PATIENT PERSPECTIVES

Perceived uncertainty, social support and psychological adjustment in

older patients with cancer being treated with surgery
Chin-Yen Lien, Hung-Ru Lin, Ing-Tiau Kuo and Mei-Ling Chen

Aim. The purpose of this longitudinal correlative study was to explore the degree, compare the differences and to detect the
relationships of uncertainty, social support and psychological adjustment for older cancer patients who were undergoing
surgery.
Background. While the number of the older cancer patients has been increasing, there has been little research exploring their
needs with respect to psychological adjustment during cancer treatment.
Design. The study used a pre-/postdescriptive design.
Methods. Purposive sampling was used to recruit 43 patients aged 6584 from six surgery wards in a medical centre in northern
Taiwan from Jaunary 2005May 2005. Participants were interviewed one to two days prior to surgery and interviewed again
one to two days before hospital discharge. Demographic data, Mishels Uncertainty Illness Scale, Hospital Anxiety and
Depression Scale and the Interpersonal Support Evaluation List were used to collect data.
Results. Uncertainty varied with cancer stage. At the time of surgery, the patients had moderate levels of uncertainty. There was
a significant decrease in uncertainty at the second data collection period before hospital discharge. In these participants, anxiety
was significantly associated with past medical history. The participants obtained social support from family members, physicians, nurses, relatives and other patients. Married patients had higher levels of social support than those without a spouse.
Significant relationships were found among uncertainty and anxiety and depression. Interestingly, a positive relationship
between anxiety and social support after surgery was also identified.
Conclusion. Increasing levels of social support could ameliorate the degree of uncertainty, anxiety and depression in older
cancer patients. Nurses should provide resources to establish an effective social network to older cancer patients who were being
treated surgically.
Relevance to clinical practice. These findings can assist nurses in understanding the psychological adjustment needs among older
cancer patients who were undergoing surgery and provide appropriate intervention in nursing care.
Key words: cancer, nurses, nursing, psychosocial, quantitative, surgical
Accepted for publication: 15 June 2008

Data from the World Health Organization (WHO 2008b)

showed that there were 600 million people aged 60 and over

in the world in 2000. It is estimated that the number of older

people will be 12 billion by 2025 and 2 billion by 2050
worldwide. In almost every country in the Western Pacific
Region, populations are ageing. These demographic shifts are

Authors: Chin-Yen Lien, MS, RN, Assistant Head Nurse,

Department of Nursing, Taipei Veterans General Hospital, Taipei,
Taiwan; Hung-Ru Lin, PhD, RN, Associate Professor and Associate
Chief, Department of Nursing in National Taipei College of Nursing,
Taipei, Taiwan; Ing-Tiau Kuo, PhD, MD, Associate Professor,
Institute of Clinical Medicine in National Yang-Ming University,
Taipei, Taiwan and Principal Investigator, Laboratory of
Epideminology & Biostatistics and Physician, Taipei Veterans

General Hospital, Taipei, Taiwan; Mei-Ling Chen, PhD, RN,

Professor, School of Nursing in Chang Gung University, Tao-Yuan,
Taiwan
Correspondence: Hung-Ru Lin, Associate Professor and Associate
Chief, Department of Nursing, National Taipei College of Nursing,
365, Ming Te Rd, Pei Tou, Taipei, Taiwan (112). Telephone: (02)
2822-7101 ext. 3197.
E-mail: hungru@ntcn.edu.tw

Introduction

2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 23112319
doi: 10.1111/j.1365-2702.2008.02549.x

2311

C-Y Lien et al.

because of large birth cohorts in the past and higher rates of

survival, even in the older age groups. In Taiwan, the average
life expectancy has been rising, which has resulted in an
increase in the number of senior citizens who are alive. Data
from November 2007 reports that senior citizens make up
102% of the total Taiwanese population (Department of
Statistics, Ministry of the Interior 2008). By 2051, it is
estimated that senior citizens will account for 37% of the
total population (Council for Economic Planning and Development 2006). As one in four residents will be a senior
citizen, it is important that their health needs and problems
be seriously addressed.
Cancer is one of the significant diseases in the world. More
than 11 million people are diagnosed with cancer every year.
It is estimated that there will be 16 million new cases every
year by 2020. In addition, Cancer causes 76 million deaths
worldwide in 2005 (WHO 2008a). In 2006, cancer was the
leading cause of death for older persons, accounting for
256% in Taiwan (Department of Health, Executive Yuan,
R.O.C. 2008). Surgery is the usual method of treatment,
which produces feelings of uncertainty and anxiety. Mishel
and Braden (1988) have noted that when an individual
experiences uncertainty arising from illness or treatment, this
can result in stress that imacts the mind, body and social
relationships. Yang (1993) asserted that when facing the
threat of illness and surgery, the older cancer patient often
fears pain and discomfort from future treatment. After the
surgery, the patient is likely to experience pain, temporary
loss of the body function and self-control and have some level
of dependence on others for activities of daily living. In
addition, older people who have cancer continue to experience illness uncertainty, fear about cancer recurrence and
symptoms from treatment side-effects (Gil et al. 2006), which
reduces the sense of well-being (Clayton et al. 2006) and
increases emotional distress (Dirkson 2000). Tsai et al.
(2002) noted that during hospitalisation, the older cancer
patient is in dire need of a support system, and that if the
patient is unsuccessful in adjusting to the illness, emotional
disturbances are the likely result.
Several studies have reported a significant positive
relationship between social support and health outcomes
in cancer patients, including health-related quality of life
(Bloom et al. 2001, Devine et al. 2003, Makabe &
Nomizu 2007). One goal of cancer nursing is to make the
patient more comfortable in terms of body, mind and
social relationships while coexisting with illness and to
provide social support to maximise the patients well-being
(Mo 2003). For the patient with cancer, this alignment of
body, mind and social relationships can help the patient to
confront the threat of the illness; social support plays an
2312

important part in this process (Flanagan & Holmes 2000,

Arora et al. 2007). Given that depression has been
associated with lack of social support in cancer patients
(Walker et al. 2006), social support can affect an
individuals ability to engage in healthy behaviours and
assist with behaviour adjustment, a sense of control, a
feeling of stability, enhance self-esteem and relief of anxiety
(Langford et al. 1997). In addition, social support may
directly or indirectly decrease the feeling of uncertainty
(Mishel 1988, Mishel & Braden 1988). Therefore, social
support plays an important role in uncertainty and
psychological adjustment.
Culturally, in Taiwan, for older persons, cancer is synonymous with approaching death. Although the relationships
between social support, uncertainty and psychological adjustment have been reported by many researchers in different
countries, the results conducted in other cultures should be
considered with caution for Taiwanese populations. To date,
little research exploring older cancer patients needs with
respect to social support, uncertainty and psychological
adjustment during cancer treatment has been published in
Taiwan.

The study
Aims
This study was undertaken in an attempt to:
1 Identify the levels of uncertainty, social support and psychological adjustment during the surgical treatment experience in older patients with cancer.
2 Compare the differences in uncertainty, social support and
psychological adjustment before and after surgery in these
patients.
3 Explore the relatedness among uncertainty, social support
and psychological adjustment during the period of the
surgery.

Terms
For this study, the key terms were defined as follows:
1 Older cancer patient is a patient age 65 or more, who has
been diagnosed by a physician as having cancer. In this
study, patients were hospitalised and their cancer was
being treated surgically.
2 Uncertainty refers to the older cancer patients uncertainty
of diagnoses, surgery, care systems and so on. In this study,
uncertainty was measured by the Chinese version of Mishels Uncertainty Illness Scale (MUIS; Sheu & Hwang
1996).

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Patient perspectives

3 Social support indicates the support that the older cancer

patient received from family members, relatives, physicians, nurses and other patients. Supportive behaviours
include emotional, informational, appraisal and instrumental support. In this study, social support was measured
by the Chinese revised version of the Interpersonal Support
Evaluation List (ISEL), developed by Cohen et al. 1985 and
translated by Wan 1997.
4 Psychological adjustment is the older cancer patients
attitude and methods of coping with all sources of stress
such as diagnosis, surgery and the healthcare systems. In
this study, psychological adjustment was operationalised
as the level of anxiety and depression as measured by the
measured by the Chinese version of Zigmond and Snaiths
(1983) Hospital Anxiety and Depression Scale (HADS)
translated by Chen et al. (2000).

Methods
Research design
The study used a pre-/postdescriptive design. Participants
were recruited one to two days prior to surgery and
interviewed again one to two days before hospital discharge.
A 1014-day interval elapsed between the two data collection
periods.

Sample
Inclusion criteria for study participation included:
1 age 65 or more
2 no impairments in communication and able to communicate in Mandarian or Taiwanese
3 no history of mental illness
4 willing to participate as signified by signing an informed
consent.
Using procedures described by Cohen (1977), with a power
of 080, alpha of 005 and medium effect, with three variables
(uncertainty, social support and psychological adjustment),
the minimum sample required was determined to be 32
participants.
Using purposive methods (Polit & Sherman 1990), 58
participants were recruited from six general and colorectal
surgical wards of a medical centre located in northern
Taiwan from Jaunary 2005May 2005. Finally, the total
sample size was 43. Fifteen participants did not count for the
study sample because two of them were diagnosed with
benignant tumors, two participants had a further worsening
of physical condition and 11 did n0t complete the second
interview after surgery.

Psychological adjustment in older cancer patients

Research instruments
Demographic data
Demographic data included age, gender, education, religion,
medical history, surgical experience, marital status, living
status, surgical types, cancer stage, understanding of illness
and two open-end questions regarding the older cancer
patients feelings about their surgery.
Mishel Uncertainty Illness Scale
The Chinese version of MUIS was used in this study, which
was translated from English to Chinese by Sheu and
Hwang (1996). The MUIS is a 25-item scale that asks
participants to rate items on a five point scale that depicts
the two components of illness uncertainty: ambiguity and
complexity. This scale yields a single composite score, with
higher scores reflecting greater illness uncertainty. In this
study, the Cronbachs alpha is 088 for the total MUIS; it is
085 for the subscale of ambiguity and 077 for the
complexity part.
Hospital Anxiety and Depression Scale
The Chinese version of Zigmond and Snaiths HADS (1983)
was used, which was translated from English by Chen et al.
(2000) with permission. The scale consists of 14 questions
with two subscales: anxiety (seven questions) and depression
(seven questions). Cronbachs alpha for the anxiety subscale
is 084 and 075 for the depression subscale.
Interpersonal Support Evaluation List
The Chinese version of ISEL translated by Wan (1997) was
used to measure social support. With permission from Wan,
the scale was modified to reflect the experience of the patients
in this study. The scale includes 16 questions that are divided
into four subscales: emotion, information, appraisal and
instrumental support. Emotional support refers to the feelings
of understanding and receiving. Informational support is the
provision of information to the patient during a time of
stress. Appraisal support refers to the patients ability to
reflect and self-evaluate and instrumental support refers to
material aid and assistance. The overall Cronbachs alpha of
the instrument is 094.

Data analysis
Data were analysed by SPSS for Windows version 120 (SPSS
Inc., Chicago, IL, USA) using frequency, percentage, range,
mean, SD, Wilcoxon signed-rank test, Mann-Whitney U-test,
KruskalWallis test and Person product-moment collelation
coefficient.

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C-Y Lien et al.

Results

Uncertainty

In this study, 58 patients were recruited prior to surgery. Of

this group, 43 were available for a second interview prior to
hospital discharge, for a total sample size of 43.

Uncertainty scores prior to surgery ranged from 4289, with

a mean of 596 (SD 877). This score reflects moderate
uncertainty. After surgery, prior to discharge, the participants scores ranged from 2685 with a mean of 556 (SD
1056). Responses to the open-ended questions helped to
clarify the uncertainty that the patients were experiencing
prior to surgery: The condition of my illness is unstable and
unpredictable, I dont know how uncomfortable I will feel.
After the surgery, the patients made statements such as: I
understand the interrelation between aches and illness, For
the sake of treatments, I am not sure what I can still do and
I have many questions without definite answers.
The results showed that the overall uncertainty and
ambiguous feelings of the participants were significantly
different between the two data collection periods, with a
significant decrease on the overall score and ambiguity, but

Demographic profile
The majority of patients were men (93%) with an average age
of 75 years (range: 653838; SD 501). Approximately half
(488%) had graduated from high school or had a higher
degrees. Most (698%) were married and lived with their
family (884%). Three quarters of the sample had a prior
medical history, with 535% having been hospitalised more
than twice. Most patients (628%) understood their state of
illness, with 442% in cancer stage III or cancer stage IV.
Almost all the participants (907%) underwent abdominal
surgery (Table 1).

Variable

Group

Demographic characteristics
Gender
Male
Female
Age
6574 years
7584 years
Education
Illiteracy/literacy
Primacy/junior high
school
Over senior high
school
Religious
No
Yes
Marital status
Single/widow
Married
Living status
Living with family
Alone/veterans home
Medical history
No
Yes
Hospitalised
0
Once
Over twice
Surgical experience
0
Once
Over twice
Awareness of
Yes
condiction
No
Disease characteristics
Surgical type
Abdomen
Abdomen and
colostomy
Cancer stage
0/I stage
II stage
III/IV stage

2314

n (%)

40
3
17
26
11
11

(930)
(70)
(395)
(605)
(256)
(256)

Range

Mean (SD)

65258375

7506 (501)

Table 1 Demographic characteristics of

the participants (n = 43)

21 (488)
20
23
13
30
38
5
11
32
8
12
23
15
15
13
27
16

(465)
(535)
(302)
(698)
(884)
(116)
(256)
(744)
(186)
(279)
(535)
(349)
(349)
(302)
(628)
(372)

39 (907)
4 (93)
10 (233)
14 (326)
19 (442)

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Patient perspectives

Psychological adjustment in older cancer patients

Table 2 Comparison in uncertainty and social support (n = 43)

Mean (SD)

Variable

Before
surgery

After
surgery

p-value

Uncertainty (overall)
Ambiguity
Complexity
Social support (overall)
Family
Relatives
Patients
Physicians and nurses
Emotional support
Family
Relatives
Patients
Physicians and nurses
Informational support
Family
Relatives
Patients
Physicians and nurses
Appraisal support
Family
Relatives
Patients
Physicians and nurses
Instrumental support
Family
Relatives
Patients
Physicians and nurses

5960
3793
2167
7781
3688
1112
293
2688
2140
1044
370
112
614
1691
486
165
067
972
2479
1095
372
102
909
1472
1063
205
012
193

5563
3412
2151
8974
3921
1753
344
2956
2453
1019
619
116
700
1984
667
209
091
1016
2888
1119
626
116
1028
1649
1116
300
021
212

0032*
0003**
0631
0006**
0041*
0004**
0484
0128
0039*
0677
0001**
0954
0376
0091
0052
0222
0573
0213
0002**
0174
0004**
0711
0037*
0091
0065
0264
0524
0570

(877)
(633)
(340)
(2874)
(1076)
(1465)
(691)
(818)
(945)
(309)
(437)
(239)
(380)
(1024)
(527)
(370)
(219)
(228)
(748)
(272)
(498)
(240)
(329)
(609)
(291)
(364)
(054)
(215)

(1056)
(705)
(442)
(3001)
(1172)
(1470)
(682)
(865)
(931)
(331)
(435)
(208)
(368)
(1000)
(579)
(377)
(244)
(271)
(758)
(758)
(462)
(236)
(292)
(716)
(275)
(443)
(071)
(215)

Examined by Wilcoxon signed-rank test.

*p < 005, **p < 001.

not complexity (see Table 2). In addition, overall uncertainty

differed significantly by stage of cancer. Patients diagnosed at
stage 0 or I had a significant decrease in uncertainty
(p = 0017), from a mean of 611 (SD 759) to a mean of
489 (SD 841), a difference of 123 points. Patients diagnosed
at stages II, III and IV did not have such a large difference,
with a change of only 137165 after surgery.

significant increase in perceived emotional support from

relatives and friends (p = 0001) as well as appraisal support
from physicians and nurses (p = 0037). In addition, the
social support of the patient with a spouse was significantly
different from that of the patient without a spouse (p = 005).
The social support of married patients increased from a mean
of 759 (SD 2101) prior surgery to a mean of 923 (SD 2437)
after surgery. There was no significant difference in social
support in unmarried patients at the two data collection
periods (mean 822836).

Psychological adjustment
In this study, most of the participants reported no anxiety or
depression prior to surgery. After the surgery, anxiety
decreased from 11647% and depression decreased from
11670%. These differences were not significant. However,
medical history had a significant impact on anxiety at the two
data collection periods (p = 003). The anxiety average of
patients without a past medical history increased from 127
(SD 190) before surgery to 218 (SD 363) after surgery.
Patients with a medical history had a decrease in anxiety,
from 488 (SD 482) before surgery to 284 (SD 376) prior to
discharge.

Relationship between uncertainty and psychological

adjustment
The results demonstrated that overall uncertainty, ambiguity
and complexity were significantly related to anxiety in this
sample of patients both before and after surgery (Table 3).

Relationship among uncertainty, psychological

adjustment and social support
The complexity score (subscale of uncertainty) was negatively
correlated wih the participants measure of social support at
Table 3 Relationship among uncertainty, anxiety and depression
(n = 43)

Social support
Variable

Participants identified social support as being provided by

family members, physicians, nurses, relatives and other
patients (Table 2). Family members tended to provide
emotional, appraisal and substantial support; physicians
and nurses offered appraisal and informational support;
and relatives provided emotional and appraisal support. After
the surgery, the overall social support that older cancer
patients perceived increased (p = 0006). There was a

Anxiety level
Before surgery
After surgery
Depression level
Before surgery
After surgery

Overall
uncertainty

Ambiguous
uncertainty

Complexity
uncertainty

0480**
0411**

0489**
0509**

0328*
0168

0386*
0376*

0411**
0406**

0232
0250

Examined by Pearson product-moment correlation coefficient.

*p < 005, **p < 001.

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2315

C-Y Lien et al.

Table 4 Relationship among uncertainty, pshycological adjustment
and social support (n = 43)

Variable

Social support
before surgery

Uncertainty level
Overall
0186
Ambiguity
0175
Complexity
0154
Anxiety and depression level
Anxiety
0178
Depression
0291

Social support
after surgery

0249
0096
0443**
0303*
0071

Examined by Pearson product-moment correlation coefficient.

*p < 005, **p < 001.

the first data collection period (r = 0443; p < 001). Thus,

increased social support was seen to decrease uncertainty.
After surgery, anxiety was positively correlated with social
support (r = 0303; p < 005). It may be inferred that the
participants perceived that they needed more support to
mediate their anxiety (Table 4).

Discussion
The uncertainty of illness
Participants had a moderate level of uncertainty overall prior
to surgery. Compared with the mean uncertainty score (664)
documented by Sheu et al. (1998), the mean uncertainty score
of the present study was lower. Tsai et al. (1999) noted that
uncertainty seems to decrease with age, while younger
patients have higher levels of uncertainty. The results of this
study corroborate this finding. It may be because the
participants in this study are over 65. Many of the participants said that because they are so old, they tend not to
worry and leave everything to the doctor. Near the end of life,
when they have fewer unfinished duties and obligations, they
felt less uncertainty than when they were younger.
In this study, after surgery, the uncertainty score was in the
low middle range. This finding is similar to that of Tsai
(2003) with a mean uncertainty score of 572 for women
diagnosed with breast cancer who were treated with surgery.
The findings of the present study demonstrate that after
surgery, uncertainty in these older participants was similar to
the uncertainty level of other patients.
During the surgery, the source of uncertainty is primarily
ambiguity, which shows that the patient facing surgery
cannot predict or handle his/her own illness and the outcome
of the surgical treatment. After the surgery, the patients
worry about what will happen when they return home, i.e.
will they be able to manage and cope (Galloway & Graydon
2316

1996)? This phenomenon validates Mishels theory (1988):

when the patient is unaware of the illness condition and
necessary information, uncertainty increases.
After the surgery, the overall uncertainty and ambiguity, in
terms of the statistical analysis, apparently decreased.
According to the interviews, before the surgery, the patients
were uncertain of the operation and anaesthesia, worring
about whether they would be able to survive the procedure.
However, after a successful surgery, owing to the recovery of
health and the reduction of life threat, uncertainty and
ambiguity decreased in this sample of participants.
At the time of surgery, there were differences in overall
uncertainty among the patients at different cancer stages.
According to the interviews, uncertainty in patients with
cancer in stages 0 and I were lower for those patients who
perceived themselves as lucky, without the need to worry
about the following treatment. The illness was not seen as
life-threatening and did not impact their perception of their
lifespan. However, for patients with cancer in stages II, III
and IV, their higher levels of uncertainty were a reflection of
their need for continuous treatment and care.
Besides these, the MUIS includes five reverse-direction
questions. Although approximately half of the participants
(48%) stated that they had a high school or higher degree,
many had difficulty with the questions on this instrument.
Future methodological research in this area should address
the unique needs of the older to be able to answer structured
data collection instruments.

The condition of social support

In this study, the participants perceived that social support
came primarily from family members, physicians, nurses,
relatives, friends and other patients. The results demonstrated
that healthcare professionals were the main providers of
information; while spouses, family members and friends
provided mostly emotional support. This finding is consistent
with prior research (Dakof & Taylor 1990, Hinds & Moyer
1997).
The results of the present study also demonstrate that after
surgery, there was a dramatic increase in the emotional and
appraisal support provided by relatives and friends. Compared with the data from the interviews, the older cancer
patients tended not to inform their relatives and friends of
their impending surgery, so hospital visitors were few.
However, after the surgery, relatives and friends knew about
the surgery and there was an increase in visitors. Visiting after
surgery is typical in the Taiwanese culture. Thus, the finding
of an increase in emotional and appraisal support by relatives
and friends makes sense.

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Patient perspectives

Findings from the study demonstrate that during the

period of the surgery, the social support of the patient
without a spouse apparently increases while the social
support of the patient without a spouse does not change.
Dakof and Taylor (1990) point out that the major source
of social support comes from the patients spouse. Yang
and Yin (1999) support this assertion, noting that 85% of
social support comes from family members, particularly the
patients spouse and mother. According to these reports,
the spouse is the main provider of social support in the
social network. Findings of this study validate this
statement.

The condition of psychological adjustment

During the time of surgery, levels of anxiety and depression
for most of the participants were not increased. In
addition, data from the open-ended questions demonstrated
that the older cancer patients believed that their age gave
them a reason to not worry. This result echoes the findings
of Chang et al. (1989). These authors identified five
strategies that older patients use for psychological adjustment:
1 No matter what happens, I will depend on myself
2 I accept the fact as it is
3 Rest for a while
4 Face the problem calmly and quietly
5 Dont worry about it.
However, during the time of surgery, anxiety levels
significantly differ depending on past medical history. Before
surgery, patients without a prior medical history are more
confident of their physical health; hence their anxiety levels
are relatively lower. However, after the surgery, the patients
seemed to worry more about their future condition, thus
their anxiety levels increase. For patients with a past medical
history, anxiety levels were high, as they tended to worry
more about the surgical procedure and anaesthesia. However, after the surgery, thanks to the success of the procedure
and the subsequent recovery, anxiety levels showed a
decrease.

The relationship between uncertainty and psychological

adjustment
In this study, uncertainty, ambiguity and complexity were
significantly related, in a positive way, to anxiety, for older
cancer patients who were undergoing surgery. This validates
Sheus (2001) finding of a positive correlation between
uncertainty and anxiety. In addition, findings of this study
demonstrated that at the time of surgery, overall uncertainty

Psychological adjustment in older cancer patients

and ambiguity were significantly related to the degree of

depression. This finding supports findings of Mishel et al.
(1984), who noted that an increase in uncertainty correlated
with a decrease in optimism. This leads to dysfunction in
psychological adjustment.

The relationship among uncertainty, psychological

adjustment and social support
After surgery, the results of the analysis showed that
complexity was negatively correlated with social support.
According to some reports, increases in social support has
the effect to decrease uncertainty (Mishel & Braden 1988,
Sammarco 2001, Lee et al. 2002). Likewise, an increase in
social support has been shown to decrease anxiety and
depression (Lindsey et al. 1981, Langford et al. 1997).
Increases in social support has been shown to result in
better psychological adjustment (Tsai 2003). However, in
the present study, for the older cancer patients after
surgery, they experienced a positive correlation between
anxiety and social support. This finding may be explained
by the fact that if the patient appears to be anxious, this
will engage others to provide care and thus receive more
social support. Another explanation is that during the time
of surgery, the existing anxiety and depression are so
increased that the social support received does little to
ameliorate the effects.

Limitations
Owing to constraints of funds and time, this longitudinal
correlative study collected participants before their surgery
and near the time of discharge from only six wards of general
surgery and colorectal surgery in a medical centre. Longer
follow-up, with the patients in their homes in the community,
would provide a broader picture of their experience. In
addition, findings will be enhanced with data collected from
a wider range of settings, types of surgery and number of
participants.
Another limitation of this study was the fact that the
majority of participants (93%) were men. This is partly
accounted for by the fact that the sites used for participant
recruitment treat primarily male patients. Another interesting
reason was that family members of female patients perceived
the women would be psychologically harmed by participation and refused permission. According to some reports,
gender influences uncertainty, social support and psychological adjustment (Mishel 1981, Cheng 1996, Kim et al.
2002, Tsai 2003). Replication of this study would be
enhanced with more female participants.

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C-Y Lien et al.

Conclusions
The findings of this study provides guidance for nurses
engaged in clinical practice as well as research.

the Caring Elders Foundation and the editorial assistance of

Leslie H. Nicoll, PhD, MBA, RN in the preparation of this
manuscript. Finally, the authors thank the health professionals in the nursing department of Taipei Veterans General
Hospital for their kind help in data collection.

Relevance to clinical practice

For those in practice, interventions would be appropriate;
and the results of this study suggest the following: (i)
Provide individualised care and varied patient education.
Before surgery, uncertainty of the participants was at a
mid-level and came from ambiguous factors. Patients were
uncertain about the effectiveness of the surgery and pain
and discomfort they would experience. Therefore, before
surgery, patients should be encouraged to discuss their
understanding and perceptions of the procedure. They
should be provided with appropriate education to correct
any misconceptions and inform them of what will or could
occur. Other patients, who have previously undergone
similar procedures, may be a source of information and
support; the nurse should consider arranging such a meeting. After surgery, the patients were shown to worry about
their care needs after returning home. Therefore, the health
professionals are advised to listen carefully and clarify their
doubts. Health professionals should take the time to teach
about treatment and potential complications, the need for
nutrition and wound care. (ii) Help the patient to establish
an effective social support network. Findings of this study
show that, in addition to family members, physicians and
nurses do serve as an important source of social support.
Therefore, the physicians and nurses should provide timely
social support to their hospitalised patients. The patient
who does not have a spouse has a particular need to build a
social support network to successfully cope with the stress
of surgery and illness.
For nurses in academic settings, it is appropriate to include
content on uncertainty theory, cancer nursing and older care,
so that students have the appropriate knowledge and skill to
effectively care for older patients with a cancer diagnosis.

Contributions
Study design: CYL, HRL; data collection and analysis: CYL,
HRL, ITK, MLC and manuscript preparation: CYL, HRL.

Acknowledgements
The authors are grateful to the participants and their family
members who shared their experiences as part of this study.
In addition, the authors acknowledge the funding support of
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References
Arora NK, Rutten LJF, Gustafson DH, Moser R & Hawkins RP
(2007) Perceived helpfulness and impact of social support provided
by family, friends and health care providers to women newly
diagnosed with breast cancer. Psycho-Oncology 16, 474486.
Bloom JR, Stewart SL, Johnstone M, Banks P & Fobair P (2001)
Sources of support and the physical and mental well-being of
young women with breast cancer. Social Science and Medicine 53,
15131524.
Chang WH, Huang MF & Chang SM (1989) The relation between
the adjustment strategy and health self evaluation of the senior
citizens in Taipei area. Chinese Journal of Public Health 9, 6882.
Chen ML, Chang HK & Yeh CH (2000) Anxiety and depression in
Taiwanese cancer patients with and without. Journal of Advanced
Nursing 32, 944951.
Cheng SZ (1996) Exploration of social support system for elderly in
aging society. Journal of Chinese Home Economics 25, 6676.
Clayton MF, Mishel MH & Belyea M (2006) Testing a model of
symptoms, communication, uncertainty and well-being, in older
breast cancer survivors. Research in Nursing and Health 29,
1839.
Cohen J (1977) Statistical Power Analysis for the Behavioral
Sciences. Academic Press, New York.
Cohen S, Mermelstein R, Kamarck T & Hoberman H (1985) Measuring the functional components of social support. In Social
Support: Theory, Research and Applications (Sarason IG & Sarason BR eds). Martinus Nijhoff Publishers, Dordrecht, The Netherlands, pp. 2137.
Council for Economic Planning and Development (2006) Population
Projections for Taiwan Area 2006-1051. Available at: http://
www.cepd.gov.tw/encontent/m1.asp (accessed 26 January 2008).
Dakof GA & Taylor SE (1990) Victims perceptions of social support: what is helpful from whom? Journal of Personality and Social
Psychology 58, 8089.
Department of Health, Executive Yuan, R.O.C. (2008) Statistics of
Causes of Death. Available at: http://www.doh.gov.tw./EN2006/
DM/DM2_p01.asp (accessed 26 January 2008).
Department of Statistics, Ministry of the Interior (2008) Monthly
Bulletin of Interior Statistics: Resident Population by 5-year Age
Group. Available at: http://www.moi.gov.tw./stat (accessed 26
January 2008).
Devine D, Parker PA, Fouladi RT & Cohen L (2003) The association
between social support, instrusive thoughts, avoidance and
adjustment following an experimental cancer treatment. PsychoOncology 12, 453462.
Dirkson SR (2000) Predictng well-being among breast cancer survivors. Journal of Advanced Nursing 32, 937943.
Flanagan J & Holmes S (2000) Social perceptions of cancer and their
impacts: implications for practice arising from the literature.
Journal of Advanced Nursing 32, 740749.

2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 23112319

Patient perspectives
Galloway SC & Graydon JE (1996) Uncertainty, symptom distress
and information needs after surgery for cancer of the colon. Cancer
Nursing 19, 112117.
Gil KM, Mishel MH, Belyea M, Germino B, Porter LS & Clayton M
(2006) Benefits of the uncertainty management intervention for
African American and White older breast cancer survivors: 20month outcomes. International Journal of Behavioral Medicine 13,
286294.
Hinds G. & Moyer A (1997) Support as experienced by patients with
cancer during radiotherapy treatments. Journal of Advanced
Nursing 26, 371379.
Kim HS, Yeom HA, Seo YS, Kim NC & Yoo YS (2002) Stress and
coping strategies of patients with cancer: a Korean study. Cancer
Nursing 25, 425431.
Langford CP, Bowsher J, Maloney JP & Lillis PP (1997) Social
support: a conceptual analysis. Journal of Advanced Nursing 25,
95100.
Lee MY, Shaw CK, Sheu S & Change HT (2002) A study of breast
cancer patients uncertainty and impact factors. Tzu Chi Nursing
Journal 1, 5765.
Lindsey AM, Norbeck JS, Carrieri VL & Perry E (1981) Social
support and health outcomes in postmastectomy women: a review.
Cancer Nursing 4, 377384.
Makabe R & Nomizu R (2007) Social support and psychological and
physical states among Japanese women with breast cancer before
and after breast surgery. Onclogy Nursing Forum 34, 883889.
Mishel MH (1981) The measurement of uncertainty in illness.
Nursing Research 30, 258263.
Mishel MH (1988) Uncertainty in illness. Image The Journal of
Nursing Scholarship 20, 225232.
Mishel MH & Braden CJ (1988) Finding meaning: antecedents of
uncertainty in illness. Nursing Research 37, 98103.
Mishel MH, Hostetter T, King B & Graham V (1984) Predictors of
psychosocial adjustment in patients newly diagnosed with gynecological cancer. Cancer Nursing 7, 291299.
Mo HC (2003) Bio-Psychosocial Adjustment and Social Support of
Patients with Colorectal Cancer. Graduate School of Nursing,
National Yang-Ming University.
Polit DF & Sherman RE (1990) Statistical power in nursing research.
Nursing Research 39, 365369.

Psychological adjustment in older cancer patients

Sammarco A (2001) Perceived social support, uncertainty and quality
of life of younger breast cancer survivors. Cancer Nursing 24,
212219.
Sheu S (2001) [Uncertainty and anxiety in patients with initial attack
of myocardial infarction: the effect of coping methods]. Hu Li Yan
Jiu 9, 159171.
Sheu S & Hwang SL (1996) Mishels uncertainty in illness scale,
Chinese version. The Journal of Nursing Research 4, 5967.
Sheu S, Hwang SL & Lin HS (1998) Perception of uncertainty and
coping behaviors of hospitalized patients with acute myocardial
infarction. Formosan Journal of Medicine 2, 498507.
Tsai PS (2003) Factors Related to Anxiety, Depression and Uncertainty of Breast Surgery. The Graduate School of Social Work, Fu
Jen Catholic University.
Tsai SW, Lai YH, Chen ML & Chen CC (1999) The relationship
between physio-sensory characteristics of cancer pain and uncertainty in illness. The Journal of Nursing Research 8, 5969.
Tsai LF, Kuo ML, Chen SC & Chang PR (2002) Needs of cancer
patients during hospitalization. Chang Gung Nursing 13,
116125.
Walker MS, Zona DM & Fisher EB (2006) Depressive symptoms
after lung cancer surgery: their relation to coping style and social
support. Psycho-Oncology 15, 684693.
Wan SM (1997) The Relationship of Symptom Distress, Social
Support and Self-Care Behaviors in Heart Transplant Patients.
Graduate School of Nursing, National Defense Medical Center.
World Health Organization (2008a) Cancer Control: Knowledge
into Action. Available at: http://www.who.int/cancer/modules/en/
(accessed 26 January 2008).
World Health Organization (2008b) The World is Fast Ageing
Have We Noticed? Available at: http://www.who.int/ageing/en/
(accessed 26 January 2008).
Yang CY (1993) The adjustment behavior of a senior citizen with
stomach caner for the surgery. The Journal of Nursing 40,
5764.
Yang KP & Yin TJC (1999) Defining the content domain of health
relation quality of life for terminally ill cancer patients. The
Journal of Nursing Research 7, 129144.
Zigmond AS & Snaith RP (1983) The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica 67, 361370.

2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 23112319

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