APPLICATION TO ADMINISTRATION

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he qualitative research literature addressing issues uniquely related to nursing administration is limited, possibly because many of the issues that lend themselves to qualitative education in nursing administration overlap with the practice arena. For example, studies related to professional nurse behavior and work satisfaction, successful leadership strategies, and perspectives on nurse empowerment would cross over between administra- tion and practice. An example of this overlap is the study by Duchscher (2001), “Out in the real world: Newly graduated nurses in acute-care speak out.” This article describes the perceptions of five nurses regarding their work environment. Although the implications from the study relate directly to nursing practice, they can also be applied to nursing administration in that the result provides “insight into, and enhances understanding of, re- cruitment and retention issues for nursing administrators who serve as gate- keepers to the practice orientations and ongoing workplace environments of new nursing graduates” (p. 426). This study, reported as a phenomeno- logical investigation, provides an example of how this particular methodol- ogy can be applied to nursing administration.

For purposes of the critique, the following study, which is purely admin- istrative, is reviewed. The study “Management from four different perspec- tives” by Lindholm, Uden, and Rastam (1999) is presented as one example

of the application of qualitative research in the area of nursing administra- tion. The phenomenon of interest, clearly identified in the study, focused on gaining an understanding of the process of nursing management in a devel- oping organization. The specific rationale for using a qualitative format, as well as the philosophic underpinnings of the approach, was clearly de- scribed. Despite the fact that the Swedish health care system has a variety of management positions to which nurses have legal access, nurses have tradi- tionally held middle management positions. Ongoing decentralization has moved nurses into senior management positions. Therefore, “Elucidating the significance of nursing management increases the possibility of devel- oping the management area of the nursing profession and of using recently acquired knowledge to influence the development of the nursing profes- sion” (Lindholm et al., 1999, p. 102).

The purpose of the study was to “illuminate nursing management in a developing organization from the perspectives of nurse managers, chief physicians, hospital directors and politicians, respectively” (Lindholm et al., 1999, p. 102). The authors make explicit their purpose and support it with a review of the literature.

The sample included 15 nurse managers, 11 chief physicians, and 3 poli - ticians who were chairmen of the local health boards. “The nurse managers were all women, except for one. In the other groups all the participants were men’’(Lindholm et al., 1999, p. 102).

The method used to collect data was compatible with the research pur- pose and adequately addressed the phenomenon of interest. Lindholm et al. (1999) interviewed their participants individually. All interviews were tape-recorded and transcribed verbatim. The authors used Ricoeur’s process of phenomenological hermeneutics. Detailed examples of the steps of the hermeneutic circle are provided, demonstrating for the reader how the researchers followed the stated method. Although the researchers do not make an explicit statement regarding data saturation, they do comment that the interviews were comprehensive and “provided good coverage of the issues leaving no need to increase the number of informants” (Lindholm et al., 1999, p. 102).

Data analysis followed the phenomenological hermeneutic approach inspired by Ricoeur. The author provides clear examples of the data analysis process in relationship to each step of the hermeneutic circle.

The first step was the naïve reading of each interview to acquire a sense of the whole of the text, to gain an impression and to formu- late ideas for further analysis. The second step was a structural analysis to identify meaning units, to explain, through revealing the structure and the internal dependent relations, what constitutes the static state of the text. The third step was the understanding of the interpreted whole, from reflection on the naïve reading and the structural analysis (Lindholm et al., 1999, p. 103).

The findings demonstrate the participants’ realities, and the researchers relate the findings of the study to what is already known. Through the dis- cussion of the findings, the researchers provide a context for their use and conclusions are drawn. Recommendations for future research are made and the conclusions and implications are clearly related to the findings. This work makes an important contribution to the nursing administration knowledge base.

SUMMARY

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he body of published phenomenological research has grown consider- ably since the first publication of this book. Clearly, the body of prac- tice-related research is expanding, with considerable development of research in the area of education and administration. Examples of phenom- enological research applied to the areas of nursing practice, education, and administration emphasize the important contribution that phenomenolog- ical research has made to nursing’s substantive body of knowledge. The critiquing guidelines provide the reader with a guide to evaluating phenom- enological research. Examples of phenomenological research using the method interpretations described in Chapter 5 have been highlighted to facilitate method comprehension and application.

Phenomenology as a research approach provides an avenue for investi- gation that allows description of lived experiences. The voice of professional nurses in practice, education, and administration can be a tremendous source of data that have yet to be fully explored. Identifying subjective phe- nomena unique to the domains of nursing education, practice, and admin- istration is important to the ever-expanding body of nursing knowledge.

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Research Article

Coping with Breast Cancer: A Phenomenological Study

Myrna A. A. Doumit, PhD, RN; Huda Abu-Saad Huijer, RN, PhD, FEANS;

Jane H. Kelley, PhD, RN; Nagi El Saghir, MD; Nada Nassar, RN, MSN

Background:Breast cancer is the most common malignancy affecting women worldwide. In Lebanon, a country of 4 million people, breast cancer is also the most prevalent type of cancer among Lebanese women.

Objective:The purpose of this study was to gain a more in-depth understanding of the coping strategies espoused by Lebanese women with breast cancer.

Methods:The study followed purposeful sampling and saturation principles in which 10 female participants diagnosed as having breast cancer were interviewed. Data were analyzed following a hermeneutical process as described by Diekelmann and Ironside (Encyclopedia of Nursing Research.

1998:50–68).

Results:Seven main themes and 1 constitutive pattern emerged from the study describing the Lebanese women’s coping strategies with breast cancer.

The negative stigma of cancer in the Lebanese culture, the role of women in the Lebanese families, and the embedded role of religion in Lebanese society are bases of the differences in the coping strategies of Lebanese women with breast cancer as compared to women with breast cancer from other cultures.

Conclusion:These findings cannot be directly generalized, but they could act as a basis for further research on which to base a development of a frame- work for an approach to care that promotes coping processes in Lebanese women living with breast cancer.

Implications for Practice:Nursing and medical staff need to have a better understanding of the individual coping strategies of each woman and its impact on the woman’s well being; the creation of informal support group is indispensable in helping these women cope with their conditions.

Keywords:Breast cancer, Coping, Culture, Qualitative, Women’s issues

Authors’ Affiliations: School of Nursing, American University of Beirut, Beirut, Lebanon (Drs Doumit and Huijer); University of Mississippi, Medical Center, Jackson (Dr Kelley); and School of Medicine, American University of Beirut (Dr El Saghir), and American University of Beirut Medical Center (Ms Nassar), Beirut, Lebanon.

This research was supported by a grant from the Medical Practice Plan at the American University of Beirut.

Corresponding author: Myrna A. A. Doumit, PhD, RN, School of Nursing, American University of Beirut, Beirut, Lebanon (ma12@aub.edu.lb).

Accepted for publication October 12, 2009.

From Doumit MAA, Huijer HA-S, Kelley JH, et al. Cancer Nursing.vol. 33, issue 2, pp. E33–E39. Copyright

© 2010 by Lippincott Williams & Wilkins. Reprinted with permission.

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reast cancer is the most frequent malignancy affecting women worldwide. In Lebanon, a country of 4 million people, breast cancer is also the most prevalent type of cancer among Lebanese women. It corresponds to 42% of all female cancers (Lebanese Ministry of Public Health, World Health Organization, and National Non- communicable Diseases Programme).¹It is noted that at least half of the women with breast cancer will survive 5 years, as has been found for those living in developing countries.²Therefore, as the survival rates of breast cancer increase, the number of women living with long-term consequences of breast cancer treatment will also augment. Women’s responses to and coping with the diagnosis of breast cancer have become an area of growing concern to many researchers.^3–5However, most research on women’s coping with breast cancer has been conducted in western countries. So far, no documented research study is found on the experience of coping in Lebanese women with breast cancer. Consequently, the intention of this study was to gain more in-depth insights into how Lebanese women cope with breast cancer so that culturally sensitive care can be provided.

Background

Breast cancer diagnosis, and its subsequent treatment, is a traumatic experience with intense impact on all facets of human life.^4,6Several studies have investigated coping strategies and their effect on cancer. According to Taleghani et al,⁷ Iranian women used a religious approach for coping. They used positive suggestions, hope, and intentional forgetfulness as coping mechanisms. Coping strategies as described by African American women included relying on prayer, avoiding negative people, developing a positive attitude, having a will to live, and receiving support from family, friends, and support groups.⁸In a study on 100 newly diagnosed women with breast cancer in China, Li and Lambert⁹reported that planning, positive reframing, and self- distraction were the most commonly used coping strategies. Manual et al,¹⁰ in a study on coping in young women diagnosed as having breast cancer, reported that the most frequently used coping strategies were positive cognitive restructuring, wishful thinking, making changes, social support engaging in physical activity, using medica- tions, and resting. This study also highlighted that different coping strategies were considered best in response to different stressful aspects of dealing with cancer.

Comparable results were also highlighted by Stanton et al.¹¹In a study on coping fol- lowing breast cancer and psychological adjustments, Hack and Degner¹² reported that women who respond to their breast cancer diagnosis with passive acceptance and resignation are at a significant risk for poor long-term psychological adjustment.

Butow et al¹³reported that women with metastatic breast cancer who minimized the effect of cancer as a disease on their lives survived longer. Those who used minimiza- tion as a coping strategy revealed that the cancer did not influence social, work, or family life, nor was it an important cause of anxiety or depression. These women, who accepted their illness and its life-threatening potential, showed a better social adjust- ment, an ability to shift between appropriate mourning for their loss of health and ap- proaching death, and a tendency to concentrate on ongoing positive aspects of their lives. These results imply that adequate support, active coping, and finding positive meaning in life can lead to a diminution of cancer’s effect.

Although research has indicated that coping strategies have a great impact on women’s adaptation and response to breast cancer, nothing is known about how Lebanese breast cancer women cope with breast cancer. Therefore, the intent of the

present study was to gain a more in-depth understanding of the coping strategies fol- lowed by breast cancer Lebanese women so that culturally sensitive healthcare and culturally relevant coping strategies could be encouraged by healthcare providers.

Methods Design

Our reflections on the concept of coping with breast cancer emerged while conducting a qualitative study about the lived experience of Lebanese women with breast cancer¹⁴following a phenomenological approach as described by Barritt et al.¹⁵This approach was chosen because it allows descriptions of phenomena as experienced in life and aims to offer an understanding of the internal meaning of a person’s expe- rience in the world.¹⁶Thus, a comprehensive, culturally competent understanding of the phenomenon was obtained.

The idea of coping with breast cancer emerged from the participants’ interviews as an important feature for living with the diagnosis of breast cancer. A second analysis of textual data (narratives) from the initial study was done following a 7-stage hermeneu- tical process as described by Diekelmann and Ironside.¹⁷The previous interviews be- came the narratives that constituted the text for the present analysis. The second analysis was conducted immediately at the end of data collection when the re- searchers realized that coping was an important element of the women’s lived experi- ence. The focus of the second analysis was the coping process. To maintain scientific rigor in the second analysis, researchers’ biases were reduced by careful attention to the text, use of team approach for analysis, and verification of the findings with the par- ticipants. In addition, findings were supported in the text by participants’ excerpts.

Participants

Ten participants were chosen based on purposive sampling, saturation principles, and according to the following inclusion criteria: (1) Lebanese Arabic speaking; (2) living in Lebanon; (3) age of 25 years or older; (4) diagnosed as having breast cancer, stages (I-III); (5) without distant metastases, previous history of mental disorders, or the existence of other forms of cancer or other chronic diseases; and (6) agreed to be interviewed without the presence of a third person to ensure liberty for the participant to express her feelings.

Recruitment Strategies and Techniques

After securing the approval of the institutional review board of the American Uni - versity of Beirut, the primary researcher talked about the study with community inter- mediaries (nurses, housewives, friends) and oncologists. After the community intermediaries identified the participant, the primary researcher phoned each potential participant and presented a request to join the study. Then, the researcher arranged for an interview date, time, and place with each participant according to her preferences. All participants read and signed a consent form.

Setting

All interviews were conducted at the participants’ homes in rural and urban areas of Lebanon.

Data Collection

Data were collected between December 2007 and May 2008. Interviews were con- ducted in Arabic by the researcher. Each interview was translated to English by a translator and back translated to Arabic by a research assistant to check for accu- racy of translation. In each interview, the participant was the main speaker, and the researcher was mostly a listener and a facilitator. The participants were reminded that their participation is voluntary and that at any time they could decline or with- draw from the study without any obligation. At the end of the second interview, each woman received a “mug” as a token of appreciation for her participation in the study.

The interviews were audio taped, and field notes were recorded. Each interview was coded so that only the researcher has a knowledge of the persons who partic- ipated. Participants were guaranteed confidentiality, and pseudonyms were used.

The code list and the original tapes were placed in a locked file cabinet in the re- searcher’s office for a period of 3 years, at which time the notes will be destroyed and the tapes erased.

The interval between the first and second interviews was 2 weeks. The first in- terview took 50 to 60 minutes, and the second interview took 30 to 40 minutes.

The objective of the second interview was to validate the preliminary analysis with the participant. It is worth noting that the consensus between the researcher’s in- terpretation and the participants was almost more than 95% in all interviews.

The first set of interviews was based on the following broad or grand tour ques- tion: “What has it been like for you since you were diagnosed with breast cancer?”

Moreover, during the second interview, each participant was asked to validate if the statements, ideas, and words reported by the researcher illustrate her experience of coping with breast cancer.

Analysis

The second data analysis started at the end of the first study. Narratives (texts) were interpreted following a 7-stage hermeneutical process as described by Diekelmann and Ironside.¹⁷The objective of this process is to portray shared prac- tices and common meanings. The analysis team included the principal investigator and an experienced graduate assistant in qualitative analysis. Each text was ex - amined as a whole to gain an overall understanding. Possible common meanings were identified from the texts with excerpts to support the interpretation. The researchers compared their interpretations for similarities and differences at biweekly meetings, reaching further clarification and consensus by returning to the original text. All texts were reread to uncover themes that linked them. Researchers described a constitutive pattern that showed the relationship across themes among all texts. According to Diekelmann and Ironside,¹⁷the discovery of a consti- tutive pattern forms the highest level of hermeneutical analysis. A situation is con- stitutive when it gives actual content to a person’s self-understanding or to a person’s way of being in the world. Furthermore, themes were validated by the par- ticipants of the study. At the end, the principal investigator produced the final sum- mary, including verbatim quotes that allow for validation by the reader. This multistage process permitted clarification and validation, which helped in eliminat- ing unconfirmed meanings. The hermeneutic circle involves constant checking of the whole and the parts of the text. It is worth noting that the continuous reference to the text guaranteed that interpretations were grounded and focused.¹⁷