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The Effects of Concrete Objective Information
and Relaxation on Maintaining Usual Activity
During Radiation Therapy
Norma J. Christman, PhD, RN, FAAN, and Linda B. Cain, PhD, RN
Key Points . . .
Purpose/Objectives: To examine the effects of concrete objective in-
formation (COI) and relaxation instruction (RI) on patients undergoing
radiation therapy, as well as the contribution of symptom uncertainty and
Receiving either concrete objective information or relaxation
body awareness to the intervention effects.
instruction can help patients to maintain more of their usual ac-
Design: Three-group randomized trial. Assignment was stratified by
tivities during radiation therapy for cancer.
cancer site. Data collectors were blinded to group assignments.
Concrete objective information can help patients to cope with
Setting: University medical center radiation therapy department serv-
ing both urban and rural communities in the southeastern United States.
the effects of radiation therapy by reducing their uncertainty
Sample: 76 adults having radiation with curative intent for gyneco-
about treatment-related symptoms.
logic, head and neck, or lung cancer. Most were Caucasian and had in
Understanding why interventions are effective and why some
situ to stage II disease. Mean age was 55 years.
patients may benefit more than others may aid decisions about
Methods: COI and RI were delivered by tape recordings. Outcome
their use in practice.
measures were indicators of usual activities and emotions at treatment
week 3 and two and four weeks post-treatment.
Main Research Variables: Intervention group; social, household, and
recreational activities; anxiety, depression, and anger; body awareness;
and symptom uncertainty.
about use of interventions in practice (Conn, Rantz, Wipke-
Findings: Participants receiving either intervention reported more
Tevis, & Maas, 2001).
social activity during treatment. Those given RI who were high in body
Individual characteristics, such as a tendency to use certain
awareness reported more household activity during treatment. No effects
coping strategies more than others (Miller & Mangan, 1983;
were found regarding emotion. Symptom uncertainty partially explained
Watkins, Weaver, & Odegaard, 1986; Wilson, 1981), the ex-
COI effects.
tent to which one wants information (Auerbach, Martelli, &
Conclusions: The findings provide additional support for the effec-
Mercuri, 1983), the level of anxiety prior to an anticipated
tiveness of COI in helping patients to maintain more of their usual activi-
event (Sime & Libera, 1985), and the degree of optimism
ties during radiation therapy. Instruction in progressive muscle relaxation
(Johnson, 1996), have been reported to modify responses to
also may help in maintaining activities.
Implications for Nursing: COI helps patients to cope with treatment
COI. Yet other researchers have reported no differences in in-
by reducing their uncertainty about symptoms. RI effects may vary by ac-
tervention effects by variation in individual characteristics
tivity type and awareness of usual body sensations.
(Rainey, 1985), or the intervention effects by individual char-
acteristic variations differed by outcome measure (Auerbach et
al.; Miller & Mangan; Shipley, Butt, Horwitz, & Farbry, 1978).
oncrete objective information (COI), guided by self-
regulation theory (Johnson, 1999) and varied relax-
Norma J. Christman, PhD, RN, FAAN, is an associate professor in the
ation strategies (Hyman, Feldman, Harris, Levin, &
College of Nursing at the University of Kentucky in Lexington, and
Malloy, 1989), has been found to be effective in a variety of
Linda B. Cain, PhD, RN, is an associate professor at the Lansing
patient populations, including those with cancer. Knowing that
School of Nursing at Bellarmine University in Louisville, KY. This re-
search was supported by National Institutes of Health Grant R29 NR/
an intervention is effective is important, as is understanding
CA01830. (Submitted May 2003. Accepted for publication October
why it is effective and whether some groups of patients ben-
30, 2003.)
efit more than others. Information that provides explanations
for intervention effects may be helpful when making decisions
Digital Object Identifier: 10.1188/04.ONF.E39-E45
Oldham, 1982; Wells, 1982) have been demonstrated in a
In addition, limited evidence supports hypotheses about
variety of populations (Devine & Westlake, 1995; Hyman et
why COI is an effective intervention. Johnson (1973) pro-
al., 1989; Johnston & Vögele, 1993). Generally, the relax-
posed that COI increases the congruence between patients'
ation literature is silent with regard to the effects of indi-
expectations and experiences because they are assisted in
vidual differences (Hillenberg & Collins, 1983; Tarler-
forming accurate images of the experiences and use these
Benlolo, 1978). Yet some findings suggest that not all people
images during events to validate their experiences and guide
respond positively to relaxation strategies (Benson, Alex-
their behaviors (Johnson, Rice, Fuller, & Endress, 1978;
ander, & Feldman, 1975) and that some may, at least ini-
Leventhal & Johnson, 1983). Although this interpretation is
tially, respond negatively (Heide & Borkovec, 1983). Nega-
consistent with the parallel response model of coping, which
t i v e effects were postulated as related to self-focused
is a part of self-regulation theory (Johnson, 1996, 1999), evi-
attention or increased awareness of bodily experience that
dence supporting the congruence hypothesis is limited to self-
was aversive for some people (Heide & Borkovec, 1984). A
report of expectations and experiences as more similar for
tendency to be more or less aware of normal internal bodily
patients given COI than for those not given the information
sensations, such as heart beat and hunger pangs (Miller et al.,
(Johnson, Christman, & Stitt, 1985; Johnson, Lauver, & Nail,
1981), may explain differential effects of relaxation. When
1989). Perhaps COI induces the processing of more specific
required to attend to their bodies with relaxation instruction
information rather than a general comparison of what is ex-
(RI), people less aware of normal bodily sensations may re-
pected and experienced. The congruence between expected
spond less positively, and those who are more aware of such
and experienced physical sensations may be particularly im-
sensations may respond more positively.
portant in producing the beneficial effects of COI. A more
In this study, the following hypotheses were tested.
direct test of the congruence hypothesis may be achieved by
1. Patients receiving COI will report maintaining more of
determining whether perceived uncertainty (Mishel, 1999),
their usual activities than those not receiving the informa-
specifically that associated with sensory or symptom experi-
ences, helps to explain why COI is effective. Uncertainty
2. Patients receiving RI will report less emotional distress
about sensory experiences may disrupt regulation of coping
than those not receiving instruction.
behavior. COI, which includes the typical sensory experi-
3. The effects of both interventions will be greater in pa-
ences, their causes, and how they change over time, may re-
tients reporting more awareness of bodily sensations than
duce symptom uncertainty, thereby enhancing coping out-
those reporting less awareness.
4. Uncertainty about symptom experiences will help to ex-
Considerable evidence shows that cognitive interpretation
plain why COI is effective.
of physical sensations guides behavior during illness and
treatment experiences (Leventhal et al., 1997). People moni-
tor their physical sensations or symptoms, assign meaning to
them, and act based on their interpretations. For example,
symptom experiences influenced decisions to take medica-
tion in people with hypertension (Meyer, Leventhal, & Gut-
Eligibility criteria included receiving radiation therapy
mann, 1985), patients receiving chemotherapy were more
(RT) with curative intent for uterine, cervical, head and neck,
distressed by ambiguous symptoms (Nerenz, Leventhal, &
or lung cancer; being at least 21 years of age, having no con-
Love, 1982), and older adults were more likely to attribute
current psychiatric diagnosis or medical conditions that lim-
vague symptoms to age than to illness (Leventhal & Diefen-
ited functional ability; having no concurrent chemotherapy
bach, 1991).
or prior RT; and being able to read and understand English.
Variations in the tendency to focus on the self also may
Eligible patients were provided with verbal and written ex-
help to explain the effects of sensory information. Carver and
planations of the study and had an opportunity to ask and re-
Scheier (1981) suggested that people vary in the degree to
ceive answers to any questions. Those agreeing to participate
which they attend to the public and private aspects of the self
gave written consent after the verbal explanation of study
and that such differences influence behavioral responses.
participation and the opportunity for questions and answers.
People also vary in their disposition to attend to internal
A total of 161 patients met the eligibility criteria, and 91
bodily sensations (Miller, Murphy, & Buss, 1981), which is
(57%) consented. The majority (70%) of those declining par-
an aspect of the private self. These notions, combined with
ticipation cited travel time, time involved, and lack of inter-
the findings of Pennebaker (1982) and others who indicated
est. Among those who gave consent, 6 withdrew from the
a link between an internal attentional focus and symptom
study and 9 were excluded from data analysis because of
reports (Bekker, Croon, & Vermaas, 2002; Ferguson &
change in treatment plan (chemotherapy [n = 1], a second
Ahles, 1998; Higgins, 1995), suggest that people who tend to
cancer diagnosis [n = 2], discovery of advanced disease [n =
be more aware of their internal bodily sensations may be
3], refusal of further treatment [n = 1], or not meeting inclu-
more responsive to unanticipated changes in the sensations.
sion criteria [history of psychiatric disorder, n = 1; prior RT,
Thus, people who tend to be more aware of internal physical
n = 1]). Those who withdrew or were excluded from analy-
sensations and changes in sensations may benefit more from
sis were distributed across the experimental groups.
COI than those who tend to be less aware of their internal
sensations. Variation in attention to internal bodily sensa-
tions also may influence responses to relaxation techniques.
For women having RT for gynecologic cancer, the COI
Positive effects of relaxation on symptoms such as nausea
messages describing what patients typically see, hear, and
(Burish & Lyles, 1981), pain (Stam, McGrath, & Brooke,
feel during RT incorporated symptom descriptors from a
1984), and emotional distress (Lyles, Burish, Krozely, &
prior study of women having RT for gynecologic cancer
(Christman, Oakley, & Cronin, 2001). Because the symptom
sures was moderate as expected and ranged from 0.30 for
descriptors varied by operative status, separate messages
social activity to 0.54 for household activity. Unlike the
were developed for women at the pre- and postoperative
SIP, higher scores indicate higher function. To decrease
stages. For patients with lung or head and neck cancer, symp-
error variance, all scales were converted from the VAS for-
tom reports described by King, Nail, Kreamer, Strohl, and
mat to 10-point scales ranging from 0 (unable to do because
Johnson (1985) and congruent with those more recently de-
of my health) to 10 (normal for me).
scribed by Johnson, Fieler, Jones, Wlasowicz, and Mitchell
Emotional distress: The anxiety (9 items), depression (15
(1997) were incorporated into the COI messages. Each COI
items), and anger (12 items) subscales of the Profile of
message included the changes in symptoms over the course
Mood States (POMS) (McNair, Lorr, & Droppleman, 1992)
of therapy, explained how they were related to the effects of
were used. A 5-point Likert-type response format ranging
RT, and described symptoms as "the typical symptoms most
from 0 (not at all) to 4 (extremely) with a "past week" time
people experience while having RT" for a condition like
frame was used. Internal consistency estimates for the three
theirs. Two messages were used for each patient group. The
subscales ranged from 0.90­0.95. Data support the factorial,
first described the typical experiences during treatment and
construct, and predictive validity of the POMS (McNair et
was provided during the first treatment week; the second de-
al.). The POMS also has been used widely with people who
scribed the changing pattern of experiences after treatment
have cancer (Cassileth, Lusk, Brown, & Cross, 1985; McNair
completion and was given during the last treatment week. All
et al.).
messages were professionally recorded onto audiotape and
Body awareness: The private body consciousness subscale
accompanied by written summaries of the information.
of the Body Consciousness Questionnaire (Miller et al.,
RI was adapted from the progressive relaxation technique
1981) was used to measure differences in awareness of inter-
used by Wilson (1981) and Wilson, Moore, Randolph, and
nal body sensations. This 5-item scale uses a 5-point response
Hanson (1982) and professionally recorded onto audiotape.
format ranging from 0 (extremely uncharacteristic) to 4 (ex-
The first tape, which was given to participants during the first
tremely characteristic) to assess the degree to which the re-
treatment week, included an introduction to relaxation and
spondent tends to be aware of internal sensations, such as
focused practice in progressive and systematic relaxation of
hunger contractions of the stomach, temperature changes,
all muscle groups. The second message, given during the last
and heart beat. Test-retest reliability was 0.69, and the scores
treatment week, was a shortened version of the initial tape
were unrelated to social anxiety, hypochondriasis, and emo-
and included the suggestion that relaxation also might be
tionality as predicted (Miller et al.). The alpha coefficient
helpful in dealing with daily life events. Participants were
w a s 0.73 in a prior sample of 87 people having RT
provided with copies of these recordings and tape players
(Christman, 1995). In the present sample, the alpha coeffi-
with earphones to take home with them.
cient was 0.80.
To control for the attention given to participants in the
Symptom uncertainty: The Symptom Uncertainty Scale
experimental groups by the researchers, those assigned to the
(SUS) was derived from Mishel's Uncertainty in Illness Scale
control group also received professionally recorded messages
(MUIS) (Mishel, 1981, 1984). Ten items that reflected symp-
and written summaries of the messages. Information from the
tom perception or could be reworded to specifically assess
National Institutes of Health booklet Radiation Therapy and
symptom experiences were selected from the MUIS. The 5-
You (National Institutes of Health, 1985/2001) was incorpo-
point Likert response format ranging from 1 (strongly dis-
rated as appropriate to the treatment and post-treatment
agree) to 5 (strongly agree) was retained from the MUIS. In the
phases. The first message focused on general information
sample of 87 people having RT, the alpha coefficients were
about RT, how it works, its benefits, and skin markings. The
0.69 during treatment week 3 and 0.81 four weeks after treat-
second message included general information about follow-
ment completion. The relationship between the two scores was
up care.
moderate (r = 0.63) as expected because of changing symptom
experiences over time. One item was reworded based on ex-
amination of the item-total correlations and factor analysis
(Christman, 1995). In the present sample, the alpha coefficient
Usual activities: Measures of household, recreation and
was 0.67 during treatment week 3. Also at treatment week 3,
pastime, and social activities were selected from the 18 vi-
symptom uncertainty was unrelated to body awareness
sual analog scales (VAS) derived by Selby, Chapman,
(r = 0.09) and negatively related to perceived predictability
Etazadi-Amoli, Dalley, and Boyd (1984) from the Sickness
(r = ­0.53, p < 0.01) and understanding (r = ­0.48, p < 0.01)
Impact Profile (SIP) (Bergner, Bobbitt, Carter, & Gilson,
of treatment-related experiences, supporting the scale's dis-
1981). Test-retest reliability coefficients ranged from 0.63­
criminant and concurrent validity (Christman, Cain, Cronin, &
1.00, and the split half reliability coefficient was 0.91 for
Corley, 2002).
the 18 VAS in a sample of women with breast cancer. Cor-
Symptom experiences: A symptom inventory adapted from
relations between the VAS and SIP subscale scores were
the McCorkle and Young (1978) Symptom Distress Scale and
more than 0.60 for 9 of the 16 scales; the correlation be-
similar to that used by Johnson et al. (1985) and Johnson, Nail,
tween total scores of the two measures was 0.70. The VAS
Lauver, King, and Keys (1988) was used to measure the num-
m e t h o d also distinguished clinically different patient
ber and severity of symptoms commonly associated with RT.
groups as expected (Selby et al.). In an earlier study of pa-
The symptoms listed were those included in the RT consent
t i e n t s receiving RT for a variety of cancer diagnoses
form for the cancer site where the participant was being
(Christman, 1995), the correlations between the original
treated. Participants were asked to rate the severity of their
SIP subscales and the VAS were moderately strong: house-
symptoms on a 6-point scale ranging from 0 (have not had) to
hold, 0.60 (N = 87); recreation and pastime, 0.62 (N = 88);
6 (extremely bad).
and social, 0.57 (N = 88). The stability of the VAS mea-
Design and Procedures
The only effect on emotional distress was for the covariate
preintervention distress (F [1, 57] = 36.69, p < 0.001). No
A three-factor experimental design was used to test the
significant effects on recreation and pastime activities were
hypotheses. The first factor was intervention group (COI,
found. For social activity, with the effects of the covariates
RI, or control). The second factor was body awareness with
removed, the only other significant effect was a within-sub-
two levels using a median split. The third factor was time,
jects group by time interaction (see Table 1). As shown in
using treatment week 3 and post-treatment weeks 2 and 4.
Figure 1, during treatment week 3, participants in both the
Stratified random assignment by cancer site was used to
COI (Newman-Keuls q[7] = 4.59, p = 0.05) and RI (q[8] =
achieve proportional distribution across the experimental
5.43, p = 0.05) groups reported more social activity than did
those in the control group. Neither group differed from the
Participants were enrolled in the study during the first
control group two and four weeks after treatment completion.
treatment week. After informed consent and before the
Analysis of effects on household activities produced a
first intervention, participants completed the measures of
within-subjects group by body awareness by time interaction.
b o d y awareness and emotional distress. The SUS was
For the people low in body awareness (see Figure 2), neither
completed one day after each intervention. Additional
the COI nor RI groups differed from the control group across
measures of emotional distress were obtained during treat-
the measures of household activity. In the people high in
m e n t week 3 and two and four weeks after treatment
body awareness, household activity was greater in the RI
completion, as were the measures of usual activities and
group than in the control group (q[15] = 5.11, p = 0.05) only
symptom experiences. Research assistants who were blind
during treatment week 3. Although the COI group also re-
t o the participants' group assignments collected all
ported more household activity than the control group dur-
postintervention data. Post-treatment data were obtained
ing treatment week 3, the difference was not significant.
by mail with postcard reminders and follow-up telephone
Neither of the experimental groups differed from the control
calls as necessary.
group two and four weeks after treatment.
The hypothesized role of symptom uncertainty in explain-
ing the effects of COI was examined with the social activity
The final sample included 76 patients, 25 in the COI
scores from treatment week 3. The researchers used the re-
group, 25 in the RI group, and 26 in the control group. Ran-
gression approach to testing mediation effects suggested by
dom assignment, stratified by cancer site, achieved propor-
Baron and Kenny (1986). First, symptom uncertainty was
tional distribution of participants across the three groups (gy-
regressed on the contrast between COI versus the control
n e c o l o g i c cancer, 16%­18%; head and neck cancer,
group means. Second, social activity was regressed on the
9%­13%; and lung cancer, 5%). The sample included 52
group contrast. Lastly, social activity was regressed on both
(68%) women and 24 (32%) men; most were Caucasian
symptom uncertainty and group. Group explained 5.15% of
(92%). Their mean age was 55 years (SD = 12.2). More than
the variance in symptom uncertainty (COI X = 30.44, control
half of the participants were married (61%, n = 46), and 41%
X = 33.15; F[1, 74] = 4.02, p < 0.05) and 8.41% of the vari-
(n = 31) were employed outside the home. The others were
ance in social activity (F[1, 73] = 6.71, p < 0.02). When so-
either homemakers (n = 24, 32%) or retired or disabled (n =
cial activity was regressed on symptom uncertainty (7.72%
21, 28%). Most were within one month of diagnosis (n = 63,
83%); all were less than one year from initial diagnosis.
Table 1. Analysis of Variance for Usual Activity Scores
More than half of the sample had in situ to stage II disease
(59%, n = 45); 36% had stage III or IV disease (n = 27). Stag-
ing data were unavailable for four participants. The mean
number of RTs was 31.
Initially, the data were examined to assess the adequacy
of randomization. The experimental groups did not vary
significantly by gender (X  2[2, N = 76] = 2.17, not signifi-
Between subjects
cant). The mean scores for body awareness did not differ by
group (F[2,73] = 0.58, not significant). No systematic dif-
Body awareness
ferences existed in usual activities or emotional distress by
Group x body awareness
cancer site. As a manipulation check for the use of relax-
Subject within group error
56 (55)
ation across the groups, participants were asked four weeks
Within subjects
after treatment to indicate whether they had used any of a
number of coping strategies since beginning RT. The pro-
portion of patients reporting use of a relaxation strategy was
Time x group
greater in the RI group than in the other two groups (X  2[2,
Time x body awareness
N = 69] = 7.55, p < 0.03).
Time x group x body awareness
Repeated measures analysis of covariance was used to test
Time x subject within group error
113 (111)
the hypothesized effects of COI, RI, and body awareness on
Note. Values in parentheses are df changes caused by missing data and mean
usual activities and emotional distress. Number of reported
square errors.
symptoms at each time of measurement was the covariate for
* p < 0.05
analyses of effects on usual activities; emotional distress
** p < 0.01
prior to intervention was the covariate for analysis of effects
on emotional distress.
*** p < 0.001
descriptors in the information messages for patients with
head and neck or lung cancer might have influenced the find-
ings. However, this is unlikely because the information did
not include descriptions of side-effect severity, which most
likely is influenced by treatment advances.
The effects of COI were not influenced by level of aware-
ness of bodily sensations as predicted. Although patients less
aware of bodily sensations reported engaging in more house-
hold activities two weeks after treatment than those who were
more aware of such sensations, their level of activity did not
differ from that reported by the highly aware people in the
control group. Cioffi (1991) suggested that measures of so-
2 weeks after
4 weeks after
matic symptom perception do not capture degree of attention
week 3
to the sensation but that they do capture the degree of negative
interpretation generated by a person's awareness of the sensa-
tion. The effects of RI for those high in body consciousness
Concrete objective information
may be interpreted in light of such understanding. Perhaps the
Relaxation instruction
use of relaxation short-circuited the patients' tendency to pro-
cess their subjective experiences negatively, permitting more
Figure 1. Mean Scores for Social Activity by Intervention
involvement in usual household activities. That level of body
Group and Time
awareness influenced the effect of RI on household activity but
of the variance, F[1, 73] = 6.10, p < 0.02) and group, the
Low Body Awareness
amount of variance explained by group decreased to 5.01%
(F[2, 72] = 4.14, p < 0.05).
As hypothesized, patients receiving COI reported maintain-
ing higher levels of usual function than those not receiving this
information but only for social activity during treatment. The
effects of COI were explained partially by symptom uncer-
tainty. Preparatory information describing typical experiences,
including symptom experiences, helped patients form a mental
schema that reduced uncertainty about their symptom experi-
2 weeks after
4 weeks after
ences. Knowing what to expect and that the experiences were
week 3
typical and resulted from treatment helped patients to focus on
ways to deal with the experiences rather than on interpreting
and giving meaning to them (Leventhal & Diefenbach, 1991).
High Body Awareness
The information served as a resource for proactive coping
(Aspinwall & Taylor, 1997) as the participants dealt with the
effects of RT. Reducing symptom uncertainty may contribute
to understanding the experience, which Johnson et al. (1989)
found to explain the effects of COI in men having RT for pros-
tate cancer.
Unlike the findings of Johnson et al. (1988), COI in the
present study did not produce positive effects over time or
consistent effects across the measures of usual function.
Sample heterogeneity, particularly with respect to gender and
cancer site, most likely contributed to the lack of post-treat-
ment effects. Randomization may have failed to control for
2 weeks after
4 weeks after
the post-treatment clinical course and gender-related varia-
week 3
tions in usual activities. The lack of effects over time also
may be a result of reduced-dose effect. In contrast to prior
studies, the researchers of the current study were unable to
Concrete objective information
enroll participants prior to simulation and the first treatment.
Relaxation instruction
Thus, participants did not receive preparation for the simu-
lation experience or the first treatment. Also, self-care strat-
Figure 2. Mean Scores for Household Activity by
egies were not included in the messages, as done by Johnson,
Intervention and Time for Low and High Body Awareness
Fieler, Wlasowicz, Mitchell, and Jones (1997). Because of
advances in treatment planning and delivery, the symptom
Implications for Nursing
not its effect on social activity may relate to the specific na-
ture of these two activities and the potential differential effects
The findings of this study provide further support for the
of personality traits. Activities requiring greater physical en-
use of COI in the care of patients undergoing RT. RI also
ergy expenditure, such as work around the house, may call into
may help these patients maintain more of their usual activi-
play a person's tendency to be more aware of bodily sensa-
ties during treatment. In evaluating the effects of these inter-
tions. In this case, RI short-circuited the tendency to process
ventions in practice, assessing various types of usual activi-
subjective experiences negatively, permitting more involve-
ties may be important. Both COI and RI helped patients
ment in usual household activities. For activities involving less
maintain more of their usual social activities during treat-
physical energy expenditure that also distract attention from
ment, whereas only RI was effective for household activity
self, such as social activities, the tendency to interpret bodily
and only for those people more aware of normal physical
sensations negatively may be less operative.
sensations. Clinicians may consider assessing patients' ten-
The findings of this study provide additional support for the
dency to pay attention to their physical sensations when
positive effects of COI on functional status and suggest that RI
evaluating the effects of these interventions. They also may
also may enhance functional status during RT for cancer. Of-
find COI to be more effective when the intervention is started
ten overlooked is that, by increasing functional status, inter-
prior to simulation and combined with self-care information
ventions may decrease the social costs of treatment for cancer.
for dealing with the effects of RT.
Further, these findings suggest specific processes by which
COI and RI produce their effects on the outcomes of coping
The authors gratefully acknowledge the contributions of Jean E. Johnson,
with stressful treatment for cancer. Greater understanding of
PhD, RN, FAAN, John F. Wilson, PhD, and John V. Haley, PhD, as consult-
the processes by which these interventions produce effects on
ants. They also thank Marsha G. Oakley, MSN, RN, Theresa Kessler, PhD,
patient outcomes increases the probability of identifying other
RN, Gail Moddeman, PhD, RN, and Mary Beth Culross, PhD, RN, for their
interventions that may similarly affect the processes and, thus,
assistance in data collection, as well as the people who volunteered to par-
ticipate in this study.
patient outcomes. Most important to identifying new and in-
novative interventions is that symptom uncertainty helped to
explain the effects of COI. Such findings may be useful in
Author Contact: Norma J. Christman, PhD, RN, FAAN, may be
identifying other approaches for helping patients to deal with
reached at njchri1@uky.edu, with copy to editor at rose_mary@earth
stressful healthcare events.
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