NOTE TO USERS
This reproduction is the best copy available
PREFERENCES OF PATIENTS UNDERCOING ANCtOCRAM FOR PARTICIPATION IN TREATMENT DECISIONS: COPtNC SWLE AND
THE PROBLEM SOLVINC-OECISION MAKINC SCALE
Nancy Kraetschrner
A thesis submitted in conformity with the requirements for the degree of Master's of Science
Craduate Department of Cornmunity Health University of Toronto
(c) Nancy Kraetschmer 1994
, National Library I*I of Canada Bibliothèque nationale du Canada
Acquisitions and Acquisitions et Bibliographie Services seMces bibliographiques
395 Wdiingtor, Street 395, rue WOmgtQCI Ottawa ON K1A ON4 OnawaON K 1 A W carlada canada
The author has granted a non- exclusive licence aliowing the National Library of Canada to reproduce, loan, distribute or sell copies of this thesis in microfonn. paper or electronic formats.
The author retains ownership of the copyright in this thesis. Neither the thesis nor substantial exbracts fkom it may be printed or othenvise reproduced without the author's permission.
L'auteur a accordé une licence non exclusive permettant à la Bibliothèque nationale du Canada de reproduire, prêter, distribuer ou vendre des copies de cette thèse sous la fome de microfiche/nlm, de reproduction sur papier ou sur format électronique.
L'auteur conserve la propriété du droit d'auteur qui protège cette thèse. Ni la thèse ni des extraits substantiels de celle-ci ne doivent être imprimés ou autrement reproduits sans son autorisation.
TABLE OF CONTENTS
Tables and Figures
Abstract
Executive Summary
Acknowledgements
CHAPTER 1: LITERATURE REVIEW
Introduction
Patient Participation In Treatment Choice The Roles of Physician and Patient Dimensions of Participation Preference for Information and Involvement Problem Solving and Decision Making Individual Variations in Preferences to Participate
Coping Style Coping Measure: Repression-Sensitization
CHAPTER II - METHODOLOCY
Study Population Ethical Review Sam pling Procedure Response Rate Questionnaire Content Scales Used Reliability and Validity Coding Data Quality Data Management Statistics Employed
v
X
xi
xvi i
CHAPTER III: SCALE DEVELOPMENT
Factor Analysis Reliability Analysis
CHAPTER IV: CHARA-ERISTICS OF PATIENT SAMPLE
CHAPTER V: PARTICIPATION IN TREATMENT CHOICE
Hypothesis 1: Information Hypothesis II: Problem Solving Hypothesis III: Decision Making Hypothesis IV: Preference for Control
CHAPTER VI: COPINC STYLE
Hypothesis V: Coping Style 1 1 1 Hypothesis VI Coping Style/Problem Solving-Decision-Making 1 1 7
CHAPTER VII: SUMMARY AND CONCLUSIONS
Discussion Limitations Directions for Future Research Conclusions
APPENDIX A
Health Care Decisions Survey: Patient Version Health Care Decisions Survey: Nursing Student Version Health Opinion Survey (Krantz 1980) Repression-Sensitization Scale (Weinberger et al. 1 979) Autonomy Preference index (Ende et al. 1 989)
APPENDIX B Statistical Analysis
Factor Anafysis Results Coping Style Results
BIBLIOGRAPHY
TABLES
Tab
Tab
Table 3.3
Table 3.4
Table 3.5
Table 3.6
Table 3.7
Table 3.8
Table 3.9
Table 4.1
Table 4.2
Table 4.3
Table 4.4
Table 4.5
Table 4.6
Table 4.7
Table 5.1
Table 5.2
Mean Scores for Patient Population
Initiai Principle Components Matrix, Varimax Rotation, for Morbidity Vignette
Initial Principle Components Matrix, Varimax Rotation, for Mortality Vignette
Initial Principle Components Matrix, Varimax Rotation, for Quality o f Life Vignette
Varimax Rotation, Two Factor Forced, for Morbidity, Mortality, and Quality of Life Vignettes
Cronbach's Coefficient Alpha (Patient Population)
Item Anaiysis
Demographic Characteristics: Nursing Sample
Test-retest Correlations: Nursing Sampfe
Age of Respondents
Marital Status of Respondents
Respondent's Level of Education
Respondent's Employment Status
Characteristics of Patient Sample
Attitudes Toward Medical Care
Satisfaction with Cardiologist
HOS Information Preference by Age Croup
Morbidity Vignette: Problem Solving Questions
Table 5.3
Table 5.4
Table 5.5
Table 5.6
Table 5.7
Table 5.8
Table 5.9
Table 5.10
Table 5.1 1
Table 5.12
Table 5.1 3
Table 5.14
Table 5.1 5
Table 5.16
Table 5.17
Table 5.18
Morbidity Vignette: Proportion o f Scores in each Control Category (Problem Solving Questions)
Mortality Vignette: Problern Solving Questions
Monality Vignette: Proportion o f Scores in each Control Category (Problem Solving Questions)
Quality o f Life Vignette: Problem Solving Questions
Quality o f Life Vignette: Proportion o f Scores in each Control Category (Problem Solving Questions)
Morbidity Vignette: Decision Making Questions
Morbidity Vignette: Proportion o f Scores in each Control Category (Decision Making Questions)
Mortality Vignette: Decision Making Questions
Mortality Vignette: Proportion o f Scores in each Control Category (Decision Making Questions)
Quaiity o f Life Vignette: Decision Making Questions
Quality o f Life Vignette: Proportion o f Scores in each Control Category (Decision Making Questions)
Mortality Vignette (Diagnosis): Control Category by Age Croup
Mortality Vignette (Treatment Options): Control Categow by Age Croup
Mortality Vignette (Risks/Benefits): Controi Category by Age Croup
Mortality Vignette (Probabilities): Control Category by Age Croup
Mortality Vignette (Utilities): Control Category by Age Croup
Table 5 - 1 9 Mortality Vignette (What is Done): Control Category by Age Croup
Table 5.20 Cornparisons Across Three Vignettes
Table 6.1 Coping Categories
Table 6.2 Summary of Analysis of Variance between Krantz information Scale and Coping Croups
Table 6.3 HOS Information Preference by Coping Style
vii
FIGURES
Figure 5.1
Figure 5.2
Figure 5.3
Figure 5.4
Figure 5.5
Figure 5.6
Figure 5.7
Figure 5.8
Figure 5.9
Figure 5.1 0
Figure 5.1 1
Figure 5.1 2
Figure 5.1 3
Figure 5.1 4
Figure 5.1 5
Figure 5.1 6
Figure 5.1 7
Figure 5.1 8
Figure 5.1 9
Figure 5.20
Figure 6.1
HOS Information Preference Subscale
HOS Information Preference by Age Croup
Morbidity Vignette: Diagnosis Question
Morbidity Vignette: Treatment Options Question
Morbidity Vignette: Risks/Benefits Question
Morbidity Vignette: Probabilities Question
Mortality Vignette: Diagnosis Question
Mortality Vignette: Treatment Options Question
Mortality Vignette: Risks/Benefits Question
Mortality Vignette: Probabilities Question
Quality of Life Vignette: Diagnosis Question
Quality of Life Vignette: Treatment Options Question
Quality o f Life Vignette: Risks/Benefits Question
Quality of Life Vignette: Probabilities Question
Morbidity Vignette: Utilities Question
Morbidity Vignette: What is Done Question
Mortality Vignette: Utilities Question
Mortality Vignette: What is Done Question
Quality o f Life Vignette: Utilities Question
Quality of Life Vignette: What is Done Question
HOS Information Preference by Coping Style
Figure 6.2
Figure 6.3
Figure 6.4
Figure 6.5
Figure 6.6
Figure 6.7
Figure 6.8
Figure 6.9
Figure 6.1 0
Figure 6.1 1
Figure 6.1 2
Figure 6.1 3
Figure 6.1 4
Figure 6.1 5
Figure 6.1 6
Figure 6.1 7
Figure 6.1 8
Figure 6.1 9
Morbidity Vignette: Diagnosis by Coping Style
Mortality Vignette: Diagnosis by Coping Style
Quality of Life Vignette: Diagnosis by Coping Style
Morbidity Vignette: Treatment Options by Coping Style
Mortality Vignette: Treatment Options by Coping Style
Quality of Life Vignette: Treatrnent Options by Coping Style
Morbidity Vignette: Risks/Benefits by Coping Style
Mortality Vignette: Risks/Benefits by Coping Style
Quality of Life Vignette: Risks/Benefits by Coping Style
Morbidity Vignette: Probabilities by Coping Style
Mortality Vignette: Probabilities by Coping Style
Quality of Life Vignette: Probabilities by Coping Style
Morbidity Vignette: Utilities by Coping Style
Mortality Vignette: Utilities by Coping Style
Quality of Life Vignette: Utilities by Coping Style
Morbidity Vignette: What i s Done by Coping Style
Mortality Vignette: What is Done by Coping Style
Quality of Life Vignette: What is Done by Coping Style
Kraetschmer, Nancy. (c) 1994
PREFERENCES OF PATIENTS UNDERGOING ANGIOGRAM FOR PARTICIPATION
iN TREATMENT DECISIONS: COPING STYLE AND THE PROBLEM
SOLWG-DECISION MAKING SCALE
A thesis submitted in conformity with the requirements for the degree of Master's of Science
Graduate Department of Community Health University of Toronto
Although current ideology suggests patients should be active participants in decision-making
about their care, the literature suggests patients wish to be informed, but not involved. We
studied preferences of 300 cardiac patients for information and involvement, and the influence
of their coping style. We developed a reliable instrument based on the Deber-Baumann
(1 989) hypothesis that choice can be subdivided into "problem-solving" (one right answer)
and "decision-making" (preferences for outcomes matter) tasks. Our key findings were that
most patients:
- want to be infonned;
- do not want to be involved in problem-solving;
- want to be involved in decision-making;
- are more inclineci to hand control over to physicians in situations involving risk of
mortality than those invoiving morbidity or quality of life.
- Coping style was correlated with information desired and with patient preferences for
some (but not all) decision-making tasks, but not with preferences for problem-solving tasks.
X
EXECUTWE SUM MARY
Although current ideology suggests that patients should be active
participants in decision making about their own care, the literature has
suggested that patients wish to be informed, but not involved. Several
studies have docurnented patients' desire for information among a variety
of patient populations (Blanchard et al. 1988; Cassileth et al. 1980; Faden
et al. 1981 ; Strull et al. 1984) and have found that most patients reported
a strong preference for information and detailed disclosure. However, the
literature was less clear about the extent to which patients want to be
active participants in decision making about their own care (Cassileth et al.
1 980; Faden et al. 1 981 ; Haug and Lavin 1 981 ; Harris poll cited by Ende et
al. 1989), with many concluding patients wished to be informed but not
involved.
The purpose of this study is largely exploratory in intent. This study
exarnined patient preferences for involvement in treatment decision
making and desire for information. We also examined the influence o f
patient coping style on preferences for information and decision making.
The conceptual framework for this study was based on Deber and
Baumann's (1 989) theory o f patient participation which postulates that
previous studies have made insumcient recognition o f two distinct
elements of choice behaviour - problem solving (PS, identifying the one
right answer) and decision making (DM, selecting the most desired bundle
of outcornes). We have hypothesized that patients want their doctor to do
the problem solving, but that many want to be involved in decision
making. The coping style theory was based on previous research by
Weinbeger et al. (1 979) and Shaw et al. (1 985,1986) that suggests a
patient's coping style is correlated with a desire for information.
We approached 464 patients at the Cardiovascular lnvestigative Unit of a
Toronto teaching hospital. Of those. 41 6 (8996) were eligible for the study,
41 (9%) were excluded and 7 (196) refused to participate. Three hundred
(72%) responses were received.
For the purpose o f this study, we devised a new scale entitled "The
Problem Solving-Decision Making Scale" (PSDM). Three vignettes were
used: The morbidityvignette read: "Suppose you often experience a
burning sensation when you go to the bathroom. You usually have to
push to begin t o urinate and sometimes dribbling occurs after urination";
The mortalityvignette read: "Suppose you had mild chest pain for three
days and decided that you should visit your doctor about this". The quality
of life vignette read: "Suppose you and your partner have been trying for
pregnancy, but have been unsuccessful for more than a year". Responses
were elicited for 6 statements, written to encompass the domain of
preferences for role in problem solving and decision making situations in
medical treatment. Four items were deemed problem solving tasks: (a) Who
should determine (diagnose) what the likely causes of your symptoms are?
(b) Who should determine what the treatment options are? (c) Who should
de termine what the risks and benefits for each treatment option are?,
(d) Who should determine how likely each of these risks and benefits are to
happen? Two items were deemed decision making tasks:(e) Given the risks
and benefits of these possible treatments, who should decide how acceptable
those risks and benefits are for you?, and (O Given al1 the information about
risks and benefits of the possible treatments, who should decide which
treatment option should be selected? The response categories were similar
to that used by Ende (1 989) in his Autonomy Preference Index. The five
xii
response categories were: "1 =the doctor alone"; "2=mostly the doctorl*;
"3=both equally"; "4=mostly me"; and "5=rne alone".
To determine content validity of the instrument, approximately 10 people
including healthy people, physicians, academics and research
methodologist were asked to judge the scope and design of the
instrument. All respondents judged the format and content of the scale to
be satisfactory.
Two methods were employed for scale validation: factor analysis and
reliability testing. Factor analysis produced two factors: problem solving
and decision making. The variance extracted by the first factor was 37.8
per cent and 17.5 per cent for the second factor; the total extracted
variance for the two factors was 55.3 per cent. The full scale had reliability
(Cronbach's alpha) ranging from 0.71 to 0.90 for one vignette to three
vignettes, respectively.
A test-retest reliability study was then conducted with a sample of nursing
students; 50 completed the pretest, 41 the retest; 22 pairs could be
matched. The test-retest reliability score for each subscale was calculated
using Pearson product-moment correlations. Test-retest reliability for the
Problem Solving subscale was 0.46 and for the Decision Making subscale
was 0.68. To determine test-retest reliability we also used paired t-tests.
Test-retest reliability for the Problem Solving subscale
(t=-0.61 ,df=20,p=0.514), and for the Decision Making subscale
(t=0.31 ,df=21 ,p=0.76), indicated no significant differences over time.
Using this instrument, we found that patients overwhelmingly wished the
problem solving tasks to be performed by or shared with the doctor
(98.4% of the 12 PS score were between 1 and 3), but wanted to be
involved in decision making (78% o f the 6 DM scores were between 3
and 5 ) . Preference for handing over contrcl to the doctor was significantly
greater for the mortality vignette then for the morbidity or quality o f life
vignettes.
In addition t o O u r scale (PSDM), the instrument included questions on
preferred decision making role, desire for information, coping style, and
demographic and background material. We used the Ende et al. (1 989)
Autonomy Preference Index, the Krantz (1 980) Health Opinion Survey, and
the Weinberger (1 979) Sensitization-Repression Scale.
Our findings on these items confirmed that the patients we studied had a
moderate preference for information.
Coping style was measured using the Repression-Sensitization Scale
adopted by Weinberger et al. (1 979) which characterizes an individual's
response to anxiety provoking stimuli through desire for information.
Coping style was measured on a scale that combined the Taylor Manifest
Anxiety Scale (TMAS) and the Marlowe Crowne Social Desirability Scale
(MCSD). Coping was measured on a scale, wi th the TMAS and MCSD scores
split at the mean t o yield the four coping categories: 1) True Repressors
(low TMAS and high MCSD) characterized by information avoidance; 2) Low
Anxious (low TMAS and low MCSD) also referred to as effective copers who
are able to handle stress in an effective manner; 3) True Anxious (high
TMAS and low MCSD) also referred t o as sensitizers and characterized by
seeking out o f information; and 4) Repressive Anxious (high TMAS and
high MCSD) also referred t o as sensitizers.
We found a relationship between coping style and desire for information.
True repressors wanted a moderate amount o f information, low anxious
xiv
and true anxious individuals wanted a medium to high level of
information, and repressive anxious wanted a medium to low level of
information. Sirnilar results have been reported by Shaw et al. (1 985;
1 986) and Murphy et al. (1 989).
Our findings also indicate a significant relationship between coping style
and the Decision Making Subscale (Utilities question) across al1 three
vignettes. For the Morbidity Vignette (chi-square=27, 1 Zdf, p=0.006);
Mortality Vignette (chi-square= 32.868, 1 Zdf, p-0.001); and Quality of Life
Vignette (chi-square=2 5.1 95, 1 Zdf, p=0.014).
We also found that age, sex, and coping style did not explain variation for
preference in retaining control over problem solving or relinquishing
control to the physician.
These findings suggest two major roles for clinicians - assisting the patient
in structuring the decision (e.g., the problem solving), and supporting
them in making often difficult decisions. Experts cannot determine what
value will be placed on a particular outcorne. How unpleasant it is to live
with pain, or to be forced to limit one's activities, is inherently a personal
value judgement. Our results suggest that many patients agree that they
should play a major role in decision making with the pannership and
support of providers. ldentifying the alternatives does not always tell you
which one should be selected.
In conclusion, we have developed an instrument to measure patient
preferences in treatment choice - problern solving and decision making - and shown that:
1) most patients want to be informed;
2 ) most patients do not want to be involved in problem solving;
3) most patients want to be involved in decision making;
4) patients are more inclined to hand control over to physicians in
situations involving risk of mortality than those involving morbidity or
quality of life.
We have also found that:
5) coping style was correlated with the arnount of information patients
desired such that i) sensitizers wanted a high level of information, whereas
ii) repressors wanted a low level of information; and
6) coping style was correlated with patient preferences in treatment choice
for the Utility question of the Decision Making Subscale, but was not
correlated with patient preferences in treatment choice for the Problem
Solving Subscale and the What is Done question of the Decision Making
Su bscale.
ACKNOWLEDCEMENTS
I would like to express my sincere thanks to Dr. Raisa Deber, chair of my
thesis cornmittee, for her support, direction, and encouragement throughout
this thesis projea. I would also like t o thank the members of my committee,
Drs. Jane lrvine and Allan Detsky, who provided invaluable input throughout
this project.
Dr. Gladstone, Director of the Cardiovascular Investigation Unit (CIU), al1 the
cardiologists who permitted me to approach and recruit their patients into
the study, and to the staff of the CIU who were always friendly and helpful.
I would also Iike to thank Andrea Baumann and Dr. John Trachtenberg for
their contribution t o this research project. Thanks to Michael Murray,
and Sandra Gardner for their willingness t o share their statistical expertise.
The study could have not been done without the great cooperation we
received from the 300 people who completed the questionnaire. and the
nursing students.
Thanks to the Social Science Research Council of Canada, whose financial
support o f a grant to Dr. Deber, 410-92-0725 "Medical Decision Making: Who
and How? Patient Empowerment and Decision Rules", helped to make this
study possible.
I am grateful to my parents for the love and support they have given me
throughout my lifetime. I would like t o express thanks to my sister, Brenda
and brother, Terry for their encouragement and support o f my work. As well,
special thanks to Mark Shorey, for his patience and understanding throughout
my thesis work. I would also like to thank Ruth Hall and al1 the other friends
and colleagues who offered support.
CHAPTER I
INTRODUCTION
What role do patients want to play in making decisions about their own
treatment? The current ideology suggests that patients should be active
participants in decision making about their own care; the literature has
suggested that patients wish to be informed, but not involved. Can those
views be reconciled? We thought it might be possible to take this a step
further and analyze whether underlying 'coping style' might predict a
patient's desire for information and preference for participation in decision
making.
The purpose of this study was to examine the roles patients wish to play in
making decisions about their own treatment. The objectives of the study
were:
(1) to assess the role patients wish to play in making treatrnent choices about their own care and the amount of information patients want; and
(2) to determine if coping style (sensitization-repression) influences the patient's desire for information or role in problem solving or decision making.
The study was largely exploratory in intent. It was composed of two parts:
choice and coping style. The choice component was based on a theory by
Deber and Baumann (1989) that there are two elements of clinical
reasoning: problem solving and decision making. According to Baumann
and Deber problem solving "refers to the search for the single 'correct'
solution to a problem. and decision making refers to a situation in which a
choice, often requiring trade-offs, must be made from a number of
possible alternatives" (Baumann and Deber, 1989). Baumann and Deber
(1 989) postulated that most patients want their physician to do the
problem-solving, but that many want t o be actively involved in the
decision making component of choice behaviour. The coping style theory
was based on previous research by Weinbeger et al. (1 979) and Shaw et al.
(1 985,l 986) that suggests a patient's coping style i s correlated with a
desire for information. Since Deber and Baumann's theory of choice
behaviour had never been empirically tested, thus providing no research
to suggest what might be expected, a detailed program of exploratory
analysis was done. For the purpose of this study, we devised a new scale
entitle "The Problem Solving-Decision Making Scale (PSDM)".
The questions to be studied were determined by extensive research of the
literature on patient decision-making and coping style. Considerable
research has been done on the role patients want to play in making
choices about their treatment, but no work has been done testing Deber
and Baumann's (1 992) theory of patient participation. Furthermore, very
l i t t le research has been done on coping style as it relates to a patient's
desire to be provided with information and desire for involvement in
treatment selection.
The following hypotheses were tested:
Hypothesis I
Most patients want to be informed.
Hypothesis II
Most patients do not want to be involved in problem solving.
Hypothesis III
Most patients want to be involved in decision making.
Hypothesis IV
Patients will be more inclined to hand control over to physicians in situations involving risk of mortality than those involving morbidity or quality of life.
Hypothesis V
Coping style will be correlated with the amount of information patients desire:
i) sensitizers will want a high level of information; and ii) repressors will want a low level of information.
Hypothesis VI
Coping style will be correlated with patient preference in treatment choice:
i) sensitizers will want to be involved in treatment choice to a greater degree than repressors.
Two populations were studied - patients undergoing angiogram and
nursing students. The first chapter provides a review of the literature on
medical choice and coping style. The second chapter describes how the
study was carried out. dealing with methodology, the research subjects.
questionnaire construction, coding, testing the quality of the data and
analysis of the data. Chapter three provides results on scale development.
Chapter four presents data on characteristics of the patient sample.
Chapter five describes the results on participation in treatment choice.
Chapter six describes the results on coping style. The final chapter
summarizes and interprets the results and suggests future research.
Medical decision making is a complex issue and the role o f patient
involvement in making medical decisions has received considerable
attention over the past years. The issues o f concern are: How much do
patients wish t o be informed about their diagnosis, possible treatments,
and likely outcornes? To what extent do patients wish to be involved in
their therapy, including treatment decisions?
Although the current ideology suggests that patients should be active
participants in decision making about their own care, the literature
suggests that patients wish to be informed, but not involved (Strull et al.
1984; Ende e t al. 1989). For example, Deber and Baumann have suggested
that much o f the research done in the area of patient participation has
made insufficient recognition o f the difference between two elements o f
choice, which they term problern solving and decision making. Problern
solving refers t o the search for the single correct solution; thus, it requires
expertise. Decision making refers t o choices that require trade-offs among
possible alternatives; thus, values and preferences must be considered.
This chapter wi l l f irst examine the literature on patient participation i n
medical decision rnaking in respect t o the problem solving and decision
making distinction. It draws upon a review of the literature done by Deber,
Pendleton, and Bouchard, for the Royal Commission on New Reproductive
Technologies (forthcoming). A secondary literature review was undertaken
to develop an understanding o f coping style and i t s relation to preference
for information and role in decision making.
THE ROLES Of PHYSICIAN and PATIENT
Historically, medicine has been dominated by the paternalistic model
which places the physician as the expert for whom the patient seeks help.
This was characterized by "professional autonomy on the part of the
physician with a corresponding attitude of benign paternalisrn toward the
patient" (Kaufman 1983, 1991). This ideology was further supported
"because medical knowledge is so complicated, the information possessed
by the physician as t o the consequences and possibilities of treatrnent i s
necessarily very much greater than that of the patient" (Arrow 1965).
Thus, l i t t le emphasis was placed on encouraging active participation from
patients. As noted by Katz (1 984) "physicians have shown a keen
sensitivity to patients' decision making limitations but considerable
insensitivity to their capacities to decide" (Katz 1984.87). In theory, this
model took into account patient preferences and values, but left them a
minimal role in decision making.
As we move further into the age o f consumerism the traditional medical
ideology is being undermined. The consurneristic model signifies a
change in the public's attitude toward health care professionals and health
care delivery. In this model, the doctor wil l still be seen as the expert, but
the patient as the consumer should be able to "buy" the information and
take as much control in the treatment decision as is desired. Thus, the
emergence o f consumerism has lead to a growing interest in the concepts
of autonomy and beneficence. In turn, this has lead to the debate over
whether patient choice is more important than what is in the best interest
o f the patient. There has also been much attention paid to the principle o f
informed consent which is rooted in legal, ethical, social, and moral
concerns.
Much attention has been paid to the question of how much a physician
should tell patients about their diagnosis and prognoses. There are both
ethical and practical issues involved in decision-making. Recognition of the
extent to which patients' mental attitudes and hope can influence
outcornes led many physicians to argue that it was inhumane and perhaps
unethical to tell a patient that there was no longer hope for cure. This
view saw the ethical principle of beneficence as dominating; patient
information and choices would be manipulated "for their own good."
Others argued for telling patients the t ru th under al1 circumstances, both
on pragmatic grounds (a deceived patient is less likely to be compliant)
and out of ethical repugnance o f violating a patient's autonomy (e.g. Katz
1984). Medical ethicists argued that autonomy is more important than
beneficence; thus, patients should be informed whether they want the
knowledge o r not (Sider and Clements 1985). The forgoing review
suggests that patient participation is probably, on balance, a "good thing".
Moreover, there is also evidence that, given a choice, many people want
to be involved in decision making. For example, a desire for increased
information and participation in decision making was expressed by
individuals testifying t o the Royal Commission on New Reproductive
Technologies (What We Heard-Issues and Questions Raised During the
Public Hearings). Several studies have documented a patient's desire for
information (Cassileth 1980; Ende et al. 1989; Strull et al. 1984).
Altering the balance, between beneficence and autonomy produces
different answers. Katz noted that physicians admit among themselves
that medicine is an inexact science and uncertainties exist (Katz 1984a).
Physician uncertainty undermines the very foundations that the medical
profession is bu i l t on: esoteric knowledge which allows for power and
control over decision making. However, it has been argued that
"a physician's ability to preserve his own power over the patient in the
doctor-patient relationship depends largely on his ability to control the
patient's uncertainty .... The less uncertain the patient becomes about the
nature of his illness and the effects of treatment, the less willing he may
be to relinquish decision-making power to the physician" (Katz 1984a, 42).
Katz argures that this reluctance to acknowledge uncertainty is harmful to
the fostering of a trusting physician-patient relationship and undermines
the capability of genuine, shared decision making.
The strongest argument for patient involvement may be the discovery
th roug h decision-analysis techniques that optimal treatrnent in many
clinical situations is uncertain. McNeil, Weichselbaum, and Pauker (1 978)
investigated the importance of patient attitudes toward survival, involving
the choice between surgical and medical therapy. Under certain
circumstances, the value assigned by the decision maker to particular
outcornes determines the optimal treatment (Barry et al. 1988;
Fowler et al. 1988; Pauker and McNeil 1981 ; and Wennberg et al. 1988).
Optimal choice of therapy would thus require knowing those values which
in turn requires knowing the patient's wishes. From a procedural
viewpoint, however, acceptance of this normative model of decision
making requires either that the clinician become an excellent judge of
patient wishes or that patients be allowed to participate. Otherwise,
outcomes are likely to be suboptimal, even judged from a purely technical
stand point. "Some decisions are subjective, based on moral principles or
preferences rather than on scientific grounds" (Abrams, 1993). For
example, studies have found that patient's wishes had an impact on
treatment decisions; decisions were based on the social, traditional and
religious reasons and largely ignored the medical information
(Christensen-Szalanski et al. 1987, McClain 1987). Therefore, health care
providers need t o recognize that treatment decisions will ultimately
involve both medical information as well as patients' wishes. As stated by
Ende e t al. (1 989) " the physician-patient relationship should be based not
on preordained policies, but rather on an accommodation to each patient's
preferences and needs" (Ende et al. 1989. 28).
Research studies have also shown that participation leads to better
outcomes and more satisfaction among patients (Kaplan 1991 ; Schulman
1979; Brody et al. 1989). Kaplan (1 991) postulates that patients who
perceive they have control or choice over their health status have
"enhanced or protected immune functioning" indirectly resulting in better
outcomes. Other studies have also found that patients who believe they
have control over their health status have better outcomes than those who
do not perceive their control (Schulman 1979; Brody 1989). Patients who
are active participants are "apt to accept, believe in, understand and carry
out treatment recommendations" (Schulman 1979, 278). Overall, it
appears that perceived control affects health outcomes. lnvolving
patients in treatment decision making may enhance their sense of control
and ultimately facilitate better health outcomes.
In general, the literature indicates that the relationship between patient
participation and patient satisfaction is ambiguous. t t i s important to note
that patient satisfaction is not necessarily related to a good outcorne.
Instead, evidence suggests that patient satisfaction may be more
influenced by interpersonal factors in the physician-patient relationship
(Ben-Sira 1976; Woolley et al. 1978; and Speedling and Rose 1985). In a
study examining the relationship between physician-patient
communication and patient satisfaction, Wartman et al. (1 983) found that
compliance was negatively correlated with satisfaction with
communication during visit and that patient satisfaction with physician-
patient communications does not always reflect effective communication
about drug regimen.
Research studies have found that increased participation does not always
engender greater happiness. Examples included Roter's (1 977) finding
that encouraging patients to ask their physicians more questions resulted
in lower satisfaction, or Greenfield's (1 985) finding that participating ulcer
patients were no more satisfied than the controls- These results could
have arisen if clinicians failed t o respond satisfactorily to their patients'
efforts; however, they could also refiect a distinction noted by Ware et al.
(1 976) between the "art of care" and the "technical aspect of care." Most
patient-satisfaction surveys suggested that "from the patient's perspective,
the technical component is taken for granted, leaving the non-technical
open to scrutiny and evaluation" (Speedling and Rose 1985). In a pilot test
o f their Perceived Involvement in Care Scale, Lerman et al. (1 990) found
that, although there was a weak bu t significant relationship between self-
reponed patient involvement with decision making and satisfaction with
their physician's technical cornpetence, there was no correlation with the
art of care. Thus, participation probably has an overafl positive effect but
does not guarantee a happy, satisfied patient.
A Swedish study measuring patient satisfaction and perceived involvement
in the decision making process found that the majority o f patients were
satisfied with their perceived involvement in the decision making process,
being involved in the decision-making as much as desired (Larson et al.
1989).
Another argument for patient participation stems for studies that have
shown that doctors are not good predictors o f what their patients want
(Strull e t al. 1984; England 1992).
Although legal and ethical thinking now in effect requires participation
(e.g., "informed consent") there are practical barriers. Katz (1 984)
postulates that there are three significant barriers t o the implementation
of patient participation in medical decision making: These are:
(1) Authority. There is a debate between the traditional view that patients
benefit the most if they follow doctors orders and the notion o f informed
consent which argues that physician and patient share in the decision-
making; (2) Autonomy. Despite the implication that both physician and
patient have the ability t o make decisions, it must be recognized that
illness can impair a patient's competency for decision making, rendering
patient autonorny less practical; and (3) Uncertainty. In many instances
the medical knowledge needed for confident decision making is simply
unavailable.
The current medical environment tends not t o be conducive t o patient
involvement. An environment rnust be established that enhances patients'
independence by facilitating their involvement in making decisions, by
ascertaining the patients' goals and values, and by educating the patients
about the risks and benefits o f alternative treatments (Brody 1980).
Another potential difficulty is that "physicians and patients rnay be bound
by potent unconscious factors, such that patients rnay need to be taken
care of by powerful paternal or materna1 figures" (Quill 1983.223). Some
patients rnay adhere to what is known as "the sick role" , temporarily
handing control for their health over to the doctor (Katz 1984). Yet others
rnay be too i l 1 t o act as decision makers, having to rely on their physician
to be the decision maker.
Another set of obstacles rnay result from the reality o f busy clinical
practice; that is, physicians rarely have time to provide information (Faden
1991 ; Beisecker and Beisecker 1990), and the patient rnay be reluctant to
"bother the doctor".
DIMENSIONS OF PARTICIPATION
The literature seems to highlight three dimensions o f participation. The
much-disputed issue o f paternalism have engendered the developrnent o f
alternatives to the paternalistic model which supports the shift frorn
physician control over decision making toward more patient control
(Veatch 1972; Brody 1989; Quill 1983). In the 'priestly model', the
physician was seen both as the technician and decision maker, deciding
what was best for the patient. The 'engineering model' developed by
Veatch (1 972) saw the physician as technician and the patient as sole
decision maker. Veatch's 'collegial model' recognized the imbalance o f
knowledge and viewed the patient and physician as equal partners.
ln the 'shared contractual rnodel' (Brody 1989; Quill 1983) the physician
contributes the "expertise in diagnosis and management", while the
patient contributes "personal moral values or lifestyle preferences" about
which they "could be expected t o know more than the physician couldw
(Brody 1989,70). Thus, choosing a best treatment requires the
contributions of both the physician and patient (Brody 1980; Lerman et al.
1990; Quill 1983; and Weiss 1986; President's Commission for the Study o f
Ethical Problems in Medicine and Biomedical and Behaviour Research
1982).
Various approaches t o enhance active patient participation have been
studied and ernpirically tested. Studies have used the "coaching" approach
to empower patients (Creenfield e t al. 1985, 1988; Roter 1977). With this
method patients are trained to read their medical records, ask questions.
negotiate medical decisions, and are provided with information about the
cause, complications, and treatment. Some studies have found this
method to be effective in helping patients obtain information from
physicians (Creenfield et al. (1 985, 1986) whereas others have failed t o
find these results. Roter (1 977) studied poor. black women and found that
"coached" patients asked more questions; however, their interactions with
the physician appeared to be characterized by more anger and anxiety,
and they were less satisfied with the visit than the uncoached consults.
Other studies have shown that patient participation can be increased
through improving a patient's comprehension (Robinson and Whitefield
1985). The results suggest that having health care providers state their
willingness to answer questions may be insufficient to elicit genuine
participation. When patients were asked specifically "to imagine carrying
out instructions, to notice any problems which might arise, and to raise
these with the doctor" (Robinson and Whitefield 1985) there were
significantly more questions and comments and fewer errors and
omissions in their accounts of the recommended treatment. Wateworth
and Luker (1 990) concluded that promoting individualized care is not
necessarily synonymous with active patient involvement.
PREFERENCES FOR INFORMATION and INVOLVEMENT
Studies have found that patients ovennrhelmingly want to be informed. As
an example of patients' desire for information, one study found that 98 per
cent of cancer patients indicated a desire to know about al1 possible side
effects of treatment (Cassileth, 1980).
Several studies have documented patients' desire for information among a
variety o f disease states and found that most patients have a strong
preference for information and detailed disclosure (Beisecker and Beisecker
1990; Blanchard et al. 1988; Cassileth 1980; Faden et al. 1981 ; Ende et al.
1989; Strull e t al. 1984; and Sutherland e t al. 1988).
Beisecker and Beisecker (1 990) investigated patient information-seeking
behaviour among 106 rehabilitation medical patients at an outpatient
clinic. Data collection included: 1 ) sociodemographic questionnaire
administered immediately before the doctor-patient interaction; 2) a tape
recording o f the entire interaction between patient and doctor(s); 3) a tape-
recorded interview with the principal investigator immediately following
the doctor-patient encounter; and 4) an opinion survey mailed to the
patient ten t o fourteen days after the appointment. To measure
information and participation the Desire for Medical Information and Locus
of Authority in Medical Decision Making Scale, developed by Beisecker and
Beisecker (1 988) were used. The Desire for Information Scale asked the
question "How important is it to you to be given information in the
following areas?" and used a five-point Likert-type Scale with l=not at al1
important t o 5=very important. The Locus o f Authority Scale asked the
question "Following are some areas i n which decisions are made in
medicine. Who do you think should make the decisions in each area?"
Respondents were given three categories t o choose from: doctor, patient.
or both doctor and patient.
The results revealed that patients ovenvhelmingly desired information
about a variety o f medical topics but wanted the doctor to be the sole
decision maker. Although patients wanted information, they showed little
indication for engaging in information-seeking behaviours. The
researchers suggest that patient disease might be a confounding factor
stating "chronic disease or disabilities partially explains their lack of
information seeking behaviour" (Beisecker and Beisecker 1990.26)-
As well, their findings suggested that situational variables are a strong
determinant o f information seeking communication behaviour than patient
attitudes and sociodemographic variables. Patient attitudes only become a
predicting factor in information-seeking behaviour when patient-physician
consultation time i s o f a certain length since "short interactions minimize
patient question asking and expression of patient attitudes" (Beisecker and
Beisecker 1 990,28).
There have been several empirical studies examining both preference for
information and participation in treatment decision making. One of the
first studies to look at the extent to which patients wished to be involved
in treatment decision making and preference for information was by
Cassileth et al. (1 980). The study population was 256 cancer patients.
They found that younger patients were more likely to adopt a participatory
approach then older patients. The data showed that 87 per cent in age
group 20-39, 62 per cent of those in age group 40-59 and 51 per cent of
those aged 60 and older preferred to participate in decisions about their
medical care and treatment. However, 96 per cent in age group
20-39, 79 per cent aged 40-59 and 80 per cent of those 60 years and over
indicated that they wanted to have alf information - good and bad.
Sirnilarily, in a study examining the extent to which patients desired to
participate in medical decision making, Strull et al (1 984) concluded that
patients wished to be informed but not be involved in decision making.
The study focused on three aspects of decision making: 1) amount of
discussion about therapy; 2) how decisions are usually made; and
3) preferences for roles in decision making. The questionnaire was
adrninistered to patients and their physician. For instance, they asked a
question such as the "clinician should make the decision using al1 that's
known about the rnedicines" (Strull et al. 1984). The researchers
concluded that patients desired information, but "that half of the patients
did not want to play any role in actual decision making".
Another study by Llewellyn-Thomas et al. (1 991) examined preferences for
participating in decision making used a modified version of the
questionnaire from Cassileth et al. (1980) and Strufl et al. (1 984). The
questionnaire was administered to cancer outpatients and analyzed
according to their attitudes towards clinical trial entry. Patients were
broken down into two groups: Agreers and Refusers. Responses on the
Decision Making Preference Questionnaire were collapsed to indicate two
styles of decision making: 1) physician- dominate (based on the questions
"The doctor should make the decisions using al1 that's known about the
treatment", 'The doctor should make the decisions but strongly consider
rny opinion"; and 2) patient participate (based on the questions "The
doctors and I should make the decisions together on an equal basis", 1
should make the decisions, but strongly consider the doctor's opinion", "1
should make the decisions using al1 1 know or learn about the treatments).
O f the 60 cancer patients. 28 fell into the physician-dominated category
whereas, 32 patients were in the patient participate category. It was noted
that patients who refused to enter into a clinical trial were not as willing to
relinquish their role in treatment decision rnaking (Llewellyn-Thomas,
1991, 39).
Similarily, Siminoff et al. (1 991) survey of 100 breast cancer patients about
their involvement in making decisions about adjuvant treatment. The
findings showed that 80 per cent of the patients relied on their physicians
to make the prirnary treatrnent decision; only 3 per cent of the patients
surveyed did not select any of the possible treatment options (Siminoff et
al. 1991).
Degner and Russel (1 988) also examined preferences for treatment
decision making among 60 cancer patients. They postulated that people
have ideal points along the psychological dimensions of keeping, sharing
or giving away control over decision making. A scale developed by the
researchers consisted of eight vignettes describing various levels of
control over treatment decisions. Using a card sort procedure, patients
were asked to rank the cards depicting the eight vignettes. Using this
scale, the researchers found that preferences for control over decision
making, fifty-nine of the sixty patients was consistent with this underlying
psychological dimension; and that most patients preferred shared control
over handing control over to a family member.
A study by Blanchard e t al. (1 988) of cancer patients examined preferences
for information and decision making. Patients preference for information
to be given was assessed using the categories: 1) minimal; 2) only if it is
good news; and 3) good or bad. Preference for participation was measured
using the categories 1 ) prefer doctor makes therapeutic decisions and
2 ) prefer to participate in decisions. The results indicated that 92 per cent
wanted al1 information, good or bad, to be given, but only 69 per cent
desired to participate in treatment decision rnaking. Of those who wanted
information, 24.9 per cent preferred the doctor make the decisions. The
investigators postulated that "these findings suggest that the preference
for information does not always rnean that the patient then wants to
participate in therapeutic decisions" (Blanchard et al. 1988, 1 143).
The relationship between patients' desire for information and their
preference for participation in decision making was also examined by
Sutherland et al. (1 989).
Approximately 77% reported that they had participated in decision making
to a desired extent. As in the Ende study, many patients actively sought
information, but a majority preferred the physician to be the primary
decision maker. The researchers concluded that "professionals, in an
attempt to encourage informed, autonomous decision rnaking, may
provide information which many patients may indeed desire to have"
(Sutherland et al. 1989, 263), but it must be remembered that patients s t i l l
may desire the physician to make the decision.
A questionnaire was developed by Ende et al. (1 989) t o distinguish
between elements o f patient autonomy: desire for information and desire
for participation. Patient desire for information and participation were
measured by the Autonomy Preference Index, consisting o f two scales: an
eight-item scale on information seeking and a fifteen-item scale on
decision rnaking. The "decisions" they asked about were questions such as
"whether a cardiologist should be consulted" if you discovered you were
having a heart attack.
They concluded that "patients prefer that decisions be made principally by
their physicians, not themselves, although they very rnuch want to be
informed". However, there was no correlation between patients' decision
making and information seeking preference.
Although the current ideology seerns t o suggest that patients should be
active participants in making decision about their own medical care,
indicating a move toward shared decision making (Katz 1 984; Childress
1983; Wennberg 1990; Brock 1990), a large body of research has
accumulated which appears to indicate that patients wish to be informed,
but s t i l l prefer their doctor to be the primary decision maker (Ende et al.
1989; Strull et al. 1984; Cassileth et a1.1980; Beisecker and Beisecker
1 991).
One explanation for the contradiction that exists between current ideology
and empirical evidence is that the research may not be accurate. Deber
and Baumann (1 989) have postulated that the literature has made
insufficient recognition between two elements of choice behaviour -
problem solving and decision making.
PROBLEM SOLVINC and DECISION MAKINC
According to Baumann and Deber problem solving "refers to the search for
the single 'correct' solution to a problem, and decision making refers to a
situation in which a choice, often requiring trade-offs, must be made from
a number of possible alternatives" (Deber and Baumann 1992, 140).
In problem solving we are presented with a search problem: how to
discover that correct answer most efficiently. Problem solving tasks thus
require both a knowledge base and a set of problem solving skills to
identify the possible alternatives and the probabilities of each likely
outcome, but have a Iimited role for patient involvement (Baumann and
Deber, 1989). The problem solving and decision making tasks are not
linear, but rather embedded within each other; they do not exist in
isolation, but rather they comprise a continuous process. In medicine the
process used in determining the correct diagnosis would illustrate problem
solving whereas, the process of selecting a treatment would be an example
of decision making (Deber and Baumann 1 989). For example, a
cardiologist's job would be to diagnose the symptoms, identify treatment
alternatives and determine the probability of each outcome. In contrast,
decision rnaking requires prior problem solving, but relies heavily upon
patient preferences. It does not rnatter whether an individual would prefer
that they do not have cardiac disease - the diagnosis is what it is.
However, identification of treatment options does not determine what
should be done; the only person who can decide whether he/she can live
with angina or risk surgery, is the person who has that condition. This
distinction would imply that the job of the health professional i s to
perform the problem solving, and to support the patient in making
subsequent decisions.
Studies suggesting patients do not wish to be decision makers have not
always noted this distinction. Strull et al. (1 984) failed to distinguish
between the problern solving and decision making components thus, the
lack of distinction has lead Strull et al. (1 984) to conclude "that half of the
patients did not want to play any role in actual decision-making". As well,
Ende et al41 989) concluded that "patients prefer that decisions be
made principally by their physicians, not thernselves, although they very
rnuch want to be informed", they do not distinguish between problem
solving and decision making. The "decisions" they asked about were
questions such as "whether a cardiologist should be consulted" if you
discovered you were having a heart attack, decisions for which patients
not surprisingly felt a need for expert input.
This distinction would imply that the job of the health professional is to
perform the problem solving, and to support the patient in making
subsequent decisions. The distinction is similar to that made by Kassirer
(1 983) when he wrote about "usurping patients' prerogatives." A similar
distinction was made by Arrow (1 973). This is supported by a Harris poll
cited by Ende et al (1 989) noting 72 percent of patients surveyed preferred
the option "The doctor discusses alternatives with the patient and the two
of them decide together how to proceed".
Based on this literature, we hypothesized that most patients will prefer to
have experts perform the problem solving tasks, but will wish to take a
more active role in decision making.
INDlVl DUAL VARIATIONS IN PREFERENCES TO PARTICIPATE
Several studies have identified factors that may contribute to whether or
not a patient wants information or wants to participate in decision making.
Some of these are: age, education. social class, and disease state (Cassileth
e t al. 1980; Strull et al. 1984; Brody 1980; Blanchard 1 988; Lidz 1983).
Studies have found that patients are dissatisfied with the information they
receive (Waitzkin and Stahl 1980). Matthews (1 983) suggested the
communication of information may be more problematic because of the
different frames of references about what information should be shared
and social distance between the physician and patient. To be understood,
information must be presented in a way appropriate to the patient.
Clearly, format, content, and timing of the material are important;
however, that is not the focus of this thesis.
Ende e t aL(l989) found that older patients have less desire than younger
patients to make decisions and to be informed. Younger patients tend to
adhere to the concept of shared participation whereas, older patients tend
to prefer the traditional non-participatory approach (Degner et al. 1 988;
Cassileth et al. 1980; Beisecker and Beisecker 1990; Blanchard 1990).
Pendleton et al. (1 984) in their study of poor low-income diabetics found
that they expressed little desire to actively involved in their health care or
seeking information about it as compared to college students who
indicated preferences for active involvement.
There appear to be differences in decision-making patterns between
chronically i l 1 verses acutely il1 patients. Patients with acute illness tend t o
adhere to what is known as "the sick role", temporarily handing complete
control over their body t o the doctor, whereas patients with chronic
diseases are less will ing to relinquish control over their bodies (Lidz
1983,542).
Beisecker and Beisecker (1 990) found that patient-physician consultation
time was an important factor in patient participation.
Another determination o f individual differences may be related t o a
dimension of coping style. This leads us to the literature review on coping
style. Civen that the fiterature in this area is quite extensive, only the
literature directly related to our measure has been reviewed.
COPINC STYLE
The concept of coping usually refers t o the ways individuals react to the
threatening (stressful) aspects of a situation. Coping is an important
concept for research in health. A review of the literature suggests that an
individuals coping style may have health-relevant consequences. More
specifically, studies have shown that coping style influences responses to
information. (Shipley e t al. 1979; Shaw e t al. 1985, 1986; Murphy e t al.
1989).
Cohen e t al. (1 987) have suggested five major coping strategies:
information-seeking, direct action, inhibition of action, intrapsychic
processes, and turning to others for support. The mode of coping that
this paper will focus on is that of information-seeking. We have chosen
information-seeking as it relates to the literature that States that patients
want to be informed.
The literature highlights two approaches to coping style which treats
coping as a personality characteristic as opposed to a process which
adheres to the theory that coping changes over time as a function of i t s
situational context (Averill and Opton 1988; Cohen and Lazarus 1973,
1979; Cohen 1987; Lazarus 1993). The primary focus of this literature
review will be on the style approach and the specific measure of
repression-sensitization.
Historically, coping theory and research treated coping as a dispositional
style. The majority of research on coping style employed measures which
were hierarchical and developmental in formation, such as the
undimensional trait measures which have been termed repression-
sensitization or avoidance-coping; the tendency to avoid or seek out
threatening information (Lazarus 1993). In Measurement of Coping,
Cohen (1 987) cites a nurnber of instruments developed to operationalize
the construct of repression-sensitization. For example, Byrne's (1 961)
Repression-Sensitization Scale; Epstein and Fenz's (1 967) modified
Repression-Sensitization Scale; the Rorschach index of Repressive Style
(Gardner, Holzman, Klein, Linton, and Spence 1959; Levine and Speivack
1964); and Weinberger, Schwartz and Davidson's (1 979) Repressive Style
Index. The construct of avoidance-vigilance is measured by the Coldstein's
(1 959) Coping-Avoidance Sentence Completion Test (Andrew 1 967, 1 970).
Other scales used multidimensional approaches such as the Defense
Mechanisrn lnventory (Gleser and lhilevich 1969) and the Joffe and
Naditch's (1 977) Coping-defense measure.
COPINC MEASURE: REPRESSION-SENSITIZATION
The repressive literature stems from the denial literature. Repressors
when presented with threatening situations or stimuli tend to avoid
disturbing cognitions by ignoring the threat or denying its existence.
Sensitizers, however, are very alert to threatening situations and tend to
focus on and magnify their ability t o do harm (Budd 1985; Roth 1986;
Weinberger 1979). Repressors tend to underplay or deny their anxiety,
whereas sensitizers tend to exaggerate their anxiety. Since a repressor is
characterized by defensiveness and preoccupation with avoiding negative
emotions (anxiety) we would expect them to be information-avoidant,
believing that avoiding information will help them to better cope with the
situation. Sensitizers, on the other hand, who are viewed as extremely
vigilant would be information-seeking, believing that information will help
them to better cope with the situation.
To operationalize the concept of repressor and sensitizer the Byrne
Repression-Sensitization Scale (Byrne 1 961 ) was developed. Although, the
Byrne (1 961 ) scale has been frequently used, its psychornetric and
theoretical properties have been questioned (Lazarus 1974; Weinberger
1979). Weinbeger e t al. (1 979) developed their own repression-
sensitization measure t o overcome some of the problems inherent in the
Byrne (1 963) measures such as distinguishing between true repressors
(repression of anxious feelings) and truly low-anxious persons (experience
low levels o f anxiety, showing no emotional upsets). Weinberger et al.
(1 979) combined the Marlowe-Crowne Social Desirability Scale and the
Talyor Manifest Anxiety Scale to establish the classification o f repressor
and sensitizer. The Marlowe-Crowne Social Desirability Scale was used t o
differentiate between low-anxious persons and repressors by classifying
them according to the degree of defensiveness (low or high). The Talyor
Manifest Anxiety Scale rates the respondent's degree o f anxiety (low or
high). These scores were then combined and divided at the mean to create
four defensiveness categories: true repressors (low anxiety, high social
desirability); truly anxious (high anxiety, low social desirability); repressive
anxious (high anxiety, high social desirability); and truly low anxious (low
anxiety, low social desirability).
Although the literature examining the influence of coping style on
preference for information i s sparse the studies that have been done
suggest that coping style influences information gain and medical
outcomes (Shaw et al. 1985.1 986; Murphy et al. 1989; Levine et al. 1987;
Shipley 1978).
Shaw et al. (1 985) used the Weinberger et al. (1 979) measure of
sensitization-repression in his study that examined the influence of coping
style on information gain and medical outcomes. The results indicated
that patients who denied more gained less information; patients who
scored high on social desirability gained less information and repressors
gained less information. Repressors with high risk factor information
reported more complications and poorer psychomedical functioning, and
2) sensitizers with low risk factor information reported poorer social
functioning. The researchers concluded that sensitizers should be more
comfortable in a high information setting whereas repressors should be
more comfortable in low information setting.
Another study conducted by Shaw et al. (1 986) examined the relationship
between coping style, information and medical outcomes. They combined
the low anxious and repressive anxious categories developed by
Weinberger because they found little difference between the two. The new
categories that they employed were labelled: true repressors, effective
copers and sensitizers. Using this classification system they found that
repressors with a high level o f cardiac information (coping style-
information level mismatch) and no history of heart attack were at higher
risk for late medical complications; and sensitizers with a low level o f
cardiac information (coping style-information level mismatch) and whose
PTCA was only moderately successful were at higher risk for coronary
artery re-stenosis.
A study by Murphy et al. (1 989) examined coping style and patient
knowledge. Prior to their procedure, patients were required to attend a
structured educational program. The researchers found that patients with
a repressive coping style learned less and the low anxious learned more
than the other coping groups during hospitalization, however, they
did not find significant difference at 6 month or two year follow-up. They
found that effective copers maintained that highest level of knowledge
over the 2-year period.
Shipley et al. (1 979) investigated the ef fea of information on and coping
style. The researchers found that sensitizers experienced less anxiety
given information whereas repressors who had either no effect or an
increase in anxiety. Shipley et al. (1 978) suggests that "sensitizers be
prepared extensively and repressors left alone or at least left with their
defenses" (Shipley et al. 1978, 506).
Coping style may also be related to patient satisfaction with
communication, and medical knowledge (Steptoe et al. 1991). The results
indicated that patients who reported the highest level of satisfaction with
information were more avoidant and less anxious. The researchers
conclude that " patients' predispositions to cope with stress by seeking out
information about the threat or by avoiding information has an impact on
satisfaction with communication" and thus "patients must be able to select
a level of detail and a degree of confrontation with their condition that
they require" (Steptoe e t a1.631,1991).
To date, no studies have been done that examine the relationship between
coping style and preference for participation in treatment decision making.
Based on this literature, we hypothesized that coping style would be
correlated with the amount of information patients desire such that,
sensitizers will want a high level of information whereas, repressors will
want a low level of information.
We therefore tested the following hypotheses:
Hypothesis I
Most patients want to be informed.
Hypothesis II
Most patients do not want to be involved in problem solving.
Hypothesis III
Most patients want to be involved in decision making.
Hypothesis IV
Patients will be more inclined to hand over control to physicians in situations involving risk of mortality than thcsc involving morbidity or quality of life.
Hypothesis V
Coping style will be correlated with the amount of information patients desire:
i) sensitizers will want a high level of information; and ii) repressors will want a low level of information.
Hypothesis VI
Coping style will be correlated with patient preference in treatment choice:
i) sensitizers will want to be involved in treatment choice to a greater degree than repressors.
CHAPTER II
METHODOLOCY
This chapter deals with:
study population; ethics; sample size; sampting procedures; sample quality; the questionnaire; scales used; coding; data quality; strengths and limitations of methods used.
STUDY POPULATION
There were two groups of potential respondents: cardiac patients and
nursing students. The f i r s t comprised four hundred and sixty-four
patients undergoing a coronary artery angiogram, of whom 300 returned
completed questionnaires. The second group comprised a convience
sample of approximately fifty nursing students taking an university class
and was used for evaluating test-retest reliability.
ETHICAL REVIEW
The questionnaire was submitted to and approved by the Human Subject
Certification for Physical Sciences 6 Life (including Medical) Sciences
Review Committee of the University of Toronto. Patients provided
informed consent by returning the mailed questionnaire.
SAMPLINC PROCEDURES
The study population was patients at the Cardiovascular Investigation Unit
of a Toronto teaching hospital. The hospital was primarily selected
because it treated a large number of patients from the Toronto and
surrounding area (Le. Barrie). Other influencing factors were its size,
proximity, and the investigators familiarity with the hospital.
A l ist of al1 the cardiologists who referred patients to the Cardiovascular
lnvestigative Unit (CU) at the Toronto hospital was obtained, and each
cardiologist was sent a letter asking permission to approach their patients
at the time of angiogram for recruitment into the study. Confirmation of
participation by the cardiologist was either written or verbal.
Approximately ten cardiologists were approached.
All cases were located through a daily patient caseload sheet provided by
the coordinator for the Cardiovascular Investigation Unit. The
exclusionary criteria that were used were: patients had to be staying in
either the Day Bed Unit or the Short Stay Unit, had to speak and read
English, were not experiencing complications in hospital, and did not
refuse.
Before participating in the study, al1 subjects were approached by the
researcher, either before or after the patient had their procedure, and were
asked to participate in the study. Each patient was explained the purpose
of the study and asked to take the Health Care Decisions Survey home with
them, complete it, and t o return it as soon as possible to the principal
investigator using a self addressed postage paid envelope. If the
questionnaire package was not returned within about four weeks, a
telephone follow-up was carried out (approximately 25). If questionnaires
were said to have been returned by the subject, but were never received
by the principal investigator, the subject was sent another questionnaire
to complete.
Four hundred and sixty-four patients schedufed for an angiogram were
approached. Of those, 41 6 (89%) were recruited into the study, 41 (9%)
were excluded, and 7 (1%) refused to participate. Subjects who were
recruited into the study were given a questionnaire to take home,
complete and mail back within three weeks. Subjects who forgot the
questionnaire in hospital were coded as missing (approximately 4). Data
collection began on January 6 , 1993 and was completed April 8, 1 993.
On average. recruitment of subjects took place three days per week.
RESPONSE RATES
Eligible questionnaires received on or before June 1 5. 1 993, were coded
and included in the study. The response rate for those recruited into the
study was 300 (72%). Two additional questionnaires were received after
the cut-off date and are not included. According to Babbie (1 986) a
response rate of 70 per cent or greater is considered to be very good.
QUESTIONNAIRE CONTENT
The questionnaire consisted of four sections. The first section consisted
of three vignettes with questions focusing on problern solving and
decision rnaking. The second section inquired about attitudes toward
medical care, preference for decision making and information. To measure
this the Ende (1 989) Autonomy Preference Index (API) and the Krantz
(1 980) Health Opinion Survey (HOS) were employed. The third section
concerned coping abilities and used the Repression-Sensitization Scale.
The final section consisted of basic demographic and background
information questions including marital status, education level,
employment status, past medical history, and overall health.
SCALES USE0
The Problem Solving-Decision Making Scale (PSDMS) had been developed
for the purpose o f this study. Three established questionnaires were
emplyed: 1) Health Opinion Survey, 2) Autonomy Preference Index, and
3) Repression-Sensization Scale.
Health Opinion Suwey (HOS)
The Health Opinion Survey was developed by Krantz (1 980) to measure
patient attitudes towards toward treatment approaches and consists of
two subscales, one measuring preferences for information and the other
measuring preferences for behavioral involvement. The first scale
measures information, composed of seven items measuring a patients
desire to be informed about medical decisions. The second scale
measures behavioral involvement, composed of nine items measuring a
patients attitude toward self-treatment and active behavioral involvement
o f patients in medical care. The total combined score of the two a priori
subscales provides an overall measure of attitude toward medical
treatment. A high score indicates positive attitude toward participation in
medical care, conversely a low score indicates a passive att i tude towards
participation.
One o f the objectives of this study was to assess the relationship between
coping style and information preference. The Health Opinion Survey was
selected on the following grounds: it is an accepted measure for
information preference and it has been widely used (Neufeld 1986). The
total HOS has a reported Kuder-Richardson reliability o f -77. the Behavioral
Involvement and Information subscales were -74 and .76, respectively
(Krantz 1980).
Repression-Sensitization Scale
The Repression-Sensization measure used in this study was the rnodified
version o f the Byrne Repression-Sensitization Scale adopted by Weinberger
e t al. (1 979). The scale used the short forrns o f the Taylor Manifest
Anxiety Scale (1 953) and the Marlowe-Crowne Social Desirability Scale
(1 960). 60th scales have 20 true-false statements, which were interrnixed
to form one questionnaire. The Taylor Manifest Anxiety Scale (TMAS) and
the Marlowe-Crowne Social Desirability (MCSD) scores were split at the
mean to yield the coping groups: "repressive anxious" (high TMAS and
high MCSD), "true anxious" (high TMAS and iow MCSD), "low anxious"
(low TMAS and low MSCD) and "true repressors" (low TMAS and high
MCSD).
Adequate reliability and validity for the TMAS and MCSD scales exist;
however, these scales were used to form the Weinberger et al. (1 979)
repressive style groups. Reliability has not been established for the
combination o f the TMAS and MCSD scales in measuring repression-
sensitization. However. several studies provide suppon for the pred ictive
and concurrent validity o f this measure (Shaw 1985, Weinberger 1979,
Asendorpf 1983).
The Autonomy Preference lndex (API)
The Autonomy Preference lndex was developed by Ende et al. (1 989) to
distinguish between components o f patient autonomy: desire for
information and desire for participation. This test instrument consists of
two scales: an 8-item scale on information seeking and a 15-item scale on
decision making (6 general items and 9 items related to 3 clinical
vignettes). items are scored on a five point Likert scale. Total scores are
linearly adjusted to range from O to 100, where O i s deemed to indicate no
desire for information or participation in decision making and 100
indicates a strong desire for information and participation in decision
making.
Ende (1 989) reported the test-retest reliability (calculated using Pearson
product-moment correlations) for the decision making scale was 0.84; for
the information-seeking scale 0.83. They reported al1 interna1 consistency
reliability coefficient using the Cronbach alpha coefficient was 0.82 for
each scale.
The Autonomy Preference Index was chosen for i t s information and
decision making subscales. The information subscale was deemed useful
for assessing the relationship between coping style and information
preference. The decision making subscale would seem to be a good
cornparison against our scale.
For the purposes of our study we only used 6 of the 1 5 decision making
items. The 6 questions employed were: 1) The important medical decisions
should be made by your doctor, not by you; 2) You should go along with
your doctor's advice even if you disagree with it; 3) When hospitalized, you
should not be making decisions about your own care; 4) You should feel
free to make decisions about everyday medical problems; 5) If you were
sick, as your illness became worse you would want your doctor to take
greater control; and 6) You should decide how frequently you need a
check-up. The patients were to respond to each item on a five-point Likert
scale; response categories ranged from "strongly disagree" to "strongly
ag ree".
The remaining 9 decision making questions were not employed because
they were specific to three hypothetical vignettes which were not going to
be used in our study.
Problern Solving-Decision Making Scale (PSDMS)
For the purpose of this study. we devised a new scale, which used the
same response categories employed by Ende et al. (1 989) in his Autonomy
Preference Index. The five response categories were: "1 =the doctor alone";
"2=mostly the doctor"; "3=both equally"; "4=mostly me"; and "5-me alone".
The scale used three vignettes briefly describing a health problem.
Responses were elicited for 6 statements, written to encompass the
domain of preferences for rote in problem solving and decision making
situations in medical treatment.
Four items were deemed problern-solving tasks, concerned with patients
attitudes toward active participation in the problem-solving component of
clinical behaviour: (a) Who should determine (diagnose) what the likely
causes of your symptoms are? (b) Who should determine what the
treatment options are? (c) Who should determine what the risks and
benefits for each treatment option are?, (d) Who should determine how
likely each of these risks and benefits are to happen? Two items were
deemed decision-making tasks measuring the desire to be actively
involved in the decision making component medical decision- making:
(e) Civen the risks and benefits of these possible treatments, who should
decide how acceptable those risks and benefits are for you?. and (O Given
all the information about risks and benefits of the possible treatments.
who should decide which treatment option should be selected?
Three vignettes were used describing various health situations. The
morbidity vignette read: "Suppose you often experience a burning
sensation when you go to the bathroom. You usually have to push to
begin to urinate and sometimes dribbling occurs after urination";
The mortalityvignette read: "Suppose you had mild chest pain for three
days and decided that you should visit your doctor about this". The quality
of life vignette read: "Suppose you and your partner have been trying for
pregnancy, but have been unsuccessful for more than a year".
RELlABlLlTY & VALlDlTY
The reliability and validity of the instrument is addressed in Chapter III.
CODINC
The questionnaire was coded and after the coding, every questionnaire
was checked for coder errors. Questions in which the respondent
indicated two answers were coded as missing if the answers were
categorical and averaged if numeric. When respondents circled more than
one response for educational level, the highest circled educational level
was taken. When a respondent indicate a number range (i.e. 9 to 10) the
numbers were averaged.
DATA QUALITY
Two basic checks were made of the raw data. Basic frequency tables for
each item were reviewed to see if codes were present which were not
correct, and the raw data was manually checked with the questionnaires to
detect any data entry errors. Once errors detected in this way had been
eliminated, we tested for reliability of the decision making and information
preference measures and the psychological measure.
DATA MANAGEMENT
The data was managed using the SAS-PC statistical program. This
consisted of data records identified by respondents unique identification
nurnber making sure that there was no information available that would
have enabled these subjects to be identified or traced. All identifying
information was kept in the possession of the research student until the
completion of the analysis and then destroyed.
During the course of the study, data was entered directly in SAS-Pt
statistical program. Backup of the data was performed on a weekly basis.
At the completion of the study, subsequent analysis was performed on an
IBM-compatible micro-computer, using both the SAS-PC and SPSS-PC
statistical programs.
STATISTICS EMPLOVED
Ordinal data were analyzed using both pararnetric and nonparametric
statistics. Since both techniques gave us similar results, it was decided
that the parametric tests would primarily be presented in the main body of
t he report as they have the advantage of being more powerful and flexible
than nonparametric techniques. When necessary the equivalent
nonparametric statistics are presented in the main body of the report (see
also Appendix B). Much of the analysis will be descriptive (e.g.,
frequencies and cross-tabuiations, with tests of significance and
associations). Univariate analysis and multivariate analysis techniques
were ernployed.
CHAPTER I I I
SCALE OEVELOPMENT
For scale development we decided t o use two methods for scale validation:
factor analysis and reliability testing. Factor analysis was utilized as an
adjunct to the other methods for scale development. Since we had
previously anticipated item groupings. factor analysis would provide us
with some information on the factorial validity of the Problem Solving and
Decision Making Scales.
For reliability testing, we used a nursing student sample for the test-retest
component. The results wil l be presented afier the factor analysis results.
ADEQUACY OF SAMPLE SlZE
Factor analysis was utilized as an adjunct to the other methods for scale
validation. Nunnally (1 978) States that in scale development an adequate
sample size would be 300, while Kline (1 986) recommended 200. The
larger the sample, the less subject variance will be a significant concern.
Comrey (1 988) indicated that an acceptable sample size for ordinary factor
analysis that involved no more than 40 items would be 200, while
Nunnally (1 978) presents a more stringent position of 20 subjects per
variable. Boyle (1 985) indicated that a minimum sample of 250 subjects is
required for factor analysis. The present sample of 300 subjects satisfies
al1 these criteria.
METHODS
To support our hypothesis that the two scales problem solving and
decision making, were two constructs, the items were subjected to a
principal-components analysis with a varimax rotation, listwise deletion.
An item was judged to load on a component if it had a loading of 0.50 or
greater with no loading of 0.50 or more on any other component. A factor
loading with an absolute value o f 0.40 or more i s considered acceptable.
(Kerlinger 1973; Munro e t al.1986).
Before embarking on a decision of the factor analysis results it is necessary
to describe the variables employed. The morbidity vignette (scenario) is
denoted SCENA, the mortality scenario SCENB, and the quality of life
scenario SCENC. The final letter refers to the item as follows:
A: Diagnosis: "Who should determine (diagnose) what the likely causes of your symptoms are?' (SCENAA, SCENBA, SCENCA).
B: Options: "Who should determine what the treatment options are?" (SCENAB, SCENBB, SCENCB).
C: Risks and Benefits: 'Who should determine what the risks and benefits for each treatment option are?" (SCENAC, SCENBC, SCENCC).
D: Probability: 'Who should determine how likely each of these risks and benefits are to happen?" (SCENAD, SCENBD, SCENCD).
E: Utility. "Civen the risks and benefits of these possible treatments, who should decide how acceptable those risks and benefits are for you?" (SCENAE, SCENBE, SCENCE).
F: What is Done: "Given al1 the information about risks and benefits of the possible treatments, who should decide which treatment option should be selected?" (SCENAF, SCENBF, SCENCF).
The rnean scores for each item on the scale ranged between 1.56 and 3.22;
the mean scores for the problem solving items (A,B,C,D) ranged between
1.56 and 2.02, indicating handing over control; for the decision making
(E,F) items 2.94 t o 3.22, indicating sharing control (see Table 3.1).
Table 3.1 Mean Score for Patient Population
Mean Standard Item Score deviation
SCENAA SCENAB SCENAC SCENAD SCENAE SCENAF
SCENBA SCENBB SCENBC SCENBD SCENBE SCENBF
Quality of Life:
SCENCA SCENCB SCENCC SCENCD SCENCE SCENCF
Total
As a starting point a univariate correlation matrix was done to determine
what combinations of items should be subjeaed to principle-components
analysis (see Appendix B). Although, the theory suggested that there
should be two dimensions, we d id not initially specify a two factor
solution. The communality estimates for al1 the factor analysis solutions
were acceptable (Comrey 1973). Only the rotated factor solutions have
been presented (see Appendix 0 for unrotated factor solutions). All
significant loadings have been italicized.
Factor analysis was run for each vignette separately and then for the
pooled items. The first correlation matrix to be inputed into the factor
analysis included the six items from the morbidity vignette. Factor I
consisted of four items, which indeed highlighted the problem-solving
dimension. The variables extracted were: scenaa (0.737). scenab (0.723).
scenac (0.776), scenad (0.705). Factor II involved the two decision making
items: scenae (0.850), and scenaf (0.823). The variance extracted by the
first factor was 42.7 per cent and 2 1.4 per cent for the second factor; the
total extracted variance for the two factors was 64.1 pet cent. The
correlation between the factors was 0.539 (see Table 3.2).
TABLE 3.2 Initial Principal components matrix, varimax rotation for morbidity vignette
Item Factor I Factor II Communality h2
SCENAA SCENAB SCENAC SCENAD SCENAE SCENAF Eigen-value Variance (%)
Similarly, factor analysis of the six items from the rnortality vignette gave
the four problem solving items as Factor 1: scenba (0.682'). scenbb (0.876),
scen bc (0.794). scenbd (0.782). Factor II again involved the two decision
making items: scenbe (0.870) and scenbf (0.850). The variance extracted
was 46.2 per cent for the first factor and 20.1 per cent for the second
factor; the total extracted variance for the two factors was 66.3 per cent.
The correlation between the factors was 0.475 (see Table 3.3).
TABLE 3.3 Initial Principal components matrix, varimax rotation for mortality vignette
Item Factor I Factor II Communality h2
SCENBA SCENBB SCENBC SCENBD SCENBE SCENBF Eigen-val ue Variance (%)
Next, the six items from the quality of life vignette was subjected to factor
analysis. Again, Factor I consisted of the four items highlighting problem
solving: scenca (O. 702). scencb (0.794). scencc (0.825). scencd (0.805).
Factor II again involved the two items highlighting decision making: scence
(0.897) and scencf (0.898). The variance extracted by the first factor was
62.8 per cent and 22.6 per cent for the second factor; the total extracted
variance for the two factors was 85.4 per cent. The correlation between
the factors was 0.470 (see Table 3.4).
TABLE 3.4 Initial Principal components rnatrix. varimax rotation for quality of life vignette
SCENCA SCENCB SCENCC SCENCD SCENCE SCENCF Eigen-value Variance (%)
Factor I Factor II Communality h2
-702 -794 -825 . BOS 1 39 1 1 7 2.807
62.8
Based on the results f rom the previous factor analyses, it was decided that
t he final correlation rnatrix t o be inputed into the factor analysis prograrn
would include al1 eighteen items from the three vignettes. Since we had
already established that two factors would be extracted, a 2 factor forced
solution was specified.
For the final analysis, the significant loadings on Factor I involved al1 the
problem-solving dimension. The relevant variables were: scenaa (0.602),
scenba (0.563), scenca (0.583), scenab (0.6 1 6 ) . scenbb (0.772), scencb
(O.689), scenac (O.680), scen bc (0. V O ) , scencc (0.772), scenad (0.6631,
scenbd (0.73 1 ) , scencd (0.73 1). Factor II focused on the decision-making
component. The variables were: scenae (0.786), scenbe (0.793), scence
(0.799), scenaf (0.824), scenbf (0.834), scencf (0.814). The variance
extracted by the first factor was 37.8 per cent and 17.5 per cent for the
second factor; the total extracted variance for the two factors was 55.3 per
cent. The correlation between the two factors was 0.543 (see Table 3.5).
Table 3.5 Principal components matrix, varimax rotation, two forced for morbidity, mortality and quality of life vignettes
Item Factor 1 Factor 2 Cornmunality Ma
SCENBB ,772 SCENCC ,772 SCENBC .770 SCENBD .731 SCENCD ,731 SCENCB ,690 SCENAC .680 SCENAD .663 SCENAB .616 SCENAA -602 SCENCA -583 SCENBA .563 SCENBF 1 52 SCENAF 1 2 5 SCENCF 1 24 SCENCE 124 SCENBE 1 09 SCENAE 1 3 3 Eigen-value 6.81 1 Variance(%) 37.8
RELIABILITY
Establishing reliability is a priority for scale development. The reliability
coefficient is determined from the intercorrelations of items on test; i ts
size i s based on the average correlation among items (Nunnally 1978).
In accordance with Nunnally's (1 978) proposals, coefficient alpha was used
to ascertain the internal consistency of the scale (Cronbach 1970).
According to Streiner (1 989) and Nunnally (1 978) Cronbach's alpha's
should exceed 0.80.
We investigated the reliability (internal consistency) of the scale using both
the patient and nursing student sample.
To begin with Cronbach's alpha coefficient was calculated for al1 the scales
employed. Alpha coefficient for internal reliability was very high for both
the problem-solving and decision-making subscales. Cronbach's alpha was
acceptable for al1 other scales (alpha ~ ~ 0 . 7 3 ) except for the Ende
Information Scale (alpha = 0.1 1 ), Ende Decision Making Scale (alpha =
0.60), Ende Cornbined (alpha =.56), and the two item Decision Making-
Mortality Vignette (alpha =0.68) (Table 3.6).
Cronbach's alpha for the problem-solving subscale using the 12 items from
the rnorbidity, rnortality and quality of life vignettes was 0.901 ; the 8 items
from the morbidity and rnortality vignettes was 0.860; and the 4 items
from the mortality vignette 0.787. Cronbach's alpha for the Krantz
lnformation and behavioural subscales using our patient sample was 0.73
and 0.75, respectively. Our results are very similar to what Krantz (1 980)
reported in his original work. Cronbach's alpha for the Ende Information
subscale was very 0.1 1 , which is very low compared the original
alpha = 0.80 reported by Ende (1 989). Since we did not employ the entire
Ende (1 989) Decision Making subscale. the alpha that i s reported in this
study cannot be compared to that originally reported by Ende (1 989).
Table 3.6 Cronbach's Coefficient Alpha (Patient Sample)
Variable Alpha N
Cases Items
Taylor Manifest Anxiety Scale Marlowe Crowne Social Desirability Health Opinion Survey-Information Health Opinion Survey-Behaviour Health Opinion Survey Autonomy Preference Index/Decision Making Autonomy Preference Scale-Information Problem Solving (3 vignettes) Problem Solving (2 vignettes - A & B) Problem Solving (1 vignettes - B) Decision Making (3 vignettes) Decision Making (2 vignettes - A & 8) Decision Making (1 vignette - B) Problem Solving and Decision Making (3 vignettes) Problem Solving and Decision Making (2 vignettes - A & B) Problem Solving and Decision Making (1 vignette - A) Problem Solving and Decision Making (1 vignette - B) Problem Solving and Decision Making (1 vignette - C)
ITEM-TOTAL CORRELATION
Item-total correlation was done using the eighteen problem solving and
decision making items. All item correlation coefficients were significant
and coefficient alpha was 0.901, showing a high level o f interna1
consistency. We also looked at Cronbach's alpha with items deleted.
reliability of the scale. Deleting items did not change alpha significantly.
Cronbach's alpha was cafculated using several combinations of items
(Table 3.7).
Table 3.7 ltem analysis (N =18)
Squared alpha Item-Total Multiple item
Item Correlation Correlation deleted
SCENAA -328 .368 SCENAB .547 -462 SCENAC .609 .616 SCENAD 590 .578 SCENAE .532 .681 SCENAF -560 .693 SCENBA -450 -407 SCEN88 .643 -61 O SCENBC .643 -634 SCENBD S72 -561 SCENBE - 5 1 9 .680 SCENBF 5 9 2 -739 SCENCA -406 .407 SCENCB -559 -532 SCENCC -573 -637 SCENCD -594 5 9 6 SCENCE .545 .618 SCENCF .552 .703 Total 40.40 9.68
Alpha Standardized item alpha
(n=25O)
Elimination of the decision making items frorn the scale caused little
change in alpha. From the results we can assume that this scale is
useable. For future use, we plan t o use mortality and morbidity vignette
since the fertil ity vignette does not add much t o our alphas.
CORRELATIONS WlTH OTHER SCALES
Concurrent validity was established among the Problem Solving-Decision
Making subscales using two other measures: 1) Krantz Behaviour Subscale;
and 3) an i tem that asked patients t o indicate, "Which statement best
describes your attitude towards medical care?" by choosing one o f five
statements: 'The patient should take complete control"; The patient
should have more control than the doctorf*; ''The patient and the doctor
should share control equally"; " The doctor should have more control than
the patient"; and 'The doctor should take complete control". There was a
moderate correlation with patients' responses to this scale and the
decision making scores (r=-0.44; p<0.0001), and only a low correlation
with the Krantz Behavioural Subscale (r=0.27; p<0.0001).
NURSES DATA: PAIRED T-TESTS
To examine the reproducibility o f the scale we employed the test-rest
reliability method. This would provide us wi th some information regarding
the stability of our instrument. The 50 nursing students were
administered the PSDMS in conjunction with the Health Opinion Survey
(Krantz 1980). and the Autonomy Preference Index (Ende 1989) twice over
approximately a 4-week period t o determine test-retest reliability.
NURSINC SAMPLE: DEMOCRAPHIC INFORMATION
Table 3.8 reports demographic information for the nursing sample. The
pretest sample included 5 0 subjects; the posttest sample consisted o f 41
subjects. The total number of subjects matched for the combined pretest
and posttest sample was 22.
In sumrnary, our nursing sample was predominately Young, fernale,
university educated, tended to be employed part-time or full-time and had
a positive health status.
Table 3.8 Demographic Characteristics: Nursing Sample
Pre-test Post-test 6) No. (46)
Male Fernale
Marital Status Never Married 27 (54.0%) 16 (39.0%) Married (common-law) 21 (42.0%) 1 (2.4%) Separated --- 4 (9.6%) Divorced 2 (4.0%) --- Widowed --- ---
Table 3.8 Continued-Demographic Characteristics: Nursing Sample
Pre-test Post-test No. (%) No. (96)
Educational Level Some University/College 23 (46.0%) 25 (61.0%) Corn pleted University/College 21 (42.0%) 16 (39.0%) Some Professional/Craduate 4 (8.0%) --- Completed Professional/Graduate 2 (4.0%) ---
Employrnent Status Employed Full-time Employed Part-time Not Employed Other
Health Status Excellent Very Cood Cood Fair
Pre-test: Mean age 30.9 years, SD 9.68 years Post-test: Mean age 34.6 years, SD 9.68 years
To determine stability of the Problem Solving-Decision Making measure we
employed test-retest Pearson product-moment correlation (r) as a measure
of reliability. The test-retest correlations must be signficantly correlated.
Paired t-tests were also computed.
Results are based on 22 cases who completed both tasks. It is compared
on seven variables which are parts of the scales used (endedms, endinfs,
krantzs, krbehav, krinfos, scendm, scenps). Table 3.9 presents the results
from the test-retest correlations.
Table 3.9 Test-retest Pearson Produd-moment Correlations: Nursing Sample
- - - - - - - --
Variable Cases Cross-Prod Dev Variance-Covar r* P
ENDEDMS ENDEDMSZ 22 807.796 38.466 .336 1 2 7
ENDEINFS ENDINFSZ 22 1194.957 56.902 5 1 6 .O1 4
KRANTZS KRANTZSZ 22 1 .S90 .O75 .46 1 .O3 1
KRBEHAS KRBEHASZ 22 6.454 -307 -722 .O00
KR1 N FOS URI N FOS2 22 1.454 .O69 .393 .O70
SCENDM SCENDMZ 22 8.988 -428 -687 .O00
SCENPS SCENPSZ 21 2.326 -1 16 .462 .O35
"Pearson product-moment correlation coefficients
The Pearson product-moment correlation (r) revealed significant
differences between the pretest and posttest for al1 scales except the Ende
(1 989) Decision Making Subscale. These results indicate good stability of
the scales over time.
Further confidence in stability arises because the paired t-test analysis
revealed no significant difference between pretest and posttest for any of
the scales. The results are presented in Table 3.1 0.
Table 3.10 Paired T-tests: Nursing Sample
SE of Paired Differences Variable Mean SE of Mean t-value df 2-tail sig
ENDEDMS ENDEDMSZ
KRANTZS KRANTZS2
KRBEHAS KRBEHAS2
KR1 NFOS KRINFOSZ
*SCENPS SCENPSZ
SCENDM SCENDMZ
n=22, *n=21 p . 0 5 95% confidence lnterval
Individual items were also subjected to paried t-test analysis (see Apendix
B). The results indicated that there were no significant differences
between pretest and posttest scores.
In conclusion, we can see that our scale has proven validity and reliability.
Factor analysis was utilized as an adjunct to the other methods for scale
development. Since we had previously anticipated item groupings, factor
analysis would provide us with some information on the factorial validity
of the Problem Solving-Decision Making Scale. As part o f our reliability
testing we Cronbachgs alpha coefficient was calculated for al1 the scales
employed. Alpha coefficient for interna1 reliability was very high for both
the problern solving and decision rnaking subscales. Cronbach's alpha was
acceptable for al1 other scales. The results show that our PSDM has good
test characteristics, and is in the same range as other scales employed.
The results supported Our hypothesis that the problem solving-decision
making were two constructs.
CHAPTER IV
CHARACTERISTICS OF PATIENT SAMPLE
Basic Demographic Characteristics
This chapter presents data on some basic characteristics of the patient
participants. including sex, age, marital status, educational level.
employment status, and health state.
Sex
In our sample 74.7 per cent were male, 25.3 per cent female; there were
I l rnissing.
Age
Table 4.1 shows the age of respondents at time of angiogram. The age
range was quite broad: the youngest respondent was 24.5 years; the
oldest was 82.6 years. The mean age was 59.6 years, SD 10.7 years.
Table 4.1 Age of Respondents - -
Age Croup No. (%) - -- - -
5 0 and under 60 (21 -3%)
5 1 to 65 140 (49.6%)
Over 65 82 (29.1%)
(n=282)
Marital Status
Age was related to marital status. Civen that the mean age of our sample
was 59 years it is not surprising that most (86%) were married or common-
law (Table 4.2).
Table 4.2 Marital Status of Respondents
Marital Status No.(%) -- --
Never Married 8 (3.0%)
Married/common-law 247 (86.0%)
Separated S (2.0%)
Divorced 14 (5.0%)
Widowed 1 3 (4.0%)
(n=287)
Ed ucation
Table 4.3 shows education o f respondents, in eight categories: some
elementary school, cornpleted elementary school, some high school,
cornpleted high school, some university/college, cornpleted
university/college. some professional or graduate school. completed
professional or graduate school.
The sample may be roughly divided into quarters: one-quarter with some
to complete elementary education, one-quarter with some to complete
secondary education, and one-quarter with some to complete university
education and one-quarter with some to complete professional or graduate
education.
Table 4.3 Respondent's Level of Education (n=29 1 )
Level of Education No. (%)
Some Elementary School
Completed Elementary School
Some High School
Completed High School
Some University/College
Completed University/College
Some Professional/Craduate School
Completed Professional/Craduate School
Employment Status
Table 4.4 shows employment status. Almost two thirds of our sample
were either employed full-time (34 per cent) or retired (39 per cent).
Table 4.4 Respondent's Ernployment Status
Employment Status No. (%)
Employed Full-time 99 (34.0%)
Employed Part-time 17 (6.0%)
Not employed 12 (4.0%)
Retired 1 14 (39.0%)
Homemaker 20 (7.0%)
*Other 30 (1 0.0%)
(n=292)
'Other includes: self employed, students
Previous Angiogram
Almost one-third of our sample indicated that they have had an angiogram
in the past. For the remaining two-thirds this was their first angiogram.
Only 9 pet cent of respondents indicated that they have had angioplasty to
open up their arteries and 10 per cent indicated they had bypass surgery.
O f these, 2.4 per cent have undergone both angioplasty and bypass
surgery (see Table 4.5).
Not surprisingly, about two-thirds of respondents indicated they had other
health/illness problems. Some of the reported illnesses were: low back
pain, arthritis, diabetes, hypertension, stroke, prostate surgery.
Overall health
Overall health was divided into five categories: excellent, very good, good,
fair and poor. Of al1 respondents, only 6 (2.1 %) indicated that their health
was excellent, 36 (1 2.5%) indicated very good, 89 (31%) were good,
128 (44.6%) rated their health as fair and 28 (9.8%) as poor.
Table 4.5 Characteristics of Patient Sample
No. (%)
Previous angiogram No 181 (62.6%) Yes 108 (37.4%)
Previous angioplasty No 264 (91 .O%) Yes 26 ( 9.0%)
Previous bypass No 261 (89.7%) Yes 30 (10.3%)
Other health problems No 102 (35.2%) Yes 188 (64.8%)
Attitudes Toward Medical Care
Table 4.6 reports views on medical care people receive in general and
satisfaction with the treatment of their cardiac condition.
Table 4.6 Attitudes Toward Medical Care
Question and Response Categories No. (%)
1. Generally, people are satisfied with the medical care they receive.
Strongly disagree Disagree Neither agree/disagree Agree Strongly agree
2. The quality of medical care that most people receive could be better.
Strongly disagree Disagree Neither agree/disagree Agree Strongly agree
Table 4.6 Continued - Attitudes Toward Medical Care
Question and Response Categories No. (%)
3. The care I have received from doaors in the last few years is just about perfect.
Strongly disagree Disagree Neither agree/disagree Agree Strongly agree
4. There are things about the medical care I have received that could be better.
Strongly disagree Disagree Neither agree/disagree Agree Strongly agree
5. Attitude toward medical care
The patient should take complete control The patient should have more control than the doctor The patient and doaor should share control equally The doctor should have more control than the patient The doctor should take cornplete control Other
Patients were asked about how they fe l t about the medical care people
receive i n general. Four questions were asked and patients were to give
their opinion using a five-point scale: 'strongly disagree', 'disagree',
'neither agree nor disagree', 'agree' and 'strongly agree'. The questions
were:
(1) Cenerally, people are satisfied wi th the medical care they receive;
(2) The quality o f medical care that mor t people receive could be bette r;
(3) The care I have received from doctors in the last few years is just about perfect;
(4) There are things about the medical care I have received that could be better; and
(5) Which statement best describes your own attitude towards medical care.
Overall. it appears that the ovenivhelming majority of patients agree that
generally people are satisfied w i th the medical care they, al though they
indicated tha t the quality o f medical care that most people receive could
be better.
About two-thirds of respondents indicated that the care they received from
doctors in t he last few years is just about perfect. Only about 20 per cent
thought there could be improvements with the care that they received.
Again, approximately 60 per cent of patients indicated that there are
things about the medical care they have received that could be bener.
About 20 per cent did not feel that improvements needed t o be made.
Satisfaction with Cardiologist
Respondents were asked a series of questions that provided us with some
descriptive information about their attitudes about the treatment of their
cardiac condition. Table 4.7 provides a sumrnary of the questions and
results.
Table 4.7 Satisfaction with Cardiologist
Questions and Responses No. (96)
Doctors seen about cardiac symptorns Family doctor 248 (84.9%) Cardiologist 276 (94.5%) Cardiac (heart) surgeon 98 (33.6%) Other 34 (1 1.6%)
(n=292)
I was pleased with how decisions were made? Strongly disagree 3 (1.0%) Disagree 12 (4.1%) Neither agree/disagree 29 (10.0%) Agree 178 (61 -2%) Strongly agree 69 (23.7%)
(n=291)
Table 4.7 Co-Wwed - Satisfaction with Cardiologist
Questions and Responses No. (%)
My role in rnaking these decisions was: Much more than I liked 2 (0.7%) More than I liked 7 (2.6%) Just Right 218 (80.1%) Less than I liked 40 (1 4.7%) Much less than f liked 5 (1.8%)
(n=272)
The doctors took charge: Much more than I liked More than I liked Just Right Less than I liked Much less than I liked
Information provide was: Much more than 1 liked More than I Iiked Just Right Less than I liked Much less than I liked
*Overall, satisfaction with medical care Extremely Satisfied 117 (40.9%) Satisfied 142 (49.7%) Neither Satisfied/Dissatisfied 19 ( 6.6%) Dissatisfied 6 (2.1%) Extremely Dissatisfied 2 (0.7%)
(n=286)
'Overall, how satisfied are you with the medical care that you have received for your current cardiac condition.
The following statement was given 'The next few questions ask specifically
how your feel about the way you and your specialist (Le. cardiologist)
made decisions about the treatment of the cardiac symptoms for which
you are now seeking help'. Based on this statement patients were asked
the following questions:
1 ) Which doctors have you seen about your cardiac symptoms?
2) 1 was pleased with how decisions were made. Patients were asked to rate using a five-point scale ranging from 'strongly disagree' to' strongly agree';
Questions 3,4 and 5 used a five point scale with the response categories:
'much more than I liked', 'more than I liked', 'just right', 'less than I liked'
and 'much less than I Iiked'.
3) My role in making the decisions was:
4) The doctors took charge:
5) Information provided was:
Patients, were also asked:
6) Overall, how satisfied are you with the medical care that you have received for your CU rrent cardiac condition?
The results indicated that the majority of patients had seen both a family
doctor and cardiologist about their cardiac symptoms.
An overwhelming majority, 85 per cent. of patient's were pleased with
how decisions were made. Only about 5 per cent indicated
dissatisfication.
The majority of patients, 80.1 per cent. indicated that their role in making
these decisions was 'just right'. Less that a fifth of respondents indicated
that their role in decision making was less that they liked. About 3 per
cent of patients indicated that their role in decision making was more than
they liked.
About 85.7 per cent indicated that their doctor took charge just the right
amount, whereas 10 per cent thought the doctor took charge more than
they liked. About 3 per cent o f patients thought the doctor should have
taken more control.
The majority of patients were satisfied with their role in decision making,
with only 25 per cent of patients reporting that the information provided
was less than they liked. Sixty-nine per cent felt that the information
provided was just right. About 3 per cent o f the patients felt that they
were given too much information.
An overwhelming majority. 90.6 per cent. of respondents indicated that
they were satisfied with the medical care that they had received for their
current cardiac condition.
To get some idea of patients attitudes toward the role o f the patient and
doctor should have in medical care. we asked them gave them six
statements and asked them to choose the one that best described their
own attitude towards medical care. The response categories were:
1) The patient should take complete control;
2) The patient should have more control than the doctor;
3) The patient and doctor should share control equally;
4) The doctor should have more control than the patient;
5) The doctor should take cornpletc control; and
6) Other
The results showed that over 60.3 per cent thought the patient and doctor
should share control equally, 6.4 per cent thought the patient should have
more control than the doctor. Only 24.8 per cent indicated that doctor
should have more control that the patient, and 5.7 per cent thought the
doctor should take cornplete control. These results, at first glance, indicate
little desire from these patients to control their care - most prefer shared
control, with a sizable minority wishing to hand over control to their
doctor. From this we can conclude that most patients do indeed want to
participate in treatment decision making although they do not want to
take complete control.
CHAPTER V
PARTICIPATION IN TTREATMENT CHOlCE
HYPOTHESIS I
Most Patients do want to be informed
The Health Opinion Survey (Krantz 1980) was constructed to
operationalize preference for self-care, active behavioral involvement in
health care, and health-related information. Although, the Health Opinion
Survey (HOS) provided descriptive data regarding patients attitudes toward
assuming an active and informed role in the health care process, this
section will only address the results from the information subscale.
Our results confirm the literature findings that most patients have a high
desire for information. Fifty-eight (20.1%) o f patients had low scores,
129 (44.6%) had medium scores and 102 (35.3%) had high scores for the
information subscale. About 20% of patients showed little desire to ask
questions and to be informed o f and involved in medical decisions
(Figure 5.1 ).
Figure 5.1
HOS Information Preference Subscale
LOW Medium High
El Level of Information
Our findings frorn the HOS information subscale are further suppo~ed by
Ende et al. (1 989) Autonomy Preference Index information subscale.
Expressed on a scale adjusted ta range frorn O to 100, where O refers to
strong disagreement with statements favouring patients' being informed,
5 0 to a neutral reaction to such statement, and 100 to a strong agreement,
the mean score for information seeking was 81 -39 2 10.79.
Table 5.1 and Figure 5.2 show Krantz lnformation Seeking Preference by
Age Croup. We see that 10.8 per cent in the age group '50 and under' want
low level of information compared to 16.4 per cent in the group '51 -65'
and 32.2 per cent in the greater than 65 group. We see that 43.1 per cent
want high information in the '50 and under' group, compared to 40.3 per
cent in the '51 -65' group, and 22.2 per cent in the greater than 65 group.
Table 5.1 HOS Information Preference by Age Croup
Age Croup lnformation Preference 50 and under 51 to 65 Creater
than 65 - -
Low 7 (1 0.8%) 22 (1 6.4%) 29 (32.2%)
Medium 30 (46.1%) 58 (43.3%) 41 (45.6%)
High 28 (43.1%) 54 (40.3%) 20 (22.2%)
Total (n=65) (n=134) (n=90) (n=289)
Figure 5.2
HOS Information ,Preference by Age Group 50 i t
Low Medium High
Level of Information
The results indicate that patients had a moderate preference for
information. Our findings support other studies that have documented
patients' desire to be informed (Vertinsky et al. 1 974; Strull et al. 1 984;
Lidz et al. 1982; Cassileth et al. 1980; Faden et al. 1981 ; and Harris et al.
1982).
In general, patients who were younger tended to prefer to be informed,
compared to older patients who preferred less information. This finding i s
consistent with other studies that have documented that older patients do
not want as much information (Ende et al. 1989; Degner et al. 1988;
Cassileth e t al. 1 980; Beisecker and Beisecker 1 990; Blanchard et al.
1 990).
Now that we have established that patients do indeed want information
the next question is what role do they want to play in making treatment
decisions.
Most Patents do not want to be involved in problem solving.
This section will deal with the hypothesis that most patients do not want
to be involved in problem solving. The results for al1 three vignettes will
be presented. To reiterate, the vignettes read as follows:
The Morbidity vignette read: "Suppose you often experience a burning sensation when you go to the bathroom. You usually have to push to begin to urinate and sometimes dribbling occurs after urination";
The mortality vignette read: "Suppose you had mild chest pain for three days and decided that you should visit your doctor about this".
The quality of life vignette read: "Suppose you and your partner have been trying for pregnancy, but have been unsuccessful for more than a year".
Once again, the four problem solving questions were:
A: Diagnosis: 'Who should determine (diagnose) what the likely causes of your symptoms are?"
B: Options: 'Who should determine what the treatment options are?"
C: Risks and Benefits: "Who should determine what the risks and benefits for each treatment option are?*'
D: Probability 'Who should determine how likely each of these risks and benefits are to happen?''
The response categories were: 'Doctor Only'; 'Mostly Doctor', Doctor and
you equally', 'rnostly you' and 'you only'.
Looking at the results from the morbidity vignette, we can see that
patients overwhelming want to give control to their doctor (Table 5.2).
Table 5.2 Morbidity Vignette: Problem Solving Questions
Doctor Mostly Mostly You N Item Alone Doctor 60th You Alone Cases
Scenaa 1 32(46.2%) 90(31.5%) 62(21.7%) 1 ( 0.3%) U 0.3%) 286
Scenab 120(41.8%) 1 02(35.5%) 63(22.0%) 1 ( 0.3%) l ( 0.3%) 287
Scenac 97(33.7%) 1 02(35.4%) 83(28.8%) 6( 2.1%) - 288
Scenad 1 1 1(38.8%) 1 33(43.0%) 45(15.7%) 7( 2.4%) - 286
Figure 5.3 presents the results from the diagnosis question, Figure 5.4
presents the results from the treatment option question, Figure 5.5
presents the results from the risks and benefits question, and Figure 5.6
presents the results for the probabilities question.
Figure 5.3
Morbidity Vignette: Diagnosis
Doctor Oniy Most& Ooctor 60th Mostly you You oniy
Figure 5.4
Morbidity Vignette: Treatment Options
Doctor Only MosUy Doctor Both Mostly you You only
Figure 5.5
Morbidity Vignette: RisksIBenefits
Doctor Oniy Mostfy Doctor 60th Masüy you You only
Figure 5.6
Morbidity Vignette: Probabilities
-
Doctor Only Mostly Ooctor Both Mostly you You only
Table 5.3 Proportion of scores in each Control Category (Morbid ity vignette)
Control Categories
Hand Over Share Retain No.Cases k 3 ) (3) (>3)
Diagnosis 77.7% 21.7% 0.6% 286
Options 77.3% 22.0% 0.6% 287
Ris k/benefit 69.1 % 28.8% 2.1% 288
Probability 81 -8% 15.7% 2.4% 286
Similarity, the results from the mortality vignette indicate that patients do
not wish to be involved in problem solving (Table 5.4).
Table 5.4 Mortality Vignette: Problem Solving Questions
Doctor Mostly Mostly You N Item Alone Doctor Both You Alone Cases
Scen ba 175(60.1%) 89(30.6%) 25(8.6%) 2 ( 0 . 7 % ) - 291
Scenbb 1 42(49.1%) 1 07(37.0%) 38(13.1%) 1 ( 0.3%) - 289
Scen bc 122(42.4%) 92(31.9%) 70(24.3%) 4 ( 1 . 4 % ) - 288
Scen bd 122(42.4%) 1 18(41 .O%) 43(14.996) 5 ( 1.7%) - 288
Figure 5.7 presents the results from the diagnosis question. Figure 5.8
presents the results from the treatment option question, Figure 5.9
presents the results from the risks and benefits question, and Figure 5.10
presents the results for the probabilities question.
Figure 5.7
Mortality Vignette: Diagnosis
Doctor Only Mostly Doctor Both Moatty you You only
Figure 5.8
Mortality Vignette: Treatment Options
Ooctor Only Mostly Ooctor 60th M q YOU You only
Figure 5.9
Mortality Vignette: RisksIBenefits
Dactor Only Mosüy 'ooctor Mostty you You only
Figure 5.10
Mortality Vignette: Proba bilities
Doctor Only Mostly Ooctor Mosüy you You only
Table 5.5 Proportion of scons in each Control Category (Mortality vignette)
Control Categories
Hand Over Share Retain No.Cases ( ~ 3 ) (3) (>3)
Diagnosis 90.7% 8.6% 0.7% 291
Options 86.1% 13.1% 0.3% 289
Risk/benefit 74.3% 24.3% 1.4% 288
Pro bability 83.4% 14.9% 1 -7% 288
Again. the results from the quality o f life vignette compare t o that o f the
previous two vignettes (Table 5.6).
Table 5.6 Quality of Life Vignette: Problem Solving Questions
Doctor Mostly Mostly You N Item Alone Doctor 60th You Alone Cases
- -
Scenca 1 36(51.1%) 82(30.8%) 44(16.5%) 2( 0.8%) 2( 0.8%) 266
Scencb 1 OS(39.896) 98(37.1%) 56(21.2%) 5( 1.996) - 264
Scencc 84(32.2%) 91 (34.996) 80(30.7%) 6( 2.3%) - 261
Scencd 89(34.2%) 97(37.3%) 64(24.6%) 8(3.1%) 2( 0.8%) 260
Figure 5.1 1 presents the results from the diagnosis question, Figure 5.1 2
presents the results from the treatment option question, Figure 5.1 3
presents the results from the risks and benefits question. and Figure 5.14
presents the results for the probabilities question.
Figure 5.11
Quality of Life Vignette: Diagnosis
Doctor Onîy Mostly Doctor 60th Mosüy you Vou onîy
Figure 5.12
Quality of Life Vignette: Treatment Options
Doctor Only Mostly Doctor 60th Mostly you You only
Figure 5.13
Quality of Life Vignette: RisksIBenefits
Doctor Oniy Mostly Ooctor 80th Mcmtly you You only
Figure 5.14
Quality of Life Vignette: Probabilities
Doctor Only Mosüy Doctor Both Mostiy you You only
Table 5.7 Proportion of scores in each Control Category (Quality of Life vignette)
Control Categories
Hand Over Share Retain No.Cases (<3) (3) (>3)
Diagnosis 81.996 16.5% 1 -6% 266
Options 76.996 21.2% 1.9% 264
Risklbenefit 67.1% 30.7% 2.3% 261
Probability 71.5% 24.6% 3.1% 260
For the four problem solving questions we can see that patients
overwhelming want to give control to their doctor. Some patients did want
to share control, but no respondents indicated that wanted to take
complete control. The results clearly show that the majority of patients do
not want to do the problem solving but want to hand over control to the
doctor.
HYPOTHESIS III
Most Patients want to be involved in decision making
This section will deal with the hypothesis that rnost patients want to be
involved in decision making. The results for al1 three vignettes will be
presented. To reiterate, the vignettes read as follows:
The Morbidity vignette read: "Suppose you often experience a burning sensation when you go t o the bathroom. You usually have to push to begin to urinate and sometimes dribbling occurs after urination";
The mortulityvignette read: "Suppose you had mild chest pain for three days and decided that you should visit your doctor about this".
The quality of life vignette read: "Suppose you and your partner have been trying for pregnancy, but have been unsuccessful for more than a year".
Once again, the two decision making questions were:
E: Utiliry: "Civen the risks and benefits of these possible treatments, who should decide how acceptable those risks and benefits are for you?"
F: Who should decide: "Civen al1 the information about risks and benefits o f the possible treatments, who should decide which treatment option should be selected?
The response categories were: 'Doctor Only'; 'Mostly Doctor', Doctor and
you equally', 'rnostly you' and 'you only'.
Looking at the results from the morbidity vignette, we can see that
patients overwhelming want shared or to retain control for the decision
making questions (Table 5.8).
Table 5.8 Morbidity Vignette: Decision Making Questions
Doctor Mostly Mostly You N Item Alone Doctor Both You Alone Cases
- - - - - -
Scenae 24( 8.4%) 24( 8.4%) 147(5 1 -2%) 71 (24.7%) 2 1 ( 7.3%) 287
Scenaf 32(11.1%) 43(15.0%) 127(44.3%) S4(18.8%) 31 (1 0.8%) 287
Figure 5.1 5 presents the results from the utilities question and Figure 5.1 6
procents the results from the what is done question.
Figure 5.15
Morbidity Vignette: Utilities
Ooctor Only Mostly Doctor Botti Mostly you You only
Figure 5.1 6
Morbidity Vignette: What is Done
Doctor Only Mostly Dactor Both Mostly you You only
Table 5.9 Morbidity Vignette: Proportion of scores in each control category (Decision Making Questions)
Control Categories
Hand Over Share Retain No.Cases (<3) (3) (>3)
- - - - - - - - - -
Utilities 16.8% 51 -2% 32.0% 287
What to do 26-1% 44.3% 29.6% 287
Similarly, the results from the mortality vignette show that patients want
to participate in treatment decision making (Table 5.1 0).
Table 5.1 0 Mortality Vignette: Decision Making Questions
Doctor Mostly Mostly You N Item Alone Doctor 60th You Alone Cases
Scenbe 28( 9.7%) 32(11.0%) 145(50.0%) 67(23.1%) 1 8( 6.2%) 290
Scenbf 38(13.1%) 51 (1 7.696) 1 36(46.996) 37(12.8%) 28( 9.7%) 290
Figure 5.1 7 presents the results from the utilites question, and Figure 5.1 8
presents the results form the who should decide question.
Figure 5.17
Mortality Vignette: Utilities
Uoctor Only Mostly Ooctor 80th Mostfy YOU You onty
Figure 5.18
Mortality Vignette: What is Done
Ooctor Only Mosüy Doctor Both
1 O4
Mostly you You only
Table 5.1 1 Mortality Vignette: Proportion of scons in each control category (ûecision Making questions)
Control Categories
Hand Over Share Retain No.Cases (<3) (3) (>3)
Utilities 16.8% 5 1 -2% 32.0% 2 8 7
What to do 26.1 % 44.3% 29.6% 287
The fertility vignette shows very similar results to that of the morbidity
and rnortality vignettes (Table 5.1 2).
Table 5.12 Quality of Life: Decision Making Questions
Doctor Mostly Mostly You N Item Alone Doctor 60th You Alone Cases
Scence 1 7( 6.4%) 29(10.996) 1 32(49.6%) 64(24.1%) 24( 9.0%) 2 6 6
Sce n cf 3 1 1 1 6 % 28(10.5%) 1 1 7(43.8%) 56(2 1 .O%) 35(13.1%) 267
Figure 5.1 9 presents the results from the utilities question. and Figure
5.20 presents the results form the who should decide question.
Figure 5.1 9
Quality of Life Vignette: Utilities 100 1 ,
t - - ---- - - - - -- - . - - -
1 i i
80 r - -- - - - ----- - A--p--- - - - -
I
I 70 - . - - - - - -- -- l 60 C - -- . - - - --- --- - - - - *
I
Doctor Only Mosüy Doctor Both Mosüy you Vou only
Figure 5.20
Quality of Life Vignette: What is Done
Doctor Only Mostly Doctor Mostly you You only
Table 5.1 3 Quality of Life Vignette: Proportion of scons in each control category (Decision Making questions)
Control Categories
Hand Over Share Retain No.Cases (<3) (3) (>3)
- - - - -
Utilities 1 7.3% 49.6% 33.1% 266
What to do 22.1% 43.8% 34.1% 267
The results have shown that patients indeed want to hand over the
problem solving tasks, but want to have shared or control over the
decision making aspects of their care. We have shown that in light of the
problem solving decision rnaking distinction, many patients do indeed
want to be involved in decision making and do desire information.
Patients will be more inclined to hand over control to the physician in situations involving risk of mortality than those involving morbidity or quality of life.
We compared our hypothesis using the Wilcoxon Matched-Pairs Signed
Ranks Test. This nonparametric test is used with two related samples to
test the hypothesis that the distributions of two variables are the same.
The Wilcoxon signed-rank test takes into account the direction of the
differences between the pairs and the magnitude of the differences
between the two related samples. Paired t-tests were also calculated,
giving sirnilar results (see Apendix B).
To test our hypothesis we cornpared the Morbidity, Mortality, and Quality
of Life Vignettes for each item. Comparing the mean rank for SCENAA and
SCENAB, we see that mean rank for SCENAA is less than for SCENBA, and
significantly different. Thus, we can conclude that patients are more
inclined to hand over control t o their physician in the mortality situation
rather than in the morbidity situation. Comparing the rnorbidity and
quality of life scenarios for the diagnosis question (SCENA), no significant
difference between the two scenarios were found. Similar results are
indicated when comparing the other variables. The results support pan of
our hypothesis that patients will be more inclined to hand over control to
the physician in situations involving risk of mortality than those involving
morbidity or quality of life. However, we did not find any significant
difference between the morbidity and quality of life vignette for patients
desire to hand over control to their doctor. The results are presented in
Table 5.20
Table 5.20 Cornparisons across three Vignettes
MEAN RANK Z 2-Tailed p n
Mortality vs. Morbidity:
SCENAA 57.51 -5.1 71 9 .WOO 285 SCENBA 53.17
SCENAB 53.72 -3.9848 .O00 1 286 SCENBB 51.20
SCENAC 50.11 -2.9883 .O028 285 SCENBC 46.85
SCENAD 39.53 -1 -1 41 5 -2537 284 SCENBD 41.88
SCENAE 44.33 -1.9638 -0495 286 SCENBE 46.1 4
SCENAF 45.73 -3.0790 .O02 1 285 SCENBF 42 .O0
- - -
Continued on next page
Table 5-20 Continued - Cornparisons across thne Vignettes
MEAN RANK Z
Mortality vs. Quality of Life:
SCENBA 42.75 -3.3852 SCENCA 50.67
SCENBB 37.69 -4.2953 SCENCB 48.67
SCENBC 30.46 -3.602 5 SCENCC 43.35
SCENBD 41.85 -4.5583 SCENCD 44.64
SCENBE 42.38 -2.5048 SCENCE 45.71
SCENBF 40.61 -4.3763 SCENCF 41 -1 1
Morbidity vs. Quality of Life:
SCENAA 53.31 -1 S478 SCENCA 58.92
SCENAB 48.28 -0.8685 SCENCB 55.51
SCENAC 43.1 1 -1.1 024 SCENCC 52.59
SCENAD 46.1 5 -3.03 5 1 SCENCD 51.28
SCENAE 51.58 -0.6567 SCENCE 53.32
SCENAF 47.23 -1.5873 SCENCF 44.40
CHAPTER VI
COPINC STYLE
HYPOTHESIS V
Coping style will be correlated with the amount of information patients desire:
i) sensitizers will want a high level of information
ii) repressors will want a low level of information
Before embarking on a discussion o f the results it is important to clarify
the various coping groups. The Repression-Sensitization rneasure used
was the modified version of the Byrne Repression-Sensitization Scale
adopted by Weinberger et al. (1 979). Coping was broken down into four
distinct groups which characterize an individual's response t o anxiety
provoking stimuli through desire for information. Coping style was
measured on a scale that cornbined the Taylor Manifest Anxiety Scale
(TMAS) and the Marlowe Crowne Social Desirability Scale (MCSD). Coping
was measured on a scale, with the TMAS and MCSD scores split at the
mean to yield the four coping categories (also see Table 6.1):
A. true repressors (low TMAS and high MCSD) characterized by information avoidance;
B. low anxious (low TMAS and low MCSD) also referred to as effective copers who are able to handle stress in an effective manner;
C. true anxious (high TMAS and low MCSD) also referred to as sensitizers. Characterized by the seeking out of information; and
D. repressive anxious (hig h TMAS and hig h MCSD). Characterized by information avoidance.
Table 6.1 Coping Categories (Wein berger et al. 1979)
LOW TMAS
The total number of respondents in each of the coping caterogeries was:
HlCH TMAS
, LOW MCSD
HlCH MCSD
True Repressors = 78 (27.5%) Low Anxious = 59 (20.7%) True Anxious = 90 (31.7%) Repressive Anxious = 5 7 (20.1%)
low anxious
True Repressor
true anxious
repressive anxious
The relationship between coping style and other scale variables (coping
style) was studied with the aid o f analysis o f variance (ANOVA) where the
scale variables represented the dependent variables and coping style
served as independent variable. One-way analysis o f variance was applied
to test the hypothesis that coping style was related to preference for
information and desire to be involved in treatment decision making.
Based on the literature, we would expect t o f ind true repressors and
repressive anxious wanting litt le information, low anxious individuals
wanting a moderate amount o f information, and true anxious individuals
desiring a lot o f information.
The results show that the relationship between information preference and
coping style is only partly the way we originally predicted. As predicted
we see that low anxious had the highest mean score on the HOS
Information Scale, and true anxious had the lower scores. However, true
repressor had the third lowest score and repressive anxious scored the
lowest o f all; we would have expected t o find the two categories reversed
so that true repressors had the lowest mean score. With 3 and 278
degrees of freedom, an F o f 5.805 is significant at .O5 (but not at .01).
Significant differences were found between the following groups:
repressive anxious and true anxious, repressive anxious and low anxious,
true repressor and true anxious, true repressor and low anxious
(Table 6.2).
Table 6.2 Summary of Analysis of Varknce Between Coping Croups on HOS Information Preference Scale
Coping Croup N Mean SD STERR
1 =true repressor 77 2.013 7 1 6 .O82 2=low anxious 59 2.373 .667 .O87 3==true anxious 90 2.289 .707 .O75 4srepressive anxious 56 1.929 .760 -102
Source df 55 MS F Ratio F Prob
Between Croups 3 8.832 2.944 5.805 -0007 Within Croups 278 140.98 -5071
Using crosstabulation, we find that of the true repressors 24.7 per cent
indicated little desire for information, 49.3 per cent wanted a moderate
amount, and 26 per cent favoured a high level of information. Of the low
anxious we find that only 10.1 per cent want a low level of information
compared to 42.4 per cent wanting a medium and 47.5 per cent wanting a
high level of information. Again, of true anxious category, only 14.5 per
cent fell into the low category, with 42.2 per cent and 43.3 per cent
indicating medium to high, respectively. However, for those in the
repressive anxious category we find that 32.1 per cent want low, 42.9 per
cent moderate and only 25 per cent high level of information (see Table
6.3 and Figure 6.1).
Table 6.3 HOS Information Preference by Coping Style
True Low True Repressive Repressor Anxious Anxious Anxious
- ~ - - - -- -- --
Low 19 (24.7%) 6 (1 0.1%) 13 (1 4.5%) 18 (32.1%)
Medium 38 (49.3%) 25 (42.4%) 38 (42.2%) 2 4 (42.9%)
High 20 (26.0%) 28 (47.5%) 39 (43.3%) 1 4 (25.0%)
Total (n=77) (n= 5 9) (n=90) (n=S6)
chi-square-1 7.444, 6df, p=0.008, (n=282)
Figure 6.1
HOS Information Preference by Coping Style
Low Medium High
Level of Information
ElTrue Repressor ffl Low Anxious
In surnmary, we found that there was correlation between coping style and
preference for information. As expected, individuals classified as true
repressors and repressive anxious preferred a low level of information,
whereas those classified as low anxious a nd true anxious wanted a
medium to high level of information.
Hypothesis VI
Coping style will be correlated with patient preference in treatment choice:
i) sensitizers will want to be involved in treatment choice to a greater degree than npressors.
To test this hypothesis we used crosstabulations to see whether there
were any significant results. Crosstabulations were done comparing coping
style with the four Problem Solving and two Decision Making questions for
each of the three vignettes: rnortality, morbidity and quality of Iife
vignettes.
The results wil l be presented in the following manner: 1) The four Problem
Solving questions (Diagnosis, Treatment Options, Risks/Benefits, and
Probabilities) for the Morbidity, Mortaiity and Quality o f Life Vignettes; and
2 ) The two Decision Making questions (Utilitics and What is done) for the
Morbidity, Mortality and Quality of Life vignettes. For each question a
Figure will be presented; see Appendix B for the corresponding Table.
The results indicate no significant difference between Diagnosis and
Coping style and for the Morbidity, Mortality, and Quality o f Life vignettes.
See Figure 6.2 for the Morbidity vignette; Figure 6.3 for the Mortality
vignette; and Figure 6.4 for the Quality o f Life vignette.
Figure 6.2
Morbidity Vignette: Diagnosis by Coping Style
Doctor Only Mostly Doctor Shared Mostly You You Only
Control Categos,
1 Coping Category I 1 El Tnie Repressor E9 Low Anxious l 1 Elfrue Amcious E3 Re~ressive Anxious 1
Figure 6.3
Mortality Vignette: Diagnosis by Coping Style
Doctor Only Mostly Doctor Shared Mostly You You Only
Control Category
El True Repressor ffl Low Anxious
Figure 6.4
Quality of Life Vignette: Diagnosis by Coping Style
Doctor Only Mostly ûoctor Shared Mostl y You You Only
Contrd Category Coping Category
ElTrue Repressor =Law Anxious
The results indicate no significant difference between Treatment Options
and Coping Style for the Morbidity, Monality, and Quality of Life vignettes.
See Figure 6.5 for the Morbidity vignette; Figure 6.6 for the Mortality
vignette; and Figure 6.7 for the Quality of Life vignette.
Figure 6.5
Morbidity Vignette: Treatment Options by Coping Style
Doctor Only Mostly Doctor Shared Mostly You You Only
Control Category Coping Category
ElTrue Repressor Low Anxious
i=';1 True Anxious E3 Repressive Anxious
Figure 6.6
Mortality Vignette: Treatment Options by Coping Style
Doctor Only Mostly Doctor Shared Mostly You You Only
Control Category
ElTrue Repressor E3 Low Anxious
ElTrue Anxious Eil Repressive Anxious
Figure 6.7
Quality of Life Vignette: Treatment Options by Coping Style
Doctor Only Mostly ûoctor Shared Mostly You You Only
Contrd Category Coping Category
Elbe Repressor EiILow Anxious El True Anxious El Repressive Anxious
The results indicate no significant difference between Risks/Benefits and
Coping Style for the Morbidity, Mortality, and Quality of Life vignettes. See
Figure 6.8 for the Morbidity vignette; Figure 6.9 for the Mortality vignette;
and Figure 6.1 0 for the Quality of Life vignette.
Figure 6.8
Morbidity Vignette: RisksIBenefits by Coping Style
Doctor Only Mostly Doctor Shared Mostly You
Contrd Category
El True Repressor ffl Low Anxious
EITrue Anxious ES Repressive Anxious
You Only
Figure 6.9
M ortality Vignette: Risks/Benefits by Coping Style
Doctor Only Mostly Ooctor Shared Mostly You You Only
Controf Category Coping Category
ElTrue Repressor Low Anxious
nTrue Anxious EZ3 Repressive Anxious i
Figure 6.1 0
Quality of Life Vignette: RisksIBenefits by Coping Style
Doctor Only Mostly Dodor Shared Mostly You
Controi Category
EITrue Repressor L w Anxious WTrue Anxious Repressive Anxious
You Only
The results indicate no significant difference between Probabilities and
Coping Style for the Morbidity, Mortality, and Quality of Life vignettes. See
Figure 6.1 1 for the Morbidity vignette; Figure 6.1 2 for the Mortality
vignette; and Figure 6.1 3 for the Quaiity of Life vignette.
Figure 6.1 1
Morbidity Vignette: Probabilities by Coping Style
Doctor Only Mostly Doctor Shared Mostly You You Only
Contrai Category Coping Category
Ellrue Repressor Low Anxious iB! True Anxious ES Repressive Anxious
Figure 6.1 2
Mortality Vignette: Probabilities by Coping Style
Doctor Only Maçtly Doctor Shared Mostly You You Only
Control Category Coping Category
ElTrue Repressor Low Anxious
El True Anxious E3 Repressive Anxious
Figure 6.1 3
Quality of Life Vignette: Probabilities by Coping Style
( Mostly Doctor Shared Mostly You You Only Control Category Coping Category
EZITrue Repressor l3Zl Low Anxious True Anxious E3 Re pressive Anxious
The results indicate significant difference between the control categories
for the Utilities questions and Coping Style for the Morbidity, Mortality,
and Quality of Life vignettes. See Figure 6.1 4 for the Morbidity vignette;
Figure 6.1 5 for the Mortality vignette; and Figure 6.1 6 for the Quality of
Life vignette.
Figure 6.1 4
Morbidity Vignette: Utilities by Coping Style
Doctor Only Mostly ûoctor Shared Mostly You
Contrd category
ElTrue Repressor ffl Low Anxious E3True Anxious Re~ressive Anxious
You Only
Figure 6.1 5
Mortality Vignette: Utilities by Coping Style
Doctor Only Mostly Doctor Shared Mostly You You Only
Contrd Category Coping Category
El True Repressor El Low Anxious 1 El True Anxious El Repressive Anxious 1
Figure 6.1 6
Quality of Life Vignette: Utilities by Coping Style
Doctor Onll ( Mostly Doctor Shared Mostly You You Only
Coping Categoiy E3True Repressor Low Anxious E 3 True Anxious 5 Repressive Anxious
The results indicate no significant difference between control categories
for the What is Done question and Coping Style for the Morbidity,
Mortality, and Quality of Life vignettes. See Figure 6.1 7 for the Morbidity
vignette; Figure 6.1 8 for the Mortality vignette; and Figure 6.1 9 for the
Quality of Life vignette.
Figure 6.1 7
Morbidity Vignette: What is' Done by Coping Style
Doctor Only Mostly Doctor Shared Mostly You You Only
Contrd Category
EITrue Repressor 5 L w Anxious True Anxious El Repressive Anxious
Figure 6.18
Mortality Vignette: What is Done by Coping Style
Doctor Only Mostly Doctor Shared Mostly You You Only
Contrd Category Coping Category
El True Repressor ffl Low Anxious 1 El True Anaious E3 Re~ressive Anxious 1
Figure 6.1 9
Quality of Life Vignette: What is Done by Coping Style
Doctor Only Mostly ûoctor Shared Mostly You You Only
This hypothesis was not supported by the results for the four Problem
Solving questions (Diagnosis, Treatrnent Options, Risks/Benefits and
Probabilities) and one of the Decision Making questions (What is Done).
However, our hypothesis was supported for the Utilities question in both
the Morbidity vignette (chi-square=27.484, 1 Zdf, p=0.006), Mortality
Vignette (chi-square=32.868, 12 df, p=0.001) and the Quality of Life
vignette (Chi-square=ZS.I 9 5 , 1 Zdf, p=0.014).
In summary, the results did suggest some relationship between repressive
styles and treatment choice further investigation is needed.
DISCUSSION
The conceptual framework for this study was based on Deber and
Baumann's (1 989) theory of patient participation which postulates that
previous studies have made insufficient recognition of two distinct
elements of choice behaviour - problern solving (PS, identifying the one
rig ht answer) and decision making (DM, selecting the rnost desired bundle
of outcomes).
We devised a new scale entitled "The Problem Solving-Decision Making
Scale" (PSDM) to measure patients' preference for involvement in treatment
decisions. To determine content validity of the instrument, approximately
10 people were asked to judge the scope and design of the instrument.
Two methods were employed for scale validation: factor analysis and
reliability testing. Content validity of the instrument was determined. The
interna1 consistency and test-retest reliability of the PSDM scale were more
than sufficient for cornparisons of groups (Streiner et al. 1989). Factor
analysis confirmed the hypothesis that there were two dimensions to
choice behaviour; problem solving and decision rnaking.
Using this instrument, we found that patients overwhelmingly wished the
problem solving tasks to be performed by or shared with the doctor
(98.4% o f the 12 OS scores were between 1 and 3), but wanted to be
involved in decision making (78% o f the 6 DM scores were between 3
and 5).
Our results along with other published reports strongly support the
contention that patients want to be active participants in decision making
about their own care (Kassirer 1983; Arrow 1973; Cassileth e t al. 1980;
Faden et al. 1981 ; Haug and Lavin 1981 ; and Harris poll cited by Ende et al.
1989)
Our findings also indicate that patients have a strong preference for
information. Several studies have docurnented patients' desire for
information among a variety of patient populations (Blanchard et al., 1984;
Cassileth et al. 1980; Faden et al. 1981 ; and Strull e t al. 1984) and have
found that most patients report a strong preference for information and
detailed disclosure.
Our findings also indicate that there is a relationship between coping style
and desire for information. We found that individuals classified as true
repressors preferred a low level of information, whereas those classified as
low anxious and true anxious preferred a medium t o high level of
information. However, we did not find repressive anxious individuals to
want a high level of information as was expected, but rather they wanted a
low level of information. Similar results have been reported by Shaw e t al.
(1 985; 1986) and Murphy e t al. (1 989).
We also found that there was a relationship between repressive styles and
utilities question from the Decision Making subscale. Otherwise, coping
style did not explain why certain individuals wanted to hand over control
to their doctor or retain control for treatment choices.
These findings suggest two mrjor roles for clinicians - assisting the patient
in structuring the decision (e.g., the problern solving), and supporting
them in making often difficult decisions. Experts cannot determine what
value will be placed on a particular outcorne. How unpleasant it is to live
with pain, or to be forced to limit one's activities, i s inherently a personal
value judgement. But we also argue that decision making should
ultimately be the patient's job. identifying the alternatives does not always
te l l you which one should be selected.
Only a few patients wanted to retain control over probiem solving. We
found that age, sex, or coping style did not explain why certain patients
did not want to retain control over problem solving. Nor did any of the
variables explain why certain patients did not want to relinquish control to
the physician.
In summary, the following hypothesis have been evaluated and have
shown that:
Hypothesis I: Most patients want to be informed.
Supported. Our results clearly show that patients do indeed want to be
informed.
Hypothesis I I : Most patients do not want to be involved in problem solving.
Supported. Our results show that patients overwhelmingly wished the
problem solving tasks to be perforrned by or shared with the doctor.
Hypothesis I I I : Many patients want to be involved in decision making.
Supported. Our results indicated most patients wanted to be involved in
decision making. There was a statistically significant shift from doctor
control to shared control.
H ypot hesis IV: Patients will be more inclined to hand over control to the
physician in situations involving ris& of mortality than those involving
morbidity or quality of life.
Supported. Our results indicated that individuals were more wil l ing t o
hand over control t o their doctor in the mortality vignette than for the
morbidity or quality o f life vignette. However, no difference was found
between the rnorbidity and quality o f life vignette as orginally expected.
Hypothesis V: Coping style will be correlated with the amount of
information patients desire: i) sensitizers will want a high level of
information; and ii) repressors will want a low level of information.
Supported. We found that sensitizers d id want more information than did
repressors.
Hypothesis VI: Coping style will be correlated with patient preference in
treatrnent choice.
Partially supported. Our results showod a significant relationship between
repressive style and utilities. Although, the results did suggest some
relationship between repressive styles and treatment choice further
investigation is needed. One possible explanation for the finding that
coping style was not related to treatment choice is that the coping
measure itself does not measure what it intended to measure (Esterling et
al. 1993). Since so many patients wanted to be involved in problern
solving, the "normative" response may he so strong there is no variance is
le f t to be explained by coping style. When you look at the results, the data
is in the predicted direction so the negative results may be a statistical
power problem.
LIMITATIONS
As with any study. this study i s subject to methodological limitations
which need to be addressed and taken into consideration when
interpreting data. Because the research was conducted within a tirne
frame available for completion of this study certain limitations were
unavoidable.
One limitation of the study was that al1 scenarios were presented in the
same order thereby potentially biasing and confounding the responses to
the other scenarios. The impact of randornizing the order or scenarios can
not be known. In future studies, the scenarios should be presented in a
randomized order to see whether or not an ordering effect i s present.
The results may not be generalizable across other disease States. Severity
of illness rnay be a potential limitation therefore, it is necessary to study
other patient populations.
Another potential limitation arises from the coping style construct
ernployed. Do to the nature o f the scales there is a potential of
rnisclassifying patients such that patients rnay be truly low in anxiety and
high in social desirability which rnay be independent o f defensiveness.
Therefore, these patients would be placed into the 'repressed' category
which rnay not be indicative of the actual case (false positive). Conversely,
false negative patients rnay be high in social desirability and anxiety and
classified as 'defensive' but actually use 'repressive coping' (Esterling et al.
1993).
FUTURE RESEARCH
More research is needed to clarify the relationship between coping style
and patients preferences in treatment decision making. Future testing of
the Problem Solving-Decision Making scale among different patient
populations who have various severity of illness is needed. As well. the
predictive validity of the Decision Making subscale needs to be evaluated
against patients decisional behaviour.
CONCLUSION
In conclusion, we devised a new scale entitled 'The Problem Solving-
Decision Making Scale" to measure patients' preference for involvement in
treatment decisions. The PSDM scale was based on Deber and Baumann's
(1 989) theory of patient participation which identified two elements of
choice behaviour: problem solving and decision rnaking. The results
indicated that most patient's wish to leave the problern solving tasks to
their physician, but very much want to be involved in the decision making
tasks. Thus, the current ideology suggesting that patients should be
active participants in decision making about their own care is consistent
with Our findings that suggest most patients wish to be involved in
decision making. We also found that coping style was predictive of degree
of information, with true repressors preferring a low level of information,
compared to other coping groups. As well, there also appears to be a
relationship between repressive coping style and utilities component of
the Decision Making subscale. The relationship between coping style and
decision making needs to be further investigated in future studies.
APPENOIX A
Questionnaires and Scales Used in the Study
HEALTH CARE DECISIONS SURVEY: PATIENT VERSION
HEALTH CAR€ DECtSlONS SURVEY
Raisa 8. Dobor, Ph.0. Nancy Krastschmor. MSc. Candichte
YcYunich Building - 2nd Flow Toronto, Ontario MSS 1AB (416) 978-8366
n i e purpose of thh st* b to k o k i t the mk patients wirh to gky in making docision8 about th& own mediil trertment. ïho fobwing questions uk y w &out your mitudes towards pirtidprtbtg in maWng ddsionr whh your doctor about you medeai ueatmclrt. your gemd outlaok. and your wphg abilith. Thi, study b funded by 8 p t from tha Sadil M u w s wd Humanitka Fbsemch Coundl of canada.
ïh smmy rhauM onîy trke 20 minutes to complete. M the infornucion Out you @va us wüi tm kept strictly c o n t i i . Ibsults will be reponed h mregate form O*, so there wiN ôe no wry to identify yw.
For di questions. JmOly uuwer by circiing the iwnnbet cr httu that -tes the answer or op- which is mort rccwate for y w .
Nothing is more important to this study thui the confidence and coopcrath of the respondents. May we ask you to take a few minutes now to corndete the questionnaire. glace it in the envebpe, seai and return it to the nursing station.
Thank you for your participation in this study; your coopetath is greatly appteciated.
. . - - - - -
Today's Oate: 1 / Research Numkr: day mth year
d
SECTION A
In lhir section, three meôïcxt conditions rra dartnbed. Each condition is foflowtd by s o m strtements rslarsd to making decirioris- Plsasa ClRCLE t h m r m k r which best indicacas how you would tael .bout each statement if you actuaNy h.d the medical condition which is descriôed. Remember, there are no RIGHT or WRONG answers. We are interested in your opinions.
Suppose you often experience 8 burning sensation when you go to the bathroom. You usually have to push to begh to urinate and somctimtr ddôiïng occurs after urination. (WC one numbcr for each quesrion)
b. Who should dete& wilbr the treatmew @ms arrt I
c. W l i o r h o v l d & t e ~ * t k r i r i b 1 M d k n @ s * e o d c r ~ q p b n 1 are?
d Who rlbutd deterntlnc Ibw 1- Lod # ~ s e r l c b d & ~ o n t o 1
e GIwnrlirrirltrMdkn@s#rkrr posslMe treafnunts, dia s l b J d &&Ibwacccp~etlburirband 1 kw@S art*yau?
How much expmience have you had with the dinical situation described in the above scenaria. (Picase c i d e dl feuem th& q&.)
a. 1 haw h d pcrsonol qperience wih ir. b. 1 b w w offmily membtrs or close fiends who hou upcrienced it. c. 1 h4w r e d about it. d. I do not know much o b o ~ it.
Suppose you hrd mild chest pains for three days and decided that you should visit your doctor about t his. (Clde ont mrinkr for euch quesrhn.)
a. Who should dctennine (diagnose) Wh41 the liL3( causes o/your symptomr an?
6- Who sho& determine t h a t rhc rreamunr ciplilms are?
' c. Who shoufd detcnnine wihcil the ris& und ~ I I C ~ ~ I S & euch treatment oprion arc?
d. Who shodd &tenn&u how lUcïy each o / tkse ris& d bt iuf ls are to WP-?
e. GlwntlrrriribMdkn@scfthese parsiMe iTCQIIIYII## * rliodd d e c I d c h o w ~ e i I b u bc~v f ls on&pv?
doclor and you equally
- - - - - - - - -- -
SCENARIO C
Suppose you and your panner have k e n tryinq for pregnancy, but have k e n unsuccessful for more . - than a year. (CYrdc ore- rwnber for each qws6~)
a. who should determine (diagnoscJ whcu the liûeiy causes of yow condition ore?
b Wlro should detennine A- :h rreQInvnt options are?
c. Wlio shoirld dctennitw wihor the ri& a d btwfts for each neornunt qnim arc?
d. Who shoirld detennlry Ibw Iike r a d of *SC rlrb Md k W am IO
W ! ?
How much experience have you hrd with the c ü d d situation d e m i in the above scenark. (t'tcasc drde OU feüem th& qp l ' . )
a. I haw hOd prsotuû clpcriencc w?h it. 6. I know of fmiiy members or close fiends d o haw e ~ @ e ~ e d il. c. IhaureudQbOWb. d. I do nor Lnow much about ii.
1. The ne- questions ask about how vou teel about the medical crie oeopk rcceiva in generd. There - - are no right or wrong answers. WU are only interestcd in your opinions.
-
(Chdo on. numbmr for wch quostloci.)
1 b. Ilu qualfty of nudlcd care thut most ptbpk receiw codd k kt ter .
1
î l e care 1 have receivrd fioril doctors In the Iastjbv p a r s b jwc about peqeu.
1 à. are things mdiaû
L cme I have receiud rhat could k beaer.
The next questions rsk specifii8ily how you leel about the way you and your specialist (i.0. cardiologist) have made decisions about the traatment of the cardiac symptoms for which you are now secking help.
3. Which doctors have you seen about your caidiac symptoms? (Cirde dl Ietfers th& oppi")
a. Fmily dm01 b. C4rdiologist c. ClIrdioc (HCM) surgeon d. Ww, @iease specifiI:
1. I wu plemed wih how decisions wre maùe.
Strongo DIsogree
J
Disagree
2
Neither Agree nor Disagree
3
A
4
Strongl) Agree
1
S
- -- - - - - -- - --
9. Now we would Iike to know how you fed about some qeneral health related issues. There are no ripht or wrona rnswcn. We ara interested only in vour-opinionr.
a ï?u lmponant medical decisions should be ma& ôy your donor, no! by you.
b. You should go dong wi~h p u r dmor 't &CC ewn i / p u disugree with it.
M e n hospitolired, you should not be
e. Uyou w r e si& as pw Ulncrr &CMK wrse you wdiî wmt y t w dwor to t a k gre01er comrd.
J You should d e d e I i o w ~ ~ l y ywr need a check-up.
h. You should understand conlpIete& -&lrqppcfi~~-ww~ a resdt of yow Utnc#.
1. Ewn qthe n c ~ Ir &, you Jlbuld k wl1 I r J o d .
J. Yow dm01 shouîd CTplain the purpose of yow loburmoty tests.
( k. You should be jiwn in~ormruion oonly
I whcn you ask for ir. -
1. II is imponarirf'ior you ro know all the side efects of yow medIcation.
!
( m. In/ormation about your illuess Ir as imporran! to you as rreomunt.
I n. M e n rhere is more thon one merlrod ro mat a problcm. p should be rold abour eoch one.
10. Please read each staiernerit and decide whether you AGREE or MSAGREE with it. There are no ri& or won# answrs. Wt are inferesred only In yow opinions. (plcase cir& eithcr A p t or Lüsapw for each s I d c m r ~ # )
a. I vsually don 'r ad the dmor or nurse many qvcsrlons about r k y are dolng dwing a mcdlcal upni.
b. Exccpi for serious i l l ~ s s . il's generdy k n c r to r& cure of you dmi health than ro seek professional heip.
d. Insrcad of mairing f i r rhem ru tell me. I w d l y ask rhe docror or nwse immediately a#er an crom abuu my hedth.
c. It i r better ta rety on the jdgemcnts of dxiors are experts) than to reb on 'comnwn sense' In t&t care 01-yow own body.
f: ahla and hospitds on id *ces to go for help rince it 3 &srW d l c d apcns ro r a k respantîbility for hedth care.
j. Ir t bmer ta muî the &or or nwse k thttr#e #a d c d p m d ù m
may crcate morr lronn rhon g d .
1. Recowy is w d l y qulutcr d e r the care of a docror or nwse than t h e m
m. rit cosrs the same. 1 ii r a k r haw o dmor or nurse giw nu trcamcnts rhan ro do the same rrtarments myscr/:
n. I r is bcnlr to rely Iess on pliyriciuns and more on your own cornmon sense when ir coma to coring for your bsdy.
o. I uswlly wit for rhe doctor or nurse to tell me the results of a meàicd uam r&r rhan dtùing hem hwdiate!y.
p. l 'd raihcr In giwn many choices abow whaf 's k s t for my heafrh thon ro Iiaw the d m o r tmk t h e decisions for me.
SECTION C CHARACTERISTICS ABOUT YOU
Please read each statement and decide whether it is TRUE as applied to you, or FALSE 8s apptied to you. If the statement is true or mostly true of you, circle 'TRUE'. I f it is falsa or mostly false of you. circle 'FALSE'. Rcmemôer to Q ~ v ~ E YOUR OWN opinion of yourself . There is no RlGHT or WRONG answer.
1. 1 ncwr hesttate to go out of my u q tu klp sonuone in rrouble.
2. 1 w r k d e r a gretat deai of tension,
3 I A4w new i ~ense ly distiktd somcone.
4. lflnd ir lrard to Lccp my mi& am ta tarit orjob.
S. / sometfmcr feef rcse- w k n I don 3 get my own wuy.
16. 1 hove ptriods #such grau res~iessness rhor I conmi sir long in a chair.
17. I kf ieve 1 am no more nemw rhan mort 0 t h .
18. 1 sometitnes try ro ga cwn r&r rhan forgiw and forger.
19. M e n 1 don 'r kmnu sonuthing. I don 't at al1 m i d aâmining ir.
20. Li/c is a main for me much of the rime.
21. 1 am alwzys c o u ~ e o w , m n ta pop le wilro arc disagrecabte.
22. I am more sensitiw thon m m other people.
23. 1 cannoi k e p my mi& on one thing.
24. At rimes I hir reaily lnsisted on having things my own w y .
27. &re haw k e n O C C ~ ~ C M S whcn l/eIt If& smashlng rlilngs. T 1 F r
28. f 4m not unwuta& se~5onsclow. 1 T 1 F 29. 1 hau sonutimcr /el! rlbr diflcultfes w r e piling up su high rhat I could not T F
ovcrcomr rhem.
30. I um w d f y cdm a d 1101 easlly tpset. 1 T 1 F 1
J I . 1 u w l d nncr thlmû tflenlng s o m e o ~ else be punislud fw my wongdoings. 1 T 1 F T a
SECTION D
2. S u : a. M a k b. F c d e ( C i d e one I c ~ e r )
2. Year of birth: \ \ day mit year
3. Whot is your trhnic background?
4. What is your current marital status? (Circle one latter)
a. Newr marricd 6. Marrîed or cornmon-lm rtlationship c. Separated d. Diwrced e. Wdowd PLEASE N R N OVER ...
6. What ia the highert levol of educetion you hava racaived? (ad8 one fcaer)
a. S o m cfcn~ntar) , SM (y IO grade 8) 6. Cdmpleted e!enurirar)r SM c. Some high SC-
d. Compkred liigh scheol c. Some uniwrsi~y/colIcge /: Compktrd rrniursiry/cdIege 8. Som professional or grodwe SCW A. Completcd prufessionol or ~ r d u a t e SC-
a. Eqployed f i 1 1-litne (30 lrours or wwre per wtk ) b. Ehployed port-tinu c. Nor enlployed d. Retired c. Hontemzkr f. W r , @learc spccifi):
7. Typically. how often do you visit your f m doctor in 8 year (La. for eithtr check-ups or other masont)?
(ruoiibcr of t h u in ypicd yrcu)
8. Do you have chest pain? (CYidt onr IaWr)
9. Have you had an angiogmm belore? (CltrSI one krrrr)
10. Have you ever had angioplasty to open up yow ancries? (CYd. OM irdler)
1 1. Have you ever had bypass surgery to open up yow artcries? one klîef)
12. Have you had any other health/iliness problerns? ( M c one Icaer)
a. No b. Yes, pltase specifi:
13. Overall, how would you rate your health now? (Cirdt oru number)
Excellent Vcty Gsod Gnnf Fair Poor I 2 3 4 s
HEALTH CAR€ DEClSlONS SURVEY: NURSING STUDENT VERSION
HEALTH CARE DECJSIONS SURVEY
Raise 6. Deber, Ph.0. Nancy Kraetschmar, MSc. Candidat.
McMurrich ûuiiding - 2nd Flow Toronto. Onterio M5S 1 A 8 (4 16) 978-8366
The purpose of this study is to look at the role patients wish ta play in making decislons about thcir own medbl trcatment. Ths fokwkrg questbns ask you about you rîtitudes towards partictpitirig Jn making dedsions 6 t h your ôoctor about your meôical treatment, pur generd outbok, and your copina abilitks. This s t w & tunded by a orant from the SOeW Sciences ud Humanitks Research Coundi of Clnadi.
The survey should only t a b 20 minutes to complets. Al the information thrt you ive us wA ôa kept strictly c o n f i i t i d . Results wül ba reportcd in iggregate f m O*, so thcm will ba no way to Mcntify you.
For a l questions, simply answer by c i rc f in~ the number or lettw thai indikates the answer or oginion which is most accwate for you.
Nothing is more important to this study than the confhnce a d coopcration of the respondents. May we ask you to take a few minutes now to complete the questionnaire. glace it in the envelope, sei l and return it to the nursing station.
Thank you for your participation in this study; your cooperation is grcatly appreciated.
4
Today's Date: 1 / Research Number: day mth year
SECTION A
In this section. three medical conditions are described. Each condition is followed b y soma statements relstsd to making decisions, fleass ClRCLE the number which best indicates how you woufd f e d about each statement if you actually had the meûiiaf condition which is described. Rcmember, there are no RlGHT or WRONG answers. We are interestcd in your opinions.
Suppose you often experience a burninp sensation wh tn you QO to the bathroom. You usually have to push to beqin to urinate and sometimes dribbling occurs ofte; urination.
b. Who should detendne dw the neantunt opllonr are?
c. Whoshoulddetennlncnrhrrrthertb ond &IU~~IS& d h C m N on?
e. Glw~ther i rbdkn@s#theae psslbk R C Q I ~ ~ C ~ ~ I S , wiho s W d decWr how ucceproMe t h s e dsitr a d hencfirs art for yw?
J Gïwn dl tk Iqfomatîon abow rfsb and bewpts qf the potsiMe heamunts, wiho shodd decldc d i c h trtunnettî option shouîd bc selecrcd?
"1 ' and you
How much experience have you had with the clinical situation described in the above scenario. (Plrase c i d e aü leplers rchr 4pply.)
a. I haw hcd persona/ uptrience with ü. 6. I know offamily metnbers or cloreJkiends uho haw upcrienccd it. c. I haw reaâ abow it. d. 1 do not how much about if.
p~ - -
SCENARIO 8
Suppose you had rniid chest pains for three days and decided that you shoold visit your doctor about this. (Cïrde one aunbrr for euch qtustkr.)
o. Who shoutd detemine (diagnose) w h the l&ty causes of yow rympr0m.s aw?
6. Who shouid derennine w h t ht
Who shoufd detemine wlhr the risks and bcnefiis for eoch neamtnt opriosi
docror and you equally
How much experience have you hrd with the cWcd situation described in the above sceriario. (pieme &e dl luien thd 4ppIy.)
SCENARIO C
Suppose you and your oanner have bcen twinn for preonancy, but have been unsuccessfui for mare
mosrly the
doCror
mostly yod
jmrtner
a. Who should detmnint (diagmse) w h a ~ the liùely causes ofyow condition arc?
b. Wlio shudd determine wihor the rrcatnunî options are?
c. Who should detennint wihor the nsb and bencjit~lor CO& i r e ~ i r r option are?
How much exptnence have you had with the clinical situation described h the above scenario. (Pieare d d c dl Ieaem tha 0ppry.J
4. 1 h w had pcrsonol cypcrience with it. 6. I h w of fmily members or close /ncnds wha haw experienced it- c. f haw r e d obow if. d. I do not know much about it.
SECTION 6
1. The next questions ask about how you feel about the medical care people receive in qeneral. There are no right or wrOng YUWCIS. We are only interested in your opiniork.
-
(Circla m a numkr for œdm questiott.1
a. Cenerally, ptofle are satl@cd wlwlth the medical care they recelte. 1 2 3 4
b. & qudity of medicd c m thar most people receiw couid bc btner. 1 2 3 4
C. carc r hou rcceiwdpom docrors in the last/nu y e n & jwt 1 2 3 4 aboui ixden.
p~ - -
d. flu care I haw reuhrdjkn nurses in t k last* yats is/w &ut pcgect.
2. Which stitemtnt ks t describes yow own attitude towards meâilcrl care? (PIe-c dndr rlir wrwpnb& f e r . )
a 7)ic pntiem slbvld t& &ete ctmtrd. b. 7he potlrnt rlbvld h m morr contrd than tk domr. c. 7he paient Md h o 1 shovld s h r e the ccmtrol equally. d. The docttw M d haw more conrrd t h the paientN e. Inr dmor slbvld t& coqdete corilrd. j #her,@lease spccifi):
3. Which srorement bcsr describts yow own attitude i m r d s the rde nurses should play in decision making? (PIcare cirdc rhe cippmpMIe feüer.)
a. 7he nurse should bt respomible for decision mahing. b. ïRe nurse should be inwlwd at the decision mab'ng hul. c. 71u nurse should largcly bt concerntd with implemcnring the decisions of ofhers. d. ïk nurse should be more concerned wirh the opra t ioml aspects of purient care than with dtcision
making. e Orher, @case spcilj.):
\
4. Now w noufd likt to bww how you f ie l &ut sorm gentrai k a l t h relaced issues. Tlure arc no rlght or wrong anncrrs. We are INCICS~&! O& in pur opini&. ( C i d e one nwnber for each qrurtion)
r Strongly Disagree
Ncirhcr Agree no? Disagree
Strongfy Agree Disagree Agree
'fhc Unponant mcdicd dccisions should k made by your docior, not by
b. You shoufd go dong with yow d m o r 'I tuivice cwn Uyou disagree with if.
c. Wlim hospitdizcd. you slwdd not k mukinn decirions &w mur own c m .
d. You shouid fcdfiec to maûe declsionr about ewryday nudicd pobiemr.
~ - --
f: You shavld &&te howfiquedy pu nted a check-rqp.
I tdd more a d m e &ut ywu Ulriut.
Ewn ~thtruwrishd,yousl iouldk 1 " rrll lnl-d.
1 k You shouid bt g iwn information only when you as& for it.
1 I . /t is impo~arufior you to know al1 the
I side cffects of your medication.
1 m. Information about your illness ù as
I importaru IO you as treamunt.
I n. Whcn A m is more than one n u t h d to treat a probfcm, you shoufd & t d d about each one.
10. Please read each statemcnt and decide wheiher you AGREE or DISAGREE with it. Tlure are no riglu w wons amwrs. We are Interested onty in yow bpinions. (Please ctCtrcle eaher A p e or magrte for each stdement)
a. I u s d y don 1 os& rhe doaor or nurse many quesiionr about r h q are doing during a medicd u ~ i .
b. f icept /or str iow Ukss. i l 's generaNy k t te r to r a k care ofyou own k d ~ h than IO seek professionol klp.
- - - - -- - - -
c. I 'd rorhcr haw d0~1ors and nurses make the decisions about wihar 3 &sr rhan for t h to g i u me O whdc lot of chices.
d. Insread of w i t i ng for rlCun ro reli nu, I wuaity osk r k docror or nurse immcdiateiy a#tr an uoin abou my hedrh.
e. Ir is btner IO rely on the Judgenurils o fdb~~ors (iuho are the crprns) rhan to rely on 'counmon sense' in iuùint c m of your own W.
I than ro question tduu rlCL)I are d*.
k Lroming hUw to cure s m e dyow IfInus w i f h tontacting a physlcian may create more honn t h g d .
i. Recowry is usually qui&r d e r the cure # a dmor or nurse t h w k n polienrs t& care of themseIws.
1 n. I r is bencr tu rely Iess on physiciens and more on your own common sense
C whcn i r cornes to carïng for your body.
1 o. I wrrally *oit for the dmor a nurse to tell n e the resulir of a medical uatn
I rarher rhan usking t k m ùnmtdiately.
1 'â rarher k giwn many choices cbow W * s best /or my healrh rhan ro 1 han the docror ma* the decidons for me.
SECTION D
Finaily, w wuld l ik to ask you swne questions &ut yow ôacùground.
2. Year of binh: \ \ day mrh year
3. Whnl ir yow eihnic background?
4. What is your current marital status? (Cird. one ktîar)
a. N w r tnarried b. Mam'ed or common-law rcluionship c. Sepratcd d, Diwrced e. Wdoued P U A S E TURU OVER ...
What is the highest kvel of education you have received? (Cide one Ietier)
Typically. haw often do you visit your family doctor in a year (Le. for either check-ups or other reasonsl?
(n&r o/times in rypical year)
Overall, how would you rate your health now? (Circlc one nwnber)
Ercclferu Very Goad G d Fair Pcwr 1 2 3 4 5
I mis is che end of thc questionnaire. 'Ilrad you wty much /or your parriciporion.
HEALTH OPINION SURVEY
980 D s KR.4372, A B.4L:M. ASD M WlDEM.4S
T a b l e I I k m s a-d Sbf~rfur jar ~ h e Kronrt Healtrl Optnron S u n e ?
I usually don2 ask t h t d a i m or nurw many questions about vhat thcy'tc doing durrna r medical e u m . (1).
l'd nthcr have doctors and nurses m r k r the dtcirions about what'r b a t ihan for thcm 10 (ive m e a whok lot d choiccs. (31.
l n u u d of vaiting for thtm to tell me. 1 urually ark t hc d a c o r or n u n immediately d t e r a n e u m aimut my hcalth (41
1 usually ark the doctor or nunc brr of qucrriorir about the p r d u r e , during i m c d i u l exam. (8)
I t i~ k t t e r t o t m u t b t dator or n u r r in charge d a medical procedure thrn to question what thcy ut k i n g . (10).
1 usually va i t l a the Qcra or nurw t o tell m t t h e r t ru l t r d a medical uun -cher than aiking t h t m inrmdiatcly. (1 5).
r d m h e r k givtn -y choices about rha t ' r ôert for my health than t o have the doctor make t h e dtciiiona for me. (16)-
- - -~ -
& h r v i o d Invotvtment r u b l a k
Excrpi for d o u s Un- iter gcncrally k t t e r t o takt wt d p u r own b u l t h than t o u k prd-orid bdp. (2)
1t in k t t e r to rely on tk jcidgcmcntr d doetors (=ho are t h e e x p n r ) than t o rely on "cornmon w n r " in trking u r c d p u r own body- QP
Oinics and horpi tds are pod phmn to go lœ k l p rina i?s &sr /a iridrd
aws & && rrspors;bJdy l a health a r c . (6). L u r n i n g hor to cure nome d pour o v n iltncw r i t h o u t coritacting r phpician Y a gord idta. (7)
It'r Jmort Jwaya br t t e r t o w k p r d n r i o n r l help t h a n to ty t o t r u t puruIf. (9)'
karning hor to cure morne d your illnev vithout contact int a phyritian iruy -te mœe bum Chan good. (II) .
Rnwcry in uwally qukker unâer the u r e d r &or or rurw than d e n prient6 ukc a r e d iIcris&s. (12).
U ir tort6 t)n ume, l'd r r th t r have r daetor or nurne *ve me t r u t m e n t r rhan to do t h e m m t m t m n t a m p l f . (13).
l t u k t t e r ro rely km on pbysicians and more on your o v n common w n r wbtn it Lomu to &ng for p u r body. (14)
-
Nok. Cohelationi arc point-biscrial item-temainder correlations bvd on 200 o w r . T h t x correlation, am d l p i t i v e because woring im r c n r u d foi ncgativcly rorded items. vhich arc dtnot td by ruptrscript r'r h ' u m k r s in parentheses i n d i o i e the wqucnce d i tems on the -le. Verbatim instructions may k obtained from the first ruthor.
Xegatively worded item.
in mtdical crrc. The xcoad scak, d l t d I i i jonrot ior (1). u dt6ncd by w w n items mtuwing Lbt &in IO uk questions and wrntina to k inforrnrd about mtdio l dtcisions Remaining i t t m not cornlrting vi tb cithtr of th- scrks wert clirninrted. 7 à c h n d \-toion of iht i a t , crllrd ùie Krrata H d t h Opiqion Survty (HOS). tbtrtlorc coiuiitr of 16 i t e m . crch r a i d in r binuy, rgreedisr8rce format. The test yit- 8 ~ r i o d - n i b o l e s and
-a total score merrurint compaùtc at t i tude t o d trtrtmrnt rpplo&hes W b x o r u u p r o l o t laver-
I
r b k attitudes iowrrd xlf-dirtcied œ inforwd trut- ment. II shouM k aottd tbrt tbcu i t e m pmraDy rcftr to routine u p c î s of media1 u r r rad do W rcfer t o wvrrt or triumrtk 9 m s . 18 rdditiaq future rc6nmtn t of ibc rcak mry require r b b - tion ot rome rcdundrncy in tbt r d* ol tb r i tem.
70 drirrmint dkriminrnt vfity, t b t t m ru then rdministercd Io 100 male i a d 100 f c d undcmraduatt~ r t the University of Sou tbcr~ C.b'- fornia togeibcr rith tht Crornc-Marlowe
REPRESSION-SENSITIZATION SCALE
P a t l e n t Number -,,,---- Date ,-------
P A T 1 €NT I NVENTORY
I n s f ~ u ~ ; f l ~ n s : T h i s l n v e n t o r y c o n s l s t s o f t h r e e p a r t s , e a c h w i t h separa te I n s t r u c t i o n s .
PART I R e a d e a c h s t a t e m e n t and d e c l d e w h e t h e r i t 1s f ~ u a ns a n ~ l l e d &QU, or f d l S e an a o n l l a d la XQU. Then c i r c l e e l t h e r t h e T ( f o r t r u e ) o r t h e F ( f o r f a l s e ) I n t h e c o l u m n o n t h e r l g h t . E e n e p h e ~ t o g l v e YOUR OWN o p i n i o n o f y o u r s e l f. Please t r y t o a n s w e r e v e r y
/ q u e s t i o n e v e n I f y o u h a v e t o g u e s s . You may f e e l t h a t a q u e s t i o n d o e s n o t a p p 1 y e x a c t i y t o y o u - p l e a s e t r y t o answer There I s n o r l g h t o r wrong answer.
1. 1 never h e s i t a t e t o go out of my r a y t o h e l p sonieone I n t r o u b l e.
7 '* I work u n d e r a g r e a t deal o f t e n s l o n
M J * l have never i n t e n s e l y d l s l l k e d sorneone
4 . l f l n d l t hard t o k e e p my mlnd on a tesk o r Job.
S. 1 sometlaes fuel r c s e n t f u l when I don ' t g e t my oun ray . .m.-
6. 1 a i c e r t a l n l y l e c k l n g I n s e l f - c o n f Idence.
7 . 1 am happy caost o f t h e t lm.
th I Ilke t o goss lp a t t l m e s .
0 CI) 9 . T h e r e have been t l m e s when I f e l t Ilke r e b e l l i n g a g a l n s t people I n a u t h o r l t y evem though I knew t h e y were r l g h * .
( 0 . I c a r t a i n l y f e e l u s e l e s s a t t l m e s .
.: 1 . 1 can renenber " p l a y i n g s l c k n t o g e t o u t o f somethlng.
There have becn o c c a s i o n s when I t o o k advantage ' 1 2 * o f soneone.
13. I ' m aiways r l i l l n g t o a d m i t l t when I t v e nade a mlstake.
I t anyway.
T 1 4 . 1 f r e q u e n t l y f l n d myself r o r r y i n g a b o u t somethlng. @ rC\ 15 . I always t r y t o p c a c t i c e what I preach. 0
16. l have p e r l o d s o f such g r e a t r e s t l e s s n e s s t h a t I canno t s l t l o n g I n a c h a l r .
Cr 1 7 . b e l l e v e I am no more nervous than most o t h e r s .
I sometlmes t r y t o g e t even r a t h e r t h a n f o r g l v e f"l l e - an, f o r g e t .
9 When I d o n ' t know somethlng. I d o n ' t a t a l 1 mlnd a d m i t t l n g I t .
20. L i f e I s a s t r a l n f o r me nuch o f the t l m e .
fi 21. 1 am a l r a y s cou r teous . even t o peop le w h o a r e d i sag reeab le.
22. 1 a i more s e n s l t i v e t h a n most o t h e r p e o p l e .
23. 1 canno t keep my m l nd on one t h lng .
pC(24. A t tlnes I have r e a l t y I n s l s t e d on h a v l n g t h l n g s my o r n way.
I f e e l a n x l e t y abou t somethlng or soneone a l m o s t 25* 81 1 th. tlu.
T 26. 1 am t n c l l n e d tp t a k e t h l n g i hard,
n\ 27. There have been occasions when I f e l t I l ka smashlng t h t n g s .
28. 1 a i n o t unusua l l y se l f - consc lous ,
29. I have sometlmes f e l t t h e t d l f f l c u l t l e s were plllng up so h l g h t h a t I c o u l d not overcome them.
T JO. I am u s u a l l y c a l m and n o t e a s l l y u p s e t .
3 1 I r o u l d never t h l n k o f l e t t l n g soneone e f s e be pun i s h e d fo r my urongdo l ngs.
32. A t t l m e i I t h l n k I a m no good a t a l l .
p 33. I n e r e r r a s a n t b e l ng a s k e d t o r e t u r n a f a v o r .
4 I have never been l r k e d when people e x p r e s s e d ldeas v e r y d l f f e r e n t fcom my own.
T 3 5 . 1 a m a h l g h - s t r u n g person. , 36. There have b e e n t i m e s rhen I r a s q u l t e j e a l o u s o f t h e good f o r t u n e o f o the rs .
7 37. 1 s h r l n k f r o n f a c l n g a crlsls o r d i f f l c u l t y .
r 39. 1 s o n s t l n o i l c e l t h e t 4 a m a b o u t t o go t o p l e c e i . F
(y\ 40. 1 have n e v e r d e l l b e r a t e l y s a l d s o m e t h l n g t h e t h u r t someone's f e e l lngs. O
AUTONOMY PREFERENCE INDEX
1 . I'm very s a t i s f i e d u i t h the mcdicrl c a r e 1 r e c e l v e .
2. Most people r e c e i v c mebicrl c i r a that cou ld bc b e t t e r .
3 , The c i r e 1 have rece iveâ from d o c t o r s i n the l a r t few years is j u s t about perfcct,
4 . There a r e chinqs aboiit the rneàical care 1 receive that cou ld be better.
Strongly Disagram
0
01
cl
Stronqly Aqree
PACE 3
8. The important medical declriona should ba made by the doctor, not the patient.
9. Patients should go along 4 t h the daceor's rdvice evtn i f thsy disagree with At.
10. Hospit~lized patients should not be mrking decisions rbout t h d r ovn medical csre.
11. Patients should fecl fret to make deciriona about everyday medical probl ems .
12. Patients should not makc decisions about a problem which might be life-threatening.
13. I f you were s i c k , as your illness becamc uorse , you would want the doctor to cake qreatet control .
. SECTION I I
S t rongly Diragroo
14. Patients should decide hou frtquently they need a check-up.
15. As patients become sickor, they should be told more and more about their illness. 0
16. Patients should understand completely what 1s happening inside thelr bodies as r rcsult of their Allnons.
17. Even if the news is bad, patienta should ba uell i n f o m d . u
18. Doctors should ewplain the purpose of laboratory tests.
19. Patients should be given informa- tion only whcn thay ask for At. n
20. It Ls important for patients to know all the side effects of their medication.
21. Informlng 4 patient lm 4s important as trerting him. 11 u
22. When thete is more than one method to trcit a problem, the patient should be told about cach one. II
N d thor Agroa Nor Diragree
PAGE 4
SC rongly
PACE 5 a
PLEASE CHECK THE BOX WHICH INDICCITES HOW YW mnrto AsoüT W STATU(eNT Ir YOU ACrVALLY HA0 TItE HEDICAL PROBLEH WHXCII IS DESCRJBED.
'Ihr Poctor And You nostly The The Doctor
You Alone M O i t l y You bQri.tl~ boctor Alone
23. Whether you should be seen by the doctor.
24. If a chest X-ray should be trken.
25. I f you should stay home Zrom uork.
26. I f you should try trking cough syrup.
SECTION I I I
. PAGE 6
a. SUPPOSE YOU WENT TO THE OOCIOR FOR A wwrxm Pwrsrw, ~ N C I T I O N MD HE OR SHE FOUND MAT EVERYTI~INC WAS ALL RXCHT EXCEPT TMAT YOUR BlMlO PRlFSSURL W A S HXoi (17O/lOO). WHO SMouLP M U 1HE F O L W I N G DEClSlONS?
Th. boctor And YOu l iort ly The The Ooctor
You Aloiu motly You Dqurlly ~octor Alone
27. When the newt v i s i t to check your blood pressura should k.
28. Whethtr you should takt r o m cime off from work to re;ar.
29. Uhcther hboratory tests rhould be donc,
30. Whethcr you shou1d be treated w i t h madication or d h t .
31. Whethtr a s p e c i a l i s t i n high blood pressure rniqht be h t l p f u l .
* PACE 7
C. SUPPOSE YOU HAD AN ATTACK OF SEVeRE CHEST PAIN WIiM LASr#) IDR UnOST AN HOUR, PRICHTENINC YOU ENOUGll SO TWAT YOU WEHT TO THE EIiERGENCY ROOU. IN TliE EHE#IPrcu iwm TilB m m D1s-R M T WU ARE HAVINC A HEART ATTACK. YOUR OWN DOC?DR IS CULED IN AND YOU ARS T m UP 'K) I m s m au WfT;
WHO SHOULD HAKE THE FOLIXIWINC DECXSIOHS?
32. Hou of ten the nurses should uake you up to check. yout fempetature and blood p r e s a u r e . . .
33. Whether you -y have visitors aride from your imncdiate fsmily.. .
34. Whethtt a h a r t specialist (crrdio!oglst) should be consulteci.. .
m r t l y ~ h e The boctor I)octor Alone
PACE 0
D. SWPOSE IT IS NOW ?UO WEEKS AFT'ER YOüR HEART A T T X K . YW SmLL IN THE HOSPITAL, WAITING TO (;O IiOHE. -
Tho Doctor And Yeu no i t ly ma ~ h e mctor
YOu ~~ Moitly YOu b p ~ l l ~ h c t o r hlone
35. When you w i l l be ready to 90 hons. 4 Li
36. When you 411 be ready to go b c k to your usual actlvitlei. U O ' O O cl
37. Whethtr i t is necessary for you to gfve up an activlty which you really enjoy.
' SECTION I V PACE 9
THE NEKT F I V E QUESTIONS REFER TO YOOR EXPtRIL)(GS WlTH -1CAL Chm.
38. In your mort recent exptrience ui th the doctor you have just seen, ,
hou much d i d you prrtlcipate in the deciiions that uere made?
II II II 39. When you are vel l , hou much do
you uant t o participate i n the medical decislons that are made?
40. ühen you get sick, hou much do you wrnt to participate in the medical decisions that are made?
41. Whcn you are scriously i11, hou much do you want to partlcipate An the medical decisionr that are made?
A Great ûerl
ühich statemcnt best describca your oun at t i tude towrrdr iwdlcil car07 (Pleaie choosc one).
42 . The patient should The patient should ni8 patient and Th. doctor rhould The doctor should Cake complete control. have moto control doctor M d 8- have more contra1 trkc complete
than the doctor. thrcontrolwpmlly. t h . n t h a p . t i e n t . control .
APPENOIX B
Statistical Analysis
CHAPTER 3
SCALE DEVELOPMENT
FACTOR ANALYSIS
Intercorrelation matrix for a11 18 problem solving and decision making items
Continued - intercorrelation matrix for al1 18 problem solving and decision making items
ltem BE
Morbidity Vignette: Unrotated Solution
Initial Principal components matrix, for rnorbidity vignette
Item Factor I Factor II Eigenvalue Var % Communality h2
SCENAA -500 -.586 2.5632 42.7 1 .O00 SCENAB -689 -.264 1.281 4 21.4 1 .O00 SCENAC .81 O 4 7 3 7 7 0 3 12.8 1 .O00 SCENAD .762 -.l 18 .S654 9.4 1 .O00 SCENAE -568 .646 .4802 8.0 1 .O00 SCENAF -529 .638 .3395 5-7 1.000
Mortality Vignette: Unrotated Solution
Initial Principal components matrix, for mortality vignette
Item Factor I Factor II Eigenvalue Var % Communality h2
SCENBA .632 -.264 2.7692 46.2 1 .O00 SCENBB ,777 -.278 1.2060 20.1 1 .O00 SCENBC -802 -.188 .7408 12.3 1 -000 SCENBD .74S -.268 .4674 7.8 1 .O00 SCENBE .5 16 -71 O .4552 7.6 1 .O00 SCENBF 5 4 9 -669 .3615 6.0 1 .O00
Quality of Life Vignette: Unrotated Solution
initial Principal components matrix, for quality of life vignette
Item Factor I Factor Il Eigenvalue Var X Communality h2
SCENCA .643 -.287 2.8068 46.8 1 .O00 SCENCB .7 76 -.232 1.3548 22.6 1 .O00 SCENCC .771 -.307 .7177 12.0 1 .O00 SCENCD .790 -.2 30 .4624 7.7 1 .O00 SCENCE .544 ,726 .3 506 5.8 1 .O00 SCENCF .526 .738 -3078 5.1 1 .O00
Nursing sample: Paired T-tests
Variable
DSCENAA DSCENAB DSCENAC DSCENAD DSCENAE DSCENAF DSCENBA DSCENBB DSCENBC DSCENBD DSCENBE DSCENBF DSCENCA DSCENCB DSCENCC DSCENCD DSCENCE DSCENCF
CHAPTER 5
PARTICIPATION IN TREATMENT CHOICE
HYPOTHESIS #5 PARAMETRIC TESTS
Paired t-tests Scenario A, 8, C - - - - - - - -
Variable Mean Std Error T Prob>JTI
AVSBA AVSBB AVSBC AVSBD AVSBE AVSBF
AVSCA AVSCB AVSCC AVSCD AVSCE AVSCF
BVSCA BVSCB BVSCC BVSCD BVSCE BVSCF
CHAPTER 6
COPtNC STYLE
HYPOTHESIS # 5 NON-PARAMETRIC EQUIVALENT
Summary of Krushel-Wallis One Way Analysis Between Coping Style and Krantz Information
Mean Rank Chi-Sq. df P
1 = true repressor 126.02 16.3575 3 .O01 O 2= iow anxious 163.42 3= true anxious 154.89 4= repressive anxious 118.16
HYPOTHESIS # 6
Tables correspond with Figures presented in the main body of thesis.
Table 6.4 Morbidity Vignette: Diagnosis by Coping Style
Coping Category
Control True Low True Repressive Category Repressor Anxious Anxious Anxious
--- - - .
Doctor Only 42 (53.8%) 29 (50.096) 31 (35.6%) 22 (40.0%)
Mostly Doctor 23 (29.5%) 19 (32.896) 31 (35.6%) 17 (30.996)
Shared 12 (1 5.4%) 10 (17.2%) 2s (28.7%) 1 5 (27.3%)
Mostly You ---- ---- ---- 1 ( 1.8%)
You Only 1 ( 1 3 % ---- ---- ---- Total (n=78) (n=58) (n=87) (n=SS)
Table 6.5 Mortality Vignette: Diagnosis by Coping Style
Coping Category
Control True Low True Repressive Category Repressor Anxious Anxious Anxious
Doctor Only 54 (69.2%) 31 (53.4%) 50 (59.6%) 34 (59.7%)
Mostly Doctor 20 (25.6%) 24 (41.496) 27 (30.0%) 17 (29.8%)
Shared 4(S.2%) 3(5.2%) 11(12.2%) 6(10S%)
Mostly YOU ---- _-__ 2 ( 2 . 2 % ) ----
Total ( ~ 7 8 ) (n= 5 8) (n=90? (n=57)
Table 6.6 Quality of Life Vignette: Diagnosis by Coping Style
Coping Category
Control True tow True Repressive Category Repressor Anxious Anxious Anxious
Ooctor Only 38 (54.3%) 29 (53.7%) 40 (46.0%) 22 (45.8%)
Mostly Doctor 20 (28.6%) 16 (29.696) 28 (32.3%) 18 (37.5%)
Shared 11 (15.7%) 9(16.7%) 17(19.5%) 7(14-6%)
Mostly You ---- ---- l ( l . l % ) l ( l . l % )
You Only 1 ( 1 .4%) ---- 1 ( 1 1 % ----
Total (n= 70) (n=S8) (n=87) (n=48)
Chi-square=5.75 3 , l Zdf,p=0.928, ( 1 ~ ~ 2 5 9 )
Table 6.7 Morbidity Vignette: T reatment Options by Coping Style
Coping Category
Control True Low True Repressive Category Repressor Anxious Anxious Anxious
Doctor Only 38 (48.7%) 21 (35.6%) 31 (35.3%) 22 (40.0%)
Mostly Doctor 25 (32.196) 28 (47.5%) 37 (42.0)6) 13 (23.796)
Shared 1 4 (17-9%) 10 (16.996) 20 (22.796) 19(34.5%)
Mostly YOU 1 ( 1 .3%) ---- ---- ----
You Only ---- ---- ---- 1 ( 1.8%)
Total (n=78) (n= 5 9) (n=88) (n=55)
Chi-square=22.825, 1 5df. p=0.088, (n=280)
Table 6.8 Mortality Vignette: Treatment Options by Coping Style
Coping Category
Control True Low True Repressive Category Repressor Anxious Anxious Anxious
Doctor Only 45 (57.7%) 28 (49.1%) 37 (41.1%) 24 (42.9%)
Mostly Doctor 24 (30.8%) 23 (40.4%) 40 (44.4%) 21 (37.5%)
Shared 9(11.5%) 6(10.5%) 12(13.4%) 11 (19.6%)
Mostly YOU ---- ---- 1 ( 1 1 %) ---- You Only ---- a---
---- ----
Total (n=78) (n=57) (n=90) (n=56)
Chi-square=9.138, 9df, p=0.424, (n=283)
Table 6.9 Quality of Life Vignette: Treatment Options by Coping Style
~ o p i n g Category
Control True Low True Repressive Category Repressor Anxious Anxious Anxious
Doctor Only 30 (42.9%) 23 (42.6%) 32 (37.3%) 16 (34.1%)
Mostly Doctor 23 (32.8%) 24 (44.4%) 3 1 (36.0%) 1 9 (40.4%)
S hared 16(22.9%) 6(11.1%) 21 (24.496) 1 1 (23-4%)
Mostly You 1(1.4%) 1 (1 .9%) 2(2.3%) 1(2.1%)
You Only ---- -a-- ---- -O-_
Total (n=70) (n=54) (n=86) (n=47)
Chi-square=S.447, 9df, p=0.793, (n=257)
Table 6.1 0 Morbidity Vignette: Risks/Benefits by Coping Style
Coping Category
Control True Low True Repressive Category Repressor Anxious Anxious Anxious
Doctor Only 34 (43.6%) 19 (32.2%) 2s (28.4%) 14 (25.5%)
Mostly Doctor 22 (28.2%) 27 (45.8%) 29 (33.0%) 24 (43.6%)
Shared 21 (26.9%) 13 (22.0%) 31 (35.2%) 1 5 (27.3%)
Mostly YOU 1 ( 1.3%) ---- 3(3.4%) 2(3.6%)
You Only ---- -O*- ---- ----
Total (n=78) (n=59) (n=88) (n= 5 5)
Table 6.1 1 Mortality Vignette: Risks/Benefits by Coping Style
Coping Category
Control True Low True Repressive Category Repressor Anxious Anxious Anxious
Doctor Only 38 (49.4%) 22 (37.996) 34 (37.8%) 22 (40.0%)
Mostly Doctor 23 (29.996) 24 (41.496) 26 (28.996) 19 (34.596)
Shared 16 (20.8%) 12 (20-7%) 27 (30.0%) 13 (23.6%)
Mostly You ---- O-w- 3 (3.3%) 1 (1.996)
You Only ---- ---- ---- ----
Total (n=77) (n=58) (n=90) (n=5 S)
Chi-square=9.815, 9dfl p=0.366, (n=283)
Table 6.12 Quality of Life Vignette: Risks/Benefits by Coping Style
Coping Category
Control True Low True Repressive Category Repressor Anxious Anxious Anxious
Doctor Only 26 (37.1%) 17 (31 -5%) 24 (28.6%) 13 (28.3%)
MostlyDoctor 2 5 ( 3 5 . 7 % ) 21(38.996) 28(33.3%) 16(34.8%)
S hared 18 (25.7%) 1 5 (27.8%) 29 (34.5%) 16 (34.8%)
Mostly You 1(1.4%) 1(1.9%) 3(3.6%) 1 ( 2 . 2 % )
You Only ---- ---- O--- ----
Total (n= 70) (n=S4) (n=84) (n=46)
Ch i-square=3.594, 9df. p=0.936. (n-2 54)
Table 6.1 3 Morbidity Vignette: Probabilities by Coping Style
Coping Category
Control True Cow True Repressive Category Repressor Anxious Anxious Anxious
Doctor Only 33 (42.996) 26 (44.1%) 30 (34.5%) 16 (29.1%)
Mostly Doctor 32 (41 -6%) 25 (42.4%) 36 (41 -4%) 29 (52.7%)
Shared 12 (1 5.6%) 7 (1 1 -996) 16 (1 8.4%) 9 (1 6.4%)
Mostly You ---- 1 ( 1.796) 5 ( 5.7%) 1 ( 1.8%)
You Only ---- ---- ---- ---- Total (n=77) (n= 5 9) (n=87) (n= 5 5)
Chi-square=10.489, gdf, p=O.3 1 2 , (n=278)
Table 6.14 Mortality Vignette: Probabilities by Coping Style
Coping Category
Controi Truc Low True Repressive Category Repressor Anxious Anxious Anxious
- - -
Doctor Only 37 (48.1%) 26 (44.8%) 32 (36.0%) 21 (37.5%)
Mostly Doctor 29 (37.7%) 25 (43.1%) 36 (40.4%) 26 (46.4%)
Shared 11(14.3%) 7(12.1%) 16(18.0%) 9(16.1%)
Mostly YOU ---- ---- S ( 1 .6%) ----
Total (n=77) (n-58) (n=89) (n=S6)
Table 6.1 5 Quality of Life Vignette: Probabilities by Coping Style
Coping Category
Control True Low True Repressive Category Repressor Anxious Anxious Anxious
Doctor Only 22 (32.4%) 21 (38.9%) 29 (34.1%) 13 (28.3%)
Mostly Doctor 31 (45.6%) 23 (42.6%) 26 (30.6%) 1 5 (32.696)
Shared 1 4 (20.6%) 1 0 (18.5%) 23 (27.1%) 16 (34.8%)
Mostly YOU 1 ( 1 -5%) ---- 6 ( 7.1%) 1 ( 2.2%)
You Only ---- ---- 1(1.2%) 1(2.2%)
Total (n=68) ( n 4 4 ) (n=8S) (n=46)
Chi-square=l5.949, 1 Zdf, p-0.193, (n=253)
Table 6.1 7 Morbidity Vignette: Utilites by Coping Style
Coping Category
Control True Low True Repressive Category Repressor Anxious Anxious Anxious
Doctor Only 9(11.5%) ---- 4(4.6%) 8(14.5%)
Mostly Doctor 8 (1 0.3%) 2 ( 3.4%) 10 (1 1.5%) 3 ( 5.5%)
Shared 37 (47.4%) 3 4 (57.6%) 43 (49.4%) 30 (54.5%)
Mostly You 19 (24.4%) 13 (22.0%) 27 (31.0%) 12 (21.8%)
You Only S(6.4%) 10(16.9%) 3(3.4%) 2(3.6%)
Total (n=78) (n= 5 9) (n=87) (n=55)
Table 6.1 8 Mortality Vignette: Utilites by Coping Style
Coping Category
Control True Low True Repressive Category Repressor Anxious Anxious Anxious
Doctor Only S(6.4%) 1(1.7%) 9(10.0%) 10(17.9%)
Mostly Doctor 1 3 (1 6.7%) 4 ( 6-996) 1 1 (1 2.2%) 4 ( 7.1 %)
Shared 37 (47.4%) 36(62.1%) 39(62.1%) 31 (55.4%)
Mostly You 20 (25.6%) 8 (1 3.8%) 28 (31.1%) 9 (1 6.1%)
You Only 3 ( 3.8%) 9 (1 5.5%) 3 ( 3.3%) 2 ( 3.6%)
Total (n= 78) (n=58) (n=90) (n=56)
Chi-square=32.868, 1 Zdf, p=0.001, (n=283)
Table 6.1 9 Quality of Life Vignette: Utilites by Coping Style
Coping Category
Control True Low True Repressive Category Repressor Anxious Anxious Anxious
Doctor Only 3 ( 4.2%) 1 ( 1.996) 6 ( 6.9%) 5 (1 0.6%)
Mostly Doctor 1 3 (1 8.3%) ---- 1 3 (1 4.996) 3 ( 6.4%)
Shared 33 (46.5%) 33 (61 -1%) 38 (43.7%) 27 (57.4%)
Mostly You 1 s (21.1%) 11 (20.4%) 25 (28.7%) 10 (21.3%)
You Only 7 ( 9.9%) 9 (1 6.7%) 5 ( 5.7%) 2 ( 4.3%)
Total (n=71) (n=S4) (n=87) (n=47)
Table 6.20 Morbidity Vignette: What is done by Coping Style
Coping Category
Control True Low True Repressive Category Repressor Anxious Anxious Anxious
-
Doctor Only 12(15.4%) 2(3.4%) 7(8.0%) 10(18.2%)
Mostly Doctor 1 7 (2 1.8%) 8 (1 3.6%) 1 5 (1 7.0%) 2 ( 3.6%)
Shared 33 (42.3%) 31 (52.5%) 31 (35.2%) 30 (54.5%)
Mostly You 10 (12.8%) 13 (22.0%) 21 (23.9%) 8 (14.5%)
You Only 6 (7.7%) 5 (8.5%) 14 (15.9%) 5 (9.1%)
Total (n=78) (n= 5 9) (n=88) (n=S 5)
Chi-square=25.947, 1 Zdf. p=0.011, (n=280)
Table 6.21 Mortality Vignette: What is done by Coping Style
Coping Category
Control True Low True Repressive Category Repressor Anxious Anxious Anxious
Doctor Only 13 (1 6.7%) 3 ( 5.2%) 13 (1 4.4%) 7 (1 2.5%)
Mostly Doctor 1 5 (1 9.2%) 1 5 (25.9%) 16 (1 7.8%) 4 ( 7.1%)
S h ared 3 4 (43.6%) 28 (48.3%) 35 (38.996) 36 (64.3%)
Mostly You 9(11.5%) 8(13.8%) 14(15.6%) 6(10.7%)
You Only 7(9 .0%) 4(6.9%) 12(13.3%) 3(5.4%)
Total (n= 7 8) (n= 5 8) (n=90) (n= 5 6)
Chi-square-1 8.293, 12df, p=0.107. (n=283)
Table 6.22 Quality of Life Vignette: What is donc by Coping Category
Coping Category
Control True Low True Repressive Category Repressor Anxious Anxious Anxious
Doctor Only 1 O (1 4.1 %) 4 ( 7.4%) 9 (1 0.3%) 7 (1 4.6%)
Mostly Doctor 9 (1 2.7%) S ( 9.3%) 1 3 (1 4.9%) 1 ( 2.1%)
Shared 2 9 (40.8%) 22 (40.7%) 35 (40.2%) 28 (58.3%
Mostly You 1 1 (1 5.5%) 18 (33.3%) 18 (20.7%) 8 (1 6.7%)
You Only 1 2 (1 6.9%) 5 ( 9.3%) 12 (1 3.8%) 4 ( 8.3%)
Total (n=71) (n=54) (n=87) (n=48)
Chi-square=l7.258, 1 Zdf, p=0.140, ( ~ 2 8 3 )
BIBLIOCRAPHY
Abrams FR. The doctor with two heads: the patient verses the costs. The New England Journal of Medicine. 328(13):975-976, 1993.
Alwin DF. The use of factor analysis in the construction of linear composites in social research. Sociolog ical Methods & Research. Sage Publications, Inc,. 2(2):191-213, 1973.
Arrow KJ. ( 1 973). Theoretical Issues in Health Cure. The University of Essex Noel Buxton Lecture.
Babbie E. The practice of social research (4th ed). Wadsworth Pu blishing Co. 1986.
Batt i n M P. Non-patient decision-making in medicine: the eclipse of altruism. The Journal of Medicine and Philosophy. 10:19-44, 1 985.
Barry MJ, Mulley AC, Fowler FJ, Wennberg JW. Watchful waiting vs. immediate transurethral resection for symptomatic prostatism. JAMA. 259:3010-7, 1988
Baumann A, Deber RB. Decision making and problem solving in nursing: An overview and analysis of relevant literature. Toronto: Faculty of Nursing Literature Review Monographs, 1989.
Becker C , Nachtigal l RD. Ambiguous responsibility in the doctor-patient relationship: The case of infertility. Social Science and Medicine. 32:875- 885, 1991.
Beisecker AE, Beisecker TD. Patient information-seeking behaviours when communicating with doctors. Medical Care.28(1): 1 9-28, 1 990.
Be n-Si ra Z. The function of the professional's affective behaviour in client satisfaction: a revised approach to social interaction theory. ]ou rnal of Health and Social Behaviour. 1 7:3-11, 1976.
Bille DA. A study of patients' knowledge in relation to teaching format and compliance. Supervisor Nurse. 5 5-62, March 1 977.
Birke L, Himmelweit 5, Vines C. ( 1 990). Tomorrow's child: reproductive technologies in the 90's. London: Virago Press.
Blanchard CC, Labrecque MS, Ruckdeschel JC, Blanchard EB. Information and decision-making preferences of hospitalized adult cancer patients. Soc Sci Med. 27(11):1 139-1 145, 1988.
Boyd NF, Sutherland HJ, Heasman KZ, Tritchler DL, Cummings BJ. Whose utilities for decision analysis? Medical Decision Making. 1 0: 58-67, 1 990.
Brett AS, McCullough LB. When patients request specific interventions: defining the limits of the physician's obligation. New England Journal of Medicine. 31 91346-1351, 1 986.
Brock DW, Wattman SA. Sounding Board: When competent patients make irrational choices. The New England Journal of Medicine. 322(22):1595- 1 599, 1990.
Brody OS. The patient's role in clinicul decision-making. Annaîs o f Interna1 Medicine. 93:718-722, 1 980.
Brody DS, Miller SM, Lerrnan CE, Smith DG, Caputo CC. Patient perception of involvement in medical cure: relationship to illness attitudes and outcornes. J. Cen. Intern. Med.4506-5 1 1 , 1 989a.
Brody DS, e t al. The relationship between patients' satisfaction with their physicians and perceptions about interventions they desired and received. Medical Care. 4: 506-S 1 1 , 1 989b.
Brod y H . Autonomy revisited: progress in medical ethics: discussion paper. Journal o f the Royal Society of Medicine. 78:380-387, 1 985.
Brownlea A. Participation: myths, realities, and prognosis. Social Science and Medicine. 25:605-614, 1 987.
Budd EC. Clopton JR. Meaning of the repression-sensitization scale: defensive style or self-report or symptoms of psychopathology. J of Clin ical Psychology. 41 ( 1 ):63-68, 1985.
Bunker JP, Brown BW Jr. The physician-patient as an informed consumer of surgical services. New England Journal o f Medicine. 290:105 1-1 055, 1 974.
By rne O, Barry j, Nelson D. Relation of the revised repression-sensitizution scale to measures of self-description. Psychology Reports. 13:323-334, 1 963.
Canada. Royal Commission on New Reproductive Technologies. (1 991 ). What we Heard: lssues and questions raised during the public hearings. Ottawa. RCNRT.
Cassileth BR, Zupris RV, Sutton-Smith K, March V. lnformation and participation preferences among cancer patients. Annais of Internai Medicine. 92:832-836, 1980.
Childress JF. (1 982). Who should decide?: paternalism in health cure. New York: Oxford University Press.
Childress JF. The normative pnnciples of medical ethics. In: Medical Ethics. (2 7-48) (Ed: Veatch,RM) Jones and Bartlen, Boston. 1 982.
Christensen-Szalanski 1. Boyce T. Harrell H. Gardner MM. Circumcision and informed consent. Medical Care. 25(9):856-867, 1 987.
Cody RP. Smith J K. Applied statistics and the SAS programming language (3 rd ed). Elsevier Science Publishing Co., New York. 1991.
Cohen F. (1 987). Meusurement of Coping Ch. 10. In: Stress and Health: Issues in Research Methodology. John Wiley & Sons Ltd.
Cohen F, Lazarus RS. Active coping processes, coping disposition and recovery from surgery. Psychosomatic Medicine. 3 5:3 75-389, 1 973.
Corn rey AL. Common methodological problems in factor analysis. Journal of Consulting and Clinical Psychology. 46:648-59, 1978.
Cou l ton CJ . Decision-making in support: patient perceptions and preferences. Journal of Clinical Epidemiology. 43(Suppl.): 5 1 S-545, 1 990.
Cronbach 4. Coefficient alpha and the interna1 structure of test. Psychometrika. 16:297-334, 195 1 .
Crown DP, Marlowe 0. A new scale of social desirability independent of psychopatho/cgy. Journal o f Consulting Psychology. 24(4):349-354, 1 960.
Deber RB, Kraetschmer NU, lrvine J. What role do patients wish in treatment decision making? Medical Decision Making. 13(4):384, 1993.
Deber RB, Pendleton A, Bouchard H. Royal Commission on New Reprod ua ive Tech nolog ies. lmplementing Shared Decision Making. (forthcoming).
De ber RB, Bau man n AO. Clinical reasoning in medicine and nursing: Decision making versus problem solving. Teach ing and Learning in Medicine. 4: 140-1 46, 1 992.
Deber RB. The determinants of treatment choice in end-stage renal disease: can we generalize about decision making from specific studies? Medical Decision Making. 6:23 1-238, 1 986.
Degner LF. Russel CA. Preferences for treatment control among adults with cancer. Research in Nursing & Health. 1 1 :367-374, 1988.
Del C reco L, Walop W. Questionnaire development: 1 . formulation. CMN. 1361583-585, 1987.
Del Greco L, Walop W, McCarthy RH. Questionnaire development:2. validity and reliability. CM&. 1 36:699-700, 1 987.
Del Greco L, Walop W, Eastridge. Questionnaire development:3. translation. CMN. 136:817-1 18 , 1987.
Del Greco LI Walop W. Questionnaire deve1opment:S. The pretest. CMql.l36:102 5-1 026, 1987.
Dimsdale JE, Hackett TP. Effect of Denial on Cardiac Health and Psychological Assessment. Am J Psychiatry. 1 39(1 1 ): 1 477-1 480, 1 982.
Eisenthal S. Lazare A. Evaluation of the initial interview in a walk-in clinic: the patient's perspective on a 'customer approach. Journal o f Nervous and mental disease. 1 62: 1 69-1 76, 1 976.
Elste i n AS. Paradigms for research on clinical reasoning: a researcher's commentary. Teaching and Learning in Medicine. 4(3):147-149, 1992.
Ende J, Kazis L. Moskowitz MA. Preferences for autonomy when patients are physicians. Journal of Ceneral lnternal Medicine. 5506-509, 1990.
Ende J, Kazis L, Ash A, Moskowitz MA. Measuring patients' desire for autonomy: decision rnaking and information-seeking preferences among medical patients. Journal of Ceneral lnternal Medicine. 4:23-30, 1989.
England 5 , Evans J. Patients choices and perceptions after an invitation tu participate in treatment decisions. Soc Sci Med. 34(1 1 ): 1 2 1 7-1 22 5, 1 992.
Eraker SA, Politser P. How decisions are reached: Physician and patient. Annals of lnternal Medicine.97:262-268, 1982.
Esterling BA. Antoni MH. Kumar M. Schneiderman N. Defensiveness, Trait Anxiety, and epstein-barr viral capsid antigen antibody titers in healthy college students. Health Psychology. 1 2(2): 1 32-1 39, 1 993.
Faden RR. (1 991 ). Autonomy, choice, and the new reproductive technologies: the role of informed consent in prenatal genetic diagnosis. In Women and New Reproductive Technologies: Medical Psychosocial, Legal, and Ethical Dilemmas, ed. J-Rodin and A.Collins. Hilldale: Lawrence Erlbaum Associates.
Fowler FJ, Wennberg JE, Timothy RP, Barry MJ, Mulley AC, Hanley D. Symptom status and quality of life after prostatectomy. JAMA 2 5 9: 3 0 1 8, 1988.
Fox E, O'Boyle C, Barry H, McCreary C. Repressive coping style and anxiety in stressful dental surgery. British Journal of Medical Psychology. 62(Pt 4): 371 -380, 1989.
Francis VB, Korsch M. Morris MJ. Caps in doctor-patient communication. patient's response tu medical advice. New England Journal of Medici ne. 280:535-540, 1969.
Greenfield S, Kaplan S, Ware JE. Expanding patient involvement in care: Effects on patient outcomes. Annals of lnternal Medicine. 1 02:520-528, 1985.
Greenfield S, Kaplan 5 , Ware JE, Yano EM, Frank HJL. Patients' participation in medical care: Effects on blood sugar control and quality of life in diabetes. Journal of Ceneral lnternal Medicine. 3:448-457, 1988.
Gentry WD, Foster 5, Haney T. Denial as a determinant of anxiety and perceived health status in the coronary care unit. Psychosomatic Medicine. 34:39-44, 1972.
Hall JA, Epstein AM, DeCiantis ML, McNeil J. Physicians' Iiking for their patients: more evidence for the role of affect in medical care. Health Psychology. 12(2):140-146, 1993.
Haug M RI Lavin B. Public challenge of physician authority. Medical Care. 17~844-858, 1979.
Haug MR, Lavin B. Practitioner or patient - who's in charge? J Health Soc Behav 22:212-219, 1981.
Haug MR, Lavin B. Consumerism in Medicine: challenging physician authority. Beverly Hills: Sage Publications, 1983.
Hum p hrey BG. Littlewood JL. Kam ps WA. Physician/patient communication: a mode1 considering the interaction of physicians' therapeutic strategy and patients' coping style. J Cancer Education. (72): 1 47-1 52, 1 992.
Jones JA, Phillips CM. (1 988). Communicating with your doctor. Southern Illinois University Press.
Kaplan RM. Health-related quality of life in patient decision making. J of Social Issues. 47(4):69-90, 1 991 .
Kaprowy JA. A descriptive study to investigate end stage renal disease patients' desire for information and preferences about roles in treatment decision making. Canadian Nurses Association. August 1991.
Kassirer J P. Adding insult to injury: usurping patients' prerogatives. New England Journal o f Medicine. 308(15): 898-901, 1983.
Katz J. Why doctors don? disclose uncertainty.The Hastings Center Report. 3 5-44, 1 984a.
Katz J . The Silent World of Ooctor and Patient. New York: Free Press, 1984b.
Kaufman n CL. lnformed consent and patient decision making: two decades of research. Social Science and Medicine. 1 7(2 1 ):1657-1664, 1 983.
Kerlinger FN. Foundations of behavioral research (3 rd ed). Holt, Rine hart and Winston, Inc. 1987.
Kline P. A handbook for test construction. Methuen, London. 1 986.
Kneier AW, Temoshok L. Repressive coping reactions in patients with malignant melanoma as compared to cardiovascular disease patients. Journal o f Psychosomatic Research. 28(2): 1 45-1 5 5 , 1 984.
Korsch BM, Negrete VF. Doctor-patient communication. Scientific American 227(August):66-74, 1 972.
Korsch BM, Gozzi K. Francis V. Caps in doctor-patient communication. 1 . doctor-patient interaction and patient satisfaction. Pediatrics. 42:B 5 5-87 1 , 1968.
Krantz DS. Baum A. Widerman MV. Assessment of preferences for self- treatment an information in health cure. J Pers Soc Psychol. 39:977-990, 1989.
Larsson US, Svardsudd K, Wedel H, Saljo R. Patient involvement in decision- making in surgical and orthopaedic practice: The project perioperative risk. Soc. Sci. Med. 28(8):829-835, 1989.
Lazarus RS, Averill JR. Opton EM: The psychology of coping: issues of research and assessment. In Coelho CV, Hamburg DA, Adams JE (eds), Coping and Adaptation. New York, Basic Books (249-3 1 5) 1974.
Lazarus RS. Coping theory and research: past, present and future. Psychosomatic Medicine. 55234-247, 1993.
Legg England S. Evans J. Patients' Choices and perceptions after an invitation to participate in treatment decisions. Soc. Sci. Med. 34(1 1 ): 1 2 1 7- 1225, 1992
Lerman CE, et al. Patients' perceived involvement in care scale: relationship to attitudes about illness and medical care. Journal o f Ceneral lnternal Medicine. 929-33, 1 990.
Levenson JL, Mis hra A, Harner RM, iiastilio A. Denial and medical outcome in unstable angina. Psychosomatic medicine. 5 1 :27-35, 1 989.
Lidz CW. Meisel A. Osterweis M. Holden J. et al. Barriers to informed consent. Annals of lnternal Medicine. 99539-543, 1 983.
Llewellyn-Thomas HA, McGreal MJ, Thiel EC, Fine S. Erlichman C. Patients' willingness to enter clinical trials: rneasuring the association with perceived benefit and preference for decision participation. Social Science and Medicine. 32(1) 35-42, 1991.
Ludwick-Rosenthal R, Neufeld Rw. Preparation for undergoing an invasive medical procedure: interacting effccts of information and coping style. Journal of Consulting & Clinical Psychology. 61 (1):156-164, 1993.
Mathews JJ. The communication process in clinical setting. Social Science and Medicine. 1 7:1371-1378, 1983
Matthews KA, Kuller LH, Siegal JM, Thompson M, Varat M. Determinants of decisions to see k medicol treatrnent by patients wi th acute m yocardial infarction symptorns. 44(6): 1 1 44-1 1 56, 1 983.
Mazur DJ. Hickam D. Treatmentpreferences ofpatients and physicians: influences of summary data when framing effects are controlled. Medical Decision Making. 10:2-5, 1990.
McClain CS. Why women choose trial of labour o r repeat cesarian section. Journal of Family Practice. 1 1 :210:216, 1985.
McClain CS. Patient decision making: the case of delivery method after a previous cesarean section. Culture, Medicine and Psychiatry. 1 1 :495-508, 1987.
M cCreary C. Turner J . Locus of control, repression-sensitizution, and psychological disorder in chronic pain patients. J of Clinical Psychology. 40(4):897-901, 1 984.
McDowell 1 , Newell C. (1 987). Measuring health: a guide to rating scales and questionnaires. New York: Oxford University Press.
McNeil BJ, Pauker SC. The patient's role in assessing the value of diagnostic tests. Radiology. 1 32:605-610, 1979.
Meisel A, Roth LH. What we do and do not know about informed consent. JAMA. 246:2473-2477, 1981.
Merz JF, Fisch hoff B. lnformed consent does not mean rational consent: cognitive limitations on decision making. journal of Legal Medicine. 1 1 : 3 2 1 - 350, 1990.
Miller SM, Leinbach A, Brody DS. Coping style in hypertensive patients: nature and consequences. Journal of Consulting and Clinical Psychology. 57(3):333-337, 1989.
Miller SM, Mangan CE. lnteracting effects of information and coping style in adapting to gynecological stress: should the doctor tell all?J Pers Soc Psychol. 45223-36, 1983.
M i rvi s DM. Physicians' autonom y-the relation between public and professional expectations. The New Engfand Journal of Medicine. 328(18): 1 346-1 349, 1 993.
Munro BH, Visintainer MA, Page EB (1 986). Statistical methods for health care research. Philadelphia: Lippincot.
Nouris MJ. SPSS Inc. SPSS for Windows.
Nunnally J-C. Psychometric theory (2nd edn). McCraw-Hill, New York. 1978
Pauker SC, McNeil BJ. Impact of patient preferences on the selection of therapy. J . Chron. Dis. 34:77-86, 1981.
Pendleton L, Hause WC. Preferences for treatment approaches in medical cure: College students verses diabetic outpatients. Med ical Care.2 2(7):644- 646, 1984.
Prince R. Denial: is its use in heart diseuse a bad thing? lntegr Psychiatry. 3 166-67, 1 985.
Qui l l TE. Partnerships in patient care: a contractual approach. An nais of Interna1 Medicine. 98:228-234, 1983.
Robinette RL. The relationship between the marlowe-crowne form c and the validity scales of the MMPI. Journal o f Cl inical Psychology. 47(3): 3 96-3 99. 1991.
Robinson O, Whitfield MJ. lmproving the etficiency of patientsw comprehension monitoring: a way of increasing patientsw participation in general practice consultations. Social Science and Medicine. 2 1 :91S-919, 1985.
Rofe Y. Blittner M. Lewin 1. Emotional experiences during the three trimesfers of pregnacy. J of Clinical Psychology. 49(1):3-12, 1 993.
Roscoe JT. Fundamental research statistics for the be havioral sciences (2nd ed). Holt, Rinehart and Winston, Inc. 1975.
Roter DL. Patient question asking in physician-patient interaction. Heal t h Psychology. 3(5):395-409, 1 984.
Rote r DL. Patient participation in the pa tien t-provider in teraction: the e ffects of patient question asking on the quality of interaction, satisfaction, and cornpliance. Health Education Monographs. 5:281-315, 1977.
SAS. The SAS lnstitute Inc., 1993
Schulman BA. Active patient orientation and outcomes in hypertensive trea tmen t: application of a socio-organizationa perspective. Med ical Care. 1 7:267-280, 1 979.
Shaw RE. Cohen F, Doyle 6, Palesky J. The impact of denial and repressive style on information gain and rchabilitation outcomes in rn yocardial infarction patients. Psychosomatic Medicine. 47(3):262-273, 1 985.
Shaw RE, Cohen F, Fishman-Rosen J, Murphy MC, e t al. Psychologic predictors of psychosocial and medical outcomes in patients undergoing coronary angioplasty. 48(8):582-597, 1 986.
Shipley RH, Butt JH, Honnritz EA. Preparation to reexperience a stressfui rnedical examination: e ffect of repe titious videotape exposure and coping style. Journal of Consuking and Clinical Psychology. 47(3):485-492, 1979.
Siegel S. Nonparametric statistics for the behavioral sciences. McG raw-H i l 1 Kogakusha, Ltd. 1956.
Sieg ler M. Decision-making strategy for clinical-ethical problems in medicine. Arch. Intern. Med. l42:2 1 78-2 1 79, 1 982.
Sieg l e r M. The physician-patient accommodation: a central event in clinical medicine. Arch lntern Med. 1 42: 1 899-1 902, 1 982
Sloug h N, Kleinknecht RA, Thorndike RM. Relationship of the repression- sensitization scales to anxiety. Journal o f Personality Assessment. 48(4):378-379, 1 984.
Speedl ing 9, Rose DN. Building and effective doctor- patient relationship: from patient satisfaction to patient participation. Soc Sci Med. 2 1 : 1 1 5- 1 20, 1985.
Starfield B. e t al. The influence of patient-practitioner agreement on outcome of care. American Journal of Public Health. 71 :127-13 1 , 1 981 .
Steptoe A, Vogele C. lndividual differences in the perception of bodily sensations: the role of trait anxiety and coping style. Behaviou r Research and Therapy. 30(6):597-607, 1 992.
Steptoe A, Sutcliffe f , Allen BI Coombes C. Satisfaction with communication, medical knowledge, and coping style in patients with metastatic cancer. Social Science and Medicine. 32(6):627-632, 1 991 .
S t i les WB e t al. Dimensions of patient and physician roles in medical screening interviews. Social Science and Medicine. 1 3A:33 5-341 , 1 979.
Sti mson CV. Obe ying doctor's orders: a view from the other side. Social Science and Medicine. 8:97-104, 1974.
S t rah an RI Cerbasi KC. Short, homogeneous versions of the marlowe-crowne social desirability scale. 1 9 1 - 1 9 3.
Streiner DL. Norman CR. (1 989). Health measurement scales: a pructical guide to their development and use. New York: Oxford University Press.
Strull WN, Lo B, Charles G . Do patients want to participate ifi medical decision making? Journal of the American Medical Association. 252:2990- 2994, 1984.
SulsJ, Fletcher B. The relative effcacy of avoidantand nonavoidant coping strategies: a meta-analysis. Health Psychology. 4(3):249-288, 1985.
Sutherland Hj e t al. Cancer patients: their desire for information and participation in treatment decisions. Journal o f the Royal Society of Medicine. 82:260-263, 1989.
Szasz TS. Hollander MH. A contribution to the philosophy of medicine. The basic models of the doctor-patient relationship. Arch lntern Med. 97;585- 592, 1956.
The Health Services Research Croup. Studying patients'preferences in health care decision making. Can Med Assoc J. 147(6):859-864, 1992.
Thom pson IE. Fundamental ethical principles in health care. British Medical Journal. 2 9 5 1 461 -1 465, 1987.
Thomasma DC. Autonomy in the doctor-patient relation. Theoretical Medicine5 1-7, 1 984.
Tuckett DA, Boulton M. Olson C. A new approach to the meusurement of patients' understanding of what they are told in medical coniultations. J of Health and Social Behavior. 26:27-38, 1985.
United States. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behaviorial Research. 1982. Making health care decisions: the ethical and legal implications of informed consent in the patient-practitioner relationship. Vol. 1 . Was hingston, OC: Covernment Printing office.
Veatch RM. Models for ethical medicine in a revolutionary age. What physician-patient roles foster the most ethical Relationship? Hastings Centre Report 2 (June): 5-7, 1972.
Veatch RM. The patient-physician relation: the patient as partner, part 2. Bloomington: lndianna University Press, 1991.
Vertinsky IB, Thompson WA, Uyeno D. Measuring consumer desire for participation in clinical decision-making. Heal t h Se W. Res. 9: 1 2 1 -1 34, 1 974
Vickers RRJr, Hervig LK, Rahe RH, Rosenman RH. Type A behaviour pattern and coping and defense. Pyschosornatic Medicine. 43(5):381-396, 1981.
Vingerhoets M M , Flohr PJM. Type A behaviour and self-reports of coping preferences. British Journal o f Medical Psychology. 57:1 5-21, 1984.
Waitzkin H. Doctor-patient communication: clinica/ implications of social scientific research. JAMA. 2 52:2441-2446, 1 984.
Waitzkin Hl Stoeckle JD. The communication of information about illness: clinical, sociological, and methodological considerations. Advances in Psychosomatic Medicine. 8: 1 80-2 1 5, 1 972.
Walop W, Del Greco LI Eastridge L, Marchand 8, Szentveri K. Questionnaire development: 4. preparation for anulysis. CMN. 1 36:W 7-928, 1 987.
Ware JE Jr, Snyder MK. Dimensions of patient attitudes regarding doctors and medical services. Medical Care. 1 3:669-682, 1 975.
Ware JE Jr, Snyder Mk, Wright WR. (1 976). Development and validation of scales to measure patient satisfaction with health care services. Vol. 1 o f a Final Report. Part B. Results Regarding Scales Constructed from the Patient Satisfaction Questionnaires and Measures of other Health Perceptions. Carbondale: Southern Illinois University School of Medicine.
Wartman SA. Morlock L, Malitz F. Patient Understanding and satisfaction as predictors of compliance. Medical Care. 2 1 (9):886-891, 1 983.
Waterworth S, Luker KA. Reluctant collaborators: do patients want to be involved in decisions concerning care? Journal of Advanced Nursing. 1 5:971-976, 1 990.
Weinberger DA, Schwartz GE, Davidson N. Low-anxious, high-anxkus, and repressive coping styles: ps ychome tric patterns and behavioral and physiological responses to stress. Journal o f Abnormal Psychology. 88(4):369-380, 1979.
Weiner JL. Boyer EC, Farber NJ. A changing health care decision-making environment. Human Relations. 39:647-659, 1 986.
Weiss GB. Paternalism Modernized. Journal of Medical Ethics. 1 1 : 1 84-1 87, 1985.
Weiss SJ. Consensual norms regarding patient involvement. Social Science of Medicine. 22:489-496, 1986.
Wen n berg JE et al. An assessrnent of prostatectorny for benign urinary tract obstruction: geographical variations and the evaluation of medical care outcomes. JAMA. 259:3027-3030, 1 988.
Wilson J. Patients' wants versus patients' interests. Journal o f Medical Ethics. 12:127-132, 1986.
Wol fgarten A, Khan A. Medical decision-making: patient participation. Medico-Legal Journal. 52:180-190, 1 984.
Woolley FR et al. The effects of doctor-patient communication on satisfaction and outcome of care. Social Science and Medicine. 12: 123-1 28, 1978.