1 School of Nursing and Midwifery, University of Glasgow, Glasgow; 2 CRC Trials Unit, Beatson Oncology Centre, Western Infirmary, Glasgow, UK
Received 23 April 2002; revised 30 July 2002; accepted 31 July 2002
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Abstract |
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Despite the known benefits of screening, early detection and advances in treatment modalities, negative attitudes to cancer persist among health care professionals, and cancer remains the most feared disease in modern society. Attitudes to cancer may create a barrier to communication between patients and health care professionals, hinder early detection, treatment and rehabilitation, and may influence decision making about referral to specialist services and the selection of appropriate treatments.
Design:
A descriptive survey was conducted, within a Regional Cancer Centre, to evaluate oncology health care professionals attitudes towards cancer. Attitudes were measured using the Burns Cancer Belief Scales.
Results:
Regardless of gender, profession and clinical experience, all health care professionals displayed persistently negative attitudes towards cancer. No statistically significant difference was detected between gender, profession, clinical experience or specialist education, and although small in number, no major differences were found between group means.
Conclusions:
Oncology health care professionals hold negative attitudes towards cancer and changing these attitudes presents a significant challenge. Educational programmes and supportive strategies may alleviate fears and promote a more positive image of cancer. However, such strategies must be based on an understanding of current attitudes towards this phenomenon.
Key words: attitudes, cancer, health care professionals
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Introduction |
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There has been increasing interest in the attitudes of health professionals and the general public, their effects on the quality of care that patients with cancer receive and the effects of attitudes on an individuals likelihood to present with symptoms. A survey conducted by Murray and McMillan [5] indicated that cancer remains the most feared disease in modern society. Whereas the public might be excused for their negativity, one could assume that as a result of education, health professionals attitudes would be more positive. It is concerning, therefore, to note that to some extent the attitudes formed while part of the wider society prevail, despite conscious or subconscious suppression, suggesting that personal experience is a stronger former of attitudes than formal education [3]. Early work by Elkind [6, 7] identified several factors such as personal and professional cancer experience, seniority and specialist education as mediating negative attitudes in a positive direction. However, a consistent pattern of positive influences remains elusive.
Significant differences have been found between medical and nursing staff with regard to aggressive treatment, with medical staff more favourable towards aggressive treatment and less concerned with the emotional aspects of care [810].
Corner [11] found that professional experience seemed to reinforce attitudes held or even increase nurses negative attitudes. This is increasingly worrying when one considers that staff holding negative attitudes may be likely to make different decisions regarding the treatment and care of patients with cancer than those with positive attitudes, placing low value on the patient and psychological care [4]. Furthermore, McCaughan and Parahoo [12] found that 35.6% of nurses held a negative attitude to active treatment, believing that patients were subjected to illness and pain without benefit. The authors concluded that education and support for nurses were essential to ensure that negative attitudes do not compromise the nature and quality of care.
Two studies have utilised similar techniques to compare attitudes towards cancer treatment decision making between professional groups and patients [10, 13]. Both clearly identified substantial differences in attitude among patients, between patients and those treating them, and between health professionals. These findings lead one to question whether the influence of negative societal attitudes can explain the somewhat negative attitudes of oncology health professionals and also whether these attitudes are strong enough to influence referral and treatment patterns. This presents a considerable challenge for future decision making and highlights the importance of attitudes towards cancer and cancer treatments in clinical practice. The potential exists for negative attitudes towards cancer to influence decision making. The dearth of knowledge regarding oncology health care professionals attitudes towards cancer prompted this current study.
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Aims and methods |
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Setting and sample
The research was supported by, and performed in, a Regional Cancer Centre in Scotland. The sample included all registered health professionals (medical, nursing and radiography staff) working within the Cancer Centre at the time of data collection (n = 197). All were recruited to the survey.
Research design
The research was conducted using a descriptive survey design in order to obtain information regarding the prevalence and distribution of variables within the population [14] and was inherently non-experimental [15]. This design was chosen as there was a need for clearer delineation of the phenomena before causality could be established. A structured survey was carried out using Burns Cancer Belief Scales [4]. This scale was chosen as it has been suggested that the results obtained reflect individuals experiences or thoughts that are difficult to express directly [4]. It has also been suggested that the Burns scale is quick and simple to complete and that results are generalisable to a variety of populations, professional as well as public [16].
The Burns Cancer Belief Scales was developed between 1977 and 1981 [4, 17]. A semantic differential technique was used to develop the 22 scales, which capture the affective component of meaning and use strategies similar to word association to reflect the unconscious. While evaluating overall attitudes towards cancer, added insight can be gained by dividing the scales into three factors: fear of the cancer situation, hopelessness and stigma. Reliability and content, construct, concurrent and divergent validity have been established by Burns. The scale was administered concurrently with other instruments thought to measure the same concept, the Hoffmeister Cancer Attitude Questionnaire [4] and the Beck Hopelessness Questionnaire [18]. Pearson productmoment correlations were used to correlate factor scores of the Burns scales with factor scores of the Beck scale and the Hoffmeister questionnaire. Tests for concurrent validity with 58 subjects were calculated using a Pearson product moment correlation, with all three factors of Burns scales correlating significantly beyond the 0.001 level with the factors of Hoffmeisters scale. While the pessimistic factor of the Beck scale correlated with all the factors of the Burns scale, two other factors indicated no significant correlation with either the Burns scales or Hoffmeister clusters [4]. Burns [4] suggests that this is because two factors from the Beck scale measure a phenomenon unrelated to cancer. Three factors of the Burns scale were correlated with the cancer optimism cluster of the Hoffmeister questionnaire. The two scores were significantly negatively correlated to establish divergent validity [4]. Subsequent studies have compared favourably with Burns initial findings [19, 20].
Data collection and analysis
Data were collected over a period of 6 weeks. The questionnaire and demographic detail schedule were sent with a letter explaining the purpose of the research and assuring the respondents of anonymity and confidentiality. The staff code numbers were used only to identify non-responders to ensure respondents anonymity. No reference was made to the code following completion of data collection.
Data were analysed using SPSS (Statistical Package for the Social Sciences). Analysis of variance techniques were used to compare the various groups. A test for linear trend was utilised when examining grades of nursing staff. Responses to Burns scales were coded 17. Overall attitudes towards cancer could be evaluated by calculating a total score, while scores for each of the factors were also calculated.
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Results |
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Discussion |
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The results support the work of Corner [11], who found that professional experience acted to reinforce or increase already negative attitudes. However, it could be that these negative attitudes may well reflect the picture presented daily to those working in a Cancer Centre and future research comparing this group with those working in Cancer Units and the community may provide interesting comparisons. Nevertheless, it would seem that societal attitudes prevail through professional attitudes as no statistical differences could be detected between gender, professional group, education or clinical experience. Such negative attitudes, especially regarding fear of the cancer situation, may lead one to question the effectiveness of the support offered to patients with cancer when health care professionals themselves hold such fearful attitudes.
Optimistically, although health care professionals did hold negative attitudes regarding fear of the cancer situation and hopelessness, they were more positive regarding stigma, indicating that they did not place any blame on the patients for their diagnosis. This supports the findings of previous studies [17, 19]. However, negative attitudes to cancer in health care professionals present a considerable challenge when one considers their potential impact on clinical decision making.
The more we know about attitudes held by oncology health care professionals towards cancer, the more we can predict behaviour and perhaps influence behaviours in a direction resulting in reduced mortality and morbidity and enhanced quality of life. The facts that no large differences in mean attitude scores and no statistically significant differences were found between attitudes according to clinical experience, gender or education support the theory that attitudes towards cancer are formed while part of the wider society. Indeed, it would seem that attitudes are more strongly developed by personal experience and are likely to be held even when presented with the facts in the course of formal education.
Limitations
The concept of attitude measurement and the choice of tools selected should be considered. The tenuous link between attitudes and behaviour weakens attitude measurement using measurement scales. Despite these concerns, the selection of the Burns attitude scale was supported by its self-report nature, wide-ranging content, ease of completion and previous use. The investigators acknowledge that single-survey instruments are not always the most appropriate to capture the multidimensional nature of attitudes or individual heterogeneity. The lack of male respondents and the greater number of females in the sample may have resulted in some bias in the results. However, the sample does reflect the gender balance within health care.
Despite the limitations, these results have served as a catalyst for the investigators to advocate the use of more innovative methods of attitude measurement, taking into consideration recent scientific advances, treatment management and cultural change. Nevertheless, as there is a dearth of knowledge surrounding this topic, this exploratory study has provided a starting point from which the attitudes already identified can be further investigated.
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Conclusions |
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Acknowledgements |
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Footnotes |
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References |
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