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Swanson's Caring Theory in Anxiety and Depression in Cancer Patients

University of Cincinnati

Running head: SWANSON'S CARING THEORY IN ANXIETY AND DEPRESSION 1

SWANSON'S CARING THEORY IN ANXIETY AND DEPRESSION 11

Abstract

A cancer diagnosis can be a very emotional and trying time for a patient. Along with all the physical ailments that come with a cancer diagnosis, there are also emotional symptoms as well. Anxiety and depression are common in patients following a cancer diagnosis. The reduction of this anxiety and depression are important to the quality of life of this patient population. The purpose of this paper is to establish how Swanson’s Theory of Caring could be applied to the reduction of anxiety and depression in cancer patients. A succinct summary of the state of the science was performed on multiple recent research articles. Swanson’s theory will be applied to this clinical situation within the theoretical framework that is provided.

Keywords: Swanson, caring theory, anxiety, depression, cancer

SWANSON'S CARING THEORY IN ANXIETY AND DEPRESSION 3

Swanson’s Theory of Caring

Swanson’s theory of caring was originally developed in 1991 by Kristen M. Swanson. Swanson’s theory is a middle range nursing theory of caring that was developed in the context of perinatal case studies (Swanson, 1991). In the development of the theory, Swanson constructs a definition of caring by analyzing five different caring processes.

The first concept of caring that Swanson describes is knowing. Knowing is working to understand what meaning an event has in the life of the other person. With knowing, the provider avoids assumptions about the meaning of an event, and focuses on the one being cared for. This allows for an in-depth cue-seeking assessment of the other persons experience. The second concept of caring is being with. This concept is very simply being there for the other person. This includes conveying availability, and a mutual sharing of pleasant and unpleasant feelings (Swanson, 1991). The other person must know that their experience is important to the caregiver. The third concept of caring is doing for. Doing for is described by Swanson as providing skillful, competent care for others as they would normally do for themselves if it were possible. The fourth concept is enabling. This is to help the other person through life changes and events that they may be unfamiliar or uncomfortable with (Swanson, 1991). This would include offering emotional support and helping them formulate a plan or action. The final concept of caring is maintaining belief. This is keeping faith in the other persons ability to make it through a transition and find a meaningful future (Swanson, 1991).

As Swanson conducted case studies in the perinatal setting she developed these previously mentioned concepts of caring. From that, she derived the following definition of caring. “Caring is a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility” (Swanson, 1991, p. 165). In Swanson’s original work, she failed to relate these concepts together. In an update to her theory in 1993 she added a structural component to the theory that depicts the relationship between these concepts. “The proposed structure for the theory depicts caring as grounded in maintenance of a basic belief in persons, anchored by knowing the other's reality, conveyed through being with, and enacted through doing for and enabling” (Swanson, 1993, p. 357). The applicability to my topic was derived from these five caring processes and their relationship to each other defined in Swanson’s theory. Nurses provide a pivotal role in providing care to cancer patients. This is both physical, emotional and spiritual. I believe that all five of these caring concepts could be applicable to providing care to the cancer patient with anxiety and depression.

State of Science

A thorough search of the literature was conducted. The findings of this search will be used to describe the current state of the science. A search was performed using the database CINAHL and Google scholar. The search terms that I used in these databases were Swanson, comfort theory, anxiety and depression, and cancer. Inclusion criteria included articles less than five years old, English language, and peer reviewed. Exclusion criteria included no meta-analysis or systematic reviews. My final search yielded four scholarly research articles that I will analyze and describe in detail in the following paragraphs.

A phase II single descriptive study was performed to look at the effect that complementary and alternative medicine (CAM) had on quality of life, depression, anxiety, and fatigue of cancer patients who were actively receiving treatment. The study sample included 135 cancer patients in the Division of Oncology at Ramban Health Care Campus in Haifa, Israel. Convenience sampling was used. The patients in the study were given three questionnaires that were completed upon starting the study, after the six-week treatment, and 6 weeks after treatment ended. The first questionnaire was the Hospital Anxiety and Depression Scale (HADS), the second was the Brief Fatigue Inventory (BFI), and finally the QoL-EORTC-C30 which assesses the quality of life of cancer patients specifically. CAM therapy was provided once per week for six weeks for the study participants. This included art therapy, music therapy, guided imagery, shiatsu, and cranio-sacral therapy among others (Bar-Sela et al., 2014). All measurement tool questionnaires demonstrated validity and reliability in various settings. Statistical software was used to measure outcomes and compare values from baseline scores, post-treatment score, and follow-up scores. The results found that six weeks of CAM treatment had a statistically significant improvement on anxiety, depression, fatigue, and quality of life measurements both post-treatment, and six weeks after treatment (Bar-Sela et al., 2014). A major limitation to this study was that it was not performed as a randomized control trial. The patients were self-referred with no comparison to other practices. This would make it difficult to generalize the results to other populations. This article would be considered a level V study of evidence due to the lack of a control group, the inability to compare outcomes between groups, and lack of random sampling (Facchiano & Snyder, 2012).

The second study is a quasi-experimental study performed to look at the effects of music therapy on depression and anxiety levels in cancer patients. Sixty patients were recruited per a random sampling method. They were divided into a control group and an intervention group. The intervention group listened to quiet music for twenty minutes a day for 3 days. The control group did not listen to any music. Anxiety and depression levels were assessed by HADS once prior to initiation of therapy and once 3 days after therapy was completed. The article is clear that the validity of HADS is highly sensitive and widely used. Statistical software was used running multiple different statistical tests including t-test, pearson, and ANOVA. Results of the study indicated statistically significant decrease in anxiety and depression levels on patients who received the musical therapy intervention compared to those who did not (Jasemi et al., 2016). There is one major limitation noticeable in this study. The sample size of 60 patients is considerably low (Jasemi et al., 2016). This article would be considered a level III study of evidence, due to the well-designed control groups with lack of complete randomization (Facchiano & Snyder, 2012).

The third article that was reviewed was another quasi experimental study that evaluated how effective counseling was on anxiety and depression for hospitalized cancer patients who are receiving radiation therapy. A quasi experimental pre-test, post-test study design was used. 100 participants were included in the study. The sample method used was convenience sampling. Fifty participants were placed in the control group, and the other 50 participants were placed in the intervention group. Patients in the intervention group received individual counseling sessions one time per week for a total of 4 weeks. Therapy would consist of emotional support, active listening, clarifying problems, and helping develop coping skills in terms of symptom management. Data collection was based on standardized tools used to measure depression and anxiety levels. State and trait anxiety inventory (STAI) and Beck depression inventory were used to measure anxiety and depression levels at baseline and after 4 weeks of intervention. Cronbach’s alpha of tool for STAI was 0.86. Cronbach’s alpha of tool for Beck’s depression inventory was .82. This indicated both tools were reliable within this study sample. The statistical analysis of this data indicated a clinically significant reduction in anxiety and depression levels for hospitalized cancer patients who received counseling (Pathak et al., 2013). One limitation of this study was sample size. An additional limitation identified by the author were that variables such as social support and self-efficacy were not able to be controlled (Pathak et al., 2013). This article would be considered a level III study of evidence due the well-designed study with control groups. A lack of randomization decreases the strength of findings (Facchiano & Snyder, 2012).

The final article reviewed for the state of the science is a descriptive study. The purpose of this article was to “quantitatively test Swanson’s theory of caring by measuring the relationship between nurse caring behaviors and mother’s confidence in a convenience sample of primiparous mothers” (Mott, 2016, p. 96). Although there was no literature available applying Swanson’s theory of comfort to the anxiety and depression of cancer patients, there is significant importance in seeing the theory applied to a clinical situation. Data collection for this study was from a convenience sample of 104 participants. Institutional review board approval was received prior to the study. Participants were recruited by nurse managers following discharge from the labor and delivery unit. After discharge, mothers completed the Wolf’s CBI-24 and the Maternal Confidence Questionnaire (MCQ). The Wolf’s CBI-24 is a questionnaire that measure behaviors that the patient perceives as being caring. Chronbach’s alpha of tool was 0.88. The MCQ is a scale where the mother would indicate her level of maternal confidence. Chronbach’s alpha for this tool was .863 in this study (Mott, 2016). “This study shows explicitly how the caring characteristics of the nurse identified by Swanson manifest a trusting nurse-patient relationship that significantly correlates to maternal confidence” (Mott, 2016, p. 100). The first identified limitation of this study is the use of a convenience sample. Another limitation of this article was that the sample was predominantly women of higher education as compared to others in the region. Additionally, this study excluded mothers who did not speak or read English. This article would be considered a level V study of evidence due to the lack of control group and the inability to compare outcomes between groups (Facchiano & Snyder, 2012).

Three of the articles that were reviewed were specifically related to my clinical topic of reducing anxiety and depression among cancer patients. All of these articles introduced therapies and interventions that showed statistically significant improvement in anxiety and depression among cancer patients. The final article that was studied gave a quantitative study in applying Swanson’s Theory of Caring. My review of the state of the science yielded two lower level of evidence studies. Two of the articles were rated at a level V due to lack of random sampling, and lack of control groups. In the two level V studies, only one of them tested the validity and reliability of the tools and screenings that were used. My review of the literature also yielded two higher level research studies. I reviewed two quasi-experimental studies that were well-designed and included control groups. Although randomization was not used in these samples, the ability to compare outcomes to a control group give this evidence a higher validity.

In all articles reviewed, the purpose of the study was very clearly stated. All articles listed specifically all the statistical data they used as evidence to state their findings. Additionally, all the articles followed a logical flow through the study process, making it easy to identify findings, statistical data, and other important aspects of the study. Limitations were clearly addressed in all articles. Small sample size and lack of randomization common limitations among my research. Taking into consideration that all the articles had some elements of high quality research, I would consider the quality of the data to be moderate. Additional large-scale randomized controlled studies are needed in the reduction of anxiety and depression among cancer patients.

Application to Advanced Nursing Practice

Cancer diagnoses can provoke enormous anxiety along with other psychological reactions. Swanson’s Caring Theory can be applied to this clinical topic in an effort to reduce anxiety and depression. This could in turn improve quality of life for these cancer patients. Applying Swanson’s theory would require breaking the theory down into the five caring concepts that were mentioned earlier. Understanding knowing, being with, doing for, enabling, and maintaining belief are essential to applying these concepts to practice. One way to apply this theory to practice would be to provide an education intervention to the health care workers who will be caring for these patients on a regular basis. Enabling a nurse-patient relationship that promotes patient well-being can be constructed through this education. Swanson’s theory was applied to new mothers and found that the concepts of being with, enabling, and maintaining belief were important in promoting confidence in their transitional phase (Mott, 2016). Based on this, caretakers who are educated on the development of this nurse-patient relationship based on caring theory could help these patients work through their transitional phase of a cancer diagnosis. Based on the complexity and multiple concepts in the framework of this theory, at least two educational sessions at two hours each would be necessary. Content would include a detailed summary of the theory along with multiple examples of each concept and how their actions and words can convey these concepts. Measurable outcomes would be necessary to ensure that the caretakers have a good understanding of the theory and its application. Being able to identify each concept of caring, along with examples of each would be necessary for successful implementation of the education.

A second application of Swanson’s theory would be to provide cancer patients with a counseling session once per week with an emphasis on Swanson’s caring concepts. “Counseling was found effective to significantly reduce anxiety and depression in hospitalized cancer patients” (Pathak et al., 2013, p. 133). Integrating counseling with Swanson’s theory could provide a significant reduction in anxiety and depression of cancer patients. The knowing portion of the counseling would include trying to understand how the cancer diagnosis has meaning in the patient’s life. The being with portion would consist of being available and the sharing of mutual feelings and making it known that the patient’s situation is important to the caregiver. Doing for would consist of providing care for the patient that they would normally provide themselves. Enabling would consist of the caregiver using their expertise to provide comfort and assistance in facilitating growth and healing. Finally, in the maintaining belief portion of counseling the caregiver would offer realistic optimism to face the future (Swanson, 1991). It is likely that a 30-60-minute counseling session once per week would be sufficient to apply Swanson’s Caring Theory. A reduction in anxiety and depression would be measurable by a valid, reliable screening tool given to patients prior to the counseling and after to measure anxiety and depression levels.

Summary

An in-depth study of Swanson’s Theory of Caring, and a succinct review of the current state of the science were performed. This revealed the significant need for the reduction of anxiety and depression levels in cancer patients. According to the state of the science, there are multiple interventions that have shown effective in reducing anxiety and depression. Using this evidence and integrating the previously discussed caring concepts of Swanson’s theory, I made two care recommendations with the potential to improve patient outcomes. The applicability of Swanson’s theory to this clinical challenge was revealed in the staff education sessions, and patient counseling sessions that were described in detail. A great responsibility is placed on health-care workers to be well-informed and base care interventions on evidence. Using evidence based in science and integrating this into a theoretical framework have the potential to improve the care that we give.

References

Bar-Sela, G., Danos, S., Visel, B., Mashaich, T., & Mitnik, I. (2014). The effect of complementary and alternative medicine on quality of life, depression, anxiety, and fatigue levels among cancer patients during active oncology treatment: Phase II study. Support Care Cancer, 23(1), 1979-1985. https://doi.org/10.1007/s00520-014-2560-

Facchiano, L., & Snyder, C. H. (2012). Evidence-based practice for the busy nurse practitioner: Part one: Relevance to clinical practice and clinical inquiry process . Journal of the American Academy of Nurse Practitioners, 24, 579-586. https://doi.org/10.1111/j.1745-7599.2012.00748.x

Jasemi, M., Aazami, S., & Zabihi, R. E. (2016). The effects of music therapy on anxiety and depression of cancer patients . Indian Journal of Palliative Care, 22(4), 455-458. https://doi.org/10.4103/0973-1075.191823

Mott, B. (2016). Measurement of Swanson’s theory of caring using primiparous mothers. International Journal for Human Caring, 20(2), 96-101. https://doi.org/10.20467/1091-5710-20.2.96

Pathak, P., Mahal, R., Kohli, A., & Nimbran, V. (2013). A quasi experimental study to evaluate the effectiveness of counseling on anxiety and depression among hospitalized cancer patients receiving radiotherapy. International Journal of Nursing Education, 5(2), 133-138. https://doi.org/10.5958/j.0974-9357.5.2.080

Swanson, K. M. (1991). Empirical development of a middle range theory of caring. Nursing Research, 40(3), 161-166. Retrieved from http://nursing.sites.unc.edu/files/2012/11/ccm3_032548.pdf

Swanson, K. M. (1993). Nursing as informed caring for the well-being of others. Journal of Nursing Scholarship, 25(4), 352-357. Retrieved from http://nursing.unc.edu/files/2012/11/ccm3_032549.pdf