Scand J Caring Sci Vol. 6, No. 3 1992
Relaxation Training as an Integral Part of Caring Activities for Cancer Patients: Effects on Wellbeing Gerry Larsson and Bengt Starrin
ABSTRACT. The purposes of this study were twofold. The first was to investigate if relaxation training conducted by nurses as an integral part of their caring activities affected breast cancer patients’ experiences of radiotherapy sessions as well as their general wellbeing. Second was to evaluate a pedagogical model for large scale application of relaxation training as an integral part of caring. The sample consisted of 64 consecutive outpatients with breast cancer at a Swedish oncology clinic, receiving their first radiotherapy treatment course following surgery. Every second patient was assigned to an experimental group ( n = 32, mean age: 59.5 years) and every other second patient was assigned to a control group (n = 32, mean age: 60.0 years). The programme resulted in the following general effects: fewer perceived daily hassles and a more cheeful overall mood state. The following treatment situation specific effects were noted: programme participants appraised the treatment sessions as successively more benign-positive and less threatening. They also reported more perceived muscular tensions during treatment sessions. Most goals concerning the routinization of the pedagogical model were reached. Key words: Cancer, caring, nurses, relaxation training, wellbeing.
INTRODUCTION Cancer constitutes a major source of stress which often results in mood disturbances (Maguire 1981). According to the model of stress and coping developed by Lazarus and his colleagues (Lazarus & Folkman 1984), psychological wellbeing in mentally stressful situations depends on how the individual cognitively appraises and copes with the situation. If the situation is appraised as benign-positive and challenging rather than as threatening, and if cognitive coping processes of a positive-thinking character are used rather than negative processes, e.g., self-blame, the individual is more likely to reduce anxiety and experience benign emotions-and vice versa. Finding ways to help cancer sufferers cope psychologically with the illness, as well as with side effects of chemotherapy and radiotherapy, is thus desirable. Relaxation training has been found to reduce psychological distress in a wide variety
of settings (Larsson 1987a, Lichstein 1988, Setterlind 1983). Relaxation training has been successful in oncology settings (Lichstein 1988). Systematic studies reporting advantageous results have usually used experts such as researchers or psychologists, who are not ordinarily involved in the treatment, as instructors of relaxation (Bridge et al. 1988, Radda Livet 1988). However, systematic studies including relaxation training as a nursing intervention are lacking (Sims 1987, Snyder 1984). High quality caring GERRY LARSSON, PhD and BENGT STARRIN, PhD. The Centre for Public Health Research, The County Council of Varmland, Sweden. Submitted for publication May 5, 1991, accepted November 19, 1991. Correspondence: G. Larsson, The Centre for Public Health Research, The County Council of Varmland, S-65182 Karlstad, Sweden. Scand J Caring Sci
180
G. Larsson, B. Starrin
for cancer patients could be assumed to have a benign effect on the patient’s stress level, and, following from this, on the patient’s ability to cope with the illness and its treatment. Traditionally, nurses are mainly responsible for the caring of the patients. The basic premise of the present study was to include relaxation training as an integral part of the nurses’ caring activities. No differentiation in the present study is made between different techniques of relaxation. Advocates of the different schools frequently claim unique (and remarkable) results. However, Setterlind (1983) found that different techniques lead to similar physiological and psychological (and less remarkable) results. No method seems to be universally superior, and choice of technique should ideally depend on the individual. In addition to the need for controlled studies using nurses as relaxation training instructors, Sims (1987) and Snyder (1984) also point to the need for studies using theory based assessment techniques and an explicit teaching model. Therefore, the aim of the present investigation was to determine whether relaxation training, conducted by nurses as an integral part of their caring activites, leads to: (a) breast cancer patients experiencing less distress during treatment sessions and (b) these patients experiencing a higher general wellbeing. A secondary aim was to evaluate a pedagogical model for large scale application of relaxation training as an integral part of caring.
METHOD Training of nurses Training of three voluntarily recruited nurses at the oncology clinic at Karlstad’s hospital, Sweden, was conducted by the principal author in November and December in 1987. The training consisted of four lessons ( 1 h per lesson) with intermediate periods of one week, during which relaxation was practiced individually. As a final step, each nurse selected one patient to whom they taught the relaxation technique under supervision by the principal author (who has psychotherapeutic training).
Training aids The nurses were given a popular report on stress and relaxation (Setterlind & Larsson
1983) including tape recorded relaxation training programs. Programs included progressive relaxation ( 15 min) and autogenic training (10 min). The same tape recorded programs were given to the patients.
Participants The sample consisted of 64 consecutive voluntary outpatients with breast cancer at the oncology clinic at the hosptial in Karlstad, Sweden, receiving their first radiotherapy treatment course following surgery. Every second patient was asked if she was willing to learn relaxation and answer questions regularly as part of a research project at the clinic (experimental group). Every other second patient was asked if she was willing to answer questions regularly as a control group member. Exclusion criteria for both groups were: (a) patients with documented psychiatric problems, (b) patients who did not understand Swedish, (c) patients with seriously impaired hearing, and (d) patients with seriously reduced cognitive capacity (patients who did not understand the information given about the study and/or who could not be expected to have the ability to follow the instructions in a relaxation exercise according to the judgement of the responsible nurse). Two patients did not want to participate and thus became drop-outs. The experimental group consisted of 32 patients, with a mean age of 59.5 years, ranging from 36 to 81 years, all patients but seven were 45-75 years old. The control group consisted of 32 patients, with a mean age of 61.0 years, ranging from 41 to 80 years, all patients but five were 45-75 years old. The majority of participants (81% in both groups) had basic school education, 19% had high school education or academic training. About 75% of the patients in both groups were married and about 45‘%)in both groups had an unfavourable medical prognosis.
Procedure The radiotherapy treatment course consists of 20 sessions spaced over a 25 days period. Two weeks before the first treatment session, all participants filled in a questionnaire designed to measure general stress level and mood state (see below). Participants in the experimental group were taught relaxation by a nurse on this occasion. The instruction took about 15 min Scand J Curing Sci
Relaxation training
18 1
and was given in a separate room at the clinic. words describing different emotions. Beside The patient received the cassette with tape each word are four response choices. Circle the recorded relaxation exercises and was encour- choice which best describes how you felt right aged to practice at least four times per week. then (during the radiation treatment session During the first radiotherapy sessions, the just completed). Respond with the alternative nurse discussed the relaxation training with the that first comes to your mind!” The response patients to confirm that they had mastered the scale was also described. One item in the ESRQ, indifferent, is designed technique. On the lst, loth, and 20th radiotherapy ses- to reflect the appraisal irrelevant. Three items, sion, all participants responded to a question- happy, relaxed, and satisfied, are designed to naire designed to measure treatment related correspond to the appraisal benign-positive. experiences (see below). After the 20th radio- Four items, bright, concentrated, sharp, and therapy session, all patients also filled in the vigorous, are designed to map challenge apquestionnaire dealing with general stress level praisals. Six items, angry, disappointed, heated, mad, uncertain, and worried, are designed to and mood state once again. reflect the appraisal harm-loss and/or threat. The items were randomly ordered on the answer Measures sheet. Scoring of the ESRQ consists of summing General psychological stress level was assessed with a short version of the Hassles and Uplifts raw scores on items representing each kind of Scale (Kanner et al. 1981) which is claimed to cognitive appraisal and dividing that total by be a valid measure of psychological stress the numbek of items in the category. The (Lazarus & Folkman 1984). Participants indi- ESRQ indices have reported reliability cocated the frequency of five hassles and five efficients ranging from 0.66 to 0.81 and validity uplifts during the previous month and the in- coefficients in performance situations ranging tensity of their reactions. The frequency score from 0.34 to 0.59 (Larsson 1987b). Treatment session specijic cognitive coping was could range from 5 (low frequency) to 20 (high frequency), and, similarly, the intensity score assessed with a 10-item questionnaire, develcould range from 5 (low intensity) to 20 (high oped for this study, adapted from the Self-Stateintensity). Overall mood state during the previ- ment Questionnaire (Larsson 1989). Each item ous month was assessed with the Faces Scale consisted of a self-statement. The responses (Andrews & Withey 1976). Scores could range were entered on a 3-point scale (1 = not used; from 1 (most sad) to 7 (most cheerful). 2 =u s e d somewhat; 3 =used quite a bit or a Treatment session specific appraisal was as- great deal). The instructions were: “Please read sessed with the Emotional Stress Reaction each item below and indicate, by circling the Questionnaire (ESRQ) developed by Larsson appropriate category, to what extent you used (1987b). Cognitive appraisal of meaning and it” (during the radiation treatment). significance is difficult to observe empirically Five items represented self-talk typical of because the person may be unaware of some or positive thinking (e.g., “Now we’re gonna beat all of the basic elements of an appraisal. How- this illness”) and five items represented self-talk ever, the appraisal process affects the quality typical of negative thinking (e.g., “Typical me and intensity of the emotional reaction in a not being able to handle this”). In terms of given situation. Thus, from a particular kind of stress and coping theory, the self-statements emotion, it may be possible to deduce the were regarded as emotion-focused coping particular kind of appraisal that produced it strategies. Indices of positive and negative (Lazarus & Folkman 1984). thinking were formed by adding the raw scores The raw data in the ESRQ consist of scores of the five items representing each strategy. indicating the emotions experienced in a given Scores could range from 5 to 15 on each of situation. The response format is a 4-point these two indices. Treatment session specijic experience of scale ranging from 0 (the word does not correspond to how you felt right then) to 3 (the tensed muscle groups was assessed with a checkword completely corresponds to how you felt list containing 16 muscle groups arranged in a top-down order; beginning with the forehead right then). The instructions were: “Below is a list of and ending with the feet and toes. Participants Scand J Caring Sci
182
G. Larsson, B. Starrin
were asked to check muscle groups they felt were tense during the radiotherapy session. Scores could range from 0 to 16. Collection of self-report data concerning relaxation training experiences occurred at the Ist, the loth, and the 20th radiotherapy session (participants in the experimental group only). Participants were asked to rate and compare their “ability to relax now with prior to training.” A 5-point scale ranging from “much worse” ( 1 ) to “much better” (5) was used. The nurses who had taught relaxation to patients were interviewed about their experiences at the end of the study. Comments were transcribed immediately thereafter, using brief notes made during the interviews.
RESULTS Relaxation training frequency and experiences The relaxation training program was carried out with a lower training frequency than planned. Basic relaxation training consisted of
3.3 sessions per week on the average (SD = 1.1) instead of the planned four. Most patients (28 out of 32) practiced relaxation at least two times per week; no patient practiced less than once a week. The following mean scores were obtained on the question where the experimental participants were asked to rate and compare their ability to relax now with prior to training ( a 5-point scale from much worse ( 1 ) to much better (5) : First radiotherapy session = 4.1 1, 10th radiotherapy sesion = 4.25, and 20th radiotherapy session = 4.45.
General psychological stress level and mood The pre- and post-relaxation training programme assessments of general psychological stress level and mood state are presented in Table I. Perusal of Table I shows that the control group had comparable scores on all scales on the pre- and post-programme assessments. In the experimental group, significant differences
Table I. General psychological stress level and mood state Pre-programme assessment
Post-programme assessment ~~~~
Variable __
M
SD
M
SD
1.17
17.38
2.81
1.13
1.12
12.42
1.64
1.07
2.78
1 1.29
3.01
2.28*
2.20 1.33
8.08 5.29
1.95 0.86
2.31* 2.56**
8.00
1.41
17.04
3.35
1.28
2.81
1.40
12.35
2.51
0.52
1.25
3.08
12.04
3.92
0.57
8.94 4.34
2.11 1.77
8.58 4.74
2.80 1.83
0.90 1.02
~~~
.-
Experimental group (n = 32) Daily upliftsfrequency 8.35 Daily uplifts2.87 intensity Daily hassles2.71 frequency Daily hasslesintensity 9.68 Mood 4.3 1 Control group (n = 32) Daily upliftsfrequency Daily upliftsintensity Daily hasslesfrequency Daily hasslesintensity Mood
“Wilcoxon matched-pairs signed-ranks test. * p < 0.05. **p < 0.01. Scand J Caring Sci
183
Relaxation training
of means (in a favourable direction from a stress and health perspective) were noted on the two hassles scales and on the general mood state scale. Comparisons (Mann-Whitney U-tests) between the experimental and control groups gave the following results. On the pre-programme measurement, the experimental group reported a significantly higher mean score on the daily hassles-frequency scale ( z = 2.26, p < 0.05). No significant differences of means were noted on the post-programme measurement.
two scales within the experimental group with Scheffk tests; the most conservative test with respect for Type I errors. On the benign-positive appraisal scale a signficant difference of means (0.05 level) was noted between the 1st and the 10th sessions. Comparisons ( Mann-Whitney U-tests) between the two groups yielded the following significant differences of means. On all three radiotherapy sessions, the control group reported significantly fewer tensed muscle groups (1st session: z = 2.91, p < 0.05; 10th session: z = 3.53, p < 0.01; 20th session: z = 2.17, p < 0.05). On the 20th radiotherapy session, the Treatment speclfic appraisal and experimental group showed significantly higher cognitive coping scores on benign-positive appraisal ( z = 2.19, Scores on the treatment specific appraisal and p < 0.05) and challenge appraisal ( z = 1.98, cognitive coping scales are shown in Table 11. p
Relaxation Training as an Integral Part of Caring Activities for Cancer Patients: Effects on Wellbeing Gerry Larsson and Bengt Starrin
ABSTRACT. The purposes of this study were twofold. The first was to investigate if relaxation training conducted by nurses as an integral part of their caring activities affected breast cancer patients’ experiences of radiotherapy sessions as well as their general wellbeing. Second was to evaluate a pedagogical model for large scale application of relaxation training as an integral part of caring. The sample consisted of 64 consecutive outpatients with breast cancer at a Swedish oncology clinic, receiving their first radiotherapy treatment course following surgery. Every second patient was assigned to an experimental group ( n = 32, mean age: 59.5 years) and every other second patient was assigned to a control group (n = 32, mean age: 60.0 years). The programme resulted in the following general effects: fewer perceived daily hassles and a more cheeful overall mood state. The following treatment situation specific effects were noted: programme participants appraised the treatment sessions as successively more benign-positive and less threatening. They also reported more perceived muscular tensions during treatment sessions. Most goals concerning the routinization of the pedagogical model were reached. Key words: Cancer, caring, nurses, relaxation training, wellbeing.
INTRODUCTION Cancer constitutes a major source of stress which often results in mood disturbances (Maguire 1981). According to the model of stress and coping developed by Lazarus and his colleagues (Lazarus & Folkman 1984), psychological wellbeing in mentally stressful situations depends on how the individual cognitively appraises and copes with the situation. If the situation is appraised as benign-positive and challenging rather than as threatening, and if cognitive coping processes of a positive-thinking character are used rather than negative processes, e.g., self-blame, the individual is more likely to reduce anxiety and experience benign emotions-and vice versa. Finding ways to help cancer sufferers cope psychologically with the illness, as well as with side effects of chemotherapy and radiotherapy, is thus desirable. Relaxation training has been found to reduce psychological distress in a wide variety
of settings (Larsson 1987a, Lichstein 1988, Setterlind 1983). Relaxation training has been successful in oncology settings (Lichstein 1988). Systematic studies reporting advantageous results have usually used experts such as researchers or psychologists, who are not ordinarily involved in the treatment, as instructors of relaxation (Bridge et al. 1988, Radda Livet 1988). However, systematic studies including relaxation training as a nursing intervention are lacking (Sims 1987, Snyder 1984). High quality caring GERRY LARSSON, PhD and BENGT STARRIN, PhD. The Centre for Public Health Research, The County Council of Varmland, Sweden. Submitted for publication May 5, 1991, accepted November 19, 1991. Correspondence: G. Larsson, The Centre for Public Health Research, The County Council of Varmland, S-65182 Karlstad, Sweden. Scand J Caring Sci
180
G. Larsson, B. Starrin
for cancer patients could be assumed to have a benign effect on the patient’s stress level, and, following from this, on the patient’s ability to cope with the illness and its treatment. Traditionally, nurses are mainly responsible for the caring of the patients. The basic premise of the present study was to include relaxation training as an integral part of the nurses’ caring activities. No differentiation in the present study is made between different techniques of relaxation. Advocates of the different schools frequently claim unique (and remarkable) results. However, Setterlind (1983) found that different techniques lead to similar physiological and psychological (and less remarkable) results. No method seems to be universally superior, and choice of technique should ideally depend on the individual. In addition to the need for controlled studies using nurses as relaxation training instructors, Sims (1987) and Snyder (1984) also point to the need for studies using theory based assessment techniques and an explicit teaching model. Therefore, the aim of the present investigation was to determine whether relaxation training, conducted by nurses as an integral part of their caring activites, leads to: (a) breast cancer patients experiencing less distress during treatment sessions and (b) these patients experiencing a higher general wellbeing. A secondary aim was to evaluate a pedagogical model for large scale application of relaxation training as an integral part of caring.
METHOD Training of nurses Training of three voluntarily recruited nurses at the oncology clinic at Karlstad’s hospital, Sweden, was conducted by the principal author in November and December in 1987. The training consisted of four lessons ( 1 h per lesson) with intermediate periods of one week, during which relaxation was practiced individually. As a final step, each nurse selected one patient to whom they taught the relaxation technique under supervision by the principal author (who has psychotherapeutic training).
Training aids The nurses were given a popular report on stress and relaxation (Setterlind & Larsson
1983) including tape recorded relaxation training programs. Programs included progressive relaxation ( 15 min) and autogenic training (10 min). The same tape recorded programs were given to the patients.
Participants The sample consisted of 64 consecutive voluntary outpatients with breast cancer at the oncology clinic at the hosptial in Karlstad, Sweden, receiving their first radiotherapy treatment course following surgery. Every second patient was asked if she was willing to learn relaxation and answer questions regularly as part of a research project at the clinic (experimental group). Every other second patient was asked if she was willing to answer questions regularly as a control group member. Exclusion criteria for both groups were: (a) patients with documented psychiatric problems, (b) patients who did not understand Swedish, (c) patients with seriously impaired hearing, and (d) patients with seriously reduced cognitive capacity (patients who did not understand the information given about the study and/or who could not be expected to have the ability to follow the instructions in a relaxation exercise according to the judgement of the responsible nurse). Two patients did not want to participate and thus became drop-outs. The experimental group consisted of 32 patients, with a mean age of 59.5 years, ranging from 36 to 81 years, all patients but seven were 45-75 years old. The control group consisted of 32 patients, with a mean age of 61.0 years, ranging from 41 to 80 years, all patients but five were 45-75 years old. The majority of participants (81% in both groups) had basic school education, 19% had high school education or academic training. About 75% of the patients in both groups were married and about 45‘%)in both groups had an unfavourable medical prognosis.
Procedure The radiotherapy treatment course consists of 20 sessions spaced over a 25 days period. Two weeks before the first treatment session, all participants filled in a questionnaire designed to measure general stress level and mood state (see below). Participants in the experimental group were taught relaxation by a nurse on this occasion. The instruction took about 15 min Scand J Curing Sci
Relaxation training
18 1
and was given in a separate room at the clinic. words describing different emotions. Beside The patient received the cassette with tape each word are four response choices. Circle the recorded relaxation exercises and was encour- choice which best describes how you felt right aged to practice at least four times per week. then (during the radiation treatment session During the first radiotherapy sessions, the just completed). Respond with the alternative nurse discussed the relaxation training with the that first comes to your mind!” The response patients to confirm that they had mastered the scale was also described. One item in the ESRQ, indifferent, is designed technique. On the lst, loth, and 20th radiotherapy ses- to reflect the appraisal irrelevant. Three items, sion, all participants responded to a question- happy, relaxed, and satisfied, are designed to naire designed to measure treatment related correspond to the appraisal benign-positive. experiences (see below). After the 20th radio- Four items, bright, concentrated, sharp, and therapy session, all patients also filled in the vigorous, are designed to map challenge apquestionnaire dealing with general stress level praisals. Six items, angry, disappointed, heated, mad, uncertain, and worried, are designed to and mood state once again. reflect the appraisal harm-loss and/or threat. The items were randomly ordered on the answer Measures sheet. Scoring of the ESRQ consists of summing General psychological stress level was assessed with a short version of the Hassles and Uplifts raw scores on items representing each kind of Scale (Kanner et al. 1981) which is claimed to cognitive appraisal and dividing that total by be a valid measure of psychological stress the numbek of items in the category. The (Lazarus & Folkman 1984). Participants indi- ESRQ indices have reported reliability cocated the frequency of five hassles and five efficients ranging from 0.66 to 0.81 and validity uplifts during the previous month and the in- coefficients in performance situations ranging tensity of their reactions. The frequency score from 0.34 to 0.59 (Larsson 1987b). Treatment session specijic cognitive coping was could range from 5 (low frequency) to 20 (high frequency), and, similarly, the intensity score assessed with a 10-item questionnaire, develcould range from 5 (low intensity) to 20 (high oped for this study, adapted from the Self-Stateintensity). Overall mood state during the previ- ment Questionnaire (Larsson 1989). Each item ous month was assessed with the Faces Scale consisted of a self-statement. The responses (Andrews & Withey 1976). Scores could range were entered on a 3-point scale (1 = not used; from 1 (most sad) to 7 (most cheerful). 2 =u s e d somewhat; 3 =used quite a bit or a Treatment session specific appraisal was as- great deal). The instructions were: “Please read sessed with the Emotional Stress Reaction each item below and indicate, by circling the Questionnaire (ESRQ) developed by Larsson appropriate category, to what extent you used (1987b). Cognitive appraisal of meaning and it” (during the radiation treatment). significance is difficult to observe empirically Five items represented self-talk typical of because the person may be unaware of some or positive thinking (e.g., “Now we’re gonna beat all of the basic elements of an appraisal. How- this illness”) and five items represented self-talk ever, the appraisal process affects the quality typical of negative thinking (e.g., “Typical me and intensity of the emotional reaction in a not being able to handle this”). In terms of given situation. Thus, from a particular kind of stress and coping theory, the self-statements emotion, it may be possible to deduce the were regarded as emotion-focused coping particular kind of appraisal that produced it strategies. Indices of positive and negative (Lazarus & Folkman 1984). thinking were formed by adding the raw scores The raw data in the ESRQ consist of scores of the five items representing each strategy. indicating the emotions experienced in a given Scores could range from 5 to 15 on each of situation. The response format is a 4-point these two indices. Treatment session specijic experience of scale ranging from 0 (the word does not correspond to how you felt right then) to 3 (the tensed muscle groups was assessed with a checkword completely corresponds to how you felt list containing 16 muscle groups arranged in a top-down order; beginning with the forehead right then). The instructions were: “Below is a list of and ending with the feet and toes. Participants Scand J Caring Sci
182
G. Larsson, B. Starrin
were asked to check muscle groups they felt were tense during the radiotherapy session. Scores could range from 0 to 16. Collection of self-report data concerning relaxation training experiences occurred at the Ist, the loth, and the 20th radiotherapy session (participants in the experimental group only). Participants were asked to rate and compare their “ability to relax now with prior to training.” A 5-point scale ranging from “much worse” ( 1 ) to “much better” (5) was used. The nurses who had taught relaxation to patients were interviewed about their experiences at the end of the study. Comments were transcribed immediately thereafter, using brief notes made during the interviews.
RESULTS Relaxation training frequency and experiences The relaxation training program was carried out with a lower training frequency than planned. Basic relaxation training consisted of
3.3 sessions per week on the average (SD = 1.1) instead of the planned four. Most patients (28 out of 32) practiced relaxation at least two times per week; no patient practiced less than once a week. The following mean scores were obtained on the question where the experimental participants were asked to rate and compare their ability to relax now with prior to training ( a 5-point scale from much worse ( 1 ) to much better (5) : First radiotherapy session = 4.1 1, 10th radiotherapy sesion = 4.25, and 20th radiotherapy session = 4.45.
General psychological stress level and mood The pre- and post-relaxation training programme assessments of general psychological stress level and mood state are presented in Table I. Perusal of Table I shows that the control group had comparable scores on all scales on the pre- and post-programme assessments. In the experimental group, significant differences
Table I. General psychological stress level and mood state Pre-programme assessment
Post-programme assessment ~~~~
Variable __
M
SD
M
SD
1.17
17.38
2.81
1.13
1.12
12.42
1.64
1.07
2.78
1 1.29
3.01
2.28*
2.20 1.33
8.08 5.29
1.95 0.86
2.31* 2.56**
8.00
1.41
17.04
3.35
1.28
2.81
1.40
12.35
2.51
0.52
1.25
3.08
12.04
3.92
0.57
8.94 4.34
2.11 1.77
8.58 4.74
2.80 1.83
0.90 1.02
~~~
.-
Experimental group (n = 32) Daily upliftsfrequency 8.35 Daily uplifts2.87 intensity Daily hassles2.71 frequency Daily hasslesintensity 9.68 Mood 4.3 1 Control group (n = 32) Daily upliftsfrequency Daily upliftsintensity Daily hasslesfrequency Daily hasslesintensity Mood
“Wilcoxon matched-pairs signed-ranks test. * p < 0.05. **p < 0.01. Scand J Caring Sci
183
Relaxation training
of means (in a favourable direction from a stress and health perspective) were noted on the two hassles scales and on the general mood state scale. Comparisons (Mann-Whitney U-tests) between the experimental and control groups gave the following results. On the pre-programme measurement, the experimental group reported a significantly higher mean score on the daily hassles-frequency scale ( z = 2.26, p < 0.05). No significant differences of means were noted on the post-programme measurement.
two scales within the experimental group with Scheffk tests; the most conservative test with respect for Type I errors. On the benign-positive appraisal scale a signficant difference of means (0.05 level) was noted between the 1st and the 10th sessions. Comparisons ( Mann-Whitney U-tests) between the two groups yielded the following significant differences of means. On all three radiotherapy sessions, the control group reported significantly fewer tensed muscle groups (1st session: z = 2.91, p < 0.05; 10th session: z = 3.53, p < 0.01; 20th session: z = 2.17, p < 0.05). On the 20th radiotherapy session, the Treatment speclfic appraisal and experimental group showed significantly higher cognitive coping scores on benign-positive appraisal ( z = 2.19, Scores on the treatment specific appraisal and p < 0.05) and challenge appraisal ( z = 1.98, cognitive coping scales are shown in Table 11. p
