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Keywords: Occupational therapy, Cognitive behavioral therapy, Psycho-oncology, Cultural competency
This editorial is a critique of an article about the role of nursing in psycho-oncology in Japan . The research was accomplished by Mariko Kaneko, PhD, a Japanese Associate Professor of Nursing at the Graduate School of Nursing at Tokyo Women’s Medical University, who Published several articles about the role of nurses in treating Japanese patients with cancer [2-4]. In 2010, the Japanese health insurance system approved counseling of people with cancer as a billable service by Certified Nurse Specialists in Mental Health Nursing or in Cancer Nursing, thus initiating the need for research to address evidence-based practice to validate nursing outcomes .
There were a few concerns with the methodology reported in Dr. Kaneko’s article . First, the author neglected to provide the necessary data about the standardization for each of the widely used, self-report psychological questionnaires for Japanese people. It was discovered that the three questionnaires were adequately standardized, but readers should not have to check for them to discover the information [5-7]. Secondly, the demographic information of the convenience sample interview group was limited to age range, sex, and stage of cancer, and whether the patients Received date: inpatient or outpatient therapy. In a mixed-method study such as this, qualitative descriptions about participants undergoing interviews would be customarily reported in a very detailed table, to enable readers to gain a better picture about how their own patients with cancer might have similarities and differences to the study group. It is vital for readers to gather enough information about the sociocultural context in which the research was conducted, in order to learn more about the lived experience of cancer as it challenged people of Japan, in order to form an opinion as to whether and to what extent the author’s insights might be applicable and transferable to their own group and sociocultural context, since qualitative research cannot be generalized.
Especially when publishing in an international journal, it would be important to share details about the health beliefs and cultural attitudes of Japanese people towards death, dying, life after death, or the continuity between life and death. The author might consider that a description enlightening readers about Eastern thinking and enhancing a reader’s cultural-awareness was not the purpose of the article and would be considered a distraction from her specific aim. However, Eastern thinking has been determined to be fundamentally different than Western thinking on these issues . Since the author chose to publish her research findings in an open access article in English, many readers in the Western culture might have their own concerns about how to provide holistic culturally-competent care to people from a culture that is different than their own, keeping in mind that Japanese people live all over the world in other societies.
Cognitive Behavioral Therapy (CBT), pioneered in the U.S.A. by psychologist Donald Meichenbaum, represented an integration of the behavioral modification techniques of Edward Thorndike with the cognitive therapies of Aaron Beck and Albert Ellis [9,10]. CBT would see anxiety as a maladaptive emotion that represented a thinking disorder that has interfered with adjustment to cancer. Followers of CBT seek to alter the patient’s maladaptive thinking by changing behaviors. The counseling experience would guide the patient through a problembased, cognitive process to modify their actions. The question that remained unanswered by the article was whether CBT was executed in Japan by the Certified Nurse Specialists, as it is done in the USA. The topical issues reported in the conversations between interviewer and interviewee were helpful, covering categories of patient issues such as returning to home, returning to work, identifying solutions for medical treatment challenges, discussing concerns about family relationships, and using a problem-solving approach. These topics seemed similar to those that might also be discussed in Western cultures.
Due to medical advances in cancer treatment during this decade, cancer has emerged as a chronic disease rather than a terminal illness. Cancer can be controlled and sent into remission over time, even after several reoccurrences, to extend lives. Cancer has been likened to other chronic illnesses such as heart disease and diabetes . As people experience the treatment interventions to control the disease, support has been found to be essential for both the patient and their families .
Overall, Dr. Kaneko’s study achieved her aim. In this grant funded pilot study, outcomes were exploratory. Due to the small convenience sample using subjects as their own controls, no statistical analysis was performed. Changes in the group were reported using diagrams showing trends as mean scores before and after the intervention. To raise the level of future research, Dr. Kaneko should use quantitative methodology to report the statistical changes using the same three standardized self-report questionnaires with a much larger study group(s), comparing subjects with early cancer to subjects with advanced cancer. The author might consider expanding the mixedmethod to delve deeper into the cultural aspects of the lived experience of cancer among Japanese patients experiencing the CBT supportive interviews, which are qualitative in nature. By following a qualitative methodological design using audio-taped interviews, the researcher should transcribe transcripts to derive codes and identify themes for cohort group(s) that will increase the veracity and richness of her findings. In addition, a succinct description of exactly how the CBT supportive interviews were provided with examples, by the certified Japanese nurses, would increase clarity and enable duplication of the study format by other researchers. Eventually, a randomized control trial would perpetuate Dr. Kaneko’s continued funding in this important research area and support nursing evidence-based practice.
Evidence-based practice has been determined to be imperative for perpetuation of all health care professions today because reimbursement for intervention has been based on justification of productive outcomes. It is essential to understand the cultural background and context when working with people from a culture unlike one’s own. If Dr. Kaneko would continue targeting international journals, it would be especially relevant to explain to readers the similarities and differences of CBT and supportive interviews in Japan. For example, it would be helpful to discuss Japanese communication concepts such as the use of silence, gesture, body language, word stress and intonation in conversation; the concepts of time and acceptance of uncertainty; rules of conduct, self-control, toleration of crisis, resilience; and the strong connection and loyalty to family and the collectivist group for protection against adversity, which would describe cultural meanings for readers . Delving into this kind of detail would effectively substantiate thematic findings in a discussion section. In addition, to fully follow reporting standards for qualitative and quantitative methodology, the study could be reported in separate 5,000 word articles.
Japanese occupational therapists enable a person with chronic disease or terminal illness to develop the skills and coping mechanisms to continue to find meaning in life through occupation. Occupational therapists often modify the environment to facilitate his/her capacities to function in everyday activities as skills decline, for as long as possible [9,12]. Japanese occupational therapists working on psychooncological medical teams share similar concerns with nurses about psychological and behavioral adjustment of patients living with cancer.
Emotions seem to be universal when discussing how a person experiences the challenges of a life-threatening chronic disease, but the cultural context can be very different. It is essential for nurses to provide culturally- competent care wherever the Japanese patient lives, while considering their generational status in the new country.