Optimism and resilience in patients with chronic illness

Optimism

Impact of Optimism on Quality of Life and Patient Outcome

Search and Focus Strategies

Optimism and Patient Outlook

Can Optimism/Resiliency Be Taught?

Impact of Optimism on Quality of Life and Patient Outcome

This study examines the relationship between optimism and resiliency and quality of life reported by patients with chronic or debilitating illnesses. The researcher engages in a qualitative examination of the literature currently available with respect to optimism and patient outcomes.

An analysis of the current literature available shows that optimism and resilience are related to each other in several ways. Much of the literature reviewed supports the hypothesis that optimism results in greater resilience and quality of life. The researcher concludes at this time however, there is little evidence supporting the notion that optimism itself may result in improved disease outcomes.

The research also suggests that optimism is a dispositional attribute that may be inherent in a patient. Optimism may also be learned however. There is adequate evidence supporting training for healthcare professionals to encourage optimistic attitudes in patients. These ideas and more are explored in greater detail below.

Introduction

In recent years there has been much attention given to optimism and it's role in patient rehabilitation. Many researchers have suggested that optimism may improve resiliency and quality of life. Others suggest that optimism is a factor of resilience and thus related to patient outcomes. There are an equal number of researchers however, that argue that optimism is independent of resilience and has no long-term benefit on disease progression. Because of the many benefits patients stand to gain from improved quality of life, it is important to examine this topic in great detail.

The focus of this research study will be an examination of the role optimism and resiliencies have on quality of life. The research will also examine whether patients can learn to adopt optimistic mindsets that may contribute to an improved quality of life. Quality of life for purposes of this study is defined as individual perceptions regarding their well-being and life status. Numerous studies have adopted the use of self reporting to measure quality of life (Lyons, et. al, 2004; Segerstrom, 2005; Lyons, et. al, 2004).

For years researchers have confirmed that both optimism and pessimism impact patients in both negative and positive ways (Lyons, et. al, 2004). Segerstrom (2005) suggests that dispositional optimism, especially in immunologically compromised patients such as HIV or cancer patients, can impact quality of life and future immunity. Much of the research conducted related to this suggest that optimists are more likely to be engaged during difficult treatment spells, contributing to a more positive outcome (Segerstrom, 197).

There may also be some evidence suggesting that optimism is only beneficially when the patient is dealing with a brief and controllable illness (Segerstrom, 197). Optimism and pessimism have long been noted to predict psychosocial behaviors (Brown, O'Grady, Battjes & Farrell, 448). It is fair therefore to conclude that the same personality traits may affect health and immunity (Segerstrom, 197).

Purpose

The purpose of this research analysis is to determine (1) whether optimism and/or resiliency improve the quality of life together or independent of another and (2) whether resiliency can be taught patients. The researcher intends to find whether optimism is a personality trait or something that can be taught patients to encourage more promising health outcomes.

There is much research that has been conducted related to psychosocial factors and illness. Much of the research has incorporated previous studies related to the effects of optimism on quality of life. Other research relates to self-assessment, optimism and long-term treatment options. For purposes of this study the researcher will examine research that supports and refutes the hypothesis listed above, if such research is available.

Search and Focus Strategies

The intent of this study is to link resilience factors including optimism with improved quality of life outcomes for patients suffering from chronic or debilitating illnesses. Numerous theorists have hypothesized that optimism contributes to an improved outcome and reported quality of life among patients.

To investigate this premise, the researcher will investigate many studies that have been conducted related to optimism and its effects on quality of life and wellness. As part of this approach, the investigator will examine what other psychosocial factors may contribute to patient wellness. An evaluation of material supporting the hypothesis and any refuting it will be examined.

The primary focus of the research will be on research that supports the hypothesis that optimism benefits patients. However, it is important that the researcher also examine any evidence that points to the contrary, so the conclusions drawn from the study are objective. Thus any evidence that conflicts with the premise that optimism is beneficial will also be examined in great detail. If appropriate, the researcher will attempt to refute this information with appropriate studies.

Literature Review

The purpose of the literature review is a close examination of the research currently available related to optimism, resilience and quality of life. The researcher will first examine how optimism affects resilience or quality of life, then examine whether optimism is a trait that can be learned or taught.

Quality of life is important to review for many reasons. Numerous studies report that improved quality of life is a key predictor of an individual's success and future well-being in the short- and long-term (Lyons, et. al, 356; Lert, 2000). Medicine serves little purpose of patients are cured of disease only to go on to lead a life with poor quality. Most patients seek out medical treatment in the hopes that it will not only result in better disease outcome but also improved quality of life (Lyons, et. al, 2004).

In one cross-sectional qualitative study. Researchers examine patient and caregivers understanding of advance directive concepts including life sustaining treatment. The findings of the study suggest that there are many goals for therapy, including (1) extending the individuals' life, (2) improving the quality of life and (3) maintaining or improving a patients physiological state and biological functions (Rodriguez & Young, 1). In addition patients were concerned with helping improve their short-term health status. Clearly however, quality of life is an important reason that patients seek out care for debilitating illnesses. Interestingly the study also finds that patients felt that most caregivers were more concerned with extending their life and providing life sustaining treatment than "quality-based outcomes," thus many patients discussed life sustaining treatment as a means for continuing life in the short rather than long-term (Rodriguez & Young, 1).

Why is this study important? It emphasizes the importance of noting patient preferences and end of life goals. It emphasizes the need to focus not simply on sustaining life, but also on maximizing patient's quality of life, in the short- and long-term (Rodriguez & Young, 1). The more in line patients and caregivers goals are, the more likely a patient is to adopt an optimistic mind set and realize better quality of life regardless of the disease outcomes. It is important that quality of life is thus examined more closely, to determine what factors may contribute to it and improve patient resilience.

Can Optimism/Resiliency Be Taught?

Wilkes, O'Baugh, Luke & George (2003) suggest that it is important for cancer patients to adopt a positive attitude for present treatment outcomes. Further their studies show tat patients definitions of positive and negative attitudes and perceptions of quality of life are influenced by the care they receive. The researchers conclude that resiliency can be taught if nurses engage in optimistic behaviors with patients. Key to patient's perceptions in this case was a positive and supportive environment and a "pleasant environment" at the treatment center and at home (Wilkes, O'Baugh, Luke & George, 413).

Another study examining stroke patients suggest that patients can maintain high expectations and a positive outlook for recovery when caregivers provide good communication and encouragement (Wiles, Ashburn, Payne & Murphy, 842). Further the study suggests that while caregivers should encourage patients to be optimistic, they must also be realistic in their expectations to promote more active participation from patients and skill acquisition.

There is support for teaching resiliency and optimism in certain medical situations. Many liken mental optimism in health to mental preparation before a sporting event (Ramsden, 119). There are techniques taught for example, to women preparing for childbirth that help contribute to a successful outcome. These techniques include concentrating on an optimistic and positive birthing process, which includes pushing, and breathing successfully (Ramdsden, 119).

One of the more commonly cited cases that supports resiliency as a learned process is a case with for the treatment of Cancer. In 1986 Siegel describes a situation where a young boy was taught to imagine he had a video game in his head. He was then told to use the video game to use missiles to kill the cancer tumor in his brain. Several months later the tumor was gone, supporting the notion that visualization techniques and optimism can have positive effects on ones health (Ramsden, 119; Brudal, 1995).

Brudal (1995) suggests that health professionals must be trained to teach patients coping techniques to help them activate positive resources they can access. Further she suggests that patients need not only to be comforted, but also given an opportunity to create positive self-awareness.

Fournier, De Ridder & Bensing (2002) conducted a study to examine the role optimistic beliefs had on chronic diseases including multiple sclerosis and rheumatoid arthritis. Their findings suggest that even unrealistic beliefs may help patients confront uncontrollable diseases, particularly when self-care options are limited. There study however suggests that optimism is inherent in the person with the disease and may relate to patients perceived self-care choices and future abilities.

In another study by Fournier, De Ridder & Bensing (1999) the meaning of optimism is examined. The researchers concluded that optimism consists of three dimensions, including "outcome expectancies, efficacy expectancies and unrealistic thinking" (p. 304). It is unclear the extend to which each of these dimensions may be impacted by outside forces, including health care opinions and expectations regarding ones illness.

Upon examining multiple sclerosis patients, Finger (1998) finds that optimism and resilience result from an unconcerned and unrealistic expectation of patient's ongoing physical deterioration (p. 243). Further he suggests that some patients, particularly MS patients, tend to break into "uncontrollable laughing, even with no reason to be happy," suggesting that their state of mind is pre-determined rather than taught (p. 243).

Segerstrom (2005) investigates the effects of dispositional optimism, which he characterizes as "generalized positive expectations for the future"(p.195). He examines experimental and naturalistic studies concluding that evidence is available suggesting that optimism is more likely a consequence of the patients engagement during the healing process. Further, segerstrom suggests that conscientiousness, which he defines as "a personality facet related to engagement" accounts for the effects of mood on outcome (195).

Many studies also point out that patient focused care, especially highly individualized care, is a good predictor of patient outcome and overall disposition. Feldman, Behnam, Behnam & Koo (2005) point out that many chronic inflammatory diseases are associated with increased psychosocial morbidity and a reported decrease in quality of life. However, the researchers also point out that better caregiver involvement, management and patient centered care improves not only communication, but patient optimism and recovery. Their studies suggest that quality of life is vastly affected by the communication established and support given during treatment (Feldman, et. al, 85). This work like many others suggest that the caregiver role is vital to the overall well being of patients and their ability to adopt an optimistic or resilient disposition. Of the more important elements contributing to a patient's ability to adopt an optimistic attitude include their sense of shared communication with their health care providers. Many studies have shows that a majority of patients feel they need to be adequately informed, not only of their condition but also of their treatment options (Voogt, et. al, 2005). Other factors that contribute to a patients sense of well being include information about where they can get help, support and complementary care. Patients that felt the most adequately informed were most likely to report optimistic feelings and subsequently adopt behaviors that encouraged better quality of life after discharge (Voogt, et. al, 2005).

Summary of Research Findings

As pointed out in the beginning of the literature review, it is vital that patient and physician's goals are aligned. Far too often physician's focus mainly on extending life in the short-term, rather than following patients goals of improving quality of life in the short- and long-term. Quality of life is reported as a very critical component of care for most patients. Many studies point out that patients are more likely to be optimistic about care and realize a higher quality of life when their goals are aligned with that of their physician (Rodriguez & Young, 2005). For this reason alone it is important to find out how to improve quality of life.

There are numerous studies that show a direct relationship between psychosocial factors including individual psychological characteristics and patients reported quality of life (Triemstra, et. al, 581). Psychological variables are often reported as the "strongest determinants of well-being" in patients with chronic, debilitating conditions including Parkinson's, MS, HIV, Hemophilia and more (Triemstra, et. al, 581).

Support for optimism as a mode for improving quality of life is abundant. Lyons, et. al (2004) confirms that optimism may influence the quality of life for patients with Parkinson's. Further the researcher concludes that optimism and pessimism may reflect the attitudes of clinicians dealing with patients. Clinicians that are more optimistic about a patient's outcome and quality of life typically work with patients that are more optimistic (Lyons, et. al, 2004). Interestingly enough, clinicians that have negative perceptions of a patients' outcome are more likely to work with patients that realize a poor quality of life. Studies like this definitely support the idea that optimism and pessimism both are traits that can not only be learned, but shared from one person to the next.

Likewise Lert (2000) while examining HIV patients finds that pessimism may contribute to poor outcomes. Pessimism may result from many different factors according to the researcher. The most commonly cited reasons include a dire prognosis, lack of information, lack of treatment options and the patients general sense that they are ill informed of their choices. His work suggests that more research need be done into optimism and its effects on treatment outcomes. His works also highlights the importance of aligning patient goals and communication efforts with those of physicians.

Giltay, et. al, (2004) firmly conclude that dispositional optimism creates a protective relationship in patients. This optimism may be inherent or learned behavior on the part of the patient. Pessimism is also cited as a possible contributor to increased mortality and poor behavior. This study is unique in that it also points out that the more pessimistic an individual, the more likely the patient is to participate in unhealthy lifestyle habits. These habits may contribute to a lower quality of life and poor prognosis over time. This supports other studies that suggest that optimism contributes to a better quality of life, in part because patients who are optimistic tend to adopt more healthy lifestyle habits both during and after treatment.

In a direct examination of optimism and quality of life, Matthews, et. al, (2004) report that patients with optimistic attitudes are more likely to engage in active coping behaviors. These behaviors contribute to a better quality of life. This confirms the study conducted by Giltay, et. al (2004) with respect to patient behaviors and optimism. Optimistic patients are more likely to demonstrate greater resilience. This is particularly the case for multiple sclerosis patients and patients with other chronic ailments like diabetes (De Ridder, Fournier & Bensing, 2004).

It is also important to note that the research suggests that optimistic personality traits, while beneficial, may also be harmful if they are unrealistic. Lee, et. al (2003) suggest that overly optimistic patients may feel let down when their perceived quality of life does not improve over time. This supports the notion that while it is important for caregivers to provide patients with hope it is equally important that they share with patient's detailed and correct information about their prognosis. Patients that feel they are more fully informed are less likely to suffer negative consequences from being overly optimistic than those that have unrealistic expectations, because they set reasonable expectations and hopes for themselves.

It is important to derive from the research that optimism may improve quality of life, but may not improve a patient's outcome. Fording (2004) points out in her article that there is a study showing that optimism does not extend the life of patients suffering debilitating illnesses like cancer. However, patients with positive attitudes are more likely to report a better quality of life in part by encouraging individuals to take better care of themselves (Fording, 2004).

Sears, et. al (2004) examines resilience factors including positive health expectations and global optimism on quality of life scores for cardiac patients. The results of the study show that patients with positive health expectations generally report better health at long-term follow up assessments. Highly optimistic patients also reported better mental health and social functioning in the short-term. Thus it is easy to conclude that quality of life is improved by resilience factors like optimism and positive health.

The majority of research presented above confirms the hypothesis that optimism results in reported higher quality of life from patients with chronic illnesses. Among the illnesses surveyed include multiple sclerosis, Parkinson's, HIV, hemophilia, diabetes and cancer. For all intents and purposes from the research one may conclude that optimism is a factor of resiliency. Still other research points to optimism as a predictor for successful self-regulation and care in determining one's quality of life (Grant & Higgins, 1521).

The research supporting optimism as an inherited vs. learned trait is less clear, though most of the studies lean toward the suggestion that optimism is both an inherited and learned trait. From the studies mentioned above one might conclude that pessimism and optimism are as much the result of inherent disposition as they are the result of caregivers attitudes and treatment of patients in there care. Why else would patients working with pessimistic caregivers feel more pessimistic? It is also positive that patient's attitudes 'rub off' on their caregivers.

There is some evidence suggesting that optimism on the part of health care providers including nursing professionals may impact patient's perceptions of their quality of life. There is other evidence that suggests that optimism in a trait that one is born with. The best conclusion to make thus is that optimism is both a dispositional quality that a patient may bring into a relationship, but also one that a patient may learn through the course of treatment.

For some patients optimism and resiliency may be taught, especially when caregivers engage in optimistic behaviors with patients. There is much evidence supporting the notion that patients cared for in an optimistic and supportive environment are more likely to report a higher quality of life and more conviction to looking on the bright side of their situation (Wilkes, O'Baugh, Luke & George, 413).

Ramsden (2004) points out that optimism can be taught much like a person can learn to mentally prepare for a sporting event. He cites birthing preparation classes that teach women to remain calm and optimistic during the birthing process. Likewise another study conducted by Siegel in 1986 suggests that patients can learn to use optimism to defeat life threatening illnesses like cancer. Mental visualization techniques combined with optimistic thinking may result in positive effects on health and longevity in chronically ill patients (Brudal, 1995).

For optimism to successfully infiltrate the psyche of patients, nurses and other health professionals first must learn to teach patients coping techniques (Brudal, 1995). This will help patients learn to adopt more optimistic approaches to their care.

Practice Implications

The implications for the studies provided are many. Much of the research investigated supports the hypothesis that optimism and resilience contribute to a better quality of life during and after treatment. Though some of the research also supports the idea that optimism is an inherent trait, still other research suggests that patients can learn to be optimistic. Because the benefits of optimism and other psychosocial factors are clearly defined, it is important that caregivers adopt practices that encourage patients to have positive behaviors. Thus, the goal of practice should be to find ways to encourage patient optimism regarding their condition.

One of the ways to enable patients to achieve optimism is through education. It is important that caregivers learn to teach patients about their condition and find ways to provide them with hope. One way to do this is via clear and direct communication. Much of the literature available suggests that a majority of patient's cite communication as one of the most important factors related to care and their perceived quality of life.

Segerstrom (2005) points out the importance of clear communication with patients. His studies clearly show that straightforward communication lead to a more positive relationship between optimism and immunity. Patients that are less clear on their predicted outcome are more likely to demonstrate a negative relationship between health and behavior (p. 197).

There is adequate evidence supporting training for health care professionals in psychosocial interventions, which may help promote optimism for patients (Brooker, Saul, Robinson, King & Dudley, 731). Effective training in psychosocial intervention is necessary for providers to efficiently develop better coping strategies and engage in therapeutic optimism techniques (Brooker, et. al, 731). Training may take place in the classroom or at work. Staff members might consider working together to develop a set of steps or criteria for establishing a good patient/caregiver relationship. The level of communication necessary to achieve this should be outlined clearly.

Johnson (1996) finds that regardless of a patient's demeanor, whether positive or negative, concrete and reliable information and shared communication has a positive effect on patient's mood and well-being. For this reason it is important that health care providers provide objective and reliable information to patients to help them make informed decisions.

Conclusions

There is adequate evidence suggesting that further research is necessary to quantify the relationship that exists between psychosocial outcomes and patients with chronic illnesses (Triemstra, et. al, 590). One may also conclude that optimism both promotes resilience but is also a factor of resilience. Thus, with regard to the researchers first hypothesis, optimism and resilience are factors that can contribute to a greater quality of life. This conclusion is based on substantial evidence supporting better outcomes and reported self satisfaction from patients with a variety of ailments including Parkinson's, diabetes, Multiple Sclerosis, HIV, cancer and more.

Patients who are optimistic in their thought processes are more likely to realize a better quality of life before, during and after treatment regardless of the severity of their condition. This may be the result of healthier behaviors the patients engage in post treatment. Much of the research presented above suggests that patients who are more optimistic are more likely to engage in health promoting behaviors after treatment and diagnosis of illness.

It is important to note these conclusions are specifically tied to quality of life rather than patient immunity or disease outcome. This does not suggest however that optimism is capable of reducing the severity of actual disease, though some research does point offer hope in this area. Specifically some of the information provided above suggests that patients with an optimistic frame of reference may more successfully increase immunity in the long-term. At this time however there is not enough evidence to firmly conclude that optimism correlates exactly to better disease outcomes (Segerstrom, 197). However there is enough evidence supporting more research in this area.

Can optimism be learned? Probably. Based on the research provided there is strong evidence that individuals can learn to have more optimistic outlooks. The research conducted thus far suggests that patients can learn to adopt optimistic behaviors and attitudes when caregivers surround them with support and understanding. Optimism and pessimism seem to be traits that spread from one person to another. Thus there is enough evidence supporting training for health care providers to encourage optimistic attitudes in patients. However, those that have optimistic personalities to begin with are more likely to have an easier time realizing positive change than those that must work on it.

References:

Allison, P.J., Guichard, C. Fung, K., Gilain, L. (2003, Feb). "Dispositional optimism predicts survival status 1 year after diagnosis in head and neck cancer patients." J. Clin Oncol, 21(3): 543-8

Beadle, G.F., Yates, P.M, Najman, J.M, Clavarino, a., Thomson, D., Williams, G.,

Kenny, L. Roberst, S., Mason, B., & Schlect, D. (2004-Jan). "Illusions in advanced cancer: the effect of belief systems and attitudes on quality of life." Psychooncology, 13(1): 26-36.

Brooker, C., Saul, C., Robinson, J., King, J. & Dudley, M. (2003, Sep). "Is training in psychosocial interventions worthwhile? Report of a psychosocial intervention trainee follow-up study." Int J. Nurs Stud, 40(7): 731-47.

Brown, B.S., O'Grady, K., Battjes, R.J., & Farrell, E.V. (2004, Oct-Dec). "Factors associated with treatment outcomes in an aftercare population." Am J. Addict, 13(5): 447-54.

Brudal, LF (1995) H. lsopsykologi. Aktivering av Psykiska Resurser vid Sjukdom. Lund:

Studentlitteratur

De Ridder, D., Fournier, M., & Bensing, J. (2004, Mar). "Does optimism affect symptom report in chronic disease? What are its consequences for self-care behavior and physical functioning?" J. Psychosom Res, 56(3): 341-50.

Feldman, S., Behnam, S.M., Behnam, S.E., & Koo, J.Y. (2005, Jul). "Involving the patient: impact of inflammatory skin disease and patient focused care." J. Am Acad Dermatol., 53(1 Suppl 1): S78-85

Finger, S. (1998). "A happy state of mind: a history of mild elation, denial of disability, optimism and laughing in multiple sclerosis." Arch Neurol, 55(2): 241-50.

Fording, L. (2004, Feb). "The trouble with optimism." Newsweek. Online. Available:

http://www.msnbc.msn.com/id/4269238/

Fournier, M., De Ridder, D. & Bensing, J. (2002, Nov). "Optimism and adaptation to chronic disease: The role of optimism in relation to self-care options of type 1 diabetes mellitus, rheumatoid arthritis, and multiple sclerosis." Br J. Health Psychol 7(4): 409-432

Fournier, M., De Ridder, D. & Bensing, J. (1999, Aug). "Optimism and adaptation to multiple sclerosis: what does optimism mean?" J. Behav Med, 22(4): 303-26.

Giltay, E.J., Geleijnse, J.M, Zitman, F.G., Hoekstra, T. & Schouten, E.G. (2004-Nov).

Dispositional optimism and all-cause and cardiovascular mortality in a prospective cohort of elderly Dutch men and women." Arch Gen Psychiatry, 61(11):1126-35.

Global Parkinson's Committee. (2002, Jan 17). "Factors impacting on quality of life in Parkinson's disease: results from an international survey." Mov Disord, 17(1): 60-8.

Grant, H. & Higgins, E.T. (2003, Dec). "Optimism, promotion pride, and prevention pride as predictors of quality of life." Pers Soc Psychol Bull, 29(12): 1521-32

Johnson, J.E. (1996, Feb). "Coping with radiation therapy: optimism and the effect of preparatory interventions." Res Nurs Health, 19(1): 3-12.

Lee, S.J., Loberiza, FR, Rizzo, JD., Soiffer, RJ, Antin, JH, Weeks, JC. (2003, Jun).

Optimistic expectations and survival after hematopoietic stem cell transplantation." Biol Blood Marrow Transplant. 9(6): 389-96.

Lyons, KS, Stewart, BJ, Archbold, PG, Carter, JH, Perrin, NA. (2004-Nov-Dec).

Pessimism and optimism as early warning signs for compromised health for caregivers of patients with Parkinson's disease." Nurs Res., 54(6): 354-62.

Lert, F. (2000-Dec). "Advances in HIV treatment and prevention: should treatment optimism lead to prevention pessimism." AIDS Care. 12(6):745-55.

Matthews, K.A., Raikkonen, K., Sutton-Tyrrell, K. Kuller, L.H. (2004-Oct). "Optimistic attitudes protect against progression of carotid atherosclerosis in healthy middle-aged women." Psychosm Med, 66(5): 640-4

Ramsden, E. (1999). The person as patient: Psychosocial perspectives for the heath care professional. London: W.B. Saunders.

Rozanski, a. & Kubzansky, L.D. (2005, May-Jun). "Psychologic functioning and physical health: a paradigm of flexibility." Psychosom Med, 67(1): S47-53.

Rodriguez, K.L, & Young, a.J. (2005, Jun). "Patients' and healthcare providers' understanding of life sustaining treatment: Are perceptions of goals shared or divergent?" Soc Sci Med, 30(1).

Sears, S.F., Serber, E.R., Lewis, T.S., Walker, R.L., Conners, N., Lee, J.T., Curtis, a.B,

Conti, J.G. (2004, Sept-Oct). "Do positive health expectations and optimism relate to quality of life outcomes for the patient with an implantable cardioverter defibrillator?" Journal of Cardiopulmonary Rehabilitation, 24(5): 324-331.

Segerstrom, S.C. (2005, May). "Optimism and immunity: do positive thoughts always lead to positive effects? Brain Behav Imm. (19(3): 195-200.

Shifren, K. (1996, June). "Individual differences in the perception of optimism and disease severity: a study among individuals with Parkinson's." J. Behav Med., 19(3): 241-81.

Triemstra, a.H., Van der Ploeg, H.M., Smit, C., Briet, E. Ader, H.J., Rosndaal, F.R.

1998, Sep). "Well-being of haemophilia patients: a model for direct and indirect effects of medical parameters on the physical and psychosocial functioning." Soc Sci Med, 47(5): 581-93.

Voogt, E., Van Leeuwen, a.F., Visser, a.P., Van der Heide, a., Van der Maas, P.J.

2005, Apr). "Information needs of patients with incurable cancer." Support Care Cancer, 27(1):1

Wiles, R., Ashburn, a, Payne, S., Murphy, C. (2002, Nov). "Patients' expectations of recovery following stroke: A qualitative study." Disabil Rehabil, 24(16): 841-50.

Wilkes, L.M, O'Baugh, J., Luke, S. George, a. (2003, May-Jun). "Positive attitude in cancer: Patients' perspectives." Oncol Nurs Forum, 30(3):412-6.