research and studies

Need Priorities of Adrenalectomy Patients as Perceived by Patients, Nurses, and Physicians

M A R S H A MARECKI, RNC, EdD

Adrenalectomy is one method of palliative and therapeutic treatment for advanced metastatic breast cancer. The physical and psychosocial ramtfications of adrenalectomy on the patient are many, and she will need help in adapting to a new lifestyle. To identijy need priorities of adrenalectomy patients as perceived by nurses, physicians, and patients, a study was undertaken of these patients and their health care providers. The findings showed that patients, nurses, and physicians dzffered in their perception of need priorities of adrenalectomy patients.

Carcinoma of the breast is a leading cause of death among Caucasian women in the United States, and it is a major health problem in women 39-54 years of age.’ Of the women diagnosed with carcinoma of the breast, 75% underwent treatment for ad- vanced metastatic breast cancer af- ter a radical mastectomy.2 An esti- mated one-half of these women would live an average of five years.2

Since carcinogenic tumors of the breast are hormone-dependent, adrenalectomy is one method of palliative and therapeutic treat- ment for advanced metastatic breast cancer. In palliative and therapeutic treatments for breast cancer, the objectives are to con- trol the tumor growth, reduce pain and anxiety, maintain physi- cal and mental activity, and seek remission, if possible.3 Adrenalec- tomy usually does not cure breast cancer, but does alleviate or cure some of the metastatic ~yrnptoms.~

It is difficult to assess the exact number of women undergoing ad- renalectomy because various com- binations of treatment are used. However, in 1978, out of the 90,000 women diagnosed as hav- ing breast ~ a n c e r , ~ one-half devel- oped metastases. Of the women who develop metastases, 15-20 undergo adrenalectomy surgery each year.4 Protocol for patient selection for this procedure may vary according to the individual physician’s philosophy of care. Suggested criteria include the pa- tient’s having symptomatic meta- static breast cancer in sites likely to respond, such as bony or local re- gional metastatic pleural effu- s i o n ~ ~ ; discrete pulmonary or me- diastinal metastases with a two- year “tumor free” interval after primary treatment*; or local or re- gional metastases which could not be managed by simpler methods4; and that the patient had an oopho- rectomy.6 Liver metastases and ce- rebral and pulmonary metastases

of lymphangitic type are contrain- dications for adrenalectomy sur- g e r ~ . ~

The physical and psychosocial ramifications of adrenalectomy on the patient are many, and she will need help in adapting to a differ- ent life-style. One method of as- sessing patient needs is by encour- ag ing a n d allowing her to com-municate in words and ges- tures what she is experiencing, feeling, believing, or remember- ing. The patient’s disclosures are an attempt to communicate how her world and body seem to her.’

Adrenalectomy patients can be viewed as experiencing a state of crisis. Usually the individual is striving to maintain a state of equi- librium through a continual series of adaptive maneuvers and characteristic problem-solving ac- tivities through which basic need fulfillment occurs. However, in a crisis situation discontinuities in the homeostatic mechanism result, contributing to a state of disequi- librium. Habitual problem-solving activities prove to be inadequate.s

In working with adrenalectomy patients, a nurse may have to learn to alter her goals. Oriented toward restoration of a patient’s complete health, the nurse may be frus- trated and unhappy since the nursing goal for adrenalectomy

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patients is limited to promoting as comfortable and as useful a life as possible. When the nurse accepts a realistic goal, she is less apt to avoid these patients or hold her personality in check because of the feelings of helplessness and guilt she may have resulting from her inability to fulfill her unrealistic objective for such patients.’~~

The physician’s role, as defined by Parsons,’O is one of technical competence, emotional neutrality, and collective orientation. Since ill- ness is a crisis situation for both patient and family, the physician is considered the savior. The physi- cian may not be able to save the patient in all instances; however, the physician is reassuring to the family in that he is capable of handling the threat of illness.”

In assessing priority needs of physicians, nurses, and patients, in the care of adrenalectomy pa- tients, the focus must be on patient needs not only as health care pro- fessionals perceive them, but more important, as the patient perceives them. If this endeavor of collabo- rative health assessment is not achieved, therapeutic and pallia- tive intervention may result in a disastrous illusion for the patient.

Leone believes that 1) the pa- tient of her own accord recognizes her need for help, 2) the patient knows that scientific care will be beneficial, and 3) the outpatient health team will understand the patient’s need and meet it.’* Leone also believes that health care per- sonnel need deeper knowledge in the area of perception of patients’ needs. Therefore, the specific problem investigated in this study was the identification of need pri- orities of adrenalectomy patients as perceived by nurses, physicians and patients.

Methodology

All patients included in the study met the following criteria: white female, 33-75 years of age; had undergone adrenalectomy surgery; diagnosed as having ad- vanced carcinoma of the breast; and had been treated in the outpa- tient clinic.

Fourteen of the patients were married, three were widows, and three were single. Seven of the women were childless, three had one child, five had two children, two had five children, and one had seven children. Job status of the study sample was that of home- maker (widowed or unmarried, but maintaining responsibilities for parents and children) with dual roles, such as nurses and teachers.

The selected nurses who will- ingly participated in this study were registered nurses knowledge- able in the nursing care of patients who had undergone an adrenalec- tomy. The selected physicians who willingly participated in the study specialized in the medical care of patients who had undergone an adrenalectomy. The total popula- tion included 20 clinic patients, five nurses and five physicians.

Data relevant to the needs of patients following an adrenalec- tomy were obtained exclusively from a review of the literature pertinent to the area under inves- tigation. Two instruments (avail- able from author) were then devel- oped and set up on a modified Likert scale. The purpose of the instruments was to find out if need priorities of adrenalectomy pa- tients are similar to, or different from, those perceived by nurses and physicians. Instrument I was to be administered to the nurses and physicians, Instrument I1 to the patients.

Each instrument listed 34 possi- ble need priorities of adrenalec- tomy patients. Medical terminol- ogy was rearranged or changed on Instrument I1 to facilitate clearer interpretation on the part of the individual patient. A panel of ex- perts in the care of adrenalectomy patients was selected from names submitted by the nurse clinician to the investigator. The panel con- sisted of a nurse clinician, nurse supervisor, and physician. The panel reviewed the list of patients’ needs on both instruments. Only minor revisions in the rephrasing of statements were made. Bio- graphical data were obtained from the patients’ charts.

Needs were set up in no specific order to determine what needs were considered most important by the rater. Needs included possi- ble physical, psychological, and psychosocial needs. The physical needs were reflected in 15 state- ments on the Instruments, (e.g., Knowledge of medication). Psy- chological needs were identified on 7 statements (e.g., Counseling pertinent to realization and accep- tance of being drug-dependent for life). The third category, psycho- social needs, was reflected in 12 statements (e.g., Inclusion and in- volvement of the family in the fol- low-up care). The rating scale was 1-5 (1, least important; 2, less im- portant; 3, average importance; 4, more important; 5, most impor- tant).

It was predicted that the advan- tage of a pilot study would be negligible, since patients varied in age, educational background, and experience; and nurses and physi- cians varied in their approach to the treatment of patients with ad- vanced cancer.

Prior to the administration of Instrument I to the nurses and physicians, and Instrument I1 to the patients, the investigator briefly informed the subjects of the general nature of the study and how confidentiality would be protected. In addition, the investi- gator gave direction in the use of the instrument to each of the indi- vidual participants, clarified any misunderstandings, and remained with each subject during the ad- ministration of the instrument.

Results Analysis of the rating scale was

accomplished through the descrip- tive method. Statistical analysis of attitudes indicated on this modi- fied Likert scale was based upon mean profile analysis.

All three categories of needs of adrenalectomy patients-physical, psychological, and psychosocial- were rated differently on a cumu- lative basis by patients, physicians, and nurses (Figure 1). In examin- ing how the three groups ranked each need, there seems to be a wide margin of difference in the

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5

4

3

2

1

3.17

5

4

3

2

1

- 4.54 r 4.46

2.60

a Patients Nurses Physicians b Patients Nurses Physicians

2 j I

2.56

C Patients Nurses Physicians Figure 1. Cumulative rating of needs of adrenalectomy patients in priority of importance as perceived by patients, nurses, and physicians: a (lef&-Physical needs b (cenferj-Psychological needs c (right)-Psychosocial needs

perception of priorities of needs of all three participant groups.

In general, the patients rated all needs, except support and interac- tion with women who have had the same type of surgery, at the top of the hierarchy of needs. Nurses and physicians had a wider varia- ,tion in rating needs. The nurses rated a majority of the needs high on the scale of priorities, and the physicians rated a majority of the needs low on the scale. However, nurses and physicians showed a

4.93

4.46

t Physical f Cl Psychological

Psycho- Social

wider variation in rating needs than patients did.

Physical needs were rated the highest in importance by patients and physicians, followed by psy- chological and psychosocial needs. Psychological needs were given the highest priority by nurses, fol- lowed by physical and then psy- chosocial needs. Although psycho- social needs were ranked lowest in importance by all three groups, patients rated these needs higher than did the nurses and physi-

4.15

m

4.01

Physical b Psycho- Social

cians. (See Figure 2). None of the three study groups

agreed on any one need as being most important. All three groups rated each need differently in re- gard to importance.

Discussion The different ratings of needs

by the three groups present poten- tial problems in the health care delivery of adrenalectomy pa- tients. An explanation of how to

3 47

Psycholog ica I Physica I

C Psycho - Social

Figure 2. Priority of importance of needs of adrenalectomy patients: a (leff)-As perceived by patients b (cenfe+As perceived by nurses c (righo-As perceived by physicians

September/October 198 1 JOGN Nursing 38 1

avoid stressful situations which re- sult in frustration and anxiety was rated by the patients as more im- portant, by the nurses as of aver- age importance, and by physicians as less important. A simple ex- planation of how to avoid stress situations might diminish the pos- sibility of an adrenal crisis for the patient, yet health care providers don’t see this need as important. Information and explanation on why blood pressure is taken in the lying and then sitting position dur- ing the postoperative period were ranked more important by pa- tients, of average importance by nurses, and least important by physicians. This might indicate that information on procedures is scarce, and that patients and fam- ilies are uninformed and, there- fore, fear the unknown. Counsel- ing pertinent to life-long drug- dependence was ranked most important by patients and nurses, but only of average importance by physicians. Drug dependency might have serious psychological effects on a person who is very independent. This need was one of many physical needs (e.g., side effects of drugs, effects of surgery, prognosis) which were rated lower in the hierarchy of needs by physi- cians. These physicians were pri- marily concerned with treating the disease and not the patient as a unified whole.

Needs concerning family inclu- sion and involvement in care were given high priority by patients, and in some instances by nurses, but the physicians gave these needs either average or low prior- ity. The family can play a very important role in the patient’s ad- justment to surgery, hospital re- habilitation, and follow-up care. This must be considered not only by nurses, but also by physicians.

The need for information about a change in daily living patterns was considered more important by patients and nurses and of average importance by physicians. Health care providers must be made aware that the interruption of daily living patterns can be a prime factor in causing stress. Health

teaching to recognize new signs and symptoms was ranked most important by patients, more im- portant by nurses, and less impor- tant by physicians. If patients are not exposed to a well-planned in- dividualized health teaching pro- gram, there is a possibility that new signs and symptoms of the disease might be regarded as insig- nifican t .

Purchasing and wearing a medi- cal identification bracelet were considered more important by pa- tients and nurses and of average importance by physicians. Patients wearing the identification can be treated immediately if an adrenal crisis occurs. Distribution of fol- low-up care was rated most impor- tant by patients and nurses, and of average importance by physicians. Informative literature for review would be helpful since follow-up care is not always synthesized in the hospital setting.

Since these patients have a ter- minal illness and are facing death, religious counseling and support were ranked more important by this group. However, both nurses and physicians gave this need av- erage priority. And, in these cases, the chaplain was not considered an essential health team member.

The need for a meaningful rela- tionship with the nursing and medical staff was rated most im- portant by patients, more impor- tant by nurses, and of average im- portance by physicians. These ratings may reflect detached con- cern by the health care team.

Summary Patients in this study identified

needs they considered important. Perceived need priorities of ad- renalectomy patients need to be identified and met both pre- and postoperatively by health team members. Patient-centered nurs- ing and medical conferences should be arranged to provide comprehensive patient care. Establishment of guidelines, based on need priorities perceived by the patient, will provide a master care plan which can assist nurses and physicians in meeting patient

needs. These guidelines are im- portant since patients need not only an immediate care plan, but also a long-term plan of care de- signed to meet individual needs and ever-changing problems of the long-term illness.

The study findings show that patients, nurses, and physicians differ in their perception of need priorities of adrenalectomy pa- tients. Nurses and physicians must take heed of patient concerns. Nurses, especially, must realize the needs of the patient in order to provide support, counseling, and education.

The necessity for total aware- ness of patients’ needs and percep- tions is illustrated by one cancer patient’s comments:

“Although the disease was diag- nosed early and responded suc- cessfully to treatment, there was a numbness and fear, the cold chills that accompanied the awareness of the diagnosis and later the al- tered perception of life, of friends and associates that grew out of the realization that death was never far away.

“A human organism with a malig- nant neoplasm is more than a body with a disease. It is also a reacting individual who has feel- ings about his illness, and these feelings influence the way he per- ceives his medical personnel and utilizes his advice and care.”13

It is important that all members of the health team acquire a better understanding of the various need theories and the importance of perceiving the needs of patients as the patient perceives them. In ad- dition, it is essential for health team members to continually refer to the relevant literature concern- ing needs to improve the quality of total patient-family care.

References 1. Steiner PE: Cancer: Race and Ge-

ography. Baltimore, Williams & Wilkins, 1954, p 1954

2. O’Donnell WE, Day E, Venet L: Early Detection and Diagnosis of Breast Cancer. St. Louis, CV Mos- by, 1962, p 155

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3. Thornblad I: Hormonal ablative therapy for the premenopausal patient with advanced cancer. Nurs Clin North Am 2:659-670, 1967

4. Devitt JE, Hardwick JM: The role of bilateral adrenalectomy and 00-

phorectomy in the management of patients with metastatic breast cancer. Am J Surg 137:629-633, 1979

5. Strax P: Evaluation of screening programs for the early diagnosis of breast cancer. Surg Clin North Am 58:667, 1978

6. Ferguson D: Personal communi- cation. Rush-Presbyterian-St. Luke’s Medical Center

7. Jourard S: The Transparent Self.

New Jersey, VanNostrand, 1964, p 124

8. Parad HJ: Crisis Intervention. New York, Family Service Associ- ation of America, 1965, p 24

9. Lubic RW: Nursing care after ad- renalectomy and hypophysec- tomy. Am J Nurs 62:84-86, Apr 1962

10. Parsons T: The Social System. Illi- nois, Tree Press, 1951, pp 428- 473

11. King SH: Perceptions of Illness and Medical Practice. New York, Russel Sage Foundation, 1962, pp

12. Leone LP: The patient who walks, Nursing in Ambulatory Units. Ed- ited by E Schultz, E Rudick. Du-

165-166, 207

buque, Iowa, William C Brown,

13. Neuberger RL: When I learned I had cancer. Harper 218:42-45, June 1959

1966, pp 93-100

Address correspondence to Marsha Marecki, RNC, EdD, School of Nurs- ing, SUNYAB, 1104 Stockton Kimball Tower, Buffalo, NY 14214.

Marsha Marecki is asistant professor kn the School of Nursing at State UniversiEy of Neu York at Buffalo (SUNYAB). Dr. Marecki attended D’Youville College (BS) in Buffalo and SUNYAB (MS, E D ) , and L a member of NAACOG, ANA, and Sigma Theta Tau.

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