Oncology health care professionals’ attitudes to cancer: a professional concern

N. Kearney1,+, M. Miller1, J. Paul2, K. Smith2 and A. M. Rice1

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


    Abstract
 Top
 Abstract
 Introduction
 Aims and methods
 Results
 Discussion
 Conclusions
 References
 
Background:

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


    Introduction
 Top
 Abstract
 Introduction
 Aims and methods
 Results
 Discussion
 Conclusions
 References
 
Despite advances in medical science that have led to effective treatments for cancer, myriad myths and biases related to cancer pervade both patients’ and professionals’ ideas on causation, course of illness, treatment and recovery, and act as hindrances to early detection, treatment and rehabilitation [1]. It has been suggested that regardless of rationality, education or sophistication the attitudes or beliefs that lead to fear of cancer exist to some extent in everyone [2]. Attitudes to cancer may create a barrier to communication between patients and health care professionals and may influence decision making about referral to specialist services and the selection of appropriate treatments [3, 4].

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 individual’s 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.


    Aims and methods
 Top
 Abstract
 Introduction
 Aims and methods
 Results
 Discussion
 Conclusions
 References
 
The aim of the project was to explore the attitudes held by oncology health professionals towards cancer. The specific research questions were: (i) What attitudes do oncology health care professionals hold towards cancer? (ii) Do differences exist in attitudes towards cancer between physicians, nurses and therapeutic radiographers? (iii) Do the variables of clinical experience, gender and education have an impact on attitudes towards cancer?

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 individual’s 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 product–moment 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 Burn’s scales correlating significantly beyond the 0.001 level with the factors of Hoffmeister’s 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 1–7. Overall attitudes towards cancer could be evaluated by calculating a total score, while scores for each of the factors were also calculated.


    Results
 Top
 Abstract
 Introduction
 Aims and methods
 Results
 Discussion
 Conclusions
 References
 
Response by profession
The vast majority of respondents (91%) were females, with males representing 9% of respondents; this reflects the gender imbalance within health care, with nursing and radiography staff (n = 163) constituting the greater part of the total sample. Considering years of experience in the field of oncology, the majority of registered nursing staff had up to 15 years experience, radiography staff generally had between 16 and 25 years experience, whereas medical staff’s experience was broadly spread between 0 and 25 years. Respondents’ ages ranged from 21 to 58 years, with a mean of 37 years. Table 1 shows the response rates from each profession. Overall response rate of 58% is high for a questionnaire survey; however, this is significantly skewed due to the low response rate from the radiographer population.


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Table 1. Response to questionnaire
 
Cancer attitudes
The lower the Burns’ score, the more negative the attitudes held towards cancer or the particular factor under consideration. The mean total score and individual factor scores for the entire population are given in Table 2. The total score indicating a neutral attitude is 88; the neutral score for factor 1, fear of the cancer situation is 40; factor 2, hopelessness is 16; and factor 3, stigma is 28. Analysis according to professional group revealed no statistically significant difference: total and individual factor scores are presented in Table 3. Comparison between genders indicates no statistically significant difference and results are presented in Table 4. Scores for both total scores and individual factor scores were calculated to allow comparison between seniority of nursing and medical staff and these results are presented in Tables 5 and 6. The effects of specialist education on total attitude scores and individual factor scores are presented in Table 7. Attitudes towards cancer in this study population are generally negative, and analysis according to individual factors reveals that negative attitudes prevail regarding hopelessness and fear of the cancer situation. However, no statistical differences can be detected according to gender, professional group or specialist education. More positive than neutral attitudes are evident towards the stigma factor.


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Table 2. Burns’ scores (± standard deviation) for all health professionals
 

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Table 3. Burns’ scores (± standard deviation) for physicians, nurses and radiographers
 

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Table 4. Burns’ scores (± standard deviation) comparing genders
 

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Table 5. Burns’ scores (± standard deviation) comparing grades of nursing staff (seniority was evaluated according to the national grading scale)
 

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Table 6. Burns’ scores (± standard deviation) comparing seniority of medical staff
 

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Table 7. Burns’ scores (± standard deviation) comparing effects of specialist oncology education
 

    Discussion
 Top
 Abstract
 Introduction
 Aims and methods
 Results
 Discussion
 Conclusions
 References
 
The results from this study indicate that, despite working within a Cancer Centre, oncology health care professionals hold negative attitudes towards cancer. Measuring attitudes independently as opposed to in conjunction with treatment modalities and functional abilities has produced illuminating and concerning information.

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.


    Conclusions
 Top
 Abstract
 Introduction
 Aims and methods
 Results
 Discussion
 Conclusions
 References
 
The results from this study indicate that the negative attitudes towards cancer held by oncology health care professionals present a significant challenge. While one could suggest that educational programmes could alleviate fears and promote a positive image of cancer, such programmes must be based on an understanding of current attitudes towards this phenomenon. This study has begun to address the dearth of knowledge in this area. Despite the limitations, the results indicate a need for a radical change in the attitude of health care professionals towards cancer if they are to provide optimal care for this clinical population. Changing these attitudes presents oncology health care professionals with a challenge that can no longer be ignored.


    Acknowledgements
 
The authors would like to thank the staff of the Cancer Centre for their participation in this research.


    Footnotes
 
+ Correspondence to: Professor Nora Kearney, Department of Nursing and Midwifery, University of Stirling, UK. Tel: +44-1786-466-340. Back


    References
 Top
 Abstract
 Introduction
 Aims and methods
 Results
 Discussion
 Conclusions
 References
 
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5. Murray M, McMillan CL. Gender differences in perceptions of cancer. J Cancer Educ 1993; 8: 53–62.[Medline]

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10. Bremnes RM, Anderson K, Wist EA. Cancer patients, doctors and nurses vary in their willingness to undertake cancer chemotherapy. Eur J Cancer 1995; 31A: 1955–1959.[CrossRef]

11. Corner J. The impact of nurses’ encounters with cancer on their attitudes towards the disease. J Clin Nurs 1993; 32: 363–372.

12. McCaughan E, Parahoo K. Attitudes to cancer of medical and surgical nurses in a district general hospital. Eur J Oncol Nurs 2000; 4: 162–170.

13. Slevin ML, Stubbs L, Plant P et al. Attitudes to chemotherapy: comparing views of patients with cancer with those of doctors, nurses and general public. Br Med J 1991; 300: 1458–1460.[ISI]

14. Polit DF, Hungler BP. Essentials of Nursing Research. Methods, Appraisal and Utilisation, 3rd edition. Philadelphia, PA: Lippincott 1993.

15. Burns N, Grove S. The Practice of Nursing Research: Conduct, Critique and Utilisation, 2nd edition. Philadelphia, PA: Saunders 1993.

16. Miller M, Kearney N, Smith, K. Measurement of cancer attitudes: a review. Eur J Cancer Nurs 2000; 4: 233–245.

17. Burns N. Evaluation of a Supportive-Expressive Group for Families of Cancer Patients. Unpublished dissertation. Texas Women’s University, TX 1981.

18. Beck AT, Steer RA. Beck Hopelessness Scale (BHS). San Antonio, TX: The Psychological Corporation 1974.

19. Clarke L. Attitudes of Nursing Students Towards Cancer in Children and Adults. Master’s thesis. University of Missouri, Columbia, MO 1984.

20. Ash CR, McCorkle R, Tiffany R. Cancer prevention and detection course for nurses in developing countries. Cancer Nurs 1988; 11: 230–236.[ISI][Medline]





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