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Original article
Comparison of the symptoms reported by post-operative patients with cancer and nurses’ perception of patient symptoms C.K. GUNER, MSC, RN, Kastamonu University Taskopru Meslek Yuksekokulu Taskopru, Kastamonu, S. AKIN, BSC, PHD, RN, ASSOCIATE PROFESSOR, Bahcesehir University, Faculty of Health Sciences, Istanbul, & Z. DURNA, BSC, PHD, RN, PROFESSOR,
Bahcesehir University, Faculty of Health Sciences, Istanbul, Turkey
GUNER C.K., AKIN S. & DURNA Z. (2014) European Journal of Cancer Care 23, 523–530 Comparison of the symptoms reported by post-operative patients with cancer and nurses’ perception of patient symptoms The purpose of this study was to compare the symptoms reported by patients with cancer after palliative surgery and mechanical ventilation in an intensive care unit (ICU) with their primary nurses’ perception of the symptoms. The study adopted a descriptive and correlational study design. The sample comprised 60 Turkish patients with cancer who had been mechanically ventilated for 1–12 h at the ICU following palliative surgery. In addition to the patients’ reports, the nurses (= 8) independently rated their own perceptions of the patients’ symptoms. Data were collected using the Edmonton Symptom Assessment Scale (ESAS). The mean age of the sample was 62.28 years (SD = 15.02; range: 27–86). The mean score of the patients on the ESAS was 55.17 (SD = 26.16) and that of the nurses was 55.48 (SD = 27.13). The study found no statistically significant differences between scores of patients’ reports and nurses’ assessments of symptoms, except for the category of pain. Patients reported more pain than the nurses’ perceived (Z = −2.311, P = 0.021). Systematic and frequent symptom assessments of patients in ICUs after palliative surgical operations should be an integral part of nursing care.
Keywords: cancer, patient symptoms, nurse assessments, palliative surgery, pain, post-operative.
INTRODUCTION The incidence of cancer is rapidly increasing, and this increase has become a major health concern (American Cancer Society 2013). Cancer and cancer treatments have profound effects on the functional status and quality of life of patients. Patients with cancer suffer from multiple physical and functional symptoms, psychological distress, and social restraints associated with cancer and cancer Correspondence address: Semiha Akin, Bahcesehir University, Faculty of Health Sciences, Nursing Department, Ciragan Caddesi Osmanpasa Mektebi Sokak No: 4 – 6, 34353 Besiktas, Istanbul, Turkey (e-mail: [email protected], [email protected]).
Accepted 12 September 2013 DOI: 10.1111/ecc.12144 European Journal of Cancer Care, 2014, 23, 523–530
© 2013 John Wiley & Sons Ltd
treatment side-effects. Commonly reported symptoms include fatigue, pain, generally not feeling well, drowsiness, sleep disturbances, anorexia, anxiety, depression, shortness of breath, nausea, vomiting, oral stomatitis and feelings of ‘pins and needles’ in the hands (Aslan 2003; Sadirli Kurt 2008; Kang et al. 2013). Furthermore, personal factors, disease characteristics and treatment modalities all affect patients’ symptom experience and response, functional status and quality of life (Jordhøy et al. 2001). Patients’ own ratings of symptoms and the perception of these symptoms by nurses or physicians influence medical decisions and nursing care (Nekolaichuk et al. 1999); however, during cancer treatment and rehabilitation, clinicians may fail to notice or may not anticipate some of the symptoms their patients find most disturbing. Thus, patients with cancer may not receive effective,
GUNER ET AL.
systematic symptom management and sufficient support. As a result, poor outcomes may occur and the patients’ quality of life may deteriorate. Identification of the discrepancies between the patients’ and nurses’ perceptions of symptoms is important for planning appropriate interventions. Recent studies have investigated the discrepancies between the perceptions of patients, healthcare providers and significant others. These studies reported that the level of agreement was fair to good, but there were still discrepancies regarding symptoms and functioning between all three groups (Wennman-Larsen et al. 2007; Akin & Durna 2013). Indeed, the quality of life of patients with cancer and some subjective symptoms is generally overestimated by healthcare providers and significant others (Sneeuw et al. 2002). Studies report that the agreement was poorest for subjective symptoms such as pain, loss of well-being, anxiety, depression and drowsiness (McPherson & Addington-Hall 2003; Akin & Durna 2013). A study conducted in intensive care units (ICUs) found that patients experienced thirst, tiredness, discomfort, anxiety, hunger, dyspnoea, pain, depression and nausea in moderate to significant levels during ventilation (Li & Puntillo 2006). Similarly, a study conducted on critically ill patients with cancer treated in ICUs reported very distressing physical and psychological disturbances (such as pain, discomfort, anxiety, unsatisfied hunger or thirst, sleep, or communication problems) associated with ICU treatment and procedures (Nelson et al. 2001). These studies found that there were discrepancies between the ratings of symptoms by patients and nurses. While some systematic reviews and studies showed that the symptoms reported by patients with cancer were underestimated by clinicians, others found that the patients’ symptoms were overestimated by clinicians (Garyali et al. 2006; McPherson et al. 2008; Aydın & Es¸er 2010; Gilbertson-White et al. 2011; Puntillo et al. 2012; Xiao et al. 2012; Akin & Durna 2013). Another study found that ICU nurses tended to overestimate symptom intensity and distress (Puntillo et al. 2012). A comprehensive and reliable symptom assessment in palliative patients with cancer is crucial for effective symptom management. Assessment of subjective symptoms is a challenging task, especially in ICUs. In order to obtain valid and reliable information about the patients’ perceptions and discomfort, researchers should gather proxy assessments of patients’ experiences. For this reason, the number of studies investigating the reliability of proxy ratings has increased. Reliable proxy assessment results will enhance multidisciplinary care and contribute to better health outcomes of patients with cancer treated in ICUs. 524
The effective management of symptoms and improved functional status will enhance the quality of life of patients with cancer (Barg & Heard 1998; Akyol 2004), and better management and functional status can be enhanced by better symptom assessment. Such assessments should be comprehensive, systematic and continuous, and collaboration between patients and healthcare providers is essential to their effective outcome. Data about the agreement between patient and healthcare team perceptions will support the development of valid and reliable tools for use in specialised units.
Study aims The purpose of this study was to compare the symptoms reported by patients with cancer during mechanical ventilation in an ICU after palliative surgery with the primary nurses’ perception of the patients’ symptoms and to describe symptom perception in relation to personal, disease-or treatment related characteristics of patients and nurses reports. The research questions were as follows: 1 What are the symptoms experienced by patients with cancer who received mechanical ventilation in the ICU after palliative surgery? 2 Are there differences between the patient report and the perception of nurses of symptoms? 3 What personal, disease or treatment characteristics are associated with a patient’s report of symptoms?
METHODS Study design This is a descriptive/correlational study. The research was conducted in the 16-bedded ICU of a private hospital in Istanbul.
Study participants The participants of this study comprised patients with cancer and the nurses who were responsible for these patients. The patients with cancer had received mechanical ventilation in the ICU following palliative surgery. The inclusion criteria for the patients were (1) a diagnosis of cancer; (2) a major palliative surgical intervention; (3) mechanical ventilation between hours 1 and 12 post-surgery in the ICU; (4) consciousness following extubation; (5) agreement to participate in the research; (6) the ability to complete an interview; and (7) not under © 2013 John Wiley & Sons Ltd
Comparison of patients’ symptoms with nurses’ perceptions
the effect of sedatives or opioids at the time of the interview. The number of patients treated in the ICU in the study timeframe was 76. Sixteen patients were excluded: six underwent mechanical ventilation longer than hour 12 post-surgery and took sedatives in the ICU, and 10 patients were not intubated. Thus, a total of 60 patients met the inclusion criteria. There were 16 nurses working in the ICU, all of which were approached for recruitment; eight nurses who were not directly involved with patient care, on their annual leave, unwilling to participate, or treating patients that did not meet study criteria were excluded from the study. Thus, eight nurses were included as participants.
Data collection The Institutional Review Board at the hospital where this study was conducted approved this study. Furthermore, permission to use the measurement scale was obtained from the researcher who tested the validity and reliability of the Turkish version of the scale. The participants were informed about the purpose of the research, guaranteed confidentiality, and gave their verbal informed consent. Data about patient characteristics and symptoms following palliative interventions were collected. The severity of patients’ symptoms was rated using a structured interview known as the Edmonton Symptom Assessment Scale (ESAS). The interview was conducted within 24 h of extubation and regaining consciousness in each patient’s room in a closed ICU. The primary nurse in charge of each patient’s care was interviewed in an office at the ICU to exclude patient influence. The ESAS was also used for the nurse interview.
Measurement instruments The interviews were conducted by the researcher (CKG). Patient demographics and medical history were collected using the Patient Information Form, which includes personal characteristics (age, gender, education level, marital status) and the illness-related characteristics (history of chronic illness, cancer treatment and duration of mechanical ventilation). The information about the cancer stage was collected from the patients’ medical files. The ESAS, used in the structured interview with both patients and nurses, was developed by Bruera et al. (1991) to evaluate the symptoms commonly experienced by patients with cancer. The symptoms on the scale are pain, tiredness, nausea, depression, anxiety, drowsiness, © 2013 John Wiley & Sons Ltd
changes in appetite and well-being, and shortness of breath. In the ‘other problems’ section, the researchers may include additional symptoms; in this study, oral stomatitis, thirst and discomfort due to catheters or probes were added. The severity of each symptom is rated on a scale of 0 (no or best possible) to 10 (worst possible) with larger values representing greater symptom distress (Nekolaichuk et al. 1999). The ESAS is valid and reliable tool for measuring the symptom severity of palliative patients with cancer (Bruera et al. 1991; Richardson & Jones 2009). The ESAS was adapted for use in Turkish populations, and the validity and reliability for this version have been empirically established (Sadirli Kurt 2008; Usta Yes¸ilbalkan et al. 2008). In the current study, Cronbach’s alpha coefficient was 0.87 for the patient group and 0.86 for the nurse group.
Statistical analysis The data were analysed using SPSS, version 11.0 (SPSS Inc., Chicago, IL, USA). The descriptive statistics were reported as means, standard deviations, minimums, maximums and percentages. Mean scale scores were compared with personal and disease-related characteristics using Kruskal–Wallis test and Mann–Whitney U-tests. The mean scores of the patient reports and the perceptions of the nurses were compared with the Wilcoxon signed-rank test. Furthermore, one-sample t-tests were conducted.
RESULTS Characteristics of patients and nurses More than one half of the patients (60%) were male; the mean age was 62.28 years [SD = 15.02; range = 27–86; 95% confidence interval (CI) [58.40, 66.16]]. The patients were being treated for pancreatic cancer (16.7%), colon cancer (13.3%), and gastric cancers (13.3%) (Table 1). Some patients reported a previous history of hospitalisation (46.7%, n = 28). A large number of the group (83%) had a history of readmission to the ICU: 83% for bleeding, 46.7% for pain, 41.7% for hypotension and 33.4% for respiratory distress. The mean time in the ICU was 42.77 h (SD = 27.05; range = 15–144; 95% CI [35.78, 49.75]) and the length of the ventilation support was 4.58 h (SD = 3.76; range = 1–12; 95% CI [3.61, 5.55]). The mean time of the patient interview following extubation was 2.73 h (SD = 2.72; range = 1–20; 95% CI [2.03, 3.44]; Table 1). The observed types of palliative surgical procedures were pancreatic duct or biliary stent placement to alleviate obstruction (16.7%, n = 10), palliative resection of 525
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Table 1. Patient characteristics (n = 60) n Age, years (mean ± SD) 60 years old or younger Over the age of 60 Marital status Not married Married Presence of another chronic disease* Diabetes mellitus Hypertension, chronic heart failure Chronic obstructive lung disease (COPD) None Diagnosis of the disease Pancreatic cancers Colon cancers Gastric cancer Liver cancers Lung cancers Other (rectum cancer, brain cancer, breast cancer etc.) Stage of cancer Stage I Stage II Stage III Stage IV History of chemotherapy Yes No Reason for current admission to intensive care unit* Bleeding Pain Hypotension Respiratory distress Types of palliative surgery Palliative pancreatic duct or biliary stent placement to alleviate obstruction Palliative resection of advanced stomach and colon cancer Palliative resection in liver cancers Surgical palliation of airway obstruction Nerve block procedure Palliative resection of rectal cancer Palliative craniotomy A stent placement to alleviate biliary obstruction Other palliative interventions
%
62.28 ± 15.02 (range: 27–86) 25 41.7 35 58.3 20 40
33.4 66.7
14 34 3 25
23.3 56.6 5.0 41.6
10 8 8 7 6 21
16.7 13.3 13.3 11.7 10.0 36.1
2 25 24 9
3.3 41.7 40.0 15.0
16 44
26.7 73.3
54 28 25 20
83.0 46.7 41.7 33.4
10
16.7
8
13.3
7 6 4 4 4 1
11.7 10 6.7 6.7 6.7 1.7
16
26.6
*Marked more than once.
advanced stomach and colon cancer (13.3%, n = 8), palliative resection in liver cancers (11.7%, n = 7) and surgical palliation of airway obstruction (10%, n = 6; Table 1). Nurses were predominantly female (75%) and single (75%). Most were university graduates with bachelor’s degrees (62.5%, n = 5), two were nursing high school graduates (25%, n = 2), and one had a master’s degree (12.5%). The nurses had 3 years (n = 3), 4 years (n = 3) or 6 526
years (n = 2) of experience in the ICU. Nurses worked a mix of night and day shifts when caring for the patients.
Comparison of patient and nurse reports of symptoms The symptoms most severely felt by the patients during intensive care treatment were not feeling well (M = 6.40), anxiety (M = 6.30), discomfort due to probes or catheters (M = 6.22), and pain (M = 6.13). The least severe symptoms reported by the patients were, in order, oral stomatitis (M = 1.30), nausea (M = 2.82) and changes in appetite (M = 2.97). The mean (SD) score of ESAS rated by the patients was 55.17 (SD = 26.16; range = 10–112; Table 2). The nurses reported that the patients mostly suffered from the problems of not feeling well (M = 6.50), discomfort due to probes or catheters (M = 6.28), anxiety (M = 6.23) and tiredness (M = 5.82). Nurses rated oral stomatitis (M = 1.40), changes in appetite (M = 2.85) and nausea (M = 3.05) as the least severe symptoms experienced by their patients. The mean score of ESAS rated by the nurses was 55.48 (SD = 27.13; range = 7–20; Table 2). There was no statistically significant difference between the patients’ report and nurses’ perceptions of symptoms (P > 0.05), except for the symptom of pain. The nurses reported the patients’ pain as less severe than what the patients themselves reported (Z = −2.311; P = 0.021; Table 2).
Variables related to patients’ report of symptoms Comparison of the symptom perceptions in terms of personal characteristics No differences were found between the patients’ reports and the nurses’ perceptions of symptoms by patient gender (P > 0.05). Female patients reported less severe nausea than nurses reported (P = 0.020). No statistically significant difference was found between the male patients’ report and the nurses’ perceptions about male patients’ symptoms (P > 0.05; Table 3). Statistically significant differences were found between the patient report and nurses’ perceptions of symptoms by patient age in relation to the symptoms of depression, anxiety and not feeling well (P < 0.05). The younger patient group (60 or younger) reported a higher level of sadness and anxiety and lower level of well-being than their nurses. Patients over the age of 60 reported less nausea (P = 0.034) than the nurses perceived (Table 3). Patients with an additional chronic disease reported more severe pain than nurses’ perceived (P = 0.035; Table 4). © 2013 John Wiley & Sons Ltd
Comparison of patients’ symptoms with nurses’ perceptions
Table 2. Comparison of patients’ and the nurses’ means of Edmonton Symptom Assessment Scale (ESAS) (n = 60) Assessment of patients symptoms and nurses’ perceptions about the patients’ symptoms ESAS Pain Tiredness Nausea Depression Anxiety Drowsiness Appetite Well-being Shortness of breath Oral stomatitis Feeling thirsty Discomfort due to catheters or probes
Patient ratings (n = 60) Mean ± SD
Nurse ratings (n = 60) Mean ± SD
6.13 ± 3.40 5.83 ± 3.47 2.82 ± 3.95 5.42 ± 3.50 6.30 ± 3.49 3.93 ± 3.35 2.97 ± 3.57 6.40 ± 2.69 3.22 ± 3.16 1.30 ± 2.71 4.63 ± 3.43 6.22 ± 3.64 55.17 ± 26.16 (range: 10–112)
5.77 ± 3.45 5.82 ± 3.60 3.05 ± 4.13 5.25 ± 3.71 6.23 ± 3.83 4.13 ± 3.58 2.85 ± 3.61 6.50 ± 2.89 3.27 ± 3.42 1.40 ± 2.82 4.93 ± 3.81 6.28 ± 3.79 55.48 ± 27.13 (range: 7–120)
z
P*
−2.311 −0.060 −0.852 −1.103 −0.160 −0.896 −0.506 −0.571 −0.403 −0.213 −1.622 −0.236
0.021 0.95 0.39 0.27 0.87 0.37 0.61 0.57 0.69 0.83 0.10 0.81 P > 0.05
*Wilcoxon signed-rank test.
No statistically significant differences were found between the patients’ reports and the nurses’ perception of symptoms by patient’s marital status (P > 0.05).
Symptom perception and disease- or treatment-related characteristics A statistically significant difference was found between the patients’ reports and the nurses’ perceptions of symptoms related to tiredness, nausea, depression, anxiety, drowsiness, changes in appetite, not feeling well, oral stomatitis and discomfort due to probes or catheters (P < 0.05) in terms of cancer stage. However, there were no significant differences between the patients’ reports and the nurses’ perceptions of the symptoms of pain, shortness of breath and feeling thirsty in relation to cancer stage (P > 0.05; Table 4). Patients with stage II cancer reported higher levels of nausea (P = 0.034) than perceived by nurses. Patients with stage III cancer reported higher levels of pain (P = 0.006) and depression (P = 0.033) than did the nurses (Table 3). No statistically significant differences were found between the reports of patients with stage I or IV cancer and the perceptions of the nurses (P > 0.05; Table 4). A statistically significant difference was found between the reports of patients with a history of chemotherapy and the perceptions of nurses of symptoms in pain, tiredness, depression, anxiety, drowsiness, changes in appetite, not feeling well, oral stomatitis and discomfort due to probes or catheters (P < 0.05). The patients with history of receiving chemotherapy experienced pain, tiredness, sadness, anxiety, anorexia and oral stomatitis more severely than nurses’ perceived. © 2013 John Wiley & Sons Ltd
A statistically significant difference was found between the reports of patients without a history of chemotherapy and the nurses’ perception of symptoms (P > 0.05). Patients without a history of chemotherapy reported higher levels of pain (P = 0.032) and less thirst (P = 0.033) than their nurses’ reported.
DISCUSSION The current study found there were few discrepancies between nurses’ perceptions and patients’ symptoms experienced during mechanical ventilation in the ICU, except for the symptom of pain. The fact that no statistically significant differences were found between patient reports and nurse perceptions of symptoms is important because it reveals that symptom assessment and control was well managed by the nurses in the ICU. This result adds to the body of literature supporting proxy assessments of symptoms in specialised care units. As mentioned previously, there was a discrepancy in patients’ reports and nurses’ perceptions of pain. The nurses believed patients’ pain to be less severe than what the patients themselves reported. This result is consistent with that of Aydın and Es¸er (2010), who also found that the nurses underestimated the pain of patients. In contrast, a study by Nainis et al. (2006) did not find any differences between patients’ reports and nurses’ perceptions about symptoms. Akin and Durna (2013) found that patients with cancer and nurses showed only poor to fair agreement on the symptom of pain. These findings suggest that ICU nurses underestimate their patients’ pain. Nevertheless, pain may be a particularly challenging symptom to assess and thus, it is important to have 527
528 0.09 0.42 0.034 0.29 0.80 0.56 0.67 0.66 0.19 1.00 0.80 0.29
6.48 ± 3.53 6.12 ± 3.71 2.68 ± 4.31 6.52 ± 3.70 7.60 ± 3.11 4.56 ± 3.96 3.36 ± 3.97 7.20 ± 3.01 3.68 ± 3.16 1.40 ± 2.72 4.52 ± 3.73 6.68 ± 3.86
5.57 ± 3.36 5.74 ± 3.48 3.57 ± 4.27 4.40 ± 3.47 5.34 ± 3.96 3.66 ± 3.12 2.74 ± 3.48 5.94 ± 2.58 3.14 ± 3.60 1.43 ± 3.00 4.77 ± 3.58 5.71 ± 3.75
5.89 ± 3.34 5.63 ± 3.32 2.91 ± 3.73 4.63 ± 3.16 5.37 ± 3.48 3.49 ± 2.82 2.69 ± 3.29 5.83 ± 2.31 2.89 ± 3.17 1.23 ± 2.73 4.71 ± 3.26 5.89 ± 3.50
6.04 ± 3.61 5.92 ± 3.83 2.32 ± 3.89 6.44 ± 3.77 7.48 ± 3.33 4.80 ± 4.12 3.00 ± 3.85 7.28 ± 3.16 3.44 ± 3.23 1.36 ± 2.60 5.16 ± 4.18 7.08 ± 3.76
Nurse Mean ± SD
Patient Mean ± SD
Nurse Mean ± SD
Patient Mean ± SD P*
Assessments
Assessments
0.10 0.37 0.20 0.68 0.43 0.48 0.21 0.71 0.56 0.71 0.07 0.11
P* 0.42 0.48 0.72 0.029 0.010 0.42 0.67 0.031 0.28 0.86 0.79 0.31
P† 5.96 ± 3.36 5.63 ± 3.76 3.42 ± 4.39 5.58 ± 3.40 6.46 ± 3.51 3.58 ± 3.40 3.46 ± 3.71 6.17 ± 2.63 1.67 ± 3.36 2.63 ± 3.20 4.33 ± 3.25 5.88 ± 3.81
Patient Mean ± SD
Assessments
5.46 ± 3.51 5.67 ± 3.89 4.25 ± 4.84 5.13 ± 3.85 6.00 ± 4.20 3.58 ± 3.36 3.13 ± 3.83 6.08 ± 3.09 1.83 ± 3.50 2.63 ± 3.46 4.71 ± 3.65 5.58 ± 4.12
Nurse Mean ± SD
Female patients (n = 24)
0.08 0.75 0.02 0.16 0.33 0.95 0.35 0.82 0.70 1.00 0.23 0.30
6.25 ± 3.48 5.97 ± 3.30 2.42 ± 3.63 5.31 ± 3.60 6.19 ± 3.51 4.17 ± 3.35 2.64 ± 3.49 6.56 ± 2.75 1.06 ± 2.19 3.61 ± 3.12 4.83 ± 3.58 6.44 ± 3.56
Patient Mean ± SD
Assessments
0.32 0.32 0.32 1.00 0.32 0.32 0.32 1.00 0.18 1.00 1.00 1.00
5.16 ± 3.66 3.76 ± 3.18 1.72 ± 2.91 3.72 ± 3.21 4.60 ± 3.62 2.24 ± 2.77 1.12 ± 1.83 5.24 ± 2.77 2.48 ± 3.10 0.40 ± 2.00 3.88 ± 3.35 5.12 ± 3.56
9.00 ± 1.41 8.00 ± 2.83 8.00 ± 2.83 8.00 ± 2.83 10.00 ± 0.00 6.50 ± 4.95 5.50 ± 3.54 10.00 ± 0.00 2.00 ± 0.00 00.00 ± 0.00 5.00 ± 7.07 10.00 ± 0.00
10.00 ± 0.00 9.00 ± 1.41 10.00 ± 0.00 8.00 ± 2.83 9.00 ± 1.41 6.00 ± 5.66 6.50 ± 2.12 10.00 ± 0.00 5.50 ± 0.71 0.00 ± 0.00 5.00 ± 7.07 10.00 ± 0.00
P*
Patient Mean ± SD
Patient Mean ± SD 5.00 ± 3.52 3.92 ± 3.44 2.44 ± 3.68 3.84 ± 3.60 4.12 ± 3.91 2.60 ± 3.16 0.80 ± 1.50 5.12 ± 2.98 2.88 ± 3.46 0.40 ± 2.00 4.36 ± 3.56 5.08 ± 3.82
Nurse Mean ± SD 0.64 0.33 0.034 0.81 0.18 0.17 0.28 0.75 0.10 1.00 0.10 0.71
P* 6.25 ± 2.94 6.58 ± 3.11 2.71 ± 4.11 6.38 ± 3.21 6.92 ± 3.05 4.42 ± 3.30 3.42 ± 4.00 6.79 ± 2.36 3.29 ± 2.93 1.04 ± 2.26 4.96 ± 3.51 6.33 ± 3.62
Patient Mean ± SD
Assessments
5.58 ± 3.26 6.46 ± 3.27 2.54 ± 4.03 5.88 ± 3.53 7.21 ± 3.30 4.58 ± 3.75 3.50 ± 4.08 6.96 ± 2.54 3.38 ± 3.20 1.38 ± 2.81 5.42 ± 3.83 6.63 ± 3.69
Nurse Mean ± SD
Stage of cancer stage III
*Wilcoxon signed-rank test: The comparison of nurses’ scores with patients’ scores. †Kruskal–Wallis test: The comparison of nurses scores and patients’ scores in relation to patient’s characteristics.
Pain Tiredness Nausea Depression Anxiety Drowsiness Appetite Well-being Shortness of breath Oral stomatitis Feeling thirsty Discomfort due to catheters or probes
ESAS
Assessments
Nurse Mean ± SD
Assessments
Stage of cancer stage II
Stage of cancer stage I
0.006 0.58 0.16 0.033 0.29 0.76 0.67 0.55 0.49 0.65 0.10 0.34
P*
7.67 ± 3.32 8.89 ± 1.45 4.56 ± 4.56 7.00 ± 3.50 8.78 ± 2.11 6.89 ± 2.03 6.11 ± 3.44 7.78 ± 2.05 4.56 ± 3.91 4.78 ± 3.27 5.78 ± 2.86 8.11 ± 3.26
Patient Mean ± SD
Assessments
7.67 ± 3.32 8.89 ± 2.03 5.00 ± 5.00 6.89 ± 3.66 8.67 ± 2.00 6.67 ± 2.12 6.22 ± 3.35 8.33 ± 1.66 4.33 ± 4.36 4.56 ± 3.00 5.22 ± 4.35 7.89 ± 3.41
Nurse Mean ± SD
Stage of cancer stage IV
1.00 1.00 0.58 1.00 0.65 0.48 0.65 0.18 0.56 0.52 0.39 0.32
P*
0.05 0.001 0.034 0.009 0.007 0.001 0.001 0.013 0.19 0.001 0.44 0.048
P†
P* 0.12 0.74 0.52 0.86 0.40 0.24 0.86 0.31 0.85 0.63 0.30 0.20
5.94 ± 3.53 5.77 ± 3.40 3.20 ± 3.94 5.11 ± 3.35 5.91 ± 3.64 3.74 ± 3.28 2.89 ± 3.60 5.97 ± 2.53 0.94 ± 2.27 3.23 ± 3.21 5.00 ± 3.48 5.60 ± 3.75
Patient Mean ± SD
Assessments
5.51 ± 3.51 5.83 ± 3.60 3.37 ± 4.07 4.77 ± 3.61 5.94 ± 3.99 3.94 ± 3.53 2.83 ± 3.62 6.03 ± 2.82 1.31 ± 2.73 3.40 ± 3.48 5.29 ± 3.78 5.57 ± 4.05
Nurse Mean ± SD
Patients with additional chronic disease (n = 35)
5.97 ± 3.43 5.92 ± 3.45 2.25 ± 3.42 5.33 ± 3.66 6.39 ± 3.61 4.50 ± 3.72 2.67 ± 3.51 6.78 ± 2.75 1.11 ± 2.26 3.69 ± 3.38 5.08 ± 3.96 6.75 ± 3.53
Nurse Mean ± SD
Male patients (n = 36)
Table 4. Comparison of patients’ and the nurses’ means of Edmonton Symptom Assessment Scale (ESAS) in relation to the stage of cancer (n = 60)
*Wilcoxon signed-rank test: The comparison of nurses’ scores with patients’ scores. †Mann–Whitney U-test: The comparison of nurses scores and patients’ scores in relation to patient’s characteristics.
Pain Tiredness Nausea Depression Anxiety Drowsiness Appetite Well-being Shortness of breath Oral stomatitis Feeling thirsty Discomfort due to catheters or probes
ESAS
60 years old or younger (n = 25)
Over the age of 60 (n = 35)
Table 3. Comparison of patients’ and nurses’ means of Edmonton Symptom Assessment Scale (ESAS) in relation to patient’s age group and gender (n = 60)
P†
0.035 0.71 0.52 0.13 0.95 0.44 0.89 0.72 0.27 0.43 0.22 0.69
P*
0.71 0.82 0.43 0.80 0.71 0.48 0.34 0.50 0.65 0.17 0.65 0.57
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© 2013 John Wiley & Sons Ltd
Comparison of patients’ symptoms with nurses’ perceptions
systematic and regular assessments and adopt strategies to improve pain assessment (e.g. effective and reliable methods of assessment, communication). Patients with cancer experience a multitude of physical (Graydon et al. 1995; Akdemir 2003; Fadiloglu 2003; Fillion et al. 2003; Stein et al. 2003) and psychological symptoms (e.g. anger, nervousness, loss of hope for the future and difficulty in concentrating; Ferrell et al. 1996; Akdemir 2003; Fadiloglu 2003; Stein et al. 2003). In this study, the patients reported symptoms of not feeling well, anxiety, discomfort due to probes or catheters, and pain control during the period they remained connected to the ventilator after undergoing palliative surgery. Consistent with other studies, the current study found that the most severe symptoms reported by patients with cancer during intensive care treatment were not feeling well, anxiety, discomfort due to probes or catheters, and pain, in that order. Genç (2005) stated that elderly patients experienced more symptoms than younger patients; in contrast, Aslan (2003) reported that there was no significant difference between the patients’ age and the patients’ symptom experience. In the current study, the younger patient group (60 years old or younger) reported a higher level of sadness and anxiety and a lower level of well-being than that perceived by nurses, and the older patients experienced a lower level of nausea than that perceived by nurses. Following major palliative surgery, patients need to be assessed in terms of both physical and emotional symptoms. The current study result showed that younger patients are more likely to suffer from psychological symptoms and thus need emotional support. The symptoms assessed in this study can have an adverse effect on the quality of life of patients and could decrease adherence to treatment (Stein et al. 2003). Disease-related factors (e.g. diagnosis, stage of cancer) may also impact the patients’ well-being and cause symptom-related distress (Akin & Durna 2013). A difference was found in the patient report and the perceptions of the nurses of symptoms by cancer stage. This result
REFERENCES Akdemir N. (2003) Kanser Tedavileri ve Hems¸irelik Bakımı [Cancer Treatments and Nursing Care]. I˙ç Hastalıkları ve Hems¸irelik Bakımı, I˙stanbul. Akin S. & Durna Z. (2013) A comparative descriptive study examining the perceptions of cancer patients, family caregivers, and nurses on patient symptom severity in Turkey. European Journal of Oncology Nursing 17, 30–37.
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suggests that the stage of cancer might be associated with symptoms. The primary aim of cancer treatment is to successfully manage symptom distress and improve the quality of life for patients. However, some side-effects of cancer treatment can be overlooked or inadequately treated due to the time constraints, lack of knowledge or skills, and poor communication between healthcare providers and patients (Youngblood et al. 1994). These important symptoms observed in patients can be alleviated through consistent and reliable assessments and treatment (Fortner et al. 2003). Conclusion The results showed that there were no discrepancies between nurses’ and patients’ reports of symptoms experienced during mechanical ventilation in the ICU, except in the assessment of pain, using the ESAS. The intensive care nurses reported that the patients felt the pain less severely compared with the perceptions of the patients about this symptom. Our results also underline the fact that patients in an ICU need support in managing symptoms such as not feeling well, anxiety, discomfort due to probes or catheters, and pain during mechanical ventilation. Female patients, those under the age of 60, those with a history of chronic illness, or those in the advanced stages of cancer need to be more closely assessed and supported for the management of nausea, sadness, anxiety, pain, tiredness and oral stomatitis. Study limitations The study sample comprised only 60 patients with cancer and eight nurses. Thus, the results can be generalised only to ICU patients who met inclusion criteria of current study. Patients who underwent palliative support procedures (minor palliative procedure) such as intubation procedures, vascular access procedures and biopsy procedure were not included in to study.
Akyol H. (2004) Kemoterapinin Temel I˙lkeleri [Basic Principles for Chemotherapy]. XIII. TPOG Ulusal Pediatrik Kanser Kongresi, I˙zmir. American Cancer Society (2013) Cancer Facts & Figures 2013. Available at: http://www.cancer.org/acs/groups/ content/@epidemiologysurveilance/ documents/document/acspc-036845.pdf Aslan O. (2003) Kemoterapi hastalarında semptomların deg˘erlendirilmesi ve bu semptomların kontrolünde hems¸irelik
eg˘itiminin rolü [Assessing the chemotherapy symptoms and determining the effect of nursing education role on cancer patients undergoing chemotherapy]. Dissertation. Gülhane Askeri Tıp Akademisi Sag˘lık Bilimleri Enstitüsü, Ankara. Aydın B.H. & Es¸er I˙. (2010) Hems¸irelerin ve kanserli hastaların ag˘rı deg˘erlendirmelerinin kars¸ılas¸tırılması [Comparison of the pain assessment of the nurses and cancer patients]. Ege
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Graydon J.E., Bubela N., Irvine D. & Vincent L. (1995) Fatigue reducing strategies used by patients receiving treatment for cancer. Cancer Nursing 18, 23–28. Jordhøy M.S., Fayers P., Loge J.H., Saltnes T., Ahlner-Elmqvist M. & Kaasa S. (2001) Quality of life in advanced cancer patients: the impact of sociodemographic and medical characteristics. British Journal of Cancer 85, 1478–1485. Kang J.H., Kwon J.H., Hui D., Yennurajalingam S. & Bruera E. (2013) Changes in symptom intensity among cancer patients receiving outpatient palliative care. Journal of Pain and Symptom Management 1–9. pii: S0885-3924(13) 00142-5. doi: 10.1016/j.jpainsymman. 2012.11.009 Li D.T. & Puntillo K. (2006) A pilot study on coexisting symptoms in intensive care patients. Applied Nursing Research 19, 216–219. McPherson C.J. & Addington-Hall J.M. (2003) Judging the quality of care at the end of life: can proxies provide reliable information? Social Science and Medicine (1982) 56, 95–109. McPherson C.J., Wilson K.G., Lobchuk M.M. & Brajtman S. (2008) Family caregivers’ assessment of symptoms in patients with advanced cancer: concordance with patients and factors affecting accuracy. Journal of Pain and Symptom Management 35, 70–82. Nainis N., Paice A.J., Ratner J., Wirth J.H., Lai L. & Shott S. (2006) Relieving symptoms in cancer: innovative use of art therapy. Journal of Pain and Symptom Management 31, 162–169. Nekolaichuk C.L., Maguire T.O., SuarezAlmazor M., Rogers W.T. & Bruera E. (1999) Assessing the reliability of patient, nurse, and family caregiver symptom ratings in hospitalized advanced cancer patients. Journal of Clinical Oncology 17, 3621–3630. Nelson J.E., Meier D.E., Oei E.J., Nierman D.M., Senzel R.S., Manfredi P.L., Davis S.M. & Morrison R.S. (2001) Selfreported symptom experience of critically ill cancer patients receiving intensive care. Critical Care Medicine 29, 277–282.
Puntillo K.A., Neuhaus J., Arai S., Paul S.M., Gropper M.A., Cohen N.H. & Miaskowski C. (2012) Challenge of assessing symptoms in seriously ill intensive care unit patients: can proxy reporters help? Critical Care Medicine 40, 2760–2767. Richardson L.A. & Jones G.W. (2009) A review of the reliability and validity of the Edmonton Symptom Assessment System. Current Oncology (Toronto, Ont.) 16, 55–64. Sadirli Kurt S. (2008) Kanserli hastalarda semptom kontrolünün deg˘erlendirilmesi [The Symptom assessment in cancer patients]. Dissertation. Trakya Universitesi Saglik Bilimleri Enstitusu, Edirne. Sneeuw K.C., Sprangers M.A. & Aaronson N.K. (2002) The Role of health care providers and significant others in evaluating the quality of life of patients with chronic disease. Journal of Clinical Epidemiology 55, 1130–1143. Stein K.D., Denniston M., Baker F., Dent M., Hann D.M., Bushhouse S. & West M. (2003) Validation of Modified Rotterdam Symptom Checklist for use with cancer patients in The United States. Journal of Pain and Symptom Management 26, 975–989. Usta Yes¸ilbalkan Ö., Özkütük N., Karadakovan A., Turgut T. & Kazgan B. (2008) Validity and reliability of the Edmonton Symptom Assessment Scale in Turkish cancer patients. Turkish Journal of Cancer 38, 62–67. Wennman-Larsen A., Tishelman C., Wengström Y. & Gustavsson P. (2007) Factors influencing agreement in symptom ratings by lung cancer patients and their significant others. Journal of Pain and Symptom Management 33, 146–155. Xiao C., Polomano R. & Bruner D.W. (2012) Comparison between patient-reported and clinician-observed symptoms in oncology. Cancer Nursing 1–16 [Epub ahead of print]. Youngblood M., Williams P.D., Eyles M., Warning J. & Runyon S.A. (1994) Comparison of two methods of assessing cancer therapy-related symptoms. Cancer Nursing 17, 37–44.
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Original article
Comparison of the symptoms reported by post-operative patients with cancer and nurses’ perception of patient symptoms C.K. GUNER, MSC, RN, Kastamonu University Taskopru Meslek Yuksekokulu Taskopru, Kastamonu, S. AKIN, BSC, PHD, RN, ASSOCIATE PROFESSOR, Bahcesehir University, Faculty of Health Sciences, Istanbul, & Z. DURNA, BSC, PHD, RN, PROFESSOR,
Bahcesehir University, Faculty of Health Sciences, Istanbul, Turkey
GUNER C.K., AKIN S. & DURNA Z. (2014) European Journal of Cancer Care 23, 523–530 Comparison of the symptoms reported by post-operative patients with cancer and nurses’ perception of patient symptoms The purpose of this study was to compare the symptoms reported by patients with cancer after palliative surgery and mechanical ventilation in an intensive care unit (ICU) with their primary nurses’ perception of the symptoms. The study adopted a descriptive and correlational study design. The sample comprised 60 Turkish patients with cancer who had been mechanically ventilated for 1–12 h at the ICU following palliative surgery. In addition to the patients’ reports, the nurses (= 8) independently rated their own perceptions of the patients’ symptoms. Data were collected using the Edmonton Symptom Assessment Scale (ESAS). The mean age of the sample was 62.28 years (SD = 15.02; range: 27–86). The mean score of the patients on the ESAS was 55.17 (SD = 26.16) and that of the nurses was 55.48 (SD = 27.13). The study found no statistically significant differences between scores of patients’ reports and nurses’ assessments of symptoms, except for the category of pain. Patients reported more pain than the nurses’ perceived (Z = −2.311, P = 0.021). Systematic and frequent symptom assessments of patients in ICUs after palliative surgical operations should be an integral part of nursing care.
Keywords: cancer, patient symptoms, nurse assessments, palliative surgery, pain, post-operative.
INTRODUCTION The incidence of cancer is rapidly increasing, and this increase has become a major health concern (American Cancer Society 2013). Cancer and cancer treatments have profound effects on the functional status and quality of life of patients. Patients with cancer suffer from multiple physical and functional symptoms, psychological distress, and social restraints associated with cancer and cancer Correspondence address: Semiha Akin, Bahcesehir University, Faculty of Health Sciences, Nursing Department, Ciragan Caddesi Osmanpasa Mektebi Sokak No: 4 – 6, 34353 Besiktas, Istanbul, Turkey (e-mail: [email protected], [email protected]).
Accepted 12 September 2013 DOI: 10.1111/ecc.12144 European Journal of Cancer Care, 2014, 23, 523–530
© 2013 John Wiley & Sons Ltd
treatment side-effects. Commonly reported symptoms include fatigue, pain, generally not feeling well, drowsiness, sleep disturbances, anorexia, anxiety, depression, shortness of breath, nausea, vomiting, oral stomatitis and feelings of ‘pins and needles’ in the hands (Aslan 2003; Sadirli Kurt 2008; Kang et al. 2013). Furthermore, personal factors, disease characteristics and treatment modalities all affect patients’ symptom experience and response, functional status and quality of life (Jordhøy et al. 2001). Patients’ own ratings of symptoms and the perception of these symptoms by nurses or physicians influence medical decisions and nursing care (Nekolaichuk et al. 1999); however, during cancer treatment and rehabilitation, clinicians may fail to notice or may not anticipate some of the symptoms their patients find most disturbing. Thus, patients with cancer may not receive effective,
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systematic symptom management and sufficient support. As a result, poor outcomes may occur and the patients’ quality of life may deteriorate. Identification of the discrepancies between the patients’ and nurses’ perceptions of symptoms is important for planning appropriate interventions. Recent studies have investigated the discrepancies between the perceptions of patients, healthcare providers and significant others. These studies reported that the level of agreement was fair to good, but there were still discrepancies regarding symptoms and functioning between all three groups (Wennman-Larsen et al. 2007; Akin & Durna 2013). Indeed, the quality of life of patients with cancer and some subjective symptoms is generally overestimated by healthcare providers and significant others (Sneeuw et al. 2002). Studies report that the agreement was poorest for subjective symptoms such as pain, loss of well-being, anxiety, depression and drowsiness (McPherson & Addington-Hall 2003; Akin & Durna 2013). A study conducted in intensive care units (ICUs) found that patients experienced thirst, tiredness, discomfort, anxiety, hunger, dyspnoea, pain, depression and nausea in moderate to significant levels during ventilation (Li & Puntillo 2006). Similarly, a study conducted on critically ill patients with cancer treated in ICUs reported very distressing physical and psychological disturbances (such as pain, discomfort, anxiety, unsatisfied hunger or thirst, sleep, or communication problems) associated with ICU treatment and procedures (Nelson et al. 2001). These studies found that there were discrepancies between the ratings of symptoms by patients and nurses. While some systematic reviews and studies showed that the symptoms reported by patients with cancer were underestimated by clinicians, others found that the patients’ symptoms were overestimated by clinicians (Garyali et al. 2006; McPherson et al. 2008; Aydın & Es¸er 2010; Gilbertson-White et al. 2011; Puntillo et al. 2012; Xiao et al. 2012; Akin & Durna 2013). Another study found that ICU nurses tended to overestimate symptom intensity and distress (Puntillo et al. 2012). A comprehensive and reliable symptom assessment in palliative patients with cancer is crucial for effective symptom management. Assessment of subjective symptoms is a challenging task, especially in ICUs. In order to obtain valid and reliable information about the patients’ perceptions and discomfort, researchers should gather proxy assessments of patients’ experiences. For this reason, the number of studies investigating the reliability of proxy ratings has increased. Reliable proxy assessment results will enhance multidisciplinary care and contribute to better health outcomes of patients with cancer treated in ICUs. 524
The effective management of symptoms and improved functional status will enhance the quality of life of patients with cancer (Barg & Heard 1998; Akyol 2004), and better management and functional status can be enhanced by better symptom assessment. Such assessments should be comprehensive, systematic and continuous, and collaboration between patients and healthcare providers is essential to their effective outcome. Data about the agreement between patient and healthcare team perceptions will support the development of valid and reliable tools for use in specialised units.
Study aims The purpose of this study was to compare the symptoms reported by patients with cancer during mechanical ventilation in an ICU after palliative surgery with the primary nurses’ perception of the patients’ symptoms and to describe symptom perception in relation to personal, disease-or treatment related characteristics of patients and nurses reports. The research questions were as follows: 1 What are the symptoms experienced by patients with cancer who received mechanical ventilation in the ICU after palliative surgery? 2 Are there differences between the patient report and the perception of nurses of symptoms? 3 What personal, disease or treatment characteristics are associated with a patient’s report of symptoms?
METHODS Study design This is a descriptive/correlational study. The research was conducted in the 16-bedded ICU of a private hospital in Istanbul.
Study participants The participants of this study comprised patients with cancer and the nurses who were responsible for these patients. The patients with cancer had received mechanical ventilation in the ICU following palliative surgery. The inclusion criteria for the patients were (1) a diagnosis of cancer; (2) a major palliative surgical intervention; (3) mechanical ventilation between hours 1 and 12 post-surgery in the ICU; (4) consciousness following extubation; (5) agreement to participate in the research; (6) the ability to complete an interview; and (7) not under © 2013 John Wiley & Sons Ltd
Comparison of patients’ symptoms with nurses’ perceptions
the effect of sedatives or opioids at the time of the interview. The number of patients treated in the ICU in the study timeframe was 76. Sixteen patients were excluded: six underwent mechanical ventilation longer than hour 12 post-surgery and took sedatives in the ICU, and 10 patients were not intubated. Thus, a total of 60 patients met the inclusion criteria. There were 16 nurses working in the ICU, all of which were approached for recruitment; eight nurses who were not directly involved with patient care, on their annual leave, unwilling to participate, or treating patients that did not meet study criteria were excluded from the study. Thus, eight nurses were included as participants.
Data collection The Institutional Review Board at the hospital where this study was conducted approved this study. Furthermore, permission to use the measurement scale was obtained from the researcher who tested the validity and reliability of the Turkish version of the scale. The participants were informed about the purpose of the research, guaranteed confidentiality, and gave their verbal informed consent. Data about patient characteristics and symptoms following palliative interventions were collected. The severity of patients’ symptoms was rated using a structured interview known as the Edmonton Symptom Assessment Scale (ESAS). The interview was conducted within 24 h of extubation and regaining consciousness in each patient’s room in a closed ICU. The primary nurse in charge of each patient’s care was interviewed in an office at the ICU to exclude patient influence. The ESAS was also used for the nurse interview.
Measurement instruments The interviews were conducted by the researcher (CKG). Patient demographics and medical history were collected using the Patient Information Form, which includes personal characteristics (age, gender, education level, marital status) and the illness-related characteristics (history of chronic illness, cancer treatment and duration of mechanical ventilation). The information about the cancer stage was collected from the patients’ medical files. The ESAS, used in the structured interview with both patients and nurses, was developed by Bruera et al. (1991) to evaluate the symptoms commonly experienced by patients with cancer. The symptoms on the scale are pain, tiredness, nausea, depression, anxiety, drowsiness, © 2013 John Wiley & Sons Ltd
changes in appetite and well-being, and shortness of breath. In the ‘other problems’ section, the researchers may include additional symptoms; in this study, oral stomatitis, thirst and discomfort due to catheters or probes were added. The severity of each symptom is rated on a scale of 0 (no or best possible) to 10 (worst possible) with larger values representing greater symptom distress (Nekolaichuk et al. 1999). The ESAS is valid and reliable tool for measuring the symptom severity of palliative patients with cancer (Bruera et al. 1991; Richardson & Jones 2009). The ESAS was adapted for use in Turkish populations, and the validity and reliability for this version have been empirically established (Sadirli Kurt 2008; Usta Yes¸ilbalkan et al. 2008). In the current study, Cronbach’s alpha coefficient was 0.87 for the patient group and 0.86 for the nurse group.
Statistical analysis The data were analysed using SPSS, version 11.0 (SPSS Inc., Chicago, IL, USA). The descriptive statistics were reported as means, standard deviations, minimums, maximums and percentages. Mean scale scores were compared with personal and disease-related characteristics using Kruskal–Wallis test and Mann–Whitney U-tests. The mean scores of the patient reports and the perceptions of the nurses were compared with the Wilcoxon signed-rank test. Furthermore, one-sample t-tests were conducted.
RESULTS Characteristics of patients and nurses More than one half of the patients (60%) were male; the mean age was 62.28 years [SD = 15.02; range = 27–86; 95% confidence interval (CI) [58.40, 66.16]]. The patients were being treated for pancreatic cancer (16.7%), colon cancer (13.3%), and gastric cancers (13.3%) (Table 1). Some patients reported a previous history of hospitalisation (46.7%, n = 28). A large number of the group (83%) had a history of readmission to the ICU: 83% for bleeding, 46.7% for pain, 41.7% for hypotension and 33.4% for respiratory distress. The mean time in the ICU was 42.77 h (SD = 27.05; range = 15–144; 95% CI [35.78, 49.75]) and the length of the ventilation support was 4.58 h (SD = 3.76; range = 1–12; 95% CI [3.61, 5.55]). The mean time of the patient interview following extubation was 2.73 h (SD = 2.72; range = 1–20; 95% CI [2.03, 3.44]; Table 1). The observed types of palliative surgical procedures were pancreatic duct or biliary stent placement to alleviate obstruction (16.7%, n = 10), palliative resection of 525
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Table 1. Patient characteristics (n = 60) n Age, years (mean ± SD) 60 years old or younger Over the age of 60 Marital status Not married Married Presence of another chronic disease* Diabetes mellitus Hypertension, chronic heart failure Chronic obstructive lung disease (COPD) None Diagnosis of the disease Pancreatic cancers Colon cancers Gastric cancer Liver cancers Lung cancers Other (rectum cancer, brain cancer, breast cancer etc.) Stage of cancer Stage I Stage II Stage III Stage IV History of chemotherapy Yes No Reason for current admission to intensive care unit* Bleeding Pain Hypotension Respiratory distress Types of palliative surgery Palliative pancreatic duct or biliary stent placement to alleviate obstruction Palliative resection of advanced stomach and colon cancer Palliative resection in liver cancers Surgical palliation of airway obstruction Nerve block procedure Palliative resection of rectal cancer Palliative craniotomy A stent placement to alleviate biliary obstruction Other palliative interventions
%
62.28 ± 15.02 (range: 27–86) 25 41.7 35 58.3 20 40
33.4 66.7
14 34 3 25
23.3 56.6 5.0 41.6
10 8 8 7 6 21
16.7 13.3 13.3 11.7 10.0 36.1
2 25 24 9
3.3 41.7 40.0 15.0
16 44
26.7 73.3
54 28 25 20
83.0 46.7 41.7 33.4
10
16.7
8
13.3
7 6 4 4 4 1
11.7 10 6.7 6.7 6.7 1.7
16
26.6
*Marked more than once.
advanced stomach and colon cancer (13.3%, n = 8), palliative resection in liver cancers (11.7%, n = 7) and surgical palliation of airway obstruction (10%, n = 6; Table 1). Nurses were predominantly female (75%) and single (75%). Most were university graduates with bachelor’s degrees (62.5%, n = 5), two were nursing high school graduates (25%, n = 2), and one had a master’s degree (12.5%). The nurses had 3 years (n = 3), 4 years (n = 3) or 6 526
years (n = 2) of experience in the ICU. Nurses worked a mix of night and day shifts when caring for the patients.
Comparison of patient and nurse reports of symptoms The symptoms most severely felt by the patients during intensive care treatment were not feeling well (M = 6.40), anxiety (M = 6.30), discomfort due to probes or catheters (M = 6.22), and pain (M = 6.13). The least severe symptoms reported by the patients were, in order, oral stomatitis (M = 1.30), nausea (M = 2.82) and changes in appetite (M = 2.97). The mean (SD) score of ESAS rated by the patients was 55.17 (SD = 26.16; range = 10–112; Table 2). The nurses reported that the patients mostly suffered from the problems of not feeling well (M = 6.50), discomfort due to probes or catheters (M = 6.28), anxiety (M = 6.23) and tiredness (M = 5.82). Nurses rated oral stomatitis (M = 1.40), changes in appetite (M = 2.85) and nausea (M = 3.05) as the least severe symptoms experienced by their patients. The mean score of ESAS rated by the nurses was 55.48 (SD = 27.13; range = 7–20; Table 2). There was no statistically significant difference between the patients’ report and nurses’ perceptions of symptoms (P > 0.05), except for the symptom of pain. The nurses reported the patients’ pain as less severe than what the patients themselves reported (Z = −2.311; P = 0.021; Table 2).
Variables related to patients’ report of symptoms Comparison of the symptom perceptions in terms of personal characteristics No differences were found between the patients’ reports and the nurses’ perceptions of symptoms by patient gender (P > 0.05). Female patients reported less severe nausea than nurses reported (P = 0.020). No statistically significant difference was found between the male patients’ report and the nurses’ perceptions about male patients’ symptoms (P > 0.05; Table 3). Statistically significant differences were found between the patient report and nurses’ perceptions of symptoms by patient age in relation to the symptoms of depression, anxiety and not feeling well (P < 0.05). The younger patient group (60 or younger) reported a higher level of sadness and anxiety and lower level of well-being than their nurses. Patients over the age of 60 reported less nausea (P = 0.034) than the nurses perceived (Table 3). Patients with an additional chronic disease reported more severe pain than nurses’ perceived (P = 0.035; Table 4). © 2013 John Wiley & Sons Ltd
Comparison of patients’ symptoms with nurses’ perceptions
Table 2. Comparison of patients’ and the nurses’ means of Edmonton Symptom Assessment Scale (ESAS) (n = 60) Assessment of patients symptoms and nurses’ perceptions about the patients’ symptoms ESAS Pain Tiredness Nausea Depression Anxiety Drowsiness Appetite Well-being Shortness of breath Oral stomatitis Feeling thirsty Discomfort due to catheters or probes
Patient ratings (n = 60) Mean ± SD
Nurse ratings (n = 60) Mean ± SD
6.13 ± 3.40 5.83 ± 3.47 2.82 ± 3.95 5.42 ± 3.50 6.30 ± 3.49 3.93 ± 3.35 2.97 ± 3.57 6.40 ± 2.69 3.22 ± 3.16 1.30 ± 2.71 4.63 ± 3.43 6.22 ± 3.64 55.17 ± 26.16 (range: 10–112)
5.77 ± 3.45 5.82 ± 3.60 3.05 ± 4.13 5.25 ± 3.71 6.23 ± 3.83 4.13 ± 3.58 2.85 ± 3.61 6.50 ± 2.89 3.27 ± 3.42 1.40 ± 2.82 4.93 ± 3.81 6.28 ± 3.79 55.48 ± 27.13 (range: 7–120)
z
P*
−2.311 −0.060 −0.852 −1.103 −0.160 −0.896 −0.506 −0.571 −0.403 −0.213 −1.622 −0.236
0.021 0.95 0.39 0.27 0.87 0.37 0.61 0.57 0.69 0.83 0.10 0.81 P > 0.05
*Wilcoxon signed-rank test.
No statistically significant differences were found between the patients’ reports and the nurses’ perception of symptoms by patient’s marital status (P > 0.05).
Symptom perception and disease- or treatment-related characteristics A statistically significant difference was found between the patients’ reports and the nurses’ perceptions of symptoms related to tiredness, nausea, depression, anxiety, drowsiness, changes in appetite, not feeling well, oral stomatitis and discomfort due to probes or catheters (P < 0.05) in terms of cancer stage. However, there were no significant differences between the patients’ reports and the nurses’ perceptions of the symptoms of pain, shortness of breath and feeling thirsty in relation to cancer stage (P > 0.05; Table 4). Patients with stage II cancer reported higher levels of nausea (P = 0.034) than perceived by nurses. Patients with stage III cancer reported higher levels of pain (P = 0.006) and depression (P = 0.033) than did the nurses (Table 3). No statistically significant differences were found between the reports of patients with stage I or IV cancer and the perceptions of the nurses (P > 0.05; Table 4). A statistically significant difference was found between the reports of patients with a history of chemotherapy and the perceptions of nurses of symptoms in pain, tiredness, depression, anxiety, drowsiness, changes in appetite, not feeling well, oral stomatitis and discomfort due to probes or catheters (P < 0.05). The patients with history of receiving chemotherapy experienced pain, tiredness, sadness, anxiety, anorexia and oral stomatitis more severely than nurses’ perceived. © 2013 John Wiley & Sons Ltd
A statistically significant difference was found between the reports of patients without a history of chemotherapy and the nurses’ perception of symptoms (P > 0.05). Patients without a history of chemotherapy reported higher levels of pain (P = 0.032) and less thirst (P = 0.033) than their nurses’ reported.
DISCUSSION The current study found there were few discrepancies between nurses’ perceptions and patients’ symptoms experienced during mechanical ventilation in the ICU, except for the symptom of pain. The fact that no statistically significant differences were found between patient reports and nurse perceptions of symptoms is important because it reveals that symptom assessment and control was well managed by the nurses in the ICU. This result adds to the body of literature supporting proxy assessments of symptoms in specialised care units. As mentioned previously, there was a discrepancy in patients’ reports and nurses’ perceptions of pain. The nurses believed patients’ pain to be less severe than what the patients themselves reported. This result is consistent with that of Aydın and Es¸er (2010), who also found that the nurses underestimated the pain of patients. In contrast, a study by Nainis et al. (2006) did not find any differences between patients’ reports and nurses’ perceptions about symptoms. Akin and Durna (2013) found that patients with cancer and nurses showed only poor to fair agreement on the symptom of pain. These findings suggest that ICU nurses underestimate their patients’ pain. Nevertheless, pain may be a particularly challenging symptom to assess and thus, it is important to have 527
528 0.09 0.42 0.034 0.29 0.80 0.56 0.67 0.66 0.19 1.00 0.80 0.29
6.48 ± 3.53 6.12 ± 3.71 2.68 ± 4.31 6.52 ± 3.70 7.60 ± 3.11 4.56 ± 3.96 3.36 ± 3.97 7.20 ± 3.01 3.68 ± 3.16 1.40 ± 2.72 4.52 ± 3.73 6.68 ± 3.86
5.57 ± 3.36 5.74 ± 3.48 3.57 ± 4.27 4.40 ± 3.47 5.34 ± 3.96 3.66 ± 3.12 2.74 ± 3.48 5.94 ± 2.58 3.14 ± 3.60 1.43 ± 3.00 4.77 ± 3.58 5.71 ± 3.75
5.89 ± 3.34 5.63 ± 3.32 2.91 ± 3.73 4.63 ± 3.16 5.37 ± 3.48 3.49 ± 2.82 2.69 ± 3.29 5.83 ± 2.31 2.89 ± 3.17 1.23 ± 2.73 4.71 ± 3.26 5.89 ± 3.50
6.04 ± 3.61 5.92 ± 3.83 2.32 ± 3.89 6.44 ± 3.77 7.48 ± 3.33 4.80 ± 4.12 3.00 ± 3.85 7.28 ± 3.16 3.44 ± 3.23 1.36 ± 2.60 5.16 ± 4.18 7.08 ± 3.76
Nurse Mean ± SD
Patient Mean ± SD
Nurse Mean ± SD
Patient Mean ± SD P*
Assessments
Assessments
0.10 0.37 0.20 0.68 0.43 0.48 0.21 0.71 0.56 0.71 0.07 0.11
P* 0.42 0.48 0.72 0.029 0.010 0.42 0.67 0.031 0.28 0.86 0.79 0.31
P† 5.96 ± 3.36 5.63 ± 3.76 3.42 ± 4.39 5.58 ± 3.40 6.46 ± 3.51 3.58 ± 3.40 3.46 ± 3.71 6.17 ± 2.63 1.67 ± 3.36 2.63 ± 3.20 4.33 ± 3.25 5.88 ± 3.81
Patient Mean ± SD
Assessments
5.46 ± 3.51 5.67 ± 3.89 4.25 ± 4.84 5.13 ± 3.85 6.00 ± 4.20 3.58 ± 3.36 3.13 ± 3.83 6.08 ± 3.09 1.83 ± 3.50 2.63 ± 3.46 4.71 ± 3.65 5.58 ± 4.12
Nurse Mean ± SD
Female patients (n = 24)
0.08 0.75 0.02 0.16 0.33 0.95 0.35 0.82 0.70 1.00 0.23 0.30
6.25 ± 3.48 5.97 ± 3.30 2.42 ± 3.63 5.31 ± 3.60 6.19 ± 3.51 4.17 ± 3.35 2.64 ± 3.49 6.56 ± 2.75 1.06 ± 2.19 3.61 ± 3.12 4.83 ± 3.58 6.44 ± 3.56
Patient Mean ± SD
Assessments
0.32 0.32 0.32 1.00 0.32 0.32 0.32 1.00 0.18 1.00 1.00 1.00
5.16 ± 3.66 3.76 ± 3.18 1.72 ± 2.91 3.72 ± 3.21 4.60 ± 3.62 2.24 ± 2.77 1.12 ± 1.83 5.24 ± 2.77 2.48 ± 3.10 0.40 ± 2.00 3.88 ± 3.35 5.12 ± 3.56
9.00 ± 1.41 8.00 ± 2.83 8.00 ± 2.83 8.00 ± 2.83 10.00 ± 0.00 6.50 ± 4.95 5.50 ± 3.54 10.00 ± 0.00 2.00 ± 0.00 00.00 ± 0.00 5.00 ± 7.07 10.00 ± 0.00
10.00 ± 0.00 9.00 ± 1.41 10.00 ± 0.00 8.00 ± 2.83 9.00 ± 1.41 6.00 ± 5.66 6.50 ± 2.12 10.00 ± 0.00 5.50 ± 0.71 0.00 ± 0.00 5.00 ± 7.07 10.00 ± 0.00
P*
Patient Mean ± SD
Patient Mean ± SD 5.00 ± 3.52 3.92 ± 3.44 2.44 ± 3.68 3.84 ± 3.60 4.12 ± 3.91 2.60 ± 3.16 0.80 ± 1.50 5.12 ± 2.98 2.88 ± 3.46 0.40 ± 2.00 4.36 ± 3.56 5.08 ± 3.82
Nurse Mean ± SD 0.64 0.33 0.034 0.81 0.18 0.17 0.28 0.75 0.10 1.00 0.10 0.71
P* 6.25 ± 2.94 6.58 ± 3.11 2.71 ± 4.11 6.38 ± 3.21 6.92 ± 3.05 4.42 ± 3.30 3.42 ± 4.00 6.79 ± 2.36 3.29 ± 2.93 1.04 ± 2.26 4.96 ± 3.51 6.33 ± 3.62
Patient Mean ± SD
Assessments
5.58 ± 3.26 6.46 ± 3.27 2.54 ± 4.03 5.88 ± 3.53 7.21 ± 3.30 4.58 ± 3.75 3.50 ± 4.08 6.96 ± 2.54 3.38 ± 3.20 1.38 ± 2.81 5.42 ± 3.83 6.63 ± 3.69
Nurse Mean ± SD
Stage of cancer stage III
*Wilcoxon signed-rank test: The comparison of nurses’ scores with patients’ scores. †Kruskal–Wallis test: The comparison of nurses scores and patients’ scores in relation to patient’s characteristics.
Pain Tiredness Nausea Depression Anxiety Drowsiness Appetite Well-being Shortness of breath Oral stomatitis Feeling thirsty Discomfort due to catheters or probes
ESAS
Assessments
Nurse Mean ± SD
Assessments
Stage of cancer stage II
Stage of cancer stage I
0.006 0.58 0.16 0.033 0.29 0.76 0.67 0.55 0.49 0.65 0.10 0.34
P*
7.67 ± 3.32 8.89 ± 1.45 4.56 ± 4.56 7.00 ± 3.50 8.78 ± 2.11 6.89 ± 2.03 6.11 ± 3.44 7.78 ± 2.05 4.56 ± 3.91 4.78 ± 3.27 5.78 ± 2.86 8.11 ± 3.26
Patient Mean ± SD
Assessments
7.67 ± 3.32 8.89 ± 2.03 5.00 ± 5.00 6.89 ± 3.66 8.67 ± 2.00 6.67 ± 2.12 6.22 ± 3.35 8.33 ± 1.66 4.33 ± 4.36 4.56 ± 3.00 5.22 ± 4.35 7.89 ± 3.41
Nurse Mean ± SD
Stage of cancer stage IV
1.00 1.00 0.58 1.00 0.65 0.48 0.65 0.18 0.56 0.52 0.39 0.32
P*
0.05 0.001 0.034 0.009 0.007 0.001 0.001 0.013 0.19 0.001 0.44 0.048
P†
P* 0.12 0.74 0.52 0.86 0.40 0.24 0.86 0.31 0.85 0.63 0.30 0.20
5.94 ± 3.53 5.77 ± 3.40 3.20 ± 3.94 5.11 ± 3.35 5.91 ± 3.64 3.74 ± 3.28 2.89 ± 3.60 5.97 ± 2.53 0.94 ± 2.27 3.23 ± 3.21 5.00 ± 3.48 5.60 ± 3.75
Patient Mean ± SD
Assessments
5.51 ± 3.51 5.83 ± 3.60 3.37 ± 4.07 4.77 ± 3.61 5.94 ± 3.99 3.94 ± 3.53 2.83 ± 3.62 6.03 ± 2.82 1.31 ± 2.73 3.40 ± 3.48 5.29 ± 3.78 5.57 ± 4.05
Nurse Mean ± SD
Patients with additional chronic disease (n = 35)
5.97 ± 3.43 5.92 ± 3.45 2.25 ± 3.42 5.33 ± 3.66 6.39 ± 3.61 4.50 ± 3.72 2.67 ± 3.51 6.78 ± 2.75 1.11 ± 2.26 3.69 ± 3.38 5.08 ± 3.96 6.75 ± 3.53
Nurse Mean ± SD
Male patients (n = 36)
Table 4. Comparison of patients’ and the nurses’ means of Edmonton Symptom Assessment Scale (ESAS) in relation to the stage of cancer (n = 60)
*Wilcoxon signed-rank test: The comparison of nurses’ scores with patients’ scores. †Mann–Whitney U-test: The comparison of nurses scores and patients’ scores in relation to patient’s characteristics.
Pain Tiredness Nausea Depression Anxiety Drowsiness Appetite Well-being Shortness of breath Oral stomatitis Feeling thirsty Discomfort due to catheters or probes
ESAS
60 years old or younger (n = 25)
Over the age of 60 (n = 35)
Table 3. Comparison of patients’ and nurses’ means of Edmonton Symptom Assessment Scale (ESAS) in relation to patient’s age group and gender (n = 60)
P†
0.035 0.71 0.52 0.13 0.95 0.44 0.89 0.72 0.27 0.43 0.22 0.69
P*
0.71 0.82 0.43 0.80 0.71 0.48 0.34 0.50 0.65 0.17 0.65 0.57
GUNER ET AL.
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Comparison of patients’ symptoms with nurses’ perceptions
systematic and regular assessments and adopt strategies to improve pain assessment (e.g. effective and reliable methods of assessment, communication). Patients with cancer experience a multitude of physical (Graydon et al. 1995; Akdemir 2003; Fadiloglu 2003; Fillion et al. 2003; Stein et al. 2003) and psychological symptoms (e.g. anger, nervousness, loss of hope for the future and difficulty in concentrating; Ferrell et al. 1996; Akdemir 2003; Fadiloglu 2003; Stein et al. 2003). In this study, the patients reported symptoms of not feeling well, anxiety, discomfort due to probes or catheters, and pain control during the period they remained connected to the ventilator after undergoing palliative surgery. Consistent with other studies, the current study found that the most severe symptoms reported by patients with cancer during intensive care treatment were not feeling well, anxiety, discomfort due to probes or catheters, and pain, in that order. Genç (2005) stated that elderly patients experienced more symptoms than younger patients; in contrast, Aslan (2003) reported that there was no significant difference between the patients’ age and the patients’ symptom experience. In the current study, the younger patient group (60 years old or younger) reported a higher level of sadness and anxiety and a lower level of well-being than that perceived by nurses, and the older patients experienced a lower level of nausea than that perceived by nurses. Following major palliative surgery, patients need to be assessed in terms of both physical and emotional symptoms. The current study result showed that younger patients are more likely to suffer from psychological symptoms and thus need emotional support. The symptoms assessed in this study can have an adverse effect on the quality of life of patients and could decrease adherence to treatment (Stein et al. 2003). Disease-related factors (e.g. diagnosis, stage of cancer) may also impact the patients’ well-being and cause symptom-related distress (Akin & Durna 2013). A difference was found in the patient report and the perceptions of the nurses of symptoms by cancer stage. This result
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suggests that the stage of cancer might be associated with symptoms. The primary aim of cancer treatment is to successfully manage symptom distress and improve the quality of life for patients. However, some side-effects of cancer treatment can be overlooked or inadequately treated due to the time constraints, lack of knowledge or skills, and poor communication between healthcare providers and patients (Youngblood et al. 1994). These important symptoms observed in patients can be alleviated through consistent and reliable assessments and treatment (Fortner et al. 2003). Conclusion The results showed that there were no discrepancies between nurses’ and patients’ reports of symptoms experienced during mechanical ventilation in the ICU, except in the assessment of pain, using the ESAS. The intensive care nurses reported that the patients felt the pain less severely compared with the perceptions of the patients about this symptom. Our results also underline the fact that patients in an ICU need support in managing symptoms such as not feeling well, anxiety, discomfort due to probes or catheters, and pain during mechanical ventilation. Female patients, those under the age of 60, those with a history of chronic illness, or those in the advanced stages of cancer need to be more closely assessed and supported for the management of nausea, sadness, anxiety, pain, tiredness and oral stomatitis. Study limitations The study sample comprised only 60 patients with cancer and eight nurses. Thus, the results can be generalised only to ICU patients who met inclusion criteria of current study. Patients who underwent palliative support procedures (minor palliative procedure) such as intubation procedures, vascular access procedures and biopsy procedure were not included in to study.
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