Nurses ’ Perspective on Positive Attitudes to Cancer Patients in Turkey : A Qualitative Study

The burden of cancer in developing countries is growing and is likely to be associated with heavy morbidity, mortality, and economic costs in the next few years (Ngoma, 2006). The number of global cancer deaths is projected to increase by 45% from 2007 to 2030 (from 7.9 million to 11.5 million deaths), which is partially influenced by the increasing number of ageing adults worldwide (WHO, 2008; Cebeci et al., 2011). Cancer is the second leading cause of death in Turkey (Oksel et al., 2010) One of the most important personal characteristics which can affect nursing care in any setting is the attitude of nurses. Cancer as a disease is often associated with distressing images of treatments and of suffering and death. Nurses working with people who have cancer are part of a society which regards the disease with fear and dread. As health professionals, they are expected to hold objective views and have the most up-to-date knowledge in order to give the best services possible to their clients. However, little is known about the attitudes of nurses working with cancer patients, in particular those working in medical and surgical wards of district general hospitals (McCaughan & Parahoo, 2000). Most cancer patients in the future will receive some of their care in cancer units and centres where patients can get specialist help. However, a large number of patients


Introduction
The burden of cancer in developing countries is growing and is likely to be associated with heavy morbidity, mortality, and economic costs in the next few years (Ngoma, 2006).The number of global cancer deaths is projected to increase by 45% from 2007 to 2030 (from 7.9 million to 11.5 million deaths), which is partially influenced by the increasing number of ageing adults worldwide (WHO, 2008;Cebeci et al., 2011).Cancer is the second leading cause of death in Turkey (Oksel et al., 2010) One of the most important personal characteristics which can affect nursing care in any setting is the attitude of nurses.Cancer as a disease is often associated with distressing images of treatments and of suffering and death.Nurses working with people who have cancer are part of a society which regards the disease with fear and dread.As health professionals, they are expected to hold objective views and have the most up-to-date knowledge in order to give the best services possible to their clients.However, little is known about the attitudes of nurses working with cancer patients, in particular those working in medical and surgical wards of district general hospitals (McCaughan & Parahoo, 2000).
Most cancer patients in the future will receive some of their care in cancer units and centres where patients can get specialist help.However, a large number of patients

Nurses' Perspective on Positive Attitudes to Cancer Patients in Turkey: A Qualitative Study
Yasemin Yıldırim Usta 1,4 *, Yurdanur Demir 2,4 , Huriye Yagmuroglu 3 with cancer are, and will still be, cared for at one time or other in general medical and surgical wards of district general hospitals.Although these nurses are not expected to have specialist knowledge and skills in cancer care, they must be sufficiently informed, aware and skilled in order to give optimum care and to know when and how to refer patients to appropriate specialist services.They have a vital role at crucial points in the disease trajectory, especially at the time of diagnosis and at the terminal stage.Their contribution to cancer care is often undervalued and ignored, judging by lack of research on their attitudes towards, and experience, knowledge and skills in caring for cancer patients (McCaughan & Parahoo, 2000).
Nurses play a big role in influencing a patient's attitude and are constantly encouraging them to be positive in relation to their cancer and the treatment being administered.Koopmeiners et al. found that health-care providers influence patients' perceptions of their hope (Koopmeiners et al., 1997).Nurses' behaviour can play an important part in inspiring and strengthening hope as they are constantly around the patient right from the time of diagnosis through to the end of the treatment (Valliot, 1970;Herth, 1990;O'Baugh, et al., 2008).
Traditionally, oncology units were among the least favoured places for nurses to work in Turkey.Many general nurses have reported not wanting to work with cancer patients due to their negative view of cancer as a terminal condition in addition to the comparative lack of support in general for clinical nurses in Turkey (Platin, 2010;Cebeci et al., 2011).Turkey is a developing country and new health politics are consistently being implemented.In April 2011, the Turkish Ministry of Health published nursing regulations that addressed the duties, powers and responsibilities of oncology nurses (Official Gazette No: 27910).Laws in Turkey require that nurses prepare and administer medications (Baykal et al., 2009).
Contrary to the general belief, literature also emphasizes the negative effect that 'positive thinking' can have on patients.Rittenberg argues that by forcing patients to accept the concept of 'positive mental attitude', healthcare professionals are not allowing them to face reality and this can lead to emotional disaster for patients (Rittenberg, 1995).This is further reiterated by De Reave who says that many cancer patients experience moral and psychological pressure to think positive about their disease (De Reave, 1997).This paper reports the findings of a study which investigated the meaning of 'positive attitude' for a group of medical surgical nurses.

Materials and Methods
The qualitative (case-study) method was used in this study.A qualitative approach, which emphasizes the importance of describing the subjective perceptions of participants, is essential to this orientation.This qualitative descriptive study used data from nurses who had volunteered to participate in an in-depth interview that was conducted between January and February 2012.A total of 10 nurses in general medical and surgical wards of a district hospital were interviewed.This sample consisted of ten female nurses.The participants were asked to complete a consent form before commencing the interview.Demographic data were also collected via a brief pre-interview questionnaire, which included age, gender, nursing experience and presence of cancer patients in the family or among friends.
The interviews were unstructured but addressed the following key concepts: 1.The importance of attitude to cancer patients 2. The definition of 'positive attitude' 3. The definition of 'negative attitude' 4. The impact of attitude on cancer patients All the participants were interviewed by the same person and each interview was audio-taped.Each interview took 20-30 min and was conducted in a comfortable and private setting at the district general hospital.None of the interviews were terminated prematurely and none of the participants required any sort of counselling which was offered as part of the study's ethical responsibilities.
Data were collected using semi-structured and indepth individual interviews.All the interviews were audiotape-recorded.The in-depth individual interviews were performed in an isolated room for the participants' comfort and safety.Data were obtained using descriptive and semi-structured interview forms.These forms were prepared by the researchers after completing an extensive review of the literature (Streubert & Carpenter, 1999;Graneheim & Lundman, 2004).
The audiotape-recorded interviews were transcribed and subsequently combined with notes taken during the interview.The interview transcripts were documented in MicrosoftWord, and the raw data underwent a close reading and were then categorised.All the interviews were transcribed verbatim.Data analysis of the transcripts was accomplished using the process outlined below, which was based on Graneheim & Lundman's (2004) techniques for extracting themes in qualitative data.

Data Evaluation
Content analysis method was used to assess the data.The data was read over and over.After reading, codes that may come off from each word and sentence were found.After code generation, thematic coding was done, codes were classified by the researcher and appropriate themes and sub-themes were extracted.Written documents of the interviews were examined by three field experts.Then all data interpreted according to theme was drawn up to reports.

Measures Taken for Validity and Reliability
Purposive sampling method was used to increase the reliability and validity of the study.The interviews were also supported by observations.In this study, evaluation was done by three experts with the researcher.To get confirmation of the participants, the experts were asked to review the topics and then answers were reviewed again.Detailed descriptions were made and often direct quotations were given.

Ethical Considerations
Written permission was obtained from local authorities prior to commencement of the study.The participants were volunteers who agreed to be involved in the study and were fully informed about the purpose of the study.All the participants were >18 years old and were able to give informed consent before participating in the interview.Only the research team knew the names of the individual participants.Each interview data was allocated a numerical code and no participants were identified during the analysis and report writing.

Results
A total of ten nurses working as medical surgical nurses in the field of 'cancer care' were interviewed.All the interviews were semi-structured and conducted by the same researcher.The contents were coded and the frequencies were obtained.All the nurses interviewed were female.Table 1 demonstrates the profile of the nurses interviewed.
The interviewer asked questions around the themes of defining positive attitude, defining negative attitude, how these two concepts manifest themselves in cancer patients and what, if anything, influences the attitude of cancer patients.The nurses were also asked if they were aware of anything to do with attitude and cancer and, if so, how they had become aware of this issue.
Each nurse was asked to explain what the word 'attitude' meant.Common themes that emerged were that attitude comes from within and we make assumptions about a person's attitude based on how they approach problems and how they behave in certain situations.All those interviewed implied some level of personal belief system which they defined as "….an approach about an event or situation; one's feelings, thoughts and behaviours"(4), "interest and perspective…"(1), "the individual's reaction to an event"(3), "….good or bad behaviours as a whole" (6), "desirable positive or negative behaviours of the individual"(5), "…a term covering behaviour and thinking"(8).These definitions revealed that the nurses often defined attitude as a concrete condition and behaviour.
When asked to define the concept of 'positive attitude', the nurses used three broad themes.The most common one was behaving positively.The first theme was showing empathy.One of the nurses, for example, defined it as "approaching the patient or a situation with positive attitudes or empathic perspective..." (4).
The third theme was behaving positively, which was defined as "our positive thoughts about an event or the patient and transformation of positive thoughts into action"(10), "the positive behaviours of the individual"(5), "a positive response to an event..."(3), "...... treating patients positively" (6), "having positive thoughts about patients"(7).
The nurses used four themes to define negative attitude.The first one was bias, which was defined as "... a negative point of view, bias and negative thinking" (1), "having negative thoughts about patients and reflecting these thoughts in behaviour"(7).
The second theme was not showing empathy, which was defined as "not approaching patients with tolerance"(4), "approaching patients inconsiderately or treating them negatively"( 6) The third theme was thinking and behaving negatively."...thinking negatively, behaving negatively" ( 9), "all negative thinking and behaviours"(10), "negative behaviours performed by the individual"( 5) The fourth theme is dealing with cancer patients ineffectively, which was defined as "the behaviours we exhibit due to dealing with cancer patients ineffectively even if we don't believe or think it is right..

."(8).
A number of factors were acknowledged as having an influence on the attitude of patients.These included: • Patient: "the process may be more difficult and the treatment may fail if the patient has a negative attitude against cancer, but the treatment process may be easier if the patient has a positive attitude"(3), "the patients' attitudes towards cancer affect the treatment process, complications.The patient's attitude affects his or her perspective on life, the disease and adaptation to the treatment "(9) • Nurse: "the process is more difficult if the patient is seen as a dying patient.If, despite everything, there is an effort to keep the quality of life at an optimum level, it is easier to receive response to treatment"(2), "nurses' attitudes are very important in treatment of the disease.Positive attitude should be maintained so that the treatment procedure can go well"( 5), "we should have a positive attitude towards cancer patients; every word you speak with them has an instant effect on them and plays a key role in the treatment of their disease"( 6), "…nurses' or families' attitudes ….affect the individual.In other words, we can usually relieve or completely disrupt the individual psychologically with positive or negative attitude"(10).
• Support: "cancer patients try hard to get better and hold on to life if they find support"(7), "there are positive effects for patients that can make use of positive coping mechanisms and have support"(8), "giving support to patients and trying to understand them are vital for sharing difficulties"(4).
• Family: "positive or negative attitudes towards cancer patients are important.However, what really matters at this point is the attitude of family and friends rather than those of nurses….." (10).
• Environment: "patients can cope with the disease with a positive attitude.They can overcome anything and attitude of people around them affect their disease.This shows the importance of attitude…."(1).
All participants were aware of how important it is attitude in cancer.Most of the participants believed that nurses were significant for attitude in cancer.None of the participants had difficulty in sharing their experiences on this subject.The majority of the nurses thought that the attitudes towards cancer patients were effective in patients' coping with cancer and in the treatment process.One of the nurses said: The attitude of nurses or the family affects the individual in his or her adaptation to cancer, the treatment process, efficient use of coping systems, and coping with complications which the disease or other treatment modalities such as chemotherapy or radiation therapy could pose.In other words, we can usually relieve or completely disrupt the individual psychologically with positive or negative attitude" (10).
The nurses' responses about the effect of attitude in cancer patients according to presence of cancer patients in the family or among friends revealed that most of them mentioned support and patient factor.

Discussion
Our results show that nurses are aware of the impact of being positive for cancer patients.The nurses in this study felt strongly that 'being positive' means behaving positively and wanting to get through the cancer and treatment.The nurses' perceptions are similar to those presented in the existing literature, in which 'being positive' is seen as having a heroic fighting spirit that will aid survival and may even effect a cure (Gray & Doan, 1990;Bruckbauer & Ward, 1993).Also, this study supports the finding of J O' Baugh et al. (2008).Some of the nurses in the study stated that the support from family, friends and nurses had an important role in positive attitude, which was also reported by O'Baugh J et al. (2008).Likewise, previous research suggests that support groups, which involve listening to others and talking about one's own reactions, have a positive effect (Rusteon, 1998;Isaksen & Gjengedal, 2000).
The evidence for the relationship between social support and cancer progression is sufficiently strong for breast cancer as shown by some methodologically sound studies (Nausheen et al., 2009).Bina (2009) also found that structural support indices were more frequently associated with disease progression than the indices of functional support in breast cancer.Also, low social support can lead to poor health behaviours, which may then predict an increased vulnerability toward cancer and its associated mortality (Kawahara et al.,1998;Crispo et al., 2004) and to psychosocial stress, which can influence the immune system via the endocrine system and cause angiogenesis and promotion of tumour growth (Lutgendorf et al., 2003;Steel et al., 2004).Therefore, it may be significant to identify patients who may be more at risk due to the psychosocial vulnerability resulting from low social support (Rudge et al., 2005).Nurses may need to undertake a systematic exploration of support networks with the patient, and discuss strategies for mobilizing the support that is available to them (O'Baugh et al., 2003).
The findings of our study showed that nurses have a significant place among health professionals offering support for cancer patients.However, in prior studies, patients have often seen the support given by nurses as being inadequate and that given by family and friends as more important (Anderson, 1989;Suominen et al., 1995;O'Baugh et al., 2008).O'Baugh et al. (2003) points out that more research is needed about the key role of nurses among health professionals in terms of support for cancer patients.
The nurses in this study were aware of the impact of the words and comments in their communication with cancer patients, which was similar to the findings of O'Baugh et al. (2003).As a profession, this highlights the need to examine our own biases and be aware of the possible interpretations and consequences of our words (O'Baugh et al., 2003).
The study also found that attitude of nurses plays an important role in cancer patients' efficient use of systems for coping with the treatment and coping with complications that could be posed by the disease or other treatment modalities such as chemotherapy or radiation therapy.Similarly, patients identify other people's attitudes as being extremely important in affecting their own (O'Baugh et al., 2003).
Finally, this study also analyzed the presence of cancer patients in the family and among friends, which is not a popular topic in the relevant literature.The nurses' responses about the effect of attitude in cancer patients according to presence of cancer patients in the family or among friends on revealed that most of them mentioned support and patient factor.This finding could be interpreted to indicate nurses' awareness of positive attitude towards cancer patients, which is recommended to be explored in future studies.
In conclusion, the nurses were aware of their attitudes towards being positive with cancer patients and its significance in support for cancer patients., nurses should support and encourage patients to maintain a sense of being, whether it be being positive or whatever, which is based on the patients' values and beliefs, not on the nurses' ideas of reality.The findings of this study can serve as a platform upon which educational and other support programmes can be developed in order to meet the needs of these general nurses working with cancer patients.On the other hand, future studies could explore nurses' beliefs about cancer that are thought to affect positive attitude in cancer patients.