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Psychospiritual Well-Being and Symptom Distress
in Women With Breast Cancer
Juanita K. Manning-Walsh, PhD, RN
Key Points . . .
Purpose/Objectives: To examine the relationship between symptom
distress and psychospiritual well-being in women with breast cancer.
Design: Descriptive, cross-sectional, correlational study.
➤ Breast cancer, a highly stressful experience, is associated with
Setting: Secondary analysis of data collected in 2000 from the Breast
psychological and spiritual difficulties.
Cancer Support Web site at http://pages.prodigy.net/replyasap/bc.
Sample: 100 women were invited to participate in the study after
➤ Psychospiritual well-being, a subjective experience, connects
posting an entry in the Web site guest book. Most had stage I or II
the mind and spirit with the body.
breast cancer, were nearly 46 years old, and were 10.25 months post-
➤ Symptoms experienced negatively affect psychospiritual well-
Methods: Mailed questionnaires. Women were required to meet the
following inclusion criteria: a confirmed breast cancer diagnosis, first
cancer experience, fewer than two years postsurgery for breast cancer,
18 years of age or older, and the ability to read and write in English.
dimensions, including physical, functional, social, psycho-
Symptom distress was measured using the Symptom Distress Scale.
logical, and spiritual well-being (Brady et al., 1997; Brady,
Psychospiritual well-being was measured by combining scores from
Peterman, Fitchett, Mo, & Cella, 1999; Cella et al., 1993; Lin
the psychological subscale of the breast-cancer specific version of the
& Bauer-Wu). Numerous studies have examined the effects
Functional Assessment of Cancer Therapy Scale and the Functional As-
of symptom distress on various psychological outcomes, such
sessment of Chronic Illness Therapy (Spiritual) Measurement System
as anger, depression, and hope (McCorkle, Cooley, & Shea,
12 for a composite score.
n.d.), in participants with a variety of disease conditions, but
Main Research Variables: Symptom distress, psychospiritual well-
very few have examined the effects of symptom distress on
Findings: Symptom distress and psychospiritual well-being were
spiritual outcomes (Taylor, 1993).
inversely related. No relationship was found between age and symptom
Little effort has been directed toward the elucidation of
distress; however, age was inversely related to psychospiritual well-be-
spiritual responses as they relate to symptom distress (Fer-
ing. Age and symptom distress accounted for 23.1% of the variance in
rell, Grant, Funk, Otis-Green, & Garcia, 1998; Lin & Bauer-
Wu, 2003); consequently, little is known about the effect of
Conclusions: Participants experienced a small amount of symptom
symptom distress on psychospiritual well-being, a composite
distress, which was inversely related to psychospiritual well-being.
of the psychological and spiritual well-being dimensions of
Although their symptom distress was similar to other studies, patients
QOL (Lin & Bauer-Wu). The purpose of this descriptive,
in this study reported lower psychospiritual well-being than participants
cross-sectional, and correlational study, which was a second-
in other studies.
Implications for Nursing: Psychospiritual well-being is an important
ary analysis of data collected in 2000, was to examine the
concept for nurses seeking a holistic approach to practice because it
relationship between symptom distress and psychospiritual
connects the mind and spirit with the body.
well-being. The original study (Manning, 2000) examined the
effects of a mediation model in a group of women with breast
cancer. A conceptual framework of stress and coping (Lazarus
& Folkman, 1984) guided the literature review.
breast cancer diagnosis is a highly stressful experi-
ence associated with a myriad of symptoms that
cause distress (Cimprich, 1999; McCorkle, 1987).
These symptoms can begin as early as the time of diagnosis
Juanita K. Manning-Walsh, PhD, RN, is an assistant professor in
the Bronson School of Nursing at Western Michigan University in
(Cimprich), last for two years or longer after completion of
Kalamazoo. (Submitted June 2004. Accepted for publication No-
adjuvant therapy (Glanz & Lerman, 1992), and often disrupt
vember 1, 2004.)
a patient's quality of life (QOL), specifically its psychological
and spiritual aspects (Lin & Bauer-Wu, 2003). QOL has many
Digital Object Identifier: 10.1188/05.ONF.E56-E62
ONCOLOGY NURSING FORUM VOL 32, NO 3, 2005
trate, and dissatisfaction with physical appearance (McCorkle
& Young, 1978). Although symptom distress has been inves-
tigated in relation to psychological and spiritual well-being,
Symptoms are subjective phenomena indicating a condition
it has not been evaluated in relation to psychospiritual well-
departing from normal function, sensation, or appearance (Mc-
being as one construct.
Corkle & Young, 1978). They result in physical and mental
suffering, are often unpleasant or unusual, and interfere with
comfort and productivity (Giardino & Wolf, 1993). Attempts
Spiritual well-being arises from the human spiritual dimen-
to measure or quantify symptom distress usually are made
sion. This spiritual dimension has no voice or unique means
through the evaluation of the subjective reports of individuals
of expression, thus making scientific measurement difficult
experiencing the symptom(s) (McCorkle, 1987).
(Bash, 2004). Therefore, spiritual well-being must be expressed
Individual responses to symptoms associated with the di-
through other human dimensions. Frequently, the psychological
agnosis and treatment of breast cancer vary widely (Munkres,
dimension is the conduit through which spiritual well-being is
Oberst, & Hughes, 1992; McCorkle, 1987), with symptoms
expressed (Ellison & Smith, 1991). Although studies examining
such as emotional distress, fatigue, and insomnia beginning as
the interconnectedness of the psychological and spiritual dimen-
early as the time of diagnosis (Cimprich, 1999; Cimprich &
sions offer little support for the combination of psychological
Ronis, 2003). Glanz and Lerman (1992) found that symptoms
well-being and spiritual well-being into one construct (i.e., psy-
persist for up to two years after adjuvant therapy is complete
chospiritual well-being), psychological and spiritual well-being
in 20%30% of women with breast cancer.
have been examined as one construct (Taylor, 1993).
Some symptoms may be more problematic and distressing
Along with other life-threatening conditions, a breast cancer
than others. Among the most common symptoms experienced
diagnosis changes a woman's perception of her life (Swenson,
by women receiving adjuvant therapy for breast cancer are
Fuller, & Clements, 1993) and puts her at risk for altered psy-
fatigue (Cohen, Kahn, & Steeves, 1998; Longman, Braden,
chospiritual well-being because of changes in health, symptoms
& Mishel, 1999), difficulty concentrating (Cimprich, 1999;
associated with the disease and treatment, and the abrupt need to
Longman et al.), pain, skin irritation, depression, and anxiety
face her own mortality, any of which may be related to increased
(Longman et al.), with fatigue being the most problematic
fear and anxiety and decreased psychological well-being (Ut-
ley, 1999). Study findings indicate that spiritual well-being is
Symptom distress may be a critical variable in predicting or
inversely related to depression in caregivers of disabled older
explaining patient outcomes and concerns (McCorkle, 1987).
adults (Chang, Noonan, & Tennstedt, 1998; Fehring, Miller,
A number of studies have demonstrated relationships between
& Shaw, 1997), anxiety in older women with a chronic illness
symptom distress and psychological well-being (Kurtz, Kurtz,
(Koenig, 2002), and loneliness (Miller, 1985) and uncertainty in
Given, & Given, 1995; Molassiotis, Van Den Akker, Milligan,
adults with chronic illness (Landis, 1996). Spiritual well-being
Goldman, & Boughton, 1996; Sarna, 1998; Taylor, Baird,
is positively correlated to hope in patients with cancer (Fehring
Malone, & McCorkle, 1993), and symptom distress has been
et al.) and community-dwelling older women (Zorn & Johnson,
shown to be inversely related to psychological well-being in
1997), caring behaviors in nurses working with patients with
women with recurrent breast cancer receiving chemotherapy
AIDS (Sherman, 1996), and life satisfaction among African
(Northouse, Dorris, & Charron-Moore, 1995). In a longi-
Americans (Levin, Chatters, & Taylor, 1995). Notably, few
tudinal study measuring patients' symptom distress for six
studies reporting interconnectedness between psychological
months following a breast cancer diagnosis, Longman et al.
and spiritual well-being have examined patients with cancer,
(1999) reported that the number of symptoms experienced was
and none have evaluated women with breast cancer.
inversely related to overall QOL, but the researchers did not
In an integrative literature review of 43 studies investigating
address psychological or spiritual well-being specifically.
either psychological or spiritual well-being in patients with
Some evidence shows that certain demographic variables,
advanced cancer, Lin and Bauer-Wu (2003) concluded that
such as age (Budin, 1998; Degner & Sloan, 1995) and marital
"psychospiritual well-being is a subjective experience that
status (Northouse et al., 1995), have an impact on the relation-
incorporates emotional health and meaning-in-life concerns"
ship between symptom distress and psychological well-being.
(p. 70). Psychospiritual well-being includes such attributes as
Younger women and those who are single tend to experience
optimism and peacefulness (Miller, Manne, Taylor, Keates, &
more symptom distress and disruption in psychological well-
Dougherty, 1996); meaning and purpose in life (Ferrell et al.,
being than older or married women.
1998; McSherry, 1998; Walton, 1999); connectedness with self,
Little is known about the relationship between symptom
others, nature, and a higher power (McSherry; Walton); comfort
distress and spiritual well-being. Only one study has been pub-
in faith or beliefs (Hill & Pargament, 2003); and the lack of
lished in which the effect of symptom distress on spiritual well-
negative emotions, such as nervousness, worry about the future,
being was examined. In a study of 74 participants with recur-
sadness, and hopelessness (Ballard, Green, McCaa, & Logsdon,
rent cancers of various types, symptom distress was inversely
1997; Benzein, Norberg, & Saveman, 2001; Flemming, 1997).
related to spiritual well-being, which was expressed through the
Psychospiritual well-being refers to people's experiences and
creation of a sense of meaning and purpose for the experience
the effects their experiences have on them (Bash, 2004). For
despite facing a life-threatening illness (Taylor, 1993).
this study, psychospiritual well-being was defined as a subjec-
In this study, participants reported on their symptom dis-
tive experience that incorporates psychological well-being and
tress, defined as the degree of perceived discomfort in relation
meaning in life, or spiritual well-being.
to a symptom. Symptoms of interest were nausea, changes in
Although a wide body of evidence does not exist, studies have
mood, decreased appetite, insomnia, pain, decreased mobility,
examined demographic (e.g., age, marital status, household
fatigue, altered bowel patterns, decreased ability to concen-
income) and illness-related (e.g., type of surgery, time since
ONCOLOGY NURSING FORUM VOL 32, NO 3, 2005
diagnosis) variables in relation to symptom distress and QOL.
also were collected because they could influence the amount of
Budin (1998) found that younger participants experienced more
symptom distress (Degner & Sloan, 1995) and psychospiritual
symptom distress than older ones. Wyatt and Friedman (1996)
well-being (Hill & Pargament, 2003; Koenig, 2002) a woman
found that age was inversely related to QOL in female cancer
with breast cancer was experiencing.
survivors, whereas Riley et al. (1998) found no relationship
Symptom distress was measured using the 10-item version
of the Symptom Distress Scale (SDS) (McCorkle & Young,
between age and QOL in patients with chronic illness, including
breast cancer survivors. Married women reported easier adjust-
1978). The SDS measures symptom distress in relation to the
ment to breast cancer diagnosis and higher QOL than single
following common symptoms: nausea, loss of appetite, insom-
women (Northouse et al., 1999). Higher household income
nia, pain, mobility, bowel pattern, fatigue, loss of concentra-
was predictive of better QOL in patients with chronic renal
tion, changes in appearance, and mood state. The scale has
or cardiac diseases (Ferrans & Powers, 1992; Lukkarinen &
well-established content and construct validity according to the
Hentinen, 1998). Hughes (1993) found that psychological well-
current user's manual (McCorkle et al., n.d.). Each symptom is
being was disrupted most at the time of breast cancer diagnosis
assessed using a Likert-type scale with two anchor statements,
and improved over time, whereas Northouse et al. (1999) found
reflecting a maximum or minimum amount of distress. For
no relationship among the time since breast cancer diagnosis,
example, insomnia can be scored from 1 (no distress at all) to
type of surgery, and QOL.
5 (maximum amount of distress); a score of 5 indicates that the
symptom "couldn't have been worse," and a score of 1 reflects
"a perfect night last night." The 10 response scores are summed
This study explored three research questions: (a) What is
to provide a symptom distress score. In this study, the possible
the relationship between symptom distress and psychospiritual
score range was 1050, with higher scores indicating more
well-being in women with breast cancer? (b) What are the
distress. Internal consistency using Cronbach's alpha reliability
relationships among demographic variables, illness-related
for the SDS in other studies has ranged from 0.70 (when used
variables, symptom distress, and psychospiritual well-being in
with participants with various types of cancer) to 0.92 (when
women with breast cancer? and (c) How much of the variance
used with participants with HIV or AIDS). Most studies that
in psychospiritual well-being is explained by symptom distress
use the SDS report Cronbach's alpha levels greater than 0.80.
and demographic and illness-related variables in women with
In this study, Cronbach's alpha reliability coefficient was 0.81,
similar to the 0.83 reported by Cimprich (1999) when the 10-
item version of the instrument was used in a study of women
with newly diagnosed breast cancer.
Psychospiritual well-being was measured using two instru-
ments that were combined to create one composite score: the
psychological subscale of the breast cancer-specific version of
This research was part of a larger study that examined a model
the Functional Assessment of Cancer Therapy Scale-Breast
of stress and coping in women with breast cancer and was an
(FACT-B) (Cella et al., 1993) and the Functional Assessment
exploratory secondary analysis of data collected from a conve-
of Chronic Illness Therapy (Spiritual) Measurement System
nience sample obtained through Internet recruitment. Although
12 (FACIT-Sp-12) (Fitchett, Peterman, & Cella, 1996), which
cross-sectional sampling does not allow for determination of
measures spiritual well-being. The FACT-B is a 36-item instru-
time order as a test of causality (Polit & Beck, 2003), using this
ment with five subscales that measures general QOL. The psy-
design for an initial exploration of the relationships in question
chological subscale has six items and measures psychological
is appropriate because of the limited existing research examining
well-being. The FACT-B has well-established content and con-
the effect of symptom distress on psychospiritual well-being.
struct validity, as does the psychological well-being subscale,
Sample and Setting
which was constructed to perform well as a unidimensional
indicator (Brady et al., 1997). The FACIT-Sp-12 is a 12-item
University institutional review board approval was obtained
scale that was developed by the researchers who developed the
in 2000 for the original study and in 2004 for this secondary
FACT-B and measures spiritual well-being. The FACIT-Sp-12
analysis. A convenience sample of 100 participants was re-
has well-established content and construct validity (Brady et al.,
cruited from the Breast Cancer Support Web site at http://pages.
1999). The psychological well-being subscale and the FACIT-
prodigy.net/replyasap/bc in the spring of 2000. A woman could
Sp-12 had construct validity when combined into one measure
participate in the study if she met the inclusion criteria, which
of psychospiritual well-being (K. Webster, personal commu-
were a confirmed diagnosis of breast cancer, first cancer ex-
nication, January 3, 2000). Both are Likert-type scales, with
perience, fewer than two years postsurgery for breast cancer,
items scored from 0 (not at all) to 4 (very much). Higher total
18 years of age or older, and the ability to read and write in
scores reflected better psychological and spiritual well-being.
English. Although breast cancer in men and women who are
Reliability has been reported to be 0.82 for the psychological
pregnant has been reported, these two groups were excluded
subscale (Cella et al.) and 0.87 for the FACIT-Sp-12 (Fitchett
because treatment options, associated symptoms, and psycho-
et al.). In this study sample, Cronbach's alpha reliability coef-
logical and spiritual responses vary among them.
ficient was 0.84 for the psychological subscale and 0.87 for
the FACIT-Sp-12. The scores from the psychological well-be-
ing subscale and FACIT-Sp-12 were summed to produce one
The variables in this study were measured using three in-
composite score measuring psychospiritual well-being. Because
struments. Demographic data (i.e., age, marital status, level
no published studies were found in which the psychological
of education, household income, and race) and illness-related
subscale of FACT-B and FACIT-Sp-12 were combined and
data (i.e., time since diagnosis, stage of cancer, type of surgery,
a Cronbach's alpha reliability coefficient was computed, no
adjuvant therapy, and whether adjuvant therapy was completed)
ONCOLOGY NURSING FORUM VOL 32, NO 3, 2005
Table 1. Demographic and Illness-Related Characteristics
comparative data exist for the alpha of 0.91 derived for the
of the Sample
measure in this study.
For the original study (Manning, 2000), a minimum sample
size of 84 was determined by power analysis using Cohen's
Time since diagnosis (months)
Table (Cohen, 1988), which would have a power of 0.80 to
Educational level (years)
detect a small or medium effect size (f 2 = 0.15) at a 95%
confidence level when using regression analysis. A notice was
posted on the Breast Cancer Support Web site guest book, and
Household income ($)
personal invitations were e-mailed to women with guest book
Less than 10,000
entries. The notice and e-mails briefly described the study and
invited participation. Women who responded were mailed
questionnaire packets. The women were informed that consent
More than 80,000
to participate in the study was implied by their return of the
completed questionnaire. Of the 126 questionnaires mailed,
110 (87%) were returned. Ten questionnaires were not included
Married or living with partner
in the data analysis because the respondents did not meet the
inclusion criteria, leaving a total sample of 100 women.
Demographic and illness-related characteristics of the sample
were examined using frequency distributions. All data were
inspected for normalcy (Munro, 2002). Relationships among
study variables were examined using Pearson product-moment
Type of surgery
correlations and multiple regression analysis. An acceptable
significance level for all data analysis was set at p < 0.05. SPSS®
10.0 (SPSS Inc., Chicago, IL) was used to analyze data.
Stage of cancer
Demographic and illness-related characteristics of the sample
(N = 100) are presented in Table 1. In general, the women were
well educated: 98% had graduated from high school, 43% had
Most common symptoms experienced
graduated from college, and 30% had a graduate-level educa-
tion. Most were married or had a partner (74%) and Caucasian
(93%). The average age was nearly 46 years (SD = 8.85), and
Dissatisfied with appearance
65% had an annual household income of more than $50,000.
Wide variation existed within the sample regarding combina-
tions of adjuvant therapy (i.e., chemotherapy, radiation, and
N = 100
Mean symptom distress, psychological well-being, and
graphic or illness-related characteristics were significantly re-
spiritual well-being scores are listed in Table 2. Using Pearson
lated to either symptom distress or psychospiritual well-being.
product-moment correlation, a moderate statistically significant
Because age was significantly related to psychospiritual
inverse relationship was found between symptom distress and
well-being, it was entered into the regression equation along
psychological well-being (r = 0.42, p = 0.01), symptom dis-
with symptom distress to determine the amount of variance
tress and spiritual well-being (r = 0.38, p = 0.01), and symptom
in psychospiritual well-being that could be explained by both.
distress and psychospiritual well-being (r = 0.45, p = 0.01).
Age and symptom distress accounted for 23% of the variance
After frequency distributions of the data were examined, age
in psychospiritual well-being; however, age alone did not
was collapsed into two groups--women younger than 48 years
maintain significance in the model (Multiple R = 0.48, R2 =
and women 48 years and older. This split was based on the age
0.231, F = 14.53, p < 0.001) (see Table 3).
at which a woman might anticipate menopause (i.e., 48 years)
Using one-sample t tests, additional analysis was done to
and provided for groups of similar sizes. Bivariate correlations
compare the mean symptom distress and psychospiritual well-
were examined to identify significant relationships among de-
being scores of this sample with other samples reported in the
mographic and illness-related variables, symptom distress, and
literature. Participants in this study had levels of symptom dis-
psychospiritual well-being. No relationship between age and
tress that were similar to those of a group of women with breast
symptom distress was found; however, age was significantly
cancer who recently completed radiation therapy (Graydon,
related to psychospiritual well-being (r = 0.21, p < 0.05). Using
1994); however, the current sample had significantly lower psy-
analysis of variance, the researcher determined that younger
chological (t = 10.65, df = 99, p < 0.001) (Brady et al., 1997)
women (n =-- reported significantly lower psychospiritual
and spiritual well-being (t = 6.82, df = 99, p < 0.001) (Brady
well-being (X = 4.87, SD = 1.20) than older women (n = 49,
et al., 1999) scores than were reported previously.
X = 5.41, SD = 1.32, F = 4.42, df = 1, p < 0.05). No other demo-
ONCOLOGY NURSING FORUM VOL 32, NO 3, 2005
Table 2. Symptom Distress and Psychospiritual Well-Being Scores
to Other Studies
Symptom Distress Scale
Psychological well-being subscale
Functional Assessment of Chronic Illness Therapy
(Spiritual) Measurement System 12 (FACIT-
N = 100
Psychological well-being subscale and FACIT-Sp-12 scores combined
Brady et al., 1997
Brady et al., 1999
was reported between participants receiving adjuvant therapy
and those whose therapy was complete. Women who had
Despite the finding that the women in this study experienced
completed adjuvant therapy reported slightly higher insomnia
low levels of symptom distress, an inverse relationship was
( X = 2.69, SD = 1.13 versus X = 2.32, SD = 1.11) and more
found between symptom distress and psychospiritual well-be-
difficulty concentrating X = 2.21, SD = 1.01 versus X = 2.08,
ing. Participants experienced levels of symptom distress similar
SD = 1.01) than those still in therapy, although neither of these
to other women with breast cancer (Berger, 2003; Graydon,
findings was statistically significant. Participants not currently
1994), women who had not been treated yet for diagnosed
in adjuvant therapy were experiencing symptom distress, which
breast cancer (Cimprich, 1999; Cimprich & Ronis, 2003), and
is consistent with the findings of Cimprich (1999) and Berger
those being treated for a variety of other cancers (McCorkle &
(2003), who reported that women began experiencing fatigue,
Young, 1978). Participants in this study had significantly lower
insomnia, and loss of concentration shortly after diagnosis of
psychological and spiritual well-being than has been found in
breast cancer and even before surgical intervention and adju-
other samples (Brady et al., 1997, 1999). Because no reports in
vant therapy. In addition, Glanz and Lerman (1992) found that
the literature combine the psychological subscale of the FACT-
symptoms persisted for as many as two years after adjuvant
B with the FACIT-Sp-12, no normative data existed with which
therapy was complete. Many of the women in the current study
to compare the total psychospiritual well-being score. Although
added comments to their questionnaires regarding feelings of
the reasons that women in this study had lower psychological
uncertainty about the future and that their lives had been turned
and spiritual well-being than participants in other studies are not
"upside down" after learning that they had breast cancer. The
known, they may have been experiencing some isolation that
findings of this study, along with those of Cimprich, Berger,
resulted in their seeking support on the Internet. Further stud-
and Glanz and Lerman, underscore the lingering relationship
ies using Internet recruitment of women with breast cancer are
between symptom distress and psychospiritual well-being as-
needed to explore this conjecture. The failure to find a relation-
sociated with diagnosis and treatment of breast cancer.
ship between age and symptom distress in this sample was in
Breast cancer is known to be a highly stressful experience
contrast to the findings of Degner and Sloan (1995), Cimprich
associated with psychological and spiritual difficulties (Lin &
(1999), and Budin (1998) but consistent with the findings of
Bauer-Wu, 2003). Psychospiritual well-being is a subjective
Portenoy et al. (1994), who found no relationship between
experience that incorporates psychological health and spiri-
symptom distress and age in a group of 243 participants with
tual concerns and was inversely related to symptom distress
a variety of cancers.
in this study. Although numerous studies have demonstrated
Numerous studies have measured the effects of symptom
links between symptom distress and psychological well-being
distress on a variety of outcome variables in women with breast
(Berger, 2003; Cimprich, 1999; Kurtz et al., 1995; Northouse
cancer (McCorkle et al., n.d.). Most have included women re-
et al., 1995), fewer studies have demonstrated a relationship
ceiving adjuvant therapy at the time of the study. In the current
between symptom distress and spiritual well-being (Narayana-
study, women undergoing treatment and those whose adjuvant
samy, 2004; Taylor, 1993; Taylor et al., 1993), both of which are
therapy was complete were asked about their symptoms. Nearly
elements of psychospiritual well-being. Nurses play a vital role
all of the women (98%) were experiencing distress from at least
in assisting clients with enhancing their psychospiritual well-
one symptom. No difference in mean symptom distress scores
being. Because nursing espouses holistic care as a central tenet,
nurses are well positioned to recognize evidence of decreased
psychospiritual well-being in patients, which is evidence of
symptom distress and would prompt the need for psychological
Table 3. Multiple Regression Using Study Variables
or spiritual care (Taylor, 2003). Nurses must assist clients in
finding meaning and purpose in their breast cancer experience
and provide an environment in which the spirit can find repose.
This may include allowing space and privacy so women may
commune with their higher power or providing opportunities
ONCOLOGY NURSING FORUM VOL 32, NO 3, 2005
for communication with others, time and space for spiritual
The participants were predominantly Caucasian. Future stud-
ceremonies, a quiet space for communing with the self through
ies are needed that examine symptom distress and psychospir-
music, spiritual reading, meditation, or journaling (Acton &
itual well-being in diverse samples. Purposeful recruitment
Miller, 2003), or becoming immersed in nature (Cimprich &
of minority populations, such as African American, Latino,
Ronis, 2003). Women with breast cancer may benefit from nurs-
or Native American women with breast cancer, is warranted
ing interventions that are sensitive, supportive, and responsive
because other racial and ethnic groups may experience psy-
to psychospiritual needs (Narayanasamy).
chospiritual well-being differently. Eighty-nine percent of the
The findings of this study related to symptom distress have
participants had stage I or II cancer. Women at more advanced
implications for nursing practice. When symptom distress
stages may experience more or varied symptom distress.
is present during assessment or reported by a woman with
Numerous studies have measured psychological and
breast cancer, decreased psychospiritual well-being should be
spiritual well-being, but none has measured psychospiritual
anticipated and evaluation should occur. Nurses are important
well-being. Although the psychological well-being subscale
resources for helping patients to recognize, prevent, and man-
of FACT-B and FACIT-Sp-12 have well-established reliability
age their symptoms. Women newly diagnosed with breast
and validity on their own, further research is needed to support
cancer or those in the treatment phase of the cancer trajectory
the reliability and validity of the two when combined to create
frequently have contact with healthcare professionals, which
a single measure of psychospiritual well-being and to support
provides them the opportunity to report symptom distress and
further the findings of this study.
seek assistance with treatment and relief. Women who have
completed adjuvant therapy are less likely to be in regular,
frequent contact with healthcare professionals but still are
Despite the limitations of this study, the findings suggest
likely to experience symptoms. Nurses should assess patients
potential implications for nursing practice. For nurses seeking
for continued symptoms near the end of adjuvant therapy and
to adopt a holistic approach to their practice, psychospiritual
include teaching and interventions to alleviate symptoms in
well-being is an important concept (Lin & Bauer-Wu, 2003)
patients' long-term plan of care. Nurses also should follow
within the context of breast cancer because it integrates the
up periodically with clients after treatment is completed to
mind and spirit in a way that allows for the effects of physical
determine whether the need exists for further intervention or
symptoms on them to be examined, hence supporting a mind-
teaching in response to continued symptom distress.
The women in this study experienced a small amount of
symptom distress. Their psychological and spiritual well-be-
Although this study had statistically significant findings, the
ing were lower than participants in other studies examining
relationships were modest. Future studies with larger samples
women with breast cancer or patients with a variety of can-
may yield greater effect sizes. Because of the convenience
cers. This study addressed a gap in the literature regarding
sample and cross-sectional design, these findings may not be
psychospiritual well-being. Future studies should include
generalizable beyond the current sample. Sampling bias is a
larger samples of women with breast cancer and participants
possibility because the participants selected themselves for
with health concerns other than breast cancer, as well as
the study via Internet recruitment. The cross-sectional design
examine psychospiritual well-being. When nurses have more
does not allow for an examination of symptom distress and
knowledge about psychospiritual well-being, they will be
psychospiritual well-being over time. Longitudinal studies
equipped better to assist women with breast cancer with man-
could provide understanding about how these concepts relate
aging their symptoms and understanding their psychospiritual
to each other and whether symptom distress and psychospiri-
tual well-being change over time as women become further
removed from their breast cancer diagnoses and treatments.
The women in this study, who were Internet users, were
Author Contact: Juanita K. Manning-Walsh, PhD, RN, can be
well educated when compared to the U.S. national average for
reached at Juanita.Manning@wmich.edu, with copy to editor at
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