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Needs of Ambulatory Patients With Cancer Who
Visited Outpatient Units in Japanese Hospitals
Michiyo Mizuno, PhD, RN, Hiromi Arita, MNSc, RN, and Miho Kakuta, MSN, RN
Key Points . . .
Purpose/Objectives: To document the domains and properties of the
self-reported needs of ambulatory patients with cancer.
Design: Descriptive.
Ongoing and emergent needs of Japanese patients with cancer
Setting: Outpatient units in three general hospitals in Japan.
essentially are undocumented in the literature.
Sample: 139 ambulatory patients with cancer.
Methods: The data were collected using questionnaires. Five theoreti-
If the goals of services and education are incongruent with the
cal groups, which were composed of 30 items, were extracted empirically
concerns and demands of would-be recipients, those services
as domains. Alpha coefficients for each domain ranged from 0.700.89.
and educational materials may not be accepted.
Relationships between each domain and other variables and among the
Instead of assessing patients' needs from a healthcare provider's
domains themselves were examined.
frame of reference, ask direct questions such as, "What kind of
Main Research Variables: Expressed needs of ambulatory patients
problems or burdens do you have?" and "What do you want,
with cancer, their backgrounds, medical and treatment characteristics,
need, or use in trying to attain and maintain your well-being?"
and physical functioning.
Findings: All domains for patient needs, except for healthcare needs,
were negatively correlated with the level of their physical function.
Emotional, physical, and functional needs were positively correlated
with the frequency of visiting an outpatient unit. Compared with other
mortality rate from lung cancer. Among women, mortality
needs, adaptation needs were greater for patients who were employed
resulting from lung, colorectal, hepatic, and breast cancers
or within three months of discharge. Among patients with one of three
follows mortality from stomach cancer. Plans to reduce the
cancer sites (i.e., breast, stomach, and colorectal cancers), the needs
length of stay in hospitals in Japan are being developed as in
for individualized care were the lowest for patients with colorectal cancer
and highest for patients with breast cancer.
other countries.
Conclusions: From the needs that ambulatory patients with cancer
Although most scientists and healthcare providers now
expressed, five domains were derived. Those domains had relationships
recognize the need for it, the incidence of cancer diagnoses
with other variables.
throughout Japan has not been documented formally. Many
Implications for Nursing: The findings shed light on a segment of
Japanese patients with cancer are not informed of the true
ambulatory cancer nursing and may be useful when developing and
nature of their illness; however, the rate at which patients'
testing programs needed in the future.
T
Michiyo Mizuno, PhD, RN, is a professor in the Department of
he incidence of cancer death in Japan in 2002 was
Adult and Eldery Nursing, Hiromi Arita, MNSc, RN, is a lecturer
304,286, with a mortality rate of 241.5 per 100,000
in the Department of Basic Nursing, and Miho Kakuta, MSN, RN,
(Health and Welfare Statistics Association, 2004).
is an instructor of clinical practice in the Department of Adult and
These statistics indicate that more than a third of the Japanese
Elderly Nursing, all in the School of Nursing at Ishikawa Prefectural
population succumbs to cancer. Since 1993, the leading cause
Nursing University in Ishikawa, Japan. This study was supported
of cancer death in Japan has been lung cancer in men and
by a Grant-in-Aid for Young Scientists (B) (#70287051) and a part
of Grant-in-Aid for Scientific Research (C) (#15592288) from the
gastric cancer in women. The death rate per 100,000 in 2001
Japan Society for the Promotion of Science. (Submitted June 2004.
was 66.8 and 27.0 respectively, for men and women (Health
Accepted for publication November 11, 2004.)
and Welfare Statistics Association). Among men, mortality
from gastric, hepatic, and colorectal cancers follows the high
Digital Object Identifier: 10.1188/05.ONF.E63-E69
ONCOLOGY NURSING FORUM VOL 32, NO 3, 2005
E63
cancer diagnoses are being divulged is increasing gradually.
tion, and psychological support. Some patients, particularly
According to an opinion survey in 2002 (Asahi Shimbun Sou-
older adults, seem to believe that making any demands on
gou Kenkyu Center, 2002), 77% of 2,060 Japanese citizens
physicians is improper. Many may express their desires
expressed a desire to know about the cancer when it was di-
or demands to healthcare providers if they are urged to do
agnosed and 56% reported that physicians should tell patients
so, but actions never are taken on their own accord. Many
about a cancer diagnosis.
healthcare providers do not know what to ask or how to ap-
In the outpatient departments of Japanese general hospitals,
proach patients with cancer who visit healthcare facilities
healthcare providers encounter patients with various cancers
for treatment. Although healthcare professionals are familiar
whose ongoing and emergent needs essentially are undocu-
with the therapeutic protocols and symptom characteristics
mented in the literature. One of the best ways to provide care
of ambulatory patients, they may be ignorant of the needs
that meets the needs of patients is to have an accurate and
or concerns of the latter related to improving their patients'
complete assessment that also focuses on important patient
psychological quality of life. Therefore, an examination of the
cues (Murray & Atkinson, 2000). A needs assessment is the
domains of need among patients with cancer, as well as their
first step in planning ambulatory care nursing interventions
association with patients' backgrounds or characteristics, will
and programs (Hackbarth, 2001) because designing programs
provide valuable information from which to develop needed
that nobody wants, needs, or will use is nonproductive.
programs and services.
Nurses in ambulatory care should be able to assess inclu-
Conceptual Framework
sively what they deem necessary, desirable, or useful for their
patients. However, nurses may have difficulty adequately
Without knowing the expressed needs of an individual,
estimating patients' needs. According to a qualitative study
teaching the patient or family about his or her illness and self-
about the psychosocial needs of patients with cancer, patients
care might not be effective. The needs uncovered in this study
and hospital caregivers rank patient needs differently (Bunston
are from patients who had received a diagnosis of cancer,
& Mings, 1995). The needs include, but are not limited to,
which brought on stressful experiences.
family adjustment, interactions with the healthcare system,
In general, a person experiences a stressful situation when
stigmas, informational needs, sexuality, and preservation of
he or she construes a demand as taxing, exceeding available
a normal lifestyle. Researchers have found that patients have
resources, or threatening to well-being (Lazarus & Folkman,
more needs in the areas of personal care, activity manage-
1984). During this time, the individual will make cognitive
ment, and interpersonal interaction than the patients' families
and behavioral efforts to manage, reduce, or tolerate the
had expected (Longman, Atwood, Sherman, Benedict, &
demands created by the stressful experience. This combined
Shang, 1992). Even patients' families may underestimate
effort is referred to as coping (Lazarus & Folkman). If the pa-
some domains of need for the care of home-based patients
tient with cancer does make such an effort, he or she also will
with cancer.
experience needs that arise because of various coping tasks
Nursing services should be delivered to patients who actu-
necessitated by the diagnosis and resultant treatment.
ally need them in a manner befitting their ideas and lifestyle.
A person tries to cope with a situation by using internal
If the goals of the services and education are incongruent
and external resources. Antonovsky (1987) stressed the
with the concerns and demands of would-be recipients, those
significance of focusing on coping resources in the con-
services and educational materials may not be accepted. Pa-
text of one's health rather than on the stressor. The coping
tients' concerns and demands about health problems must be
resources of the individual will facilitate active adaptation
understood so that the most appropriate programs and services
to the environment. Ambulatory patients with cancer need
can be developed.
professional support that can act as an external resource to
According to a survey on healthcare-seeking behavior con-
aid in solving their healthcare problems. This demand for
ducted among 113,980 ambulatory patients at 639 medical
professional support also is one of the dimensions of need
facilities throughout Japan (Statistics and Information Depart-
in this study.
ment at Minister's Secretariat on Ministry of Health, Labor,
and Welfare, 2001), 53% of all respondents stated that they
Research Questions
generally were satisfied, including "somewhat satisfied," with
This study addressed the following questions: (a) What are
their hospitals, whereas only 6% expressed dissatisfaction.
the expressed needs of ambulatory patients with cancer? (b)
Similar responses were obtained about specific items, such as
Are domains for needs related to the backgrounds or the medi-
details of consultation and treatment, physicians' responses
cal and treatment characteristics of these patients? (c) What
to questions or consultation with physicians, and nurses' or
are the relationships between the patient's level of physical
other personnel's responses to questions and consultation.
functioning and these domains? and (d) How do the needs
However, this survey inquired only about the level of patients'
domains relate to each other?
satisfaction in predetermined, limited areas and failed to fully
describe the needs that patients might have had. Instead of
Methods
assessing the patients' needs from the healthcare providers'
frame of reference, direct questions should be asked such as,
Procedures
"What kind of problems or burdens do you have?" and "What
do you want, need, or use in trying to attain and maintain your
In this descriptive study, ambulatory patients older than the
well-being?"
age of 20 were recruited at outpatient units for digestive dis-
Japanese patients do not readily express their desires or
eases or breast cancer in three general hospitals in Japan. The
make demands, especially from physicians, even when they
patients who had not been informed of their true diagnoses
recognize the need for healthcare education, medical informa-
(despite having cancer) were treated in outpatient units with
ONCOLOGY NURSING FORUM VOL 32, NO 3, 2005
E64
other patients with and without cancer. To take into account
1. Physical, psychosocial, and interpersonal problems
those patients who were not advised of their true diagnoses,
Physical problems (11 items)
those eligible to participate were not restricted to patients
I feel pain.
with cancer. All patients who visited the outpatient units were
I suffer from diarrhea or constipation.
included. Nurses in the hospitals gave the participants an ac-
Psychosocial problems (14 items)
count of the survey and handed them a copy of the question-
I was confused by why this has happened to me.
naire and a cover sheet that explained the aim of the survey
I fear that I will have a relapse.
and the rights of the participants. The survey began in October
Interpersonal problems (7 items)
I can't speak frankly to other people about my illness.
2001 and ended when 150 questionnaires had been distributed
I am concerned about the ability of those close to me to cope with
to voluntary participants at each hospital. The questionnaires
caring for me.
were completed and mailed back anonymously. The person
Total possible score: 160
responsible for this study had charge of all of the data. Prior
to data collection, the study was approved by the research
2. Coping tasks necessitated by the cancer diagnosis and resultant treatment
ethics committee of the institution with which the authors
(14 items)
are affiliated as well as by the hospitals where the surveys
I have to change my usual routine and way of living.
were distributed.
I can't accept the changes in my body.
Total possible score: 70
Questionnaire
3. Demands for professional support
The questionnaire consisted of three parts: (a) needs of am-
Information (8 items)
bulatory patients with cancer, (b) their physical functioning,
I want to be informed of the results of my examination.
and (c) disease category, treatment, and demographic data.
I want information about the most up-to-date treatment.
The content domains of the questionnaire were generated
Coordinating interpersonal relationships (6 items)
through active discussions among four researchers and four
I want a nurse to act as a mediator among my physician, my family,
associates who had more than 15 years of experience in oncol-
and me.
ogy nursing. The discussion was carried out from three points
I hope hospital staff members are considerate of my family.
of view: physical, psychosocial, and interpersonal problems;
Health system (8 items)
coping tasks necessitated by cancer diagnosis and treat-
I want the hospital staff to attend promptly to my physical needs.
ment; and demands for professional support. The Supportive
I want to see a doctor and enter the hospital immediately, when neces-
sary.
Care Needs Survey (Bonevski et al., 2000; Sanson-Fisher et
Total possible score: 110
al., 2000; Steginga et al., 2001) was referred to during the
process. A number of differences are apparent between that
Total possible score for all sections of the questionnaire: 340
questionnaire and the survey used in this study: The question-
naire used in this study asked about psychosocial problems
Figure 1. Sample Items From Each Section of the
by using phrases that were consistent with the way in which
Questionnaire
the Japanese express their emotions and had several original
needs items (e.g., items concerning support of interpersonal
relationships). In addition, some resources of support avail-
Results
able to Japanese patients were different. Items were formatted
with five-point Likert response options that ranged from 1
Sample Characteristics
(strongly agree) to 5 (strongly disagree). A preliminary ques-
tionnaire, pilot tested on 15 people, was revised based on the
A total of 450 questionnaires were distributed and 278 were
results. The final questionnaire contained 68 items. Examples
returned by mail (62%); 139 respondents reported a cancer
of items from each section of the questionnaire are presented
diagnosis. The remaining 139 were not included in this analy-
in Figure 1. The total possible score was 160 for physical,
sis because the patients did not record a cancer diagnosis on
psychosocial, and interpersonal problems; 70 for coping tasks;
the questionnaire.
and 110 for demands for professional support. A higher score
The average age of the respondents was 60.59 years (SD =
indicates more need.
11.11); 51% were men, and 49% were women. Eighty percent
The Medical Outcomes Study (MOS) Physical Function-
were married. On average, the respondents had been ill for
ing Measure (Stewart & Kamberg, 1992) was translated into
38.01 months (SD = 50.54); 32% had colorectal cancer, 22%
Japanese and used to measure the physical functioning of the
breast cancer, 20% gastric cancer, and 26% other conditions
respondents. The physical functioning measure included 10
(e.g., cancers of the pancreas or esophagus) (see Table 1).
items, satisfaction with physical capability had one item, and
Among the three participating hospitals, no significant dif-
mobility consisted of two items. The internal consistency was
ferences were found in cancer sites, therapeutic modalities
0.92 for the 10 items about physical functioning and 0.71 for
administered, or demography.
the two-item mobility scale (Stewart & Kamberg). The score
The average MOS score for physical functioning was 76.6
was transformed to a 0100 scale, with a high score reflecting
(SD = 23.5), the score for satisfaction with physical ability was
better functioning.
55.2 (SD = 23.0), and the mobility score was 92.4 (SD = 14.3).
Study participants were asked to enter their disease entity
These scores generally agreed with those obtained by Stewart
in brackets on the questionnaire. The respondents' reports of
and Kamberg (1992), who evaluated participants in an outpatient
their diagnoses and other information about disease, treat-
clinic in an urban setting and a rural health clinic (73.2, SD =
ment, and demography were used as indicators of disease
26.4; 61.0, SD = 25.8; and 93.3, SD = 16.1, respectively), with
and treatment status.
the exception of the score for satisfaction with physical ability.
ONCOLOGY NURSING FORUM VOL 32, NO 3, 2005
E65
Table 1. Sample Characteristics
for the first time, engaged in the process of content or consen-
sual validation. By using a three-point scale (0, 1, or 2), they
Variable
n
%
examined whether each item in every hypothesized theoreti-
cal group had a high likelihood of documenting the patients'
Age (years)
functions correctly. Both researchers assigned two points (the
--
X = 60.59
highest score) to 29 of 35 items and one point to 6 items. No
SD = 11.11
items received a score of zero. Items that were assigned two
Gender (N = 139)
points were retained in the analysis, and items that were as-
Male
171
51
signed one point were evaluated further by the expert panel.
Female
168
49
Although the items captured important aspects of the patients'
Marital status (N = 138)
Married
111
80
functions, some improvement was required. Five of these
Single
127
20
items were deleted, but the remaining item was considered
Living arrangements (N = 136)
very important and therefore retained. Consequently, five
Lives with family
126
93
theoretical groups or subscales composed of 30 items each
Lives alone
110
17
were used in the analyses (see Table 2). Internal consistency
Caregiver (N = 135)
of each subscale ranged from alpha 0.700.89.
Spouse
188
65
Other
147
35
Characteristics of Items Included in Each
Employment (N = 130)
Theoretical Group
Employed
167
52
Emotional needs (10 items) focused on the patients' emo-
Unemployed
163
48
Cancer type (N = 139)
tional distress and were measured with items such as "I fear
Colorectal
144
32
becoming dependent on others in performing my daily activi-
Gastric
128
20
ties," "I am worried about what the future holds for me," and
Breast
131
22
"I am confused about why this happened to me." The mean
Other
136
26
of each item included in this theoretical group was generally
Months since diagnosis
higher (2.593.27) than for the items included in adaptation
--
X = 38.01
needs and physical and functional needs. Higher mean and
SD = 50.54
median scores for an item indicate that a larger number of
Months since discharge (N = 135)
the study's sample reported that it was a current concern for
Less than three
134
25
them. However, the highest mode score was one on a five-
More than three
101
75
Reason for seeing a doctor (N = 128)
point scale for three items: "I fear death and dying," "I fear
Treatment
168
53
pain," and "I am anxious without any specific reason." That
Follow-up
160
47
is, a number of respondents reported that the items did not
Attending hospital (N = 139)
concern them currently.
A
145
32
Adaptation needs, composed of four items, focused on
B
130
22
whether patients with cancer needed to cope with new de-
C
164
46
mands posed by their disease. The four items were "I can't
Number of times visited an
accept changes in my body," "I am forced to change my rou-
outpatient clinic
--
tine and way of living," "I have to adjust my social life so as
X = 26.00
to continue my treatment," and "I can't speak frankly to other
SD = 50.43
people about my illness."
Physical and functional needs included five items that
pertained to physical symptoms and performance in daily
Expressed Needs of Ambulatory Patients
activities. Although four items (i.e., "I suffer from diarrhea
With Cancer
or constipation," "I can't sleep well," "I feel pain," and "My
Conceptually related items were grouped by analyzing the
activities of daily life are restricted") had relatively low mean
patients' responses to the questionnaires. Five theoretical
scores, a high score was assigned to the item "I lack energy
groups were hypothesized as domains for the needs of ambu-
or feel tired." The mean for this item (2.79) was higher than
latory patients with cancer. First, based on central tendency
for the other four items.
and variability, the items with outliers in the distribution of
Needs for individualized care incorporated five items and
the scores were eliminated from the questionnaires. Then, the
were concerned with seeking healthcare professionals for
items with contents that were related conceptually to each
treatment that is customized for a particular affliction, situa-
other were grouped. For every pair of items in each group,
tion, and condition. The means of each item included in this
--
bivariate correlational analyses were repeated. When the na-
subscale were somewhat high (X = 2.673.55, median = 3
ture of the linear relationship was negative or the magnitude
or 4). The highest mean scores were for "I want the hospital
of the linear relationship was comparatively weak, one of the
staff to promptly attend to my physical needs" and "I want
pair was deleted. In the end, the 35 remaining items comprised
to be treated like a person, not just another case." The group
five groups that were conceptually named emotional needs,
also included items pertaining to responses to the patients'
adaptation needs, physical and functional needs, needs for
families and to the nurse's role, such as "I hope hospital staff
individualized care, and healthcare needs.
members are kind to and considerate of my family" and "I
In the next step, two researchers, who were specialists in
want a nurse to act as a mediator among my physician, my
oncology nursing and introduced to these theoretical groups
family, and me."
ONCOLOGY NURSING FORUM VOL 32, NO 3, 2005
E66
Table 2. Characteristics of Items Included in Each Theoretical Group
--
Theoretical Groups and Items
X
SD
Median
Mode
Emotional needs (10 items, alpha = 0.89)
I am anxious without any specific reason.
2.59
1.33
3
1
I fear becoming dependent on others in performing my daily activities.
3.01
1.48
3
4
I fear that my body will get worse or weaken.
2.96
1.39
3
4
I worry that the results of the treatment will be beyond my control.
2.85
1.36
3
4
I am worried about what the future holds for me.
3.27
1.33
4
4
I am in constant anxiety about having any treatment.
2.59
1.32
3
4
I fear death and dying.
2.76
1.31
3
1
I fear pain.
2.62
1.39
3
1
I am lonely and sad.
2.66
1.30
3
4
I am confused about why this happened to me.
3.18
1.37
4
4
Adaptation needs (4 items, alpha = 0.70)
I can't speak frankly to other people about my illness.
2.30
1.18
2
1
I can't accept changes in my body.
2.45
1.20
2
1
I am forced to change my routine and way of living.
2.46
1.32
2
1
I have to adjust my social life so as to continue treatment.
2.60
1.43
2
1
Physical and functional needs (5 items, alpha = 0.75)
My activities of daily life (housework, shopping, commuting, etc.) are restricted.
2.30
1.39
2
1
I lack energy and am tired.
2.79
1.30
3
4
I can't sleep well.
2.37
1.32
2
1
I feel pain.
2.32
1.36
2
1
I suffer from diarrhea or constipation.
2.45
1.38
2
1
Needs for individualized care (5 items, alpha = 0.81)
I hope hospital staff members are kind to and considerate of my family.
2.67
1.26
3
3
I want the hospital staff to promptly attend to my physical needs.
3.55
1.42
4
5
I want a nurse to act as a mediator among my physician, my family, and me.
2.86
1.35
3
4
I want to take the advice of a specialist in counseling or social work.
2.79
1.36
3
1
I want to be treated like a person, not just another case.
3.33
1.40
4
5
Healthcare needs (6 items, alpha = 0.78)
I want to decide whether I go in for tests or treatment.
2.77
1.40
3
1
I want to choose my medical care based on my needs.
3.22
1.39
3
4
I want information (written, diagrams, drawings) about all aspects of managing my illness and side
3.57
1.36
4
5
effects at home.
I want information about a group that supports my recuperation in a different way than medical treat-
2.74
1.35
3
3
ment.
I want to get information on predictable marital relationship problems and coping strategies.
2.56
1.33
3
1
I want to talk to someone who understands how I feel and has been through a similar experience.
3.43
1.29
4
4
N = 139
Healthcare needs consisted of six items and focused on the
and for those within three months of discharge than those who
desire to be involved in one's own health care. This category
had been outpatients for three months or more. In the category
was typified by items such as "I want to decide whether I go
of physical and functional needs, a significant difference existed
in for specific tests or treatment." In the same category, the pa-
between patients in active treatment and those in follow-up care
tients demanded information and human resources that were
after treatment was completed. The need for individualized
needed to practice self-care (e.g., "I want information about
care was higher in women than in men. In the same category, a
all aspects of managing my illness and side effects at home,"
comparison across those grouped by cancer site revealed that
"I want to talk to someone who understands how I feel and
the mean scores for breast cancer were the highest and mean
has been through a similar experience"). Just as with the need
scores for colorectal cancer were the lowest.
for individualized care, the needs for this group were high, as
The relationship between each theoretical group and the
shown by means ranging from 2.563.57.
patient's age or frequency of visiting an outpatient unit was
evaluated using Pearson's product-moment correlation. The
Relationship to Patients' Background
emotional needs and physical and functional needs were posi-
and Characteristics
tively correlated with the frequency of visiting the outpatient
T tests were used to examine the differences among the
unit (r = 0.20, p < 0.05; r = 0.22, p < 0.05, respectively). None
theoretical groups or subscales in relation to gender differences,
of the theoretical groups was correlated with age. No associa-
occupational status, time elapsed since hospital discharge (more
tion was found between healthcare needs and the patients'
or less than three months), and treatment status. Analysis of
background and medical characteristics.
variance was used to examine differences caused by the ana-
Relationship With Patients' Physical Functions
tomic sites affected by cancer (see Table 3). The adaptation
needs were higher for patients who were employed at the time
The relationship between patients' expressed needs and
of the survey when compared to those who were unemployed
their physical function was assessed by Pearson's correlation
ONCOLOGY NURSING FORUM VOL 32, NO 3, 2005
E67
Table 3. Association With Background and Characteristics
Employed +
More or Less Than Three
Treatment +
Colorectal + Gastric +
Theoretical Group
Men + Women
Unemployed
Months Postdischarge
Follow-Up
Breast Cancers
Needs
(N = 139)
(N = 130)
(N = 135)
(N = 128)
(N = 103)
Emotional
Adaptation
t = 2.02**
t = 2.00*
Physical and functional
t = 2.80***
Individualized care
t = 1.82*
F = 3.19** (df = 2)
Health care
* p < 0.1, ** p < 0.05, *** p < 0.01
analysis. The MOS scale, which consisted of three sets of
low range, with fatigue being the most distressing symptom.
subscales (i.e., a physical function measure, satisfaction with
Cancer fatigue generally is not relieved by rest, and 72%99%
physical capability, and mobility), was used as an index for
of individuals with cancer complain of fatigue during the
patients' physical functions. Except for healthcare needs, each
course of their disease and treatment (McDaniel & Rhodes,
theoretical group or subscale for needs was negatively corre-
2000). The physical and functional needs of patients under-
lated with all subscales of the MOS scale (r = 0.22 to 0.55,
going treatment presumably are important to satisfy, but the
p < 0.05). Healthcare needs were negatively correlated only
imminent concern prevalent among ambulatory patients with
with satisfaction with physical ability (r = 0.25, p < 0.01).
cancer was fatigue.
Adaptation needs included items related to the difficulty
Relationships Among Theoretical Groups
of accepting physical changes, disclosing the illness to oth-
Bivariate correlations were examined for all combina-
ers, and the need to change one's way of living and adjusting
tions of the five theoretical groups (see Table 4). A strong
one's social life to meet the demands of a particular thera-
correlation was noted for all combinations. In particular, the
peutic regimen. Patients with highly expressed needs in this
emotional needs showed a strong correlation coefficient of
domain clearly recognized some difficulties posed by their
0.61 or more with all four of the other theoretical groups.
cancer and the need to change their lifestyles. In a study about
Also, the correlation between needs for individualized care
adaptation to chronic illness, Pollock (1993) found that the
and healthcare needs was strong (r = 0.69). The weakest cor-
perceived level of disability caused by a chronic illness was
relation coefficient was 0.36 for the combination of physical
related positively to psychosocial adaptation. When patients
and functional needs and healthcare needs.
with cancer adapt to the cancer experience, their recognition
of the difficulty posed by the cancer may be significant. Ef-
Discussion
fective healthcare education may motivate afflicted people to
change behaviors to be conducive to optimal health. Com-
An analysis of the expressed needs of ambulatory patients
pared with the other needs, adaptation needs were greater for
with cancer indicated that five key domains of need exist. The
patients who were employed and within three months of being
relationships among the domains, patient characteristics, and
discharged from the hospital. Clearly, if a group of similar
diagnostic groups suggest that nursing and supportive care
patients is targeted and if a healthcare education program
programs are needed for these unique populations.
focusing on the domain of adaptation needs is developed and
The physical and functional needs were significantly
provided, the probability of effectiveness is higher.
greater for patients under treatment than for those currently
The needs for the individualized care category were
under observation. However, except for a lack of energy or
comprised of items about asking healthcare professionals
a feeling of constant fatigue, the scores (mean, median, and
for treatment that is customized for a particular affliction,
mode) for all of the items included in this domain were low.
situation, or condition. The scores were higher among
Compared to a study that evaluated participants after surgery
women. When comparing the three cancer sites, the scores
for colon cancer (Galloway & Graydon, 1996), the symptom
for this domain for patients with colorectal cancer were the
distress scores among patients in the current study were in the
lowest and for patients with breast cancer were the highest.
Gender differences may exist in the psychological response
to cancer (Anastasia & Carroll-Johnson, 1998), which may
Table 4. Correlation Coefficients Between Theoretical
explain why patients with breast cancer placed the greatest
Groups
emphasis on the needs in this domain. However, gender dif-
ferences cannot explain why, among the three cancer sites,
Theoretical Group Needs
A
B
C
D
E
patients with colorectal cancer expressed the lowest needs
for this domain. In their study about the psychosocial needs
A.
Emotional
1.00
0.71*
0.61*
0.73*
0.61*
of patients with cancer, McIllmurray et al. (2001) verified
B.
Adaptation
0.56*
0.49*
0.46*
that patients with colorectal cancer, when compared to those
C.
Physical and functional
0.43*
0.36*
with other tumor types (e.g., breast cancer, lymphoma,
D.
Individualized care
0.69*
lung cancer), showed a significantly lower level of need for
E.
Health care
1.00*
healthcare professionals. Some peculiar factors may exist
that reduce the needs for individualized care among this
N = 139
group of patients.
* p = 0.01
ONCOLOGY NURSING FORUM VOL 32, NO 3, 2005
E68
Healthcare needs had no statistical association with the
better health. These needs were expressed regardless of the
patients' physical function, background, or treatment status;
patients' background and physical condition. The degree to
however, the scores on all items in this domain were high
which patients expressed a need for individualized care, im-
when compared with the other domains. Healthcare needs
plying a desire for customized support, differed depending on
were comprised of items concerned with making healthcare
gender or cancer site. Although a support program to satisfy
decisions for oneself and demanding information and human
healthcare needs is acceptable to many patients, it may need
resources to practice self-care. Many respondents expressed
to be designed differently for certain individuals, depending
a strong desire for constructive health care, independent of
on whether a patient chooses to seek support to satisfy the
their background and physical function, while experiencing
need for individualized care. When developing an effective
the hardship of cancer. This may be a finding worthy of note
support program, the characteristics of each patient seeking
in developing support for ambulatory patients with cancer.
individualized care should be clarified expressly.
The average scores for the items included in emotional
This study suggested that a healthcare education program
needs were as high as those for healthcare needs, but unlike
focusing on adaptation needs would be effective for patients
the latter, the former correlated significantly with the level of
who were employed or within three months of discharge. How-
physical functioning. Also, emotional needs were correlated
ever, the heterogeneity of the cancer sites and small sample size
most closely with the other domains. Greenberg (2002) noted
posed some limitations in generalizing the results. In addition,
that people become aware of what they need when undergoing
the questionnaire should be studied further to test its validity
pain or suffering. When patients undergo physical pain and
and reliability. Furthermore, the participants in this study were
become acutely aware of their emotional needs, they may
limited to those who were aware that they were suffering from
recognize other needs. Because the mind and body are inter-
cancer. Currently in Japan, patients with cancer are not neces-
related, the effects of each are synergistic and mutually de-
sarily informed of their medical diagnoses; therefore, the find-
pendent (Benner & Wrubel, 1989). In planning interventions
ings from this study may not apply to a general population of
to meet the emotional needs of ambulatory patients with
affected patients. Nevertheless, these findings shed light on one
cancer, a systematic approach to providing support may be
aspect of nursing care for ambulatory patients with cancer. The
important to develop, as well as giving careful consideration
next study--to target ambulatory patients with cancer who are
to the relationship between this and other domains.
afflicted with a particular cancer (i.e., colorectal cancer) who
have been newly discharged and to clarify the characteristics of
Implications for Nursing
adaptation needs for patients--is being planned.
The authors gratefully acknowledge all of the participants and staff from
Study findings can be put to good use when making needs
the three hospitals who made this study possible.
assessments for ambulatory patients with cancer. In general,
patients in this study strongly expressed not only emotional
Author Contact: Michiyo Mizuno, PhD, RN, can be reached at
needs, implying emotional distress, but also manifested an
michiyo@ishikawa-nu.ac.jp, with copy to editor at rose_mary@
interest in healthcare needs, implying an intention to achieve
earthlink.net.
References
Anastasia, P.J., & Carroll-Johnson, R.M. (1998). Gender and age differences
Longman, A.J., Atwood, J.R., Sherman, J.B., Benedict, J., & Shang, T.C.
in the psychological response to cancer. In R.M. Carroll-Johnson, L.M.
(1992). Care needs of home-based cancer patients and their caregivers.
Gorman, & N.J. Bush (Eds.), Psychosocial nursing care along the cancer
Quantitative findings. Cancer Nursing, 15, 182190.
continuum (pp. 5360). Pittsburgh, PA: Oncology Nursing Society.
McDaniel, R.W., & Rhodes, V.A. (2000). Fatigue. In C.H. Yarbro, M.H. Frog-
Antonovsky, A. (1987). Unraveling the mystery of health: How people man-
ge, M. Goodman, & S.L. Groenwald (Eds.), Cancer nursing: Principles
age stress and stay well. San Francisco: Jossey-Bass.
and practice (5th ed., pp. 737753). Sudbury, MA: Jones and Bartlett.
Asahi Shimbun Sougou Kenkyu Center. (2002). Sangatsu no seron chosa [A
McIllmurray, M.B., Thomas, C., Francis, B., Morris, S., Soothill, K., &
public-opinion poll in March]. Asahi Soken Report, 156, 166167.
Al-Hamad, A. (2001). The psychosocial needs of cancer patients: Find-
Benner, P., & Wrubel, J. (1989). The primacy of caring: Stress and coping in
ings from an observational study. European Journal of Cancer Care, 10,
health and illness. Menlo Park, CA: Addison-Wesley.
261269.
Bonevski, B., Sanson-Fisher, R., Girgis, A., Burton, L., Cook, P., & Boyes,
Murray, M.E., & Atkinson, L.D. (2000). Understanding the nursing process:
A. (2000). Evaluation of an instrument to assess the needs of patients with
In a changing care environment (6th ed.). New York: McGraw-Hill.
cancer. Supportive Care Review Group. Cancer, 88, 217225.
Pollock, S.E. (1993). Adaptation to chronic illness: A program of research for
Bunston, T., & Mings, D. (1995). Identifying the psychosocial needs of individ-
testing nursing theory. Nursing Science Quarterly, 6(2), 8692.
uals with cancer. Canadian Journal of Nursing Research, 27(2), 5979.
Sanson-Fisher, R., Girgis, A., Boyes, A., Bonevski, B., Burton, L., & Cook,
Galloway, S.C., & Graydon, J.E. (1996). Uncertainty, symptom distress, and
P. (2000). The unmet supportive care needs of patients with cancer:
information needs after surgery for cancer of the colon. Cancer Nursing,
Supportive Care Review Group. Cancer, 88, 226237.
19, 112117.
Statistics and Information Department at Minister's Secretariat on Ministry
Greenberg, L.S. (2002). Emotion-focused therapy: Coaching clients to
of Health, Labor, and Welfare. (2001). Juryo koudou chousa: Heisei 11
work through their feelings. Washington, DC: American Psychological
[A survey on health care-seeking behavior in 1999]. Tokyo, Japan: Health
Association.
and Welfare Statistics Association.
Hackbarth, D.P. (2001). Leadership, inquiry, and research utilization. In J.
Steginga, S.K., Occhipinti, S., Dunn, J., Gardiner, R.A., Heathcote, P., &
Robinson (Ed.), AAACN core curriculum for ambulatory care nursing (pp.
Yaxley, J. (2001). The supportive care needs of men with prostate cancer
437452). Philadelphia: W.B. Saunders.
(2000). Psycho-Oncology, 10, 6675.
Health and Welfare Statistics Association. (2004). Kokumin eisei no doukou
Stewart, A.L., & Kamberg, C.J. (1992). Physical functioning measures. In
2004 [Health in Japan: Recent vital statistics 2004]. Tokyo, Japan: Author.
A.L. Stewart & J.E. Ware, Jr. (Eds.), Measuring functioning and well-be-
Lazarus, R.S., & Folkman, S. (1984). Stress, appraisal, and coping. New
ing: The Medical Outcomes Study approach (pp. 86101). Durham, NC:
York: Springer.
Duke University Press.
ONCOLOGY NURSING FORUM VOL 32, NO 3, 2005
E69