “relaxed,” “serenity,” “happy,” “peaceful,” and “balanced.” One of the participants said,
Whereas Solaris . . . I just walk in there because I want to walk in there, not that I’ve been told to walk in . . . I do it voluntarily. There is no piece of paper. I just hop up on a table and then someone is doing something with my body which I know is doing me good. (P16)
It made me feel better, it just made me feel even more relaxed and it made me feel better. I can’t describe it any other way. I just felt better . . . in here, in my heart. (P09)
Reductions in physical discomforts following the use of integrative therapies at the center were also described. Fatigue in particular was said to be minimized by the therapies, which evoked feelings of increased energy for some participants, “I just come out thinking ‘Phwar’ . . . I’m invincible” (P07); “What I can tell you is I was extremely tired on
Increasing Personal Control
Furthermore, the range of therapies available at the center and the ability of patients to select therapies were important factors in terms of increasing a person’s level of personal control. A participant described how she would choose a therapy based on her assessed level of need, either physical or emotional. Another participant described how she would sit and wait in the cancer support center when she had an appointment in another area of the hospital. She would tell that area to ring her when the doctor was ready to see her: It’s got a nicer ambience to sit and wait there . . . Than it has in the, the many crummy waiting rooms in hospital . . . so and I’d rather be sitting in Solaris having a cup of tea than somewhere that’s not as peaceful. (P14)
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One of the participants felt that Western medicine tended to use a less proactive approach, which she described as “an ambulance at the bottom of the cliff approach” (P05), meaning that they waited until there was a problem and then dealt with it. She perceived that her health problems could be minimized by taking an active, preventative approach. She was able to do this through the complementary integrative therapies at the cancer support center, and this increased her sense of personal control: So what Solaris is doing . . . is [helping me] to think more positively about what I’ve got. Don’t worry about it so much. Do what you can. Don’t worry about what you can’t do . . . it encourages me to look at alternative therapies, if I think they’re useful. And massage . . . get[s] me to relax. The counselling gets me to talk about things and work out in my own head of what I can be in control of and what I can’t. All of that makes me feel more in control . . . Solaris has helped me relax more. Bring things into focus a bit more . . .” (P05)
Making Sense of the Cancer Experience The cancer support center appeared to enable coping with the diagnosis and treatment of cancer and helped some participants to make sense of their experience. Four elements related to making sense of the cancer experience were identified in relation to this: reconnecting, positive interpreting, changing perspectives, and visions and dreams.
“It’s all about me and for the first time in my life and I’ve never had that . . . If that’s selfish, I’m afraid I’m selfish for a change . . . I can’t give anymore” (P09). Finding personal energy by reconnecting with self was indicated to be an important element in the healing process. Positive Interpreting. In this category, participants talked about the positive outcomes related to having cancer. One said she had more time to relax and walk on the beach now she wasn’t working: Well quite frankly I’ve never felt better . . . I’ve never spent so long off work and I’ve never walked so many times along the beach . . . I mean if it wasn’t for this thing in my head [the cancer], I’m really enjoying myself . . . (P07)
Others noticed positive changes in their behavior and outlook on life: “I’m more compassionate. I have gone through enough experiences now to understand people a lot better . . . “ (P04); “Honestly, I feel my life is more together now than it’s ever been” (P13). Some participants interpreted their current situation so positively that they actually felt better in themselves than before the cancer diagnosis.
Going back to the spiritual journey, to me it was a real wake-up call that you’re not looking after that part of your life enough and I think Solaris center really helped me with that and made me look at things that I’ve known I’ve had to look at. But it’s there; it’s just that I’m too busy. (P02)
Changing Perspectives. A change in perspectives was mentioned as a significant part of the experience of cancer and of attending the cancer support center, “I appreciate life a lot more now . . . I now pay attention to the small, very, very small things . . . “ (P04); “ I think it puts your life into perspective slightly without a doubt . . . minor things become very minor. Major things become very minor if that makes sense” (P15). A change in priorities was also described: “Family is more important. Making money is not so important . . .” (P06). Changing perspectives was partly attributed to interactions with various persons at the SolarisCare center: “We became, I won’t say friends . . . but got some empathy and started talking . . . I’ve met so many nice interesting people that I would never have met otherwise” (P06). The therapies experienced at SolarisCare were also indicated to have contributed to viewing and experiencing life in a different way:
Part of this reconnecting with self, involved focusing on self rather than others: “I didn’t want to do anything else other than focus on myself . . . [said to husband] I need to work out who I am” (P04);
It helped [therapy at Solaris] in the way of thinking of my whole body, rather than just thinking about part of me that had had the cancer cut out . . . its still quite significant but it just sort of
Reconnecting. Participants talked about revisiting spiritual elements in their life and how the center had helped with this. For some this meant becoming more involved with their chosen religion, for others new religions and spiritual paths were explored:
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Benefits of a Hospital-Based Complementary Therapies Center / Williams et al. 257 helped me connect with the . . . rest of my body and I felt relaxed afterwards, and yes and nurtured . . . (P14)
Visions and Dreams. An interesting aspect was described in relation to making sense of the cancer experience by four participants—the experience of vivid dreams and visions. Some of these had been experienced during energy-based complementary therapies at the cancer support center. The dreams and visions were described in great detail. Some saw people they knew who had passed away, others saw strangers. Animals were talked about, and beautiful places. Each of the dreams or visions had meaning for the participant and were viewed positively: “They didn’t frighten me . . . And they sort of reaffirmed how I felt” (P02).
Discussion The perceived benefits of a cancer support center offering complementary therapies within the hospital setting have been described in this article. A central theme of the center being like an oasis in the hospital was identified and three subthemes of facilitating comfort, increasing personal control, and helping make sense of the cancer experience have been described in relation to this. The facilitation of comfort was one of the subthemes identified. Comfort is an outcome that is commonly referred to in the care of hospitalized patients. McIlveen and Morse (1995) traced the role of comfort in nursing back to 1900 and described the changes that have taken place through the years. In this review, they note that between 1960 and 1980 nurses developed techniques to promote emotional comfort. In previous work by the primary author (AMW), emotional comfort was found to be important for hospitalized patient and thought to be a therapeutic state that assisted recovery (Williams & Irurita, 2006). Emotional comfort in that study referred to the comfort that was associated with the feelings of a person. It was defined as pleasant positive feelings, a state of relaxation. The interpersonal interactions experienced by patients during hospitalization had an impact on emotional comfort (Williams & Irurita, 2004), as did factors within the hospital environment (Williams & Irurita, 2005) and the personal characteristics of the patient (Williams & Kristjanson 2008). Similarities in the factors
influencing the experience of emotional comfort were noted for these outpatients attending the SolarisCare center. Increasing personal control was another of the subthemes identified in this study. Cancer can often be perceived as one of the most disempowering illnesses. Patients diagnosed with cancer commonly experience a loss of control in many areas of their lives following their diagnosis. Research in this area has started to confirm a relationship between low levels of perceived control and psychological distress (Barez, Blasco, Fernandez-Castro, & Viladrich, 2009; Beckjord, Glinder, Langrock, & Compas, 2009). Psychological distress that manifests in the form of depression, and anxiety has been linked with a lower quality of life (Brown, Kroenke, Theobald, Wu, & Tu, 2010; Kroenke et al., 2010). The health locus of control was identified as the most significant preventive factor in terms of survival from cancer in a sample of 57 patients in Taiwan (Chung, Chao, Chou, & Hui-Ling, 2009). There are indications that there is value in the development of strategies that increase perceptions of control for patients with a diagnosis of cancer, and the positive experiences described by these patients attending the SolarisCare center would support this. Helping make sense of the cancer experience was another subtheme in this study. It has previously been reported that patients reexamine their values and their goals in life as a result of the impact of the cancer diagnosis (Bakke, Purtzer, & Newton, 2002; Hernandez-Reif et al., 2004). During this time, it has been observed that they often access therapies such as massage, Reiki, and other forms of spiritual and “energy” healing, possibly to seek spiritual comfort while they question the reasons for their cancer diagnosis (Foster & 2006). Energy healing has also been suggested as providing the willpower and inner strength to overcome the challenges associated with an illness such as cancer by attuning to the mind (Ritvo et al., 1999) and revisiting spiritual beliefs (McGrath, 2004). Some religions place importance on the recollection of dreams, and a spiritual significance may be perceived. Psychotherapists often use dreams to help understand psychological trauma and distress (Stranahan, 2011). It appeared in this study that patients were positively interpreting their dreams as part of making sense of their cancer diagnosis.
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Conclusion This study has provided evidence to suggest that a support center offering complementary therapies can assist patients to better cope both emotionally and physically with the effects of a diagnosis of cancer, its treatment, and its side effects. It is speculated that the use of complementary therapies is an aspect of managing the illness that enabled patients to maintain a sense of control (Delmar et al., 2006). Patients use a range of complementary therapies for a number of reasons; access to complementary therapies provides a measure of control for which they are solely responsible for the decisions made (Bishop & Yardley, 2004). Thus, although the clinician may be informed as to the overall patient use of therapies, the patients is largely in control of what and when therapies are sought out and used. This study has demonstrated the benefits to patients in being able to access a range of complementary therapies within the hospital setting to assist in coping with the physical and emotional difficulties associated with the a cancer diagnosis and illness trajectory. However, limitations of this study include the small number of participants, self-referral method of participant selection, and use of a single site. These findings increase our understanding of a range of psychological and supportive strategies that can assist persons with a diagnosis of cancer to cope. This work is particularly relevant to oncology nurses exploring options to improve the emotional wellbeing of patients. In addition, high levels of stress experienced by nurses caring for patients with a diagnosis of cancer have been reported in the literature (de Carvalho, Muller, Bachion de Carvalho, & de Souza Melo, 2005; Florio, Donnelly, & Zevon, 1998). A systematic review and meta-analysis found that burnout was high among all cancer professionals (Trufelli et al., 2008). Part of this stress relates to a lack of time and resources to address the emotional care of hospitalized patients. Previous work by the first author has found that the distress of nurses was minimized by the availability of emotional support (Williams, Dawson, & Kristjanson, 2008). Nurses at the study hospital regularly refer patients to the SolarisCare center, and the center also offers appointments to nurses who are experiencing stress themselves. Further work exploring the impact of centers such as SolarisCare on the coping ability of nurses is warranted.
Quantitative research is now needed to measure the extent to which a cancer support center located within the acute care hospital setting can have a positive impact on patients. However, a number of challenges present themselves in the design of such studies where the intervention and the outcomes are multifaceted. The range of therapies used by patients who attend the SolarisCare center makes it difficult to accurately compare experiences. It is not known what combination of treatments are most effective, or if some treatment combinations are better for some patients than others. In addition to this, some patients have commented that they just feel better sitting in the waiting room, which highlights the difficulty in identifying the exact source or nature of a perceived benefit. A lack of clarity exists in the literature concerning the mechanism by which patients attribute therapeutic effects to psychosocial care. In a recent review of the placebo effect (Price, Finniss, & Benedetti, 2008), a number of different mechanisms were identified and associated with the effect. This current study has identified that the patient’s level of comfort is a key construct in this phenomenon, together with the person’s perceived level of personal control, and the need to make sense of the cancer experience. The SolarisCare center is a novel idea that provides a unique model of integrative care with a number of potentially positive outcomes. Further discovery and development work is now needed to explore these constructs further in relation to the experience of persons diagnosed with cancer.
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260 Journal of Holistic Nursing / Vol. 32, No. 4, December 2014 complementary therapies. Patient Education & Counseling, 38, 161-165. Soltow, D., Given, B., & Given, C. (2010). Relationship between age and symptoms of pain and fatigue in adults undergoing treatment for cancer. Cancer Nursing, 33, 296-303. Stranahan, S. (2011). The use of dreams in spiritual care. Journal of Health Care Chaplaincy, 17, 87-94. Trufelli, D. C., Bensi, C. G., Garcia, J. B., Narahara, J. L., Abrao, M. N., Diniz, R. W., . . .Del Giglio, A. (2008). Burnout in cancer professionals: A systematic review and meta-analysis. European Journal of Cancer Care, 17, 524531. Williams, A. M., Bulsara, C., & Petterson, A. (2013). Safety and side effects of non-pharmacological interventions as a therapy for cancer. In W. C. S. Cho (Ed.), Evidencebased non-pharmacological therapies for palliative cancer care (pp. 219-252). London, England: Springer. Williams, A. M., Dawson, S., & Kristjanson, L. J. (2008). Translating theory into practice: Using action research to introduce a coordinated approach to emotional care. Patient Education & Counseling, 73, 82-90. Williams, A. M., & Irurita, V. F. (2004). Therapeutic and non-therapeutic interpersonal interactions: the patient’s perspective. Journal of Clinical Nursing, 13, 806-815. Williams, A. M., & Irurita, V. F. (2005). Enhancing the therapeutic potential of hospital environments by increasing the personal control and emotional comfort of hospitalised patients. Applied Nursing Research, 18, 22-28. Williams, A. M., & Irurita, V. F. (2006). Emotional comfort: The patient’s perspective of a therapeutic context. International Journal of Nursing Studies, 43, 405-415. Williams, A. M., & Kristjanson, L. J. (2008). The development and testing of an instrument to measure the
emotional care experienced by hospitalised patients. Journal of Clinical Nursing, 17, 1069-1077. Anne M. Williams, PhD, MSc, BSc (Hons), RN, is an Associate Professor for Clinical Research and Innovation in the School of Nursing and Midwifery, Edith Cowan University. Anne is also a Research Consultant for the SolarisCare Foundation, and the Centre for Nursing Research at Sir Charles Gairdner Hospital. Caroline E. Bulsara, PhD, GradDipEdSt, BA, is an Associate Professor in the School of Nursing and Midwifery at Notre Dame University. Caroline previously worked for the Brightwater Care Group and holds and adjunct position at Edith Cowan University. David J. L. Joske, MBBS, FRACP, FRCPA, is a Consultant Haematologist at Sir Charles Gairdner Hospital and the founder and chairman of the SolarisCare Foundation. David is also a Clinical Professor at the University of Western Australia. Anna S. Petterson, PhD, MA, BA, AHTR, is the Manager of Research and Education, SolarisCare Foundation; a Medical Arts Psychotherapist and Adjunct Research Fellow at Edith Cowan University Anna K. Nowak, PhD, MBBS, FRACP, is a Professor at the University of Western Australia and a Medical Oncologist at Sir Charles Gairdner Hospital. Kellie S. Bennett, PhD, Mpsych, DipEd, is an Associate Professor in the School of Psychiatry and Clinical Neurosciences at the University of Western Australia.
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JHNXXX10.1177/0898010114526951Journal of Holistic NursingBenefits of a Hospital-Based Complementary Therapies Center / Williams et al.
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Article
An Oasis in the Hospital The Perceived Benefits of a Cancer Support Center in a Hospital Setting Offering Complementary Therapies Anne M. Williams, PhD, MSc, BSc (Hons), RN Edith Cowan University SolarisCare Foundation Sir Charles Gairdner Hospital
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research-article2014
Journal of Holistic Nursing American Holistic Nurses Association Volume 32 Number 4 December 2014 250–260 © The Author(s) 2014 10.1177/0898010114526951 http://jhn.sagepub.com
Caroline E. Bulsara, PhD, GradDipEdSt, BA Notre Dame University Brightwater Care Group Edith Cowan University
David J. L. Joske, MBBS, FRACP, FRCPA Sir Charles Gairdner Hospital SolarisCare Foundation University of Western Australia
Anna S. Petterson, PhD, MA, BA, AHTR SolarisCare Foundation Edith Cowan University
Anna K. Nowak, PhD, MBBS, FRACP Sir Charles Gairdner Hospital University of Western Australia
Kellie S. Bennett, PhD, Mpsych, DipEd University of Western Australia
Aims:The aim of this study was to explore and describe the experiences of persons attending a cancer support center, providing emotional support to cancer patients through self-selected complementary therapies offered free of charge through qualified volunteer therapists. A grounded theory methodology was used. Sources of data were 16 semistructured interviews with persons attending the center. Interviews were digitally recorded and transcribed verbatim. Analysis was conducted using the constant comparative method. Findings: The overarching theme that emerged in this study was the benefits attributed to attendance at the cancer support center. The center was described as an “oasis” in the hospital, and three aspects relating to this were identified: (a) facilitating comfort, (b) increasing personal control, and (c) helping make sense of the cancer experience. Conclusion: A drop-in center offering complementary therapies appeared to enable coping with the diagnosis and treatment of cancer by facilitating comfort and increasing perceptions of personal control. The center also helped some participants to make sense of their experience with cancer. This research has provided a unique insight into the ongoing emotional needs of cancer patients, and directions for further development and research into the provision of holistic care for patients within a hospital setting. Keywords: psychological well-being; cancer patients; empowerment; psychosocial; clinical/focus area
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Benefits of a Hospital-Based Complementary Therapies Center / Williams et al. 251
Introduction Psychological distress is commonly found in patients admitted to hospital with a variety of diagnoses (Fincher, Shaw, & Ramelet, 2012; Kristofferzon, Lindqvist, & Nilsson, 2010; Lam, Chan, & Lam, 2010). Patients with a diagnosis of cancer are a population for which emotional difficulties are well acknowledged (Lavdaniti, Barbas, Fratzana, & Zyga, 2012; Lehto, 2011; Paul et al., 2012). These difficulties relate to the life-threatening nature of cancer, together with the physical symptoms and treatment side effects (Lasheen, Walsh, Sarhill, & Davis, 2010; LeGrand & Walsh, 2010; Soltow, Given, & Given, 2010). Psychological distress may be compounded by a sense of a loss of control and disempowerment during the active treatment phase, linked to perceptions of limited choices regarding medical care and decisions (Chang, Li, & Liu, 2004; Mok & Martinson, 2000). Given the busy pace of the hospital and often rushed nature of physician consults, there is evidence that doctors sometimes have difficulty in assessing and effectively addressing the emotional needs of patients (Butow, Brown, Cogar, Tattersall, & Dunn, 2002; Pollak et al., 2007). The provision of emotional care within an institutional setting would seem crucial for patients dealing with life-threatening diseases, such as cancer, yet few institutional approaches currently exist to address these issues. In 2001, a cancer support center offering complementary therapies was created at an acute care public hospital in Perth, Western Australia. The center (now named SolarisCare) was the initiative of a hematologist (David Joske) who had a vision for “integrative medicine,” providing both physical and emotional care to patients with cancer. Integrative medicine refers to complementary therapies that are provided to patients within the acute care hospital setting, in addition to standard treatment and care.
Persons with a diagnosis of cancer self-refer to the center where volunteer professional therapists provide complementary therapies free of charge. Patients are able to make bookings for a choice of therapies; or just use the facilities provided in the center, which include a comfortable seating area, availability of hot drinks, and access to reading materials. “Meet and greet” volunteers are provided to help visitors to the center feel welcome. Therapists are assessed for having undertaken a recognized training course in the selected therapy, a minimum of 12 months experience providing the selected therapy, and a probationary period volunteering as a meet and greet person at the center before assuming the role of therapist. The drop-in center was designed to provide psychosocial care to patients with cancer through the provision of a communal welcoming environment, information resources, and the opportunity to participate in either group-based or individual complementary therapies. A number of strategies are used to ensure that the therapies delivered in the center are safe (Williams, Bulsara & Petterson, 2013). For example, all of therapies included in the center are selected on a “does no harm” basis and appraisal on their level of evidence (Joske, Rao, & Kristjanson, 2006). The therapies offered are mostly touch-based and energy therapies (e.g., massage, Reiki, pranic healing) or noninterventional mind-body–based therapies (e.g., yoga, qigong, meditation). Counseling is also provided by trained counselors. The center was established in 2005 as a charitable organization under the name of the “SolarisCare Foundation” (http://solariscare.org.au). A total of 2,798 persons received therapies at this center during 2012. This is a novel initiative as the use of complementary medicine embedded within the acute care hospital setting is limited (DiGianni, Garber, & Winter, 2002). Quality of life outcomes and symptom control for people receiving treatment at the SolarisCare
Authors’ Note: We would like to thank all of the participants in this study for sharing their experiences so willingly and honestly. We acknowledge the following individuals for their support and contribution to the project: Dr. Lyndall Steed, Mr. David Edwards, and Ms. Trish Williams. This project was funded by the New Independent Researcher Infrastructure Support Award, Department of Health Western Australia; Curtin University; and the SolarisCare Foundation. AMW, CB, DJ, AP, and AN were involved with the study conception/design; AMW carried out the data collection/analysis; AMW, CB, DJ, AP, AN, and KB participated in the drafting of the manuscript and critical revisions for important intellectual content. This study was approved by the Sir Charles Gairdner Hospital Human Research Ethics Committee, Reference No. RD-10-08. Please address correspondence to Anne M. Williams, Edith Cowan University, Building 21, 270 Joondalup Drive, Joondalup, Western Australia 6027, Australia; e-mail: [email protected].
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center were recorded between 2002 and 2008. During that time, data were collected on more than 1,000 patients and 200 carers. These data showed that the majority (77%) of patients were female and outpatients (82%), with a mean age of 55 years. A small proportion of the sample was undergoing concurrent chemotherapy (12%) or radiotherapy (17%) and had previously had surgery for cancer (28%). The center was found to treat more patients with breast cancer (45%) than any other type of cancer. Improved scores on a symptom distress scale were demonstrated consistently when measured over six supervised complementary treatments. A statistically significant 14% reduction in symptom distress over six treatments was identified (p < .001; Joske, Petterson, & Phillips, 2009). This research supports that the therapies generally produce positive results for patients and do no harm (Joske et al., 2006; Joske, Popescu, Kristjanson, Wallis, & Oliver, 2005). This article describes a study undertaken to explore the experiences of patients attending the SolarisCare center.
Method Aims The aim of this study was to explore and describe from the perspective of persons diagnosed with cancer, experiences of attending the SolarisCare center. SolarisCare is a cancer support center offering complementary therapies, located in an acute care hospital setting in Perth, Western Australia. The method of grounded theory was used. This is a systematic qualitative research method that employs an interpretative approach and can be used in theory development (Moore, 2009). There are three major approaches to grounded theory in current use: Classic, Straussian, and Constructivist (Hunter, Murphy, Grealish, Casey, & Keady, 2011). This study used the Classic approach, which stems from the original work of Glaser and Strauss (1967) using comparative analysis. When using this approach, conceptual categories are systematically developed through coding and staggered analysis (Glaser & Strauss, 1967). Ethical approval was provided by an institutional review board at the hospital in which the center is located, as well as Curtin University.
Participants All persons attending the center during the study period were given a leaflet with a lay summary of the study. Persons willing to participate recorded basic demographic information about themselves as well as their contact details, and left this in a sealed box. Purposive sampling was used initially to select suitable participants to represent a range of experiences, according to factors such as gender, age, type of cancer, type of mainstream treatment for cancer, and type of complementary therapies accessed. All participants were older than 18 years and fluent in spoken English. Theoretical sampling directed the subsequent selection of participants to ensure that theoretical saturation of categories was achieved. The trustworthiness and rigor of the research were addressed using a number of strategies, including the use of member checks. Three patients currently attending the SolarisCare center were asked to review the findings of this current study and comment on whether the description made sense in terms of their own experiences. All three patients validated the findings. Some minor changes were made based on this feedback. Potential participants were contacted and interviews were arranged at a convenient time and place. Participants provided written informed consent. Semistructured interviews were conducted by the first investigator (AMW), and some demographic information was also collected. Questions such as “Can you tell me about your experiences with the SolarisCare center?” and “What therapies have you used at the SolarisCare center?” (prompt: helpful/not helpful) guided the data collection. Interviews were digitally recorded and transcribed verbatim. Sixteen persons diagnosed with cancer and attending the drop-in center participated in interviews. There were 3 male and 13 female participants, with the majority being between 32 and 64 years. Most participants were married/defacto. Different cancer diagnoses were included, but several had brain, blood, or breast cancer. Most participants were between diagnosis and 2 years, but the sample included 2 participants who were over 5 years since diagnosis. More than half the sample had other health conditions, did not need help with activities of daily living, and had assistance available to them from family and friends. Some patients were still receiving treatment for their cancers, whereas
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Benefits of a Hospital-Based Complementary Therapies Center / Williams et al. 253 Table 1. Demographic Profile of Participants (N = 16) Characteristic
N (%)
Age, years 1 (6) 21-31 32-42 3 (19) 43-53 8 (50) 54-64 3 (19) ≥65 1 (6) Gender Male 3 (19) Female 13 (81) Marital status Married/defacto 10 (63) Separated/divorced 5 (31) Widowed 1 (6) Type of cancer Brain 4 (25) Blood 4 (25) Breast 5 (31) Lung 1 (6) Pancreas 1 (6) Skin 1 (6) Length of time since diagnosis ≤6 months 3 (19) 6 months-1 year 6 (38) 1-2 years 3 (19) 2-4 years 2 (13) ≥5 years 2 (13) Other health conditions Yes 9 (56) No 7 (44) Needing help with activities daily living Yes 4 (25) No 12 (75) Assistance of family and friends available if needed Yes 15 (94) No 1 (6) Chemotherapy Yes 6 (38) No 10 (63) Radiotherapy 7 (44) Yes No 9 (56) Home location Metropolitan 12 (75) Rural 2 (13) Outside WA 2 (13)
others had completed their treatment. The majority of participants lived in the metropolitan area, but rural participants were included (see Table 1).
Table 2. Complementary Therapies Experienced by Participants at the Cancer Support Center Acupuncture Art therapy Bowen Breath for health Chi breathing Counseling Guided imagery Healing touch
Kinsiology Massage Meditation Pranic healing Qigong Reflexology Reiki
Data analysis Data were analyzed using the constant comparative method of analysis (Glaser & Strauss, 1967). Seventeen categories were identified that described various aspects relating to a diagnosis of cancer and attendance at the center. In addition, 15 different descriptions of therapies experienced were categorized (see Table 2). This article describes a descriptive rather than theoretical level of analysis. It focuses on the overarching theme, which described the perceived positive outcomes related to attendance at the center.
Results The prominent theme that emerged from the analysis of these data was the benefits attributed to attending the SolarisCare center. The center was likened to an oasis in the hospital; it was seen as a very special, luxurious place that was valued: “I just think this is something from heaven” (P05). It was said to be a place of comfort and a haven within an unpleasant busy environment: It’s a wonderful little oasis in the center of a very busy hospital . . . you can have a cup of tea . . . and the lounges are lovely and everyone’s very pleasant and . . . it’s wonderful . . . you can relax . . . in such . . . a busy bustling place. Once you go through that door . . . it’s very, very pleasant. (P03) The moment I walked in I thought, “Gee this has got a tranquility and serenity about it and it’s an oasis” . . . it’s just the feeling of calm that you get in there, away from the hustle and bustle of the hospital . . . not the clinical environment . . . You’re not being processed. (P07)
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254 Journal of Holistic Nursing / Vol. 32, No. 4, December 2014
Figure 1. An Oasis in the Hospital: The Perceived Benefits of a Cancer Support Center
Data from each of the 16 participants interviewed reflected this perception. Three personally positive aspects relating to the cancer support center were identified: (a) facilitating comfort, (b) increasing personal control, and (c) helping make sense of the cancer experience (see Figure 1). These will now be described.
Facilitating Comfort Attendance at the cancer support center was said to facilitate comfort, both emotional and physical. The experience was different to that of the general hospital environment: “Because so much of the stuff they do at hospital is painful or you have to wait in crummy waiting rooms or you get bad results . . .” (P14). Emotionally, the cancer support center was described as a much-needed sanctuary that focused on the emotional needs of cancer patients—needs that were not attended generally to within the hospital environment: It was like I guess a heart, a place for your heart in the hospital . . . Because so much of the other stuff in . . . the hospital . . . is about your body, not so much your mind . . . But I mean . . . your heart is
going through this cancer treatment as well . . . And so to be able to go to a place that . . . can deal with sort of supporting and nurturing you, it can be really beneficial I think. (P14)
Participants described how they felt valued in the center, how they appreciated having some extra attention focused on them: “All this extra attention. It does make you feel . . . like you’re somebody and you’re special . . . you’ve got value which is a basic need of everybody you know” (P01). Another participant said, It starts from when I walk in the door of Solaris. That’s when I start feeling cosseted and cared for and yes, I just walk out of there feeling like that. Relaxed, like all my cares have gone away for a while. Happy, sort of dreamy and that’s how I feel. (P05)
Comfort was said to be facilitated by a feeling of being at home at the cancer support center: “It’s more homely . . . it’s just somewhere you can go and you can feel as comfortable as you can in a place you don’t want to be” (P14); “The minute you walk in the door at Solaris, you just feel really welcome because
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Benefits of a Hospital-Based Complementary Therapies Center / Williams et al. 255
the people there are so nice. They can’t do enough for you . . . So immediately I feel at home” (P05). The center was said to be perceived as a safe place, where patients felt comfortable to talk frankly and sometimes cry: “It’s nice to be able to have some of that stress released in a safe place” (P14). One participant gave a very vivid example of how she felt that the cancer support center had facilitated emotional comfort for her:
Thursday, but then it actually gave me enough power to give me a boost for the rest of the day” (P09). There was also a perception for some participants that their pain had been reduced: “You’re floating and you’re calm and that heart stops racing. The pain doesn’t feel as heavy. You’ve shared it with someone” (P12).
I think there would be a very hard ball inside of me, which is chronic leukemia and all the anxiety that would be bound around it and that would be sitting somewhere inside me because I wouldn’t share all of that with anyone else . . . Because I wouldn’t unload it, I wouldn’t burden anyone else with all of that. But that hard ball of probably anxiety, chronic leukemia, fears, and tears would all be rolled up in that ball and it would be somewhere hidden inside my chest. Nobody else would know it was there, but I would know it was there and I would be trying to deal with it and break it down. But I wouldn’t be able to. I can’t do it by myself . . . but that’s probably the size of a pea now because of what I’ve got from Solaris and hopefully I’ll make it disappear. I don’t know if I will. (P05)
All of the study participants had experienced feelings of reduced personal control to varying degrees, in relation to their cancer diagnosis; “And how scared I was when I found out that I had the [cancer] because it was out of my control . . .” (P05). These feelings were manifested as emotional discomforts (e.g., self-reported feelings of anxiety and distress) and were exacerbated and caused in some instances by the presence of physical discomforts. It was apparent that the cancer support center enabled patients to increase their personal control by being more proactive in their health care. Participants described how empowered they felt by attending the center. It was their choice to attend and something they did voluntarily to help themselves feel better:
The center also provided a sense of community for some participants, which was especially important for patients living away from home to receive treatment at the hospital. Patients said that they talked to each other while waiting in the lounge and found this aspect supportive. In some cases, it provided them with the opportunity to support others. The facilitation of emotional comfort was evident through the use of words such as “calm,” “relaxed,” “serenity,” “happy,” “peaceful,” and “balanced.” One of the participants said,
Whereas Solaris . . . I just walk in there because I want to walk in there, not that I’ve been told to walk in . . . I do it voluntarily. There is no piece of paper. I just hop up on a table and then someone is doing something with my body which I know is doing me good. (P16)
It made me feel better, it just made me feel even more relaxed and it made me feel better. I can’t describe it any other way. I just felt better . . . in here, in my heart. (P09)
Reductions in physical discomforts following the use of integrative therapies at the center were also described. Fatigue in particular was said to be minimized by the therapies, which evoked feelings of increased energy for some participants, “I just come out thinking ‘Phwar’ . . . I’m invincible” (P07); “What I can tell you is I was extremely tired on
Increasing Personal Control
Furthermore, the range of therapies available at the center and the ability of patients to select therapies were important factors in terms of increasing a person’s level of personal control. A participant described how she would choose a therapy based on her assessed level of need, either physical or emotional. Another participant described how she would sit and wait in the cancer support center when she had an appointment in another area of the hospital. She would tell that area to ring her when the doctor was ready to see her: It’s got a nicer ambience to sit and wait there . . . Than it has in the, the many crummy waiting rooms in hospital . . . so and I’d rather be sitting in Solaris having a cup of tea than somewhere that’s not as peaceful. (P14)
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One of the participants felt that Western medicine tended to use a less proactive approach, which she described as “an ambulance at the bottom of the cliff approach” (P05), meaning that they waited until there was a problem and then dealt with it. She perceived that her health problems could be minimized by taking an active, preventative approach. She was able to do this through the complementary integrative therapies at the cancer support center, and this increased her sense of personal control: So what Solaris is doing . . . is [helping me] to think more positively about what I’ve got. Don’t worry about it so much. Do what you can. Don’t worry about what you can’t do . . . it encourages me to look at alternative therapies, if I think they’re useful. And massage . . . get[s] me to relax. The counselling gets me to talk about things and work out in my own head of what I can be in control of and what I can’t. All of that makes me feel more in control . . . Solaris has helped me relax more. Bring things into focus a bit more . . .” (P05)
Making Sense of the Cancer Experience The cancer support center appeared to enable coping with the diagnosis and treatment of cancer and helped some participants to make sense of their experience. Four elements related to making sense of the cancer experience were identified in relation to this: reconnecting, positive interpreting, changing perspectives, and visions and dreams.
“It’s all about me and for the first time in my life and I’ve never had that . . . If that’s selfish, I’m afraid I’m selfish for a change . . . I can’t give anymore” (P09). Finding personal energy by reconnecting with self was indicated to be an important element in the healing process. Positive Interpreting. In this category, participants talked about the positive outcomes related to having cancer. One said she had more time to relax and walk on the beach now she wasn’t working: Well quite frankly I’ve never felt better . . . I’ve never spent so long off work and I’ve never walked so many times along the beach . . . I mean if it wasn’t for this thing in my head [the cancer], I’m really enjoying myself . . . (P07)
Others noticed positive changes in their behavior and outlook on life: “I’m more compassionate. I have gone through enough experiences now to understand people a lot better . . . “ (P04); “Honestly, I feel my life is more together now than it’s ever been” (P13). Some participants interpreted their current situation so positively that they actually felt better in themselves than before the cancer diagnosis.
Going back to the spiritual journey, to me it was a real wake-up call that you’re not looking after that part of your life enough and I think Solaris center really helped me with that and made me look at things that I’ve known I’ve had to look at. But it’s there; it’s just that I’m too busy. (P02)
Changing Perspectives. A change in perspectives was mentioned as a significant part of the experience of cancer and of attending the cancer support center, “I appreciate life a lot more now . . . I now pay attention to the small, very, very small things . . . “ (P04); “ I think it puts your life into perspective slightly without a doubt . . . minor things become very minor. Major things become very minor if that makes sense” (P15). A change in priorities was also described: “Family is more important. Making money is not so important . . .” (P06). Changing perspectives was partly attributed to interactions with various persons at the SolarisCare center: “We became, I won’t say friends . . . but got some empathy and started talking . . . I’ve met so many nice interesting people that I would never have met otherwise” (P06). The therapies experienced at SolarisCare were also indicated to have contributed to viewing and experiencing life in a different way:
Part of this reconnecting with self, involved focusing on self rather than others: “I didn’t want to do anything else other than focus on myself . . . [said to husband] I need to work out who I am” (P04);
It helped [therapy at Solaris] in the way of thinking of my whole body, rather than just thinking about part of me that had had the cancer cut out . . . its still quite significant but it just sort of
Reconnecting. Participants talked about revisiting spiritual elements in their life and how the center had helped with this. For some this meant becoming more involved with their chosen religion, for others new religions and spiritual paths were explored:
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Benefits of a Hospital-Based Complementary Therapies Center / Williams et al. 257 helped me connect with the . . . rest of my body and I felt relaxed afterwards, and yes and nurtured . . . (P14)
Visions and Dreams. An interesting aspect was described in relation to making sense of the cancer experience by four participants—the experience of vivid dreams and visions. Some of these had been experienced during energy-based complementary therapies at the cancer support center. The dreams and visions were described in great detail. Some saw people they knew who had passed away, others saw strangers. Animals were talked about, and beautiful places. Each of the dreams or visions had meaning for the participant and were viewed positively: “They didn’t frighten me . . . And they sort of reaffirmed how I felt” (P02).
Discussion The perceived benefits of a cancer support center offering complementary therapies within the hospital setting have been described in this article. A central theme of the center being like an oasis in the hospital was identified and three subthemes of facilitating comfort, increasing personal control, and helping make sense of the cancer experience have been described in relation to this. The facilitation of comfort was one of the subthemes identified. Comfort is an outcome that is commonly referred to in the care of hospitalized patients. McIlveen and Morse (1995) traced the role of comfort in nursing back to 1900 and described the changes that have taken place through the years. In this review, they note that between 1960 and 1980 nurses developed techniques to promote emotional comfort. In previous work by the primary author (AMW), emotional comfort was found to be important for hospitalized patient and thought to be a therapeutic state that assisted recovery (Williams & Irurita, 2006). Emotional comfort in that study referred to the comfort that was associated with the feelings of a person. It was defined as pleasant positive feelings, a state of relaxation. The interpersonal interactions experienced by patients during hospitalization had an impact on emotional comfort (Williams & Irurita, 2004), as did factors within the hospital environment (Williams & Irurita, 2005) and the personal characteristics of the patient (Williams & Kristjanson 2008). Similarities in the factors
influencing the experience of emotional comfort were noted for these outpatients attending the SolarisCare center. Increasing personal control was another of the subthemes identified in this study. Cancer can often be perceived as one of the most disempowering illnesses. Patients diagnosed with cancer commonly experience a loss of control in many areas of their lives following their diagnosis. Research in this area has started to confirm a relationship between low levels of perceived control and psychological distress (Barez, Blasco, Fernandez-Castro, & Viladrich, 2009; Beckjord, Glinder, Langrock, & Compas, 2009). Psychological distress that manifests in the form of depression, and anxiety has been linked with a lower quality of life (Brown, Kroenke, Theobald, Wu, & Tu, 2010; Kroenke et al., 2010). The health locus of control was identified as the most significant preventive factor in terms of survival from cancer in a sample of 57 patients in Taiwan (Chung, Chao, Chou, & Hui-Ling, 2009). There are indications that there is value in the development of strategies that increase perceptions of control for patients with a diagnosis of cancer, and the positive experiences described by these patients attending the SolarisCare center would support this. Helping make sense of the cancer experience was another subtheme in this study. It has previously been reported that patients reexamine their values and their goals in life as a result of the impact of the cancer diagnosis (Bakke, Purtzer, & Newton, 2002; Hernandez-Reif et al., 2004). During this time, it has been observed that they often access therapies such as massage, Reiki, and other forms of spiritual and “energy” healing, possibly to seek spiritual comfort while they question the reasons for their cancer diagnosis (Foster & 2006). Energy healing has also been suggested as providing the willpower and inner strength to overcome the challenges associated with an illness such as cancer by attuning to the mind (Ritvo et al., 1999) and revisiting spiritual beliefs (McGrath, 2004). Some religions place importance on the recollection of dreams, and a spiritual significance may be perceived. Psychotherapists often use dreams to help understand psychological trauma and distress (Stranahan, 2011). It appeared in this study that patients were positively interpreting their dreams as part of making sense of their cancer diagnosis.
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258 Journal of Holistic Nursing / Vol. 32, No. 4, December 2014
Conclusion This study has provided evidence to suggest that a support center offering complementary therapies can assist patients to better cope both emotionally and physically with the effects of a diagnosis of cancer, its treatment, and its side effects. It is speculated that the use of complementary therapies is an aspect of managing the illness that enabled patients to maintain a sense of control (Delmar et al., 2006). Patients use a range of complementary therapies for a number of reasons; access to complementary therapies provides a measure of control for which they are solely responsible for the decisions made (Bishop & Yardley, 2004). Thus, although the clinician may be informed as to the overall patient use of therapies, the patients is largely in control of what and when therapies are sought out and used. This study has demonstrated the benefits to patients in being able to access a range of complementary therapies within the hospital setting to assist in coping with the physical and emotional difficulties associated with the a cancer diagnosis and illness trajectory. However, limitations of this study include the small number of participants, self-referral method of participant selection, and use of a single site. These findings increase our understanding of a range of psychological and supportive strategies that can assist persons with a diagnosis of cancer to cope. This work is particularly relevant to oncology nurses exploring options to improve the emotional wellbeing of patients. In addition, high levels of stress experienced by nurses caring for patients with a diagnosis of cancer have been reported in the literature (de Carvalho, Muller, Bachion de Carvalho, & de Souza Melo, 2005; Florio, Donnelly, & Zevon, 1998). A systematic review and meta-analysis found that burnout was high among all cancer professionals (Trufelli et al., 2008). Part of this stress relates to a lack of time and resources to address the emotional care of hospitalized patients. Previous work by the first author has found that the distress of nurses was minimized by the availability of emotional support (Williams, Dawson, & Kristjanson, 2008). Nurses at the study hospital regularly refer patients to the SolarisCare center, and the center also offers appointments to nurses who are experiencing stress themselves. Further work exploring the impact of centers such as SolarisCare on the coping ability of nurses is warranted.
Quantitative research is now needed to measure the extent to which a cancer support center located within the acute care hospital setting can have a positive impact on patients. However, a number of challenges present themselves in the design of such studies where the intervention and the outcomes are multifaceted. The range of therapies used by patients who attend the SolarisCare center makes it difficult to accurately compare experiences. It is not known what combination of treatments are most effective, or if some treatment combinations are better for some patients than others. In addition to this, some patients have commented that they just feel better sitting in the waiting room, which highlights the difficulty in identifying the exact source or nature of a perceived benefit. A lack of clarity exists in the literature concerning the mechanism by which patients attribute therapeutic effects to psychosocial care. In a recent review of the placebo effect (Price, Finniss, & Benedetti, 2008), a number of different mechanisms were identified and associated with the effect. This current study has identified that the patient’s level of comfort is a key construct in this phenomenon, together with the person’s perceived level of personal control, and the need to make sense of the cancer experience. The SolarisCare center is a novel idea that provides a unique model of integrative care with a number of potentially positive outcomes. Further discovery and development work is now needed to explore these constructs further in relation to the experience of persons diagnosed with cancer.
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emotional care experienced by hospitalised patients. Journal of Clinical Nursing, 17, 1069-1077. Anne M. Williams, PhD, MSc, BSc (Hons), RN, is an Associate Professor for Clinical Research and Innovation in the School of Nursing and Midwifery, Edith Cowan University. Anne is also a Research Consultant for the SolarisCare Foundation, and the Centre for Nursing Research at Sir Charles Gairdner Hospital. Caroline E. Bulsara, PhD, GradDipEdSt, BA, is an Associate Professor in the School of Nursing and Midwifery at Notre Dame University. Caroline previously worked for the Brightwater Care Group and holds and adjunct position at Edith Cowan University. David J. L. Joske, MBBS, FRACP, FRCPA, is a Consultant Haematologist at Sir Charles Gairdner Hospital and the founder and chairman of the SolarisCare Foundation. David is also a Clinical Professor at the University of Western Australia. Anna S. Petterson, PhD, MA, BA, AHTR, is the Manager of Research and Education, SolarisCare Foundation; a Medical Arts Psychotherapist and Adjunct Research Fellow at Edith Cowan University Anna K. Nowak, PhD, MBBS, FRACP, is a Professor at the University of Western Australia and a Medical Oncologist at Sir Charles Gairdner Hospital. Kellie S. Bennett, PhD, Mpsych, DipEd, is an Associate Professor in the School of Psychiatry and Clinical Neurosciences at the University of Western Australia.
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