Goals and objectives
- To identify the experiences of a patient that was not expecting results of her lung cancer diagnosis hence or otherwise determine the framework of the experiences and how they impact the nursing principles of practice.
- To determine elements or factors that form the basis of a patient’s experiences after being informed on the status of lung cancer hence or otherwise determine measures for managing the factors that impact negatively on patient experiences
Methodology of the study
The study utilized phenomenology as a research method. Phenomenology was achieved through interviews of the patient and audiotape recording of patient narration. The data was presented in form of text using discourse analysis. Qualitative analysis methods were applied to achieve interpretation of the collected textual data.
Results and findings
The study established patients’ experiences are dependent on the framework for communicating a diagnosis of lung cancer. The study identified poor diagnosis, failure to provide adequate information, failure to provide adequate support to the patient through the provision of information and sharing of experiences increases patient’s depression and affects patients’ active participation. The study determined the communication of diagnosis should conform to nursing principles of care. The nurses should demonstrate compliance with the duty of care by ensuring patients are adequately managed through the provision of necessary patient support and adhering to the nursing principle of autonomy.
There were no procedures in place for communicating a diagnosis of lung cancer hence there was evidence of lack of adherence to nursing principles of care, the duty of care and conformity to holistic approaches for managing lung cancer.
Background of the study
The results of a diagnosis, regardless of whether the clinical problem is terminal illness or not, stimulates development of patient’s thoughts and feelings on the sustainability and management of the disease (Borbasi, 1996). The patient is anxious to know the results. The patient desire to know the facts on a disease affects consciousness and causes restlessness. The patient gains relief and peace of mind when they understand the implication of their disease on their health (Ehrich, 1996).
When the patient lacks understanding on the end results of a disease, the patient preconceives notions and ideas that are based on the inevitable- death. The patient spirituality balance is negatively affected by feelings and thoughts of results of a diagnosis. Some patients have demonstrated regrets on having availed themselves for the diagnosis. Waiting for the diagnosis results is traumatic for a patient if the patient has clear information on the likely outcomes of the diagnosis (Epston & White, 1989).
In many cases, results of a diagnosis are not expected to a patient. The patient may not have enough information on the disease or methods of managing the disease (Gee, 1990). In asymptomatic diseases, where the disease does not present any clinical signs, the patients do not have much expectation of possible negative impacts of the communication of the diagnosis results (Kamler, 1996).
In many instances, the patient reaction to positive diagnosis results into experiences that affect the patient behavior and attention to information dissemination. The information on positive diagnosis of a terminal illness distorts patient emotional and psychosocial faculties.
This makes studies on patient experiences when a terminal illness diagnosis is communicated an important element in clinical management of the patient (Giorgi, 1989). Patient experiences after diagnosis of diseases could be understood through use of psychological phenomenology. Phenomenology provides basis for understanding patient’s reaction when they are informed about a positive diagnosis of a terminal illness (Van-Manen, 1990).
Through use of phenomenology, it is possible to understand patient experiences as a function of patient consciousness. This is because phenomenology makes it possible to identify patient thoughts and feelings as experiences that the patient lived (Tatano, 1992). Phenomenology of patient experiences could be achieved through descriptive analysis of patient reception, though processes and feelings development.
Reliance of patient’s thoughts and feelings as derivatives of patient experiences is founded on the residual effect of the patient experiences (Reason, 1988). For instance, the patient may experience depression for long, worries, self-rejection or lack of self-acceptance and may contribute into patient’s likelihood to commit suicide (Kuhn, 1970).
The method of communicating diagnosis of a terminal illness affects patient’s vulnerability to refusing medication, poor participation in treatment options, failure to provide information that could assist in management of the disease and failure to cooperate with medical staff (Kamler, 1996).
Understanding of framework of communicating diagnosis of a terminal illness helps to identify causes of patient depression, worries, self rejection or lack of acceptance by identifying the meaning of patient experiences on continuity of healthy living and acceptance of their clinical condition (Lather, 1991). It is therefore important to understand patient experiences, how patient perceives information on diagnosis of a disease, how the patient interprets diagnosis results that help to provide inferences on patient preconceptions of the illness and impacts of the diagnosis on their life expectancy.
Patient’s feelings and thoughts that constitute patient experiences after being informed on their status of lung cancer is based on patient’s lack of enough understanding on the influence of lung cancer on the patient’s life (Taylor, 2005). If the patient has understanding of the lung cancer, they demonstrate different experiences than those that have no understanding of the lung cancer. Patients that don’t expect to be positively diagnosed with lung cancer are very much affected by being informed on their status.
Correct understanding of lung cancer and its implication son the life expectancy is important in shaping patients experiences and cooperation with treatment options (Swensen et al, 2002). Many patients after learning about their illness devote time to seek management of the disease. Phenomenology provides basis for understanding patient’s experiences with regard to patient thoughts and feelings after diagnosis (Spielgelberg, 1982). Studies on patient experiences as a constituent of patient behavior has failed to identify the meaning of patient experiences and mechanism through which the experiences remodel the lifestyle of the patient.
This case report addresses a patient that was not aware if she had lung cancer and only learned about her lung cancer status when she had gone for a prescription of antibiotics. The case study looks into the patient thoughts, feelings, and sensations and evaluates rationale of communication of the diagnosis in order to identify deficiencies in communicating lung cancer diagnosis (Storey et al, 2003).
Goals and objectives of the study
- To identify the experiences of a patient that was not expecting results of her lung cancer diagnosis hence or otherwise determine framework of the experiences and how they impact on the nursing principles of practice.
- To determine elements or factors that form basis of a patient’s experiences after being informed on status of lung cancer hence or otherwise determine measures for managing the factors that impact negatively on patient experiences
Expected outcomes or significance of carrying out the studies
The studies will help to identify if communication process of a diagnosis contributes into negative patient perception of disease or negative patient self evaluation (Mon, 2004; 1999). The study results will help to identify if there are biases in communicating diagnosis of lung cancer and if the principles of nursing practice are used satisfactorily to ensure the patient is not harmed by diagnosis results hence compliance wit the principle of beneficence and non-malfeasance.
The findings of the study will help to identify if the wishes of the patient are given high priority hence conformity to the principle of autonomy. The findings of the study will help to understand patient’s experiences through patients own accounts and reflection on the way the message of the diagnosis was communicated. This will help to understand the foundation of patient’s experiences after diagnosis (Roper & Shipira, 2000). Through dialogues and sharing of experiences with the patient, it will be possible to understand patient concerns with regard to the way information on diagnosis is communicated and how the patient receives and perceives the information on diagnosis.
The findings of the study will make it possible for reflection of patient experiences hence help in developing framework for patient behavior and perception of the illness based on how the illness affects their activities of their daily living (Hammong, Howarth & Keat, 1991). The findings of the study will help to determine suitability of using phenomenology to study internal views of a patient through understanding of patient consciousness and how the internal patient views expressed as thoughts and feelings affect patient externally displayed behavior.
Theory used to understand patient experiences
The psychological study paradigm shift recognizes patient experiences after diagnosis are based on patient beliefs on the impacts of the disease, patient values in life and level of patient acceptance of their illness (Brockbank & McGill, 1998). The paradigm on patient behavior identifies patient convictions, language of communicating diagnosis and environment the diagnosis is communicated as important elements that influence experiences of the patient.
The patient’s lived experiences form foundation of understanding methods of managing patient beliefs on the disease and possible patient acceptance of their diagnosis (Boud et al, 1985). This contributes into patient self-acceptance. This provides basis for constructing knowledge on patient experiences. Phenomenology as study of essence of lived experience provides foundation for understanding patient consciousness and behavior (Taylor, 2005).
The use of paradigm shift provides framework for managing patient experiences by adopting the subjective perspective or objective perspective based on positivists approach to patient feeling and thoughts (Speigelberg, 1982).
This section reports on past studies on patient experiences after diagnosis in order to identify sustainability of the methodologies of study used and their deficiencies.
The empirical studies (Kaneko et al, 1996) have demonstrated that patient experiences after communication of lung cancer diagnosis are based on capacity to perform activities of daily living, capability to achieve set goals and failures of the patient to have done a meaningful thing in their lives (Kitzinger, 2005).
The information of diagnosis of a terminal illness based on quantitative studies established patient experiences vary depending on the environment of communicating diagnosis, patient information on the disease, support he patient gets from family and health personnel and patient management strategies used. The patient objective views on diagnosis are influenced by culture, and level of future management of the disease. Experiences of patient during diagnosis communication affect patient meaning on life hence requirement for spirituality care in communication of a diagnosis.
Patient experiences after communication of a diagnosis presents a difficult time in the case of terminal illness (Beaver et al, 2000; Becker et al, 2004). Patient’s experiences after communication of lung cancer diagnosis impacts on the patient’s response to palliative care and level of cooperation that the patient or family members could offer. Communication of a diagnosis is demanding both morally and ethically and affects both communicator of the diagnosis and the patient (Becker, 2009).
Communication framework for terminal illnesses requires structures that recognize health and social care impacts of delivery of the diagnosis outcomes (Fontana et al, 1984; Kolb, 1984) by accounting for patient immediate experiences and essence of outcomes of patients’ experiences. The rationale for communicating a diagnosis should be based on principles of clinical practice. The perceived level of attention that follows after announcement of a diagnosis influences patient’s immediate reaction that could be passive or active depending on patient’s expectations and complexity of the medical problem (Frost et al, 1984).
Communication of diagnosis should meet patient’s psychological, psychosocial and spiritual needs that the patient could demonstrate acceptance as well as family members (Flehinger et al, 1992). Communication of diagnosis therefore should conform to framework of nursing practice, satisfy principles of healthcare delivery and conform to professional standards for nursing practice by respecting principle of beneficence, non-malfeasance, autonomy and informed consent (Beaver et al, 2000).
Communication of diagnosis should be structured around patient education, clinical effectiveness and practice development on lung cancer management strategies. Communication of diagnosis should be able to make the patient to reflect on priorities in life and enable patient to make sustainable changes in life and how the changes affect activities of daily living (Sone et al, 2000; Green et al, 1969). Communication of diagnosis should form part of patient enlightenment. This should contribute into patient positive meaning of their lung cancer.
Different patients demonstrate different experiences after communication that they have lung cancer (Eddy, 1989; Minichiello et al, 2004). The mode of communication and delivery of diagnosis results influences future patient responses and active participation in medical intervention. Communication of results of patient lung cancer diagnosis and the environment in which the diagnosis is communicated influences patient perception of the disease, patient ability to accept the diseases and patient cooperation level on treatment modalities (Siegel, 1956; Baker et al, 1980).
The mode of communication of the diagnosis should satisfy moral, ethical and legal laws on patients. Communication of diagnosis should satisfy the principle of beneficence by forging to do good to the patient. The communication framework for diagnosis should not harm the patient hence ought to comply with nursing principle of non-maleficense (Kubik & Polak, 1986). Delivery of the results of diagnosis of a lung cancer should satisfy the principle of autonomy such that the patient has overall control of process of the communication through asking of questions and being given necessary information.
Communication of diagnosis as part of care management of lung cancer should satisfy the principle of autonomy where the patient has right to decide the mode of treatment to be used post education of implication of the treatment and its sustainability in managing the disease (John et al, 2010; Ozono et al, 2004). This implies, the lung cancer diagnosis communication should satisfy the principle of informed consent and principle of justice.
The patient diagnosis communication should conform to patient needs. The patient should have information on credentials of the attending nurse and that any relationship between the nurse and the patient should purely be professional (Rusinek et al, 1998). The client should be informed about their right to lodge a complaint or file a complaint with health insurance. This study focuses on patient named S.J. in order to determine her experiences after communication that she had lung cancer.
Methodology of the study
This section reports on the method of study that was used to investigate the patient experiences when they are informed on their status of the lung cancer. The section reports on the method of collecting data used; method of data interpretation and method of data analysis. The section concludes with review of ethical considerations for the study (Borgbasi, 1996).
Method of the study
The study used phenomenology as the primary form of research. Phenomenology was used because it helps to examine the life experiences of a patient or the patient lived experiences after the communication of diagnoses (Lakoff & Johnson, 1980). Phenomenology has capacity to identify patient experiences and attach meaning and significance to patient feelings and thoughts.
Method of carrying out phenomenology
The phenomenology method involved examination of the patient experiences and analysis of the patient narrated materials by use of discourse analysis (Hammond, Howarth & Keat, 1991). The rationale was to achieve understanding of the patient essential truths of her experiences.
This could have made it possible to conceptualize the experiences of the patient. Phenomenology was used in order to identify patient concerns that should be integrated in diagnosis communication. This involved listening to the patient descriptions of diagnosis communication without interferences of researcher (Lather, 1991). This made it possible to capture patient wishes and raised issues and preconceives patient unfiltered experiences.
Identifying the participants
The process of seeking the study participants involved visiting the local health centre to determine if there had been recent cases of diagnosed lung cancer (Moon, 1999). The registered lung nurse assisted in identifying recent cases of lung cancer diagnosis and facilitated in selection process of the participants.
The lung cancer nurse proposed I use a patient that had not demonstrated clinical signs of lung cancer. The patient was in a stable state (Kamler, 1996). The lung cancer nurse indicated the other recent cases of lung cancer diagnosis were in a vegetative state and were not able to take part in the study.
The lung cancer nurse indicated use of the patients that were in vegetative state required higher level of ethical concerns and compliance of the studies with ethics required approval from the ethical committee as well as supervision since the interview could have taken place in the hospital setting (John et al, 2010). The preferences for the stable patient were arrived at due to possibility of implementing the interview in a home setting where the patient was comfortable.
Access of the participant
The local health centre provided introduction letter that indicated objectives of the interview and expected outcomes of the interview to the patient and the patient family. The introduction letter introduced the ethnographer, credentials of the ethnographer and rationale of the interview (Storey et al, 2003). The lung cancer nurse indicated she was not going to be present so that the patient could have freedom to provide her experiences after lung cancer diagnosis and communication. The lung cancer nurse indicated her presence could have resulted into biasness of the interview results.
The research instruments used
The study used open ended questionnaires in order to collect data on patient experiences after they are informed about their status of lung cancer (Minichielo et al, 2004). The open ended questions ensured the patient provided answers exhaustively to all the questions.
- What were you expecting as you entered the lung nurse room?
- How many nurses or people did you meet in the lung nurse room?
- Are there thoughts on the presence of the people in a lung nurse room when you were probably to get your lung cancer diagnosis?
- Did you suspect you could get the results on your lung diagnosis?
- What was your immediate reaction after you were told you had lung cancer?
- Based on your immediate reaction, do you think the diagnosis was correctly presented?
- What were your immediate feelings on your lung cancer diagnosis?
- What were your immediate thoughts on your lung cancer diagnosis?
- Do you think the environment in which you were told the news was appropriate?
- What type of environment did you expect to have found better for communication of lung cancer diagnosis?
- Did you get enough information on the lung cancer diagnosis?
- Did the lung nurse prepare you adequately for the presentation of the results?
- What initial activities do you think the lung nurse should have done before presenting the results?
- Do you think your rights as a patient were considered when you were informed of your diagnosis?
- Do you think the lung nurse used any procedures in communicating your lung cancer diagnosis?
- Were you satisfied with your results?
- Did the lung nurse inform you about the success of lung cancer treatment?
- Do you think it was useful to have been informed on the treatment options?
- Did you agree with any of the treatment options that were proposed?
- Did you immediately accept the results of your lung cancer diagnosis?
Method of data collection and presentation
The interview was audiotaped and later, the researcher wrote down the patient story. The collected data was presented in form of text (appendix 2) and presented in form of text for analysis (Minichiello et al, 2008). Data collection relied on study respondent’s quotations and qualitative accounts on reactions, experiences and coming to terms with the lung cancer. The respondent’s accounts were presented in form of textual narratives (Minichiello et al, 2004).
Method of data analysis
The study used discourse analysis as preferred method of data analysis. Discourse analysis was considered favorite due to its reflexive analysis of arguments in phases (Kitzinger, 2005). Data analysis began with identification of factors that negatively impacted on the patient experiences after communication of the diagnosis results. This resulted into integration of ethnographic factor analysis approach where every factor that influenced patient experiences through thoughts and feelings was analyzed based on its contribution to patients experience development (St Johns, 2004).
Comparative discourse analysis was carried out to compare patients-experience predisposing factors and framework that should have been used when communicating the diagnosis. The factors were then moderated to identify mechanism through which communication of patient diagnosis could be improved in order to enhance patient response and acceptance of the diagnosis outcomes (Hammond et al, 1991). This implies, data analysis involved abstraction and generalization of concepts.
The abstraction was used in order to facilitate in translating empirical observations on communication of diagnosis and impacts of environment of communication, medical intervention criteria and conformity to nursing principles of palliative care (Boud et al, 1985). Analysis of continuum of the textual data was carried out and measures of validity of interpretative comments and quotations done through reflections that was achieved through textual content application (Altman, 1991).
Internal consistency of the data was determined which was followed by contextual analysis and finally the data was compressed using data reduction strategies. The compressed data outcomes were analyzed by using interpretation and attaching meaning and significance followed by inducing descriptive patterns to the textual data (Sone et al, 2000). After the data interpretations were carried out, the results were reported as textual findings.
Ethical implications of the study
The study was designed to conform to ethical nursing principles for studies that involve use of human respondents as study respondents (Minichiello et al, 2004; 2008). The patient was informed on the rationale of the study, and permission was sought to audiotape the patient as the interview progressed. The study was structured to comply with the principle of beneficence and non-maleficense by ensuring it delivered nursing principle of justice (Thomas, 2003).
The open ended questionnaires (appendix 3) as the primary instruments of research were structured to have no emotional, social, psychological or mental harm to the patient care giver, patient or any other member of staff or family (Siegel, 1956). The study complied with moral, ethical and legal laws on impacts that a study could have on a patient. The study satisfied principle of beneficence by forging to do good , help the patient and manage patient’s inner self (Baker et al, 1980).
The study open questionnaires (appendix 3) satisfied the principle of non-malfeasance hence had no possible harm to the patient or impact negatively on patient’s psychotherapy or impact negatively of possible patient current treatment modalities (Ozono et al, 2004). The study satisfied the principle of informed consent by educating the patient on the rationale of the study, expected outcomes of the study and influence of the study results on future development of care management strategies for lung cancer (Swensen et al, 2002).
The patient was informed on adherence of the study to the principle of confidentiality and patient was informed on possibilities of withdrawing from the study without necessarily giving a reason for withdrawal from the study.
Results and discussion of the results
The results of the data collection are represented by appendix 1.
The results (appendix 1) indicated that the patient was not prepared for the communication of the diagnosis. The nurse should have prepared the patient for the diagnosis by ensuring the environment was conducive to communicate any information that was necessary. The nurse should have introduced the people to the patient and their role in lung cancer diagnosis.
The patient was not expecting to have had her lung diagnosis revealed. The patient had gone for an antibiotic prescription. The patient was not expecting diagnosis of lung cancer because the patient was asymptomatic.
The immediate reaction of the patient to the news should have been appropriately managed through introduction of the patient to lung cancer and. The patient should have been hinted on the possible outcomes of the sputum cytology. The patient was not represented by any relative or accompanied by friend. The patient feelings and thoughts on being informed of lung cancer demonstrated betrayal of the patient privacy to information.
The patient experiences arose due to lack of procedures in communicating a diagnosis. The patient diagnosis resulted into patient questioning of rationale of communicating the diagnosis, the impact of the disease on her health, the acceptance level of the family and degree of commitment of the family to her illness. This implies, communication of a diagnosis should be carried out in an environment where the patient has freedom to express themselves. The patient should be given a choice on who should be present hence satisfying autonomy principle.
The patient experiences indicate there was violation of nursing principle of beneficence where any communication to the patient or activity on the patient should not cause emotional, psychological or psychosocial harm. This means the patient rights were not adhered to. This was due to lack of procedures and communication with patient on their needs. The patient experiences shown that the patient was not satisfied with the results.
The patient could not understand why the nurse had informed her he could not guarantee cure. The nurse should not have informed the patient on treatment options at the stage of communicating the diagnosis. The nurse should have informed the patient on possible environment for communicating the diagnosis of the sputum cytology that had been done.
The patient experiences were found to have impact in influencing patient cooperation in accepting treatment options. The initial experiences made the patient difficult to manage. The nurse conduct had resulted into loss of confidence of the patient. The lack of inconclusiveness of three biopsies in revealing the patient had lung cancer had made the patient to belief the nurse had made a grave mistake.
The study achieved its objectives in determining the patient experiences after communication of her lung cancer status. The study determined that the patient communication of her diagnosis didn’t follow nursing principles of care. There were no procedures in communicating the diagnosis.
The environment for communicating the diagnosis was not appropriate. The communication of the diagnosis should have been done in presence of family members or any other person who could have made informed consent on behalf of the patient. The patient was not provided with enough information on lung cancer. The patient ought to have had experience sharing on lung cancer by being introduced to other patients who could have provided their experiences. The nurses should have held a discussion with the patient on mechanism through which past lung patients had been managed.
This means the communication of the patient lung cancer diagnosis didn’t follow nursing principles of care. The communication of the diagnosis didn’t follow professional ethical and moral standards or satisfy nursing principles of practice. This study proposes that future communication of the lung cancer diagnosis should be carried out based on nursing principles of care and practice.
The communication of diagnosis should be structured around nursing principles of care. The nurses should demonstrate duty of care by satisfying principle of autonomy, principle of beneficence, principle of non-malfeasance and principle of informed consent.
Limitations of the phenomenological approach
The main limitation of the phenomenological methodology of research as used in the patient experience determination was caused by lack of formulating and testing hypothesis. Phenomenology does not test hypothesis which means the inter-rater reproducability and reliability of the study across the population is not possible. The phenomenology does not contribute into development of new theories on patient communication of diagnosis.
The theory should be exploited to identify its deficiencies hence result into development of framework for minimizing negative outcomes of patient experiences. The phenomenology requires researcher’s reflection which might not be achieved by many researchers. There is limitation that the results of phenomenology are predictive of the actual lived experience or are replicable across population. It is not possible to identify if another patient could have experienced the same experiences as the patient under the study.
The study results were vulnerable to biasness. Thus, it was not fully possible to develop awareness of the patient preconceptions at the beginning of the interview and during the course of the interview. This brings in a problem of whether it’s right and essential to appropriate patient’s story into theory and practice. There are also concerns on the authority of the researcher and power to construct narrative or control the narration to achieve desired outcomes.
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