Pain and Hope in Patients With Cancer: A Role for Cognition

Mei-Ling Chen, PhD, RN


Cancer Nurs. 2003;26(1) 

In This Article


The study sample (n = 274) was drawn by convenience from inpatients with cancer at two urban medical centers in Taiwan. For inclusion in the study, patients had to be 18 years or older, aware of their diagnosis, without brain metastasis, and able to communicate in Chinese (Mandarin or Taiwanese). Of these 274 patients with cancer, 226 completed information on the measures of hope and pain. Data analysis was based on the responses of these 226 patients.

Hope. The short form of the Herth Hope Scale, the Herth Hope Index (HHI), was used to assess the level of hope.[11,23] The HHI items are rated on a 4-point Likert-type scale with a response range from 1 (strongly disagree) to 4 (strongly agree). The total HHI score can range from 12 to 48, with a higher score indicating a higher level of hope. Herth[11] reported an alpha coefficient of .97 and a test-retest reliability coefficient of .91. Criterion-related validity was supported by high correlations (.81 to .92) with instruments measuring the same construct. Although Herth[11] also identified three factors related to hope in the HHI (temporality and future, positive readiness and expectancy, and interconnectedness), a total score was used to measure hope in the current study. A Chinese version of the HHI, translated by Chen and Wang,[24] was used in the current study, and Cronbach's alpha for the total score was .88 in this study.

Sensory Dimensions of Pain. The Pain Assessment Form (PAF) in Chinese, developed by the author, was used to assess sensory characteristics of patients' pain (ie, location, intensity, duration of pain, and degree of pain relief). Pain intensity was rated using a 0 (no pain) to 10 (worst pain you can imagine) numeric rating scale. Four instances of pain intensity were assessed: current, worst, typical, and bearable. For degree of pain relief, patients were asked to rate pain relief during the preceding week on a continuum from 0% to 100%. The PAF was used in the investigator's previous studies of patients with cancer. Patients had no problem responding to the questions in the PAF. The internal consistency of the three pain intensity measures (current, typical, and worst) in the current study was .70.

Cognitive Dimensions of Pain. The Perceived Meaning of Cancer Pain Inventory (PMCPI), developed by Chen[25] in Chinese, was used to measure the meanings that patients with cancer ascribed to their pain. Four subscales of the PMCPI (Challenge, Loss, Threat, and Spiritual Awareness) were used in the current study. The Challenge and Threat subscales have four items each, and the Loss and Spiritual Awareness subscales have five items each. Patients were asked to rate the degree of likelihood that each item (statement relating to cancer pain) represented their own thought. Each item was rated on a 5-point scale with a response range from 1 (not my thought) to 5 (exactly my thought). Chen[25] reported Cronbach's alpha coefficients of .76, .78, .71, and .75 for the the Loss, Threat, Challenge, and Spiritual Awareness subscales, respectively. A confirmatory factor analysis conducted by Chen[26] supported the construct validity of the PMCPI. The PMCPI has been used in a study of 300 Thai patients with cancer, in which subscale alpha coefficients were .82 for Loss, .88 for Threat, .74 for Challenge, and .83 for Spiritual Awareness.[27] For the current study, the subscale alpha coefficients were .80 for Loss, .80 for Threat, .73 for Challenge, and .72 for Spiritual-Awareness.

Functional Status. The Karnofsky Performance Scale (KPS)[28] was used to evaluate patients' functional status. The KPS is an 11-point scale that ranks performance from 0% to 100%, in increments of 10%. Higher scores indicate better functional status. Widely used to assess physical disability in patients with cancer, the KPS and has been shown to have satisfactory validity and interrater reliability.[29,30] For Chinese patients with cancer, Chen et al[31] also reported high interrater reliability, with a correlation coefficient of .94.

Demographic and Disease-Related Information. The Demographic and Disease/Treatment Information Form, designed by the author, was used to solicit information such as gender, age, education and marital status, and religious beliefs, as well as disease diagnosis, disease stage, treatment received, and perceived treatment effect. Disease stage and perceived treatment effect were used as indicators of disease severity. Because information of disease stage based on the TNM system was not clearly recorded in the medical chart of every patient, disease stage was categorized only as metastatic or local disease. A single question-'How do you think your treatment has improved your condition?'-was designed to measure patients' perception of treatment effect. The response alternatives for perceived treatment effect were 'improved,' 'not improved,' and 'unknown.'

Protection of human subjects' rights was ensured by institutional review board approval of the study at both medical centers. Informed consent was obtained after one of three research assistants explained the study purposes and procedures to the patient. All data were collected at the hospital bedside after admission for various reasons including chemotherapy, radiation therapy, surgery, or symptom management. Data collection was conducted at a time convenient to the patient, mostly during the afternoon or evening hours. Demographic and disease/treatment information was solicited first. The research assistant then asked the patient whether he or she experienced pain during the previous week. The response to this question was used to categorize patients into a pain or pain-free group. A research assistant used the PAF to assess the pain characteristics of those who indicated they had pain in the preceding week (pain group). Patients indicating they did not have pain in the preceding week (pain-free group) were not assessed. Patients with pain then asked were to complete the PMCPI, and finally all patients completed the HHI.

Descriptive statistics (mean, standard deviation, percentage) were used to describe the sample. To test the equivalence between the pain and pain-free groups in terms of selected variables, 2 was used. Pearson correlation t test, and analysis of variance (ANOVA) were used to answer the research questions.


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