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Physicians' communication styles

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Title:
Physicians' communication styles the relationship to patients' coping strategies when confronted with the diagnosis of cancer
Creator:
Zautke, Mary Beth
Place of Publication:
Denver, CO
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University of Colorado Denver
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Language:
English
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vii, 109 leaves : forms ; 29 cm

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Subjects / Keywords:
Physician and patient ( lcsh )
Communication in medicine ( lcsh )
Cancer -- Patients ( lcsh )
Cancer -- Psychological aspects ( lcsh )
Cancer -- Patients ( fast )
Cancer -- Psychological aspects ( fast )
Communication in medicine ( fast )
Physician and patient ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Bibliography:
Includes bibliographical references.
Thesis:
Submitted in partial fulfillment of the requirements for the degree, Master of Arts, Department of Communication
Statement of Responsibility:
by Mary Beth Zautke.

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|University of Colorado Denver
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|Auraria Library
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All applicable rights reserved by the source institution and holding location.
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26909584 ( OCLC )
ocm26909584
Classification:
LD1190.L48 1992m .Z38 ( lcc )

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Full Text
PHYSICIANS' COMMUNICATION STYLES:
THE RELATIONSHIP TO PATIENTS' COPING
STRATEGIES WHEN CONFRONTED WITH
THE DIAGNOSIS OF CANCER
ty
Mary Beth Zautke
B.S., Bradley University, 1966
A thesis submitted to the
Faculty of the Graduate School of the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Master of Arts
Communication
1992


This thesis for the Master of Arts
degree by
Mary Beth Zautke
has been approved for the
Department of
Communication
by
5 -Z-?Z
Date


Zautke, Mary Beth (M.A., Communication)
Physicians' Communication Styles: The Relationship to Patients'
Coping Strategies When Confronted with the Diagnosis of
Cancer
Thesis directed by Associate Professor Pamela S. Shockley
ABSTRACT
This study investigated 1) the communication styles
exhibited by physicians, as perceived by their patients, when
delivering the life-threatening diagnosis of cancer and 2) the
relationship of communication styles to the coping strategies
adopted by the patient. The study was based on an assumption
that the affective component of the physician's communication
style may be a major factor in helping patients cope with their
cancer. Research findings supported the hypothesis that when
physicians possess a more affiliative communication style, as
perceived by their patients, patients' overall satisfaction with the
communication of their cancer diagnosis would be higher.
However, the study did not support the hypothesis that patients
will cope with the delivery of a cancer diagnosis in a more
confrontive way when their physicians are perceived to
demonstrate an affiliative communication style. Additionally, for
patients diagnosed with cancer, the findings failed to support
iii


i
I
the hypothesis that there would be a negative correlation
between communication apprehension and the use of behaviors
related to the coping strategy of confrontation as derived from
the Medical Coping Modes Questionnaire. When examining only
verbal confrontive behaviors, the research supported a negative
correlation between communication apprehension and the
patients' verbal ability to cope.
This abstract accurately represents the content of the
candidates thesis. I recommend its publication.
Signedl
Pamela S. Shockley
iv


CONTENTS
CHAPTER I
I. INTRODUCTION................................... 1
General Background to the Research Problem....1
Historical Background Relevant to
Physician Communication and Cancer Patient..... 2
The Present Nature of the Coping Process......3
Background Relevant to Coping with Cancer.... 5
Rationale and Support for the Study.......... 6
Summary...................................... 9
II. REVIEW OF THE LITERATURE.......................11
Literature Review........................... 11
Physician-Patient Communication...........11
Physician Communication
Relevant to the Cancer Patient............19
Physician Communication Style.............23
The Present Nature of the Coping Process ... 26
Coping with Cancer....................... 34
An Overview of Communication
Apprehension............................. 39
Research Hypotheses...................... 42
Summary.................................. 43
v


III. METHODOLOGY
45
Description of the Research Population...... 46
Prologue and Explication of the Hypotheses..... 47
General Explication of Methodology............... 48
Overall Procedure and Research Design............ 50
Hypothesis 1................................. 50
Hypothesis 2..................................51
Hypothesis 3..................................51
Research Plan................................ 52
Instrumentation and Measurement...................53
Data Collection...................................54
Data Analysis.....................................55
Summary.......................................... 56
IV. RESULTS............................................ 57
Primary Analyses................................. 59
Hypothesis 1..................................59
Hypothesis 2..................................60
Hypothesis 3................................ 62
Supplemental Analyses............................ 64
Quantitative Data............................ 64
Qualitative Data..............................66
Summary.......................................... 67
vi


V. DISCUSSIONS, INTERPRETATIONS,
AND CONCLUSIONS................................. 68
Summary of the Findings....................... 70
Primary Results........................... 70
Qualitative data.......................... 70
Assessment of Results......................... 71
Problems and Limitations...................75
Suggestions for Future Research............76
Summary....................................... 77
APPENDIX
A Complete Questionnaire.......................... 79
B. Confrontation Index &
Affiliative Style Variables..................... 89
G Verbal Confrontive Behaviors.................... 91
REFERENCES............................................. 93
vii


CHAPTER I
INTRODUCTION
The primary purpose of this study was to examine 1) the
communication styles exhibited by physicians, as perceived by
their patients, when delivering the life-threatening diagnosis of
cancer; and 2) the relationship of these communication styles to
the coping strategies adopted by the patient. This study was
based on an assumption that the affective component of the
physicians communication style may become a major factor in
helping patients cope with their cancer.
General Background to the Research Problem
Since the time of the Greeks, the therapeutic power of the
doctor-patient relationship has been well noted and studied.
However, only in the last twenty years have the actual dynamics
of this medical encounter been observed in any consistent
manner (Roter et al., 1988).
Historically, American society has both accepted and
supported the paternalistic nature of the physician-patient
relationship. Prior to the 1980's, this interaction between
doctor and patient was one in which the physician prescribed
and the patient complied (Ballard-Reisch, 1990).
1


There is growing evidence indicating patients are
becoming more consumerist in orientation and the new
generation of patients are likely to directly challenge physician
authority within the medical encounter (Haug & Lavin, 1983).
In the last decade, there is evidence that the relationship that
was formerly based on prescription and superior knowledge is
evolving into one of shared decision making and in which the
patient plays an active role in her or his health care (Siegler,
1981).
Historical Background Relevant to Physician Communication and
the Cancer Patient
In the past, many physicians chose to withhold the
diagnosis of cancer, agreeing that it was in their patients best
interest not to be told of their impending death (Glaser &
Strauss, 1968). According to Taylor (1988), a dramatic change
in disclosure policy occurred in North American in the late
1960s and early 1970s. Attributed to the demands of patients
who had become better informed, these changes were due in
part to 1) increased media coverage (Abrams, 1966), 2) new
laws requiring that patients understand the nature of their
disease before consenting to experimental therapy (Barber,
1980), and 3) a shift toward holistic medical care, based on the
2


idea of open communication between doctor and patient
(American Cancer Society, 1982). Opinion in more recent years,
therefore, is that the patient's right to know what is wrong
should usually override the doctor's very doubtful ability to tell
whether the patient is intelligent enough or emotionally strong
enough to receive the news (Moffit & Rossiter, 1978). The
literature contains several articles describing physicians who
advocate the new policy of total disclosure. However, it is
interesting to note that studies still cite patient dissatisfaction
with the amount of information they are given. Additionally, a
study by Lind et al. (1989, p. 589) reports that "patients are
unhappy with the mode of telling rather then the bad news
communicated by the telling."
The Present Nature of the Coping Process
Human beings are constantly trying to make sense out of
life events. They look toward many theories to aid in their
dilemma of explaining not only the events in their own lives but
in the lives of other people as well. A theory can be defined as a
viewpoint or perspective, a way of looking at the relationship
between things. Theory, therefore, becomes the very "stuff by
which life events and coping are defined (Snyder & Ford, 1987).
!
s
i
3


Over the years, coping has acquired a variety of conceptual
meanings and has been commonly used interchangeably with
such concepts as mastery, defense, and adaptation (White,
1974). The concept of "coping" in the White study refers to
"attempts made to lessen the physical and psychological pain
associated with negative life events" (Snyder & Ford, 1987, p.9).
For coping to occur, people must first select a particular
response and then somehow mobilize and sustain sufficient
energy to pursue it (Snyder & Ford, 1987).
Fleming and colleagues (1984) stated: 1) that coping
represents the expression of a complex set of factors
encompassing such variables as personality, attitudinal,
cognitive, and expectancy elements; 2) that choice of a specific
strategy is most likely multidetermined; and 3) that the
configuration of variables associated with a particular strategy is
likely to be different for each coping strategy.
According to Lazarus et al. (1974), much of the research
on coping has given greater emphasis to psychological
dispositions than to specific responses to situational conditions.
However, Pearlin and Schooler (1978) were able to demonstrate
that the style and content of coping does make a difference to
the emotional well-being of people. And furthermore, they
reported that the greater the scope and variety of the
4


individual's coping repertoire, the more protection coping
affords.
Background Relevant to Coping with Cancer
Investigators have reported a variety of coping strategies
used by medical patients in dealing with illness such as
avoidance, denial, confrontation, and acceptance-resignation.
Unfortunately, current theories in the area appear to be limited
in their ability to explain the variabilities noted in some of the
empirical data (Silver & Wortman, 1980).
Cancer can be a tremendously frightening and stressful
disease that can tax the coping resources of even the most well
adjusted of patients (Meyerowitz et al., 1989). The American
Cancer Society (1990) estimated that about 30% of the total
population of Americans now living will be diagnosed as having
cancer. Over the years, cancer will strike three of four American
families (Gotcher & Edwards, 1990).
Due to the ever-present and deadly nature of the disease, a
tremendous amount of research has focused on the medical
aspects of cancer. The psychological aspects of the disease,
unfortunately, have not been examined as extensively, even
though the emotional trauma that results from the diagnosis and
5


treatment of cancer can be as damaging to the patient as the
cancer itself (Harrell, 1972; Radley & Green, 1987).
There has been the suggestion that life-threatening
conditions may call forth coping strategies which are different in
kind or degree from those used to cope with nonlife-threatening
conditions (Silver & Wortman, 1980). Together, several studies
point to life-threat as a consequential factor in the way people
respond to their situation (Bahnson & Bahnson, 1969; Hackett
& Weisman, 1969; Knier & Temoshok, 1984; Visotsky et al.,
1961; Weisman et al., 1980). In a study published by Feifel et al.
(1986), findings appear to support those theorists who
conceptualize coping behavior in dealing with life-threat as being
shaped more by situational context than by personal style.
Rationale and Support for the Study
As the importance of physician-patient communication
becomes increasingly recognized, an area of general interest and
importance for many Americans is the communicating of the
diagnosis of cancer. According to Goldschmidt & Hess (1987),
no other doctor-patient interaction requires so much clarity,
sensitivity, and mutual understanding.
Due to the potential impact of a cancer diagnosis and the
treatment as well, several researchers have examined the role of
6


psychological states and the Individuals chance of recovery from
a life-threatening disease (Gotcher & Edwards, 1990). Greer,
Moorey, and Watson (1989) reported that the way the patient
psychologically copes with the trauma directly affects the
patients chance of survival.
Patient satisfaction is by far the most recognized and
widely used measure for assessing the effectiveness of physician-
patient communication. Studies have determined that one of
the factors important in patient satisfaction is the amount of
information given by the physician (Ley, 1982; Gotcher &
Edwards, 1990; Miller et al., 1983; Reynolds et al., 1981;
Steptoe et al., 1991; among others). However, greater
satisfaction with communication was not associated with higher
levels of factual knowledge concerning the causes and
treatments of cancer (Steptoe et al., 1991).
Research has linked patients' satisfaction with health care
to the communication styles of physicians. The patients
satisfaction with the doctor appears to be largely a result of the
physician's verbal and non-verbal communication while
interacting with the patient (Daly & Hulka, 1975; Korsch et al.,
1968; Spiro & Heidrich, 1983).
Ben-Sira (1976, 1980) argues in his social interaction
model that the affective component of the physician's
7


communication becomes a major factor because a patient enters
the medical interaction with anxiety about the medical
prognosis, less knowledge about medical techniques than the
physician, and less ability to connect treatments with
improvements.
Ben-Sira's affective component is closely related to a
concept elaborated in the communication literature as
communication style. Communication style is conceptualized by
Norton (1978, 1983) as "the way one verbally or para-verbally
interacts to signal how literal meaning should be taken,
interpreted, filtered, or understood" in a communication
context (1978, p. 99).
As previously discussed, coping has been described as a
critical component in the patient's struggle for survival and
recovery from serious illness (Sanders & Kardinal, 1977).
Numerous studies have examined the concept of coping from
the perspective of the patient. This study placed the emphasis
on the physician. The research objective of this study was to
examine physicians' communication styles in a single episode of
cancer treatment the event of telling the patient for the first
time that she/he has cancer and the subsequent influence of
that communication style on the coping process of that cancer
patient.
8


The literature review that follows further explicates the
present study and concludes with a statement of the specific
research hypotheses that were empirically tested in this study.
Summary
This first chapter has provided some general background
to the research problem under investigation. It has explicated
the historical background of physician-patient communication
and reviewed the significance of this relationship relevant to
cancer patients. Additionally, this chapter presented the
present nature of the human coping process and the significance
of coping for patients with the life-threatening illness known as
cancer. Rationale for the present study and research objectives
have also been outlined.
Next, Chapter II will review the literature relevant to the
research problem in greater depth and will present the three
specific research hypotheses that have been tested. Chapter III
addresses the research procedure and design, sampling,
instrumentation, and data collection and analyses. Chapter IV
contains the results of the study and analyses of the data with
regard to the research hypotheses. Chapter V is concerned with
interpretation of the results of the study and the implications of
those results. Also included in Chapter V is a discussion of
9


problems and limitations of the study with some suggestions for
future research.


CHAPTER II
REVIEW OF THE LITERATURE
Literature Review
The primary purpose of this study was to examine the
communication styles exhibited by physicians as perceived by
their patients when delivering a diagnosis of cancer and the
relationship of the communication styles to the coping process
employed by the patient. In the preceding chapter, background
and rationale for the study were provided. This chapter will
review relevant literature related to the research objective and
will conclude with a statement of the specific research
hypotheses. The review will include six areas: 1) generalized
physician-patient communication, 2) physician communication
relevant to cancer patients, 3) physician-communication style,
4) the nature of the coping process, 5) coping with cancer, and
6) an overview of communication apprehension.
Physician-Patient Communication
An array of studies beginning in the late 1950s have been
reported concerning the nature of the relationships between
patients and practitioners. However, this remains a difficult
literature to review. The field appears disorganized with little
11


sense of theoretical cohesiveness or rational progression. A
proliferation of terms exists without agreement on basic
definitions for coding categories or communication variables
(Roter et al., 1988). In light of these complexities, an overview
will clarify the physician-patient relationship as it pertains to
this study.
Prior to the 1960s, long-standing, one-to-one
relationships between patient and physician were the rule rather
than the exception. This provided a setting where warmth and
mutual understanding were able to develop and flourish. But as
patterns of medical care have changed, the individual doctor-
patient relationship has been replaced by short-term encounters
with numerous specialists and other healthcare workers.
Simultaneously, there has developed a discontent of the patient
population with much criticism being aimed at the lack of
warmth and humanity in the available medical care (Korsch et
al., 1968). Even as recently as 1988, the American Medical
Association (AMA) Survey of Physicians and Public Opinion on
Health Care Issues (cited in Gartland, 1989) found that the
American public feels physicians are still not communicating
well with patients, that they are regarded as arrogant, acting as
if they were better than other people.
12


The combined literature considers communication
between physicians and patients to be a critical component of
effective medical care. Diagnosis and treatment depend on the
physician's ability to exchange information with the patient.
Communication becomes a strong influence on patient
compliance (Ballard-Reisch, 1990; Burgoon et al., 1990; Korsch
et al., 1968; Sharf, 1990) among others. Equally important,
communication is the major determinant of patient satisfaction
(Buller & Buller, 1987; Korsch et al., 1968; Ley, 1982; Steptoe
et al., 1991) among others.
The interaction between physicians and patients involves
an "information game" wherein participants both seek and give
information (Goffman, 1959; 1967). In managing the course of
an illness physicians make decisions about diagnosis, treatment,
and communication.
Several communication studies in the last five years have
directed their energy toward the subtleties of health
communication that are carried out in the medical encounter.
Several different aspects of this interaction between physicians
and patients have been addressed, specifically patient power,
relational control, health promotion, decision making, giving bad
news, and interpersonal rhetoric. A brief overview of these
various aspects of physician-patient communication follows.
13


The aspect of communication that pertains to "giving bad
news" will be addressed in the following section of this chapter
titled "physician communication relevant to cancer patients".
Physicians provide services that are both needed and desired by
patients. Therefore, the doctor-patient relationship is
immediately observed as asymmetrical with the doctor
possessing legitimate, referent, and expert power. According to
A. E. Beisecker (1990), the transfer of expert power from doctor
to patient may be accomplished in the medical encounter.
Patients are able to exercise some control in the medical arena
by attempting to obtain information, being assertive when
communicating with physicians, and participating in medical
decisions.
The literature has shown multiple factors to be involved in
affecting patient power: 1) sociodemographic characteristics, 2)
role expectations and attitudes of doctor and patient, and 3)
situational factors that influence both parties in their interaction
with each other. Situational factors, however, appear to be
better predictors of a patient's assertive communication
behaviors than attitudes and sociodemographic variables
(Beisecker, 1990). Examples of situational factors would be
diagnosis, reason for patient visit, presence of a companion,
length of interaction, among others.
14


In discussing patient power, von Friederichs-Fitzwater and
colleagues (1991) have dealt with the issue of relational control,
attempts by patients and doctors to control each other. In
seeking information from their physician, patients may actually
be seeking more control over their medical situation than over
the doctor. Beisecker (1990) suggests that this might explain
the strong role played by situational factors, such as diagnosis
and reason for the visit, in explaining patients' attempts to seek
information and make suggestions regarding treatment options.
Physicians are making an effort to increase the autonomy
of their patients and to provide more information so that
patients may give their informed consent to medical treatment.
By making these efforts, doctors are actually sharing some of
their power with patients. A. E. Beisecker (1990) points out
that this sharing of power has occurred at the same time that
third-party payers (i.e., insurance companies and health
maintenance organizations) are also taking some power away
from doctors by insisting on input in medical decision making.
The doctor-patient relationship and the balance of power within
that relationship will certainly be influenced by third-party
payers who have economic power over medical decisions and
the presence of knowledgeable, assertive patients.
15


Health promotion refers to teaching people how to
prevent disease by changing their lifestyles. Evidence is
accumulating that supports the philosophy that lifestyle has
identifiable effects on health and disease. Kottke and colleagues
(1987) have listed a number of specific and practical
recommendations for persuading patients to change their life-
styles. In a recent study by Barbara Sharf (1990), the physician-
patient interaction is discussed as rhetorical activity. Observing
the clinical interview as interpersonal rhetoric has contributed
to a broader understanding of how such rhetorical activity can
significantly influence outcomes that include preventing and
curing diseases as well as prolonging life. The recent
application of narrative theory (storytelling) in rhetoric and in
medicine may provide answers to the ways that physicians and
patients shape the discourse in which they jointly participate in
an attempt to persuade each other (Polkinghome, 1988).
The final aspect of physician-patient communication to be
discussed here revolves around medical decision making. Prior
to the 1980s, the doctor-patient relationship was one in which
the physician prescribed and the patient complied. (Ballard-
Reisch, 1990). This paternalistic relationship has also been
referred to as the biomedical model (Wyatt, 1991). Partially due
to the emphasis on informed consent, this relationship has
16


undergone much change In the last decade within medical,
legal, and social spheres (Sisson, Schoomaker, & Ross, 1976;
Katz, 1984; McNeil et al., 1982). The relationship evolved into
one of shared decision making, referred to by Engel (1977) as
the biopsychosocial model. This model is a collaborative
relationship in which the patient and the doctor work together
to make decisions (Ballard-Reisch, 1990). In applying the
concept of participative decision making to the health care
setting, Brody (1980) concluded that patients who participate in
the clinical decision making have greater confidence in and
commitment to health-care decisions. Reinforcing this
perspective, the findings of Janis (1982) found that individuals
who are committed to a course of action and who accept
responsibility for it are more likely to adhere to the treatment
process.
In summary, Ley (1983) postulates that two major
problems currently exist in health-care delivery today. The first
involves providing patients with enough information concerning
their illness and treatment to conclude that they are sufficiently
informed; the second addresses the high level of noncompliance
occurring on the part of patients with prescribed medical
regimens. Both problems occur as a result of short-comings in
current patterns of communication (Roter, 1983) and decision
17


making between physicians and patients (President's
Commission, 1982).
As the focus slowly shifts from the biomedical (doctor-
centered) model to a biopsychosocial model (patient-centered,
partnership), issues of power, trust, and intimacy in the doctor-
patient relationship will become ever more significant factors in
the goal of providing optimum health care (von Friederichs-
Fitzwater et al., 1991).
Patient satisfaction is the most recognized and widely used
measure for assessing the effectiveness of physician-patient
communication. Studies have determined that one of the factors
important in patient satisfaction is the amount of information
given by the physician (Gotcher & Edwards, 1990; Ley, 1982;
Miller & Mangan, 1983; Reynolds et al. 1986; Steptoe et al.,
1991) among others. According to Ley (1982) patient
dissatisfaction and lack of compliance are linked with poor
transmission of information from doctor to patient, low
understandability of communications addressed to the patient,
and low levels of recall of information by patients.
Patient satisfaction will be discussed again later in this
chapter under "physician communication styles."
18


Physician Communication Relevant
to the Cancer Patient
Within the multitude of services which the health care
system delivers to cancer patients, a largely non-technical
activity has begun to receive increasing attention from
researchers in the last decade: Communicating facts about the
disease (Greenwald & Nevitt, 1982).
The communication process between physician and cancer
patient shares most of the general features of the standard
doctor-patient interaction as discussed in the previous section.
However, this process becomes burdened with additional
problems. L. A. Siminoff (1989) describes these problems as
revolving around a variety of factors which make the discussion
of cancer emotionally charged. Most important of these are the
fear and stigma associated with the diagnosis and treatment of
cancer (Meyerowitz et al., 1989), the complexity of the medical
information itself, and uncertainty about the benefits of
treatment or the course of the disease (Division of Cancer
Prevention and Treatment: Annual Report, 1987; Frei, 1982;
Hoy, 1985).
Among the communication issues in cancer, none has been
more widely and emotionally debated than that of telling the
diagnosis. This issue becomes the focus of this section of the
19


literature review for it exists as a pivotal element to this
empirical study.
Before 1960, the majority of physicians in the United
States, like doctors in most of the rest of the world, rarely told
patients that they had cancer (Taylor, 1988). By 1980, twenty
years later, this trend had completely reversed. Over 90% of the
doctors stated that they routinely reveal the diagnosis of cancer
(Holland et al. 1987). According to Holland (1989), this reversal
resulted from the public being better informed as well as being
less pessimistic about cancer, and from an increase in societal
concerns about patients' rights to give informed consent and to
participate in decisions about their care. The American Cancer
Society (1982: 1919-70) also attributes the change to a shift
toward holistic medical care, based on the ideal of open
communication between doctor and patient (Taylor, 1988).
A decade after acceptance of this new practice of
disclosing a cancer diagnosis, a report by Lind and colleagues
(1989) addresses the next question: how well are we doing in
handling this critically important presentation of the diagnosis
from which the experience of every cancer patient begins?
Patients' perceptions of their physicians in the Lind Study
suggest the need for attention to this subject as well as
improvement in performance.
20


Virtually any type of physician may be involved in one stage
or another of telling this diagnosis. Biopsies have been
performed almost exclusively by surgeons, the fact contributing
to the largest percent of "telling" doctors residing in that
specialty. Oncologists occasionally may be the first to tell a
patient the definitive diagnosis, but more often, oncologists must
tell the diagnosis a second or third time (Lind et al., 1989).
Holland (1989) relates that there is little empirical
literature to guide the clinician on how and in what context to
tell the diagnosis of cancer. Physicians seem to depend
primarily on personal experiences and judgments with the help
of chance comments of colleagues or teachers in deciding how
to approach an individual patient.
In the study performed at Massachusetts General Hospital
by Lind and colleagues (1989), several important questions
emerged for consideration. First, in terms of who should convey
the cancer diagnosis, the physician who knows the patient only
through doing a diagnostic procedure may not be the most
appropriate person.
Second, patients studied by Lind et al. (1989) confirmed
that content of the discussion should not be limited to revealing
the diagnosis. Prognosis and discussion of treatment were more
commonly cited, by 52% and 18%, respectively, as the most
21


important elements of the telling. Brief conversations in which
the diagnosis alone was discussed, especially on the telephone
or in the recovery room where the ability of the patient to
respond was compromised, were not only unsatisfactory, but
were perceived as insensitive and unfeeling on the doctor's part.
Third, the place in which the diagnosis is discussed must
be private enough to permit the patient to show feelings.
Fourth, the presence of a family member or friend is usually
helpful to the patient who is anxious and may have difficulty
recalling details of the conversation. Fifth, there are direct
implications from the study that training would be helpful for
doctors who must repeatedly give bad news. Most have received
no special training in counseling and talking to patients. It is
interesting to note that most physicians who have faced serious
illness themselves become far more considerate of patients'
feelings (Holland, 1989).
Lastly, patients in this study by Lind and colleagues (1989)
reported that they were unhappy with the mode of telling rather
than the bad news communicated by the telling. This facet of
physician-patient communication will be discussed in greater
detail in the following section titled "Physician Communication
Style."
22


Physician Communication Style
Researchers and health care practitioners are concerned
with identifying factors which promote patients' compliance
with physician recommendations in order to improve the quality
of health care (Korsch, Gozzi, and Francis, 1968; Burgoon et al..
1990). The patient's satisfaction with the doctor as well as the
medical treatment has been reported as an important
determinant of compliance (Korsch et al., 1968; Korsch &
Negrete, 1981; Woolley, Kane, Hughes, & Wright, 1978).
Research has demonstrated that physician communication
style is strongly linked to patient satisfaction and compliance
(Ben-Sira, 1976; Buller & Buller, 1987; Doyle & Ware, 1977;
Korsch, Gozzi, & Francis, 1968; Woolley, Kane, Hughes, &
Wright, 1978). Patient satisfaction appears to be largely a result
of the verbal and non-verbal communication of the physician
while interacting with the patient (Daly & Hulka, 1975; Korsch,
Gozzi, & Francis, 1968; Spiro & Heidrich, 1983).
Ben-Sira (1976, 1980) in his social interaction model
considers the affective component of the physician's
communication to be a major factor in patient evaluations. This
affective component consists of "behaviors directed by the
physician toward the patient as a person rather than as a 'case'"
(1980, p. 173).
23


In the communication literature, Ben-Siras affective
component is closely related to a concept called communication
style (Buller & Buller, 1987). As conceptualized by Norton
(1978, 1983), communication style is "the way one verbally or
paraverbally interacts to signal how literal meaning should be
taken, interpreted, filtered, or understood" in a communication
context (1978, p. 99).
According to Buller & Buller (1987), the literature on
physician-patient communication suggests that two general
styles are displayed by physicians in medical visits. One style,
affiliation, is composed of communication behaviors that serve to
establish and maintain a positive relationship between physician
and patient. These behaviors include those that communicate
interest, friendliness, empathy, warmth, genuineness, honesty,
respect, compassion, a desire to help, a nonjudgmental attitude,
humor, and a social orientation (Ben-Sira 1976, 1980; Collins,
1983; DiMatteo, Robin, Prince, & Taranta, 1979; Korsch et al
1968; Korsch & Negrete, 1972; Street & Wiemann, 1987). The
second style, control, includes behaviors that establish and
maintain the physician's power and control in the medical
interaction. This has been a topic of several studies because a
difference in control, power, and status is inherent in the
physician-patient interaction. This discrepancy stems from the
24


patient's limited understanding of medical problems and
treatments, the patient's increased anxiety and uncertainty about
prognosis and treatment, the physician's control of medical
information, and the institutionalized roles prescribed for the
physician and the patient (Ben-Sira, 1980; Friedson, 1970;
Waitzin, 1985). The manifestations of power, authority, and
status in a physician's communication has been noted by several
researchers (Hall, Roter, & Rand, 1981; Korsch & Negrete,
1972, Street & Wiemann, 1987).
A survey by Korsch and Negrete (1981) reported that
friendly treatment, positive affect, and warm concern for
patients' worries produced greater overall satisfaction. In the
same study, patients were found to be less satisfied when the
physicians' communication was designed to maintain authority.
In a more recent study by Buller and Buller (1987), patients
were reported to rely more on the physician's communication
style than on specific treatment information and success of
treatment when evaluating medical care. Highly affiliative and
less dominant physicians produced the most favorable
evaluations among patients. With the emphasis on the amount of
time physicians should spend talking to their patients, it is
interesting to note that this study also suggests that an affiliative
physician who takes only a short time to speak with the patient
25


seems to be just as satisfying, or even more so, than a
dominant/controlling physician who spends a longer time with a
patient.
In conclusion, communication should obviously be a major
concern for physicians as they attempt to satisfy and retain
patients (Buller & Buller, 1987). The quality and effectiveness of
medical care hinges on the establishment of positive
relationships (Roter, 1983).
The Present Nature of
the Coping Process
Coping refers to behaviors that protect people from the
physical and psychological pain associated with negative life
events (Snyder & Ford, 1987). It is a strategic effort to master a
problem, overcome an obstacle, dissipate a dilemma anything
that impedes our progress (Weismann, 1984).
Human beings are constantly looking toward theories to
aid in their dilemma of explaining not only the events in their
lives but in the lives of other people as well. A theory is a way of
looking at the causality between things. According to Snyder &
Ford (1987), theory becomes central in the process of coping
with negative life events.
26


Several broad perspectives have shaped current
approaches to understanding life crises: 1) evolutionary theory
with an emphasis on behavioral adapting, 2) psychoanalytic
concepts and human growth approaches, 3) a focus on human
development through the life cycle, and 4) information on the
process of coping with severe crises (Moos, 1986).
1) Charles Darwin's theory of evolution examined the
adaptation of animals (including humans) to their environment.
His ideas shaped the formation of ecology, the study of the link
between organisms or groups of organisms and their
environment. Evolutionary thought suggests that human beings
cannot adapt to their environment alone, that they are
interdependent and must make collective efforts to survive. The
formation of social bonds is an essential aspect of an effective
transaction with the environment. Communal adaptation is
viewed in their theory as an outgrowth of individual adaptation
and of specific coping strategies that serve to contribute to
group survival (Moos, 1986).
2) The psychoanalytic orientation (Moos, 1986) leads to
an emphasis on behavioral problem-solving activities that
enhance both individual and species survival. More recent
approaches have highlighted the role of cognition in this
adaptation. Cognitive behaviorism is concerned with an
27


individual's appraisal of the self and the meaning of an event as
well as with problem-solving skills. A sense of self-efficacy is
considered to be an essential coping resource. Bandura (1982)
relates successful coping to promote the expectation of self-
efficacy, which leads to more persistent and vigorous efforts to
master new tasks.
Sigmund Freud's psychoanalytic perspective sets the stage
for an intrapsychic counterpoint to the evolutionary emphasis on
behavioral factors. He believed that ego processes served to
resolve conflicts between an individual's instincts and the
constraints of external reality. Freud perceived these ego
processes to be cognitive mechanisms (although behavioral
components may be involved in their expression) whose main
functions are defensive (reality distorting) and emotion focused
(oriented toward tension reduction) (Moos, 1986).
The neo-Freudean ego psychologists objected to these
ideas and positioned a "conflict-free ego sphere" in which
individuals have autonomous energy and possess such aspects of
competence motivation as a sense of agency and of being in
control of their lives (Moos, 1986).
These ideas formed the basis for the new set of growth or
fulfillment theories of human development. For example, Carl
Rogers believes individuals tiy to develop their capacities in
28


ways that serve to promote growth and maintain life.
Additionally, Abraham Maslow distinguished between deficiency
and growth motivation. According to Maslow, "mature healthy
individuals perceive reality accurately, are solution-centered and
spontaneous in behavior, and have a strong social interest, a
genuine desire to help others, and a broad perspective on life "
(in Moos, 1986, p.6).
3) Psychoanalytic theorists pose that life events in infancy
strongly affect and probably determine adult personality. But
information about the growth of ego functions and normal
maturation shows that early life events do not necessarily preset
the pattern of reaction to crises and transitions. Psychoanalysis
and ego psychology, in addition to highlighting the processes of
defense and coping, have also provided the basis for
developmental approaches that consider the gradual acquisition
of personal resources over a persons life span.
Erik Erikson (1963) described eight life stages. Each
stage encompasses a new challenge or "crisis" that must be
negotiated successfully in order for the individual to cope
adequately with the next stage. Personal coping resources, such
as ego integrity and the formation of trust, are accrued during
the adolescent and young-adult years. These coping resources
are subsequently integrated into the self-concept and shape the
29


process of coping in adulthood and old age. Adequately resolving
the issues that occur at one stage in a persons life cycle leave a
legacy of coping resources that can help to resolve subsequent
crises.
Stage models such as Erickson's are often depicted as a
spiral staircase in which failure to attain one landing implies
failure to attain the next. According to Neugarten (1979),
however, adulthood is not usually composed of stages that occur
at specific chronological ages. Events that occur on time can be
anticipated and managed without taxing a person's coping
capacity. But ideas of social timing have changed dramatically
over the last two decades. The life cycle has become more fluid
as more men and women divorce and remarry, and more
middle-aged persons return to college or begin new families.
This influences how individuals cope with the transitions of
middle and old age.
4) According to Moos (1986), there has been renewed
interest in human competence and coping under extreme
conditions. The most compelling accounts are of the harrowing
conditions in the Nazi concentration camps of World War II. A
compelling question is raised: How can anyone face such
suffering and ever-present threat of death and yet survive
psychologically to bear witness about the experience?
30


Other work has considered such crises as parental and
sibling death (in Moos, 1986, Parts II & III), disasters such as a
flood or tornado (Part IX), being a victim of rape or kidnapping
(Part X), and long-term imprisonment in a war camp (Part XI).
Similar studies have examined how individuals adapt to
serious illness or injury and face life-threatening diseases and
surgery (Feifel, Strack, & Nagy, 1987; Martelli et al., 1987;
Miller, Brody, and Summerton, 1988; Moos, 1986). The
surprising fact, as Moos (1986) points out, is that many persons
cope effectively with crises of such magnitude.
This historical overview also provides a basis for the
formation of crisis theory which is concerned with how
individuals manage major life transitions and crises. The
fundamental ideas were developed by Erich Undemann who
described the process of grief and mourning and the role of
community caretakers in helping bereaved family members to
cope (Lindemann & Lindemann, 1979). These ideas, combined
with Erickson's "developmental crises" at transition points of
the life cycle, have paved the way for the outgrowth of crisis
theory (Caplan, 1964).
Crisis theory deals with the impact of disruptions so novel
or major that habitual responses are insufficient. In this state of
disequilibrium, some resolution must be found. The individual
31


may make a healthy adaptation that promotes personal growth or
a maladaptive response that foreshadows psychological
problems. Stressful life episodes may enrich a person's values
and beliefs by making it necessary to assimilate new
experiences. Thus a crisis is a transition that has profound
implications for an individuals adaptation and ability to meet
future crises (Moos, 1986).
Over the years, coping has assumed a variety of conceptual
meanings. The concept of "coping" in this study refers to "the
behaviors, cognitions, and perceptions in which people engage
when actually contending with their life problems" (Pearlin &
Schooler, 1978). For coping to occur, Snyder and Ford (1987)
point out that people must not only select a particular response,
but they must then somehow mobilize and sustain sufficient
energy to pursue it.
Coping is certainly not an unidimensional behavior but
functions at a number of levels. Fleming and colleagues (1984)
state that coping represents 1) the expression of a complex set
of factors including such variables as personality, attitudes,
cognitions, and expectancy elements; 2) that the choice of a
specific strategy is most likely multidetermined; and 3) the
combination of variables associated with a particular strategy is
likely to be different for each coping strategy.
32


Dr. Avery Weismann, in his book. The Coping Capacity,
confirms the common coping strategies incorporated by
individuals when contending with problems. Describing the list
as both too long and too short, Weismann (1984) dissects coping
strategies as follows:
COMMON COPING STRATEGIES USED BY YOU AND ME
1. Seek information; get guidance.
2. Share concern; find consolation.
3. Laugh it off; change emotional tone.
4. Forget it happened; put it out of your mind.
5. Keep busy; distract yourself.
6. Confront the issue; act accordingly.
7. Redefine; take a more sanguine view.
8. Resign yourself; make the best of what can't be
changed.
9. Do something, anything, perhaps exceeding good
judgment.
10. Review alternatives; examine consequences.
11. Get away from it all; find an escape, somehow.
12. Conform, comply; do what is expected or advised.
13. Blame or shame someone, something.
14. Give vent; feel emotional release.
15. Deny as much as possible.
(Weismann, 1984, pp. 36-37)
For the purposes of this study, these specific behaviors were
collapsed into seven coping strategies: confrontation, avoidance,
acceptance-resignation, denial, ventilation, impulsive behavior,
and blaming. Different problems call for different sets of
primary strategies.
33


i
The strategy of coping is seldom simple and unambiguous
but it seems important to relate that strategies can be learned.
Self-instruction depends on discovering new resources and
perfecting those that have worked reasonably well in the past
(Weismann, 1984). Pearlin and Schooler (1978) were able to
demonstrate in their study that the style and content of coping
does make a difference to the emotional well-being of people.
Good copers manage to deal with problems in similar ways that
prove more effective than those of bad copers. Additionally, they
reported that the greater the scope and variety of the
individual's coping responses, the more protection coping
affords. How we cope with any problem, the action that we take,
will inevitably change the nature of that problem so that it
becomes a situation that we can deal with or at the very least,
one that we can refocus into more familiar terms (Weismann,
1984).
Coping with Cancer
Cancer can be an extremely stressful and frightening illness.
The coping resources of even the most well-adjusted patients
are often taxed to their limit (Meyerowitz et al., 1989). The
American Cancer Society (1990) estimated that 76 million
Americans now living will be diagnosed as having cancer. This
34


represents about 30% of the total population. Over the years,
cancer will strike three out of four American families and many
people diagnosed with cancer will die from the illness.
Billions of dollars have been awarded toward research
focusing on the medical aspects of cancer. However, the
psychological aspects of the disease have not been examined as
extensively, even though studies have reported that the
emotional trauma resulting from the diagnosis and treatment of
cancer can be as damaging to the patient as the cancer itself
(Harrell, 1972; Radley & Green, 1987).
Due to the devastating impact of a cancer diagnosis as well
as the treatment process, a number of researchers have
examined the role of psychological states and the individual's
chance of recovering from a life-threatening disease (Gotcher &
Edwards, 1990). According to Greer, Moorey, and Watson
(1989), the way a patient copes with psychological trauma
directly affects the patient's chance of survival. Levy and
colleagues (1985) reported that characteristics such as
hopelessness and passivity in women with breast cancer are
associated with poorer chances of recovery. Coyne and Holroyd
(1982) found that the way an individual copes with the demands
of chronic illness can determine the course of the illness as well
as the medical care received. In a later study by Perseky and
35


colleagues (1987), researchers linked depression in male
subjects with subsequent mortality from cancer. These studies
add credibility to the findings by Sanders & Kardinal (1977) in
which they describe coping to be a critical component in the
patient's struggle for recovery and survival. Research has
indicated that certain mental attitudes encourage coping
strategies that enhance the body's immune system, the body's
natural healing processes, whereas others inhibit this natural
system (Reynolds & Kaplan, 1986).
Patients do not cope with the cancer (i.e., the malignant
cells), but, rather, with a wide variety of distressing and
disruptive situations, thoughts, and feelings that are associated
with the disease (Meyerowitz, Heinrich, & Schag, 1989). It
becomes extremely important for physicians and oncology
professionals to understand what these difficult situations and
problems are because they are in a unique and important
position to help patients cope with the many stressful aspects of
cancer.
Although much of the literature on coping with cancer has
focused on intrapersonal cognitive and emotional coping
responses, Meyerowitz and colleagues (1989) believe that coping
typically occurs within an interpersonal context. They found
that many of the strategies that patients use enlist people who
36


are important to them in the coping process. Research by
Reynolds and Kaplan (1986) also suggested that relationships
with others play a role in the disease coping process. These
relationships include important people such as health
professionals, family, and friends that may be involved in aiding
patients in finding effective management strategies for the
difficult situations they are experiencing. It becomes obvious
that the interpersonal interaction that occurs when the
diagnosis of cancer is first delivered may be central in setting
the stage for effective coping strategies to be developed and
tried.
There is the suggestion that life-threatening conditions may
call forth coping strategies which are different in kind or degree
from those used to cope with non life-threatening conditions
(Silver & Wortman, 1980). According to Gotcher and Edwards
(1990), specific features of communication are important in
coping with serious illness. They found these features to
include: 1) communicating about one's illness, 2) receiving
information about the disease, 3) asking questions of the health
care professionals, and 4) using communication to deal with
fears. Most cancer patients express a strong desire for open
communication and for receiving a maximum amount of
information about their illness (Meyerowitz, Heinrich, & Schag,
37


1989). But research by Emda Orr (1986) found this "openness"
construct to be multidimensional calling for further research to
be accomplished concerning such variables as the objects and
modes of communication, strength of patients' anxiety, time
aspects, cultural norms, personal values, and the specific others
that a person communicates with. Coping requires the patient
to deal with the physical effects of the illness as well as the
psychological traumas associated with the disease (Radley &
Green, 1987). Several medical researchers have called for
research concerning cancer and communication (Burish & Lyles,
1983; Craig, Comstock, & Geiser, 1974; Heinrich, Schag, &
Ganz, 1984; Johnson et al., 1989). However, very little research
has been forthcoming. Taylor (1983) has suggested that after
hearing the word cancer as one's own diagnosis, adjustment to
this personal tragedy focuses on three common themes: 1) the
patient's search to find meaning in the experience, 2) the
patient's attempt to gain a sense of mastery over the disease, and
3) the patient's engagement in efforts to enhance her/his
threatened self-esteem. The purpose of this study was to
investigate physicians' communication styles as perceived by
their patients during the event of telling a patient for the first
time that she/he has cancer and the influence that this
38


communication style may have on the coping process of that
cancer patient.
An Overview of Communication Apprehension
In this age of increased emphasis on communication
between people and computers, it might seem that human-to-
human communication has become less important than it used
to be. However, this is not the case. Most of our daily
interaction is with other people on a live, interpersonal level.
Supervisors communicate with their subordinates on a one-to-
one basis. The same one-to-one interaction occurs between
teachers and their students, lovers with each other, as well as
physicians and their patients, which is pivotal to this study. So,
even though computers play a significant role in our lives, they
simply will not replace human interaction (McCroskey &
Richmond, 1989).
Human communication, as defined by McCroskey and
Richmond (1989), is "the process by which a person (or
persons) stimulates meaning in the mind of another person (or
persons) through use of verbal and/or non-verbal messages"
(p.l). The process of human communication has seven essential
components: source, message, channel, receiver, encoding,
decoding, and feedback (McCroskey, 1984).
39


Communication apprehension (CA), as a single
communication construct, has been a major concern of
researchers and scholars since 1970. The reason for this focus
on CA is that it permeates every facet of an individual's life,
work, school, family, friendships, and so on. Communication
apprehension is the fear or anxiety associated with either real or
anticipated communication with another person or persons
(McCroskey, 1984). Many people desire to communicate with
others and even recognize the importance of doing so, but fear
or anxiety interferes.
According to McCroskey and Richmond (1989), it has been
estimated that 20 percent of the population (one in five) suffers
from communication apprehension. They report these results to
have been consistent across many samples of subjects and from
several subject populations. It is important in this study to note
that communication apprehensive people tend to be low
verbalizers. It is natural to avoid or withdraw from something
one fears and this is exactly what highly communication
apprehensive people tend to do. For example, high
communication apprehension has been linked to lack of
confidence (McCroskey, Day, & Sorenson, 1976), lowered
interaction (Wells & Lashbrook, 1970), and feelings of isolation
and ineffectiveness in social relationships (Lowe & Sheets,
40


1951). Of particular importance to this study is the finding that
communication apprehension and self-esteem are negatively
related (McCroskey & Richmond, 1989; McCroskey et al., 1977;
Stacks & Stone, 1982; Lustig, 1974; Snavely et al., 1976).
These studies indicate that the presence of either high
communication apprehension or low self-esteem is "highly"
predictive of the other.
McCroskey and Richmond (1989) discuss the concept
"immediacy" as the degree of perceived physical or psychological
closeness between two people. These immediacy behaviors may
be verbal or nonverbal. Verbal messages indicate openness,
friendship, or empathy with the other. Examples of nonverbal
immediacy behaviors include eye behavior, facial expression, and
body gestures. Highly apprehensive individuals have difficulty
engaging in immediate behaviors and therefore do not
communicate positive affect when communicating with others.
This lack of positive affect is often interpreted as not liking the
other person and there is a tendency for the other person to
reciprocate by not liking them very much either. It becomes
obvious, then, that high communication apprehension tends to
lead to ineffective or limited communication.
41


In sum, the literature suggests that high communication
apprehensives may be less confrontive than those lower in
apprehension. For purposes of this study the relationship
between communication apprehension and the coping strategy
of confrontation will be examined for cancer patients.
Research Hypotheses
In order to examine the relationships between physicians'
communication styles and patients' coping strategies, the
present study specifically hypothesized that:
1. Patients will cope with the delivery of a cancer
diagnosis in a more confrontive way when they
perceive their physicians to demonstrate an
affiliative communication style.
2. When patients perceive physicians to possess a more
affiliative communication style, patients' overall
satisfaction with the communication of the delivery
of the life-threatening diagnosis of cancer will be
higher.
3. For patients diagnosed with cancer, there will be a
negative correlation between communication
apprehension and the use of tactics related to the
coping strategy called "confrontation."
Chapter III, which follows, will further explicate these
three hypotheses including specific operational definitions.
42


Summary
This chapter has included a review of academic literature
relevant to the present study. The review was based primarily
on writings in the disciplines of health communication, speech
communication, clinical psychology, social psychology, and
medical oncology. The on-line computer search was limited to
literature published since 1980. When relevant to the study,
earlier research has been included. In addition to literature
drawn from the aforementioned disciplines, the following
academic journals were used extensively: Journal of Health and
Social Behavior. Social Science and Medicine. Patient Education
and Counseling, and a myriad of medical journals.
The first section of the review presented literature related
to six aspects of the research objective: 1) generalized
physician-patient communication, 2) physician communication
relevant to cancer patients, 3) physicians communication styles,
4) the nature of the coping process, 5) specific literature
relevant to the doctor-patient relationship in coping with
cancer, and 6) an overview of communication apprehension.
The second section outlined the three specific research
hypotheses empirically tested in this present study.
Chapter III, which follows, describes the methodology and
research procedures employed in the study. A description of
43


the instruments that were used in the study including their
reliability and validity also is provided.


CHAPTER III
METHODOLOGY
The purpose of this study was to examine the
communication styles exhibited by physicians, as perceived by
their patients, when delivering the life-threatening diagnosis of
cancer and the relationship of the communication style to the
coping strategies adopted by the patient. Chapter I provided
general background to the study and rationale for its pursuit.
Chapter II provided a review of academic literature relevant to
the research problem and presented three research hypotheses
that have been empirically tested. The present chapter
describes the research methodology utilized to investigate the
hypotheses. Specifically, this chapter includes a description of
the research population, the overall research procedure and
design, a description of how the sample and the hypotheses
were operationalized, sampling plans and procedures, the
measurement instruments and their reliability and validity, and
statistical analyses and treatment of the data.
45


Description of the Research Population
The majority of the 52 respondents were white (94.2%)
with females representing 73.1% of the sample. The majority
(59.6%) were over age fifty-five. 36.5% reported their
occupation as "retired," 25% were housewives, 19.2% in
professional or management occupations, and 11.5% were
considered clerical. The occupations of the remaining 7.6% of
the sample were reported as military, student, or "other."
46.2% reported an income ranging from $25,000 -
$50,000 with 36.5% under $25,000 and 13.%% greater than
$50,000. 32.7% of the sample population reported that they
had completed some college or technical school, 25%
completed college, and 13.5% having completed graduate work.
Most (94.2%) of the respondents knew what kind of
cancer they were afflicted with but a surprising number (38.5%)
did not know what stage their cancer was in. Although the type
of cancer reported covered a wide range, 44% of the
respondents reported having breast cancer. The physician most
frequently reported (44.2%) to have delivered the "bad news" of
the cancer diagnosis was the surgeon with the oncologist
representing 11.5% of the responses to that question. 5.8% had
known about their illness for less than a month, 28.8% for one
to six months, 15.4% for six months to a year, 13.5% for one to
46


two years, and 34.6% had known about their illness for more
than two years. 75% of the respondents considered their health
to be "good" or "excellent."
Prologue and Explication of the Hypotheses
Methodologically, the present study represents an
empirical investigation of the communication styles exhibited by
physicians, as perceived by their patients, when delivering the
life-threatening diagnosis of cancer and the relationship of these
communication styles to subsequent coping strategies employed
by the patient. This study built upon empirical research
conducted by Feifel, Nagy, & Strack (1987) which focused on
examining a range of variables considered pertinent in coping
with medical illness. The psychological and behavioral
correlates of three major coping strategies were used to
examine medically ill patients in dealing with their illness.
Subjects' coping responses were measured by a Medical Coping
Modes Questionnaire (Feifel, Nagy, & Strack, 1986) developed
to appraise three forms of coping: confrontation, avoidance, and
acceptance-resignation. This present study focused on
conceptualizing coping strategies and included denial,
ventilation, impulsive behavior, and blaming as additional coping
responses deemed to be important. Additional questions were
47


included in the questionnaire utilized in this study to address
behaviors considered to be inherent in these additional coping
responses.
General Explication of Methodology
(1) The present study examined communication
behaviors of physicians focusing on those behaviors that
comprise a particular style, afliliativeness. As defined for this
study, an affiliative communication style is one which utilizes
behaviors that relay connectedness to the patient and leave
her/him with a sense of self-satisfaction. The three behaviors in
this study that comprised this affiliative communication style
were: (1) the amount of sensitivity displayed toward the patient,
(2) the degree of genuine caring that was communicated to the
patient, and (3) the feeling of hope or optimism that was relayed
to the patient. This study investigated the relationships between
affiliative communication styles, as perceived by patients, and
patients' coping resources when confronted with cancer
diagnoses.
(2) This study also suggested that a relationship exists
between the physician's communication style as perceived by the
48


patient and overall patient satisfaction with the way their
physicians communicated the news of their illness to them.
(3) This study simultaneously addressed different
aspects of seven coping strategies in an attempt to more
thoroughly conceptualize the coping process. The seven coping
strategies operationalized in the questionnaire were
confrontation, avoidance, acceptance-resignation, denial,
ventilation, impulsive behavior, and blaming.
The literature review suggested that life-threatening
conditions may be a consequential factor in the way people cope
with their situation. To increase the merit of this research, the
sample was limited to a population of patients who have
experienced the communication of the life-threatening diagnosis
of cancer.
(4) Finally, this study examined the communication-
bound anxiety of the patients participating in the research.
Rationale for including this measurement will be provided in the
section on instrumentation.
49


Overall Procedure and Research Design
In order to investigate three research hypotheses, the
following procedures were followed:
Hypothesis 1:
To test for a systematic relationship between the
communication style of the physician as perceived by the patient
and subsequent coping strategies of the patient after receiving
the life-threatening diagnosis of cancer, a 44-item Likert-type
questionnaire was constructed and distributed to cancer
patients in three distinct population groups. The sample and
questionnaire will be further described in the sampling plan and
instrumentation sections to follow.
To operationalize Hypothesis 1, the coping strategy
referred to as confrontation was measured as a composite score
of behaviors included in items 1, 2, 5, 8, 24, 28, 33, & 34. (See
Appendix B) Examples of these questions are:
1) how much do you want to be involved in decisions regarding
your treatments? 2) how often do you tiy to talk about your
illness with friends or relatives? and 3) how much have you
learned about your illness from talking with others who know
something about it, such as doctors, nurses, etc.?
The physicians affiliative communication style was
operationalized by measuring three items in the questionnaire:
50


I
9) the communication of genuine caring for the patient, 17) the
amount of sensitivity exhibited, and 30) the degree of hope or
optimism conveyed to the patient.
Hypothesis 2:
To test the relationship of a more affiliative
communication style utilized by a physician when telling a
patient for the first time that she/he has cancer to patients'
overall satisfaction with the communication of this life-
threatening diagnosis, the 44-item Likert-scale questionnaire
was again employed.
To operationalize Hypothesis 2, the physician's affiliative
communication style was again the composite of items 9, 17,
and 30: the amount of sensitivity disclosed, how much genuine
caring was communicated, and the amount of hope transmitted
to the patient. The patient's overall satisfaction with the
communication of her/his cancer diagnosis was measured in a
single-item question on the questionnaire, item 44.
Hypothesis 3:
To test for a negative relationship between communication
apprehension and the use of tactics or behaviors related to the
coping mode called confrontation, the Personal Report of
Communication Apprehension (McCroskey, 1970) was self-
administered concurrently with the 44-item questionnaire.
51


Rationale for including this instrument will be described in the
instrumentation section to follow.
To operationalize Hypothesis 3, the PRCA-24 was scored
as indicated by McCroskey (1970) and the coping strategy called
"confrontation" became the composite of behaviors measured by
items 1, 2, 5, 8, 24, 28, 33, & 34.
Research Plan:
Questionnaires were distributed to fifty-two male and
female cancer patients over eighteen years of age, both male and
female. The participants self-selected themselves into the
sample pool which included three separate groups: 1) new and
recurring patients at the Cancer Center of Colorado Springs, 2)
cancer patients receiving radiation therapy at the Penrose/St.
Francis Healthcare System, and 3) cancer patients involved in
two designated support groups. All of these population groups
were located in metropolitan Colorado Springs, Colorado.
Questionnaires were distributed to all interested cancer
patients in the three groups. Consent forms were completed to
satisfy conditions of the Human Subjects Committee at the
University of Colorado at Colorado Springs. To insure anonymity,
patients were instructed to return consent forms separately in a
designated folder. The 44-item questionnaire and the PRCA-24
52


were subsequently returned to the researcher in self-addressed
stamped envelopes (see Appendix A for complete questionnaire).
Instrumentation and Measurement
The instruments utilized in this study were 1) a
questionnaire developed specifically for this study, and 2) the
Personal Report of Communication Apprehension (PRCA-24).
The studys 44-item Likert-scale questionnaire was
carefully developed with the help of physicians, health care
workers, and experts in the area of communication. The
involvement of these experts in the development of the
questionnaire was solicited to improve the content or face
validity of the instrument.
Nineteen of the questions in the questionnaire were
derived from the Medical Coping Modes Questionnaire (Feifel,
Nagy, & Strack, 1986). The existing four-point scale in the
Medical Coping Modes Questionnaire was converted to a five-
point Likert-scale in order to improve statistical analysis. The
additional twenty-five questions were constructed and
incorporated into the questionnaire, The alpha coefficients for
the Medical Coping Modes Questionnaire were .70 for the
confrontation scale, .66 for the avoidance scale, and .67 for the
53


acceptance-resignation scale. Billings & Moos (1984) have
noted that generally lower internal consistency estimates may be
expected for coping scales since one or two coping resources
may alleviate stress and thus reduce the use of alternative
responses within the same category (p. 881).
The Personal Report of Communication Apprehension was
developed by McCroskey in 1970 to measure communication-
bound anxiety. The reliability of all versions of the instrument is
very high, usually above .90 (McCroskey, 1984). Additionally,
there is overwhelming evidence for the validity of this
instrument to measure the construct of oral communication
apprehension (McCroskey, 1978). The rationale for using the
PRCA-24 in this study exists in previous research which relates
communication apprehension to several different personality
traits and the construct of self-esteem.
Data Collection
A total of 160 subject packets were distributed to sites
representing the three groups in this study's sample pool: 1)
the Cancer Center of Colorado Springs, 2) Radiation Therapy
Department at the Penrose Healthcare System, and 3) the
Penrose Cancer Program. At this last site, Lisa Noll and Jean
Smith (oncology R.N.s) together with Sally Kinney (oncology
54


social worker) delivered packets to the two support groups
chosen for this study, namely a Breast Cancer Support Group and
a hospital-based support group comprised of mixed diagnoses,
needs, and concerns. Fifty-two completed packets were
returned.
Data Analysis
Pearson correlation coefficients were calculated for the
following: Hypothesis 1: each participant's composite score for
the coping strategy of confrontation was correlated with each
participant's composite score for affiliative communication style;
Hypothesis 2: each participant's composite score for affiliative
communication style was correlated with each participant's
overall satisfaction with the communication of her/his cancer
diagnosis; Hypothesis 3: each composite score for the coping
strategy of confrontation was correlated with each participant's
total PRCA score. To test for additional interaction effects,
stepwise multiple regression was utilized. Additionally, each
participant's total PRCA score was correlated with those items
determined to be verbal confrontive behaviors.
55


Summary
This chapter has described the methodology and research
procedures employed in this study. The first two sections
provided an introduction to the overall procedure and described
the research design. The next two sections discussed the
sampling plan and outlined the instrumentation that was utilized
with the attendant reliability and validity. Next, procedures used
in collecting raw data were outlined. The final section described
the statistical treatment of that data. Chapter IV, which follows,
presents the results of the research procedures described in
Chapter III.
56


CHAPTER IV
RESULTS
The general purpose of this study was to examine a
possible correlative relationship between an affiliative
communication style utilized by physicians and 1) a coping
strategy this study has called "confrontation," as well as 2)
patients' overall satisfaction with the communication of the
delivery of the life-threatening diagnosis of cancer. This study
also examined a possible negative relationship between the
communication apprehension of patients diagnosed with cancer
and the use of tactics related to the coping strategy called
confrontation.
First, Chapter I provided background to the study of the
doctor-patient relationship, physician communication and
cancer patients, and the present nature of the coping process.
Chapter II reviewed the academic literature relevant to the
background of this study with additional sections related to
coping with cancer, physician communication styles, and
57


communication apprehension. At the end of the review of the
literature, it was specifically hypothesized that :
1. Patients will cope with the delivery of a cancer
diagnosis in a more confrontive way when they
perceive their physicians to demonstrate an
affiliative communication style.
2. When patients perceive their physicians to possess a
more affiliative communication style, patients' overall
satisfaction with the communication of the delivery
of the life-threatening diagnosis of cancer will be
higher.
3. For patients diagnosed with cancer, there will be a
negative correlation between communication
apprehension and the use of tactics related to the
coping strategy of confrontation.
Chapter III, the methodology section of this study, first
described the research population. Second was an explanation
of the overall research procedure and design and how the
hypotheses were operationalized. Next, research procedures for
investigating the hypotheses were described. The present
chapter, Chapter IV, describes the results of the data collection
and the analysis. The data generated by this investigation were
analyzed using Pearson correlations and stepwise multiple
58


regression. The results of the data analysis process are
presented without interpretation in this chapter. Discussion,
interpretation, and conclusions are presented in Chapter V.
Primary Analyses
Hypothesis 1
Hypothesis 1 specifically stated that: Patients will cope
with the delivery of a cancer diagnosis in a more confrontive way
when they perceive their physicians to demonstrate an affiliative
communication style.
As described in the methodology chapter, data from a 44
item Likert-type questionnaire was used to investigate
Hypothesis 1. The coping strategy referred to as confrontation
was measured as a composite score of behaviors comprised of
items 1, 2, 5, 8, 24, 28, 33, & 34. The affiliative communication
style of physicians was measure as a composite score of items 9,
17, & 30.
Pearson correlation coefficients were calculated on each
subject's composite score for the coping strategy "confrontation"
and each subject's composite score for affiliative communication
style.
The statistical analysis of the data regarding Hypothesis 1
is presented in Table 4.1.
59


Table 4.1
Correlation coefficients: Coping strategy of confrontation and
physicians' affiliative communication style.
N -50
Composite
Coping Strategy hems_____________________________ Score
V1 V2 V5 V8 V24 V28 V28 V34 Confront
V2 .036
V5 .173 .250
V8 .077 .121 -.057
V24 .094 .230 .368** .090
V28 .278* .043 .157 .044 .082
V33 .290* .063 .146 .175 .268 .215
V34 -.091 .522** .047 -.021 .034 .170 .027
Confront .399 .577** .537** .406** .561** .497** .517** .464**
V9 .019 -.080 .053 .052 -.084 -.027 -.059 -.955 -.044
V17 .078 -.146 .139 -.055 .158 -.023 .142 -.167 .023
V30 .072 -.181 .167 -.150 .004 .108 .136 -.051 .021
AFFIL .060 -.164 .144 -.037 .019 .019 .087 -.105 .001
Affiliative Style Items
V9 V17 V30
V17 .699**
V30 .589** .501**
AFFIL .895** .849** .815
* p< .05
Note: See Appendix B for variable labels.
Results in Table 4.1 indicate that Hypothesis 1 was not
supported (r=.001). None of the variables included in the
coping strategy of confrontation were correlated with affiliative
style.
Hypothesis 2
Hypothesis 2 specifically stated that: When patients
perceive their physicians to possess a more affiliative
communication style, patients' overall satisfaction with the
60


communication of the delivery of the life-threatening diagnosis
of cancer will be higher.
Data from the 44-item questionnaire were again used to
investigate Hypothesis 2. The affiliative communication style of
physicians again was measured as a composite score of items 9,
17, and 30. The patient's overall satisfaction with the
communication of her/his cancer diagnosis was measured using
a single-item question, item 44.
Pearson correlation coefficients were calculated on each
subject's composite score for affiliative communication style and
for patient satisfaction..
The statistical analysis of the data regarding Hypothesis 2
is presented in Table 4.2.
Table 4.2
Correlation coefficients: Physicians' affiliative communication
style and patient satisfaction.
N = 51
Patient Affiliative Style
Satisfaction ________________Items
V9 V17 V44 .618** .722** V9 .699** V17 V30
V30 .624** .589** .501**
AFFIL .766** .895** .849** .815**
*p <.05 **p <.01
Note: See Appendix B for variable labels.
61


As Table 4.2 indicates. Hypothesis 2 is strongly supported
(p< .01). The three items composing physician affiliative
communication style: 1) the amount of sensitivity displayed
towards patient, 2) the degree of genuine caring that was
communicated to the patient, and 3) the feeling of hope that was
relayed to the patient, were individually significant and the
composite score produced the highest correlative relationship.
Hypothesis 3
Hypothesis 3 specifically stated that: For patients
diagnosed with cancer, there will be a negative correlation
between communication apprehension and the use of tactics
related to the coping strategy of confrontation.
Pearson correlation coefficients were calculated to
establish relationships between participant's PRCA score and
each participant's composite score of the coping strategy of
confrontation.
As described earlier in the methodology chapter, the
Personal Report of Communication Apprehension (McCroskey,
1970) was self-administered concurrently with the 44-item
questionnaire. The PRCA-24 was scored as indicated by
McCroskey (1970) and the coping strategy called "confrontation"
62


was again the composite of behaviors measured by items 1, 2, 5.
8, 24, 28, 33, & 34.
The statistical analysis regarding Hypothesis 3 is
presented in Table 4.3.
Table 4.3
Correlation coefficients: PRCA score and
coping strategy of confrontation.
N 47
Composite PRCA
PRCA score _____________________Subscores_____
prca gfp meet conver pubspk
grp .786**
meet .894** .694**
conver .725** .405** .499**
pubspk .775** .372** .627** .466**
V1 -.246 -.132 -.215 -.375** -.082
V2 -.125 -.162 -.032 -.058 -.144
V5 .154 .122 .189 -.025 .187
V8 .329* .289* .369* .131 .240
V24 -.067 -.095 .064 -.059 -.130
V28 -.398** -.184 -.370* -.389** -.338*
V33 .146 .074 .105 -.389** .246
V34 -.238 -.329** -.216 -.093 -.092
Confront -.080 -.080 .005 -.174 -.022
Cooinp Strategy Items
V1 V2 V5 V8 V24 V28 V33 V34
V2 .036
V5 .173 .250
V8 .077 .121 -.057
V24 .094 .230 .368** .090
V28 .278* .043 .157 .044 .082
V33 .290* .063 .146 .175 .268 .215
V34 -.092 .522 .047 -.021 .034 .170 .027
Confront .399** .577** .537** .406** .561 .497** .517 .464**
*p< .05 **p< .01
Note: See Appendix B for variable labels.
63


In summary, the correlative relationship between the
PRCA-24 and the coping strategy "confrontation" was not
significant and Hypothesis 3 was not supported using the
confrontive behaviors derived from the Medical Coping Modes
Questionnaire (Feifel, Nagy, & Strack, 1986).
Supplemental Analyses
Quantitative Data
In addition to the Pearson correlations used to initially
investigate the hypotheses, other statistical procedures were
considered as a result of the primary findings. Stepwise multiple
regression was utilized to investigate further interactions in this
study not evident in the primary statistical procedures. This
additional statistical analysis is presented in Table 4.4.
Table 4.4
Stepwise multiple regression: Patient satisfaction with
communication, affiliative communication style and combined
effect of affiliative style x Communication Apprehension.
Step MultR Rsq AdjRsq F(eqn) SigF RsqCh FCh SigCh
1 .768 .590 .581 64.99 .000 .590 64.99 .000
3 .777 .605 .577 21.953 .000 .014 .767 .471
Variable Be tain Correl
In AFFIL .768 .768
In PRCA -.0885 -.008
IN X2 .442 .475
Note: Dependent variable = Patient satisfaction with communication
Independent variables = Affiliative communication style and the combined
effect of the affiliative style x the PRCA.
64


The Stepwise multiple regression which tested the main
effects of affiliative communication style, communication
apprehension (PRCA), and the interaction between affiliative
communication style and communication apprehension on
patient satisfaction yielded an overall significant equation.
Examination of the R square changes and F ratios associated
with the R square changes revealed that the only significant
predictor of patient satisfaction was the affiliative
communication style of physicians as perceived by their patients.
Alpha coefficients obtained for the 1) the coping strategy
called "confrontation," 2) the physician affiliative style, and 3)
the PRCA-24 are .51, .82, and .93 respectively. The coefficient
alpha of .51 obtained for the coping strategy called
"confrontation" may be considered low but may be explained by
the fact that coping strategies are not considered to be as stable
as personality traits (Feifel, Strack and Nagy, 1987). Billings and
Moos (1984) noted that lower internal consistency estimates
may be expected for coping scales since "one or two coping
responses may alleviate stress and thus reduce the use of
alternative responses within the same category" (p. 881).
Additional Pearson correlations were used to analyze the
relationships of six specific verbal communication variables
contained in the confrontation coping construct with the PRCA
65


and as patient satisfaction with the communication of their "bad
news". (See Appendix C for detailed explanation of specific
items in questionnaire). Table 4.5 presents the results of this
statistical analysis. Upon examining these verbal communication
behaviors individually, one significant relationship (p<.05)
indicates that the higher the PRCA score of the patient (the
more communication apprehensive she/he is), the less she/he
talks when asked about their illness.
Table 4.5
Correlation coefficients: Communication Apprehension. Patient
Satisfaction. Verbal Variables.
N = 47
Composite Score Verbal Behaviors
PRCA V2 V5 V24 V33
V2 -.1258
V5 .1544 .2509
V24 -.0674 .2309 .3689**
V33 .1468 .0635 .1465 .2685
V34 -.2383 .5222** .0474 .0341 .0278
V42 -.3084* .4871** .0516 .9167 -.0159
V44 -.008
*p <.05 **p <.01
Note: V44 = patient satisfaction
See Appendix C for Verbal Confrontive Variable labels
Qualitative Data
In addition to completing the 44-item questionnaire and
the PRCA-24, five respondents submitted additional handwritten
responses or short letters which further explicated their
66


individual experiences concerning the delivery of their cancer
diagnoses. This information adds a richness to the data
collection and adds credibility to the rationale for this study as
discussed in Chapter I. This qualitative data will be discussed in
more detail in Chapter V.
Summary
This present chapter presented the results of this study.
The research findings were organized into two sections. The
first section included primary analyses related directly to the
investigation of the three main hypotheses. The findings of the
study supported Hypothesis 2, but failed to support Hypotheses
1 and 3. The second section included supplementary statistical
analyses deemed necessary to clarify the results of the primary
investigation. These findings provided partial support for
Hypothesis 3 when the verbal confrontive behaviors were
examined.
The following chapter. Chapter V, provides interpretation
of the findings and discusses the results of the study. Finally,
problems and limitations of the present study are outlined along
with suggestions for future research.
67


CHAPTER V
DISCUSSIONS, INTERPRETATIONS, AND CONCLUSIONS
The purpose of tills study was to empirically examine 1)
the communication styles exhibited by physicians, as perceived
by their patients, when delivering the life-threatening diagnosis
of cancer, and 2) the relationship of the physicians
communication style to the coping strategies adopted by the
patient. There were 52 volunteer subjects in the sample pool
who completed 1) a 44-item Likert-scale questionnaire, and 2)
the Personal Report of Communication Apprehension. The
findings of this study supported Hypothesis 2 regarding patients'
satisfaction with the communication of their cancer diagnosis,
but failed to support Hypotheses 1 and 3. Hypothesis 1
examined the relationship of physicians' communication styles
to the coping strategies adopted by patients after receiving the
"bad news" of their cancer diagnosis. Hypothesis 3 examined
the relationship of the patients' level of communication
apprehension to the coping strategy called "confrontation."

68


Supplemental statistical analyses provided partial support for
Hypothesis 3 when verbal confrontive behaviors were examined.
Chapter I provided background and rationale for the
present study. Chapter II reviewed academic literature related
to six aspects of the study: 1) generalized physician-patient
communication, 2) physician communication relevant to cancer
patients, 3) physician-communication style, 4) the nature of the
coping process, 5) coping with cancer, and 6) an overview of
communication apprehension. Three research hypotheses were
presented at the conclusion of Chapter II. Empirical
methodology, procedures, and instrumentation for the
investigation of these hypotheses were outlined in Chapter III.
Chapter IV presented results of the investigation of the three
hypotheses including findings of supplemental analysis.
This final chapter, Chapter V, provides a summary of the
findings regarding primary and supplemental analyses, and
interpretation and conclusions regarding results. Problems and
limitations of the study are presented and suggestions for future
research are offered.
69


Summary of the Findings
Primary Results
Hypothesis 1 specifically stated that: Patients will cope
with the delivery of a cancer diagnosis in a more confrontive way
when they perceive their physicians to demonstrate an affiliative
communication style. Results failed to support this hypothesis.
Hypothesis 2 specifically stated that: When patients
perceive physicians to possess a more affiliative communication
style, patients' overall satisfaction with the communication of the
delivery of the life-threatening diagnosis of cancer will be
higher. Hypothesis 2 was supported.
Hypothesis 3 specifically stated that: For patients
diagnosed with cancer, there will be a negative correlation
between communication apprehension and the use of tactics
related to the coping strategy of confrontation. When utilizing
the Medical Coping Modes Questionnaire operationalization of
coping, Hypothesis 3 was not supported. When only verbal
behaviors were correlated to PRCA scores, the hypothesis was
partially supported.
Qualitative data. Additionally, five respondents voluntarily
submitted handwritten responses attached to their completed
questionnaires. This data support the research that has linked
70


patients' satisfaction with health care to the communication
styles of physicians. All five respondents were dissatisfied with
the way the news of their cancer diagnosis was relayed to them,
indicating that the physicians verbal communication and lack of
sensitivity and/or caring were responsible for this
dissatisfaction. Examples of statements made are: 1) "Mrs.
______, it is cancer, but it's not the end of the world"; 2) "Dr._
told me I had less than a fifty-fifty chance of recovery. . After
Dr.___ left town, I was referred to another oncologist and twelve
years later, I am still alive"; 3) "I was disappointed with the
extent that my doctor genuinely appeared to care for me. I
shared this with him and he appreciated that input."
Assessment of Results
Hypothesis 1:
The first underlying assumption of this study was that
there is a positive relationship between physicians'
communication styles, as perceived by their patients, and
patients' coping behavior. Specifically, the assumption was made
that patients will cope with the delivery of a cancer diagnosis in
a more confrontive way when their physicians demonstrate an
affiliative communication style. According to Buller and Buller
(1987), this affiliative style is composed of communication
71


behaviors that serve to establish and maintain a positive
relationship between physician and patient. This style,
therefore, appears to be desirable. However, the concept of
"coping" is extremely complex and the choice of a specific
strategy appears to be multidetermined. This complexity may
also be responsible for the lack of statistical relationships for
Hypothesis 1.
Although the basic assumption of Hypothesis 1 was not
statistically supported, other correlations were significantly
related and deserve discussion. The more often patients
reported asking their doctor for advice concerning their illness,
the more they felt they had learned about their illness from
talking to those who have the expertise (p<.01). Patients also
reported wanting to be more involved in decisions regarding
their treatments (p<.05) when two things occurred: 1) as they
learned more about their illness from reading books, magazines,
or newspapers; and 2) as questions about their illness to their
doctors increased.
Hypothesis 2:
The second underlying assumption for this study was that
when patients perceive their physicians to possess a more
affiliative communication style, patients' overall satisfaction with
the communication of the delivery of their cancer diagnosis will
72


be higher. This relationship has been reported in the literature
and was statistically significant in this study as expected.
In considering the results of the investigation of
Hypotheses 1 and 2 as a whole, a summative finding emerges.
The physician's communication style has an impact on an
immediate variable or factor, that is, the patient's sense of
satisfaction with the communication interaction with the
physician. The relationship between physician communication
style and patient satisfaction does not appear to extend to a
variety of later events such as communication with others or
later coping strategies of the patient.
Hypothesis 3:
The third underlying assumption in this study was that for
patients diagnosed with cancer, there will be a negative
correlation between communication apprehension and the use of
tactics related to the coping strategy of confrontation. The
primary results indicated a failure to support this assumption.
The behaviors comprising "confrontation" were derived from the
Medical Coping Modes Questionnaire. The reliability of all
versions of the PRCA is very high and there is overwhelming
evidence for the validity of the instrument. The high reliability
obtained in this study (.93) indicates that questions in this
instrument were not misinterpreted. The complexity of the
73


coping strategy of confrontation as operationalized in the
Medical Coping Modes Questionnaire may again be responsible
for the lack of significant statistical findings for a relationship
that theoretically appears to be obvious. The Medical Coping
Modes Questionnaire confrontation construct contains behaviors
not specifically confined to oral communication behaviors.
Although not significant as a total entity, the coping
strategy of confrontation contains two items that are statistically
related to communication apprehension in this study. As an
individual's communication apprehension increased, she/he
learned less about her/his illness from reading books,
magazines, or newspapers (r=-.40, p<.01). Patients also
reported thinking about certain things in their lives in a more
positive way as their communication apprehension increased
(r=.33, pc.05).
Upon further examination of the items comprising the
coping strategy confrontation, it became obvious that the
behaviors were not homogeneous. Some of the items were
behavioral involving talking and asking questions, while other
items were attitudinal such as thinking about certain things in
your life in a more positive way. Supplemental analysis
administered only to verbal confrontive behaviors provided
partial support for the underlying assumption of Hypothesis 3.
74


Problems and Limitations
The first problem encountered in this study relates to the
difficulty in obtaining the sample population. One physician
group initially designated for distribution of the questionnaire
became reluctant to become involved without more control over
the questions and the targeted population. Additionally this
reluctance was relayed to the researcher through the use of a
third party. This occurrence confirms the call for more
research concerning cancer and physician-patient
communication as discussed in Chapter II. According to Und
and colleagues (1989), concerns about the psychological harm
resulting from such a study of this patient group do not appear
to be warranted. Patients in the Lind study, as well as in this
present study, expressed the desire to contribute to improving
the experience of future patients through participation in such
research.
The second problem of the present study, relating to
methodology, has already been discussed in the assessment of
results for Hypotheses 1 and 3. This problem has to do with the
scope and complexity of the coping strategy called
"confrontation." This problem could be twofold: 1) there may
have been a possible inadequacy of the test instrument to assess
the communication behaviors determined to comprise
75


"confrontation," or 2) as Billings and Moos (1984) note, lower
internal consistency estimates may be expected for coping
scales since one or two coping responses may be helpful in
alleviating stress and thus reduce the use of alternative
responses within that same category. If this reasoning is
accurate, this problem may be difficult to alleviate in future
studies that involve the concept of coping.
Limitations of this study include specifics of the sample
population: 1) 59.6% of the respondents were over age 55:
2) the sample pool was a volunteer group rather than a random
sample: and 3) females represented 73.1% of this sample.
Additionally, the consideration must be made that when
faced with a life-threatening illness such as cancer, patients
might not initially react and cope in ways that they would
normally cope with negative life events.
Suggestions for Future Research
Two suggestions for future replication of the present study
speak to the methodological problems. First, future researchers
need to explore varying ways of operationalizing and
conceptualizing the coping strategy of confrontation. This may
prove to be a difficult task as was discussed earlier in this
chapter. The suggestion is offered to be aware of blending items
76


of a more homogeneous nature into the coping strategy of
confrontation. For example, separating behavioral items from
attitudinal items may prove productive and subsequently
improve the reliability of its application in future studies.
A second suggestion for future replication relates to a
limitation of this study, the age of the sample population. 59.6%
of the respondents in this study were over age fifty-five. Future
researchers might want to consider using a sample population
representative of a broader age span.
Summary
This present study investigated 1) the communication
styles exhibited by physicians, as perceived by their patients,
when delivering the life-threatening diagnosis of cancer and 2)
the relationship of these communication styles to the coping
strategies adopted by the patient. This study was based on an
assumption that the affective component of the physician's
communication style may be a major factor in helping patients
cope with their cancer. Research findings supported the
assumption that when physicians possess a more affiliative
communication style, patients overall satisfaction with the
communication of their cancer diagnosis would be higher.
However, the study was not able to support the assumption that
77


patients will cope with the delivery of a cancer diagnosis in a
more confrontive way when their physicians demonstrate an
affiliative communication style. An individual's ability to cope
with negative life events, as developed over their life span, may
remain the dominant factor in coping with such a stressful,
frightening illness. Additionally, for patients diagnosed with
cancer, when using behaviors related to the coping strategy of
confrontation as derived from the Medical Coping Modes
Questionnaire, the findings did not support the assumption that
there would be a negative correlation between communication
apprehension and coping. However, when only verbal
confrontive behaviors were examined, this underlying
assumption was partially supported.
78


APPENDIX A


CONSENT FORM
Thank you for volunteering to participate in a study examining communication
between physicians and their patients and how this relates to dealing with illness. Below
you will find a description of the study and an explanation of your rights as a research
subject. In accordance with the policies of the University of Colorado, we ask that you
read this information carefully and sign in the space provided indicating that you have read
and understand this information. To maintain anonymity, return this consent form
separately to the folder available.
I am a graduate student in the Department of Communication at the University of
Colorado at Colorado Springs and I have worked in the healthcare field for several years.
This study has been designed to provide valuable information about the needs and
concerns of patients regarding communication with their physicians.
Certain rights are guaranteed to you as a research subject. First, you can be
assured that all the information that you provide on the questionnaire will be kept strictly
confidential. Secondly, your decision regarding whether or not to participate will nol
affect your health care or treatment at this medical facility in any way, and thirdly, it is your
absolute right to terminate the questionnaire at any point that you wish.
Return the questionnaire as soon as possible to the researcher in the self-
addressed envelope. Do not put your name on the questionnaire. Again, I am
suggesting that you return the consent form separately to the folder available to maintain
anonymity.
If you have any questions about the study or concerning your participation,
please call me at 635-4642 or contact my advisor, Dr. Pamela Shockley, at 593-3159.
Your contribution to this effort is greatly appreciated. If you would like a summary
of the results, please print your name and address on the back of the return envelope and
I will see that you receive it. The results will also be available in the Communication
Department at the University of Colorado, Colorado Springs, by Summer 1992.
Sincerely,
Beth Zautke, MT (ASCP)
Penrose Hospital Laboratory
Graduate Teaching Assistant (UCCS)
Participant
80


PART 1:
BACKGROUND INFORMATION
Please respond to the following questions by circling the appropriate answer or by filling in the
blank.
1. What is your age?
1. 18-30 years of age
2. 31 -40 years of age
3. 41-55 years of age
4. over 55 years of age
2. What is your sex?
1. Male
2. Female
3. What is your ethnic background?
1. Asian
2. Black
3. Hispanic
4. White
5. Other___________________
4. What is your family income?
1. Less than $15,000/year
2. $15,001 - $25,000/year
3. $25,001 - $50,000/year
4. Greater than $50,000/year
5. What is the last level you completed in school?
1. Less than high school graduate
2. High school graduate
3. Some college or technical school
4. Completed technical school
5. Completed college
6. Graduate work
6. What is your occupation?__________________________________________________
7. Do you know what kind of cancer you have? Yes No______
If you answered yes, what kind?__________________________________
8. Approximately how long ago were you informed of your illness?
1. Less than one month
2. One to six months
3. Six months to one year
4. One to two years
5. More than two years
81


9.
The doctor who communicated the news of your illness to you has a speciality in?
1. Family Practice
2. Internal Medicine
3. Surgery
4. Gynecology
5. Oncology
6. Other ___________
7. Don! know
10. In what stage is the cancer?
1. Stage I
2. Stage II
3. Stage III
4. Stage IV
5. Dont know
11. How do you currently view your health status?
1. Excellent
2. Good
3. Fair
4. Poor
5. Dont know
{
I
}
82


PABIII;
DIRECTIONS: Listed below are several questions asking about your typical thoughts, feelings, and
behaviors as they relate to your current illness. Please indicate your answer by circling the number which
corresponds to your response choice.
1. How much do you want to be involved in decisions regarding your treatments?
1 2 3 4 5
A great deal Very much Some Very little Not at all
2. How often do you try to talk about your illness with friends or relatives?
1 2 3 4 5
Never Infrequently Occasionally Frequently All the time
3. In conversations about your illness, how often do you find yourself thinking about other things?
1 2 3 4 5
Never Infrequently Occasionally Frequently All the time
4. How often do you feel there is really no hope for your full recovery?
1 2 3 4 5
All the time Frequently Occasionally Infrequently Never
5. In the past few months, how much have you learned about your illness from talking with others who
know something about it, such as doctors, nurses, etc.?
1 2 3 4 5
None Very little Some Very much A great deal
6. How often do you feel that you don't care what happens to you?
1 2 3 4 5
Never Infrequently Occasionally Frequently All the time
7. To what extent do you talk to your friends and your family because you wont have to think about your
illness?
1 2 3 4 5
Not at all Very little Some Very much A great deal
8. How much has your illness caused you to think about certain things in your life in a more positive way?
1 2 3 4 5
Not at all Very little Some Very much A great deal
9. When you were told about your illness, to what extent did you feel that your doctor genuinely cared
about you?
1 2 3 4 5
A great deal Very much Some Very little Not at all
10. When you were informed of your illness, how much time did your doctor spend with you?
1 2 3 4 5
A great deal Very much Some Very little Not at all
11. To what extent do you think that someone or something is responsible for your illness?
1 2 3 4 5
Not at all Very little Some Very much A great deal
12. To what extent have you decided that there is really nothing physically wrong with you?
1 2 3 4 5
83


Not at all
Very little
Some
Very much
A great deal
13. Since you have been informed of your illness, have you purchased items without planning to do so?
1 2 3 4 5
Never Infrequently Occasionally Frequently All the time
14. Since you have been aware of your illness, how often have you cried?
1 2 3 4 5
Never Infrequently Occasionally Frequently All the time
15. Since you have found out about your illness, how important has it been for you to join a support group?
1 2 3 4 5
Not at all Very little Some Very much A great deal
16. How much have you relied on spiritual resources, whether privately within yourself, or with your pastor or
other Church members?
1 2 3 4 5
Not at all Very little Some Very much A great deal
17. How sensitive was your doctor, in your opinion, when he/she informed you about your illness?
1 2 3 4 5
A great deal Very much Some Very little Not at all
18. When friends or close relatives try to talk to you about your illness, to what extent do you try to convince
them that you aren't ill?
1 2 3 4 5
All the time Frequently Occasionally Infrequently Never
19. Have you questioned your behavior about some of your decisions since you have been informed of your
illness?
1 2 3 4 5
Not at all Very little Some Very much A great deal
20. To what extent have you felt angry about having your illness?
1 2 3 4 5
Not at all Very little Some Very much A great deal
21. How much have you felt that professional therapy would help you through this?
1 2 3 4 5
A great deal Very much Some Very little Not at all
22. When you were informed of your illness, to what extent did you feel that questions were encouraged by
your doctor?
1 2 3 4 5
Not at all Very little Some Very much A great deal
23. When you think about your illness, how often do you try to distract yourself by doing something else?
1 2 3 4 5
All the time Frequently Occasionally Infrequently Never
24. How often do you ask your doctor for advice about what to do concerning your illness?
1 2 3 4 5
All the time Frequently Occasionally Infrequently Never
84


25. When friends or relatives try to talk to you about your illness, how frequently do you tty to change the
subject?
1 2 3 4 5
Never Infrequently Occasionally Frequently All the time
26. When you were informed of your illness, in your opinion, how much information was given by your
doctor?
1 2 3 4 5
A great deal Very much Some Very little None
27. Since you have known about your illness, how often have you had an argument with your spouse,
children, or close friend?
1 2 3 4 5
Not at all Very little Some Very much A great deal
28. In the past few months, how much have you learned about your illness from reading books, magazines,
or newspapers?
1 2 3 4 5
A great deal Very much Some Very little None
29. How often do you feel like giving in to your illness?
1 2 3
All the time Frequently Occasionally
Infrequently
5
Never
30. When you were informed of your illness, to what extent were you left with a feeling of hope?
1 2 3 4 5
Not at all Very little Some Very much A great deal
31. Since you have known about your illness, to what extent have you become controlling of your close
friends or relatives?
1 2 3 4 5
Never Infrequently Occasionally Frequently All the time
32. To what extent do you try to forget about your illness?
1 2 3
Not at all Very little Some
Very much
33. To what extent have you questioned your doctor about your illness?
12 3 4
Not at all Very little Some Very much
A great deal
A great deal
34. When you meet someone with your kind of illness, how much do you talk about the details of the
illness?
1 2 3 4 5
Not at all Very little Some Very much A great deal
35. Since you have known about your illness, how often do you find yourself more irritable than usual with
close friends or relatives?
1 2 3 4 5
All the time Frequently Occasionally Infrequently Never
36. Since you have been informed of your illness, have you done some things without thinking and have
regretted doing them later?
1 2 3 4 5
Not at all Very little Some Very much A great deal
85


37. To what extent do you feel that your doctor invited your participation in you treatment decisions?
1 2 3 4 5
A great deal Very much Some Very little Not at ail
38. Since you have known about your illness, to what extent are you demanding of your dose friends
or relatives?
1 2 3 4 5
Never Infrequently Occasionally Frequently All the time
39. Since you have known of your illness, have there been times that you have questioned your
judgment?
1 2 3 4 5
Never Infrequently Occasionally Frequently All the time
40. How often do you go to the movies or watch TV in order not to think about your illness?
1 2 3 4 5
Never Infrequently Occasionally Frequently All the time
41. To what extent do you feel there is nothing you can do about your illness?
1 2 3 4 5
A great deal Very much Some Very little Not at all
42. When close relatives or friends ask you about your illness, how often do you talk to them about it?
1 2 3 4 5
All the time Frequently Occasionally Infrequently Never
43. When you were informed about your illness, what amount of optimism was expressed by your doctor
concerning the successful treatment of your illness?
1 2 3 4 5
A great deal Very much Some Very little None
44. How satisfied are you with the way your doctor communicated the news of your illness to you?
1 2 3 4 5
Not at all Very little Some Very much A great deal
86


DIRECTIONS: This instrument is composed of 24 statements concerning your feelings about
communication with other people. Please indicate by circling the appropriate number, the degree to
which each statement applies to you There are no right or wrong answers. Work quickly, just
record your first impression.
Strongly Agree Agree Undecided Disagree Strongly Disagree
1 2 3 4 5 1. 1 dislike participating in group discussions.
1 2 3 4 5 2. Generally, 1 am comfortable while participating in a group discussion.
1 2 3 4 5 3. 1 am tense and nervous while participating in group discussions.
1 2 3 4 5 4. 1 like to get involved in group discussion.
1 2 3 4 5 5. Engaging in a group discussion with new people makes me tense and nervous.
1 2 3 4 5 6. 1 am calm and relaxed while participating in group discussions.
1 2 3 4 5 7. Generally, 1 am nervous when 1 have to participate in a meeting.
1 2 3 4 5 8. Usually 1 am calm and relaxed while participating in meetings.
1 2 3 4 5 9. 1 am very calm and relaxed when 1 am called upon to express an opinion at a meeting.
1 2 3 4 5 10. 1 am afraid to express myself at meetings.
1 2 3 4 5 11. Communicating at meetings usually makes me uncomfortable.
1 2 3 4 5 12. 1 am very relaxed when answering questions at a meeting.
1 2 3 4 5 13. While participating in a conversation with a new acquaintance, 1 feel very nervous.
1 2 3 4 5 14. 1 have no fear of speaking up in conversations.
1 2 3 4 5 15. Ordinarily 1 am very tense and nervous in conversations.
87


1 2 3 4 5 16. Ordinarily I am very calm and relaxed in conversations.
1 2 3 4 5 17. While conversing with a new acquaintance, I feel very relaxed.
1 2 3 4 5 18. I'm afraid to speak up in conversations.
1 2 3 4 5 19. I have no fear of giving a speech.
1 2 3 4 5 20. Certain parts of my body feel very tense and rigid while giving a speech.
1 2 3 4 5 21. 1 feel relaxed while giving a speech.
1 2 3 4 5 22. My thoughts become confused and jumbled when 1 am giving a speech.
1 2 3 4 5 23. 1 face the prospect of giving a speech with confidence.
1 2 3 4 5 24. While giving a speech 1 get so nervous, 1 forget facts 1 really know.
i
i
88


APPENDIX B


Confrontation Coping Strategy Variables
V2 How often do you try to talk about your illness with friends
or relatives?
V5 In the past few months, how much have you learned about
your illness from talking with others who know something
about it, such as doctors, nurses, etc.?
V8 How much has your illness caused you to think about
certain things in your life in a more positive way?
V24 How often do you ask your doctor for advice about what to
do concerning your illness?
V28 In the past few months, how much have you learned about
your illness from reading books, magazines, or
newspapers?
V33 To what extent have you questioned your doctor about your
illness?
V34 When you meet someone with your kind of illness, how
much do you talk about the details of the illness?
(Feifel, Nagy, & Strack, 1986)
Affiliative Style Variables
V9 When you were told about your illness, to what extent did
you feel that your doctor genuinely cared about you?
V17 How sensitive was your doctor, in your opinion, when
he/she informed you about your illness.
V30 When you were informed of your illness, to what extent
were you left with a feeling of hope?
90


APPENDIX C


Verbal Communication Confrontive Behaviors
V2 How often do you try to talk about your illness with friends
or relatives?
V5 In the past few months, how much have you learned about
your illness from talking with others who know something
about it such as doctors, nurses, etc.?
V24 How often do you ask your doctor for advice about what to
do concerning your illness?
V33 To what extent have you questioned your doctor about your
illness?
V34 When you meet someone with your kind of illness, how
much do you talk about the details of the illness?
V42 When close relatives or friends ask you about your illness,
how often do you talk to them about it?
5
i
92
s
i


REFERENCES
Abrams, R. D. (1966). The patient with cancer his changing
pattern of communication. New England Journal of
Medicine. 274. 317-322.
Aday, L. (1989). Designing and conducting health surveys: A
comprehensive guide. San Francisco: Jossey-Bass, Inc.,
Publishers.
Albrecht, T. L., & Adelman, M. B. (Eds.). (1987).
Communicating social support. Newbury Park, CA: Sage
Publications.
American Cancer Society (1982). American Cancer Society
Working Conference the psychological, social and
behavioral medicine aspects of cancer: research and
professional education needs and directions for the
1980s. Cancer. 5£(9), 1919-1970.
American Cancer Society. (1990). Cancer facts and figures -
1990. New York: Author.
Amir, M. (1987). Considerations guiding physicians when
informing cancer patients. Social Science and Medicine.
24(9), 741-748.
Bahnson, M.D., & Bahnson, C. B. (1969). Ego-defenses in cancer
patients. Annals of the New York Academy of Science.
164. 546-559.
Ballard-Reisch, D. S. (1990). A model of participative decision
making for physician-patient interaction. Health
Communication. 2(2). 91-104.
Bandura, A. (1982). Self-efficacy mechanism in human agency.
American Psychologist. 37. 122-147.
Barber, B. (1980). Informed consent in medical therapy and
research. State University of New Jersey: Rutgers
University Press.
93


Full Text

PAGE 1

PHYSICIANS' COMMUNICATION STYLES: THE RELATIONSHIP TO PATIENTS' COPING STRATEGIES WHEN CONFRONTED WITH THE DIAGNOSIS OF CANCER by Mary Beth Zautke B.S., Bradley University, 1966 A thesis submitted to the Faculty of the Graduate School of the University of Colorado at Denver in partial fulfillment of the requirements for the degree of Master of Arts Communication 1992

PAGE 2

This thesis for the Master of Arts degree by Mary Beth Zautke has been approved for the Department of Communication by s-2Date

PAGE 3

Zautke, Mary Beth (M.A., Communication) Physicians' Communication Styles: The Relationship to Patients' Coping Strategies When Confronted with the Diagnosis of Cancer Thesis directed by Associate Professor Pamela S. Shockley ABSTRACT This study investigated 1) the communication styles exhibited by physicians, as perceived by their patients, when delivering the life-threatening diagnosis of cancer and 2) the relationship of communication styles to the coping strategies adopted by the patient. The study was based on an assumption that the affective component of the physician's communication style may be a major factor in helping patients cope with their cancer. Research findings supported the hypothesis that when physicians possess a more aftlliative communication style, as perceived by their patients, patients' overall satisfaction with the communication of their cancer diagnosis would be higher. However, the study did not support the hypothesis that patients will cope with the delivery of a cancer diagnosis in a more confrontive way when their physicians are perceived to demonstrate an afflliative communication style. Additionally, for patients diagnosed with cancer, the fmdings failed to support iii

PAGE 4

the hypothesis that there would be a negative correlation between communication apprehension and the use of behaviors related to the coping strategy of confrontation as derived from the Medical Coping Modes Questionnaire. When examining only verbal confrontive behaviors, the research supported a negative correlation between communication apprehension and the patients' verbal ability to cope. This abstract accurately represents the content of the candidate's thesis. I recommend its iv

PAGE 5

CONTENTS CHAPTER I 1. INIRODUCilON . . . . . . . . . . . . . . . 1 General Background to the Research Problem . . 1 Historical Background Relevant to Physician Communication and Cancer Patient. . . 2 The Present Nature of the Coping Process . . . . 3 Background Relevant to Coping with Cancer . . . 5 Rationale and Support for the Study . . . . . . 6 5'U.nUllaiY' . . . . . . . . . . . . . . . . . . 9 II. REVIEW OF THE LITERATURE ................... 11 Uterature Review . . . . . . . . . . . . . . 1 1 Physician-Patient Communication ........... 11 Physician Communication Relevant to the Cancer Patient . . . . . . . 19 Physician Communication Style . . . . . . 2 3 The Present Nature of the Coping Process . 26 Coping with Cancer .......... 34 An Overview of Communication Apprehension . . . . . . . . . . . . . 39 Research Hypotheses. . . . . . . . . . . 4 2 S'U.nUllaiY' . . . . . . . . . . . . . . 4 3 v

PAGE 6

III. 45 Description of the Research Population . . 4 6 Prologue and Explication of the Hypotheses . . 4 7 General Explication of Methodology . . . . . . 4 8 Overall Procedure and Research Design . . . . 50 Hypothesis 1 . . . . . . . . . . . . . . 50 Hypothesis 2 . . . . . . . . . . . . . . 5 1 Hypothesis 3. . . . . . . . . . . . . . . 5 1 Research Plan . . . . . . . . . . . . 52 Instrumentation and Measurement ............. 53 Data Collection . . . . . . . . . . . . . . . 54 Data Analysis. . . . . . . . . . . . . . . . . 55 Su.mm.aiy' . . . . . . . . . . . . . . . . 56 IV. RESUL1'S. . . . . . . . . . . . . . . . . . 57 Prim.aiy Analyses . . . . . . . . . . . . . . 59 Hypothesis 1 . . . . . . . . . . . . . . 59 Hypothesis 2 . . . . . . . . . . . . . . 60 Hypothesis 3. . . . . . . . . . . . . . . 62 Supplemental Analyses . . . . . . . . . . . 64 Quantitative Data.. . . . . . . . . . . . 64 Qualitative Data ........................... 66 Su.mm.aiy' . . . . . . . . . . . . . . . . . 6 7 vi

PAGE 7

V. DISCUSSIONS, INTERPRETATIONS, AND CONCLUSIONS . . . . . . . . . . . . . 68 SUilllllaiY of the Findings . . . . . . . . . . 7 0 Primary' Results . . . . . . . . . . . . . 7 0 Qualitative data . . . . . . . . . . . . . 7 0 Assessment of Results . . . . . . . . . . . . 7 1 Problems and Umitations . . . . . . . . . 7 5 Suggestions for Future Research . . . . . . 7 6 SUilllllaiY . . . . . . . . . . . . . . . . . 7 7 APPENDIX A Complete Questionnaire . . . . . . . . . . . . 7 9 R Confrontation Index & Affillative Style V a:riables . . . . . . . . . . . 8 9 C Verbal Confrontive Behaviors . . . . . . . . . . 9 1 REFERENCES . . . . . . . . . . . . . . . . . 9 3 vii

PAGE 8

CHAFfER I INTRODUCTION The primary purpose of this study was to examine 1) the communication styles exhibited by physicians, as perceived by their patients, when delivering the life-threatening diagnosis of cancer; and 2) the relationship of these communication styles to the coping strategies adopted by the patient. This study was based on an assumption that the affective component of the physician's communication style may become a major factor in helping patients cope with their cancer. General Back"round to the Research Problem Since the time of the Greeks. the therapeutic power of the doctor-patient relationship has been well noted and studied. However, only in the last twenty years have the actual dynamics of this medical encounter been observed in any consistent manner (Roter et al., 1988). Historically, American society has both accepted and supported the paternalistic nature of the physician-patient relationship. Prior to the 1980's, this interaction between doctor and patient was one in which the physician prescribed and the patient complied (Ballard-Reisch, 1990). 1

PAGE 9

There is growing evidence indicating patients are becoming more consumerist in orientation and the new generation of patients are likely to directly challenge physician authority within the medical encounter (Haug & Lavin. 1983). In the last decade. there is evidence that the relationship that was formerly based on prescription and superior knowledge is evolving into one of shared decision making and in which the patient plays an active role in her or his health care (Siegler. 1981). Historical Relevant to Physician Communication and the Cancer Patient In the past. many physicians chose to withhold the diagnosis of cancer. agreeing that it was in their patients' best interest not to be told of their impending death (Glaser & Strauss. 1968). According to Taylor ( 1988). a dramatic change in disclosure policy occurred in North American in the late 1960s and early 1970s. Attributed to the demands of patients who had become better informed. these changes were due in part to 1) increased media coverage (Abrams. 1966). 2) new laws requiring that patients understand the nature of their disease before consenting to experimental therapy (Barber. 1980). and 3) a shift toward holistic medical care. based on the 2

PAGE 10

idea of open communication between doctor and patient (American Cancer Society. 1982). Opinion in more recent years. therefore, is that the patient's right to know what is wrong should usually override the doctor's very doubtful ability to tell whether the patient is intelligent enough or emotionally strong enough to receive the news (Moffit & Rossiter, 1978). The literature contains several articles describing physicians who advocate the new policy of total disclosure. However, it is interesting to note that studies still cite patient dissatisfaction with the amount of information they are given. Additionally, a study by Lind et al. (1989, p. 589) reports that "patients are unhappy with the mode of telling rather then the bad news communicated by the telling." The Present Nature of the Copinfl Process Human beings are constantly trying to make sense out of life events. They look toward many theories to aid in their dilemma of explaining not only the events in their own lives but in the lives of other people as well. A theory can be defined as a viewpoint or perspective. a way of looking at the relationship between things. Theory. therefore, becomes the very "stuff' by which life events and coping are defined (Snyder & Ford, 1987). 3

PAGE 11

Over the years, coping has acquired a variety of conceptual meanings and has been commonly used interchangeably with such concepts as mastery, defense, and adaptation (White, 1974). The concept of "coping" in the White study refers to "attempts made to lessen the physical and psychological pain associated with negative life events" (Snyder & Ford, 1987, p.9). For coping to occur, people must first select a particular response and then somehow mobilize and sustain sufficient energy to pursue it (Snyder & Ford, 1987). Fleming and colleagues (1984) stated: 1) that coping represents the expression of a complex set of factors encompassing such variables as personality, attitudinal, cognitive, and expectancy elements: 2) that choice of a specific strategy is most likely multidetermined; and 3) that the configuration of variables associated with a particular strategy is likely to be different for each coping strategy. According to Lazarus et al. (1974), much of the research on coping has given greater emphasis to psychological dispositions than to specific responses to situational conditions. However, Pearlin and Schooler (1978) were able to demonstrate that the style and content of coping does make a difference to the emotional well-being of people. And furthermore, they reported that the greater the scope and variety of the 4

PAGE 12

individual's coping repertoire, the more protection coping affords. Back(i!round Relevant to Copin(i! with Cancer Investigators have reported a variety of coping strategies used by medical patients in dealing with illness such as avoidance, denial, confrontation, and acceptance-resignation. Unfortunately, current theories in the area appear to be limited in their ability to explain the variabilities noted in some of the empirical data (Silver & Wortman, 1980). Cancer can be a tremendously frightening and stressful disease that can tax the coping resources of even the most well adjusted of patients (Meyerowitz et al., 1989). The American Cancer Society (1990) estimated that about 300/o of the total population of Americans now living will be diagnosed as having cancer. Over the years, cancer will strike three of four American families (Gotcher & Edwards, 1990). Due to the ever-present and deadly nature of the disease, a tremendous amount of research has focused on the medical aspects of cancer. The psychological aspects of the disease, unfortunately, have not been examined as extensively, even though the emotional trauma that results from the diagnosis and 5

PAGE 13

treatment of cancer can be as damaging to the patient as the cancer itself (Harrell, 1972; Radley & Green, 1987). There has been the suggestion that life-threatening conditions may call forth coping strategies which are different in kind or degree from those used to cope with nonlife-threatening conditions (Silver & Wortman, 1980). Together, several studies point to life-threat as a consequential factor in the way people respond to their situation (Bahnson & Bahnson, 1969; Hackett & Weisman, 1969; Knier & Temoshok, 1984; Visotsky et al., 1961; Weisman et al., 1980). In a study published by Feifel et al. (1986), findings appear to support those theorists who conceptualize coping behavior in dealing with life-threat as being shaped more by situational context than by personal style. Rationale and Support for the Study As the importance of physician-patient communication becomes increasingly recognized, an area of general interest and importance for many Americans is the communicating of the diagnosis of cancer. According to Goldschmidt & Hess (1987), no other doctor-patient interaction requires so much clarity, sensitivity, and mutual understanding. Due to the potential impact of a cancer diagnosis and the treatment as well, several researchers have examined the role of 6

PAGE 14

psychological states and the individual's chance of recovery from a life-threatening disease (Gotcher & Edwards, 1990). Greer, Moorey, and Watson (1989) reported that the way the patient psychologically copes with the trauma directly affects the patient's chance of survival. Patient satisfaction is by far the most recognized and widely used measure for assessing the effectiveness of physicianpatient communication. Studies have determined that one of the factors important in patient satisfaction is the amount of information given by the physician (Ley, 1982; Gotcher & Edwards, 1990; Miller et al., 1983; Reynolds et al., 1981; Steptoe et al., 1991; among others). However, greater satisfaction with communication was not associated with higher levels of factual knowledge concerning the causes and treatments of cancer (Steptoe et al., 1991). Research has linked patients' satisfaction with health care to the communication styles of physicians. The patient's satisfaction with the doctor appears to be largely a result of the physician's verbal and non-verbal communication while interacting with the patient (Daly & Hulka, 1975; Korsch et al., 1968; Spiro & Heidrich, 1983). Ben-Sira (1976, 1980) argues in his social interaction model that the affective component of the physician's 7

PAGE 15

communication becomes a major factor because a patient enters the medical interaction with anxiety about the medical prognosis, less knowledge about medical techniques than the physician, and less ability to connect treatments with improvements. Ben-Sira's affective component is closely related to a concept elaborated in the communication literature as communication style. Communication style is conceptualized by Norton ( 1978, 1983) as "the way one verbally or para -verbally interacts to signal how literal meaning should be taken, interpreted, filtered, or understood" in a communication context (1978, p. 99). As previously discussed, coping has been described as a critical component in the patient's struggle for survival and recovery from serious illness (Sanders & Kardinal, 1977). Numerous studies have examined the concept of coping from the perspective of the patient. This study placed the emphasis on the physician. The research objective of this study was to examine physicians' communication styles in a single episode of cancer treatment -the event of telling the patient for the first time that she/he has cancer-and the subsequent influence of that communication style on the coping process of that cancer patient. 8

PAGE 16

The literature review that follows further explicates the present study and concludes with a statement of the specific research hypotheses that were empirically tested in this study. Summruy This frrst chapter has provided some general background to the research problem under investigation. It has explicated the historical background of physician-patient communication and reviewed the significance of this relationship relevant to cancer patients. Additionally, this chapter presented the present nature of the human coping process and the significance of coping for patients with the life-threatening illness known as cancer. Rationale for the present study and research objectives have also been outlined. Next, Chapter II will review the literature relevant to the research problem in greater depth and will present the three specific research hypotheses that have been tested. Chapter III addresses the research procedure and design, sampling, instrumentation, and data collection and analyses. Chapter IV contains the results of the study and analyses of the data with regard to the research hypotheses. Chapter V is concemed with interpretation of the results of the study and the implications of those results. Also included in Chapter V is a discussion of 9

PAGE 17

problems and limitations of the study with some suggestions for future research. 10

PAGE 18

CHAPTER II REVIEW OF THE LITERATURE Literature Review The primary purpose of this study was to examine the communication styles exhibited by physicians as perceived by their patients when delivering a diagnosis of cancer and the relationship of the communication styles to the coping process employed by the patient. In the preceding chapter, background and rationale for the study were provided. This chapter will review relevant literature related to the research objective and will conclude with a statement of the specific research hypotheses. The review will include six areas: 1) generalized physician-patient communication, 2) physician communication relevant to cancer patients, 3) physician-communication style, 4) the nature of the coping process, 5) coping with cancer, and 6) an overview of communication apprehension. Physician -Patient Communication An array of studies beginning in the late 1950s have been reported concerning the nature of the relationships between patients and practitioners. However, this remains a difficult literature to review. The field appears disorganized with little 11

PAGE 19

sense of theoretical cohesiveness or rational progression. A proliferation of terms exists without agreement on basic definitions for coding categories or communication variables (Roter et al., 1988). In light of these complexities, an overview will clarify the physician-patient relationship as it pertains to this study. Prior to the 1960s, long-standing, one-to-one relationships between patient and physician were the rule rather than the exception. This provided a setting where warmth and mutual understanding were able to develop and flourish. But as patterns of medical care have changed, the individual doctorpatient relationship has been replaced by short-term encounters with numerous specialists and other healthcare workers. Simultaneously, there has developed a discontent of the patient population with much criticism being aimed at the lack of warmth and humanity in the available medical care (Korsch et al., 1968). Even as recently as 1988, the American Medical Association (AMA) Survey of Physicians and Public Opinion on Health Care Issues (cited in Gartland, 1989) found that the American public feels physicians are still not communicating well with patients, that they are regarded as arrogant, acting as if they were better than other people. 12

PAGE 20

The combined literature considers communication between physicians and patients to be a critical component of effective medical care. Diagnosis and treatment depend on the physician's ability to exchange information with the patient. Communication becomes a strong influence on patient compliance (Ballard-Reisch, 1990; Burgoon et al., 1990; Korsch et al., 1968; Sharf, 1990) among others. Equally important, communication is the major determinant of patient satisfaction (Buller & Buller, 1987; Korsch et al., 1968; Ley, 1982; Steptoe et al., 1991) among others. The interaction between physicians and patients involves an "information game" wherein participants both seek and give information (Goffman, 1959; 1967). In managing the course of an illness physicians make decisions about diagnosis, treatment, and communication. Several communication studies in the last five years have directed their energy toward the subtleties of health communication that are carried out in the medical encounter. Several different aspects of this interaction between physicians and patients have been addressed, specifically patient power, relational control, health promotion, decision making, giving bad news, and interpersonal rhetoric. A brief overview of these various aspects of physician-patient communication follows. 13

PAGE 21

The aspect of communication that pertains to "giving bad news" will be addressed in the following section of this chapter titled "physician communication relevant to cancer patients". Physicians provide services that are both needed and desired by patients. Therefore, the doctor-patient relationship is immediately observed as asymmetrical with the doctor possessing legitimate, referent. and expert power. According to A. E. Beisecker (1990), the transfer of expert power from doctor to patient may be accomplished in the medical encounter. Patients are able to exercise some control in the medical arena by attempting to obtain information, being assertive when communicating with physicians, and participating in medical decisions. The literature has shown multiple factors to be involved in affecting patient power: 1) sociodemographic characteristics, 2) role expectations and attitudes of doctor and patient, and 3) situational factors that influence both parties in their interaction with each other. Situational factors, however, appear to be better predictors of a patient's assertive communication behaviors than attitudes and sociodemographic variables (Beisecker, 1990). Examples of situational factors would be diagnosis, reason for patient visit, presence of a companion, length of interaction, among others. 14

PAGE 22

In discussing patient power, von Friederichs-Fitzwater and colleagues (1991) have dealt with the issue of relational control, attempts by patients and doctors to control each other. In seeking information from their physician, patients may actually be seeking more control over their medical situation than over the doctor. Beisecker (1990) suggests that this might explain the strong role played by situational factors, such as diagnosis and reason for the visit, in explaining patients' attempts to seek information and make suggestions regarding treatment options. Physicians are making an effort to increase the autonomy of their patients and to provide more information so that patients may give their informed consent to medical treatment. By making these efforts, doctors are actually sharing some of their power with patients. A. E. Beisecker (1990) points out that this sharing of power has occurred at the same time that third-party payers (i.e., insurance companies and health maintenance organizations) are also taking some power away from doctors by insisting on input in medical decision making. The doctor-patient relationship and the balance of power within that relationship will certainly be influenced by third-party payers who have economic power over medical decisions and the presence of knowledgeable, assertive patients. 15

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Health promotion refers to teaching people how to prevent disease by changing their lifestyles. Evidence is accumulating that supports the philosophy that lifestyle has identifiable effects on health and disease. Kottke and colleagues (1987) have listed a number of specific and practical recommendations for persuading patients to change their life styles. In a recent study by Barbara Sharf (1990), the physicianpatient interaction is discussed as rhetorical activity. Observing the clinical interview as interpersonal rhetoric has contributed to a broader understanding of how such rhetorical activity can significantly influence outcomes that include preventing and curing diseases as well as prolonging life. The recent application of narrative theory (storytelling) in rhetoric and in medicine may provide answers to the ways that physicians and patients shape the discourse in which they jointly participate in an attempt to persuade each other (Polkinghome, 1988). The final aspect of physician-patient communication to be discussed here revolves around medical decision making. Prior to the 1980s, the doctor-patient relationship was one in which the physician prescribed and the patient complied. (Ballard Reisch, 1990). This paternalistic relationship has also been referred to as the biomedical model (Wyatt, 1991). Partially due to the emphasis on informed consent, this relationship has 16

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undergone much change in the last decade within medical, legal, and social spheres (Sisson, Schoomaker, & Ross, 1976: Katz, 1984: McNeil et al., 1982). The relationship evolved into one of shared decision making, referred to by Engel ( 1977) as the biopsychosocial model. This model is a collaborative relationship in which the patient and the doctor work together to make decisions (Ballard-Reisch, 1990). In applying the concept of participative decision making to the health care setting, Brody (1980) concluded that patients who participate in the clinical decision making have greater confidence in and commitment to health-care decisions. Reinforcing this perspective, the findings of Janis (1982) found that individuals who are committed to a course of action and who accept responsibility for it are more likely to adhere to the treatment process. In summary, Ley (1983) postulates that two major problems currently exist in health-care delivery today. The first involves providing patients with enough information concerning their illness and treatment to conclude that they are sufficiently informed: the second addresses the high level of noncompliance occurring on the part of patients with prescribed medical regimens. Both problems occur as a result of short-comings in current pattems of communication (Rater, 1983) and decision 17

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making between physicians and patients (President's Commission, 1982). As the focus slowly shifts from the biomedical (doctor centered) model to a biopsychosocial model (patient-centered, partnership), issues of power, trust, and intimacy in the doctorpatient relationship will become ever more significant factors in the goal of providing optimum health care (von Friederichs Fitzwater et al., 1991). Patient satisfaction is the most recognized and widely used measure for assessing the effectiveness of physician-patient communication. Studies have determined that one of the factors important in patient satisfaction is the amount of information given by the physician (Gotcher & Edwards, 1990; Ley, 1982; Miller & Mangan, 1983; Reynolds et al. 1986; Steptoe et al., 1991) among others. According to Ley (1982) patient dissatisfaction and lack of compliance are linked with poor transmission of information from doctor to patient, low understandability of communications addressed to the patient, and low levels of recall of information by patients. Patient satisfaction will be discussed again later in this chapter under "physician communication styles." 18

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Physician Communication Relevant to the Cancer Patient Within the multitude of services which the health care system delivers to cancer patients. a largely non-technical activity has begun to receive increasing attention from researchers in the last decade: Communicating facts about the disease (Greenwald & Nevitt, 1982). The communication process between physician and cancer patient shares most of the general features of the standard doctor-patient interaction as discussed in the previous section. However, this process becomes burdened with additional problems. L.A. Siminoff (1989) describes these problems as revolving around a variety of factors which make the discussion of cancer emotionally charged. Most important of these are the fear and stigma associated with the diagnosis and treatment of cancer (Meyerowitz et al .. 1989). the complexity of the medical information itself, and uncertainty about the benefits of treatment or the course of the disease (Division of Cancer Prevention and Treatment: Annual Report. 1987; Frei, 1982; Hoy. 1985). Among the communication issues in cancer. none has been more widely and emotionally debated than that of telling the diagnosis. This issue becomes the focus of this section of the 19

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literature review for it exists as a pivotal element to this empirical study. Before 1960, the majority of physicians in the United States, like doctors in most of the rest of the world, rarely told patients that they had cancer (Taylor. 1988). By 1980, twenty years later, this trend had completely reversed. Over 90% of the doctors stated that they routinely reveal the diagnosis of cancer (Holland et al. 1987). According to Holland (1989), this reversal resulted from the public being better informed as well as being less pessimistic about cancer, and from an increase in societal concerns about patients' rights to give informed consent and to participate in decisions about their care. The American Cancer Society (1982: 1919-70) also attributes the change to a shift toward holistic medical care, based on the ideal of open communication between doctor and patient (Taylor. 1988). A decade after acceptance of this new practice of disclosing a cancer diagnosis, a report by Und and colleagues (1989) addresses the next question: how well are we doing in handling this critically important presentation of the diagnosis from which the experience of every cancer patient begins? Patients' perceptions of their physicians in the Und Study suggest the need for attention to this subject as well as improvement in performance. 20

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Virtually any type of physician may be involved in one stage or another of telling this diagnosis. Biopsies have been performed almost exclusively by surgeons, the fact contributing to the largest percent of "telling" doctors residing in that specialty. Oncologists occasionally may be the frrst to tell a patient the definitive diagnosis, but more often, oncologists must tell the diagnosis a second or third time (Lind et al., 1989). Holland (1989) relates that there is little empirical literature to guide the clinician on how and in what context to tell the diagnosis of cancer. Physicians seem to depend primarily on personal experiences and judgments with the help of chance comments of colleagues or teachers in deciding how to approach an individual patient. In the study performed at Massachusetts General Hospital by Lind and colleagues (1989), several important questions emerged for consideration. First, in terms of who should convey the cancer diagnosis, the physician who knows the patient only through doing a diagnostic procedure may not be the most appropriate person. Second, patients studied by Und et al. (1989) confirmed that content of the discussion should not be limited to revealing the diagnosis. Prognosis and discussion of treatment were more commonly cited, by 52% and 18%, respectively, as the most 21

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important elements of the telling. Brief conversations in which the diagnosis alone was discussed, especially on the telephone or in the recovery room where the ability of the patient to respond was compromised, were not only unsatisfactory, but were perceived as insensitive and unfeeling on the doctor's part. Third, the place in which the diagnosis is discussed must be private enough to permit the patient to show feelings. Fourth, the presence of a family member or friend is usually helpful to the patient who is anxious and may have difficulty recalling details of the conversation. Fifth, there are direct implications from the study that training would be helpful for doctors who must repeatedly give bad news. Most have received no special training in counseling and talking to patients. It is interesting to note that most physicians who have faced serious illness themselves become far more considerate of patients' feelings (Holland, 1989). Lastly, patients in this study by Lind and colleagues (1989) reported that they were unhappy with the mode of telling rather than the bad news communicated by the telling. This facet of physician-patient communication will be discussed in greater detail in the following section titled "Physician Communication Style." 22

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Physician Communication Style Researchers and health care practitioners are concerned with identifying factors which promote patients' compliance with physician recommendations in order to improve the quality of health care (Korsch, Gozzi, and Francis, 1968; Burgoon et al .. 1990). The patient's satisfaction with the doctor as well as the medical treatment has been reported as an important determinant of compliance (Korsch et al., 1968; Korsch & Negrete, 1981; Woolley, Kane, Hughes, & Wright, 1978). Research has demonstrated that physician communication style is strongly linked to patient satisfaction and compliance (Ben-Sira, 1976; Buller & Buller, 1987; Doyle & Ware, 1977; Korsch, Gozzi, & Francis, 1968; Woolley, Kane, Hughes, & Wright, 1978). Patient satisfaction appears to be largely a result of the verbal and non-verbal communication of the physician while interacting with the patient (Daly & Hulka, 1975; Korsch, Gozzi, & Francis, 1968; Spiro & Heidrich, 1983). Ben-Sira (1976, 1980) in his social interaction model considers the affective component of the physician's communication to be a major factor in patient evaluations. This affective component consists of "behaviors directed by the physician toward the patient as a person rather than as a 'case"' (1980, p. 173). 23

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In the communication literature, Ben-Sira's affective component is closely related to a concept called communication style (Buller & Buller, 1987). As conceptualized by Norton (1978, 1983), communication style is "the way one verbally or paraverbally interacts to signal how literal meaning should be taken, interpreted, filtered, or understood" in a communication context (1978, p. 99). According to Buller & Buller (1987), the literature on physician-patient communication suggests that two general styles are displayed by physicians in medical visits. One style, affiliation, is composed of communication behaviors that serve to establish and maintain a positive relationship between physician and patient. These behaviors include those that communicate interest, friendliness, empathy, warmth, genuineness, honesty, respect, compassion, a desire to help, a nonjudgmental attitude, humor, and a social orientation (Ben-Sira 1976, 1980; Collins, 1983: DiMatteo, Robin, Prince, & Taranta, 1979; Korsch et al., 1968: Korsch & Negrete, 1972: Street & Wiemann, 1987). The second style, control, includes behaviors that establish and maintain the physician's power and control in the medical interaction. This has been a topic of several studies because a difference in control, power, and status is inherent in the physician-patient interaction. This discrepancy stems from the 24

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patient's limited understanding of medical problems and treatments, the patient's increased anxiety and uncertainty about prognosis and treatment, the physician's control of medical information, and the institutionalized roles prescribed for the physician and the patient (Ben-Sira, 1980; Friedson, 1970; Waitzin, 1985). The manifestations of power, authority, and status in a physician's communication has been noted by several researchers (Hall, Roter, & Rand, 1981; Korsch & Negrete, 1972, Street & Wiemann, 1987). A survey by Korsch and Negrete (1981) reported that friendly treatment, positive affect, and warm concern for patients' worries produced greater overall satisfaction. In the same study, patients were found to be less satisfied when the physicians' communication was designed to maintain authority. In a more recent study by Buller and Buller (1987), patients were reported to rely more on the physician's communication style than on specific treatment information and success of treatment when evaluating medical care. Highly afflliative and less dominant physicians produced the most favorable evaluations among patients. With the emphasis on the amount of time physicians should spend talking to their patients, it is interesting to note that this study also suggests that an affiliative physician who takes only a short time to speak with the patient 25

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seems to be just as satisfying, or even more so, than a dominant/ controlling physician who spends a longer time with a patient. In conclusion, communication should obviously be a major concern for physicians as they attempt to satisfy and retain patients (Buller & Buller, 1987). The quality and effectiveness of medical care hinges on the establishment of positive relationships (Roter, 1983). The Present Nature of the Coping Process Coping refers to behaviors that protect people from the physical and psychological pain associated with negative life events (Snyder & Ford, 1987). It is a strategic effort to master a problem, overcome an obstacle, dissipate a dilemma anything that impedes our progress (Weismann, 1984). Human beings are constantly looking toward theories to aid in their dilemma of explaining not only the events in their lives but in the lives of other people as well. A theory is a way of looking at the causality between things. According to Snyder & Ford (1987), theory becomes central in the process of coping with negative life events. 26

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. I I Several broad perspectives have shaped current approaches to understanding life crises: 1) evolutionary theory with an emphasis on behavioral adapting, 2) psychoanalytic concepts and human growth approaches, 3) a focus on human development through the life cycle, and 4) information on the process of coping with severe crises (Moos, 1986). 1) Charles Darwin's theory of evolution examined the adaptation of animals (including humans) to their environment. His ideas shaped the formation of ecology, the study of the link between organisms or groups of organisms and their environment. Evolutionary thought suggests that human beings cannot adapt to their environment alone, that they are interdependent and must make collective efforts to survive. The formation of social bonds is an essential aspect of an effective transaction with the environment. Communal adaptation is viewed in their theory as an outgrowth of individual adaptation and of specific coping strategies that serve to contribute to group survival (Moos, 1986) . 2) The psychoanalytic orientation 1986) leads to an emphasis on behavioral problem -solving activities that enhance both individual and species survival. More recent approaches have highlighted the role of cognition in this adaptation. Cognitive behaviorism is concerned with an 27

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individual's appraisal of the self and the meaning of an event as well as with problem-solving skills. A sense of self-efficacy is considered to be an essential coping resource. Bandura (1982) relates successful coping to promote the expectation of self efficacy, which leads to more persistent and vigorous efforts to master new tasks. Sigmund Freud's psychoanalytic perspective sets the stage for an intrapsychic counterpoint to the evolutionary emphasis on behavioral factors. He believed that ego processes served to resolve conflicts between an individual's instincts and the constraints of external reality. Freud perceived these ego processes to be cognitive mechanisms (although behavioral components may be involved in their expression) whose main functions are defensive (reality distorting) and emotion focused (oriented toward tension reduction) (Moos, 1986). The neo-Freudean ego psychologists objected to these ideas and positioned a "conflict-free ego sphere" in which individuals have autonomous energy and possess such aspects of competence motivation as a sense of agency and of being in control of their lives (Moos, 1986). These ideas formed the basis for the new set of growth or fulfillment theories of human development. For example, Carl Rogers believes individuals try to develop their capacities in 28

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ways that serve to promote growth and maintain life. Additionally, Abraham Maslow distinguished between deficiency and motivation. According to Maslow, "mature healthy individuals perceive reality accurately, are solution-centered and spontaneous in behavior, and have a strong social interest, a genuine desire to help others, and a broad perspective on life (in Moos, 1986, p.6). 3) Psychoanalytic theorists pose that life events in infancy strongly affect and probably determine adult personality. But information about the growth of ego functions and normal maturation shows that early life events do not necessarily preset the pattern of reaction to crises and transitions. Psychoanalysis and ego psychology, in addition to highlighting the processes of defense and coping, have also provided the basis for developmental approaches that consider the gradual acquisition of personal resources over a person's life span. Erik Erikson (1963) described eight life stages. Each stage encompasses a new challenge or "crisis" that must be negotiated successfully in order for the individual to cope adequately with the next stage. Personal coping resources, such as ego integrity and the formation of trust, are accrued during the adolescent and young-adult years. These coping resources are subsequently integrated into the self-concept and shape the 29

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process of coping in adulthood and old age. Adequately resolving the issues that occur at one stage in a person's life cycle leave a legacy of coping resources that can help to resolve subsequent crises. Stage models such as Erickson's are often depicted as a spiral staircase in which failure to attain one landing implies failure to attain the next. According to Neugarten (1979), however, adulthood is not usually composed of stages that occur at specific chronological ages. Events that occur on time can be anticipated and managed without taxing a person's coping capacity. But ideas of social timing have changed dramatically over the last two decades. The life cycle has become more fluid as more men and women divorce and remarry, and more middle-aged persons return to college or begin new families. This influences how individuals cope with the transitions of middle and old age. 4) According to Moos ( 1986), there has been renewed interest in human competence and coping under extreme conditions. The most compelling accounts are of the harrowing conditions in the Nazi concentration camps of World War II. A compelling question is raised: How can anyone face such suffering and ever-present threat of death and yet survive psychologically to bear witness about the experience? 30

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Other work has considered such crises as parental and sibling death (in Moos, 1986, Parts II & III), disasters such as a flood or tornado (Part IX), being a victim of rape or kidnapping (Part X), and long-term imprisonment in a war camp (Part XI). Similar studies have examined how individuals adapt to serious illness or injury and face life-threatening diseases and surgery (Feifel, Strack, & Nagy, 1987; Martelli et al., 1987; Miller, Brody, and Summerton, 1988; Moos, 1986). The surprising fact, as Moos (1986) points out, is that many persons cope effectively with crises of such magnitude. This historical overview also provides a basis for the formation of crisis theory which is concerned with how individuals manage major life transitions and crises. The fundamental ideas were developed by Erich Lindemann who described the process of grief and mourning and the role of community caretakers in helping bereaved family members to cope (Lindemann & Lindemann, 1979). These ideas, combined with Erickson's "developmental crises" at transition points of the life cycle, have paved the way for the outgrowth of crisis theory (Caplan, 1964). Crisis theory deals with the impact of disruptions so novel or major that habitual responses are insufficient. In this state of disequilibrium, some resolution must be found. The individual 31

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may make a healthy adaptation that promotes personal growth or a maladaptive response that foreshadows psychological problems. Stressful life episodes may enrich a person's values and beliefs by making it necessary to assimilate new experiences. Thus a crisis is a transition that has profound implications for an individual's adaptation and ability to meet future crises (Moos, 1986). Over the years, coping has assumed a variety of conceptual meanings. The concept of "coping" in this study refers to "the behaviors, cognitions, and perceptions in which people engage when actually contending with their life problems" (Pearlin & Schooler, 1978). For coping to occur, Snyder and Ford (1987) point out that people must not only select a particular response, but they must then somehow mobilize and sustain sufficient energy to pursue it. Coping is certainly not an unidimensional behavior but functions at a number of levels. Fleming and colleagues (1984) state that coping represents 1) the expression of a complex set of factors including such variables as personality, attitudes, cognitions, and expectancy elements: 2) that the choice of a specific strategy is most likely multidetermined: and 3) the combination of variables associated with a particular strategy is likely to be different for each coping strategy. 32

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Dr. Avery Weismann, in his book, The Copin2 Capacity. confrrms the common coping strategies incorporated by individuals when contending with problems. Describing the list as both too long and too short, Weismann (1984) dissects coping strategies as follows: COMMON COPING STRATEGIES USED BY YOU AND ME 1. Seek information; get guidance. 2. Share concern; find consolation. 3. Laugh it off; change emotional tone. 4. Forget it happened; put it out of your mind. 5. Keep busy; distract yourself. 6. Confront the issue; act accordingly. 7. Redefine; take a more sanguine view. 8. Resign yourself; make the best of what can't be changed. 9. Do something, anything, perhaps exceeding good judgment. 10. Review alternatives: examine consequences. 11. Get away from it all: find an escape, somehow. 12. Conform, comply: do what is expected or advised. 13. Blame or shame someone, something. 14. Give vent; feel emotional release. 15. Deny as much as possible. (Weismann, 1984, pp. 36-37) For the purposes of this study, these specific behaviors were collapsed into seven coping strategies: confrontation, avoidance, acceptance-resignation, denial, ventilation, impulsive behavior, and blaming. Different problems call for different sets of primary strategies. 33

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The strategy of coping is seldom simple and unambiguous but it seems important to relate that strategies can be learned. Self-instruction depends on discovering new resources and perfecting those that have worked reasonably well in the past (Weismann, 1984). Pearlin and Schooler (1978) were able to demonstrate in their study that the style and content of coping does make a difference to the emotional well-being of people. Good copers manage to deal with problems in similar ways that prove more effective than those of bad copers. Additionally, they reported that the greater the scope and variety of the individual's coping responses, the more protection coping affords. How we cope with any problem, the action that we take, will inevitably change the nature of that problem so that it becomes a situation that we can deal with or at the very least, one that we can refocus into more familiar terms (Weismann, 1984). Copinfl with Cancer Cancer can be an extremely stressful and frightening illness. The coping resources of even the most well-adjusted patients are often taxed to their limit (Meyerowitz et al., 1989). The American Cancer Society ( 1990) estimated that 76 million Americans now living will be diagnosed as having cancer. This 34

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represents about 300k of the total population. Over the years, cancer will strike three out of four American families and many people diagnosed with cancer will die from the illness. Billions of dollars have been awarded toward research focusing on the medical aspects of cancer. However, the psychological aspects of the disease have not been examined as extensively, even though studies have reported that the emotional trauma resulting from the diagnosis and treatment of cancer can be as damaging to the patient as the cancer itself (Harrell, 1972; Radley & Green, 1987). Due to the devastating impact of a cancer diagnosis as well as the treatment process, a number of researchers have examined the role of psychological states and the individual's chance of recovering from a life-threatening disease (Gotcher & Edwards, 1990). According to Greer, Moorey, and Watson (1989), the way a patient copes with psychological trauma directly affects the patient's chance of survival. Levy and colleagues (1985) reported that characteristics such as hopelessness and passivity in women with breast cancer are associated with poorer chances of recovery. Coyne and Holroyd (1982) found that the way an individual copes with the demands of chronic illness can determine the course of the illness as well as the medical care received. In a later study by Perseky and 35

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colleagues (1987), researchers linked depression in male subjects with subsequent mortality from cancer. These studies add credibility to the findings by Sanders & Kardinal (1977) in which they describe coping to be a critical component in the patient's struggle for recovery and survival. Research has indicated that certain mental attitudes encourage coping strategies that enhance the body's immune system, the body's natural healing processes, whereas others inhibit this natural system (Reynolds & Kaplan, 1986). Patients do not cope with the cancer (i.e., the malignant cells), but, rather, with a wide variety of distressing and disruptive situations, thoughts, and feelings that are associated with the disease (Meyerowitz, Heinrich, & Schag, 1989). It becomes extremely important for physicians and oncology professionals to understand what these difficult situations and problems are because they are in a unique and important position to help patients cope with the many stressful aspects of cancer. Although much of the literature on coping with cancer has focused on intrapersonal cognitive and emotional coping responses, Meyerowitz and colleagues (1989) believe that coping typically occurs within an interpersonal context. They found that many of the strategies that patients use enlist people who 36

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are important to them in the coping process. Research by Reynolds and Kaplan ( 1986) also suggested that relationships with others play a role in the disease coping process. These relationships include important people such as health professionals, family, and friends that may be involved in aiding patients in finding effective management strategies for the difficult situations they are experiencing. It becomes obvious that the interpersonal interaction that occurs when the diagnosis of cancer is first delivered may be central in setting the stage for effective coping strategies to be developed and tried. There is the suggestion that life-threatening conditions may call forth coping strategies which are different in kind or degree from those used to cope with non life-threatening conditions (Silver & Wortman, 1980). According to Gotcher and Edwards (1990), specific features of communication are important in coping with serious illness. They found these features to include: 1) communicating about one's illness, 2) receiving information about the disease, 3) asking questions of the health care professionals, and 4) using communication to deal with fears. Most cancer patients express a strong desire for open communication and for receiving a maximum amount of information about their illness (Meyerowitz, Heinrich, & Schag, 37

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1989). But research by Emda Orr (1986) found this "openness" construct to be multidimensional calling for further research to be accomplished concerning such variables as the objects and modes of communication, strength of patients' anxiety, time aspects, cultural norms, personal values, and the specific others that a person communicates with. Coping requires the patient to deal with the physical effects of the illness as well as the psychological traumas associated with the disease (Radley & Green, 1987). Several medical researchers have called for research concerning cancer and communication (Burish & Lyles, 1983; Craig, Comstock, & Geiser, 1974; Heinrich, Schag, & Ganz, 1984; Johnson et al., 1989). However, very little research has been forthcoming. Taylor ( 1983) has suggested that after hearing the word cancer as one's own diagnosis, adjustment to this personal tragedy focuses on three common themes: 1) the patient's search to find meaning in the experience, 2) the patient's attempt to gain a sense of mastery over the disease, and 3) the patient's engagement in efforts to enhance her /his threatened self-esteem. The purpose of this study was to investigate physicians' communication styles as perceived by their patients during the event of telling a patient for the frrst time that she/he has cancer and the influence that this 38

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communication style may have on the coping process of that cancer patient. An Overview of Communication Apprehension In this age of increased emphasis on communication between people and computers, it might seem that human-tohuman communication has become less important than it used to be. However, this is not the case. Most of our daily interaction is with other people on a live, interpersonal level. Supervisors communicate with their subordinates on a one-to one basis. The same one-to-one interaction occurs between teachers and their students, lovers with each other, as well as physicians and their patients, which is pivotal to this study. So, even though computers play a significant role in our lives, they simply will not replace human interaction (McCroskey & Richmond, 1989). Human communication, as defmed by McCroskey and Richmond (1989), is "the process by which a person (or persons) stimulates meaning in the mind of another person (or persons) through use of verbal and/or non-verbal messages" (p.l). The process of human communication has seven essential components: source, message, channel, receiver, encoding, decoding, and feedback (McCroskey, 1984). 39

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Communication apprehension (CA), as a single communication construct, has been a major concern of researchers and scholars since 1970. The reason for this focus on CA is that it permeates every facet of an individual's life, work, school, family, friendships, and so on. Communication apprehension is the fear or anxiety associated with either real or anticipated communication with another person or persons (McCroskey, 1984). Many people desire to communicate with others and even recognize the importance of doing so, but fear or anxiety interferes. According to McCroskey and Richmond (1989), it has been estimated that 20 percent of the population (one in five) suffers from communication apprehension. They report these results to have been consistent across many samples of subjects and from several subject populations. It is important in this study to note that communication apprehensive people tend to be low verbalizers. It is natural to avoid or withdraw from something one fears and this is exactly what highly communication apprehensive people tend to do. For example, high communication apprehension has been linked to lack of confidence (McCroskey, Day, & Sorenson, 1976), lowered interaction (Wells & Lashbrook, 1970), and feelings of isolation and ineffectiveness in social relationships (Lowe & Sheets, 40

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1951). Of particular importance to this study is the finding that communication apprehension and self-esteem are negatively related (McCroskey & Richmond, 1989: McCroskey et al., 1977; Stacks & Stone, 1982: Lustig, 1974; Snavely et al., 1976). These studies indicate that the presence of either high communication apprehension or low self-esteem is "highly" predictive of the other. McCroskey and Richmond ( 1989) discuss the concept "immediacy" as the degree of perceived physical or psychological closeness between two people. These immediacy behaviors may be verbal or nonverbal. Verbal messages indicate openness, friendship, or empathy with the other. Examples of nonverbal immediacy behaviors include eye behavior, facial expression, and body gestures. Highly apprehensive individuals have difficulty engaging in immediate behaviors and therefore do not communicate positive affect when communicating with others. This lack of positive affect is often interpreted as not liking the other person and there is a tendency for the other person to reciprocate by not liking them very much either. It becomes obvious, then, that high communication apprehension tends to lead to ineffective or limited communication. 41

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In sum, the literature suggests that high communication apprehensives may be less confrontive than those lower in apprehension. For purposes of this study the relationship between communication apprehension and the coping strategy of confrontation will be examined for cancer patients. Research Hypotheses In order to examine the relationships between physicians' communication styles and patients' coping strategies, the present study specifically hypothesized that: l. Patients will cope with the delivery of a cancer diagnosis in a more confrontive way when they perceive their physicians to demonstrate an affiliative communication style. 2. When patients perceive physicians to possess a more affiliative communication style, patients' overall satisfaction with the communication of the delivery of the life-threatening diagnosis of cancer will be higher. 3. For patients diagnosed with cancer, there will be a negative correlation between communication apprehension and the use of tactics related to the coping strategy called "confrontation." Chapter III, which follows, will further explicate these three hypotheses including specific operational defmitions. 42

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Summruy This chapter has included a review of academic literature relevant to the present study. The review was based primarily on writings in the disciplines of health communication, speech communication, clinical psychology, social psychology, and medical oncology. The on-line computer search was limited to literature published since 1980. When relevant to the study, earlier research has been included. In addition to literature drawn from the aforementioned disciplines, the following academic journals were used extensively: Journal of Health and Social Behavior, Social Science and Medicine, Patient Education and and a myriad of medical journals. The first section of the review presented literature related to six aspects of the research objective: 1) generalized physician-patient communication, 2) physician communication relevant to cancer patients, 3) physicians' communication styles, 4) the nature of the coping process, 5) specific literature relevant to the doctor-patient relationship in coping with cancer, and 6) an overview of communication apprehension. The second section outlined the three specific research hypotheses empirically tested in this present study. Chapter III, which follows, describes the methodology and research procedures employed in the study. A description of 43

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the instruments that were used in the study including their reliability and validity also is provided. 44

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CHAPTER III METHODOLOGY The purpose of this study was to examine the communication styles exhibited by physicians, as perceived by their patients, when delivering the life-threatening diagnosis of cancer and the relationship of the communication style to the coping strategies adopted by the patient. Chapter I provided general background to the study and rationale for its pursuit. Chapter II provided a review of academic literature relevant to the research problem and presented three research hypotheses that have been empirically tested. The present chapter describes the research methodology utilized to investigate the hypotheses. Specifically, this chapter includes a description of the research population, the overall research procedure and design, a description of how the sample and the hypotheses were operatlonalized, sampling plans and procedures, the measurement instruments and their reliability and validity, and statistical analyses and treatment of the data. 45

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Description of the Research Population The majority of the 52 respondents were white (94.2%) with females representing 73.1% of the sample. The majority (59.6%) were over age fifty-five. 36.5% reported their occupation as "retired," 25% were housewives, 19.2% in professional or management occupations, and 11.5% were considered clerical. The occupations of the remaining 7.6% of the sample were reported as military, student, or "other 46.2% reported an income ranging from $25,000 $50,000 with 36.5% under $25,000 and 13.%% greater than $50,000. 32.7% of the sample population reported that they had completed some college or technical school, 25% completed college, and 13.5% having completed graduate work. Most (94.2%) of the respondents knew what kind of cancer they were afflicted with but a surprising number (38.5o/o) did not know what stage their cancer was in. Although the type of cancer reported covered a wide range, 44% of the respondents reported having _breast cancer. The physician most frequently reported (44.2%) to have delivered the "bad news" of the cancer diagnosis was the surgeon with the oncologist representing 11.5% of the responses to that question. 5.8% had known about their illness for less than a month, 28.8% for one to six months, 15.4% for six months to a year, 13.5% for one to 46

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two years, and 34.6o/o had known about their illness for more than two years. 75o/o of the respondents considered their health to be "good" or "excellent." and Explication of the Hypotheses Methodologically, the present study represents an empirical investigation of the communication styles exhibited by physicians, as perceived by their patients, when delivering the life-threatening diagnosis of cancer and the relationship of these communication styles to subsequent coping strategies employed by the patient. This study built upon empirical research conducted by Feifel, Nagy, & Strack (1987) which focused on examining a range of variables considered pertinent in coping with medical illness. The psychological and behavioral correlates of three major coping strategies were used to examine medically ill patients in dealing with their illness. Subjects' coping responses were measured by a Medical Coping Modes Questionnaire (Feifel, Nagy, & Strack, 1986) developed to appraise three forms of coping: confrontation, avoidance, and acceptance-resignation. This present study focused on conceptualizing coping strategies and included denial, ventilation, impulsive behavior, and blaming as additional coping responses deemed to be important. Additional questions were 47

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included in the questionnaire utilized in this study to address behaviors considered to be inherent in these additional coping responses. General Explication of ( 1) The present study examined communication behaviors of physicians focusing on those behaviors that comprise a particular style. affiliativeness. As defined for this study. an affiliative communication style is one which utilizes behaviors that relay connectedness to the patient and leave her /him with a sense of self-satisfaction. The three behaviors in this study that comprised this affiliative communication style were: ( 1) the amount of sensitivity displayed toward the patient. (2) the degree of genuine caring that was communicated to the patient. and (3) the feeling of hope or optimism that was relayed to the patient. This study investigated the relationships between affiliative communication styles. as perceived by patients. and patients' coping resources when confronted with cancer diagnoses. ( 2) This study also suggested that a relationship exists between the physician's communication style as perceived by the 48

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patient and overall patient satisfaction with the way their physicians communicated the news of their illness to them. ( 3) This study simultaneously addressed different aspects of seven coping strategies in an attempt to more thoroughly conceptualize the coping process. The seven coping strategies operationalized in the questionnaire were confrontation, avoidance, acceptance-resignation, denial, ventilation, impulsive behavior, and blaming. The literature review suggested that life-threatening conditions may be a consequential factor in the way people cope with their situation. To increase the merit of this research, the sample was limited to a population of patients who have experienced the communication of the life-threatening diagnosis of cancer. ( 4) Finally, this study examined the communicationbound anxiety of the patients participating in the research. Rationale for including this measurement will be provided in the section on instrumentation. 49

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Overall Procedure and Research Desi"n In order to investigate three research hypotheses, the following procedures were followed: Hypothesis 1: To test for a systematic relationship between the communication style of the physician as perceived by the patient and subsequent coping strategies of the patient after receiving the life-threatening diagnosis of cancer, a 44-item Ukert-type questionnaire was constructed and distributed to cancer patients in three distinct population groups. The sample and questionnaire will be further described in the sampling plan and instrumentation sections to follow. To operationalize Hypothesis 1, the coping strategy referred to as confrontation was measured as a composite score of behaviors included in items 1, 2, 5, 8, 24, 28, 33, & 34. (See Appendix B) Examples of these questions are: 1) how much do you want to be involved in decisions regarding your treatments? 2) how often do you try to talk about your illness with friends or relatives? and 3) how much have you learned about your illness from talking with others who know something about it, such as doctors, nurses, etc.? The physician's affiliative communication style was operationalized by measuring three items in the questionnaire: 50

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9) the communication of genuine caring for the patient, 1 7) the amount of sensitivity exhibited, and 30) the degree of hope or optimism conveyed to the patient. Hypothesis 2: To test the relationship of a more affiliative communication style utilized by a physician when telling a patient for the first time that she/he has cancer to patients' overall satisfaction with the communication of this lifethreatening diagnosis, the 44-item Likert-scale questionnaire was again employed. To operationalize Hypothesis 2, the physician's aftlliative communication style was again the composite of items 9, 17, and 30: the amount of sensitivity disclosed, how much genuine caring was communicated, and the amount of hope transmitted to the patient. The patient's overall satisfaction with the communication of her /his cancer diagnosis was measured in a single-item question on the questionnaire, item 44. Hypothesis 3: To test for a negative relationship between communication apprehension and the use of tactics or behaviors related to the coping mode called confrontation, the Personal Report of Communication Apprehension (McCroskey, 1970) was selfadministered concurrently with the 44-item questionnaire. 51

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Rationale for including this instrument will be described in the instrumentation section to follow. To operationalize Hypothesis 3, the PRCA-24 was scored as indicated by McCroskey ( 1970) and the coping strategy called "confrontation" became the composite of behaviors measured by items 1, 2, 5, 8, 24, 28, 33, & 34. Research Plan: Questionnaires were distributed to fifty-two male and female cancer patients over eighteen years of age, both male and female. The participants self-selected themselves into the sample pool which included three separate groups: 1) new and recurring patients at the Cancer Center of Colorado Springs, 2) cancer patients receiving radiation therapy at the Penrose/St. Francis Healthcare System, and 3) cancer patients involved in two designated support groups. All of these population groups were located in metropolitan Colorado Springs, Colorado. Questionnaires were distributed to all interested cancer patients in the three groups. Consent forms were completed to satisfy conditions of the Human Subjects Committee at the University of Colorado at Colorado Springs. To insure anonymity, patients were instructed to return consent forms separately in a designated folder. The 44-item questionnaire and the PRCA-24 52

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were subsequently returned to the researcher in self-addressed stamped envelopes (see Appendix A for complete questionnaire). Instrumentation and Measurement The instruments utilized in this study were 1) a questionnaire developed specifically for this study, and 2) the Personal Report of Communication Apprehension (PRCA-24). The study's 44-item Likert-scale questionnaire was carefully developed with the help of physicians, health care workers, and experts in the area of communication. The involvement of these experts in the development of the questionnaire was solicited to improve the content or face validity of the instrument. Nineteen of the questions in the questionnaire were derived from the Medical Coping Modes Questionnaire (Feifel, Nagy, & Strack, 1986). The existing four-point scale in the Medical Coping Modes Questionnaire was converted to a fivepoint Likert-scale in order to improve statistical analysis. The additional twenty-five questions were constructed and incorporated into the questionnaire, The alpha coefficients for the Medical Coping Modes Questionnaire were 70 for the confrontation scale, .66 for the avoidance scale, and .67 for the 53

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acceptance-resignation scale. Billings & Moos (1984) have noted that generally lower internal consistency estimates may be expected for coping scales since one or two coping resources may alleviate stress and thus reduce the use of alternative responses within the same category (p. 881). The Personal Report of Communication Apprehension was developed by McCroskey in 1970 to measure communicationbound anxiety. The reliability of all versions of the instrument is very high, usually above .90 (McCroskey, 1984). Additionally, there is overwhelming evidence for the validity of this instrument to measure the construct of oral communication apprehension (McCroskey, 1978). The rationale for using the PRCA-24 in this study exists in previous research which relates communication apprehension to several different personality traits and the construct of self-esteem. Data Collection A total of 160 subject packets were distributed to sites representing the three groups in this study's sample pool: 1) the Cancer Center of Colorado Springs, 2) Radiation Therapy Department at the Penrose Healthcare System, and 3) the Penrose Cancer Program. At this last site, Usa Noll and Jean Smith (oncology R.N.s) together with Sally Kinney (oncology 54

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social worker) delivered packets to the two support groups chosen for this study, namely a Breast Cancer Support Group and a hospital-based support group comprised of mixed diagnoses, needs, and concerns. Fifty-two completed packets were returned. Data Analysis Pearson correlation coefficients were calculated for the following: Hypothesis 1: each participant's composite score for the coping strategy of confrontation was correlated with each participant's composite score for affiliative communication style; Hypothesis 2: each participant's composite score for affiliative communication style was correlated with each participant's overall satisfaction with the communication of her /his cancer diagnosis; Hypothesis 3: each composite score for the coping strategy of confrontation was correlated with each participant's total PRCA score. To test for additional interaction effects, stepwise multiple regression was utilized. Additionally, each participant's total PRCA score was correlated with those items determined to be verbal confrontive behaviors. 55

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Surornruy This chapter has described the methodology and research procedures employed in this study. The first two sections provided an introduction to the overall procedure and described the research design. The next two sections discussed the sampling plan and outlined the instrumentation that was utilized with the attendant reliability and validity. Next, procedures used in collecting raw data were outlined. The final section described the statistical treatment of that data. Chapter IV, which follows, presents the results of the research procedures described in Chapter III. 56

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CHAPTER IV RESULTS The general purpose of this study was to examine a possible correlative relationship between an affiliative communication style utilized by physicians and 1) a coping strategy this study has called "confrontation," as well as 2) patients' overall satisfaction with the communication of the delivery of the life-threatening diagnosis of cancer. This study also examined a possible negative relationship between the communication apprehension of patients diagnosed with cancer and the use of tactics related to the coping strategy called confrontation. First, Chapter I provided background to the study of the doctor-patient relationship, physician communication and cancer patients, and the present nature of the coping process. Chapter II reviewed the academic literature relevant to the background of this study with additional sections related to coping with cancer, physician communication styles, and 57

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communication apprehension. At the end of the review of the literature, it was specifically hypothesized that : 1. Patients will cope with the delivery of a cancer diagnosis in a more confrontive way when they perceive their physicians to demonstrate an affiliative communication style. 2. When patients perceive their physicians to possess a more affiliative communication style, patients' overall satisfaction with the communication of the delivery of the life-threatening diagnosis of cancer will be higher. 3. For patients diagnosed with cancer, there will be a negative correlation between communication apprehension and the use of tactics related to the coping strategy of confrontation. Chapter III, the methodology section of this study, first described the research population. Second was an explanation of the overall research procedure and design and how the hypotheses were operationalized. Next, research procedures for investigating the hypotheses were described. The present chapter, Chapter IV, describes the results of the data collection and the analysis. The data generated by this investigation were analyzed using Pearson correlations and stepwise multiple 58

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regression. The results of the data analysis process are presented without interpretation in this chapter. Discussion, interpretation, and conclusions are presented in Chapter V. Primruy Analyses Hypothesis 1 Hypothesis 1 specifically stated that: Patients will cope with the delivery of a cancer diagnosis in a more confrontive way when they perceive their physicians to demonstrate an affiliative communication style. As described in the methodology chapter, data from a 44 item Likert-type questionnaire was used to investigate Hypothesis 1. The coping strategy referred to as confrontation was measured as a composite score of behaviors comprised of items 1, 2. 5. 8. 24. 28. 33. & 34. The afflliative communication style of physicians was measure as a composite score of items 9. 17. & 30. Pearson correlation coefficients were calculated on each subject's composite score for the coping strategy "confrontation" and each subject's composite score for affuiative communication style. The statistical analysis of the data regarding Hypothesis 1 is presented in Table 4.1. 59

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Table 4.1 Correlation coefficients: strateeY of confrontation and physicians' affiliative communication style. QQwog Sll:illf!gX V1 V2 V5 V2 .036 V5 .173 .250 VB .on .121 -.057 V24 .094 .230 .36B** V2B .27B* .043 .157 V33 .290* .063 .146 V34 -.091 .522** .047 Confront .399 .577** .537** V9 .019 -.OBO .053 V17 .07B -.146 .139 V30 .072 -.1B1 .167 AFFIL .060 -.164 .144 Affi!iatjye Style ttems V9 V17 V30 V17 .699** V30 .589** .501** AFFIL .895** .849** .B15** VB .090 .044 .175 -.021 .406** .052 -.055 -.150 -.037 P< .05 **p< .01 .tmli: See Appendix B for variable labels. V24 .OB2 .26B .034 .561** -.084 .15B .004 .019 N-50 Composite Sg;u V2B V2B V34 Confront .215 .170 .027 .497** .517** .464** -.027 -.059 -.955 -.044 -.023 .142 -.167 .023 .10B .136 -.051 .021 .019 .OB7 -.105 .001 Results in Table 4.1 indicate that Hypothesis 1 was not supported (r=.OOI). None of the variables included in the coping strategy of confrontation were correlated with afffiiative style. Hypothesis 2 Hypothesis 2 specifically stated that: When patients perceive their physicians to possess a more affiliative communication style, patients' overall satisfaction with the 60

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communication of the delivery of the life-threatening diagnosis of cancer will be higher. Data from the 44-item questionnaire were again used to investigate Hypothesis 2. The affiliative communication style of physicians again was measured as a composite score of items 9, 17, and 30. The patient's overall satisfaction with the communication of her /his cancer diagnosis was measured using a single-item question, item 44. Pearson correlation coefficients were calculated on each subject's composite score for affiliative communication style and for patient satisfaction .. The statistical analysis of the data regarding Hypothesis 2 is presented in Table 4.2. Table 4.2 Correlation coefficients: Physicians' affiliative communication style and patient satisfaction. N =51 V9 Vl7 V30 AFFIL Patient Satisfaction V44 .618** .722** .624** .766** Afllliative Style Items V9 Vl7 .699** .589** .895** .501** .849** *p <.05 **p <.01 Nma: See Appendix B for variable labels. 61 V30 .815**

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As Table 4.2 indicates, Hypothesis 2 is strongly supported (p< .01). The three items composing physician affiliative communication style: 1) the amount of sensitivity displayed towards patient, 2) the degree of genuine caring that was communicated to the patient, and 3) the feeling of hope that was relayed to the patient, were individually significant and the composite score produced the highest correlative relationship. Hypothesis 3 Hypothesis 3 specifically stated that: For patients diagnosed with cancer, there will be a negative correlation between communication apprehension and the use of tactics related to the coping strategy of confrontation. Pearson correlation coefficients were calculated to establish relationships between participant's PRCA score and each participant's composite score of the coping strategy of confrontation. As described earlier in. the methodology chapter, the Personal Report of Communication Apprehension (McCroskey, 1970) was self-administered concurrently with the 44-item questionnaire. The PRCA-24 was scored as indicated by McCroskey (1970) and the coping strategy called "confrontation" 62

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was again the composite of behaviors measured by items 1, 2, 5. 8, 24, 28, 33, & 34. The statistical analysis regarding Hypothesis 3 is presented in Table 4.3. Table 4.3 and Qf N-47 Composite PRCA fBQ.! Sh!mll!li prca grp meet conver pubspk grp .786** meet .894** .694** conver .725** .405** .499** pubspk .775** .372** .627** .466** V1 -.246 -.132 -.215 -.375** -.082 V2 -.125 -.162 -.032 -.058 -.144 V5 .154 .122 .189 -.025 .187 V8 .329* .289* .369* .131 .240 V24 -.067 -.095 .064 -.059 -.130 V28 -.398** -.184 -.370* -.389** -.338* V33 .146 .074 .105 -.389** .246 V34 -.238 -.329** -.216 -.093 -.092 Confront -.080 -.080 .005 -.174 -.022 CcpirQ Strategy Items V1 V2 V5 V8 V24 V28 V33 V34 V2 .036 V5 .173 .250 V8 .077 .121 -.057 V24 .094 .230 .368** .090 V28 .278* .043 .157 .044 .082 V33 .290* .063 .146 .175 .268 .215 V34 -.092 .522** .047 -.021 .034 .170 .027 Confront .399** .577** .537** .406** .561** .497** .517 .464** *p<.05 **p< .01 Nma: See Appendix B for variable labels. 63

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In summary, the correlative relationship between the PRCA-24 and the coping strategy "confrontation" was not significant and Hypothesis 3 was not supported using the confrontive behaviors derived from the Medical Coping Modes Questionnaire (Feifel, Nagy, & Strack, 1986). Supplemental Analyses Quantitative Data In addition to the Pearson correlations used to initially investigate the hypotheses, other statistical procedures were considered as a result of the primary fmdings. Stepwise multiple regression was utilized to investigate further interactions in this study not evident in the primary statistical procedures. This additional statistical analysis is presented in Table 4.4. Table 4.4 Stepwise multiple Patient satisfaction with communication. a{filiative communication style and combined effect of affiliative style x Communication Apprehension. Step MultR Rsq AdJRsq F(eqn) SigF RsqCh FCh SigCh 1 .768 .590 .581 64.99 .000 .590 64.99 .000 3 .777 .605 .577 21.953 .000 .014 .701 .471 Variable Betaln Correl In AFFIL .768 .768 In PRCA -.0885 -.008 IN X2 .442 .475 Note: Dependent variable = Patient satisfaction with communication Independent variables = Affiliatlve communication style and the combined effect of the afilliatlve style x the PRCA. 64

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The Stepwise multiple regression which tested the main effects of afflliative communication style, communication apprehension (PRCA), and the interaction between affiliative communication style and communication apprehension on patient satisfaction yielded an overall significant equation. Examination of the R square changes and F ratios associated with the R square changes revealed that the only significant predictor of patient satisfaction was the affiliative communication style of physicians as perceived by their patients. Alpha coefficients obtained for the 1) the coping strategy called "confrontation," 2) the physician affiliative style, and 3) the PRCA-24 are .51, .82, and .93 respectively. The coefficient alpha of .51 obtained for the coping strategy called "confrontation" may be considered low but may be explained by the fact that coping strategies are not considered to be as stable as personality traits (Feifel, Strack and Nagy, 1987). Billings and Moos ( 1984) noted that lower internal consistency estimates may be expected for coping scales since "one or two coping responses may alleviate stress and thus reduce the use of alternative responses within the same category" (p. 881). Additional Pearson correlations were used to analyze the relationships of six specific verbal communication variables contained in the confrontation coping construct with the PRCA 65

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and as patient satisfaction with the communication of their "bad news". (See Appendix C for detalled explanation of specific items in questionnaire). Table 4.5 presents the results of this statistical analysis. Upon examining these verbal communication behaviors individually, one significant relationship (p<.05) indicates that the higher the PRCA score of the patient (the more communication apprehensive she/he is), the less she/he talks when asked about their illness. Table 4.5 Correlation coefficients: Communication Apprehension. Patient Satisfaction. Verbal Variables. N = 47 Composite PRCA V2 V5 V24 V33 V34 V2 -.1258 V5 .1544 .2509 V24 -.0674 .2309 .3689 .. V33 .1468 0635 .1465 .2685 V34 -.2383 .5222** .0474 .0341 .0278 V42 -.3084* .4871** .0516 .9167 -.0159 .4653 V44 -.008 *p<.05 **p <.01 Note: V44 = patient satisfaction See Appendix C for Verbal Confronttve Variable labels Qualitative Data In addition to completing the 44-item questionnaire and the PRCA-24, five respondents submitted additional handwritten responses or short letters which further explicated their 66

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individual experiences concerning the delivery of their cancer diagnoses. This information adds a richness to the data collection and adds credibility to the rationale for this study as discussed in Chapter I. This qualitative data will be discussed in more detail in Chapter V. Summazy This present chapter presented the results of this study. The research findings were organized into two sections. The first section included primary analyses related directly to the investigation of the three main hypotheses. The findings of the study supported Hypothesis 2. but failed to support Hypotheses 1 and 3. The second section included supplementary statistical analyses deemed necessary to clarify the results of the primary investigation. These findings provided partial support for Hypothesis 3 when the verbal confrontive behaviors were examined. The following chapter, Chapter V. provides interpretation of the findings and discusses the results of the study. Finally, problems and limitations of the present study are outlined along with suggestions for future research. 67

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CHAPTER V DISCUSSIONS, INTERPRETATIONS, AND CONCLUSIONS The purpose of this study was to empirically examine 1) the communication styles exhibited by physicians, as perceived by their patients, when delivering the life-threatening diagnosis of cancer, and 2) the relationship of the physician's communication style to the coping strategies adopted by the patient. There were 52 volunteer subjects in the sample pool who completed 1) a 44-item Likert-scale questionnaire, and 2) the Personal Report of Communication Apprehension. The findings of this study supported Hypothesis 2 regarding patients' satisfaction with the communication of their cancer diagnosis, but failed to support Hypotheses 1 and 3. Hypothesis 1 examined the relationship ofphysicians' communication styles to the coping strategies adopted by patients after receiving the "bad news" of their cancer diagnosis. Hypothesis 3 examined the relationship of the patients' level of communication apprehension to the coping strategy called "confrontation." 68

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Supplemental statistical analyses provided partial support for Hypothesis 3 when verbal confrontive behaviors were examined. Chapter I provided background and rationale for the present study. Chapter II reviewed academic literature related to six aspects of the study: 1) generalized physician-patient communication, 2) physician communication relevant to cancer patients, 3) physician-communication style, 4) the nature of the coping process, 5) coping with cancer, and 6) an overview of communication apprehension. Three research hypotheses were presented at the conclusion of Chapter II. Empirical methodology, procedures, and instrumentation for the investigation of these hypotheses were outlined in Chapter III. Chapter N presented results of the investigation of the three hypotheses including findings of supplemental analysis. This final chapter, Chapter V, provides a summary of the findings regarding primary and supplemental analyses, and interpretation and conclusions regarding results. Problems and limitations of the study are presented and suggestions for future research are offered. 69

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Summazy of the Primazy Results Hypothesis 1 specifically stated that: Patients will cope with the delivery of a cancer diagnosis in a more confrontive way when they perceive their physicians to demonstrate an afflliative communication style. Results failed to support this hypothesis. Hypothesis 2 specifically stated that: When patients perceive physicians to possess a more afflliative communication style, patients' overall satisfaction with the communication of the delivery of the life-threatening diagnosis of cancer will be higher. Hypothesis 2 was supported. Hypothesis 3 specifically stated that: For patients diagnosed with cancer, there will be a negative correlation between communication apprehension and the use of tactics related to the coping strategy of confrontation. When utilizing the Medical Coping Modes Questionnaire operationalization of coping, Hypothesis 3 was not supported. When only verbal behaviors were correlated to PRCA scores, the hypothesis was partially supported. Qualitative data. Additionally, five respondents voluntarily submitted handwritten responses attached to their completed questionnaires. This data support the research that has linked 70

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patients' satisfaction with health care to the communication styles of physicians. All five respondents were dissatisfied with the way the news of their cancer diagnosis was relayed to them, indicating that the physician's verbal communication and lack of sensitivity and/ or caring were responsible for this dissatisfaction. Examples of statements made are: 1) "Mrs. __ it is cancer, but it's not the end of the world"; 2) "Dr. told me I had less than a fifty-fifty chance of recovery ... After Dr._ left town, I was referred to another oncologist and twelve years later, I am still alive"; 3) "I was disappointed with the extent that my doctor genuinely appeared to care for me. I shared this with him and he appreciated that input." Assessment of Results Hypothesis 1: The frrst underlying assumption of this study was that there is a positive relationship between physicians' communication styles, as perceived by their patients, and patients' coping behavior. Specifically, the assumption was made that patients will cope with the delivery of a cancer diagnosis in a more confrontive way when their physicians demonstrate an affiliative communication style. According to Buller and Buller (1987), this affUiative style is composed of communication 71

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behaviors that serve to establish and maintain a positive relationship between physician and patient. This style, therefore, appears to be desirable. However, the concept of "coping" is extremely complex and the choice of a specific strategy appears to be multidetermined. This complexity may also be responsible for the lack of statistical relationships for Hypothesis 1. Although the basic assumption of Hypothesis 1 was not statistically supported, other correlations were significantly related and deserve discussion. The more often patients reported asking their doctor for advice concerning their illness, the more they felt they had learned about their illness from talking to those who have the expertise (p<.Ol). Patients also reported wanting to be more involved in decisions regarding their treatments (p<.05) when two things occurred: 1) as they learned more about their illness from reading books, magazines, or newspapers: and 2) as questions about their illness to their doctors increased. Hypothesis 2: The second underlying assumption for this study was that when patients perceive their physicians to possess a more afflliative communication style, patients' overall satisfaction with the communication of the delivery of their cancer diagnosis will 72

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be higher. This relationship has been reported in the literature and was statistically significant in this study as expected. In considering the results of the investigation of Hypotheses 1 and 2 as a whole. a summative finding emerges. The physician's communication style has an impact on an immediate variable or factor, that is, the patient's sense of satisfaction with the communication interaction with the physician. The relationship between physician cmnmunication style and patient satisfaction does not appear to extend to a variety of later events such as communication with others or later coping strategies of the patient. Hypothesis 3: The third underlying assumption in this study was that for patients diagnosed with cancer, there will be a negative correlation between communication apprehension and the use of tactics related to the coping strategy of confrontation. The primary results indicated a failure to support this assumption. The behaviors comprising "confrontation" were derived from the Medical Coping Modes Questionnaire. The reliability of all versions of the PRCA is very high and there is overwhelming evidence for the validity of the instrument. The high reliability obtained in this study (.93) indicates that questions in this instrument were not misinterpreted. The complexity of the 73

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coping strategy of confrontation as operationalized in the Medical Coping Modes Questionnaire may again be responsible for the lack of significant statistical findings for a relationship that theoretically appears to be obvious. The Medical Coping Modes Questionnaire confrontation construct contains behaviors not specifically confined to oral communication behaviors. Although not significant as a total entity, the coping strategy of confrontation contains two items that are statistically related to communication apprehension in this study. As an individual's communication apprehension increased, she/he learned less about her /his illness from reading books, magazines, or newspapers (r=-.40, p<.Ol). Patients also reported thinking about certain things in their lives in a more positive way as their communication apprehension increased (r=.33, p<.05). Upon further examination of the items comprising the coping strategy confrontation, it became obvious that the behaviors were not homogeneous. Some of the items were behavioral involving talking and asking questions, while other items were attitudinal such as thinking about certain things in your life in a more positive way. Supplemental analysis administered only to verbal confrontive behaviors provided partial support for the underlying assumption of Hypothesis 3. 74

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Problems and Limitations The first problem encountered in this study relates to the difficulty in obtaining the sample population. One physician group initially designated for distribution of the questionnaire became reluctant to become involved without more control over the questions and the targeted population. Additionally this reluctance was relayed to the researcher through the use of a third party. This occurrence confirms the call for more research concerning cancer and physician-patient communication as discussed in Chapter II. According to Lind and colleagues (1989), concerns about the psychological harm resulting from such a study of this patient group do not appear to be warranted. Patients in the Lind study, as well as in this present study, expressed the desire to contribute to improving the experience of future patients through participation in such research. The second problem of the present study, relating to methodology, has already been discussed in the assessment of results for Hypotheses 1 and 3. This problem has to do with the scope and complexity of the coping strategy called "confrontation." This problem could be twofold: 1) there may have been a possible inadequacy of the test instrument to assess the communication behaviors determined to comprise 75

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"confrontation," or 2) as Billings and Moos (1984) note, lower internal consistency estimates may be expected for coping scales since one or two coping responses may be helpful in alleviating stress and thus reduce the use of alternative responses within that same category. If this reasoning is accurate, this problem may be difficult to alleviate in future studies that involve the concept of coping. Umitations of this study include specifics of the sample population: 1) 59.6% of the respondents were over age 55: 2) the sample pool was a volunteer group rather than a random sample: and 3) females represented 73.1% of this sample. Additionally, the consideration must be made that when faced with a life-threatening illness such as cancer, patients might not initially react and cope in ways that they would normally cope with negative life events. for Future Research Two suggestions for future replication of the present study speak to the methodological problems. First, future researchers need to explore varying ways of operationalizing and conceptualizing the coping strategy of confrontation. This may prove to be a difficult task as was discussed earlier in this chapter. The suggestion is offered to be aware of blending items 76

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of a more homogeneous nature into the coping strategy of confrontation. For example, separating behavioral items from attitudinal items may prove productive and subsequently improve the reliability of its application in future studies. A second suggestion for future replication relates to a limitation of this study, the age of the sample population. 59.6% of the respondents in this study were over age fifty-five. Future researchers might want to consider using a sample population representative of a broader age span. Summazy This present study investigated 1) the communication styles exhibited by physicians, as perceived by their patients, when delivering the life-threatening diagnosis of cancer and 2) the relationship of these communication styles to the coping strategies adopted by the patient. This study was based on an assumption that the affective component of the physician's communication style may be a major factor in helping patients cope with their cancer. Research findings supported the assumption that when physicians possess a more affiliative communication style, patients' overall satisfaction with the communication of their cancer diagnosis would be higher. However, the study was not able to support the assumption that 77

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patients will cope with the delivery of a cancer diagnosis in a more confrontive way when their physicians demonstrate an afflliative communication style. An individual's ability to cope with negative life events, as developed over their life span, may remain the dominant factor in coping with such a stressful, frightening illness. Additionally, for patients diagnosed with cancer, when using behaviors related to the coping strategy of confrontation as derived from the Medical Coping Modes Questionnaire, the fmdings did not support the assumption that there would be a negative correlation between communication apprehension and coping. However, when only verbal confrontive behaviors were examined, this underlying assumption was partially supported. 78

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APPENDIX A 79

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CONSENT FORM Thank you for volunteering to participate in a study examining communication between physicians and their patients and how this relates to dealing with illness. Below you will find a description of the study and an explanation of your rights as a research subject. In accordance with the policies of the University of Colorado, we ask that you read this information carefully and sign in the space provided indicating that you have read and understand this information. To maintain anonymity, return this consent form separately to the folder available. I am a graduate student in the Department of Communication at the University of Colorado at Colorado Springs and I have worked in the healthcare field for several years. This study has been designed to provide valuable information about the needs and concerns of patients regarding communication with their physicians. Certain rights are guaranteed to you as a research subject. Rrst, you can be assured that all the information that you provide on the questionnaire will be kept strictly confidential. Secondly, your decision regarding whether or not to participate will .em. affect your health care or treatment at this medical facility in any way, and thirdly, it is your absolute right to terminate the questionnaire at any point that you wish. Return the questionnaire as soon as possible to the researcher in the self addressed envelope. Do not put your name on the questionnaire. Again, I am suggesting that you return the consent form separately to the folder available to maintain anonymity. If you have any questions about the study or concerning your participation, please call me at 635-4642 or contact my advisor, Dr. Pamela Shockley, at 593-3159. Your contribution to this effort is greatly appreciated. If you would like a summary of the results, please print your name and address on the back of the return envelope and I will see that you receive it. The results will also be available in the Communication Department at the University of Colorado, Colorado Springs, by Summer 1992. Participant 80 Sincerely, Beth Zautke, MT (ASCP) Penrose Hospital Laboratory Graduate Teaching Assistant (UCCS)

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PARI 1: BACKGROUND INEOBMAJ!ON Please respond to the following questions by circling the appropriate answer or by filling in the blank. 1 What is your age? 1 18-30 years of age 2. 31-40 years of age 3 41-55 years of age 4. over 55 years of age 2. What is your sex? 1. Male 2. Female 3. What is your ethnic background? 1. Asian 2. Black 3. Hispanic 4. White 5. Other -------4. What is your family income? 1 Less than $15,000/year 2. $15,001 $25,000/year 3. $25,001 $50,000/year 4. Greater than $50,000/year 5. What is level you completed in school? 1 Less than high school graduate 2. High school graduate 3. Some college or technical school 4. Completed technical school 5. Completed college 6. Graduate work 6. Whatisyouroccupation? -------------------7. Do you know what kind of cancer you have? Yes __ r-b __ H you answered yes, what kind? _____________ 8. Approximately how long ago were you informed of your illness? 1 Less than one month 2. One to six months 3. Six months to one year 4. One to two years 5. More than two years 81

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9. The doctor who communicated the news of your illness to you has a speciality in? 1. Family Practice 2. Internal Medicine 3. Surgery 4. Gynecology 5. Oncology 6. ------------------7 Don'tknow 1 0. In what stage is the cancer? 1. Stage I 2. Stage II 3. Stage Ill 4. Stage IV 5 Don't know 11. How do you currently view your health status? 1 Excellent 2. Good 3. Fair 4. Poor 5. Don't know 82

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PART II: DIRECTIONS: Listed below are several questions asking about your typical thoughts, feelings, and behaviors as they relate to your current illness. Please indicate your answer by circling the number which corresponds to your response choice. 1. How much do you want to be involved in decisions regarding your treatments? 1 2 3 4 5 A great deal Vtary much Some Very little Not at all 2. How often do you try to talk about your illness with friends or relatives? 1 2 3 4 5 Never Infrequently Occasionally Frequently All the time 3. In conversations about your illness, how often do you find yourself thinking about other things? 1 2 3 4 5 Never Infrequently Occasionally Frequently All the time 4. How often do you feel there is really no hope for your full recovery? 1 2 3 4 5 All the time Frequently OccasionaUy Infrequently Never 5. In the past few months, how much have you learned about your illness from talking with others who know something about it, such as doctors, nurses, etc.? 1 2 3 None Very little Some 4 Very much 6 How often do you feel that you don't care what happens to you? 1 2 3 4 Never Infrequently Occasionally Frequently 5 A great deal 5 All the time 7. To what extent do you talk to your friends and your family because you won't have to think about your illness? 1 Not at all 2 Very little 3 Some 4 Very much 5 A great deal 8. How much has your illness caused you to think about certain things in your life in a more positive way? 1 2 3 4 5 Not at all Very little Some Very much A great deal 9. When you were told about your illness, to what extent did you feel that your doctor genuinely cared about you? 1 2 A great deal Very much 3 Some 4 Very little 5 Not at all 1 0. When you were informed of your illness, how much time did your doctor spend with you? 1 2 3 4 5 A great deal Very much Some Very little Not at all 11. To what extent do you think that someone or something is responsible for your illness? 1 2 3 4 5 Not at all Very little Some Very much A great deal 12. To what extent have you decided that there is really nothing physically wrong with you? 1 2 3 4 5 83

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Not at all Very little Some Very much A great deal 13. Since you have been informed of your illness, have you purchased items without planning to do so? 1 2 3 4 5 Never Infrequently Occasionally Frequently All the time 14. Since you have been aware of your illness, how often have you cried? 1 2 3 4 5 Never Infrequently Occasionally Frequently All the time 15. Since you have found out about your illness, how important has it been for you to join a support group? 1 2 3 4 5 Not at all Very little Some Very much A great deal 16. How much have you relied on spiritual resources, whether privately within yourself, or with your pastor or other Church members? 1 2 Not at all Very little 3 Some 4 Very much 5 A great deal 17. How sensitive was your doctor, in your opinion, when he/she informed you about your illness? 1 2 3 4 5 A great deal Very much Some Very little Not at all 18. When friends or close relatives try to talk to you about your illness, to what extent do you try to convince them that you aren, ill? 1 2 All the time Frequently 3 Occasionally 4 Infrequently 5 Never 19. Have you questioned your behavior about some of your decisions since you have been informed of your illness? 1 Not at all 2 Very little 3 Some 4 Very much 20. To what extent have you felt angry about having your illness? 1 2 3 Not at all Very little Some 4 Very much 5 A great deal 5 A great deal 21. How much have you felt that professional therapy would help you through this? 1 2 3 4 5 A great deal Very much Some Very little Not at all 22. When you were informed of your illness, to what extent did you feel that questions were encouraged by your doctor? 1 Not at all 2 Very little 3 Some 4 Very much 5 A great deal 23. When you think about your illness, how often do you try to distract yourself by doing something else? 1 2 3 4 5 All the time Frequently Occasionally Infrequently Never 24. How often do you ask your doctor for advice about what to do concerning your illness? 1 2 3 4 5 All the time Frequently Occasionally Infrequently Never 84

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25. When friends or relatives try to talk to you about your illness, how frequently do you try to change the subject? 1 2 Never Infrequently 3 Occasionally 4 Frequently 5 All the time 26. When you were informed of your illness, in your opinion, how much information was given by your doctor? 1 2 A great deal Very much 3 Some 4 Very little 5 None 27. Since you have known about your illness, how often have you had an argument with your spouse, children, or close friend? 1 2 Not at all Very little 3 Some 4 Very much 5 A great deal 28. In the past few months, how much have you learned about your illness from reading books, magazines, or newspapers? 1 2 A great deal Very much 3 Some 29. How often do you feel like giving in to your illness? 1 2 3 All the time Frequently Occasionally 4 Very little 4 Infrequently 5 None 5 Never 30. When you were informed of your illness, to what extent were you left with a feeling of hope? 1 2 3 4 5 Not at all Very little Some Very much A great deal 31. Since you have known about your illness, to what extent have you become controlling of your close friends or relatives? 1 2 Never Infrequently 3 Occasionally 32. To what extent do you try to forget about your illness? 1 2 3 Not at all Very little Some 4 Frequently 4 Very much 33. To what extent have you questioned your doctor about your illness? 1 2 3 4 Not at all Very little Some Very much 5 All the time 5 A great deal 5 A great deal 34. When you meet someone with your kind of illness, how much do you talk about the details of the illness? 1 Not at all 2 Very little 3 Some 4 Very much 5 A great deal 35. Since you have known about your illness, how often do you find yourself more irritable than usual with close friends or relatives? 1 2 All the time Frequently 3 Occasionally 4 Infrequently 5 Never 36. Since you have been informed of your illness, have you done some things without thinking and have regretted doing them later? 1 2 Not at all Very little 3 Some 85 4 Very much 5 A great deal

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37. To what extent do you feel that your doctor invited your participation in you treatment decisions? 1 2 3 4 5 A great deal Very much Some Very little Not at all 38. Since you have known about your illness, to what extent are you demanding of your close friends or relatives? 1 2 Never Infrequently 3 Occasionally 4 Frequently 5 All the time 39. Since you have known of your illness, have there been times that you have questioned your judgment? 1 2 Never Infrequently 3 Occasionally 4 Frequently 5 All the time 40. How often do you go to the movies or watch TV in order not to think about your illness? 1 2 3 4 5 Never Infrequently Occasionally Frequently All the time 41. To what extent do you feel there is nothing you can do about your illness? 1 2 3 4 5 A great deal Very much Some Very little Not at all 42. When close relatives or friends ask you about your illness, how often do you talk to them about it? 1 2 3 4 5 All the time Frequently Occasionally Infrequently Never 43. When you were informed about your illness, what amount of optimism was expressed by your doctor concerning the successful treatment of your illness? 1 2 3 A great deal Very much Some 4 Very little 5 None 44. How satisfied are you with the way your doctor communicated the news of your illness to you? 1 2 3 4 5 Not at all Very little Some Very much A great deal 86

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DIRECTIONS: This instrument is composed of 24 statements concerning your feelings about communication with other people. Please indicate by circling the appropriate number, the degree to which each statement applies to you There are no right or wrong answers. Work quickly, just record your first impression. Strongly Strongly Agree Agree Undecided Disagree Disagree 1 2 3 4 5 1. I dislike participating in group discussions 2 3 4 5 2. Generally, I am comfortable while participating in a group discussion. 2 3 4 5 3. I am tense and nervous while participating in group discussions. 2 3 4 5 4. I like to get involved in group discussion. 2 3 4 5 5. Engaging in a group discussion with new people makes me tense and nervous. 2 3 4 5 6. I am calm and relaxed while participating in group discussions 2 3 4 5 7. Generally, I am nervous when I have to participate in a meeting. 2 3 4 5 8. Usually I am calm and relaxed while participating in meetings. 2 3 4 5 9. I am very calm and relaxed when I am called upon to express an opinion at a meeting. 2 3 4 5 10. I am afraid to express myseH at meetings. 2 3 4 5 11. Communicating at meetings usually makes me uncomfortable. 2 3 4 5 12 I am very relaxed when answering questions at a meeting. 1 2 3 4 5 13 While participating in a conversation with a new acquaintance, I feel very nervous. 2 3 4 5 14. I have no fear of speaking up in conversations. 2 3 4 5 15. Ordinarily I am very tense and nervous in conversations. 87

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2 3 4 5 16 Ordinarily I am very calm and relaxed in conversations. 2 3 4 5 17. While conversing with a new acquaintance, I feel very relaxed. 2 3 4 5 18. I'm afraid to speak up in conversations. 1 2 3 4 5 19. I have no fear of giving a speech. 2 3 4 5 20. Certain parts of my body feel very tense and rigid while giving a speech. 2 3 4 5 21. I feel relaxed while giving a speech. 2 3 4 5 22. My thoughts become confused and jumbled when I am giving a speech. 2 3 4 5 23. I face the prospect of giving a speech with confidence. 2 3 4 5 24. While giving a speech I get so nervous, I forget facts I really know. 88

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APPENDIX B 89

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Confrontation Copin2 StratefZY Variables V2 How often do you try to talk about your illness with friends or relatives? V 5 In the past few months, how much have you learned about your illness from talking with others who know something about it, such as doctors, nurses, etc.? V8 How much has your Ulness caused you to think about certain things in your life in a more positive way? V24 How often do you ask your doctor for advice about what to do concerning your illness? V28 In the past few months, how much have you learned about your illness from reading books, magazines, or newspapers? V33 To what extent have you questioned your doctor about your illness? V34 When you meet someone with your kind of illness, how much do you talk about the details of the illness? (Feifel. Nagy, & Strack, 1986) Affiliative Style Variables V9 When you were told about your illness, to what extent did you feel that your doctor genuinely cared about you? V 17 How sensitive was your doctor, in your opinion, when he/she informed you about your illness. V30 When you were informed of your illness. to what extent were you left with a feeling of hope? 90

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,.-' I I I APPENDIX C 91

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Verbal Communication Confrontive Behaviors V2 How often do you try to talk about your illness with friends or relatives? VS In the past few months, how much have you learned about your illness from talking with others who know something about it such as doctors, nurses, etc.? V24 How often do you ask your doctor for advice about what to do concerning your illness? V33 To what extent have you questioned your doctor about your illness? V34 When you meet someone with your kind of illness, how much do you talk about the details of the illness? V 42 When close relatives or friends ask you about your illness, how often do you talk to them about it? 92

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Brody, D.S. (1980). The patient's role in clinical decision making. Annals of Internal Medicine, 93, 718-722. Bronner-Huszar, J. (1971). The psychological aspects of cancer in man. Psychosomatics, 12, 133-138. Buller, M. K., & Buller, B. D. (1987). Physicians' communication style and patient satisfaction. Journal of Health and Social Behavior, 2.a. 375-388. Burgoon, M., Parrott, R., Burgoon, J.K., Coker, R., Pfau, M., & Birk, T. (1990). Patients' severity of illness, noncompliance, and locus of control and physicians' compliance-gaining messages. Health Communication, 2(1}, 29-46. Burish, T. G., & Lyles, J. N. (1983). Coping with the adverse effects of cancer treatments. InT. G. Burish & L.A. Bradley (Eds.), with chronic disease, (pp. 159-189). New York: Academic. Carmines, E. G., & Zeller, R. A. (1979). Reliability and validity assessment. Beverly Hills, CA: Sage Publications. Caplan, G. ( 1964). Principles of preventive psychiat:Iy. New York: Basic Books. Collins, Mattie (1983). Communication in health care: The human connection in the life cycle. St. Louis, MO: Mosby. Coyne, J. C. & Holroyd, K. (1982). Stress, coping, and illness: A transactional perspective. InT. Millon, C. Green, & R. Meagher (Eds.), Handbook of clinical health (pp. 106-128). New York: Plenum. Craig, T. J., Comstock, G. W., & Geiser, P. B. (1974). The quality of survival in breast cancer: A case-control comparison. 1451-1457. Daly, M.B., & Hulka, B. S. (1975). Talking with the doctor, 2. Journal of Communication, 25, 148-152. 95

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Hopper, S. V., & Fischback, R. L. (1989). Patient-physician communication when blindness threatens. Patient Education and Counselin2. 14, 69-79. Howell-Karen, P. R., & Tinsley, B. J. (1990). The relationships among maternal health locus of control beliefs and expectations, pediatrician-mother communication, and maternal satisfaction with well-infant care. Health Communication, 233-253. Hoy. A. M. (1985). Breaking bad news to patients. British Journal of Hospital Medicine, 96-99. Ivic, R. L .. (Ed.). (1990). Communication in medical consultations: A review essay. Quarterly Journal of Speech, 1.2. 315-357. Janis, I. (1982). Effective interventions in decision counseling: Implications of the findings from 23 field experiments. In I. Janis (Ed.), Counselin2 on personal decisions: Themy and research on short-term helpin2 relationships (pp. 341-375). New Haven, CT: Yale University Press. Janis, 1., & Mann, L. (1977). Decision makin2: A psycholoflical analysis of conflict. choice. and commitment. New York: Free Press. Johnson, J. E., Lauver, D. R, & Nail, L. M. (1989). Process of coping with radiation therapy. Journal of Consulting and Clinical PsycholoLtr .Q.Z, 358-364. Kaplan, S. H .. Greenfield, S., & Ware, J. E. Jr. (1989). Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Medical Care, 27(3), Supplement. Katz, J. (1984). The silent world of doctor and patient. London: Free Press Klein, S. D., & Klein, R. E. (1987). Delivering bad news: The most challenging task in patient education. Journal of the American Optometric Association, .Q.a(8), 660-663. 99

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Lowe, G. M., & Sheets, B. V. (1951). The relation of psychometric factors to stage fright. Speech Mono(lraphs, 266-271. Lustig, M. W. (1974). Verbal reticence: A reconceptionalization and preliminary scale development. Paper presented to the Speech Communication Association Convention, Chicago, IL. Maguire, P., & Faulkner, A. (1988, 8 October). Communicate with cancer patients: Handling bad news and difficult questions. British Medical Journal, 297, 907-909. Maguire, P., & Faulkner, A. (1988, 15 October). Communicate with cancer patients: Handling uncertainty, collusion, and denial. British Medical Journal, 297, 972-97 4. Martelli, M. F., Auerbach, S.M., Alexander, J., & Mercuri, L. G. ( 1987). Stress management in the health care setting: Matching interventions with patient coping styles. Journal of Consultin(l and Clinical Psycholoi.tf, 55, 201-207. Matthews, D. A, Sledge, W. H., & Ueberman, P. B. (1987). Evaluation of intern performance by medical inpatients. The American Journal of Medicine, B.a. 938-944. McCabe, P. M., Schneiderman, N., Field, T., & Skyler, J. (Eds.). (1991). Stress. coping. and disease. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc. McCrae, R. R. (1984). Situational determinants of coping responses: Loss, threat, and challenge. Journal of Personality and Social Psycholofl.Y, 46, 919-928. McCroskey, J. C. (1970). Measure of communication-bound anxiety. Speech Mono(lraphs, .a.z. 269-277. McCroskey, J. C. (1978). Validity of the PRCA as an index of oral communication apprehension. Communication Monographs, 45, 192-203. 101

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