Documente Academic
Documente Profesional
Documente Cultură
To cite this Article Raveis, Victoria H. , Pretter, Sheindy and Carrero, Monique(2010) 'It Should Have Been Happening To
Me: The Psychosocial Issues Older Caregiving Mothers Experience', Journal of Family Social Work, 13: 2, 131 148
To link to this Article: DOI: 10.1080/10522150903503002
URL: http://dx.doi.org/10.1080/10522150903503002
This study has been funded by grants from the Department of Defense, Breast Cancer
Initiative, DAMD17-00-1-0215 and the New York State Breast Cancer Research and Education
Fund, NYS DOH C017945.
Address correspondence to Dr. Victoria H. Raveis, Psychosocial Research Unit on Health,
Aging and the Community, New York University College of Dentistry, 380 Second Avenue,
Suite 301, New York, NY 10010. E-mail: victoria.raveis@nyu.edu
131
132
V. H. Raveis et al.
When a family member becomes ill, the ramifications of the illness are
experienced throughout the family system. Over the last few decades, an
expanding body of family-based research has been documenting the impact
of cancer on the family (Baider, Cooper, & Kaplan De-Nour, 2000; Dorval
et al., 2005; Mitschke, 2008; Ponto & Barton, 2008). These efforts have
informed the growing movement for a paradigm shift from a biomedical
model of care to one that is patient and family centered (Kelly, Reinhard,
& Brooks-Danso, 2008; Rolland, 2005).
Families face a set of psychosocial challenges imposed by their relatives
cancer including coping with uncertainty, dealing with illness-related losses,
and adapting to the changes engendered by the cancer and its treatment
(Raveis, 2007). Investigations have found elevated levels of emotional and
psychological distress among family members (Ferrario, Zotti, Massari, &
Nuvolone, 2003; Matthews, Baker, & Spillers, 2003; Mitschke, 2008; Raveis,
Karus, & Siegel, 1998; Raveis & Pretter, 2005a; Toseland, Blanchard, &
McCallion, 1995), sometimes higher than that of the cancer patients themselves (Gilbar & Rephaeli, 2000; Northouse, Mood, Templin, Mellon, &
George, 2000). Family members may experience a period of crisis fraught
with severe emotional distress and life=death concerns upon learning of their
loved ones cancer diagnosis, which parallels the existential plight cancer
patients encounter following their diagnosis (Raveis & Pretter, 2005b).
A relatives cancer diagnosis may also be indicative of heightened susceptibility to the disease in the family. Family members learning of their relatives illness may be simultaneously confronted with their own increased
cancer risk. Women with one first-degree relative with breast cancer have
almost twice the risk of the disease compared to those with no family history
of breast cancer. Women with two first-degree relatives have almost three
times the risk (Collaborative Group on Hormonal Factors in Breast Cancer,
2001; Metcalfe et al., 2009). Investigations have documented that women at
increased risk for breast cancer due to a family history of the disease have
heightened anxiety levels associated with their risk status (Kash, Holland,
Halper, & Miller, 1992; Lerman et al., 1993). Some women, who are at
increased risk for breast cancer, experience a paralyzing sense of
cancer-related worry that severely affects their ability to function on a daily
basis (Lerman et al., 1993).
As in other illness situations, the family is integral to the care and
support provided to persons receiving treatment for cancer (Schumacher,
Stewart, Archbold, Dodd, & Dibble, 2000; see reviews by Kotkamp-Mothes,
Slawinsky, Hindermann, & Strauss, 2005; Northouse, 2005). Family caregivers
assist cancer patients in dealing with the diseases physical and psychosocial
consequences, in addition to addressing any treatment-related needs. Their
care can encompass emotional support, financial aid, and the provision of
services ranging from instrumental aid and assistance with personal care,
to health care tasks and mediation with formal care providers (Raveis et al.,
133
1998). With public policies and practice models shifting the focus of care to
outpatient settings and the community, there is widespread recognition of
the critical disease management and care provision tasks families perform.
This awareness has led policy makers and the health and social service
professions to acknowledge that family caregivers must be recognized as
partners in care (Reinhard, Brooks-Danso, Kelly, & Mason, 2008, p. 4)
and need to be supported in their care responsibilities (Given, Given, &
Kozachik, 2001; Rolland, 2005). Indeed, in 2008 the State of the Science
Symposium: Professional Partners Supporting Family Caregivers issued a
primary recommendation to develop and promote a patient- and familycentered service paradigm (Kelly et al., 2008, p. 9).
Family-centered care is vital to maintaining family functioning and
enabling families to sustain their involvement in disease management. Not
only can a diagnosis of cancer significantly affect the family (Pitceathly &
Maguire, 2003; Raveis & Pretter, 2005b), but a compelling body of evidence
has established that family caregiving imposes burdens and strains that may
further compromise family functioning (see review by Kim & Given, 2008).
The demands of caregiving compete with the day-to-day role responsibilities
of the family caregivers own life, particularly when care provision is
long-lasting or intense, as can occur with diseases such as cancer. Although
informal caregiving takes place within a family context, it can affect adversely
on the caregivers everyday life, impose strains on the broader family system,
challenge the caregiver, who has to balance the needs of the care recipient
with those of other family members, and necessitate major lifestyle changes
(B. A. Given et al., 2001; Kotkamp-Mothes et al., 2005). Studies have
documented a variety of emotional sequelae of caregiving for the familial
cancer caregiver, including increased levels of depression, anxiety, helplessness, hopelessness, emotional exhaustion, low morale, distress, feelings of
isolation, guilt, and anger (B. A. Given et al., 2001; C. W. Given et al.,
1993; Haley, LaMonde, Han, Burton, & Schonwetter, 2003; Kotkamp-Mothes
et al., 2005; Pitceathly & Maguire, 2003; Raveis et al., 1998).
Family members who are at increased risk for cancer may experience
additional stress caring for their relative with cancer. As caregivers, they
are afforded firsthand exposure to their relatives cancer experience.
Although this can serve to normalize or demystify the cancer experience
for the caregiver, the opportunity to witness their relatives treatment and disease difficulties may intensify their own fears and dread of cancer (Raveis &
Pretter, 2005b). Any anxiety and concern these caregivers may be experiencing about the risk of cancer for themselves or other family members can be
compounded by the distress and strain engendered by their care provision.
These familial caregivers are further challenged in that they must
simultaneously deal with their anxieties and concerns about their relatives
prognosis while integrating their reactions to their own risk status and the
uncertainty of their future (Raveis & Pretter, 2005a,b).
134
V. H. Raveis et al.
METHOD
Data on a subsample of older caregiving mothers were drawn from an investigation of family caregivers to breast cancer survivors. In-depth focused
interviews (Merton, Fiske, & Kendall, 1990) were used to obtain dense
description from the family caregivers about their cancer experience and provision of support. The protocol for the study was reviewed and approved by
an Institutional Review Board.
135
contacted, via letter and follow-up phone call, to discuss study participation.
Only those patientcaregiver dyads in which both members were willing to
participate were accrued.
Qualitative Analysis
The audio-taped caregiver interviews were transcribed verbatim into
computer text files and subjected to content=thematic analysis (Miles &
Huberman, 1994; Polkinghorne, 1989). This allowed for the systematic
identification of topics of discourse (themes) present in the caregivers narratives and the specification of relationships among these themes and=or with
contextual factors (Atkinson, 1998; Polkinghorne, 1989).
An iterative process of analysis was followed in which the investigative
team read, reread, and discussed a randomly selected subset of the interview
transcripts to develop an initial set of codes that reflected a provisional conception of the factors likely to be of theoretical importance in understanding
the family caregivers cancer experiences. These initial codes emerged from
the caregivers narrative accounts and were further informed by prior
136
V. H. Raveis et al.
research, clinical experience with patients, and their familial caregivers and
the extant literature. This coding scheme underwent further revision and
expansion as additional interview transcripts were read and coded. Through
this iterative process a set of core codes representing the phenomena of
central interest was developed. For each core code, subsequently one or
more secondary codes were established that represented either more specific or restricted aspects of the phenomena. These secondary codes served
to contextualize the phenomena and suggest underlying personal meanings.
Ultimately, the investigative team developed shared definitions of the core
and secondary cores and a common set of criteria by which to identify
and code them. This constituted the coding manual.
Two members of the research team independently read and coded the
interview transcripts on an ongoing basis. Interrater agreement of the codes
assigned was assessed on a subsample of interviews and was found to be
excellent (i.e., exceeding 90% agreement). Isolated coding discrepancies
were resolved through joint discussion and verification of the text with other
interviews having the same code. As the data gathering proceeded, the coding scheme (and manual) continued to be refined and expanded upon to
reflect and incorporate emerging insights from the focused interviews. Revisions to the coding scheme were also applied to interviews that were coded
earlier. Pertinent coded material was retrieved, stored in separate text files,
and subjected to content analysis. NVivo, a software package for the analysis
of qualitative data, was used to facilitate coding, text searches, and retrieval
(Richards, 1999).
Participant Characteristics
The current analysis is focused on the subsample of older caregiving
mothers to adult daughters with breast cancer (N 13). Caregiving
mothers ranged in age from 56 to 78, with a mean age of 68 years. About
two fifths (38%) were employed at the time of the interview. More than
one half (54%) were currently married, 38% were divorced or widowed,
and 8% were single or living with a partner. Sixty-nine percent of
the caregiving mothers self-identified as White, non-Hispanic; 23% as
Hispanic; and 8% as Black, non-Hispanic. Their ill daughters were
between age 34 and 56 years, with a mean age of 44. More than one half
(54%) of the daughters were employed. Thirty-eight percent were married, 31% were widowed, divorced, or separated, and 31% were single
and=or living with a partner. Eight-five percent of the ill daughters had
children; most (76%) had two or more children. About one fourth
(23%) of the ill daughters shared a household with their caregiving
mothers. Forty-six percent had been diagnosed with local disease, 46%
with regional, and 8% had metastatic breast cancer. Eight-five percent
had been diagnosed with breast cancer between 6 and 12 months ago.
137
RESULTS
In-depth focused interviews enabled each caregiving mother to fully
articulate her reactions to her adult daughters cancer diagnosis and the
meaning and implications of the cancer experience on their family life.
Analysis of the mothers narratives documents that the occurrence of
cancer was an event of significant importance to family functioning.
The salient issues that emerged from the mothers interviews focus on
three broad categories relevant to family-centered care: (1) family members emotional responses to the illness, (2) family functioning during
the illness, and (3) hereditary risk.
138
V. H. Raveis et al.
The mothers accounts of their response when they learned of their daughters cancer diagnosis and processed the implications documented that cancer evoked an instinctual reaction in them that raised fears and worries about
their daughters survival. I just felt like the world was coming to an end, for,
for my world was coming to an end, and I just, just couldnt accept the fact
that my daughter might come to a premature death.
Although the initial concerns mothers held about their daughters health
generally diminished over time, some mothers remained troubled and uncertain about the ultimate outcome. But still, within me, it bothers me, because
I dont know if shes going to overcome this. I just dont know. Mothers
were challenged by uncertainty over the efficacy of their daughters treatment for her long-term survival. You wonder if the treatment is going to
be successful. You wonder if the treatment is going to be the right treatment.
Another mothers comments illustrate the enduring nature of these concerns
and worries for the family,
I dont think anything is going to make me feel perfectly secure. Its
impossible. Until someone says: Whoopee, we have found a cure and
no one ever again will die from cancer! Until somebody does that, I
dont think any of us can feel reassured. I think well always have doubts.
Apprehension over the possible pain and suffering they envisioned their
daughter would endure further contributed to the distress the mothers were
experiencing. These concerns are evident in the following mothers reflection
on her thoughts when she learned that her daughter had breast cancer. I
didnt think about death. What I thought about was what she would have
to go through . . . I said to myself: This is going to be a tough road to hoe.
The mothers accumulated life experiences and long-held beliefs regarding cancer and its probable consequences contributed to their fears and
worries about their daughters well-being. As one mother shared,
I know so many people who have not been able to recover completely,
that it lurks in the back of my mind, and its very hard for me to forget.
And thats why I say terror, and thats why I say fear, and thats why,
Im very, Im still frightened about it, even though my daughters outlook
is very optimistic and very upbeat.
139
asynchronous development in the family life cycle; and (4) caregiving affects
family relationships.
140
V. H. Raveis et al.
The caregiving mothers reports documented that their daughters illness was
a development that disrupted expectations they held about life and their
future. As one caregiving mother stated,
It has opened my eyes to a lot of things that could happen within a short
time . . . I expect to be the first one in the family to leave this earth, but
sometime it doesnt happen that way . . . . So you never know what in life,
even what can happen in a lifetime.
The mothers accounts also indicated that the timing of the onset of their
daughters illness shattered basic assumptions they held about the developmental stages of family life. As one caregiving mother explained, Its
like a curse, its a curse, because mothers are supposed to get sick before
children.
The mothers comments revealed that their reactions to their daughters
illness took into consideration not only their daughters stage of the life cycle,
but also their own. Some older mothers shared that, as elderly persons, they
felt they had already fully lived their lives. They explained further that they,
not their daughter, should have been the one who developed cancer. As one
mother explained, It should be happening to me, not to my child. Im the
one whos old, Im the one who could go, and my child is young and has
a life ahead of them. Similar sentiments are reflected in another mothers
statement. I hate to see her like that. Like I said, this is what I should be
going through, not her. Im 72 years old, you know, so what, if I have breast
cancer, you know? I mean, Ive already gone through my life.
Caregiving affects family relationships. As children grow into adulthood,
they generally become self-sufficient and self-reliant. The motherdaughter
141
Its a fine line, we march on. And you have to be very careful. Its one
thing when your kids are little and you can control things. Its a whole
other thing after they reach adulthood . . . . You have to be careful with
what you say and how you say it.
142
V. H. Raveis et al.
CULPABILITY
Part of the distress that mothers experienced about their daughters illness
related to their attribution of the probable cause of their daughters cancer.
One mother described these concerns and feelings of self-blame. I was
asking: Why was this happening to my child? And I couldnt understand
it, you know, couldnt understand why this was happening . . . where did it
come from, why did it happen to her . . . . Did I do something in my life that
caused my child to have this?
Some mothers explicitly verbalized their beliefs about their own
culpability.
One of the things you always do [as a parent, is think]: Is there something that I could have done? Is it something I could have done better? I
mean, well, even with the cancer; maybe I should have had a different
gene pool, my gene pools a mess.
143
DISCUSSION
With the continuing shift of cancer treatment and management to
community-based care, family members are centrally involved in their relatives care and need to be regarded as part of the care team. Family-centered
care recognizes that supporting family members in their critical support
functions is integral to the medical and psychosocial health of the patient.
However, understanding of the various ways in which the diagnosis,
treatment, and resolution of the disease affect family functioning is still
evolving. Little is known about the cancer experience in the extended
family. The current investigation documents that the occurrence of cancer
is an event of significant importance to the extended family. The caregiving mothers narrative accounts establish that they are a vulnerable group,
profoundly affected by their daughters health situation. The findings
substantiate the complexity of social connectedness in the family system
and the necessity when delivering family-centered care to incorporate
an understanding of the familys illness perceptions, the clinical course
of the disease, as well as consideration of the specific family developmental stages (Carter & McGoldrick, 1999) represented in the extended family
system.
The analysis suggests that older caregiving mothers have complicated
emotional reactions to their daughters illness. Cancer evoked an instinctual response in caregiving mothers, informed by their accumulated life
144
V. H. Raveis et al.
145
Limitations
It is important to recognize that this investigation focused on one type of
cancer, breast cancer, a cancer that has a fairly good prognosis for long-term
survival. The 5-year relative survival rate for all stages of breast cancer at
diagnosis is 89% (American Cancer Society, 2009). For women diagnosed
with localized disease, the 5-year relative survival rate is 98%. The majority
of the patients in this sample had localized disease.
The type of cancer treatments the patients in the sample received did
not generate long-term caregiving needs. The mothers reports of their care
provision described tasks that were not overly complex. The intensity and
duration of their care was more limited than in other types of cancer caregiving situations, such as in end-stage disease. One could consider the
caregiving situation represented in the current analysis as a best-case scenario. Nonetheless, as this investigation documents, a range of complex
psychosocial concerns were evident in the caregiver mothers narratives
and functioning in the extended family was affected. This suggests that even
in those situations when an illness event is not life threatening and caregiving
demands are lessened, the delivery of family-focused, supportive services
and programs would be beneficial.
Clinical Implications
Clinicians who are involved in counseling or supporting families need to be
aware of the complex combination of issues that older caregiving mothers
encounter. By focusing on the experience of the older caregiving mothers,
the current analysis documents the scope of concerns extended family members may be going through. These findings suggest that treatment strategies
that exclusively focus on the emotional responses to a relatives illness may
inadvertently omit consideration of the broad array of salient issues and concerns that are contributing to family functioning during illness. Counseling
and support programs need to incorporate attention to family dynamics and
the changes in interpersonal relationships imposed by care provision and
illness-related concerns. The analysis also indicates that consideration of
the needs and concerns of extended family members merits attention.
Understanding the beliefs about cancer held by family caregivers, their
perception of the seriousness of the disease, their expectation about the
illness and its probable disease course, as well as their sense of culpability
and perception of their role in the disease outcome would inform familycentered services. It is important to recognize that there is not necessarily
consensus within the family system on these beliefs and expectations, nor
are these issues routinely discussed. Providers of family-centered care should
attempt to acknowledge the perspectives of the multiple family members
who may be affected by and involved in the patients illness and treatment.
146
V. H. Raveis et al.
By understanding and addressing the needs of family caregivers, familycentered care may reduce the strains and stressors that are experienced
and enhance family functioning during illness, a consequence which will
also beneficially affect the patients medical and psychosocial well-being
(Hodges et al., 2005; Northhouse et al., 2001; Patterson & Garwick, 1994).
REFERENCES
American Cancer Society. (2009). Breast cancer facts and figures: 20092010.
Atlanta, GA: American Cancer Society.
Atkinson, R. (1998). The life story interview. Thousand Oaks, CA: Sage Publications,
Inc.
Baider, L., Cooper, C., & Kaplan De-Nour, A. (Eds.) (2000). Cancer and the family.
New York: Wiley.
Carter, B., & McGoldrick, M. (1999). The expanded family life cycle (3rd ed.). Boston:
Allyn & Bacon.
Collaborative Group on Hormonal Factors in Breast Cancer. (2001). Familial
breast cancer: Collaborative reanalysis of individual data from 32 epidemiological studies including 58,209 women with breast cancer and 101,986 women
without the disease. The Lancet, 358, 13891399.
Denzin, N., & Lincoln, Y. (1994). Handbook of qualitative research. Thousand Oaks,
CA: Sage.
Dorval, M., Guay, S., Mondor, M., Masse, B., Falardeau, M., Robidoux, A., et al.
(2005). Couples who get closer after breast cancer: Frequency and predictors
in a prospective investigation. Journal of Clinical Oncology, 23(15), 35883596.
Ferrario, S. R., Zotti, A. M., Massari, G., & Nuvolone, G. (2003). A comparative
assessment of psychological and psychosocial characteristics of cancer patients
and their caregivers. Psycho-Oncology, 12, 17.
Gilbar, O., & Ben-Zur, H. (2002). Cancer and the family caregiver. Springfield, IL:
Charles C. Thomas Pub.
Gilbar, O., & Rephaeli, R. (2000). The relationship between adult cancer patients
adjustment to the illness and that of their parents. Family, Systems, & Health,
18, 517.
Given, B. A., Given, C., & Kozachik, S. (2001). Family support in advanced cancer.
CA: A Cancer Journal for Clinicians, 51, 212231.
Given, C. W., Stommel, M., Given, B. A., Osuch, J., Kurtz, M. E., & Kurtz, J. C. (1993).
The influence of cancer patients symptoms and functional states on patients
depression and family caregivers reaction and depression. Health Psychology,
12, 277285.
Haley, W. E., LaMonde, L. A., Han, B., Burton, A. M., & Schonwetter, R. (2003).
Predictors of depression and life satisfaction among spousal caregivers in
hospice: Application of a stress process model. Journal of Palliative Medicine,
6(2), 215224.
Hodges, L. J., Humphris, G. M., & Macfarlane, G. (2005). A meta-analytic investigation of the relationship between the psychological distress of cancer patients
and their carers. Social Science & Medicine, 60(1), 112.
147
Kash, K. M., Holland, J. C., Halper, M. S., & Miller, D. G. (1992). Psychosocial distress
and surveillance behaviors of women with a family history of breast cancer.
Journal of the National Cancer Institute, 84, 2430.
Kelly, K., Reinhard, S. C., & Brooks-Danso, A. (2008). Executive summary:
Professional partners supporting family caregivers. American Journal of
Nursing, 108(9 Suppl.), 612.
Kim, Y., & Given, B. A. (2008). Quality of life of family caregivers of cancer survivors.
Cancer, 112(11, Suppl.), 25562568.
Kotkamp-Mothes, N., Slawinsky, D., Hindermann, S., & Strauss, B. (2005). Coping
and psychological well being in families of elderly cancer patients. Critical
Reviews in Oncology=Hematology, 55(3), 213229.
Lerman, C., Daly, M., Sands, C., Balshem, A., Lustbader, E., Heggan, T., et al. (1993).
Psychological stress interferes with mammography adherence among women at
risk for breast cancer. Journal of the National Cancer Institute, 85, 10741080.
Matthews, B. A., Baker, F., & Spillers, R. L. (2003). Family caregivers and indicators of
cancer-related distress. Psychology, Health, & Medicine, 8, 4556.
Merton, R. K., Fiske, M., & Kendall, P. (1990). The focused interview: A manual and
procedures. New York: The Free Press.
Metcalfe, K. A., Finch, A., Poll, A. Horsman, D., Kim-Sing, C., Scott, J., et al. (2009).
Breast cancer risks in women with a family history of breast or ovarian cancer
who have tested negative for a BRCA1 or BRCA2 mutation. British Journal of
Cancer, 100, 421425.
Miles, M. B., & Huberman, A. M. (1994). Qualitative data analysis: An expanded
sourcebook (2nd ed.). Thousand Oaks, CA: Sage.
Mitschke, D. B. (2008). Cancer in the family: Review of the psychosocial perspectives
of patients and family members. Journal of Family Social Work, 11(2), 166184.
Mosher, C. E., & Danoff-Burg, S. (2005). Psychosocial impact of parental cancer in
adulthood: A conceptual and empirical review. Clinical Psychology Review,
25(3), 365382.
Northouse, L. L. (2005). Helping families of patients with cancer. Oncology Nursing
Forum, 32(4), 743750.
Northouse, L. L., Mood, D., Templin, T., Mellon, S., & George, T. (2000). Couples
patterns of adjustment to colon cancer. Social Science and Medicine, 50(2),
271284.
Northouse, L., Templin, T., & Mood, D. (2001). Couples adjustment to breast disease
during the first year following diagnosis. Journal of Behavioral Medicine, 24(2),
115136.
Oktay, J. S. (2004). Breast cancer daughters: Overlooked issues. Psycho-Oncology,
13, S46.
Patterson, J. M., & Garwick, A. W. (1994). The impact of chronic illness on families: A
family systems perspective. Annals of Behavioral Medicine, 16(2), 131142.
Pitceathly, C., & Maguire, P. (2003). The psychological impact of cancer on patients
partners and other key relatives: A review. European Journal of Cancer, 39,
15171524.
Polkinghorne, D. E. (1989). Phenomenological research methods. In R. S. Valle &
S. Halling (Eds.), Existential-phenomenological perspectives in psychology:
Exploring the breadth of human experience (pp. 4160). New York: Plenum.
148
V. H. Raveis et al.
Ponto, J. A., & Barton, D. (2008). Husbands perspective of living with wives ovarian
cancer. Psycho-Oncology, 17(12), 12251231.
Raveis, V. H. (1999). Facilitating older spouses adjustment to widowhood: A
preventive intervention program. Social Work in Health Care, 29(4), 1332.
Raveis, V. H. (2007). The challenges and issues confronting family caregivers to
elderly cancer patients. In S. Carmel, C. A. Morse & F. M. Torres-Gil (Eds.),
Lessons on aging from three nations, Volume II: The art of caring for older
adults (pp. 8597). New York: Baywood Publishing.
Raveis, V. H., Karus, D. G., & Siegel, K. (1998). Correlates of depressive symptomatology among adult daughter caregivers to a parent with cancer. Cancer, 83(8),
16521663.
Raveis, V. H., & Pretter, S. (2005a). Challenges of living with breast cancer in the
family: Special issues confronting adult daughter caregivers [Era of Hope
2005 meeting for the Department of Defense (DOD) Breast Cancer Research
Program]. Retrieved August 9, 2005, from http://mrmcweb4.detrick.army.
mil/bcrp/era/abstracts2005/0010215_abs.pdf
Raveis, V. H., & Pretter, S. (2005b). Existential plight of adult daughters following
their mothers breast cancer diagnosis. Psycho-Oncology, 14, 4960.
Reinhard, S. C., Brooks-Danso, A., Kelly, K., & Mason, D. J. (2008). Editorial: How
are you doing? American Journal of Nursing, 108(9 Suppl.), 45.
Richards, L. (1999). Data alive! The thinking behind NVivo. Qualitative Health
Research, 9(3), 412428.
Rolland, J. S. (2005). Cancer and the family: An integrative model. Cancer, 104(11,
Suppl.), 25842595.
Schumacher, K. L., Stewart, B. J., Archbold, P. G., Dodd, M. J., & Dibble, S. L. (2000).
Family caregiving skill: Development of the concept. Research in Nursing and
Health, 23(3), 191203.
Toseland, R. W., Blanchard, C. G., & McCallion, P. (1995). A problem solving
intervention for caregivers of cancer patients. Social Science and Medicine, 4,
517528.
Wellisch, D. K., & Lindberg, N. M. (2004). Do the daughters and sisters of breast
cancer patients have cancer-related trauma or post-traumatic stress disorder?
Psychosomatics, 45, 716.