THESIS This is to certify that the thesis entitled The Marital Dyads Perception of the Impact of a Mastectomy on Family Functioning Eight to Sixteen Weeks Post-Surgery presented by Patricia Kilroy Bednarz has been accepted towards fulfillment of the requirements for ‘ Master ' 5 degree in Nursing field/42w Major professor 0.- Date 2/22/80 ov I : murmur“- mm L! Y MT R AL: Place in book return chm. fm circulation records A”), ‘Lttcrul MARITAL DYADS PERCEPTION OF THE IMPACT 1 flit 1 OF A MASTECTOMY ON FAMILY FUNCTIONING EIGHT TO SIXTEEN WEEKS POST-SURGERY BY Patricia Kilroy Bednarz Y ‘12 tunct [“T’aicttrh . '_‘.' t r I. A THESIS Submitted to i Michigan State University ’ 2%”3358161 fulfiiiment Of the requirements §§ fife r pt. £9; the degree of" -;‘§fe C“””‘ MASTER OF scréucs “; '““'l‘” I 1:6‘:3_{'J14!y ‘ " ‘1 '.>_ :~ 3 ‘.';aj $¢ data School of Nursing - v“ ' ”w 59»; to 1hr in not Of 8 -n L--I§ao- . P 7 leQP, dud UBQ- ‘ "” ' ' ABSTRACT '. gréhhln ,. THE MARITAL DYADS PERCEPTION OF THE IMPACT _n;;f*. or A MASTECTOMY ON FAMILY FUNCTIONING .':" ‘ EIGHT To SIXTEEN WEEKS POST-SURGERY .ilé 1' BY fifth“ Patricia Kilroy Bednarz T-[a s d -'- t Relatively little is known about the internal rela- i‘iénships of the marital dyad facing the crisis of breast Zriéifiber. The purpose of this study was to investigate the bmttal dyad' s perception of the impact of a mastectomy on ‘ 3“le functioning eight to sixteen weeks post-surgery. A 3.336112 section questionnaire was mailed to 20 marital dyads . t “1:”?th the woman experienced a mastectomy eight to sixteen a prior to data collection. Two sections of the ques- *9 components of family functioning: Adaptation, Partner- - fingerowth, Affection and Resolve (APGAR) . The husband .l‘ ‘ wife .each completed one of these sections. The third therapy. In order to measure the impact of a Patricia Kilroy Bednarz $58“! on family functioning the differences in percep- . a) "A inumn husbands and wives were determined. The results 2?; and wives in perception of Adaptation, Partnership, 1“; Affection, or Resolve. In addition, no significant onship was found between the woman's perception of health and the differences in perception of APGAR. ~rzre was not a significant relationship found between 'Jily developmental stage or use of adjuvant therapy and ,Ifferences in perception of APGAR. The APGAR components 1 e found to have marked internal consistency among the Y') C r: tr. l, v 1 1.7- u r .our forthcoming child QFIICIIto nurslu- 57 “ , 0d and {-xvihfikr,“ '- . ., :4 t _\ V, ‘ I an thxnmzul :4 h£‘~4.liry Koran, ”IL‘. .. , j ,iahégions to this ;:;;,p .n .. v .3 , lz, ~77 'onil skills elm {I I n c ; ~._H la.g-. l 30' 141.4-ns' parse c. tL'fi stud; was much appretl" 51a} thanms tr gnzhy Famme‘, cugriinator ct . y in the b~1xna. area. for her help in I am grateful for her time and energy ‘_j Li this study. thanks also to 0:. iii ACKNOWLEDGMENTS Special thanks to Barbara Given, who not only has provided support and guidance throughout my graduate studies, but has also been an excellent role model. She has demonstrated diligence, creativity, and the ability to foster learning among her students. I am grateful for the opportunity to have had her as a major advisor. Special thanks also to Harriet H. Werley who took the time and patience to begin teaching the research process to an under— graduate nursing student. Her support will always be remembered and appreciated. I am thankful to my committee members, William Crano, Mary Horan, Bill Given, and Brigid Warren for their contributions to this study. Thanks to Lee Ann Slicer's organizational skills and Linda Conn's typing skills, I was able to meet the deadlines. Roger Buldains' persever- ance in analyzing the data for this study was much appreci- ated. Special thanks to Kathy Rummel, coordinator of Reach to Recovery in the Saginaw area, for her help in collecting data. I am grateful for her time and energy that was put into this study. Thanks also to Dr. v“;f-o l. . oug'I "3 [in 1. ,- if .k ‘1}: 70' ‘l .‘l 1‘ help in collecting data. em- 'fii; Dr. Surland, Dr. Dimitrov, and Dr. Delasantos I also appreciate Bill §“efforts in helping to gather more patients for Thanks to my classmates, Margaret, Karen, Jody, Very special thanks to my husband, Ralph, who has 'iyays encouraged me in any endeavors. His patience, .-§§Spport, and reassurance were unending. I will always be gfiqateful to my parents, John and Geraldine Kilroy, for their «spective on life and the encouragement of their children TABLE OF CONTENTS Page . 'tJ'ST.I ’OF TABLES O O D O I C O O O I O O I I I I I O I C ix ';:i.IST0FFIGUREs................... xi -?€£APTER THE PROBLEM . . . . . . . . . . . . . . . . . 1 Introduction . . . . . . . . . . . . . 1 Purpose of This Study . . . . . . . . . . . . 5 Hypotheses . . . . . . . . . . . . . 6 Definition of Concepts . . . . . . . . . . 7 Extraneous Variables Affe ect ing Study Outcome . 15 Assumptions . . . . . . . . . . . . . . . . 20 Limitations . . . . . . . . . . . . . . . 20 Overview of Chapters . . . . . . . . . . . . 21 CONCEPTUAL FRAMEWORK . . . . . . . . . . . . . 23 Introduction . . Rogers' Theory . . . . . . . . . . . . . . . . 23 Man . . . . . . . . . . . . . . . . . . . . . 26 Health . . . . . . . . . . . . . . . . . . . . 28 The Nursing Process . . . . . . . . . . . . . 31 summary . . . . . . . . . . . . . . . . . . 36 Implications for Nursing . . . . . . . . . . . 37 REVIEW OF THE LITERATURE . . . . . . . . . . . 39 Introduction . . . . . . . . . . . . . 39 The Impact of a Mastectomy . . . . . . . . . . 40 Prodromal Period . . . . . . . . . . . . . 41 Prediagnostic Period . . . . . . . . . . . 45 Diagnostic Period . . . . . . . . . . . . 47' PreOperative Period . . . . . . . .'. . 49 Operative Period . . . . . . . . . . . . 50_ Immediate Post-operative Period . . . .'. 51 Extended Post-operative Period . . . . . . 55‘ . Adjuvant Treatment Period . . . . . . . . 2: Recovery Period . . . . . . . . CHAPTER Page Terminal Period . . . . . . . . . . . . . 69 Summary of Literature Review of the Impact of a Mastectomy . . . . . . . . . 69 Family Functioning . . . . . . . . . . . . . . 71 Summary. . . . . . . . . . . . . . . . . . . . 76 IV. METHODOLOGY AND PROCEDURE . . . . . . .‘. . . 79 Overview . . . . . 79 Operational Definition of the Variables . . . 80 Extraneous Variables . . . . . . . . . . . . . 82 The Instrument . . . . . . . . . . . . . . . . 83 Family Functioning Section . . . . . . . 84 Scoring and Analysis of the Family Functioning Section . . . . . . . . . . 88 Health Perception Section . . . . . . . . 90 Sociodemographic Section . . . . . . . . . 92 Reliability and Validity . . . . . . . . . 93 Hypotheses and Questions Posed . . . . . . . . 95 Population . . . . . . . . . . . . . . 98 Subjects-~Criteria for Selection . . . . . . . 99 Procedure . . . . . . . . . . . . . . . . . . 99 Data Collection . . . . . . . . . . . . . . 101 Human Rights Protection . . . . . . . . . . . 103 Summary . . . . . . . . . . . . . . . . . . . 104 V. DATA PRESENTATION AND ANALYSIS . . . . . . . . 106 Overview . . . . . . 106 Descriptive Findings of the Study Population . 108 Data Presentation for Hypotheses . . . . 113 The Statistical Technique . . . . . . . . 113 Hypothesis 1 . . . . . . . . . . . . . 115 Hypothesis 2 . . . . . . . . . . . . . 119 Reliability of the Family Functioning Section of the Questionnaire . . . . . . . . 127 Extraneous Variables . . . . . . . . . . . . . 128 Health Perception . . . . . . . . . . . . 128 Adjuvant Therapy . . . . . . . . . . . . 131 Family Developmental Stage . . . . . . . . > 133 vi CHAJNPER VI. APPENDIC APPENDIX A. B. C. D. E. F. Description of the Marital Dyad's Perception of the Impact of a Mastectomy on Family Functioning Eight to Sixteen Weeks Post— —Surgery . . . . Description of the Relationship Among the Discrepancy Scores of Adaptation, Partnership, Growth, Affection, and Resolve . . . . . Construct Validity of the Family APGAR . . . Summary . . . . . . . . . . . . . . . . . . SUMMARY OF FINDINGS . . . . . . . . . . . . Overview . . . . . . . . . . . . Summary and Interpretation of Findings . . . Descriptive Findings of the Study Population . . . . . . . . . . . . . . Hypotheses . . . . . . . . . . . . . . . Hypothesis 1 . . . . . . . . . . . . Hypothesis 2 . . . . . . . . . . . . Extraneous Variables . . . . . . . . . . . Health Perception . . . . . . . . . . . Family Developmental Level . . . . . . . Adjuvant Therapy . . . . . . . . . . . Nursing Implications for Practice . . . . . Implications for Future Research . . . . . . Implications for Education . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . ES . . . . . . . . . . . . . . . . . . . . . Family Functioning Section for Both Husband and Wife . . . . . . . . . . . . . Items Developed to Measure Perception of Family Functioning Utilizing the APGAR Components . . . . . . . . . . . Anxiety and Depression Scales Taken From the SCL- 90 . . . . . . . . . Health Perception Items According to the Three Components, Current Health, Health Outlook, and Health Worry/Concern . . . . Health Perception Section . . . . . . . . Sociodemographic Section . . . . . . . . . . vii Page 133 136 136 140 144 144 144 144 145 145 154 165 165 166 167 167 176 180 181 182 182 199 201 202 205 T———‘ APPENDIX Page G. Training of Alternate Data Collectors . . . 209 H. Established Criteria for the Marital Dyad's Participation in the Study . . . . . . . 211 I. Telephone Instructions to Respondents . . . . 212 J. Cover Letter and Consent Form . . . . . . . 214 K. Absolute and Sign Discrepancy Scores Between Individuals of the Marital Dyad for Adaptation . . . . . . . . 216 L. Absolute and Sign Discrepancy Scores Between Individuals of the Marital Dyad for Partnership . . . . . . . . 217 M. Absolute and Sign Discrepancy Scores Between Individuals of the Marital Dyad for Growth . . . . . . . . . . . 218 N. Absolute and Sign Discrepancy Scores Between Individuals of the Marital Dyad for Affection . . . . . . . . 219 0. Absolute and Sign Discrepancy Scores Between Individuals of the Marital Dyad for Resolve . . . . 220 P. Summed Z Scores .for Current Health, Future Health, and Health Worry/Concern . . . . . . 221 REFERENCES . . . . . . . . . . . . . . . . . . . . . . 222 viii Table 10. 11. 12. 13. LIST OF TABLES Age of Female Subjects . . . . . . . . . . . . . Age of Male Subjects . . . . . . . . . . . . . . Number of Children of Marital Dyads . . . . . . Years of Marriage of Marital Dyads . . . . . . . Developmental Stage of Family . . . . . . . . . T—test Demonstrating the Differences Between the Means of Husbands and Wives for Each Category of APGAR . . . . . . . . . . . . . . Pearson Product Moment Correlation Between the Absolute Discrepancy Scores of Adaptation, Partnership, Growth, Affection, and Resolve . Pearson Product Moment Correlation Between the Sign Discrepancy Scores of Adaptation, Partnership, Growth, Affection, and Resolve Correlation Matrix Demonstrating the Rela- tionship Between the Components of Health Perception and the Absolute Discrepancy Scores of APGAR . . . . . . . . . ... . Correlation Matrix Demonstrating the Rela- tionship Between the Components of Health Perception and the Sign Discrepancy Scores of APGAR . . . . . . . . . . . . . . . . F Ratio Determined from Analysis of Variance of Women's Use of Adjuvant Treatment . . . . . F Ratio Determined from Analysis of Variance of Family Developmental Stage . . . . . . . . Correlation Matrix of SCL—90 Components and APGAR Absolute Discrepancy Scores . . . . . . ix Page 109 110 111 112 113 116 121 122 129 130 132 134 138 Table Page 14. Correlation Matrix of SCL-90 Components and APGAR Sign Discrepancy Scores . . . . . . . . 139 15. Correlation Matrix Between the Absolute Discrepancy Scores for APGAR Categories and the Absolute Discrepancy Scores for Anxiety and Depression for Both Husbands and Wives . . . . . . . . . . . . . . . . . . 141 16. Correlation Matrix Between the Sign Dis- crepancy Scores for APGAR Categories and the Sign Discrepancy Scores for Anxiety and Depression for Both Husbands and Wives . . . . . . . . . . . . . . . . . . . . 142 17. Absolute and Sign Discrepancy Scores Between Individuals of the Marital Dyad for Adaptation . . . . . . . . . . . . . 216 18. Absolute and Sign Discrepancy Scores Between Individuals of the Marital Dyad for Partnership . . . . . . . . . . . . . 217 19. Absolute and Sign Discrepancy Scores Between Individuals of the Marital Dyad for Growth . . . . . . . . . . . . . . . 218 20. Absolute and Sign Discrepancy Scores Between Individuals of the Marital Dyad for Affection . . . . . . . . . . . . . . 219 21. Absolute and Sign Discrepancy Scores Between Individuals of the Marital Dyad for Resolve . . . . . . . . . . . . . . . 220 22. Summed Z Scores for Current Health, Future Health, and Health Worry/Concern . . . . . . . 221 LIST OF FIGURES ). ‘ _1. The Family APGAR o I c O u o I o I a u o o o I o ‘2; Family Functioning Components . . . . . . . . . 3. Rogers' Theory Interaction . . . . . . . . . . . 4. Nursing Goals for the Marital Dyad Experi- ‘>-*“~ 'encing the Crisis of a Mastectomy . . . . . . “5‘5‘ Theoretical Model for this Study Demon- strating the Relationship Between the gifmlfivs ' Nursing Process and the Marital Dyad L '5 , Experiencing the Impact of a Mastectomy . . . " ' Will . ~5ggblsch' fa .~ . V .. 01". 0,, .__. 1: §' 11'. 71:1. (I ‘ ' ”text? 1.. -1 .p‘. hfl‘ip' u in? Eye» 5 1". < xi Page 11 12 29 32 33 CHAPTER I THE PROBLEM Introduction Breast cancer comprises 27 percent of all cancers in women and is the leading cancer site in white and black females. The data gathered from 1973 to 1977 in the Breast Cancer Digest, 1979, revealed breast cancer occurs in about 85 white women out of every 100,000 each year and about 70 black women per 100,000 each year. At the present rate, one out of every four women will develop breast cancer sometime in her life. Among whites 65 percent of the women survive breast cancer. For all white breast cancer patients from 1960 to 1972, the medium survival from time of diagnosis was six years and seven months, and for blacks, three years and eight months. The incidence of breast cancer increases rapidly as a woman enters her forties, levels off between the ages of 45 and 55, and then continues to rise at a more gradual rate (Breast Cancer Digest, 1979). With the current and forthcoming techniques in detecting and treating breast cancer the survival rate is likely to increase in the future. The woman who does survive breast cancer is faced with the loss of the breast, the possible loss of longevity, 1 loss of body image, and perhaps the loss of interpersonal relationships that will change after the diagnosis of cancer is made. Marital, family, work, and social roles may need to be adjusted. The fears and concerns about one's health that occur as a result of the breast cancer diagnosis also need to be dealt with. The woman who survives for less time than the medium survival rate will need to prepare herself and her family for death. Although the psychosocial implications of breast cancer are numerous, relatively little research has been completed on the internal roles and functions of the family facing the crisis of breast cancer of the wife/mother. The research on quality of survival has been concerned primarily with persistent physical symptoms, return to work and psycho- logical distress. Asken (1975) indicated in a literature review on the psychoemotional aspects of a mastectomy that the woman feels a threat of death, sense of mutilization, loss of femininity, change in life-style, and inability to adapt to her previous roles. In an effort to evaluate a post-mastectomy rehabilitation program, Winick and Robbins (1977) issued a three page questionnaire three months after discharge. The study revealed that 13 percent (52 of 406 patients) suffered emotional stress (stress was reported in the context of emotional ups and downs), 84 percent (661 of 790 patients) resumed normal physical activity, and the majority of women had normal range of motion in the affected arm. 1 s L‘|r‘ Schottenfeld and Robbins (1970) studied the quality of survival among 826 patients who have had a radical mastectomy. The researchers found 84 percent of the patients at five years were able to return to their daily activities. The study did not qualify the patient and family adjustment with regard to their quality of life other than employment/ household activities. Morris, Greer, and White (1977) com- pleted a two-year follow-up on both mastectomy patients and patients with benign breast disease. Psychological stress was reported by 46 percent of the mastectomy patients at three months but at one year 70 percent of these patients indicated they were no longer stressed. (Stress was measured in relation to loss/disfigurement, diagnosis, and both diagnosis and loss.) Cancer patients at two years were found to have a significantly higher level of depression (22 percent). Craig, Comstock, and Geiser (1974) studied the quality of survival in breast cancer patients compared to a control group of noncancer patients. It appeared from this study the only significant effect of breast cancer was a slight increase in disability and an increase in death rate. Abeloff and Derogatis (1977) discovered that 34 patients with metastatic breast cancer, compared to 73 patients with other types of cancer were higher on a posi— tive symptom distress index which measures the intensity I of psychological distress. Woods (1978) investigated the general quality of survival for post-mastectomy patients. The study found that women did not feel prepared for their post-operative experiences, continued to have a number of physical complications, and women having an increased number of physical symptoms were more likely to have a higher number of symptoms of depression. Other studies completed on breast cancer have focused on delay in seeking treatment (Fisher, DeCrosse, & Kaplan, 1964; Gold, 1964), possible psychological parameters that may be indicative of women prone to breast cancer (Surawiz, 1977; Greer & Morris, 1975) and women's beliefs about breast cancer (Stillman, 1977; Knopf, 1976). Breast cancer is a chronic disease and requires the adaptation skills necessary for a chronic disease. In particular, breast cancer may or may not involve surgery, relapses, remissions, and ongoing chemotherapy. These vari- ables of breast cancer management may necessitate family adaptation by the spouse in the nurturing of family members, social functions, use of community agencies and health con- ditions and practices. In summary, the literature does indicate problems do occur for the woman who has been diagnosed with breast cancer. Psychological distress, fear of disfigurement, physical complications, stress secondary to diagnosis, and feelings of being unprepared for what occurs post-surgery have been reported in the literature. What has not been reported in the literature is the woman's perception of how her family is adapting or how the family is actually adapting t£> the diagnosis of breast cancer. In addition, the family's perception of how the wife/mother is coping has not been reported. As the family is one of the basic support systems available to the woman facing breast cancer understanding of those particular dimensions of family life are necessary for health providers to understand. Counseling and educa- tion both prior and subsequent to breast surgery may be necessary for the entire family. Purpose of This Study The lack of knowledge regarding breast cancer and the resulting implications on family functioning have pro- vided the impetus for this research. The purpose of this study is to determine the impact of a mastectomy on the woman and her family facing the crisis of breast cancer. In particular, the relationship between the marital dyad will be examined to determine the individual perceptions of family functioning. Nursing is in a unique position to offer sup- port and guidance to these families undergoing this crisis. A broadened knowledge base regarding the impact of breast cancer on the family can enhance nursing care in helping families cope with this crisis. Specifically, the problem statement is: What is the marital dyad's perception of the impact of a mastectomy on family functioning eight to six- teen weeks post-surgery? Hypotheses The following hypotheses will be addressed: There is no difference between the individuals within the marital dyad in perception of the impact of a mastectomy on family functioning. Subhypotheses 1a. 1b. 1c. 1d. 1e. There is no difference between the individuals within the marital dyad in perception of the impact of a mastectomy on Adaptation. There is no difference between the individuals within the marital dyad in perception of the impact of a mastectomy on Partnership. There is no difference between the individuals within the marital dyad in perception of the impact of a mastectomy on Growth. There is no difference between the individuals within the marital dyad in perception of the impact of a mastectomy on Affection. There is no difference between the individuals within the marital dyad in perception of the impact of a mastectomy on Resolve. There is no inter-relationship among the five cate- gories of family functioning. nut} :- Subhypotheses 2a. 2b. 2c. 2d. 2e. 2f. 2g. 2h. 21. 23'. Family There is no relationship scores of Adaptation and There is no relationship scores of Adaptation and There is no relationship scores of Adaptation and There is no relationship scores of Adaptation and There is no relationship between the Partnership. between the Growth. between the Affection. between the Resolve. between the scores of Partnership and Growth. There is no relationship between the scores of Partnership and Affection. There is no relationship between the scores of Partnership and Resolve. There is no relationship between the scores of Growth and Affection. There is no relationship between the scores of Growth and Resolve. There is no relationship between the scores of Affection and Resolve. Definition of Concepts Smilkstein (1978) defined the family as a psychof discrepancy discrepancy discrepancy discrepancy discrepancy discrepancy discrepancy discrepancy discrepancy discrepancy social group consisting of the patient and one or more persons, children or adults, in which there is a commitment A for'xnembers to nurture one another. Anderson and Carter (1978) defined the family from the viewpoint of the person within it. The definition included those individuals with whom he/she interacts and performs functions within the given society. Paolucci, Hall, and Aximin (1977) viewed the family as a set of mutually interdependent organisms; inti- mate, transacting, and interrelated persons who share some common goals, resources, and a commitment to one another that extends over time. Logan (1978) indicated the family comprises a network of individuals interdependently related to one another through the performance of complementary - roles (how families interact with one another). Clearly, there are numerous definitions of the family. A main characteristic that is a component of each definition is that a relationship exists between two or more individuals. For purposes of this study the family will be defined as the traditional nuclear family consisting of two legally married adults with or without children. Family Functioning From a health perspective there are numerous approaches available to study the family. The family has been viewed as a system, an ecosystem and a social network. The developmental, structural-functional, symbolic inter- action and psychoanalytic approaches have also been utilized for further understanding of the family (Anderson & Carter, 1978; Logan, 1978). The approach of this research to A examine the family will be to study the family functions in relation to breast cancer. The definitions of family functioning in the litera- ture appear to be unclear and difficult to operationalize. Smilkstein (1978) defined family functioning as the process of nurturing that promotes emotional and physical growth and maturation of all members. Lidz (1963) indicated the family performs three sets of functions: (1) provides physical care and nurturing of the children and at the same time directs their personality development, (2) furnishes a means to personal fulfillment and stability for the spouse, and (3) takes responsibility for enculturing new members for society. Pless and Satterwhite (1973) offered a less definitive explanation of family functioning. Family func- tioning was defined by Pless and Satterwhite (1973) as the dynamics of everyday life: the way in which a family, as a unit, operates across many dimensions. Pless and Satter— white (1973) developed an instrument to assess family func- tioning which included six major categories: (1) marital satisfaction, (2) frequency of disagreements, (3) happiness, (4) communications, (5) weekends together, and (6) problem solving. Geismar, Lasorte, and Ayres (1962) measured family functioning by means of rating role performance of family members in nine categories: (1) individual behavior and adjustment, (2) family relationships and family unity, (3) care and training of children, (4) social activities, (5) economic practices, (6) household practices, (7) health A 10 condition and practices, (8) relationship to social worker, and (9) use of community resources. Tapia (1972) developed a model for assessing family functioning based on Feldman and Schery's four main tasks of the nuclear family (to provide security and physical sur- vival, emotional and social functioning, sexual differenti- ation and training of children, and growth of individual members). The Tapia model consists of five levels of family functioning: (l) chaotic family, (2) intermediate family, (3) normal family with conflicts and problems, (4) family with solutions for problems, and (5) ideal family. Although the model offers criteria on which to evaluate family functioning the concepts have not been operationalized to test the model in a research setting. Several consistent patterns emerge from these definitions of family functioning: child care, nurturance and affection, household and economic activities and social relationships. Smilkstein (1978) developed an assessment tool for measuring family functioning described as the family APGAR. The family APGAR consists of five components each with individual definitions (Figure 1). Because the family APGAR offers the most general and comprehensive definition of family functioning it is possible to incorporate the com- ponents of Pless and Satterwhite, Geismar et a1., Lidz et a1., and Feldman et a1. into the major components of the APGAR (see Figure 2). A q-u oU‘I \IU . i I}. u 11 Adaptation: Adaptation is the utilization of intra and extra familial resources for problem solving when family equilibrium is stressed during a crisis. Partnership: Partnership is the sharing of decision making and nurturing responsibilities by family members. Growth: Growth is the physical and emotional matura— tion and self-fulfillment that is achieved by family members through mutual support and guidance. Affection: Affection is the caring or loving relation- ship that exists among family members. Resolve: Resolve is the commitment to devote time to other members of the family for physical and emotional nurturing. It also usually involves a decision to share wealth and space. Figure 1. The Family APGAR. Source: G. Smilkstein, The family APGAR: A proposal for a family function test and its use by physicians. The Journal of Familerractice, 1978, 6(6), 1231- 1239. Geismar, Lasorte, and Ayres, 1962 Pless and Satterwhite, 1973 Geismar, Lasorte, and Ayres, 962 Lidz, 1963 Feldman and Scherz, 1967 Pless and Satterwhite, 1973 Geismar, Lasorte, and Ayres 1962 Lidz, 1963 Feldman and Scherz, 1967 Figure 2. Adaptation Use of community agencies Relationship to social worker Health conditions and prac- tices Partnership Problem solving Respondent-spouse communica- tions Frequency of disagreements Growth Individual behavior and adjustment Care and training of children Social activities Physical care and nurturing of children Directs personality develop- ment Enculturing new members to society Sexual differentiation and training of children Growth of individual members Social functioning Affection Marital satisfaction Family relationships and unity Personal fulfillment and stability for spouse Emotional functioning Family Functioning Components a: at.- on s. I «vent-I I ‘v ‘q. I | ‘01... 4 . \" ‘Vfl Ivaoy Resolve Pless and Satterwhite, Vacations together 1973 Weekends together Geismar, Lasorte, and Ayres, Economic practices 1962 Household practices Figure 2. Sources: Continued. F. L. Feldman & F. H. Scherz, Family social wel- fare; helping troubled families. New York: Atherton Press, 1967. L. L. Geismar; M. A. Lasorte; & B. Ayres, Measuring family disorganization, Journal of Marriage and Family Living, 1962, 51—56. T. Lidz, The family and human adaptation. New York: International Universities Press, 1963. I. B. Pless & B. B. Satterwhite, A measure of family functioning and its application, Social Science and Medicine, 1963, 1, 613—621. wr—————————————i — 14 Figure 2 provides a format to operationalize the definitions of family APGAR. For example, partnership may be measured by asking questions concerned with frequency of disagreements, communication, and decision—making between the marital dyad since the mastectomy. Affection may be measured by determining if problems exist in the dyad's physical relationship. Because this study is concerned with the marital dyad, items related to child care will not be included in the instrument. For purposes of this study, family functioning will be defined as the way each individ- ual of the marital dyad perceives how they relate to one _ another across the five dimensions of Adaptation, Partner— ship, Growth, Affection, and Resolve. Marital Dyad The marital dyad will be defined as the legally married husband and wife. The population utilized to deter— mine the marital dyad's perception of family functioning will consist of: (1) married women in the Lansing area aged 29-75 who have experienced a mastectomy (simple, modified, or radical) and are within 8-16 weeks post-surgery, and (2) the legal spouse of the woman. Women who have been clinically staged one through four for breast cancer will be included in the study. Terminal patients will be included in this study. No cultural, racial, or socioeconomic I restraints will be placed on the population. The study will not include single or widowed women; separated or divorced I... A _ qe" Vv‘ no! V on ya! a 4.. "r ... A .- I... v on. .u‘ "I‘- ... \Lu ‘H‘ ,L D 0 f"!- 1:4 d ”1‘ 15 couples; or couples living together. In addition, the popu- lation will exclude those women who have been diagnosed with other chronic disease (diabetes, renal failure). Individuals with psychosis and mental confusion and illiterate individ- uals will also be excluded. Extraneous Variables Affecting Study Outcome Previous Relationships There are several extraneous variables that will impose limitations on the study. A variable that may influ— ence results is the relationship between the marital dyad that existed before the mastectomy. Woods (1978) study of women with breast cancer found the quality of the marital relationship preoperatively influenced the marital sexual relationship postoperatively. Morris, Greer, and White (1977) completed a two year follow—up on both mastectomy patients and patients with benign breast disease. Their study found marital adjustment was similar to pre- operative adjustment in 83 percent of the cancer patients and 75 percent of the benign breast disease patients. Thus, it can be assumed the pre-operative relationship will affect the post-operative relationship although it will not be measured in this study. A second extraneous variable influencing the marital dyad's perception of family functioning is the presence or absence of children, ages of the children, number of children, and the parent's relationship with the children. For this 16 reason family functioning will only be measured within the perspective of the marital dyad (how the dyad functions as a family). It is speculated that information on the family as a whole will be lost with this limited perspective. Age and Developmental Level of Family The developmental level of the family is an extrane— ous variable influencing the study outcome. Hill (1970) defined family development as encompassing the entire range of family behaviors which are stimulated and constrained by the changing age and sex composition of the nuclear or extended families over the life span. DuVall (1977) sup- ports the developmental approach to study families. For this reason the study has limited the age range to 29-75 years. It is estimated these families will be in the School Age Stage, Teenage Stage, Launching Stage, Middle Age Stage, or Aging Stage of development (DuVall, 1977). Developmental stages are important to perception of family functioning because particular problems may arise in relation to the developmental stage of the family. For example, the middle aged woman experiencing a change in body image from the mastectomy may be already experiencing the change in body image resulting from the aging process. Sexual problems may result from the two different processes affecting body image. The younger woman may have concern for the care taking of her children. It is important to 17 note that 50 percent of the women who develop breast cancer are between 45 and 65 years of age. Ems Time is considered an extraneous variable because the literature has indicated critical points in time for the woman adjusting to a mastectomy. Therefore, the time period in this study has been limited to eight to sixteen weeks post-surgery. Worden and Weisman (1977) investigated the relation- ship between mastectomy and post-operative syndrome of depression and lowered self esteem by comparing 40 newly diagnosed breast cancer patients with 50 other women diag- nosed with other types of cancer. Their findings indicated that on an average period of six months there were no significant differences between the two groups on measures of self—esteem and depression. Their findings did indicate that peak distress occurred about the time of the second follow-up which would be about eight to ten weeks into the illness. In an effort to evaluate a post-mastectomy program Winnick and Robbins (1977) issued a three page questionnaire three months after discharge to 1,700 women who have had a mastectomy. A total of 863 women completed and returned the questionnaire. The findings indicated that the majority of women had normal range of motion in the affected arm, 84 percent resumed normal activity and 13 percent suffered 18 emotional stress. This study indicated the peak occurrence Of emotional stress would have occurred prior to the three mwnth interview. Morris, Greer, and White (1977) conducted interviews prior to the breast biopsy and at 3, 12, and 24 months after surgery to determine social adjustment and degree of depres— sion in both mastectomy patients and patients with benign breast disease. The results of the study indicated psycho— logical stress was reported by 46 percent of the mastectomy patients at three months and at one year 70 percent of these patients indicated they were no longer stressed. One quarter of the respondents failed to adjust at two years. These studies have indicated the majority of women with a mastectomy experience peak psychological distress prior to the three months and that the distress appears to decrease with time. It is difficult to estimate a point in time when the family experiences peak distress because the studies have not attempted to measure this aspect of quality of survival. The research has not focused on the time period prior to three months, therefore, it is important to determine if this is a difficult time of adjustment for both the woman and her family experiencing the effects for breast cancer. For purposes of gathering an acceptable sample size the fourth month post-mastectomy was also studied. 0‘ A1 boil: ...... ‘vh K Y“ t Y) Av V. on n 3: DH - 9.. ~ fin‘. : I,‘ ‘uu (I: f Do "1 l L, (I) '1 (I) a In .1“ 19 Health Perception The woman's perception of her health is an addi- tional variable that may influence the outcome of her per- ception of family functioning. There have been no studies completed on the health perception of a woman who has had a mastectomy but it may be an intervening variable that will be assessed in this study. Adjuvant Treatment The use of adjuvant treatment, such as, chemotherapy or radiation therapy may influence the dyads perception of family functioning. Meyerwitz, Sparks, and Spears (1979) studied the psychosocial implications of adjuvant chemo- therapy for breast carcinoma. The results of the study indicated that every woman participating in the study reported adverse changes in her life resulting from the adjuvant treatment. It was found that 23 percent of the respondents indicated disruption in marital and family relationships, 17 percent reported decreases in sexual activity, and 54 percent reported increased financial burden. Other Extraneous Variables Measurement of perception of family functioning may be affected because the instrument will be designed for self—reporting by the participants. Geographic location may also be an extraneous variable affecting the study outcome. 20 A university is based in the Lansing area which may reflect a highly mobile and educated community. Assumptions In this study the research is making the following assumptions: ing: 1. All marital dyads will have some adjustments in family functioning post-mastectomy. Responses of the dyad to the family functioning instrument are real and honest. The respondents will be able to read and understand the instrument. The group selected for study are representative of a population of women who have experienced a mastec- tomy and their spouses. The questions in the instrument are accurate representatives of family functioning. The time period for collection of data, eight to sixteen weeks, is a time period when peak distress will occur. The marital dyad will not confer when responding to the instrument. The data analysis will be thorough and correct. Limitations In this study the research is limited by the follow- 21 1. The study does not measure the quality of the marital relationship prior to the mastectomy. 2. The subjects who agree to participate in the study may be different from those who refuse. Therefore, it is possible that the research findings are not representative of all marital dyads in which the woman has experienced a mastectomy. 3. The study does not include the children in the con- cept of family functioning. 4. The mailed questionnaire was completed in the home where the dyad had the opportunity to confer with one another. 5. The study is limited with respect to the point in time in which the data was collected. Family dys— function may occur prior or subsequent to the eight to sixteen weeks post-mastectomy. Overview of Chapters This study is presented in six chapters. The introduction, statement of the problem, operational defini- tions, and the limitations and assumptions are presented in Chapter I. Chapter II describes the conceptual framework of the nursing process in relation to the family facing breast cancer. Pertinent literature in relation to the problem is reviewed in Chapter III. The research design and methodology and rationale for data analysis are described in Chapter IV. Data and the analysis of the results are A '- .';"’ g . §y*,_ ‘..-~ v . .1 3| 'il'.§i-é" I .‘ 1 :. \. 22 The summary of the research find- cenclusions and recommendations, and nursing implica- CHAPTER II CONCEPTUAL FRAMEWORK Introduction In this chapter the relationship between nursing theory and the impact of a mastectomy on family functioning will be discussed. Rogers (1977) theoretical basis of nursing was utilized as the fundamental component of this conceptual framework. The rationale for the use of this particular nursing theorist for the study on the impact of a mastectomy on family functioning will also be explored in this chapter. In addition, nursing implications will be discussed. Rogers' Theory Rogers' (1977) theory of nursing provides a method of organizing abstract concepts and demonstrating their relationships. The basic concepts to Rogers' theory are: energy field, pattern and organization, unidirectional life process, space, time dimension, and continuous man— environment interaction. The energy field was defined as' the conceptual boundary of man. The energy field is in a continual state of flux and varies in intensity, density, 23 24 and extent. The energy field is the fundamental unit of living systems. The field may extend further into the envi- ronment and at other times retreat into man's visible core (Rogers, 1977). Pattern and organization are also basic concepts to Rogers' nursing theory. Pattern and organization were described as taking on greater complexity as life varied (Rogers, 1977). Rogers (1977) indicated that the existence of organization and patterning is a phenomenon and that the nature of life's pattern and organization is in a constant process of evolution. At particular points in man's life, repatterning occurs as a revision of the immediately pre— ceeding pattern. Earlier developmental patterns are replaced by later ones (Rogers, 1977). The concept of unidirectionality of life is funda- mental to Rogers' theory. Rogers (1977) indicated the uni- directionality of life exhibits an invariant one-way trend. Inherent to the concept of unidirectionality of life is the concept of space-time continuum. The space-time concept can be explained in relation to the process of change. Change takes place in space along the time axis (Rogers, 1977). Rogers (1977) stated the relationship between uni- directionality and space-time as follows: "The life process varies irreversibly and unidirectionally along the space- Umecmmhmmm" The continuous man-environment interaction is a major concept to Rogers' theory. Rogers (1977) stated that 25 the relationship between the human field and the environ- mental field is one of mutual interaction and mutual change. Man and environment were not to be separated but perceived simultaneously. Rogers (1977) indicated that it was the man-environment interaction process which portends the future and not the flexibility of man in adjusting to envi- ronmental change. The abstractness of this theoretical perspective is what enhances its applicability to nursing problems. The major concepts of the theory explore what man is, his rela- tionship to the environment, and the life process itself. These concepts are fundamental to the understanding of how the marital dyad (man) perceives the impact of a mastectomy (environmental exchange) on family functioning. Rogers (1977) clearly believed in the growth process of man through- out the life process in addition to visualizing man as being able to affect change in his future rather than adapting to environmental influences. These beliefs of Rogers have implications for the marital dyad facing the crisis of breast cancer. According to Rogers (1977) the marital dyad has the potential to grow from this experience and plan for the future in coping with the loss of the breast, fear of death, and/or reoccurrence, and changes in the marital relationships. It may be suggested that for the dyad to grow from this exposure their perceptions of how the mastec- tomy has affected family functioning need to be similar. Rogers' (1977) definitions of man, health, and the nursing 26 process in relation to the marital dyad coping with the impact of mastectomy will be explored in the following section. These relationships will further substantiate the use of Rogers' theory for this study. plan Rogers' (1977) definition of man has several impli- cations for the study of the marital dyad facing breast cancer. Man was defined as a unified whole possessing his own integrity and manifesting characteristics that are more than and different from the sum of his parts. Key ideas related to this concept identified by Rogers (1977) are: (1) Man has the capacity to maintain himself while undergoing change, (2) Man searches for meaning in life and death, (3) Man is sentient, (4) Man seeks to organize his world of his experience and make sense of it, and man is an active participant in the patterning of his field. Women who experience breast cancer and the process of a mastectomy endure profound psychological change from the fear of death, loss of feminine image, fear of mutation, and fear of reoccurrence (Polivy, 1977; Thomas, 1978; Asken, 1975), and biological change resulting from removal of the breast. Throughout these changes the woman has the remark— able capacity to maintain herself and continues to function. Although the literature indicates problems do occur post- mastectomy for the woman there are also indications that a substantial amount of women are coping well with the l V k . h a... 1 “f ~‘un ,4 (I) ‘0 A‘U' 27 situation (Winick et a1., 1977; Mosses, 1979; Jamison et a1., 1978). The spouse, similarly, must work through the changes that are occurring as a result of the mastectomy (role change as care giver, change within the sexual relationship and also the change of living with a person who has a chronic illness). Wellisch et a1. (1978) indicated the majority of men coped well with the psychosocial stresses which occur when the spouse has experienced a mastectomy. It has been documented in the literature (Thomas, 1978; Giaquinta, 1977) that both the woman experiencing breast cancer and her family search for the meaning of cancer. There is a need for the family to understand why this has happened to them. The process of searching for the meaning of cancer and the need to make sense of one's experiences support Rogers' concept of man as one who searches for meaning in life and death. Viewing man as a sentient being (capable of feeling and perceiving) is imperative when studying the dyad experi- encing cancer. The loss of a breast, presence of a chronic illness, and threat of death cause feelings of grief, loneli- ness, anger, and fear (Thomas, 1978; Asken, 1975). These feelings will affect how the dyad perceives the impact of the mastectomy on family functioning. In addition, the differences in perception between the dyad will also affect how they are functioning as a family. The concept of man as an active participant in the patterning of his field has implications for this study A 28 because it emphasizes the importance of man having the ability to utilize his resources to make decisions in an effort to reach his maximum health potential. Thus, the dyad coping with the impact of a mastec- tomy does have the capacity to undergo change, perceive the impact of a mastectomy and search for the meaning in its unique way, and remain an active participant in making health care decisions. Repatterning of the human field can be expected to take place after the crisis of a mastectomy has occurred on life's unidirectional line (see Figure 3). The dyad may need to have similar perceptions in order to reach their maximum health potential through repatterning of the human field. Health The health goal implied by determining the marital dyad's perception of family functioning is adequately described by Rogers. Nursing practice promotes symphonic interaction between man and environment, to strengthen the coherence and integrity of the human field and to direct and redirect patterning of the human and environmental fields for the realization of maximum health potential (Rogers, 1977). The realization of the marital dyad's maximum health potential is the nursing goal for this study. The maximum health potential will be unique to each dyad as they cope with the mastectomy. .mnma .mcfimusz mo Hoonom .muflmum>flcs mumum savanna: .msanH%m ohm Eoum ompmmcd .coHuomuwucH mucosa .mummom .m musmam cofluomumucH ucmaconfl>cmlcmz 9 msflcumuumm \ 2 \‘x‘lllljl'. \ (axill): I /\ r \ /\ usmmflofluumm m>Hu04 cauoz mmNflcmmHO usmfiusmm mcflcmme How nuummm uwxmamsoo :umuummlom mewsouo wamm mcfimucfimz Hmcofiuomuwoaso I llllllllllll r. lllllllllllllllllll mcwmmmuocH vamflm noes: camflm smsdm usmEcouw>cm 30 Rogers (1977) identified specific nursing goals: (1) maintenance and promotion of health, (2) prevention of disease, (3) nursing diagnosis, (4) intervention, and (5) rehabilitation. For purposes of this study nursing diagnosis and intervention will be considered components of the nursing process. Promotion and maintenance of family health is a goal for this study as the family function ques- tionnaire will identify the limitations and sources of strength for the marital dyad. The questionnaire will indi- cate positive areas in the couple's relationship in addition to areas where the nurse may help to support the dyad. Promotion of adequate family functioning is a goal of this study as the questionnaire will attempt to identify problems soon after the couple experience the mastectomy. These problems may be related to the different perceptions the marital dyad experience resulting from the mastectomy. Rehabilitation is a goal as the nurse works with the dyad to regain their former strength and new strength as a result of growth in family functioning. Rogers (1977) indicated health and illness are part of the same continuum and are not dichotomous conditions. The chronic nature of cancer influences the health continuum of the individual and the marital dyad as it may intervene with the marital dyad reaching its maximum health potential. For this reason it is imperative that nursing does not set the goal as adaptation but attempts to assist the marital dyad to reach their maximum health potential on the health 31 continuum. Nursing accomplishes this goal of reaching the maximum health potential through the nursing process. Figure 4 demonstrates the relationship between nursing goals and the family experiencing the impact of breast cancer. The Nursing Process Rogers (1977) indicated the phenomenon central to nursing's conceptual system is the life process of man. The nursing process, therefore, exists to serve people (Rogers, 1977). The nursing process implied by the stated problem places the marital dyad central to the concern of the nurse. Through the nursing process the nurse assists the marital dyad in reaching its health potential. The process the nurse utilizes to accomplish this goal is: (l) gathering data, (2) evaluating data (nursing diagnosis), (3) determining immediate and long range health goals for the individual, family, and society, (4) initiating inter- vention, and (5) evaluation of the effectiveness of inter- ventions (Rogers, 1977). The first step of the nursing process is gathering data. The data forms the basis for the subsequent compon- ents of the nursing process. The nurse and the marital dyad can determine problem areas in family functioning, strengths in family functioning, and available resources to the family. (see Figure 5). Rogers (1977) defined the second step, nursing diagnosis, as encompassing the man-environment 32 Maximum Health Potential Patterning fter n9th tal dyad Y Stre Identify problems soon a mastectomy Prevention of disease dentif Nursing Goals Figure 4. Nursing Goals for the Marital Dyad Experiencing the Crisis of a Mastectomy. Adapted from: M. E. Rogers, Theoretical basis of nursing. Philadelphia: F. A. Davis Co., 1977. 133 BREAST CANCER NURSE Independent Central to Exists to nursing practice MAN A Sentient being 7 Constant change Seeks to organize world and searches for meaning Active participant T .J MARITAL DYAD Wife/Husband W/ ‘x / \\ ./ Gathers Data Perceived Impact on Family Functioning Nursing ox - Identifies Patterns in Family Function- ing that prevent achievement of maxi- mum health potential Determine Determine Short and Short and Long ------------------ Long Term Goals Term Goals related to APGAR Intervention — Active Participant in Pattern Change Evaluation A '9 Evaluation ‘ Goals Met Goals Not Met Maximizing Re-evaluate Goals Health and Formulate New Potential Interventions Figure 5. Theoretical Model for This Study Demonstrating the Relationship Between the Nursing Process and the Marital Dyad Experiencing the Impact of a Mastectomy. 34 relationship. The nursing diagnosis seeks to identify sequential, cross sectional patterning in the life process. The nursing diagnosis assists the nurse in identifying specific patterns of family functioning that prevent the marital dyad from reaching their maximum health potential, such as, change in sexual relations, difficulty adapting to the change in body image, and different perceptions between the individuals within the dyad (see Figure 5). The third step of the nursing process is determining immediate and long term goals. Rogers (1977) emphasized the importance of man being an integral participant in the nursing process. Both the nurse and the marital dyad set goals for the couple to reach their maximum health potential. The marital dyad may need to set goals related to achieving previous level of sexual function (Affection), reestablishing former social relationships (Growth), delegating household responsibilities (Resolve), utilizing extrafamiliar resources (Adaptation), or making decisions regarding nurturance of children (Partnership). The woman experiencing the effects of a mastectomy may need to set goals related to developing a positive self concept, adjusting to a change in body image, and/or working through the possibility of impending death (see Figure 5). Initiating intervention that will achieve the goals established is the fourth step of the nursing process. Rogers (1977) indicated nursing intervention is directed toward repatterning of man and environment for more 35 effective fulfillment of life's capabilities. Life's capa- bilities are defined as encompassing man's humaneness, his creative promise, the capacity to feel and reason, and the symphonic potential of his tangible structure and function (Rogers, 1977). The nursing interventions utilized will be dependent upon the problems identified by the dyad which may be different perceptions and mutual goal setting between the dyad and the nurse (see Figure 5). Giaquinta (1977) identified ten nursing interven- tions for the family having a member with cancer. Fostering cohesion in a family that strengthens interaction, communica— tion, COOperation, and social and emotional involvement which help a family increase its autonomy and stability was one intervention identified. Thomas (1978), based on her model, identified the need to develop nursing intervention strategies intended to alleviate stress, enhance c0ping abilities, and improve the patient's and family's chances for emotional recovery. These interventions are applicable to the marital dyad experiencing the impact of a mastectomy. The final step of the nursing process is evaluation. There are numerous strategies to determine if the goals established have been met. One method to determine if the goals for the marital dyad have been met is to determine the level of family functioning of the marital dyad at six months and one year post-surgery. Both persistent problems and those problems which have been resolved could be iden- tified. Goals of the marital dyad and nursing intervention 36 strategies can be reevaluated and interventions reformulated for persistent problems. Rogers (1977) supports this cyclical process when she stated that the dynamic nature of life signifies continuous revision of the nature and meaning of diagnostic data and concomitant revision of interventional measures (see Figure 5). Summary In summary, the nursing process seeks to help the marital dyad maximize its health potential. The nurse accomplishes this task primarily through her knowledge of the fundamental characteristics of man (sentience, search- ing for meaning, active participant, etc.). The nurse gathers data concerning the perceived impact of the mastec- tomy on family functioning. Patterns of family functioning that prevent the dyad from reaching their health potential are specified. Long and short term goals related to Adaptation, Partnership, Growth, Affection, and Resolve are mutually set between the nurse and the dyad. Intervention is directed toward repatterning man and environment for more effective fulfillment of life's capabilities. The marital dyad is an active participant in the intervention process. Evaluation is the final component of the nursing process which encompasses formulating new interventions for goals not achieved (Figure 5 presents the theoretical model) by the marital dyad. 37 Rogers' theory (1977) clearly provides a theoretical basis for nursing to assist the dyad to reach its maximum health potential. The abstract concepts of Rogers' theory provide a general knowledge about man and nursing which are the primary components in the study of the perceived impact of a mastectomy on family functioning. Implications for Nursing The study of the marital dyad's perception of family functioning has several implications for nursing practice. Rogers (1977) indicated that nursing is an empirical science; similar to other sciences its purpose is to describe, explain, and predict the phenomena central to its concern. Rogers' theory (1977) also indicated that the wholeness of man and his integrity are basic premises underwriting nursing practice. Therefore, this study will contribute to nursing practice as it will assist nursing to describe, explain, and predict about man (the marital dyad experiencing the impact of breast cancer). This particular study concerned with the marital dyad's perception of family functioning post-mastectomy will make important contributions to nursing because it is a more specific measure of quality of survival Opposed to merely measuring return to work, physical symptoms and psycho- logical distress. The family focus of the study will con- tribute to nursing knowledge in an area that has been rela- tively unexplored. Preventive measures for families with 38 cancer may be developed as consistent problems within families are identified. Home visits or contact with the family in a primary care setting may become standard care for families adjusting to the diagnosis and treatment of cancer. The literature concerned with families primarily has had a sociological, psychological, and medical basis. Nursing needs to develop its own knowledge base if it is to describe, explain, and predict about families. Rogers (1977) indicated that prediction is the key to knowledge- able intervention. This study proposes to provide informa— tion that will be useful in describing the outcome of family- focused care. CHAPTER III REVIEW OF THE LITERATURE Introduction The literature review includes research studies and papers relevant to breast cancer and family functioning. The information on breast cancer has increased tremendously since the 19603. The pathophysiologic, etiologic, preventive and diagnostic aspects of breast cancer are currently being extensively explored. However, despite this wealth of information relatively little is known about the quality of life for the woman who has undergone a mastectomy and its impact on her family. Several studies have evaluated to varying extents the quality of life for the woman diagnosed with breast cancer (Abeloff & Derogatis, 1977; Morris & Greer, 1977; Craig, Comstock, & Geiser, 1974; Winick & Robbins, 1977; Schottenfeld & Robbins, 1970; Priestman & Bawn, 1976; Jamison, Wellish, & Pasnad, 1978). With the exception of Wellish, Jamison, and Pasnad (1978), these studies have a major limitation in that the family's adjustment to the diagnosis, treatment and rehabilitation of breast cancer has been ignored. The literature concern- ing the tOpic of family functioning is scant. Thus it 39 40 becomes important to examine closely what is known about family facing the crisis of breast cancer and the gaps in knowledge concerning this topic. This literature review consists of two parts, (1) the impact of a mastectomy on the marital dyad, and (2) family functioning. The Impact of a Mastectomy Several models have been develOped to assist the health professional help the family face the crisis of cancer (Wood, 1975; Tiedt, 1975; Giaquinta, 1977; Thomas, 1978). Thomas' model (1978) was developed for the analysis and understanding of the psychosocial problems the patient and family are experiencing from the impact of breast cancer. The model is a framework covering the time period before the diagnosis was made through the recovery period. Although the focus of this study is on the extended post-operative period the total impact of a mastectomy does not occur in one time period. The events occurring within the individual and family from the onset of discovering a lump through this extended post-operative period will influence the effect of the mastectomy on the family. Because Thomas' model (1978) encompasses numerous dimensions of a family facing breast cancer it will be utilized as a basis for organizing the literature review for the research and/or scholarly papers that have been completed about breast cancer. Each ;period will be described and then the extended post-operative 19eriod and the recovery period, which are the focal periods 41 of this study, will be related to the conceptual frame— work. Thomas' model consists of ten critical event periods: (1) Prodromal period, (2) Prediagnostic period, (3) Diagnostic period, (4) PreOperative period, (5) Opera- tive period, (6) Adjuvant treatment, (7) Recovery period, (8) Terminal period. Prodromal Period The prodromal period entailed descriptions of the patient prior to the discovery of a lump in the breast. Assessment of this period is useful as an attempt to antici- pate ways in which the patient will respond or attempt to cope with problems brought on by the illness. The person- ality, ceping attitudes, health beliefs and practices, intellectual and cognitive abilities, demographic data and self-concept are among the patient and family variables assessed (Thomas, 1978). Tiedt's model (1975) also provides a framework to understand the nature of a particular response of a patient to cancer. The model points out that the patient's responses are determined by a general pattern of behavioral responses to life. Tiedt's model (1975) demon- strated a schematic representation of the psychodynamics of the human behavioral response and extended it to the human behavioral response to cancer. Although Tiedt (1975) dis- cussed hypothetical situations utilizing different patient behaviors, c0ping mechanisms, treatment courses and nursing 42 interventions in relation to the model there was no clinical research completed. Thus Tiedt's work provides only a framework to organize the client's response to a cancer diagnosis. Research has been completed on the health beliefs/ attitudes of women who have not been diagnosed with breast cancer. Stillman (1977) studied women's beliefs about breast cancer and breast self-examination. The study was limited with regard to the samgie. Within the particular pOpulation Stillman found that women who had high beliefs in perceived benefits (relative subjective effectiveness of breast self-examination in reducing the threat of breast cancer) and/or perceived susceptibility (subjective risk of controlling breast cancer) tended to practice self breast exam to some degree. Although the study did not find a significant relationship between health beliefs and health behavior, Stillman indicated an interest in determining the relationship between the beliefs women held about breast cancer and the woman's control over its course, suggesting a psychodynamic nature of cancer. Studies have attempted to identify psychological parameters that may be indicative of a woman prone to breast cancer. In a literature review on women, cancer, and emo- tions, Surawicz (1977) indicated that in the past, cancer in women was viewed as the outcome of some psychosocial_ conflict, whereas, contemporary authors focus on the women's reaction to cancer and their potential for rehabilitation 43 suggesting less blame on the woman for developing cancer and the need to help her through this crisis. Greer and Morris (1975) studied the psychological attributes of women who deve10ped breast cancer. A total of 160 patients admitted for a breast tumor biOpsy had a structured psychi- atric interview for assessment of major stressful events, reaction to stressful events, salient personality traits, and psychiatric history, in addition to several psycho- logical tests the day prior to surgery (Hamilton Rating Scale for depression assessment, Eysenck Personality Inventory, Caine and Fould's Hostility Questionnaire). Breast cancer was found in 69 patients and benign breast lesions in 91 patients. A statistically significant associ- ation was found between breast cancer patients and an abnormal release of anger and other feelings. The women with cancer tended to suppress anger and other feelings to an extreme degree or express anger and other feelings to an extreme degree; In both groups, generally, the most common symptoms reported were anxiety and depression. There were no significant differences found in hostility, extraversion, or neuroticism between the groups, thus indicating that the expression of emotions was the only difference between those women with either a benign or malignant lesion. Snell and Graham (1971) examined the relationship between the experiencing of social trauma and the develop- ment of cancer of the breast. The authors interviewed 352 breast cancer patients and 670 female control patients with 44 other types of cancer and non-neOplastic diseases of organs other than the breast and genitalia. The patients were questioned concerning specific demographic traits and specific events which occurred in the five-year period pre- ceeding the diagnosis of their current illness. The insults measured were death, divorce, illness, financial difficulties, and unemployment occurring in the individual or family. The results of the study indicated that there was no significant difference between breast cancer cases and control in the experiencing of single or cumulative numbers of insults by either members of their families or themselves. Schonfield (1972) completed a study on the psycho- logical factors related to a delayed return to an earlier life-style for cancer patients. Two interviews were com- pleted on 42 cancer patients who had previously been employed full time in a nine-month period in which 63 items of the Minnesota Multiphasic Personality Inventory (MMPI) were given in addition to a short anxiety questionnaire. The first interview occurred during the first week of radio- therapy prior to the onset of side effects. Basic demo- graphic information and course of disease were obtained during this interview in addition to items from the MMPI. The second interview found that 33 patients had returned to work and nine had not. The respondents who had returned to~ work had significantly lower scores on the Moral Loss Scale and significantly higher scores on the Well Being Scale, indicating a more positive psychological outlook. The 45 investigator indicated that although the results needed to be confirmed with further investigation they may have impli- cations for cancer patients' treatment. Those patients most likely in need of further support could be detected through the questionnaire when administered at the onset of treat- ment for malignant tumors. This information could be utilized throughout the treatment of breast cancer in order to facilitate an easier adjustment for the woman. In summary, the literature studying the prodromal period indicates that the response to breast cancer is determined by the way individuals have responded to life prior to the onset of.breast cancer. The uniqueness of each individual will most likely determine their coping mechanisms to deal with this crisis. The literature did not substantiate that a particular psychological disposition or previous stresses predispose a woman to breast cancer. Prediagnostic Period Thomas (1978) indicated that the prediagnostic period presents a state of generalized disorganization until additional information is obtained about the lump in the breast or some form of active c0ping is reestablished. Some patients may deny the symptoms exist and seek reassur- ance from family members. The patient often feels alone and confused. Tiedt's model (1975) indicated that the patient's interpretation of the presenting symptom may be either an 46 exaggeration or an underestimation of the reality of the situation. Several studies have attempted to determine the reasons behind a delay in seeking treatment. Hammerschlag, Fisher, Decosse, and Kaplan (1964) studied the psychological variables involved in patient delay with breast symptoms. A method to determine body boundary and excerpts from the Minnesota Multiphasic Personality Inventory (MMPI) were utilized to determine if delay in seeking care was related to: (1) a more definite body image boundary, and (2) a more dominant use of the ego-defense maneuvers. A signifi- cant relationship was found between high barrier scores of body boundary and length of delay, but not with use of ego defense maneuvers. Gold (1965) completed interviews with 150 women who had diseases of the breast to determine the cause of delay in seeking treatment. Reasons given for delay in seeking medical attention were grouped into socioeconomic reasons (17 percent), lack of information (23 percent expected the lump to go away), and temporizing medical advice. Proper technique of self-breast exam was not taught to 94 percent of the women. Behavioral patterns and psycho- logical factors associated with women who delayed were: fear and anxiety, lack of tactilism, negativism, narcissism, indecision, depression, compulsion and guilt. The author did not reveal the extent of delay that took place with these women. Although the family was not studied in rela- tion to delay in seeking treatment it would seem that the 47 family would be an important factor in providing support or nonsupport for seeking care. It would also be important to study the relationship between delay in seeking care and perceived impact of the mastectomy in the extended post- operative period. The prediagnostic period appears to be a time of denial, confusion, and fear. The relationship between the woman's and family's feelings at this time and their feel- ings and coping abilities in the extended post-Operative period are unknown. In addition, it is not known if sup- port and counseling during this time would alleviate the fears and anxieties occurring in later time periods. Diagnostic Period The diagnostic period occurs when the woman seeks medical advice. Thomas (1978) indicated the woman will seek reassurance when denial fails. In addition, the woman is curious about techniques and procedures at this time. Both the family and the woman are fearful of the outcome of these techniques and procedures. The family feels excluded during this time period (Thomas, 1978). Katz, Weiner, Gallagher, and Hellman (1970), studied the stress, distress and ego defenses that occurred among 30 women hospitalized prior to a breast biopsy. After a three-day period the level of hydrocortisone (hydrocortisone is a hormone that rises during stress) was determined. In addition, an extensive psychiatric interview was then 48 conducted with each of the patients by the investigator. The focus of the psychiatric interview was to determine how effectively the patient c0ped with the stress confronting her, as judged by her function, affect, and defensive ade- quacy. These items were categorized as "ego defense." Defensive adequacy was operationally defined as the success the patient was having in c0ping with the threat of a breast tumor. The researchers discovered that: (1) subjects demon- strated a broad range of values for both endocrine and psychological parameters of defensive adequacy, (2) the hydrocortisone values clustered around normal levels, and (3) a significant correlation between the rank ordering of interviewer's scores for "ego defense" and hydrocortisone production. The authors concluded that the defenses of many of the subjects were Operating with great success. Their findings indicated that "all that stresses does not evoke comparable distress; rather the latter is contingent upon the former for perceived, interpreted and defended against" (Katz, Weiner, Gallagher, & Hellman, 1970). Although there were no other studies found related to the diagnostic period the study by Katz et a1. (1970) does indicate that defense mechanisms are operating at this time. This would support Thomas' model (1978). There have been no studies completed on the family during this time period to substantiate that the family feels excluded during the diagnostic period. 49 Preoperative Period Thomas (1978) indicated the preoperative period is a time when the woman expresses a dual attitude toward health care personnel. On one hand she is resentful that they are not able to give her much reassurance but on the other hand she is sure their care is critical to her sur- vival. Thomas (1978) continued to point out that the family responds with confusion and uncertainty. There is a pre- dominance of feelings of vulnerability and uncertainty among family members. The husband's feelings were not specifically described in this time period. Klein (1971) completed a paper on the crisis of breast cancer. Included in the paper were strategies that health care professionals could utilize to facilitate the woman working through this crisis. The importance of the family in helping or hindering the patient's coping was emphasized. Klein (1971) emphasized the need to prepare children for their mother's hospitali- zation and to respond to asked and unasked questions. Although the literature contains no clinical studies related to the preOperative period for the woman and/or the family of the woman undergoing surgery for a malignant tumor from what is known it appears to be a time of con- fusion and uncertainty for a woman and her family. Again, perhaps there are strategies health care professionals could utilize in this period to facilitate better c0ping mechanisms in the extended post-operative period when the woman is left at home without the support of nurses and physicians. 50 Operative Period During the Operative period the anxiety level of both the patient and the family increases tO a peak. Thomas (1978) noted that a patient who participated in the decision- making process for her care manifests a lesser degree Of decreased self-esteem than the woman who did not participate. The patient must deal with loss Of control, disfiguration, the unknown, and loss Of femininity. The family feels left out and powerless. The Giaquinta Model (1977) supports the Thomas model beginning at the Operative period. Giaquinta viewed the family as becoming disorganized with a high level Of nonproductive behavior when the family learns Of the cancer diagnosis. Role dilemmas at this time may result from lack Of initiative and leadership in the family. The Giaquinta model also supports the Thomas model in that there is a loss Of control among family members if feelings Of helplessness and anger are suppressed. NO studies were found in the literature concerned with the immediate Opera~ tive period for either the family or the patient. Up until this time Of diagnosis hOpe and denial can be active COping mechanisms for the woman and her family. When the diagnosis is clear it may be the onset Of the actual crisis for the family. Family functioning, according tO Giaquinta (1977) is disrupted as roles must be interchanged. The unique reaction Of the woman and her family at this stage may lay the basis for family functioning in later periods, thus this may be an important time for nursing 51 intervention tO help the family cope with the actual diag- nosis. Immediate Post-Operative Period During the immediate post-Operative period, accord- ing tO Thomas (1978), the woman who has had a mastectomy will experience both a fear Of death and relief that the surgery is over. Anxieties regarding reoccurrence and death, pain, dressings, and disfiguration may be dealt with by asking questions, seeking reassurance, or not showing interest in the laboratory findings or care (Thomas, 1978). In addition, Thomas' framework (1978) points out that there will be a search by the woman for reasons why this happened tO her as well as concern for who will take care Of her family. The woman may have feelings Of loneliness, isola— tion, and uselessness (Thomas, 1978). Giaquinta (1977) also indicated, similar tO Thomas, that there is a stage when the patient and family search for meaning Of cancer, or attempt to gain intellectual mastery over the cancer process. There may also be a need tO insure that it could not happen tO another family member in this period. Quint (1965) studied the institutionalized practices and tactics used by physicians and nurses in dealing with women who have had a mastectomy. Twenty-one subjects were interviewed during their hospitalization in addition tO participant Observation by the two nurse-field workers. The 52 subjects were then interviewed five times by the same nurses within 18 months post-hospitalization. A family member was present during one Of the final interviews. In addition 14 interviews were conducted with physicians not providing direct treatment for the particular women in the sample. Conversations with the nurses and Observations Of the nurses caring for cancer patients were also completed. Quint (1965) found that the subjects were tOld in generalized terms about cancer and their surgical experience rather than specifics. The physicians and nurses were found to make it difficult for patients tO ask direct ques- tions. When positive axillary nodes were discovered the physician stretched the prognosis in a favorable direction to the patient but frank statements were given tO the family. The nursing staff utilized gestures or actions which made it difficult for patients tO initiate conversation, especially a conversation that dealt with cancer diagnosis and prognosis thus indicating the need for health profes- sionals to deal Openly about cancer with patients. Several Of the women being interviewed had difficulty with their relationship to their family. Quint (1963) in an earlier report Of this study indicated some Of the prob- lems expressed were related tO feelings that family members do not understand you are not the same way any more, the family being tOld something different from the woman, and the family being caught in the tragedy and being made impotent by it tO provide support. In summary, Quint's 53 study (1965) found that there was a lack of communication between health care providers and patients, difficulties in family adjustment, and general concerns about disfigurement, fear Of death, and an uncertain future. Although Quint's study (1965) has interesting findings it is limited with respect to (1) sample size, (2) data gathering techniques and measurement tOOls, (3) age Of study, and (4) applica- bility to different research situations. Bloom, Ross, and Burnell (1978) studied the effect Of an intervention program tO breast cancer before, during and after hospitalization. Women receiving standard medical care (n = 18) were compared tO women receiving the counsel- ing and information services (n = 21) immediately after surgery and again two months later. The study indicated that patients in the intervention program had significantly greater affective reactions tO breast cancer than those receiving standard medical care. The patients in the inter- vention groups were more tense, depressed, and confused. Perhaps this would indicate patients in the intervention group experienced less denial. NO differences were at first Observed between the groups on the measure Of self-efficacy although significant increases in sense Of efficacy were found after two months in the intervention group. At two months patients in the intervention group still scored higher on mOOd scales although the differences were not significant. The authors concluded that the patient . 54 counseling education program had a long-term positive value due tO the increases in self-efficacy found after two months. In an effort tO evaluate the post-mastectomy hospital rehabilitation program (PMRG), Winick and Robbins (1977) mailed a three-page questionnaire three months after dis- charge tO 1,700 women who had had a mastectomy. A total Of 863 women completed and returned the questionnaire. The purpose Of the PMRG program was tO help the patient regain functional use Of her arm and shoulder in addition to adapt— ing tO the loss Of her breast and diagnosis Of cancer. The program began the first post-Operative day and continued daily until discharge. Group sessions were begun on the second post-Operative day which included teaching Of exer- cises, general information concerning the surgery, and pro- tection Of the arm. Three days during the week a social worker and volunteer led a discussion group concerned with the emotional and psychological adjustments Of a mastectomy. Winick and Robbins (1977) found the majority Of women had normal range Of motion in the affected arm (dif— ferences were Observed for age and type Of surgery), 84 percent (661 Of 790 patients) resumed physical normal activ- ity, and 13 percent (52 Of 406 patients) suffered emotional stress (being stressed, difficulty readjusting, being unable tO cope, etc.). Personal relationship adjustment was mea- ' sured in patient reports Of having difficulty in "nonsexual interpersonal relations with spouse, friends, family, and employer," and "sexual readjustment problems" (p. 480). 55 The authors concluded that there was insufficient data tO support inferences about severity Of personal relationship adjustment difficulties (only 15 percent Of the patients gave an adequate response in this category). In summary, the immediate post-Operative period con- tinues tO be a time Of crisis for both the woman and her family. The family may not be able tO provide the needed support due tO their own needs Of working through the crisis and searching for the meaning Of why this happened to them. Counseling and education were found tO be beneficial tO women who have had a mastectomy in this time period. The interventions utilized by health care prOfessionals at this time may have beneficial effects in the extended post- Operative period if they are helped tO begin providing sup- port tO the woman at this time. Extended Post—Operative Period Thomas' framework (1978) pointed out that a break- down in the denial pattern occurs in the extended post- operative period resulting in the woman's anger at everyone including herself. Anger is a response Of the grieving pro- cess for the loss Of the breast. Thomas (1978) pointed out that sexual difficulties may occur with her partner as a result Of the accumulated stress from both Of their fears about her health, the anxiety surrounding the loss Of the breast, and the tension due to the lack Of communication about these issues. The family may seem less supportive as 56 they direct their energies toward returning to their life as it was prior tO the discovery Of the patient's symptoms and surgery (Thomas, 1978). WOOds (1975) developed a theoretical model concerned with factors influencing the couple's sexual adaptation tO the mastectomy. Biological (preoperative breast size, extent Of wound, pain), psychological (value Of the breast, pre- operative body image, importance Of breast stimulation, perception Of the partner's reaction) and social factors (quality Of preOperative sexual relationship, occupational role) were among the factors tO be considered when assessing the couple's sexual adaptation. WOOds defined the mastectomy as one Of the most prevalent sexually-threatening experi— ences because Of the biological, psychological and social implications tO a woman's sexuality. The model is limited in that no documented studies have utilized it to test for effectiveness. Asken (1975) completed a literature review on the psychoemotional aspects Of a mastectomy. The literature indicated that the woman feels a threat Of death, sense Of mutilization, loss Of femininity, change in life style, and an inability tO adapt tO her previous roles which supports the Thomas model in various phases. There were no studies cited on the psychoemotional aspects Of the mastectomy for‘ the family. Morris (1979) completed a comprehensive review Of the literature on the psychological adjustment following a 57 mastectomy. The author concluded that reliable evidence on the extent Of psychological morbidity is scant. Morris (1979) indicated from the review Of literature that it seems likely that about three-quarters Of married or Older women who have had a mastectomy will recover from the experience within a year Of the Operation, that the marriage relation- ship will not suffer unduly, that more distant relationships may improve, and that most women will return tO work. Based on this review, the author concluded that between one quarter and one third Of women experiencing a mastectomy will be left with feelings Of personal inadequacy, anxiety and depression, or sexual difficulties. The only study reviewed concerning the effects on the male partner was the study by Wellisch et al. (1978). NO studies concerning the effects on the family were reviewed. In summary, the extended post-Operative period may be the time when the denial breaks down'and the woman is faced with the reality Of the situation. According to Thomas (1978), the family is returning tO their normal roles and the woman is relatively alone. Studies have indicated most women recover within a year but there is little known of what takes place during this recovery period for the woman and her family. In addition, little is known about what could facilitate a more rapid recovery for the entire family. 58 Adjuvant Treatment Period The adjuvant treatment period consists Of chemo- therapy and/or radiotherapy. Not all women will undergo adjuvant treatment. This period is important due tO the stresses that occur as a result Of the length Of time and side effects from treatment. The family at this time may have feelings Of guilt, tiring Of the prolonged treatment and wanting tO return to the normal family life (Thomas, 1978). Priestman and Baum (1976) used the linear analogue self-assessment (L.A.S.A.) tO measure the quality Of life in patients receiving treatment for breast cancer. The L.A.S.A. technique measured feelings Of well being, mood, level Of activity, pain, nausea, appetite, ability to per- form housework, social activities, level Of anxiety, and the question "Is treatment helping?" Although the sample utilized was small (n = 13), the researchers found the patients who had an Objective response tO chemotherapy had a significant improvement in the L.A.S.A. scores indicating a response to treatment facilitates adjustment. Meyerowitz, Sparks, and Spears (1979) studied the psychosocial implications Of adjuvant chemotherapy for breast carcinoma. The sample included 50 women receiving chemotherapy for Stage II breast carcinoma. The women were interviewed individually by a psychologist utilizing a structured interview format. The focus Of the interview was to determine the current quality Of her life in relation 59 to the adjuvant therapy program. Five major categories were specified in relation tO the perceived effects Of chemo- therapy: marital/family relationships, sexual relationships, financial situation, general level Of activity, and level Of work—related activity. The interviewer rated the degree Of behavioral impact (changes in daily living resulting from chemotherapy) and emotional impact (patient's subjective experience Of specific life changes, e.g., increased focus, newly develOped values) on a seven point scale. The inves- ‘dgators distinguished the effects Of mastectomy from chemo- therapy by asking the women only tO speak Of the effects Of chemotherapy. The results indicated that every woman participating in the study reported adverse changes in her life resulting from the adjuvant treatment. It was found that 23 percent Of the respondents indicated disruption in marital and family relationships, 17 percent reported decreases in sexual activity, 54 percent reported increased financial burden. Meyerowitz et al. (1979) indicated the most fre- quent and marked effect Of adjuvant treatment was a decrease in both general and work-related activity. Thirty-eight percent Of the women reported less active social activities and 32 percent reported less work-related activities. It was evident from this study behavioral changes lead tO a greater disruption in life style than emotional changes. Every woman reported adverse effects to the chemotherapy. This study clearly points out the significant influence 60 Of adjuvant treatment in relation to the adjustment to mastectomy. In summary, although little research has been com- pleted in the adjuvant treatment period, it appears tO be a significant event in the course Of recovery for both the woman and her family. The effects Of adjuvant treatment may disrupt family functioning to a great extent due tO the emotional, financial, and physical burden. Recovery Period The recovery period (six months and thereafter) includes a multitude Of positive responses from both the patient and family. Emotional and physical rehabilitation occur in this period. A reordering Of values occurs in the family as a response tO the change in life style. The woman has an increased interest in work and social activ- ities, increased sexual desire, increased self-esteem, and an Optimistic but realistic outlook toward the future (Thomas, 1978). The family returns to Old routines, an increased intimacy among the members occurs, and a change Of realistic optimism about the future may be Observed (Thomas, 1978). Schottenfeld and Robbins (1970) studied the quality Of survival among 826 patients who have had a radical mastectomy. A questionnaire was completed by the respondents concerning their ability to resume pre-Operative daily activities. The researchers found that after five years 84 percent Of the patients were able to return tO 61 their daily activities. This study is limited in that it does not qualify the patient and the family adjustment with regard to their quality Of life other than employment/ household activities. The authors did not indicate the average time period (post-mastectomy) for the study group. POlivy (1975) completed a literature review on the psychologic effects Of a radical mastectomy. The literature has consistently indicated that a mastectomy is devastating tO a woman. Depression, shame, worthlessness, shock that the basic female role may be endangered, denial and decreased value Of the breast were among the psychological effects Of a mastectomy reported. Although POlivy completed a thorough literature review, much Of the literature cited was completed prior tO 1970. The literature review did indicate a lack Of information with regard tO the patient's and family's long-term adjustment tO mastectomy. Morris, Greer, and White (1977) completed a two- year follow-up on both mastectomy patients and patients with benign breast disease. A total group Of 160 patients were followed; 69 patients with breast cancer and 91 patients with benihn breast disease. Interviews were conducted prior to the breast biopsy and at 3, 12, and 24 months after surgery tO determine social adjustment and degree Of depres- sion. The Hamilton Rating Scale was used tO measure degree Of depression. Four rating scales were developed to deter- mine social adjustment: (1) marital, (2) sexual, (3) inter— personal, and (4) work satisfaction. 62 The study by Morris et al. (1977) found that if recovery was to take place it will occur fairly rapidly. Psychological stress was reported by 46 percent Of the mastectomy patients at three months and at one year 70 per- cent Of these patients indicated they were no longer stressed. It is important tO note that more than one quarter Of the respondents failed to adjust at two years post-mastectomy. Marital adjustment was similar tO preoperative adjustment. in 83 percent Of the cancer patients and 76 percent Of the benign breast disease patients. Changes for the worse in sexual adjustment were found in 32 percent Of the cancer patients and 27 percent Of the benign breast disease patients at the two—year period. The preoperative level Of work adjustment was maintained for 71 percent Of the cancer patients. Interpersonal relationships improved for 24 per- cent Of the cancer patients in the two-year period. Cancer patients at two years post—surgery were found to have a significantly higher level Of depression (22 per- cent). The authors indicated that these were features which distinguish the "at risk" category during the time Of mastectomy. Those patients likely to experience depres- sive symptoms are patients who have signs Of depression immediately prior to surgery regardless Of their psychiatric history. Perimenopausal women are those women most likely‘ tO experience sexual difficulties with a mastectomy. It is important tO note that 21 percent Of the patients 63 interviewed were dissatisfied with the information received about their diagnosis. Craig, Comstock, and Geiser (1974) studied the quality Of survival in breast cancer patients. A total Of 134 breast cancer patients and 260 control subjects were mailed an 18 item questionnaire in an effort to determine the respondents' quality Of existence currently enjoyed. Disability, health status, employment, attitude, view Of the future, and symptoms (including depression) were the vari- ables measured for quality Of survival. The majority Of cases had surgery five or more years prior tO the survey. The researchers found 19 percent Of the cancer patients had a significant disability (5 percent related tO the mastec- tomy) and 16 percent Of the control subjects had a signifi- cant disability. The cancer patients and control group were similar when rating health status. The cancer patients had 31 percent employed while the control group had 25 percent employed. The majority Of both groups rated themselves as happy (84 percent cancer patients, 89 percent control group). Both groups had an almost identical response tO their view Of the future. It appeared from this study the only signifi- cant effect Of breast cancer was a slight increase in dis- ability and an increase in death rate (11.2 percent of the cancer patients died within 18 months after surgery while‘ 3.2 percent Of the control group died). Abeloff and Derogatis (1977) describe their pre— liminary results utilizing psychologic testing Of women who 64 have had a mastectomy. The SCL-90 (a self-report inventory on psychological symptoms) is a self-administered 90 item inventory which measures nine principal dimensions Of psychi- atric symptomatology and three global indices Of distress. Abeloff and Derogatis (1977) discovered the mean distress score for 34 patients with metastic breast cancer compared to 73 patients with other types Of cancer was higher on the positive symptom distress index which measures the intensity Of psychologic distress. Breast cancer patients were found tO have a greater degree Of symptomatology than other female cancer patients. In particular, the breast cancer patients shared the highest proportion Of symptomatology in feeling critical Of others, feeling inferior to others, feeling uneasy in crowds, feeling lonely even when with others, and having thoughts about sex that are bothersome. Jamison, Wellisch, and Pasnad (1978) studied the psychological effects Of a mastectomy on the woman. A questionnaire designed to examine the mastectomy procedures, emotional responses before and after the surgery, percep- tions Of effects on relationship with spouses, and attitudes towards surgeons and the nursing staff. The mean number Of months post-surgery was 22. Post-mastectomy emotional adjustment was judged as excellent or very gOOd in 60 per- cent Of the women, 71 percent adequate, and 10 percent not very gOOd, poor, or very poor. Those women whO reported better emotional adjustment received significantly more understanding and emotional support from physicians, 65 surgeons, husbands, nursing staff, and children. The entire sample reported that spouses and friends were primary sources Of support. More than two-fifths Of the women reported that from an emotional or psychological standpoint the most difficult time was immediately after the lump was discovered. The other two periods cited as being emotionally difficult were the post-Operative period in the hospital and the second and third month after surgery. Suicidal ideation was reported in one-fourth Of the women and 15.4 percent reported their alcohol use had significantly increased. Younger women rated their post-mastectomy adjustment as signifi- cantly poorer than Older women (45 years and above). The authors emphasized there were strong indications Of success- ful coping found in the sample, 71 percent Of the women rated their husbands reactions tO the mastectomy as extremely or very understanding and 76 percent felt the loss Of the breast made nO difference or had a positive effect in their sexual satisfaction. Wellisch, Jamison, and Pasnad (1978) reported on the psychosocial aspects Of a mastectomy from the man's perspective. NO data correlation Of the previous study on psychosocial aspects Of a mastectomy Of woman was made with this study. A questionnaire eliciting information concern- ing general assessment Of the marital relationship, psycho- logical parameters, sexual relationship, decisions made prior tO actual mastectomy, and the husband's perception Of their wife's evaluation Of the relationship and response 66 tO surgery was administered to 31 men whose wives or part- ners had experienced a mastectomy. The average time since mastectomy was 22 months. The results Of Wellisch et al.'s study (1978) indi- cated that the men were generally stable, either coped well or denied psychosocial stresses, the man's involvement in the decision-making process regarding the mastectomy was important, and generally sexuality and intimacy were stressed. The authors pointed out that a smaller subgroup Of the sample was distressed, remains distressed, and reported a downward spiraling quality Of their relationship. Thus, although only one study has been completed on the male partner Of a woman who has undergone a mastectomy it does indicate that a substantial number Of men also have a difficult time COping. The literature does not indicate a relationship between the men who have a difficult time COping and the COping abilities Of their affected spouse. Derogatis, Abeloff, and Melisaratos (1979) studied the psychological COping mechanisms and survival time in 35 metastatic breast cancer patients. The patients received a psychological evaluation at the time Of their second visit tO the oncology department. The time period post-surgery was not indicated. A 40-minute structured interview was conducted by a psychological technician focusing on the patient's attitudes and expectancies concerning the disease and its treatment. In addition, patients completed the SCL-90 measuring psychological symptoms and the Affect 67 Balance Scale measuring mOOd. The interviewer completed two instruments, one measuring patient's knowledge and attitudes concerning cancer and its treatment and one instrument that reflected the interviewer's perception Of the patient's overall psychological adjustment to illness. The treating oncologist completed the same two instruments within three days Of the patient's visit tO the clinic. Patients were categorized into long (one year or more) and short-term survivors. The results Of the study indicated that long-term survivors had higher psychological distress levels than short-term survivors. The long-term survivors demonstrated significantly higher levels Of anxiety, hostility, and psychoticism. The long-term survivors also had a signifi- cantly higher overall general severity index and positive symptom total. In addition, the measurement Of mOOd states indicated long-term survivors manifested significantly higher scores Of depression, guilt, hostility and the total negative affect score. The oncologist's rating Of adjustment to illness was significantly lower for long-term survivors than short— term survivors. In addition, the oncologist and psycho- logical technician rated long-term survivors as possessing significantly more negative attitudes toward their illness. Derogatis et al. (1979) concluded that there were substantial differences in the psychological profiles Of patients with metastatic breast cancer who survived for long periods Of 68 time and those patients who survived for short periods Of time. The long-term survivors were distressed, unhappy, and able to communicate about their disease. The long-term survivors' COping styles were external whereas the short- term survivors tended tO deny the distress from the disease. POlivy (1977) measured changes in body image, self- concept, and total self-image in mastectomy patients (n = 15) and two control groups (biopsy and surgical controls, n = 29). A questionnaire measuring the three concepts was distributed at three points in time: one day prior tO surgery, six days post-surgery, and six tO eleven months later. The results Of the study indicated mastectomy patients displayed a decline in body image and total self— image, but not until months after surgery. Biopsy patients demonstrated a decline in body image and total self-image immediately after surgery and surgical patients demonstrated little overall change. The recovery phase is time tO increase interest in one's family, work, and social activities. The literature indicates that although the majority Of women do return tO presurgical activities and level Of self-esteem there is a significant pOpulation who do not. The problems encountered by these women have been identified as depression, feelings Of inferiority, feelings Of being alone, and fear Of death. One study indicated that women who reported emotional well being also found their spouses tO be supportive. For the most part, the literature does not identify the role Of 69 family support in facilitating emotional recovery or specific interactions that may enhance recovery. Individual or family characteristics that may predispose the family to more prob- lems have not been clearly specified. Terminal Period The quality Of dying was the overriding concern in the terminal phase. The woman worries over the care Of her family. Both the patient and family have feelings Of hOpe- lessness (Thomas, 1978). The final three stages Of the Giaquinta model (1977) involved restructuring the living- dying interval, bereavement and reestablishment Of family goals. Both models indicated the families may feel some relief after the death has occurred. Summary Of Literature Review Of the Impact of a Mastectomy In summary, it is known that a substantial number Of women are not able tO COpe as well as other women who have faced the crisis Of mastectomy. It is not well established in the literature as tO how tO identify these women and their families who are having a difficult time COping or even the exact time period when problems may begin tO sur- face. For those women and their families who are not cop- ing, standard criteria for counseling and supportive services have not been identified. There are no studies in the literature which indicate what facilitates or diminishes effective coping to having a mastectomy. 70 The conceptual framework, presented in Chapter II included both the extended post-Operative period and the recovery period. The extended post-Operative time period Of Thomas' model (1978) occurs when denial may break down and patterns in family functioning may be disrupted due to the fear Of reoccurrence, fear Of death, loss Of self- esteem, or difficulty in adjusting tO the change in body image. The literature supports the fact that women experi— ence difficulties in COping but it does not Offer informa- tion on how other family members cope or how these family members can facilitate the woman's coping process. It is during this time period that problems in family functioning related tO adaptation, partnership, growth, affection, and resolve could be identified. The conceptual framework also includes the recovery period, as this may be the first time that the woman and her spouse are able tO determine goals that may enhance the level Of family functioning that currently exist. In addition, the conceptual framework identifies the importance Of the dyad being an active participant in pattern change. The dual participation Of both the nurse and the dyad is impera- tive when any type Of counseling takes place. The litera- ture did not provide information regarding the role Of the nurse in providing supportive counseling and education, but did indicate the need for such services. Although the conceptual framework includes only the extended post-Operative period and the recovery period, 71 the time periods prior tO these may affect family function- ing. The women's general self-esteem, her beliefs about breast cancer, the marital relationship prior to the mas- tectomy, adjuvant treatment, and the relationship with health care providers during the Operative phase may all affect the patterns in family functioning during the extended post- operative and recovery periods. The second section Of the literature review includes studies that have been completed on family functioning. These studies are examined tO determine what research has been completed in this area in addition to presenting the family APGAR, which is a major component Of the conceptual framework (see Figure 5). Family Functioning Pless and Satterwhite (1973) developed the first family functioning index tO be utilized in Office practice. The purpose Of the index was tO indicate families requiring further attention. The principle categories Of the index were marital satisfaction, frequency Of disagreements, happiness, communications, weekends together, and problem solving. The index was administered to the parents Of 399 schOOl age children. Two hundred and nine Of these children had chronic disorders and the remainder were healthy. In addition, the psychological adjustment Of the children was assessed by case workers prior to the home interview for the family functioning index. The results Of the study 72 indicated that the total family functioning index score was not affected significantly by the child's physical handicap. The authors concluded the index had a reasonable validity through comparing index scores with those scores established case workers. Reliability was measured through demonstrat- ing a high correlation between the scores Of husbands and wives. The case worker was requested to rate the family on a five point scale designed tO reflect the content Of the family functioning index. Satterwhite, Zweig, Iker, and Pless (1976) reported on the test-retest reliability Of the Family Functioning Index over a five year period. The original index was administered tO 399 children in whom 209 had a chronic disease. Five years after the initial interview a sample Of 29 families from the chronically ill group were studied a second time. A significant correlation was found between the original and retest Family Functioning Index score. The authors concluded the finding may indicate that the way a family relates remains stable over time and/or that the measure may also indicate relative freedom from random variation Of error. NO cancer populations have been retested with this instrument. Geismar, LaSorte, and Ayres (1962) studied a tech- nique for measuring family disorganization by rating role performance Of family members in nine categories Of social functioning (Family Relationships and Family Unity, Individ- ual Behavior and Adjustment, Care and Training Of Children, 73 Social Activities, Economic Practices, Household Practices, Health Condition and Practices, Relationship tO Social Worker, and Use Of Community Resources). One hundred and fifty multi-problem families were rated on a seven point continuum ranging from a level Of functioning considered inadequate tO functioning defined as adequate. Standards for rating were indicated in terms Of criteria covering the welfare Of family members and the degree Of harmony or con- flict between the behavior Of family members and community expectations. Household, health, and economic practices were found tO be the least problematic areas. Childcare, individ- ual behavior and adjustment, and family relationships were found to be the most problematic areas. The authors con- cluded that disorganized families have greatest difficulty with interpersonal relationships but show greater competence in the physical management Of the system. Major illness or crises were not studied in this research. Maurin and Schenkel (1976) developed an exploratory study tO describe intra-family interaction Of hemodialysis patients. The focus Of the study was to determine the manner in which the families performed its primary functions. A total Of 20 family units were interviewed concerning various aspects Of family life (e.g., rOle performance, finances, assignment Of responsibilities, etc.). The results indi- cated all families cited physical reasons for the patient's level Of functioning, the majority Of families reflected a positive sympathetic response to the patient, families 74 displayed little disagreement regarding household tasks, living arrangements, social and financial matters, although all families indicated the situation demanded adjustment. The authors indicated there appeared to be an inability to verbalize feelings, that might in fact display tension. All but three Of the families reported their social world tO have narrowed. The majority Of people manifested primary levels Of very positive effect toward one another. The authors concluded the renal dialysis family is marked by the patient's manifesting great levels Of control. In addition, there was minimal regard for the needs Of the nonaffected family members. Smilkstein (1978) develOped the screening question- naire called the Family APGAR which was designed tO elicit the patient's view Of his/her family. Smilkstein defined five parameters by which a family's functional health could be measured: Adaptation, Partnership, Growth, Affection, and Resolve. The APGAR was designed tO measure both nuclear and alternative life-style families. In a follow-up study, GOOd, Smilkstein, Good, Shaffer, and Arons (1979) reported on the validity Of the Family APGAR in which the instruments index (score) was compared with the scores Of the Family Function Index developed by Pless and Satterwhite (1973) and clinical therapists. The sample included a nonclinical group Of "normal" families (n = 38) and a clinical group Of psychiatric outpatients (n 20). The findings Of the study demonstrated a low tO moderate internal consistency between 75 the five items Of the APGAR Index for each group. A sig- nificant difference was found between the scores Of the clinical and nonclinical groups. A strong correlation was found between the Family APGAR Index score and the Pless- Satterwhite score. A moderate correlation was found between the Family APGAR Index score and the therapist's family evaluation. In addition, the scores Of the husbands and wives in the nonclinical group were compared tO assess the validity Of the Family APGAR. The inter-spouses correlation was .65 for the Pless-Satterwhite scores and .67 for the Family APGAR scores. The authors concluded the APGAR is a valid measure Of family function. The literature on family functioning is scant although several significant studies have been completed indicating reliable and valid tools (Pless et a1., 1973; GOOd et a1., 1979). The specific areas Of family functioning that have been measured focused on the marital relationship, communications, time the family has spent together, use Of extrafamiliar resources, and ability to problem solve. The studies that have been completed in the area Of family functioning have not utilized the family facing the crisis Of cancer as a sample. It is unknown whether these instru- ments are sensitive enough tO identify the problems or positive areas in family functioning for these particular families, although the instruments have been able tO iden- tify problems with emotional or interpersonal relationships which these families may be more prone to experience. 76 There were nO studies completed on the cancer patient and family functioning, although the conclusions Of the study by Maurin and Schenkel (1976) may be applicable. It was found that families managing the stress Of chronic disease were unable to verbalize these feelings Of tension and disagreement (Maurin & Schenkel, 1976). Thus, these results may have implications for this particular study in that the marital dyad may not be able to express their true feelings and concerns in relation tO the mastectomy. Summary In conclusion, the literature does indicate studies have been completed tO determine the quality Of life for the woman who has undergone a mastectomy. These studies have utilized different research tOOls tO measure the quality Of life (happiness, return tO normal activities, employment, disability, anxiety and depression scales) but with the exception Of Wellisch et a1. (1978) have not included systematic studies on the family Of the cancer patient. What can be determined from the breast cancer literature is that the majority Of women cope well or are able tO deny problems associated with the mastectomy, especially one year post-surgery. The problems that dO occur for a small, but significant number Of women are depression, loss Of self-esteem, fear Of death, and feelings Of inadequacy. Although only one study was completed on the spouse Of women who have had mastectomies it did point 77 out several important issues: (1) the spouse is a key sup- port person for the woman, (2) the spouse also was found tO generally COpe well or deny difficult feelings/problems, and (3) similar to the women a small group Of men remain distressed over the mastectomy. The literature also indi- cated that counseling and educational programs were bene- ficial to women who have experienced a mastectomy. In addition, nurses were perceived as potential support persons. The literature on family functioning was less informative than the breast cancer literature. There have been two instruments measuring family functioning that have been shown tO be reliable and valid. The studies that have been completed in family functioning have shown that families have greater problems with emotional or interpersonal rela- tionships than actual task performance (e.g., economics). In addition, families undergoing the stress Of managing a chronic disease were found tO deny or be unable to verbalize feelings Of tension or disagreement. There are several implications for research from the literature review for this study on the marital dyad's per- ception Of the impact Of a mastectomy on family functioning. The necessity Of studying the family facing the crisis Of a mastectomy is evident from the lack Of research completed on this topic. Identification Of the factors in the family that may contribute tO the distressful symptoms that both the husband and wife may experience post-mastectomy should be explored. In addition, the discrepancies in perception 78 Of how the family is functioning need tO be identified as the discrepancies may lead to further deterioration Of the relationship. A data base to substantiate the importance Of counseling and education for the woman and her spouse should be develOped, particularly concerning the time period when the woman first returns home. Concrete information tO begin develOping nursing interventions for these families needs tO be provided. The literature review also pointed out a major methodological problem for this study: The study completed by Maurin et al. (1976) indicated that respondents may deny or have the inability to verbalize family tension. The marital dyad similarly may have a diffi- cult time expressing tension. These results do support the fact, though, if there is a discrepancy in perception Of family functioning perhaps one individual is having a diffi- cult time expressing his/her true feelings. In Chapter IV, the Operational variables, sample population, instruments and scoring, procedure, method Of data analyses, and hypotheses will be presented. CHAPTER IV METHODOLOGY AND PROCEDURE Overview This study was designed tO determine the marital dyad's perception Of the impact Of a mastectomy on family functioning eight tO sixteen weeks post-surgery. The sample included 20 marital dyads who were referred to the study through Reach tO Recovery, surgeons in the greater Lansing area, a group Of university oncologists, and a Family Practice Center in Tennessee. The study investi- gated the differences in perception Of family functioning between the partners within the marital dyad. The study also sought tO determine the relationship between percep- tion Of the impact Of family functioning and other extrane- ous variables, such as, the woman's health perception, use Of adjunct therapy, and family develOpmental stage. In addition, the study explored the relationship between the five concepts Of family functioning defined by Smilkstein (1978) (Adaptation, Partnership, Growth, Affection, Resolve). In this chapter, the variables will be OperatiOnally defined, hypotheses will be stated, sample characteristics Will be described, the procedure for collecting data 79 80 will be described, and human rights protection will be discussed. Operational Definition Of the Variables The major study variables are discussed below. Major Study Variables. (a) Marital dyad: The marital dyad consisted Of a legally married couple. The marital dyad differs from the family in that, children and extended family members were excluded from the study. The instrument was developed tO elicit concerns Of and about the marital dyad. Questions pertained tO both Of the spouses' perceptions and feelings 0f family functioning. Each spouse was given an identical family functioning questionnaire tO complete. It was deter- IIIined that the couple was, in fact, a marital dyad through Correspondence with the physicians and alternate data col- lectors participating in the study. (b) Perception Of impact: An individual's repre- sentation or image Of reality; an awareness Of Objects, Persons, and events (King, 1971, p. 22). Perception was measured through the family functioning section Of the CInestionnaire. Items were worded in such a way tO measure Perception (e.g., I feel, I am, My spouse is). The concept family was defined below tO provide a better understanding Of the variable family functioning. (a) Family: Traditional nuclear family consisting of the legally married adults with or without children. 81 This information was elicited through the physicians and alternate data collectors participating in the study. (b) Family Functioning: The marital dyad's per- ception Of how they related tO one another across the five dimensions Of Adaptation, Partnership, Growth, Affection, and Resolve (Smilkstein, 1978). (i) Adaptation: The utilization Of intra and extra family resources for problem solving when family equilibrium is stressed during a crisis. (ii) Partnership: The sharing Of decision-making and nurturing responsibilities by family members. (iii) Growth: The physical and emotional maturation and self fulfillment that is achieved by family members through mutual support and guidance. (iv) Affection: The caring or loving relationship that exists among family members. (v) Resolve: The commitment to devote time and energy tO other members Of the family for physical and emotional nurturing. It also usually involves a decision tO share wealth and space (Smilkstein, 1978). The family functioning section Of the questionnaire was identical for both members Of the marital dyad. The questionnaire was develOped tO measure both the individual's perception Of him/herself and the individual's perception Of the spouse in the five dimensions Of family functioning (see Appendix A). 82 Extraneous Variables In order tO study the marital dyads perception Of the impact Of a mastectomy on family functioning it was necessary to collect data on the extraneous variables that may influence the outcome Of the study. The woman's per- ception Of her health, items to elicit information regarding the developmental stage Of the family, and descriptive items concerning the events in relation to the mastectomy were among the extraneous variables measured in this study. Separate sections Of the questionnaire were developed to measure these variables. In an effort tO measure the woman's perception Of her health, Ware's (1977) health perception scale was util— ized. A detailed description Of this scale is presented in a further section Of this chapter. The sociodemographic section measured family devel- Opmental stage and events surrounding the mastectomy. Hill (1970) described family develOpment as the entire range Of family behaviors which are stimulated and contained by the changing age and sex cOmposition Of the nuclear or extended families over the life span. Items Of the questionnaire elicited information on the age and number Of children, number Of children living at home, age Of spouses, and employment status. This information was evaluated by the investigator tO determine which stage Of development the family was currently in according to DuVall's (1977) stag- ing Of family development (see Appendix F). 83 In order tO gather information concerning the mas- tectomy questions asked for type Of surgical procedure, previous history Of breast and/or other type Of cancer, family history Of cancer, participation in Reach tO Recovery, and type Of adjuvant treatment. The amount Of time since surgery was determined through the physicians and alternate data collectors participating in the study. In summary, the major variables Of this study included the marital dyad's perception Of the impact Of the mastectomy and family functioning. Extraneous variables included the woman's perception Of her health, develOpmental stage Of the family, and events surrounding the mastectomy. These variables were measured in a total Of a four section questionnaire mailed tO the marital dyad eight to sixteen weeks post-surgery. The Instrument Prior to this study, research has not been completed on the marital dyad's perception Of the impact Of a mastec- tomy on family functioning. Therefore, nO standard instru- ments were available to measure these variables. A total Of one instrument was develOped to measure the variables Of this study. The instrument was divided into four sections, two identical sections to measure both the husband's and wife's perception Of the impact Of a mastectomy on family functioning, a section to measure the woman's perception Of 84 her health, and a section to measure sociodemographic variables. Family Functioning Section There was nO instrument identified in the litera- ture to measure the marital dyad's perception Of the impact Of a mastectomy on family functioning. Therefore, the major portion Of the instrument utilized in this study tO measure family functioning was adapted from Warren and Klenk's (1978) instrument that measures family functioning post myocardial infarction. The instrument has not yet been tested for reliability and validity. The Warren and Klenk Instrument was developed from Smilkstein's definitions Of the Family APGAR components (Adaptation, Partnership, Growth, Affection, Resolve). The researcher altered this instrument in several ways: (1) deleted and added items, (2) added items from the SCL-90 related tO anxiety and depression, and (3) con- structed the instrument so that every question which elicited the respondent's perception Of family functioning post- mastectomy would also elicit the respondent's perception Of the spouse's feelings about family functioning post- mastectomy. The following items are examples Of how perception Of self and perception Of spouse are measured: 1. I show more affection toward my spouse since the mastectomy. 85 2. My spouse shows more affection toward me since the mastectomy. It will be the differences in perception Of the dyad that will measure family functioning. If the woman feels that the spouse has shown less affection since the mastectomy but the husband feels he shows more affection since the mastectomy it would indicate a difference in perception, and therefore possible discord in family functioning. The total family functioning section Of the instru- ment consisted Of a 71 item index with a Likert Scale. Each item on the index was stated in understandable, con- crete terms. The marital dyad responded to individual items in the following manner: Strongly Moderately Slightly . Slightly Moderately Strongly Agree Agree Agree UndeCided Disagree Disagree Disagree (see Appendix A for Family Functioning Section). Crano (1973) indicated the Likert Scale is a reliable attitude measurement device. This particular study will assess the attitudes of the marital dyad. Crano (1973) continued tO point out that the Likert Scale is more effective in devel- Oping scales Of high reliability. Therefore, a Likert Scale was utilized to measure the perception Of the impact Of a mastectomy on family functioning as this variable is an attitude Of the marital dyad. The SOL-90 is a 90-item self-report clinical rating scale oriented toward the symptomatic behavior Of 86 psychiatric outpatients. The SCL-90 was utilized in the family functioning index tO measure construct validity. Crano (1973) indicated that construct validation represents a series Of Operations whose aim is the investigation Of the psychological reality Of a variable (construct). Crano (1973) identified the multi trait-multi method matrix tech- nique tO measure construct validity. Because anxiety and depression are constructs to which a dysfunction in the family may be related, the SCL-90 was administered as part Of the family functioning index to determine the correlation between the two constructs. The items from the SCL-90 were develOped and tested by Derogatis, Lipman, and Covi (1973). The total SCL-90 tOOl utilized nine symptom constructs: (l) somatization, (2) Obsessive-compulsive, (3) interpersonal sensitivity, (4) depression, (5) anxiety, (6) hostility, (7) phobic anxiety, (8) paranoid ideation, (9) psychotics. The con- structs Of anxiety and depression were utilized in this index. These concepts were analyzed separately from the APGAR components. (See Appendix C for the items included in this study.) Internal consistency among the items mea- suring anxiety and depression were calculated. Craig and Abeloff (1974) utilized the SCL-90 to assess the degree tO which 30 cancer patients were distressed by each item Of the SCL-90 during the past week. The results Of the study indicated that more than half Of the patients reported moderate to high levels Of depression. 87 Thirty percent Of the patients who participated in the study reported more than minimal levels Of anxiety. Abeloff and Derogatis (1977) conducted a preliminary study on 34 patients with metatastic breast cancer utilizing the SCL-90. Breast cancer patients were found tO have higher mean distress scores when compared tO 73 patients with other types Of cancer. From their preliminary study the authors indicated that following a mastectomy women were found to have high levels Of distress in the dimensions Of interpersonal sensitivity, depression, and anxiety. Derogatis, Rickets, and Rock (1976) investigated the validity Of the SCL-90 through administering the self- report symptom inventory and the MMPI (Minnesota Multiphasic Personality Inventory). Results Of the study reflected a high degree Of convergence for the nine primary symptom dimension Of the SCL-90 and the MMPI. The authors noted that the present study was viewed as a step in the valida- tion program the SCL-90. In summary, because the SCL-90 has been shown tO be a valid measurement Of symptom distress, dimensions Of the scale were utilized tO test the validity Of the Family Functioning section Of the instrument. The individual dimensions Of the family functioning section were correlated with the anxiety and depression dimensions Of the SCL-90. The total Family Functioning section Of the ques- tionnaire included items develOped tO measure: Adaptation, 9 items; Partnership, 11 items; Growth, 9 items; Affection, 88 10 items; and Resolve, 9 items. The SCL—90 section included 21 items. The questionnaire has been arranged to distribute the items from each category throughout the instrument. A total Of 71 items were included in this section. (See Appendix B for the items develOped tO measure perception Of family functioning utilizing the APGAR components.) Scoring and Analysis Of the Family Functioning Section A seven point Likert Scale was utilized to allow a more discriminated response from the participants. The scoring Of the Likert Scale ranged from one tO seven. Those questions eliciting a positive response were scored as follows: I show more affection toward my husband since the mastectomy. Strongly Moderately Slightly . Slightly Moderately Strongly UndeCided . . . Agree Agree Agree Disagree Disagree Disagree 7 6 5 4 3 2 1 Those questions eliciting a negative response were scored as follows: I dO very little tO help with household responsibilities since the mastectomy. Strongly Moderately Slightly . Slightly Moderately Strongly UndeCided . . . Agree Agree Agree Disagree Disagree Disagree 1 2 3 4 5 6 7 Therefore, those questions eliciting a positive response will receive a high point value for strongly agree and those questions eliciting a negative response will receive a low 89 point value for strongly agree. The instrument was an Opinion scale and there were nO right or wrong answers. Because the questions varied as tO whether they would elicit a positive or negative response, in the actual instrument a positive statement was usually followed by a negative statement tO eliminate a response set. The scores were totaled for each component Of the family APGAR. A Z score was computed for each item. A Z score is Obtained by subtracting from a person's Raw Score the mean score Of the total group and then dividing the result Of the standard deviation Of the group (Borg & Gall, 1971). The Z scores were totaled for each category Of Adaptation, Partnership, Growth, Affection, and Resolve. TO measure the differences in perception between the individuals within the marital dyad both an absolute and sign discrepancy score was calculated. An absolute discrepancy score is the absolute difference between the husband's and wife's score for each category Of APGAR. The sign discrepancy score is the score with a signed value Of + or - for the difference between the husband's and wife's score for each category Of APGAR. A calculation Of coefficient alpha, the estimate Of internal consistency was completed for each category Of APGAR. Coefficient alpha is a reliability estimate. TO determine the coefficient alpha each item Of the individ- ual categories Of APGAR is correlated with the total score for the particular category. 90 The higher the item—total correlation, the more predictive was the particular item Of the attitude being investigated. If the coefficient is 80 or higher, an internally consistent scale has been developed (Crano, 1973). The mean and the mode were calculated for males and females for each category APGAR. A t-test was calculated tO demonstrate the differences between the means for males and females. A Z score was calculated for each item Of the SCL-90 and summed for both the anxiety and depression scale. The absolute and sign score for each category Of the APGAR was correlated (Pearson Product Moment Correlation) with the anxiety and depression score from the SCL-90 for both individuals Of the dyad. The SCL-90 was also scored as an absolute and sign discrepancy score which was correlated with the APGAR. Health Perception Section The health perception questionnaire, develOped by Ware (1976) was utilized tO determine the woman's perception Of her health. The scale consisted Of six main variables titled current health, prior health, health outlook, health worry/concern, resistance-susceptibility, and rejection Of sick role. Three variables were chosen for this particular study: current health, health outlook, and health worry/ concern. Current health was defined tO mean the extent tO which the respondent presently sees himself as being healthy or ill. Current health included nine items. Health outlook 91 was defined to mean the respondent's prediction Of things tO come. Health outlook included four items. Health worry/ concern was defined as the extent to which the respondent is worried or concerned about his state Of health. Health worry/concern included four items. (See Appendix D for actual items identified with each variable.) The original instrument developed by Ware was tested on approximately 2,000 respondents in five different field tests. These tests were the basis for the instrument revision. Reliabilities Of the individual items were tested by test-retest correlations on twO Of the original field test populations. The correlations ranged from 0.19 tO 0.77 with most Of the correlations falling between .4 and .6 for single items. Test-retest reliabilities for the eight subscales ranged from 0.41 to 0.86. There was evidence that the instruments were measuring what they intended tO measure (e.g., the various subscales were found to be measuring different variables). There were five response categories for each health perception item. The woman within each marital dyad responded in the following manner: Definitely Mostly Don't Mostly Definitely True True Know False False The point value assigned tO each response depended on the way the statement was worded (either a positive or negative 92 statement). For example, the statement "According to the doctors I've seen, my health is now excellent" is a positive statement. The point value for each response would be assigned as follows: Definitely Mostly Don't Mostly Definitely True True Know False False 5 4 3 2 l The statement "I have been feeling bad lately" is a negative statement. The point value for each response would be assigned as follows: Definitely Mostly Don't Mostly Definitely True True Know False False l 2 3 4 5 A Z score was calculated for each item Of the health perception scale. The Z scores were then summed for current health, future health and health worry/concern. The abso- lute and sign discrepancy score Of the APGAR for each dyad was correlated, using Pearson Product Moment Correlation, with the dimensions on the health perception scale. In addition, a reliability estimate (coefficient alpha) was also completed on each category Of the health perception section. Sociodemographic Section The sociodemographic section was develOped to pro- vide information Of the study pOpulation for descriptive purposes. The extraneous variable, woman's perception Of 93 her health, was measured in an independent questionnaire described previously. The develOpmental level Of the family was measured in the sociodemographic section. Questions elicited infor- mation regarding age and number Of children, number Of children living at home, and employment status. Families were categorized at different stages and differences in APGAR scores were assessed through an analysis Of variance. An analysis Of variance is computed to determine if groups differ significantly from one another in relation to another variable. The different treatments for breast cancer were categorized and differences in APGAR scores were assessed through analysis Of variance. Descriptive statistics were utilized tO analyze the other events in relation tO the mastectomy. (See Appendix F for the sociodemographic section.) Reliability and Validity Crano (1973) defined the validity Of a scale as the "extent Of correspondence between variations in scores on the instrument and variation among the respondents on the underlying attribute under investigation" (p. 249). Crano (1973) continued tO point out that assessment Of content validity is a subjective Operation and that most investi- gators generate a large number Of diverse items focused on the domain Of interest. The generation of items to the 94 domain Of interest was completed in the develOpment Of the Family Functioning Instrument. There are several threats tO validity which are pertinent tO this research study. One Of the threats to validity is response bias. Because Of the untested nature Of the Family Functioning Instrument and the sensitive nature Of the study the wording Of the items may determine the subject's responses rather than the actual content Of the items. Social desirability is a major threat to valid- ity of this study. The respondents may be influenced tO respond in a socially desirable way as it may be difficult to express their negative feelings about themselves or their spouse and the respondents may be pressured tO confer with one another if one spouse expresses the desire to dO so. Denial may also be taking place which may cause a threat to validity as the subject may not be aware Of what his true feelings are. Extreme-response sets is an additional threat tO validity Of this study. The subjects may be prone tO respond to the extreme qualifiers Of this particular Opinion scale. Acquiescence is also a threat tO validity Of this study as the individual may tend tO agree with positively worded statements. For this reason items were both nega- tively and positively stated, in addition tO having a nega- tive statement follow a positive statement (as much as possible) in this questionnaire. 95 Crano (1973) indicated that the degree Of interrela- tionship among items tests the scale's reliability. Inter- nal consistency describes the condition in which there is a high degree Of interrelatedness among items (Crano, 1973). The internal consistency among the items was completed by computing a coefficient alpha for each category Of APGAR described previously in this chapter. The results Of the reliability estimate are presented in Chapter V. In summary, there were four sections Of the total questionnaire developed tO measure the marital dyad's per- ception Of the impact Of a mastectomy on family functioning. The develOpment Of these individual sections has been dis- cussed in addition tO scoring and analysis Of the data. Reliability and validity were discussed in relation tO the variables Of this study. The instrument was pretested on three marital dyads in which the woman had experienced a mastectomy beyond the study criteria. Follow-up phone calls tO these participants indicated they did not have a problem reading or understand- ing the document. Hypotheses and Questions Posed The following hypotheses were tested in this study: 1. There is nO difference between the individuals within the marital dyad in perception Of the impact Of a mastectomy on family functioning. 96 Subhypotheses la. There is nO difference between the individuals within the marital dyad in perception Of the impact Of a mastectomy on Adaptation. lb. There is nO difference between the individuals within the marital dyad in perception Of the impact Of a mastectomy on Partnership. 1c. There is no difference between the individuals within the marital dyad in perception Of the impact Of a mastectomy on Growth. 1d. There is no difference between the individuals within the marital dyad in perception Of the impact Of a mastectomy on Affection. 1e. There is nO difference between the individuals within the marital dyad in perception Of the impact Of a mastectomy on Resolve. , 2. There is no interrelationship among the five cate- gories Of family functioning. Subhypotheses 2a. There is nO relationship between the discrepancy scores Of Adaptation and Partnership. 2b. There is no relationship between the discrepancy scores Of Adaptation and Growth. 2c. There is nO relationship between the discrepancy scores Of Adaptation and Affection. 97 2d. There is nO relationship between the discrepancy scores Of Adaptation and Resolve. 2e. There is no relationship between the discrepancy scores Of Partnership and Growth. 2f. There is no relationship between the discrepancy scores Of Partnership and Affection. Zg. There is no relationship between the discrepancy scores Of Partnership and Resolve. 2h. There is nO relationship between the discrepancy scores Of Growth and Affection. 2i. There is nO relationship between the discrepancy scores Of Growth and Resolve. 2j. There is nO relationship between the discrepancy scores Of Affection and Resolve. In order to test hypothesis 1 and the subhypotheses, the individual Z scores Of each partner within the marital dyad were totaled for each category Of Adaptation, Partner- ship, Growth, Affection, and Resolve (APGAR). An absolute and sign discrepancy score was computed tO measure the differences in perception between the individuals. A Pearson Product Moment Correlation was computed between each APGAR component tO test hypothesis 2 and the subhypotheses. The extraneous variables Of the study were also evaluated to determine if a relationship existed between the extraneous variables and family functioning. Families were categorized at different develop- mental stages and differences in APGAR scores were assessed 98 through an analysis Of variance. The relationship between the marital dyad's perception Of family functioning and the woman's perception Of her health was measured by correlating the discrepancy scores for the APGAR components and the three dimensions Of health perceptions. The different treatments for breast cancer were categorized and differences in APGAR scores were assessed through analysis Of variance. The data was summarized to answer the following question: What are the differences in perception between the marital dyad Of the impact Of a mastectomy on family functioning? Population The total pOpulation from which the convenience sample was drawn was every woman patient, 29-75 years Old, seen in the oncology practice at the Michigan State Univer- sity Clinical Center within a six month time period. In addition, the practice Of a university-based surgeon was utilized tO identify women meeting the study criteria within a four month time Span. A community-based surgeon also pro- vided subjects meeting study criteria in the six month time span. A Family Practice Center in Tennessee was also utilized tO identify mastectomy patients. A coordinator for a specific geographic area working for Reach to Recovery also provided subjects who met the study criteria. These particular study sites were not selected at random and therefore limit the applicability Of this study. NO 99 cultural, ethnic, or socioeconomic restraints limited the pOpulation size. The surgeons, oncologist, and Reach to Recovery coordinator were supportive Of the research process and provided the information needed tO complete the data collec- tion phase. Subjects--Criteria for Selection The pOpulation utilized to determine the marital dyad's perception Of family functioning consisted Of: (l) married women residing in Michigan or Tennessee aged 29-75, who have eXperienced a mastectomy (simple, modified, radical), (2) women in whom the mastectomy occurred eight tO sixteen weeks prior tO data collection, and (3) the legal spouse Of the woman who has experienced the mastectomy. The study did not include single or widowed women, separated or divorced couples, or couples living in the same home without being legally married. In addition, the pOpu- lation excluded those women who have been diagnosed with a chronic disease (diabetes, renal failure). Individuals with psychosis and mental confusion and illiterate individ- uals were also excluded. Procedure The investigator made personal.contact with five surgeons located in the Greater Lansing area who were known tO perform mastectomies. Three surgeons agreed tO partici- pate in the study, although one Of these surgeons could not 100 provide patients to meet the study criteria. Two surgeons refused tO participate in the study on the basis that it may be upsetting tO their patients. An oncology group located at Michigan State University agreed tO participate in the study. A community-based oncologist was contacted to determine if he would participate in the study. This oncologist was supportive Of the study, although his clients did not meet the study criteria time frame. A computer survey was completed in five Family Practice Centers to identify patients who have had a mastectomy. This survey could not identify patients who met the study criteria. A Family Practice Center in Tennessee agreed tO participate in the study. In addition, the American Cancer Society was contacted tO determine if women from the Reach tO Recovery could be asked to participate in the study. The American Cancer Society agreed tO participate on the basis that names and phone numbers Of the subjects were not given directly tO the investigator. (See Appendix G for Training the Alternate Data Collector for the Reach tO Recovery Sites.) A total Of two surgeons, one oncology group, one Family Practice Center, and the Reach to Recovery organi- zation participated in identifying subjects for this study. The study was explained tO the surgeons, oncologists, and alternate data collectors so that the importance Of the research was emphasized. The personnel in the study sites were responsible for providing a list Of women who have met 101 the criteria for participation, with the exception Of the alternate data collectors. Once permission was granted the names, date Of surgery, and phone number was given tO the investigator at which time she proceeded tO collect the data. The alternate data collector began collecting data when it was determined potential participants met study criteria. Data Collection During the data collection phase, women who have met the established criteria for participation in the study were contacted by phone. The established criteria was determined by the investigator or the alternate data collector (see Appendix H). The phone contact by the investigator tO the women who have met the established criteria to participate in the study proceeded as follows: (a) Introduction Of self by name, position, and associ- ation with physician or organization participating in the study. (b) Explanation Of the research study. (c) Indicate what amount Of time and effort is needed on the marital dyad's part to participate in the study. (d) Request for participation in the study. (e) Assurance Of anonymity and confidentiality. (f) Assure potential participants they can refuse. (g) (h) (i) (j) (k) (l) (m) 102 Assure potential participants that refusal would in no way interfere with health care from their physician. Allow time for the woman tO discuss the study with her husband if needed. Arrange a time to call back within one week Of time if needed tO discuss the study with the husband. If time is not needed tO discuss with husband, the researcher or alternate data collector will spend time giving in-depth instructions for completing the questionnaire. If participation is granted mail the questionnaire to both individuals within the marital dyad. At the time Of the second phone call if partici- pation is granted, the researcher or trained per- sonnel would spend time with the woman giving in- depth instructions for completing the questionnaire (see Appendix I). The researcher or trained personnel would call the marital dyad within four days to determine if there are any problems in completing the questionnaire. The researcher or trained personnel would Offer support at this time. The researcher/trained per- sonnel would also emphasize to participants to call him/her if further questions should arise. If potential participant refused tO be included in the study they would be thanked for their time; and 103 their name and reason for refusal would be recorded. The researcher or trained personnel will provide a telephone number to be contacted with if any ques- tions should arise. (n) The data was received through the mail at Michigan State University's School Of Nursing and stored in the investigator's desk. At completion Of the data collection phase the data was coded on Fortran coding sheets and keypunched tO prepare for data analysis. Human Rights Protection Specific procedures were adhered tO in order tO protect the right Of the respondent. The Michigan State University Committee on Research Including Human Subjects has established standard criteria for researchers tO follow when including human subjects. An explanation Of the particular research area, purpose, utilization Of results, amount Of time required and potential risks were provided tO the subjects in the consent form (see Appendix J for a sample OOpy). In addition, the Investigator's Statement included information confidentiality, freedom to withdraw, and a statement that withdrawal will in nO way affect the health care they are currently receiving. Results Of the study following its completion were Offered tO the subjects. The investigator's name, address, and phone number was 104 provided tO the participants who were asked tO call the investigator if any questions should arise. The initial phone call to potential participants also provided information on the purpose and confidential nature Of the study. In addition, the subjects were told they had a right tO refuse and that this in nO way would affect their health care. The investigator called those subjects with whom she had direct phone contact (this would exclude those subjects Obtained from Reach to Recovery and Tennessee) several days after the questionnaire arrived to determine if there were problems that were encountered by the marital dyad. The questionnaires were precoded with a subject code number, site number, and date. The questionnaires were stored in the researcher's Office. Data was recorded from the questionnaire in aggregate form. This research study was presented tO the Human Sub- jects Review Committee Of the School Of Nursing and approval was given on July 6, 1979 by the Human Subjects Review Committee chairperson. Summary Chapter IV included the research variables measured in this study. The scoring and the techniques for data analysis were discussed in this chapter. The sample and procedure were discussed. The hypotheses were also presented in this chapter. A discussion Of human rights protection 105 was included. Chapter V presents the data and analyzes the results in relation tO the research hypotheses and questions. CHAPTER V DATA PRESENTATION AND ANALYSIS Overview The data presented in this chapter describes the study pOpulation and the marital dyad's perception Of the impact Of a mastectomy on family functioning. In addition, the data will be presented to describe the relationship between extraneous variables (the woman's health perception, use Of adjuvant treatment, and family developmental stage) and the marital dyad's perception Of the impact Of a mastec- tomy on family functioning. The study population was a con- venience sample Of 20 marital dyads in whom the woman has experienced a mastectomy. In Chapter V a description Of the findings Of the study pOpulation and data presentation for the hypotheses are included. The following hypotheses were tested: 1. There is no difference between the individuals within the marital dyad in perception Of the impact Of a mastectomy on family functioning. Subhypotheses la. There is no difference between the individuals within the marital dyad in perception Of the impact Of a mastectomy on Adaptation. 106 107 lb. There is no difference between the individuals within the marital dyad in perception Of the impact Of a mastectomy on Partnership. 1c. There is no difference between the individuals within the marital dyad in perception Of the impact Of a mastectomy on Growth. 1d. There is nO difference between the individuals within the marital dyad in perception Of the impact Of a mastectomy on Affection. 1e. There is no difference between the individuals within the marital dyad in perception Of the impact Of a mastectomy on Resolve. 2. There is no interrelationship among the five cate- gories Of family functioning. Subhypotheses 2a. There is nO relationship between the discrepancy scores Of Adaptation and Partnership. 2b. There is no relationship between the discrepancy scores Of Adaptation and Growth. 2c. There is nO relationship between the discrepancy scores of Adaptation and Affection. 2d. There is no relationship between the discrepancy scores Of Adaptation and Resolve. 2e. There is nO relationship‘between the discrepancy scores Of Partnership and Growth. 108 2f. There is nO relationship between the discrepancy scores Of Partnership and Affection. 29. There is no relationship between the discrepancy scores Of Partnership and Resolve. 2h. There is nO relationship between the discrepancy scores Of Growth and Affection. 2i. There is no relationship between the discrepancy scores Of Growth and Resolve. 2j. There is nO relationship between the discrepancy scores Of Affection and Resolve. Descriptive Findings Of the StudnyOpulation The study population consisted Of 20 white women and their legally married spouse. This population ranged in age from 29 through 72. The mean age for women was 54.5 and the mean age for men was 56. The actual number and percent Of women and men for age can be seen in Tables 1 and 2. The number Of children Of the couples in this study ranged from one tO six as can be seen in Table 3. The mean number Of children for each family was three. There were nO childless dyads. Two Of the subjects had a previous history Of breast cancer (10 percent) while for 18 Of the subjects this was their first mastectomy (90 percent). Of the sample, 14 women (70 percent) had a modified radical mastectomy, one woman (5 percent) had a simple mastectomy, one woman (5. percent) had a radical mastectomy, and four women (20 109 Table 1 Age Of Female Subjects (n = 20) Age Number Of Participants Percentage 29 1 5 30 l 5 42 1 5 51 3 15 52 2 10 53 l 5 54 l 5 55 2 10 59 l 5 60 2 10 63 1 5 66 l 5 68 2 10 72 l 5 Total 20 100 110 Table 2 Age Of Male Subjects (n = 20) Age Number Of Participants Percentage 29 2 10 30 1 5 52 2 10 53 2 10 54 l 5 55 l 5 59 l 5 60 l 5 61 l 5 62 l 5 64 l 5 66 2 10 67 l 5 71 l 5 72 l 5 75 l 5 Total 20 100 111 Table 3 Number Of Children Of Marital Dyads (n = 10) Number Of Children Number Of Dyads Percentage 1 4 20 2 2 10 3 7 35 4 5 25 5 l 5 6 l 5 Total 20 100 percent) indicated they had another procedure or did not know what type Of surgical procedure they had. Four women (20 percent) had other current medical problems, such as, hypertension or arthritis. Thirteen women (68 percent) participated in Reach tO Recovery. Years Of marriage was elicited from each Of the marital dyads. The mean number Of years married was 33. The years Of marriage ranged from 6 tO 49 as can be seen in Table 4. There was one missing case. Of the partici- pants, this was the first marriage for 17 dyads (85 percent). Women participating in this study were asked about adjunctive therapy for cancer. At the time Of completing the questionnaire, five women (25 percent) were receiving chemotherapy. One woman (5 percent) was receiving radiation therapy: three women were not receiving adjuvant treatment 112 Table 4 Years Of Marriage Of Marital Dyads (n = 19) Years Of Marriage Number Of Dyads Percentage 6 2 ll 8 l 5 25 l 5 29 l 5 31 3 16 32 1 5 33 2 ll 36 l 5 39 l 5 40 l 5 44 l 5 45 l 5 46 l 5 49 2 11 Total 19 100 113 at the time but had plans tO, and eleven women (55 percent) had nO plans on receiving adjuvant therapy. One woman (5 percent) checked another category. The developmental stage for each family can be seen in Table 5. Table 5 DevelOpmental Stage Of Family (n = 10) Developmental Stage Number Of Dyads Percentage Childbearing l 5 School Age 1 5 Launching Age 7 35 Middle Age Stage 5 25 Aging 6 30 Total 20 100 The convenience sample included five women (25 per- cent who worked outside Of the home and fifteen (75 percent) women who were not employed outside Of the home. Data Presentation for Hypotheses The Statistical Technique In order tO test the hypotheses several statistical anslyses were computed. The raw scores were totaled for each component Of the family APGAR. A Z score was then com- puted for each item and summed for each category Of APGAR. 114 A 2 score is Obtained by subrracting from a person's raw score the mean score Of the total group and then dividing the result by the standard deviation Of the group (Borg & Gall, 1971). TO measure the differences in perception between the individuals within the marital dyad both an absolute and sign discrepancy score were calculated. An absolute dis- crepancy score is the absolute difference between the hus- band's and wife's score for each category Of APGAR. The sign discrepancy score is the score with a sign value Of + or - for the difference between the husband's and wife's score for each category Of APGAR. The husband's score was subtracted from the wife's score. It was then determined if the discrepancy score was significant at the .10 level to identify dyads with extreme discrepancy scores. The level Of confidence was set due tO the two-tail distribu- tion Of the scores. A two tail t-test was calculated to determine the differences between the means for males and females. For this statistical test, in order to reject the null hypoth- esis, the level Of confidence was set at .05. TO determine an interrelationship among the five categories Of APGAR a Pearson Product Moment Correlation (4) was computed. "The size Of the correlation coefficient is indicative Of the degree Of relationship between varir ables, and a low correlation indicates a low relationship" (Borg & Gall, 1971, p. 358). The interpr ables in this study 1. r from 0.00 or if close between the 2. r from 0.20 present, bu 3. r from 0.40 correlation 4. r from 0.60 high relati 5. r from 0.80 relationshi Borg and Ga coefficient is stat is sufficiently big that a true relatiO this study, in orde level Of confidence statistics. Hypothesis 1: Each APGAR 115 etation Of r computed between the vari- was: tO 0.15 or 0.20 represents negligible, tO 0.20, very slight relationship variables. tO 0.40 represents low correlation t slight. tO 0.60 represents moderate or fair tO 0.80 represents marked, somewhat onship. tO 1.00 represents high tO very high p (Van Ormer & Williams, 1941, p. 65). 11 (1971) stated that when a correlation istically significant, the coefficient b so that there is reasonable confidence nship exists between the variables. For r to reject the null hypotheses, the was set at .05 for the correlation There is no difference between the individuals within the marital dyad in perception Of the impact Of mastectomy on family functioning. component was measuring a different dimension Of family functioning. Therefore, the subhypoth- eses were develOped tO measure the differences individuals 116 experience in perception Of the impact Of a mastectomy on Adaptation, Partnership, Growth, Affection, and Resolve. The mean for each category Of APGAR was computed. A t-test was computed tO determine the differences between the means Of husbands and wives for each category Of APGAR (see Table 6). Table 6 T-Test Demonstrating the Differences Between the Means Of Husbands and Wives for Each Category Of APGAR (n = 20) APGAR Categories T-Value Degrees Of 2-Tai1 Freedom Probability Adaptation -.07 38 .947 Partnership 1.58 38 .123 Growth 1.10 38 .278 Affection -.08 38 .938 Resolve -.26 38 .798 * = Significant at the .05 level. Subhypothesis la: There is nO difference between the individuals within the marital dyad in perception Of the impact Of a mastectomy on Adaptation. Of the 20 dyads only one dyad was found tO have absolute discrepancy score significant at the .100 level. This would indicate that there are differences in perception 117 Of the impact Of a mastectomy on Adaptation for this dyad (see Appendix K). A t—value describing the difference between the mean scores Of husbands and wives on adaptation was -.07 (38df) and had a two-tailed probability Of .947 (see Table 6). This was not significant at the .05 level and thus the null hypothesis was accepted. Subhypothesis 1b: There is nO difference between the individuals within the marital dyad in perception Of the impact Of a mastectomy on Partnership. Of the 20 dyads, one dyad was found tO have both an absolute and sign discrepancy score significant at the .100 level. This would indicate that there are differences in perception Of the impact Of a mastectomy on partnership for this dyad (see Appendix L). A t-value describing the difference between the mean scores Of husbands and wives on Partnership was 1.58 (38df) and had a two-tailed probability Of .947 (see Table 6). This was not significant at the .05 level and thus the null hypothesis was accepted. Subhypothesis 1c: There is nO difference between the individuals within the marital dyad in perception Of the impact Of a mastectomy on Growth. Of the 20 dyads, three dyads were found tO have both an absolute and sign discrepancy score significant at the 118 .100 level. This would indicate that there are differences in perception of the impact Of a mastectomy on Growth among these three dyads (see Appendix M). A t-value describing the difference between the mean scores Of husbands and wives on Growth was 1.10 (38df) and had a two—tailed probability Of .278 (see Table 6). This was not significant at the .05 level and thus the null hypothesis was accepted. Subhypothesis 1d: There is nO difference between the individuals within the marital dyad in perception Of the impact Of a mastectomy on Affection. Of the 20 dyads, two dyads were found to have both absolute and sign discrepancy scores significant at the .100 level. This would indicate that there are differences in the impact Of a mastectomy on Affection for these two dyads (see Appendix N). A t-value describing the difference between the mean scores Of husbands and wives on Affection was -.08 (38df) and had a two-tailed probability Of .278 (see Table 6). This was not significant at the .05 level and thus the null hypothesis was accepted. Subhypothesis 1e: There is nO difference between the individuals within the marital dyad in perception Of the impact Of a mastectomy on Resolve. 119 Of the 20 dyads, two dyads were found to have dis- crepancy scores significant at the .10 level (see Appendix 0). One Of these dyads was found to have a significant absolute discrepancy score and the other dyad was found tO have a significant sign discrepancy score. This would indi- cate that there are differences in the two marital dyads in perception Of the impact Of a mastectomy on Resolve. A t-value describing the difference between the mean scores Of husbands and wives on Resolve was -.26 (38df) and had a two-tailed probability Of .798 (see Table 6). This was not significant at the .05 level and thus the null hypothesis was accepted. In summary, hypothesis 1a, lb, 1c, 1d, and 1e were accepted. There were nO significant differences found between the husbands and wives scores for any Of the APGAR components. Hypothesis 2: There is nO relationship among the dis- crepancy scores Of Adaptation, Partner- ship, Growth, Affection, and Resolve. Each APGAR component was intended tO measure a different dimension Of family functioning, therefore, the subhypotheses were developed to measure the relationships among the five APGAR components. Subhypothesis 2a: There is no relationship between the discrepancy scores Of Adaptation and Partnership. 120 The Pearson Product Moment correlation between the Absolute Discrepancy Score Of Adaptation and the Absolute Discrepancy Score Of Partnership was -.1085 (see Table 7). This was not significant at the .05 level. The Pearson Product Moment correlation between the sign discrepancy score Of Adaptation and the sign discrepancy score Of Part- nership was .1791 (see Table 8). This was not significant at the .05 level. The null hypothesis was accepted. There is nO relationship between the discrepancy scores Of Adap— tation and Partnership. Subhypothesis 2b: There is nO relationship between the discrepancy scores Of Adaptation and Growth. The Pearson Product Moment correlation between the absolute discrepancy score Of Adaptation and the absolute discrepancy score Of Growth was -.0715 (see Table 7). The Pearson Product Moment correlation between the sign dis- crepancy score Of Adaptation and the sign discrepancy score Of Growth was .2742 (see Table 8). The correlated dis- crepancy scores Of Adaptation and Growth were not statis- tically significant at the .05 level. The null hypothesis was accepted. There is nO relationship between the dis- crepancy scores Of Adaptation and Growth. Subhypothesis 2c: There is nO relationship between the discrepancy scores Of Adaptation and Affection. 121 .am>ma ac. ecu um unmoamacmam u «« .Hm>wa mo. may no ucmoawacmam u « oooo.a mmmm. omao. mama. mamm. m>aommm mmmm. oooo.a .mmma. somm. memo. coauomaaa omao.- «moms. moo.a mama. mamo.- auzoau mama. momm. mama. moo.a mmoa.- marmamcuamm mamo. memo. mamo.u mmoa.- oomo.a coaumummma mEOuH maoom m>a0mmm cOauOOmmd nusoao danmumcuumm coaumuQMU< wocmomaomao musaomn< O>H0mmm can .cOHuommm¢ .nuzouo .masmumcuumm .sOaumummp< mo mmaoom >ocmmmaomao musaomnd was cmmBumm cOaumamquU ucmsoz uosooum cowammm b OHQMB 122 .am>ma ao. was an acmoaaacmam u ., .am>oa mm. was so acmoauacmam u , oooo.H NMbm. «ammom. aaammm. vea.m thm. oooo.H «ammom. «mmfiv. mmvm. «ammoo. «ammom. oooo.H hmmm. Nwh.N «aammm. «mmvv. hmmm. ooo.H Hana. vham. mmwm. Nehm. Hana. oooo.H O>Homom coaaommaa £H3OH0 macmumcuamm acaumudmp< O>H0mmm COHuomww< nusoao mannawsuumm ceaumummpd O>H0mmm pom .sOHuommm< .cusoaw .oacmamcuamm .COaumummpd mo mmaoom accommaomao swam ecu cmmzumm cOaumHmuaOU ucmEOz pospoam m OHQOB mEOuH maoom wocmmmuomao swam GOmummm 123 The Pearson Product Moment correlation between the absolute discrepancy score Of Adaptation and the absolute discrepancy score Of Affection was .0078 (see Table 7). The Pearson Product Moment correlation between the sign discrepancy score Of Adaptation and the sign discrepancy score Of Affection was .3429 (see Table 8). Neither Of these correlations were statistically significant at the .05 level. The null hypothesis was accepted. There is nO relationship between the discrepancy scores Of Adaptation and Affection. Subhypothesis 2d: There is no relationship between the discrepancy scores Of Adaptation and Resolve. The Pearson Product Moment correlation between the absolute discrepancy scores Of Adaptation and the absolute discrepancy score Of Resolve was .0816 (see Table 7). This was not significant at the .05 level. The Pearson Product’ Moment correlation between the sign discrepancy scores Of Adaptation and the sign discrepancy scores Of Resolve was .2174 (see Table 8). This was not significant at the .05 level. The null hypothesis was accepted. There is no relationship between the discrepancy scores Of Adaptation and Resolve. Subhypothesis 2e: There is no relationship between the discrepancy scores Of Partnership and Growth. The Pearson Product Moment correlation between the absolute discrepancy score Of Partnership and the absolute 124 discrepancy score Of Growth was .1070 (see Table 7). The Pearson Product Moment correlation between the sign dis- crepancy score Of Partnership and the sign discrepancy score Of Growth was .3557 (see Table 8). Neither Of these corre- lations were statistically significant at the .05 level. The null hypothesis was accepted. There is nO relationship between the discrepancy scores Of Partnership and Growth. Subhypothesis 2f: There is no relationship between the discrepancy scores Of Partnership and Affection. The Pearson Product Moment correlation between the absolute discrepancy score Of Partnership and the absolute discrepancy score Of Affection was .2907 (see Table 7). This correlation was not statistically significant. The Pearson Product Moment correlation between the sign dis- crepancy score Of Partnership and the sign discrepancy score Of Affection was .4458 (see Table 8). This correlation was statistically significant at the .05 level. The null hypoth- esis was rejected. There is a relationship between the sign ciiscrepancy scores Of Partnership and Affection. Subhypothesis 29: There is no relationship between the discrepancy scores Of Partnership and Resolve. The Pearson Product Moment correlation between the absolute discrepancy score Of Partnership and the absolute discrepancy score Of Resolve was .1815 (see Table 7). This correlation was not significant at the .05 level. The 125 Pearson Product Moment correlation between the sign dis— crepancy score Of Partnership and the sign discrepancy score Of Resolve was .5881 (see Table 8). This correlation was significant at the .01 level. The null hypothesis was rejected. There is a relationship between the sign dis- crepancy scores Of Partnership and Resolve. Subhypothesis 2h: There is no relationship between the discrepancy scores Of Growth and Affection. The Pearson Product Moment correlation between the absolute discrepancy score Of Growth and the absolute dis- crepancy score Of Affection was .4968 (see Table 7). The correlation was statistically significant at the .05 level Of confidence. The Pearson Product Moment correlation between the sign discrepancy score Of Growth and the sign discrepancy score Of Affection was .5689 (see Table 8). This correlation was significant at the .01 level. The null hypothesis was rejected. There is a relationship between both the sign and absolute discrepancy scores Of Growth and Affection. Subhypothesis 2i: There is nO relationship between the discrepancy scores Of Growth and Resolve. The Pearson Product Moment correlation between the absolute discrepancy score Of Growth and the absolute dis- crepancy score Of Resolve was -.0150 (see Table 7). This correlation was not statistically significant at the .05 126 level. The Pearson Product Moment correlation between the sign discrepancy scores Of Growth and Resolve was .6058 (see Table 8). This was significant at the .01 level. The null hypothesis was rejected. There is a relationship between the sign discrepancy scores Of Growth and Resolve. Subhypothesis 2j: There is nO relationship between the discrepancy scores Of Affection and Resolve. The Pearson Product Moment correlation between the absolute discrepancy scores Of Affection and the absolute discrepancy scores Of Resolve was .2867 (see Table 7). This correlation was not significant at the .05 level. The Pearson Product Moment correlation between the sign dis- crepancy scores Of Affection and the sign discrepancy scores Of Resolve was .3732 (see Table 8). This was not signifi- cant at the .05 level. The null hypothesis was accepted. There is no relationship between the discrepancy scores Of Affection and Resolve. In summary, the null hypotheses 2a, 2b, 2c, 2d, 2e, were accepted and there was nO significant relationship between the variables. Hypotheses 2f, 29, 2h, 2i were rejected and there were significant relationships found between Partnership and Growth, Partnership and Resolve, Growth and Affection, and Growth and Resolve. 127 Reliability Of the Family Functioning Section Of the Questionnaire Coefficient alpha was computed to measure the reli- ability Of the Family Functioning Section Of the question- naire. The five categories Of APGAR were individually com- puted for coefficient alpha. The reliability coefficient for Adaptation was .71874. This alpha coefficient represented marked internal consis- tency among the items. Item 6 was deleted because it was found not tO be consistent with the other items measuring Adaptation. Prior to deletion Of this item the alpha coef- ficient was .66393. The reliability coefficient for Partnership was .73690. This alpha coefficient represents a marked internal consistency among the items for Partnership. Item 3 was deleted because it was found not tO be consistent with the other items measuring Partnership. Prior to deletion Of this item the coefficient was .72400. The reliability coefficient for Growth was .61356. This alpha coefficient represents a marked internal consis- ency among the items for Growth. Item 56 was deleted because it was found not to be consistent with the other items measuring Growth. Prior to deletion Of this item the alpha coefficient was .59664. The reliability coefficient for Affection was .78248. This alpha coefficient represents a marked internal consis- tency among the items for Affection. Items 1 and 12 were 128 deleted because they were found not tO be consistent with the other items measuring Affection. Prior to deletion Of these items the alpha coefficient was .75541. The reliability coefficient for Resolve was .65478. This alpha coefficient represents a marked internal consis- tency among the items for Resolve. Items 49 and 24 were deleted because they were found not tO be consistent with the other items measuring Resolve. Prior to deletion Of this item the alpha coefficient was .39936. Extraneous Variables There were three major extraneous variables studied in relationship to the differences in perception Of the impact Of a mastectomy on family functioning post-surgery. These variables included the woman's perception Of her health, family developmental stage, and utilization Of adjuvant therapy. Health Perception A Z score was calculated for each item Of the health perception scale. The Z scores were then summed for current health, health outlook and health worry/concern (see Appendix P). The Pearson Product Moment correlation was computed between the absolute discrepancy scores Of the APGAR with the three dimensions Of Health Perception (see Table 9). The Pearson Product Moment correlation was also computed between the sign discrepancy scores Of the APGAR with the three dimensions Of Health Perception (see Table 10). 129 .Hm>ma mo. ecu um acmOaMflcmam u « vmmo.l vaa. mOHH.I mnmm. hmmo.l GHOOGOU\>HH03 sudmmm mmwm.l mvNN.I mNHo.I mmma. mama. xOOHUDO SUHMOS memo. Hmva. vmma. vmmv. omno. QUHmmm “COHHDU . mucocomfiou m>aOmmm cOauommmm cuzoao marmamcuumm :Oaumummp4 coauomoamm Spammm mdom< mo mmaoom mosmmmaomwo musaomn< on» ps8 :Oaumwoaom Spammm mo mucmsomaoo map cmmsumm macchaumHmm may mcaumauchEmo xaaumz scaumamaaou m OHQOB 130 .am>ma mm. was an acmoaaacmam mamo.| mmmo.u omvH.I mmmm.| hmma. samucoo\>aaoz nuamwm hmma.l Hmha. hmmo. maem.l mmmo. xooauso auammm oama. hoaa. «woo. mama. mmea.l Space: ucmauso wucmcomEOU m>a0mmm cOauommm< cusoaw marmamcuamm GOaumudmp< mmwmd mo mmaoom hocmmmaomao comm may use COaudmoumm guano: mo mucmcomEOU on» cmmzuwm dazmcoaumem may mcaumaumsOEmo xaaumz coHumHmaaoo OH magma soauoooamm spammm 131 None Of these relationships were statistically significant. There was nO relationship between the woman's perception Of her health and the differences in the marital dyad's per- ception Of Adaptation, Partnership, Growth, Affection, or Resolve. Reliability analysis (coefficient alpha) was also computed for each category Of the Health Perception Scale. The alpha coefficient for health outlook was .91558; for current health was .92486, and for health worry/concern was .69379. Item 11 was deleted from health worry/concern in order tO maintain greater internal consistency among the items. Prior tO deletion Of item 11 the alpha coefficient was .54316. Adjuvant Therapy The different treatments for breast cancer were categorized and differences in APGAR scores were assessed through an analysis Of variance. Adjuvant therapy was divided into four groups. Group 1 consisted Of chemotherapy or radiation. Group 2 consisted Of no treatment at this time but will have in the next few months. Group 3 consisted Of nO plans for treatment. Group 4 consisted Of the other category. The analysis Of variance was computed tO yield an F ratio for each discrepancy score (see Table 11). 7 There were no significant differences found between the groups in relation tO the discrepancy scores Of Adaptation, 132 Table 11 F Ratio Determined from Analysis Of Variance Of Women's Use Of Adjuvant Treatment APGAR Discrepancy Scores F Ratio Absolute Discrepancy Score Adaptation .1374 Absolute Discrepancy Score Partnership 1.6181 Absolute Discrepancy Score Growth .5693 Absolute Discrepancy Score Affection .4392 Absolute Discrepancy Score Resolve 3.2227 Sign Discrepancy Score Adaptation 1.4036 Sign Discrepancy Score Partnership 3.1086 Sign Discrepancy Score Growth .8764 Sign Discrepancy Score Affection 1.0325 Sign Discrepancy Score Resolve 2.6328 * = Significant at the .05 level. 133 Partnership, Growth, Affection or Resolve. Therefore, the use Of adjuvant therapy was not related tO the discrepancy scores Of the Family APGAR. Family Developmental Stage The family developmental stages were categorized and differences in APGAR scores were assessed through analy- sis Of variance. Family develOpment was divided into four groups. Group 1 consisted Of both the childbearing and school-age stage. Group 2 consisted Of the launching stage. Group 3 consisted Of the middle-age stage. Group 4 con- sisted Of the aging stage. The analysis Of variance was computed tO yield an F ratio for each APGAR discrepancy score (see Table 12). There were nO significant differences found between the groups in relation to the discrepancy scores Of Adaptation, Partnership, Growth, Affection, or Resolve. Therefore, family developmental stage is not related tO the discrepancy scores Of the Family APGAR. Description Of the Marital Dyad's Perception Of the Impact Of a Mastectomy on Family Functioning Eight tO Sixteen Weeks Post-Surgery In order tO determine the marital dyad's perception Of the impact Of a mastectomy on Family Functioning eight tO sixteen weeks post-surgery the differences in perception were computed for each dyad. Of the 20 dyads, one dyad was found to have a statistically significant difference in perception Of Adaptation, one dyad had a statistically 134 Table 12 F Ratio Determined from Analysis Of Variance Of Family Developmental Stage APGAR Discrepancy Scores F Ratio Absolute Discrepancy Score Adaptation 1.1328 Absolute Discrepancy Score Partnership .4339 Absolute Discrepancy Score Growth .2843 Absolute Discrepancy Score Affection 1.2154 Absolute Discrepancy Score Resolve .0904 Sign Discrepancy Score Adaptation .1871 Sign Discrepancy Score Partnership .2863 Sign Discrepancy Score Growth .5791 Sign Discrepancy Score Affection 1.4503 Sign Discrepancy Score Resolve 1.2014 * = Significant at the .05 level. 135 significant difference in perception Of Partnership, three dyads were found tO have a statistically significant dif- ference in perception Of Growth, two dyads were found to have a statistically significant difference in perception Of Affection, and two marital dyads were found tO have a sta- tistically significant difference in perception Of Resolve. The t-values describing the differences between the mean scores Of husbands and wives for each APGAR component were not significant. Thus, the results indicated there were no differences in perception Of the impact Of a mas- tectomy on Adaptation, Partnership, Growth, Affection, and Resolve among husbands and wives. There appeared tO be a slight pattern among the dyads for each category Of APGAR. Dyad 6 was found to have significant difference in perception Of Growth, Affection, and Resolve. Dyad 11 was found tO have significant differ- ences in perception Of Adaptation and Growth. Dyad 20 was found to have significant differences in perception Of Partnership and Resolve. A total Of five different dyads were found tO have differences in perception in one or more Of the APGAR components (see Appendices K through 0). The extraneous variables Health Perception, Use Of Adjuvant Therapy, and Family Developmental Level were found to be not related tO the differences in perception Of the impact Of a mastectomy on family functioning. 136 Description Of the Relationship Among the Discrepanqy Scores Of Adaptation, Partnership, Growth, Affection, and Resolve Pearson Product Moment correlations were computed among the discrepancy scores Of the variables (see Tables 7 and 8). A statistically significant relationship was found between the sign discrepancy scores Of Partnership and Affection, the sign discrepancy scores Of Partnership and Resolve, the sign discrepancy scores Of Growth and Resolve, .md both the sign and absolute discrepancy scores Of Growth and Affection. The Pearson Product Moment correlations for these variables were positive indicating that as the dis- crepancy scores varied in one direction for one variable they varied in the same direction for the corresponding variable. Thus hypotheses 2f, 2g, 2h, and 2i were accepted. Construct Validity Of the Family APGAR The use Of the SCL-90 tO measure construct validity was described in Chapter IV. Several statistical analyses were computed tO determine the relationship between the SCL-90 components (anxiety and depression) and the Family APGAR discrepancy scores. The Z scores were calculated for each item Of the SCL-90 and summed for anxiety and depres- sion. A correlation matrix was computed tO determine the relationship between the wife's anxiety scores and the dis- crepancy scores Of the APGAR components, wife's depression scores and the discrepancy scores Of the APGAR components, husband's anxiety scores and the discrepancy scores Of the 137 APGAR components, and the husband's depression scores and the discrepancy scores Of the APGAR components (see Tables 13 and 14). Statistically significant correlations were found between the wives' anxiety scores and the sign discrepancy score Of Adaptation. The Pearson Product Moment correlation was -.3876. In addition, the wives' anxiety scores and the sign discrepancy scores Of Resolve were statistically significant (< .05). The Pearson Product Moment correlation was -.3809. The Pearson Product Moment correlation between the husbands' depression scores the absolute discrepancy scores Of Resolve was —.3882. This was statistically significant at the .05 level. The Pearson Product Moment correlation between the husbands' anxiety scores and the absolute discrepancy score Of Resolve was -.4029. This was statistically significant at the .05 level. The data would appear tO indicate that as the dis- crepancy scores Of Adaptation increased the wife's anxiety scores decreased. Similarly, as the discrepancy scores Of Resolve increased the wife's anxiety scores decreased. The husbands' depression scores were found tO decrease as the discrepancy scores increased for Resolve. In addition, the husbands' anxiety scores would decrease as the discrepancy scores Resolve increased. In summary, results Of the cOrre- lations between the SCL—90 components and the APGAR components indicate that although there are significant relationships among the variables these are negative relationships. There 138 .wocmpamcoo mo Hm>ma me. on» um unmoamacmam maamoaamaumum, mQHOO «mmeo.u mmmo. mama. mmmm. Noam. mumaxca m.oamnmsm mMHOU ,Nmmm.n amao. momm. mmma. mmao.u coammmamma m.o:mnmsm ammm.u omma. mmmm. ammm.u mma~.u mmaoom mumaxca m.maa3 mm mnmm.| shaa. ammo.n mmoa.u mema.l sOammmaomo Mommas . . . m>aommm ceauomumm auzoao magmawcuamm :Oaumadmsa muamc6dsoo omnaom mmuoom mosmmmaomao muoaOmn¢ sauna cam mucchQEOO omuaom mo xaaumz coaumawaaoo ma OHQMB 139 .mocmcaacoo mo am>ma mm. was am acmoaaacmam maamoaamaumumm . . . . . mmaoom . . . . . mmuoom omoa I ommo mmvo moma I memo cOammmamwo m.psmnmsm amomm.I mmma.I omom.I vmh~.I «oemm.I mmaoom humaxcd m.wma3 . . . . . mmaoom ommm I nmmm I mhhm I mahm I ovma I GOammmHmmo m.mma3 O>Hommm cOauommma cusoaw mammamcuamm coaumuomp¢ mucmsOdEOU omIqom mmaoom monommaomao comm maoma can mucmcomsoo omuaom mo xaaumz ceauMamaaoO «a magma 140 were no significant relationships found between high anxiety and depression scores and large APGAR discrepancy scores. The absolute and sign discrepancy scores Of each component Of the APGAR were correlated with the absolute and sign discrepancy scores Of anxiety and depression (see Tables 15 and 16). One significant relationship was found between the variables. The Pearson Product Moment Corre- lation between the sign discrepancy score for Adaptation and the sign discrepancy score for anxiety was -.4882. This was statistically significant at the .05 level. The negative correlation would indicate that as the differences in per- ception Of Adaptation varied in one direction the differences in perception Of symptoms Of anxiety varied in the Opposite direction. For example, if there were large differences in perception Of Adaptation there would be small differences in the anxiety scores between husbands and wives (when the husbands' scores were subtracted from the wives' scores). Reliability analysis was also computed for the SCL- 90 components. The coefficient alpha for the depression score was .9053. The coefficient alpha for the anxiety scale was .92442. Summary In Chapter V, the data was presented that described the marital dyad's perception Of the impact Of a mastectomy on family functioning. The relationship among the variables Of the Family APGAR was also presented. In addition, the 141 .am>ma mo. was an acmoamacmam u I omNH. NMHH.I momm.l momm. memo. huwflxc< muDHOmn< mmvm. Hood. ommm.I homo. moma. GOHmmmHQmD munaomnd O>HOmom coauowmmm susouw macmuocuumm coaumummpd omIAUm mm>a3 pom mpcmomsm :uom MOM cOammmaomo pom muoaxcd sow mwuoom wocmmoaomao musaOmnd on» ppm mmaaommumo mOcmomaomao musaomnd was cmmzuwm Xaaumz COHumamquO ma manna 142 .am>ma mo. man an aamoamacmam |¥ omma.- mmma.u mmma.- mmma.u mmmmv.- mamaxca swam moma.- aoam.- mamm.- asma.- mmma.u :oammmuama cmam O>H0mmm GOHHOOMMAN SHBOHO mflnmhwcuhmm COHHMHQMmXN owlAUm mm>a3 pom mpcmnmsm zoom HON :Oammwammo pom wumflxsm How mmaoom mocmomaomao swam on» com mwauoowumo m