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CriticalAppraisal-Examples-20241113.zipPublished Critical Appraisal.pdf
principles and practice
The Research Critique General Criteria for Evaluating a Research Report CHERYL TATANO BECK, CNM, DNSc
General criteria for evaluating a research report are addressed. This outline of criteria can be used as a guide for nurses in critiquing research studies. A sample research report is summarized followed by a critique of the study. Readers have an opportunity to practice critiquing by doing their own analyses before reading the critique presented in the article.
A research critique is a critical appraisal of a research study that has been systematically reviewed based on some known criteria. The focus is on judging the inves- tigation’s scientific merit and worth so that a decision can be made as to whether or not the re- sults of the study should be incor- porated into clinical practice. An appraisal of the research’s strengths and limitations is made. The critic should not concentrate onIy on the flaws in the investiga- tion.
Given the constraints of con- ducting clinical research, the cri- tic needs to assess what the inves- tigator attempted to do and to judge the strategies chosen. Iden- tification of the strengths of a study is necessary for generating scientific knowledge and imple- menting the findings into clinical practice. To critique a research study systematically, each section of the research report must be an- alyzed. Critiquing involves identi- fying answers to questions for
Accepted: March 1989
each component of the research report.
One of the purposes of a re- search critique is to provide feedback to help researchers strengthen not only the studies being critiqued but also future re- search studies being planned on the same topics. A second purpose of a research critique is to aid re- search consumers in making deci- sions on how to use the study find- ings. For example, is the study in- teresting but its research design not sound enough to warrant ap- plication of the findings to clinical practice?
This second purpose of a re- search critique is of vital impor- tance to all nurses, not just nurse researchers. One of the roles of all professional nurses is to be knowl- edgeable consumers of nursing research. Professional nurses must develop the habit of criti- cally reading nursing research journals and research studies published in their specialty jour- nals. Only through applying valid research findings in practice can the nursing profession advance.
In this article excerpts from a published research report are first summarized. This exploratory study is a replication of earlier re- search on women’s responses to fetal monitoring during labor. A criteria outline for the evaluation of research reports is presented (Table 1) as a guide to critique re- search.’-3 These suggested ques- tions are not a complete or ex- haustive list. Readers are given the opportunity to practice apply- ing the critiquing criteria to this nursing research on women’s re- sponses to fetal monitoring. For each section of the critique, the reader should do his or her own analysis before reading the study critique presented in the final seg- ment of this article.
SAMPLE RESEARCH REPORT
Research Problem
Title: Patient Acceptance of Fetal Monitoring as a Helpful Tool4
In 1972, a study was conducted to investigate women’s cognitive
18 191 January/February 1990 JOGNN
Table 1. General Criteria For Evaluating a Research Report
Step 1. Research Problem 1. Is the problem clearly and concisely stated? 2. Is the problem adequately narrowed down into a researchable problem? 3. Is the problem significant to nursing? 4. Is the relationship of the identified problem to previous research clear?
1. Is the literature review logically organized? 2. Does the review provide a critique of the relevant studies? 3. Are the gaps in knowledge about the research problem identified? 4. Are important relevant references omitted?
1. Is the theoretical framework easily linked with the problem, or does it seem forced? 2. If a conceptual framework is used, are the concepts adequately defined and are the
Step 2. Literature Review
Step 3. Theoretical or Conceptual Framework
relationships among these concepts clearly identified? Step 4. Research Variables
1. Are the independent and dependent variables operationally defined? 2. Are any extraneous or intervening variables identified?
1. Is a predicted relationship between two or more variables included in each hypothesis? 2. Are the hypotheses clear, testable, and specific? 3. Do the hypotheses logically flow from the theoretical or conceptual framework?
1. Is the sample size adequate? 2. Is the sample representative of the defined population? 3. Is the method for selection of the sample appropriate? 4. Are the sample criteria for inclusion into the study identified? 5. Is there any sampling bias in the chosen method?
1. Is the research design adequately described? 2. Is the design appropriate for the research problem? 3. Does the research design control for threats in internal and external validity of the study? 4. Are the data collection instruments described adequately? 5. Are the reliability and validity of the measurement tools adequate?
1. Are the data collection methods appropriate for study? 2. Are the data collection instruments described adequately? 3. Are the reliability and validity of the measurement tools adequate?
1. Is the results section clearly and logically organized? 2. Is the type of analysis appropriate for the level of measurement for each variable? 3. Are the tables and figures clear and understandable? 4. Is the statistical test the correct one for answering the research question?
1. Are the interpretations based on the data obtained? 2. Does the investigator clearly distinguish between actual findings and interpretations? 3. Are the findings discussed in relation to previous research and to the conceptual/
theoretical framework? 4. Are unwarranted generalizations made beyond the study sample? 5. Are the limitations of the results identified? 6. Are implications of the results for clinical nursing practice discussed? 7. Are recommendations for future research identified? 8. Are the conclusions iustified?
Step 5. Hypotheses
Step 6. Sampling
Step 7. Research Design
Step 8. Data Collection Methods
Step 9. Data Analysis
Step 10. Interpretation and Discussion of the Findings
and emotional reactions to fetal sidered routine during labor. After monitoring in labor.5 Thirty-one of the five-year period, the re- 50 women in labor had negative searcher replicated the original initial responses to fetal monitor- study to determine to what extent ing. Five years after the initial women’s responses to fetal mon- study, fetal monitoring was con- i t o r i n g h a d c h a n g e d . Once
One of the roles of all professional nurses is to be knowledgeable consumers I of nursing research.
women’s reactions to fetal moni- toring are known, nurses can tailor nursing interventions specifically to these responses.
Literature Review
The initial study was conducted in an 800-bed university teaching hospital in New England.5 Fifty women on a postpartum unit were interviewed sometime during their first three days after deliv- ery. The researcher intended to gain information that would de- scribe women’s cognitive and emotional responses to fetal mon- itoring during labor. The reactions of the 50 women to fetal monitor- ing were categorized into initial responses and later subsequent responses after the women had been attached to the monitors for periods of time. Thirty-one women had negative initial responses, and 19 women had neutral initial responses. None of the 50 women in the initial study had a positive initial response. Six mothers had negative subsequent responses, 13 had neutral subsequent re- sponses, and 3 1 had positive sub- sequent responses.
In a 1976 study, 71 women com- pleted questionnaires within one month before their deliveries6 The questionnaires concerned knowledge of fetal monitoring and attitudes. Thirty-one of the 7 1 women were monitored during labor and interviewed during postpartum hospitalization. In comparing predelivery and post- delivery attitudes, the researchers found that 2 6 women exhibited positive attitudes postdelivery, while only 12 women had reported
19:l JanuaryIFebruary 1990 JOCNN 19
positive predelivery attitudes. In a 1977 study, 10 women who had no prior fetal loss and no current labor difficulties and 25 women who had experienced fetal loss and/or current labor difficulties were interviewed during the post- partum p e r i ~ d . ~ Among the 25 women who had experienced complications, 14 indicated posi- tive attitudes, 10 indicated nega- tive attitudes, and 1 indicated a neutral attitude. Of the 14 with positive attitudes, 9 had suffered prior fetal loss. In the 10 mothers who had not experienced compli- cations, 2 indicated positive atti- tudes and 8 indicated negative at- titudes.
Research Questions
1) During labor, what are women’s cognitive and emo- tional responses to fetal moni- toring when they are initially attached to the monitor and, subsequently, after they have been on the monitor for a pe- riod of time?
2) After a five-year period, have women’s cognitive and emo- tional responses to fetal moni- toring during labor changed?
3) Do any significant associations exist between any of the demo- graphic variables studied and women’s initial and subse- quent responses to fetal moni- toring?
Definition of Terms
1) Initial response-a woman’s recollection of her immediate reaction to the thought of fetal monitoring and to the moni- toring equipment when first told that s h e and her fetus would be attached to the fetal monitoring machine.
2 ) S u b s e q u e n t response-a woman’s total reaction to fetal monitoring as the woman re- calls her entire fetal monitor-
A research critique is a critical appraisal of a study that has been systematically reviewed based on some known I criteria.
ing experience while attached to a monitor.
3) Positive reaction-a favorable, helpful, and desirable re- sponse to fetal monitoring.
4) Negative reaction-an unfavor- able, upsetting, and distressing response to fetal monitoring.
5 ) Neutral reaction-a response that cannot be categorized as being favorable or unfavorable toward fetal monitoring.
Sampling
The convenience sample con- sisted of 50 postpartum women who had delivered at a 350-bed, university-affiliated community hospital in Baltimore, Maryland. Respondents’ ages ranged from 14 to 37 years. Thirty mothers were white, and 20 were black. Thirty- two women were married, while 18 were single. Twenty-seven mothers were clinic patients, and 23 were private patients. The length of time women were on the fetal monitor ranged from 30 min- utes to 16 hours, with a mean time of 4 hours and 42 minutes.
Research Design and Data Collection Procedures
This study is a replication of the original research done in 1972. Fifty women were interviewed sometime during their first three postpartum days. As in the 1972 study, these 50 women’s re- sponses were divided into initial and subsequent responses. Each patient’s initial and subsequent responses to fetal monitoring were categorized further into positive,
negative, or neutral reactions. Re- liability of the categories was checked by having another faculty member independently categorize the 50 mothers’ initial and subse- quent responses. The percentage agreement with the researcher’s categorization was 95%.
Data Analysis
The most striking difference the investigator noticed in comparing the results of her two studies was in women’s initial responses to fetal monitoring. In 1972, not one woman interviewed had a positive initial response, while 31 women had negative initial responses. Five years later, 11 women had positive initial responses to fetal monitoring and only 11 had nega- tive initial responses. In regard to subsequent responses to fetal monitoring, 37 mothers had posi- tive reactions, 9 mothers had neu- tral reactions, and only 4 mothers had negative reactions. When comparing the subsequent re- sponses identified in this current study with those of the original study, 6 more women had positive responses, 2 fewer had negative responses, and 4 fewer had neu- tral responses in 1977.
Chi-square tests were done to test for associations between any of the demographic variables studied and women’s initial and subsequent responses to fetal monitoring. Two of these associa- tions were statistically significant at more than the -01 level. A chi- square test of 12.31 (df 2) indi- cated that a significant association between age and initial responses existed. Older mothers initially reacted more positively to fetal monitoring than younger mothers. The second significant association found was between marital status and initial responses (x’ = 9.97, df 2). Married women initially re- sponded more positively to fetal monitoring than single women.
20 19:l January/February 1990 JOGNN
Discussion
The data collected in this study support the conclusion that cur- rently initial fetal monitoring is a less upsetting experience for women in labor than such moni- toring was in 1972. The most fre- quent reason given by the women for their positive reactions was that they were familiar with the monitor before coming into the hospital in labor. Nurses who come in contact with pregnant women, either through work in ob- stetrical clinics, private offices, or prenatal education classes, should discuss fetal monitoring with their patients and show pictures of the monitor to help familiarize pa- tients with the equipment.
One of the purposes of a research critique is to help decide whether or not the results of a study should be incorporated into clinical I practice. More than half of the mothers in
the study had neutral initial reac- tions to fetal monitoring. These 28 women appeared to begin their initial experiences with fetal mon- itoring in an open, nonjudgmental manner. This finding suggests that, in labor, a woman’s initial ex- perience with fetal monitoring may be a crucial period affecting how s h e may react to the re- mainder of her monitoring experi- ence. Consequently, labor nurses must use a positive approach when introducing fetal monitoring to women.
Two significant relationships identified in this study have im- portant nursing implications. When caring for young and single women who are about to experi- ence fetal monitoring, labor and delivery nurses need to make greater efforts to give these women support.
Study Limitations
The findings of this study can- not be generalized to cover the entire maternity population be- cause the sample was not ran- domly selected.
CRITIQUE OF THE SAMPLE RESEARCH REPORT
Research Problem
The research problem is clearly stated. The investigator sought to compare women’s responses to fetal monitoring in 1972, when fetal monitoring was still new, and five years later in 1977, when fetal monitoring was considered a rou- tine part of labor. Identifying whether o r not women’s emo- tional and cognitive responses to fetal monitoring had changed is relevant and useful to nursing. With this information, labor nurses will be able to adapt their nursing intervention techniques.
Literature Review
The references are pertinent to the topic under investigation. When this study was published, the references were current. One weakness in this section, however, is the lack of any critique of the research studies cited. The inves- tigator only summarized the find- ings but did not critique the stud- ies’ designs for any limitations.
Theoretical Framework
The researcher did not identify a theoretical or conceptual frame- work on which the study had been based.
Research Variables
Independent or dependent vari- ables were not identified, which was appropriate since the study was exploratory. Theoretical defi- nitions were specifically provided for the variables of initial, subse-
To critique a research study systematically, each section of the research
1 report must be analyzed.
quent, positive, negative, and neu- tral responses.
Research Questions
Because the study was descrip- tive, research questions instead of hypotheses were appropriate. The three research questions were clear and specific.
Sampling
Because the research sample was a convenience sample, the findings have limited generaliza- bility. N o criteria for sample eligi- bility were identified. In addition, the researcher did not discuss how the subjects’ rights had been protected.
Research Designs and Data Collection Procedures
All of the subjects were inter- viewed within three days after de- liveries, which helped prevent problems of recall ability. The in- vestigator did not, however, pro- vide readers with a description of the interview schedule, the num- ber of researchers who did the in- terviewing, or the validity of the interview schedule. The re- searcher addressed the reliability of the coding categories, which was determined as 95%. Test-re- test reliability of the interview schedule was not done.
Data Analysis
The statistical tests chosen to analyze the data were appropriate for the measurement level of the variables and for the research questions. For example, chi- square analysis was used to deter- mine whether or not any signifi-
19:l January/February 1990 JOCNN 21
Professional nurses must develop the habit of critically reading nursing research studies.
cant associations existed between the demographic variables and the women’s responses to fetal monitoring. The probability level to determine significance was identified.
Discussion of the Findings
The study findings were com- pared with the original research done in 1972. Differences between the results of these two studies were identified. The researcher did not discuss the findings in re- lation to the theoretical frame- work because no framework had been used. One limitation of the study-the limited generalizabil- ity of the findings-was ad-
dressed. Other limitations, such as the lack of validity testing of the interview schedule, were not identified. Result implications for clinical nursing practice were dis- cussed, but recommendations for future research were not made.
CONCLUSION
General criteria for evaluating a research report were discussed. These criteria should help facili- tate nurses in becoming knowl- edgeable consumers of nursing research.
REFERENCES
1. Polit, D., and B. Hungler. 1987. Nursing Research: Principles and Methods. Philadelphia: J. B. Lip- pincott Company.
2. Wilson, H. 1987. Introducing Re- search in Nursing. Menlo Park, Cal- ifornia: Addison-Wesley Publish- ing Company.
3. LoBiondo-Wood, C., and J. Haber. 1986. Nursing Research: Critical Ap- praisal and Utilization. St. Louis: C. V. Mosby Company.
4. Beck, C. 1980. Patient acceptance of fetal monitoring a s a helpful tool. JOGN Nurs. 9(6):350-53.
5. Beck, C. 1972. Patients’ Cognitive and Emotional Responses to Fetal Monitoring. Masters Thesis, Yale University.
6. Dulock, H., and M. Herron. 1976. Women’s responses to fetal moni- toring. JOGN Nurs. 5:68-70.
7. Starkman, M. 1977. Fetal monitor- ing: Psychologic consequences and management recornrnenda- tions. Obstet Gynecol. 50:500.
Address for correspondence: Cheryl Tatano Beck, Florida Atlantic Univer- sity, Division of Nursing, 500 NW 20th Street, Boca Raton, FL 33431.
Cheryl Tatano Beck is an associate profes- sor at Florida Atlantic University in Boca Raton, Florida. Dr. Beck is a member of NAACOG, the American Nurses’ Associa- tion, and Sigma Theta Tau.
DO YOU WANT TO BE AN AUTHOR? If you’re thinking about writing an article for JOGNN, write for author guidelines.
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illustrations).
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22 19:l JanuaryfFebruary 1990 JO(;NN
Research Study Critical Appraisal Exemplar_Annotated_kr.pdf
Seung Hee Choi, PhD, RN
Roxane R. Chan, PhD, RN
Rebecca H. Lehto, PhD, RN
Relationships Between Smoking Status and Psychological Distress, Optimism, and Health Environment Perceptions at Time of Diagnosis of Actual or Suspected Lung Cancer
K E Y W O R D S
Anxiety
Lung neoplasms
Optimism
Perception
Smoking
Background: While much research and practice resources have addressed
smoking cessation among cancer patients, less emphasis has been placed on
personal psychological and environment factors associated with smoking at the time
of diagnosis. Objective: The aim of this study was to examine differences in
psychological distress, optimism, and perceptions of the health environment/illness
experience based on smoking status in patients with current, former, and no smoking
history with newly diagnosed suspected or actual lung cancer. Methods: Data
were derived from a descriptive study of 52 patients (34 men and 18 women
aged 37-83years) undergoing diagnostic evaluation for actual or suspected lung
cancer. Descriptive statistics were used to characterize data. Analysis of variance,
#2, and Spearman correlation tests were used to determine relationships among
main study variables (smoking status, anxiety, worry, perceived cognitive
functioning, optimistic outlook, health environment/illness experience perceptions).
Results: Current smoking status was associated with higher psychological distress
(anxiety and worry) among patients facing a new suspected or actual cancer
diagnosis. Conclusions: The study was able to provide important information
relative to smoking status and psychological distress at the time of diagnosis of
suspected or actual lung cancer. Findings demonstrate needs for assessment and
156 n Cancer NursingA, Vol. 42, No. 2, 2019 Choi et al
Copyright B 2018 Wolters Kluwer Health, Inc. All rights reserved.
Author Affiliations: College of Nursing, Michigan State University, East Lansing. This study was funded by a National Institute of Nursing Research grant
(1F31 NR07695-01A1). The authors have no conflicts of interest to disclose.
Correspondence: Seung Hee Choi, PhD, RN, College of Nursing, Michigan State University, 1355 Bogue St, Room #C250, East Lansing, MI 48824 ([email protected]).
Accepted for publication October 31, 2017. DOI: 10.1097/NCC.0000000000000579
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
targeted interventions to reduce psychological distress and to promote long-term
adaptation in patients smoking at time of diagnosis. Implications for
Practice: Nurses are positioned to provide support and resources for cancer
patients. It is critical that smoking cessation interventions also address nicotine
craving, emotion regulation, and adaptive coping skills.
L ung cancer is the leading cause of cancer death and the second most common cancer in incidence for both men and women in the United States.1 Smoking exposure is
the primary environmental factor responsible for the incidence of lung cancer.1 A diagnosis of actual or suspected lung cancer is a serious life-threatening stressor that may be compounded by its association with smoking status. Patients who are active smokers have the added stressor of smoking cessation at the time of a potentially life-threatening diagnosis of lung cancer.2 Although many patients with newly diagnosed suspected or actual lung cancer are current smokers,3,4 little research has examined rela- tionships between smoking status at diagnosis in relation to psy- chological distress and personalized perceptions relative to the healthcare environment and illness experience. Evaluating patients" perceptions about the illness context and level of psychological distress in relation to smoking status is important because it may impact adaptation over time. Therefore, the purpose of this study was to examine psychological distress and perceptions of healthcare environment and illness experience in relation to smok- ing status (current, former, and never smokers) and smoking intensity at the time of a suspected or new lung cancer diagnosis. The inquiry examines presence of an optimistic outlook related to these factors and discusses implications of these findings rela- tive to the role of the nurse as a patient advocate.
n Background
Patients who receive a new diagnosis of suspected or actual lung cancer face multiple cognitive and emotional challenges.5 Given the disease is associated with smoking, patients may feel respon- sible if they perceive the diagnosis is related to smoking behav- iors.6 Furthermore, patients may perceive stigma from healthcare providers, friends, and family that contributes to lowered per- ceptions of support.6 Problems relative to smoking behaviors and emotional vulnerability have been recognized in other cancer and medical conditions. For example, smoking continuation and relapse were associated with heightened psychological distress (anxiety, depressive symptoms, worries about potential recur- rence) in patients with oral and oropharyngeal malignancy.7
Studies have found relationships between smoking behavior and anxiety problems.8,9 Individuals with higher anxiety sensi- tivity, a fear and avoidance of anxiety symptoms, are more moti- vated to smoke and to relapse following quit attempts.10 These connections between anxiety, especially anxiety sensitivity, and smoking relapse may be attributed to a dysfunction of the neuro- logical gating system, which then leads to overestimation of mild breathing discomfort that has been shown to be corrected
through administration of nicotine through smoking or patch administration.11,12
The cognitive processing, particularly the types of content that is processed, associated with a life-threatening illness is critical to adjustment to the disease.13 Worry, involuntary aver- sive cognitions about anticipated threats and concerns, is com- mon and associated with anxiety in patients with newly diagnosed life-threatening illnesses such as cancer.14 Worry has been shown to correlate with a particular disruption in the variability of one"s breathing pattern, a disruption that is corrected through spon- taneous and on-demand sighs similar to breaths used during cigarette smoking.15,16 Environmental factors that heighten worry such as unanticipated stipulations to quit smoking, the need for forthcoming treatments associated with potential adverse effects, and personal life adjustments also may compromise perceived cognitive effectiveness for patients with newly diagnosed lung cancer.5 Realistic worry that occurs with effective cognitive func- tion and contributes to lowered negative affect may be adaptive in the face of serious stressors and/or threats where cognitive resources are targeted toward the problem so that effective strat- egies for coping can be utilized. However, in risk reduction re- search such as cancer screening, results are mixed in the role of worry in motivating positive health behavior.17
Patients" perceptions of the healthcare environment, whether positive or negative, impact illness adaptation. Patients with cancer strongly desire active participation in their treatment in- formation about options and expectations and desire time from healthcare professionals for support and communication.18
However, healthcare professional interactions have been shown to trigger the most concerns over the postdiagnosis period con- tributing to negative adaptation in patients with cancer.19
A growing literature has examined factors associated with positive adaptation to cancer.13,14,20 Dispositional optimism is a stable personality tendency to expect positive outcomes from life events.21 In the face of a life-threatening diagnosis of can- cer, patients who are realistically optimistic might reflect on positive goal-oriented or problem-solving aspects as opposed to aversive, negative self-deprecating thoughts.20 On the other hand, patients may unrealistically assume their risk of adverse health consequences is lowered despite evidence to the contrary.22 In this regard, optimistic individuals may underestimate risk and potential negative outcomes associated with smoking behaviors.22
Self-regulation research and theory articulate mechanisms for understanding how illness perceptions impact behavior and adaptation in the face of life-shattering health threats.23 In this regard, the context or environment is critical to recognizing how patients build mental frameworks that guide their interpretation, decision making, and coping strategies in the face of cancer.
Smoking Status Among Lung Cancer Cancer NursingA, Vol. 42, No. 2, 2019 n157
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Smoking conduct may be backed by beliefs that the behavior serves a self-regulation role for managing negative affect states and stress.24
While much research and practice resources have addressed smoking cessation among cancer patients, less emphasis has been placed on personal psychological and environment factors associated with smoking at the time of diagnosis. Therefore, the purpose of this study was to examine (1) differences in psy- chological distress and perceptions of the health environment/ illness experience between patients who are current, former, and never smokers; (2) differences in these associations by smoking intensity; and (3) whether optimism influences these associa- tions in relation to smoking status at diagnosis among newly diagnosed patients with suspected or actual lung cancer. We operationalize psychological distress as evidence of heightened anxiety, worry, and lowered perceived cognitive effectiveness.
n Methods
Design
Data were derived from a study of patients undergoing diag- nostic evaluation and treatment for actual or suspected lung cancer at a Midwestern university comprehensive cancer center and a Veterans Administration health system.
Sample and Setting
The convenience sample was composed of 52 patients who were assessed during the pretreatment period in relation to psycho- logical parameters, perceptions about their illness experience, and the health environment. Inclusion criteria included patients who were (a) 21years or older and (b) diagnosed as having actual or suspected nonYsmall cell lung cancer. Exclusion criteria included the following: (a) a known history of cancer other than the suspected lung cancer, (b) documented cognitive or psy- chiatric disorder (eg, dementia, schizophrenia, major affective disorder), (c) history of a debilitating medical disorder such as advanced cardiac or respiratory disease, and (d) current psy- choactive medication that would impede study participation.
Procedures
Full institutional review board approval was received from the respective university and participating medical center sites. Eli- gible volunteers were approached by the study researcher during scheduled preoperative or clinic visits where patients and phy- sicians discussed diagnostic test results and future treatment (eg, surgery). The researcher explained the purpose, requirements, risks, benefits, and rights, including the right to withdraw from participation at any time before written informed consent was obtained. If participants agreed to participate in the study, they completed the surveys in a private consulting room. At the time of the survey, 44% of the patients had only suspicious test find- ings and did not yet have a confirmed diagnosis. The diag- nosis was confirmed, and the disease stage was determined
after surgery. All measures were administered using a standard set of instructions.
Measures
Demographic information included age, marital status, race/ ethnicity, educational level, occupation, and employment status. Health history information including smoking status was obtained from the computerized medical access systems. Smoking status was categorized as current, former, and no previous history. Smoking pack-years were calculated by multiplying the number of cigarettes smoked per day and the number of years smoked.
Psychological Distress
Anxiety was measured by the validated Spielberger"s State-Trait Anxiety Inventory.25Y27 Consisting of 2 separate 20-item scales, participants were asked to rate current (state) and general (trait) perceptions about how they feel on a 1- to 4-point scale, from ‘‘not at all’’ to ‘‘very much so’’ (range, 20-80).25 In this study, the Cronbach"s ! coefficients for the state and trait anxiety scale were .94 and .87, respectively.
Worry was evaluated with measures of both general (non- specific) and cancer-related worry. The Penn State Worry Ques- tionnaire (PSWQ), a 16-item self-report instrument, was used to measure the frequency and intensity of general worry.28,29
The PSWQ is scored on a 5-point Likert scale with response options of 1 (not at all typical) to 5 (very typical), with a summed composite score (range, 16Y80). In this study, the Cronbach"s ! coefficient for the PSWQ was .90. Cancer-related worry was measured with a 3-item Cancer-Related Worry Questionnaire to evaluate perceived worry about cancer, cancer treatment, and the impact of cancer-related worry on daily functioning using a 5-point Likert scale (range, 3Y15).30,31 The Cronbach"s ! coef- ficient was .85.
Perceived effectiveness in cognitive functioning was eval- uated with the validated Attentional Function Index (AFI) con- sisting of 3 essential domains of effective action, interpersonal effectiveness, and attentional lapses.32,33 The AFI consists of 16 linear analog scales that are labeled with polar opposite phrases at each end (‘‘not at all,’’ ‘‘extremely well’’; range, 0Y100).32 The Cronbach"s ! coefficient for the current study was .87.
Health Environment Perceptions
A 7-item survey was developed to obtain information about the patient"s perceived illness experiences in relation to the health- care environment, such as perceptions about treatment partic- ipation, time taken by doctors and nurses to listen to concerns, and opportunity to make choices and ask questions relative to treatment and scheduling of appointments.5 Participants were asked to rate on a 5-point scale from 1=‘‘not at all’’ to 5=‘‘always’’ or ‘‘a lot’’ statements related to current experiences with the health- care environment (range, 7-35). Higher scores indicated stronger agreement with statements. The Cronbach"s ! coefficient was .81.
The 10-item Life Orientation TestYRevised (LOT-R) was used to measure optimistic outlook.34 The LOT-R consists of
158 n Cancer NursingA, Vol. 42, No. 2, 2019 Choi et al
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
10 Likert-scale items (0=strongly disagree, 4=strongly agree) that reflect expectations of positive versus negative life expe- riences. Only 6 items of the LOT-R are used in scoring the in- strument (4 items are filler), so the scale has a range of 0 to 24. The Cronbach"s ! coefficient was .84.
Statistical Analysis
All statistical procedures were performed using the SAS pro- gram. Descriptive statistics were computed on all variables. To examine differences in distress and perceptions about the health environment/illness experience between patients who were current, former, and never smokers, one-way analysis of var- iance (ANOVA) test for continuous variables and #2 or Fisher exact test for categorical variables were performed. Assumptions of ANOVA test were examined, and none of them were vio- lated. To examine distress and perceptions about the health environment/illness experience in relation to optimistic outlook, Spearman correlation test was conducted. Statistical significance was determined at the level of .05.
n Results
The study sample was composed of 52 adults aged 37 to 83years who were being evaluated for possible thoracic surgery following a new diagnosis of suspected or confirmed stage nonY small cell lung cancer at 2 Midwestern hospitals (Table 1). The majority of patients were either current (n=12 [23%]) or for- mer (n=37 [71%]) smokers at diagnosis with a mean 49.79 pack-years. Most participants were white (94%), male (65%), and currently married (69%). Half of the patients had a high school education or less and were retired. Most patients had either stage I or II disease (75%), reflecting their eligibility to be evaluated for potential curative surgical resection. More than half of the patients (56%) had a confirmed cancer diagnosis prior to surgery.
Table 2 shows descriptive results for the major study vari- ables. The mean state anxiety score was 43.75T14.25, demon- strating that the patients in general were experiencing anxiety. Trait anxiety ranged from 20 to 67, with the mean of 37.73 (SD, 10.44). The mean PSWQ score indicated lower levels of worry, yet there were patients in the sample with general worry comparable to psychiatric populations (range, 20-75). On the Cancer-Related Worry Questionnaire, the mean score of 11.06 was reflective of generally moderate to high levels of cancer- related worry, with scores ranging from the lowest to the highest possible score.
The AFI scores reflect low to only moderate levels of per- ceived cognitive effectiveness. Such findings suggest that pa- tients in general were experiencing symptoms of cognitive fatigue, challenges with emotion regulation, and difficulties with focus and concentration in relation to completing common tasks asso- ciated with daily life. Importantly, the range of scores of the Illness Experience Questionnaire was 13 to 35, suggesting per- ceived satisfactory interactions with the healthcare environment in general.
Scores on the optimism scale (LOT-R) ranged from 6 to 24, with the mean of 15.90 (SD, 3.7). Analysis of sex differences in the major study variables showed a trend of females having higher psychological stress (higher anxiety and worry) and higher opti- mism, albeit mostly not significant except trait anxiety (t=j2.10, P=.041).
Differences in Distress and Illness Experience Based on Smoking Status. Compared with either patients who were former or never smokers, patients who currently smoked tended to report higher anxiety (both state and trait) and worry (both general and cancer related) and lower levels of perceived effec- tiveness in cognitive function, positive perceptions about the health environment/illness experience, and optimistic outlook (Table 3). Most correlations, however, were not significant except cancer-related worry (F=3.61, P= .034), where current smoking status was associated with the highest levels of cancer-related worry. Currently smoking patients reported the least positive perceptions about their health environment and illness experience, although this was not statistically significant (F=2.56, P=.087).
To further examine these associations in relation to smoking intensity (pack-years), one-way ANOVAs were conducted (Table 3).
Table 1 & Demographic and Health Characteristics (N=52)
Mean (SD) Frequency (%)
Age, y 64.08 (11.62)
Race/ethnicity White 49 (94.23) African American 3 (5.77)
Gender
Female 18 (34.62) Male 34 (65.38)
Marital status
Married 36 (69.23) Widowed 10 (19.23) Divorced 6 (11.54)
Education, y 12.77 (1.98) Employment status
Employed 18 (34.73)
Retired 25 (51.02) Unemployed 6 (12.24)
Children Has children 48 (92.31)
No children 4 (7.69) Smoking status
Current smoking 12 (23.08)
Quit smoking 37 (71.15) Never smoking 3 (5.77)
Pack-years 49.79 (30.75)
Stage I 18 (34.62) II 22 (42.31) III/IV 12 (23.08)
Preoperative diagnosis Confirmed 29 (55.77) Suspected 23 (44.23)
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Compared with either never smokers or patients with less than 20 pack-years, patients with 20 pack-years or greater showed higher anxiety (state and trait) and worry (general and cancer related) and less positive perceptions of their health environment/ illness experience, perceived effectiveness in cognitive function, and optimistic outlook, although these associations were not significant with most variables. The only significant difference in relation to smoking intensity existed in cancer-related worry (F=3.29, P= .046).
Associations of Distress and Illness Perception With Life Orientation. While greater optimistic outlook tended to be associated with decreased levels of anxiety (state) and worry (gen- eral and cancer related) and with increased perceived effectiveness in cognitive function, these findings were not statistically signifi- cant. However, there were significant inverse relationships between optimistic outlook and trait anxiety (>=j0.36, P=.01) and posi- tive perceptions of the healthcare environment/illness experience (>=0.49, PG .001).
To further examine differences in these relationships relative to smoking status, Spearman correlations were repeatedly tested with smokers only (n=48), current smokers only (n=12), or former smokers only (n=37). Although the directions of the relationships did not significantly change in most cases, effect sizes were larger mostly when the analyses included only current smokers (Table 4).
n Discussion
The study examined differences in psychological distress and perceptions of the health environment/illness experience among
current smokers, former smokers, and never smokers who had newly diagnosed suspected or actual nonYsmall cell lung cancer. The majority of the patients had stopped smoking by the time of assessment, and only 6% of the sample had no smoking history.
Overall anxiety levels in this sample were similar to those of general medical and surgical patients or college students under stressful examination conditions.26 While the comparative find- ings depending on smoking status were not significant, the 12 patients who were currently smoking had clinically significant levels of state anxiety. As shown in the literature,35,36 increases in trait anxiety were significantly associated with decreased opti- mistic outlook. Importantly, cancer-related worry was in the highest range among current smokers.
Perceptions of effective cognitive function were the lowest among current smokers, consistent with previous studies.37,38
Underlying mechanisms of such findings are not clear, yet dec- rements may be associated with increased levels of cortisol re- sulting from high levels of psychological distress (eg, anxiety and worry) existing among current smokers at diagnosis.38 Percep- tions of effective cognitive function were significantly and posi- tively related to optimistic outlook, similar to other studies where dispositional optimism was related to improved perceived cog- nitive function.39 Our patients showed similar optimistic levels as reported in the general population.21 These findings demon- strate the importance of assessment and management of psycho- logical distress (anxiety and worry). It is critical that smoking cessation interventions address psychological distress including training in emotion regulation and physiological nicotine crav- ing management to promote cessation efforts and reduce relapse in lung cancer patients. Cognitive behavior therapies and mindfulness- based interventions that focus on adaptive coping skills and re- lieving stress might be beneficial.40,41
Limitations
The present study has limitations that must be considered. First, the study is limited by the small convenience sample that was lacking in both ethnic and racial diversity. The small sample size, especially never smokers, may provide low statistical power, leading to a reduced chance to detect a true effect and low re- producibility of results.42 However, such findings are reflective of patients with lung cancer more generally where the majority
Table 3 & Bivariate Association in Relation to Smoking Status and Smoking Intensity (N=52)
Smoking Status Smoking Intensity
Never Smokers
(n=3), Mean
Former smokers
(n=37), Mean
Current Smokers
(n=12), Mean P
Never Smokers
(n=3), Mean
G20 Pack- Years (n=11),
Mean
Q20 Pack- Years (n=38),
Mean P
Anxiety (state) 33.33 43.57 46.92 .339 33.33 37.27 46.45 .070
Anxiety (trait) 36.00 36.70 41.33 .400 36.00 33.45 39.11 .279 General worry 36.67 40.70 42.83 .746 36.67 37.45 42.24 .462 Cancer worry 6.00 11.14 12.08 .034 6.00 11.09 11.45 .046
Attentional function 72.17 60.35 56.39 .264 72.17 62.95 58.35 .243 Illness experience 32.33 29.24 25.92 .087 32.33 29.64 28.08 .348 Life orientation 16.33 16.35 14.42 .341 16.33 16.45 15.71 .850
Table 2 & Major Study Variables
Mean (SD) Range
Anxiety (state) 43.75 (14.25) 20.0Y77.0
Anxiety (trait) 37.73 (10.44) 20.0Y67.0 General worry 40.96 (12.83) 20.0Y75.0 Cancer worry 11.06 (3.70) 3.0Y15.0
Attentional function 60.12 (14.97) 28.56Y91.63 Health environment/illness
experience 28.65 (5.45) 13.0Y35.0
Life orientation 15.90 (3.97) 6.0-24.0
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is either current or former smokers.43Y45 Moreover, the aim of this study was to explore relationships between psychological and environment factors and smoking status; thus, studies with larger sample sizes are needed before findings are generalizable. The findings were reliant on self-reported smoking status. Given the social stigma associated with smoking, self-reported smoking status without biochemical verification could introduce misclas- sification of current smokers. Furthermore, the study was cross- sectional in nature. Therefore, it is unable to provide information on causal relationships as do longitudinal studies. The study was unable to provide information about anxiety sensitivity in this group of patients, which could better demarcate markers of emotional vulnerability in smoking patients.10
Nursing Implications
Nurses are cognizant of the need to provide smoking cessation counseling and resources for patients with newly diagnosed lung cancer. Patients who successfully stop smoking following a cancer diagnosis have better clinical outcomes, such as decreased fatigue and shortness of breath, increased functional activity level and quality of life, less treatment toxicity, as well as better sur- vival.46Y48 The Surgeon General"s Report ‘‘The Health Conse- quences of SmokingV50 Years of Progress’’ articulated the essential need for providing cessation interventions to cancer patients.49,50 A diagnosis of cancer can be a ‘‘teachable moment’’ because many patients are highly motivated to quit smoking as the benefits of quitting are evident.51,52 However, smoking cessation may be cognitively and emotionally overwhelming to patients who smoke to help manage stress in the face of a life- threatening stressor.2 Given that unsuccessful quit attempts may increase psychological difficulties and subsequently affect can- cer adaptation negatively, interventions beyond smoking cessa- tion counseling (eg, assessing contributing factors of continuing smoking) may be needed for patients with a smoking-related cancer diagnosis.7
Less attention has been played toward promoting optimistic outlook for patients with lung cancer. Although the benefits of smoking cessation have been well established, fatalistic view toward health consequences is prevalent among patients with
lung cancer, which may contribute to relapse.52 Identifying re- sources and helping patients to recognize positive, realistic aspects of their lives are important. The study was able to provide im- portant information relative to smoking status and psychological distress at the time of diagnosis of suspected or actual lung cancer.
Research Implications
More research is needed to develop understanding of patient and disease factors that impact smoking and smoking cessation. Further research in both lung cancer groups and other cancer populations is also needed to clarify factors associated with persistent smoking following diagnosis. Studies aimed at better understanding strategies that would help vulnerable subgroups of patients with high distress to manage the negative effects of managing an addiction coincident with receiving a life- threatening diagnosis are needed. Surprisingly, a recent Cochrane review identified no randomized controlled studies of smoking cessation interventions tailored to lung cancer patients.53 Psy- chotherapeutic modalities, such as mindfulness-based cognitive therapy, which address negative perseverant cognitions such as worry with cognitive-behavioral and mindfulness meditation prac- tices, are promising.54 Such interventions also target the relaxation response providing somatic quieting for affective activation. It is also imperative that physiological mechanisms that connect breathing patterns with psychological states such as worry, anx- iety, and negative affect are evaluated such as measurement of breathing timing parameters in persons prone to continued smoking or smoking relapse. This knowledge would guide appropriate incorporation of practices such as yoga and qigong breathing practices into mindfulness-based cessation interven- tions that may prevent smoking relapse via relief of interoceptive discomfort to reduce anxiety sensitivity.55,56 Finally, longitudi- nal studies that are able to address the impact of smoking on subsequent cancer adaptation are imperative.
n Conclusion
Given the better clinical outcomes for patients who successfully stop smoking following a lung cancer diagnosis, heightening
Table 4 & Associations With Life Orientation (N=52)a
All Patients (N=52)
All Smokers (n=49)
Current Smokers (n=12)
Former Smokers (n=37)
Anxiety (state) j0.27 j0.25 j0.34 j0.18
(P= .055) (P= .080) (P= .276) (P=.299) Anxiety (trait) j0.36 j0.33 j0.49 j0.21
(P= .010) (P= .020) (P= .109) (P=.205)
General worry j0.16 j0.14 j0.23 j0.06 (P= .247) (P= .345) (P= .472) (P=.721)
Cancer worry j0.19 j0.17 j0.33 j0.11 (P= .177) (P= .234) (P= .301) (P=.502)
Attentional function 0.19 0.16 0.16 0.18 (P= .177) (P= .258) (P= .622) (P=.281)
Health environment/illness experience 0.49 0.47 0.45 0.44
(PG .001) (PG .001) (P= .144) (P=.007)
aSpearman correlation.
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efforts to ensure that cessation is permanent are essential. Cog- nitive behavior therapies incorporating adaptive coping and stress management skills could be options to help manage distress, pro- mote effective cognitive functioning, and promote cessation efforts for smokers diagnosed as having lung cancer. Open discussion and provision of referrals for individual and/or family counseling may be needed to facilitate effective coping with a new diagnosis of lung cancer.
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