Motivation for Healing in Cancer Patients: A Qualitative Study.

BACKGROUND: Studies have revealed that motivation plays a vital role in a person's ability to heal. The nature of motivation for healing in cancer patients is unknown. The aim of this study was to explore the meaning of motivation for healing in cancer patients.
MATERIALS AND METHODS: A qualitative research approach was used as the study design. Data were collected using individual semi-structured interviews and the themes were derived from the data using the inductive content analysis method. The patients consisted of 34 cancer patients, 4 family members, 1 psychologist, 1 oncologist, and 3 nurses. The participants were interviewed in the cancer clinics or chemotherapy wards.
RESULTS: Based on the results of the interviews, three main themes and seven categories were determined. The themes were identified as (i) the desire to survive, (ii) a spirit of optimism, and (iii) belongingness and responsibility.
CONCLUSIONS: The results of this study could be used by researchers to develop tools to measure motivation in cancer patients, and to design intervention mechanisms to enhance the patients' motivation in cancer care. Moreover, a better understanding of motivation can improve psychosocial support in oncology nursing. Copyright:

Introduction

Motivation is an essential factor in initiating treatment, bearing complications, and participating in rehabilitation programs.[12] Higher levels of motivation are linked to better compliance. Motivation is a key factor in the success of therapeutic interventions and it has a positive effect on the treatment process.[134] The definition of motivation and its determinants varies according to the type of disease,[1] and motivation can be influenced by the social and cultural background of various societies. For instance, in rehabilitation, motivation is considered a part of the patient's personality.[3] Some previous studies have found that social support is useful in shaping motivation. Some researchers have defined motivation as a spiritual or religious phenomenon,[5] and others have described it as wishes, needs, desires, and goals.[123]

In recent literature, patient motivation is still an ambiguous concept, especially in chronic diseases such as cancer. With the advancement of medicine, the relative survival of cancer patients is improving. For example, in breast cancer, the chance of survival 1, 10, and 15 years after diagnosis is 90, 82, and 75%, respectively.[6] Today, cancer treatments are generally provided on an outpatient basis. Although cancer patients and their families have acknowledged the benefits of this sort of treatment, they need to be actively involved in healthcare programs.[7] The longer duration of treatments in cancer patients is associated with a decrease in the Quality of Life (QOL), mental disorders such as depression, general anxiety and panic, fatigue, and sometimes suicide. The consequences of these issues are poor decision-making, poor adherence to treatment regimens, and treatment discontinuation.[8] The health status of patients who do not take physicians' instructions seriously worsens dramatically.[13] The conceptual evaluation and clear explanation of the motivation for healing in cancer patients is helpful in understanding their behaviors during the treatment process.[18]

It is necessary that we understand how cancer patients maintain and build up their motivation. Understanding the factors that increase the motivation for healing is critical for the development of interventions designed to enhance patient motivation and improve treatment outcomes.[12] The goal of holistic nursing care is to improve the patient's health over time, and the aim of caring for the cancer patients is not only to cure the disease, but also to reduce the physical symptoms, complications, pain, and grief, and improve the overall healing. This indicates that nurses need to understand the concept of motivation for healing in cancer patients in order to support them in achieving a better QOL, and take the necessary measures to promote their healing motivation.[9] The aim of the present study was to explore the meaning of motivation among patients with cancer using a qualitative approach.

Materials and Methods

This study was part of a PhD thesis entitled development and psychometric evaluation of motivation for healing questionnaire in cancer patients that was conducted from November 2019 to November 2020 in the Kashan University of Medical Sciences, Iran. Based on the study objectives, the inductive content analysis method was used. This method is generally utilized to describe a phenomenon when limited research/theories are available in that field. This method was selected to obtain new and rich data sets.[10]

The study participants were patients who had been diagnosed with cancer by a physician. The other inclusion criteria included a minimum of 18 years of age, awareness of the disease, currently undergoing treatment, willingness to share their experience, and an appropriate mental and physical condition to participate in the interview. A total of 34 cancer patients (14 men and 20 women), 4 family members of patients, 1 psychologist, 1 oncologist, and 3 nurses participated in the study. The patients as the key participants were selected based on diverse demographic characteristics such as age, sex, marital status, educational level, and type of cancer [Table 1]. The face-to-face interviews were held in a private and calm setting in a cancer clinic or chemotherapy ward. The interviews lasted between 20 and 45 min. Purposeful sampling was continued until data saturation. To achieve a better understanding of the concept from the point of view of the other participants besides the patients, four family members of the patients and five professionals from the treatment team were also invited to participate in the interviews. The modification of the sampling strategy was acceptable because different participants were needed for comparison through different contexts or to discredit/confirm themes in the data.[11]

Table 1

Demographic features of the participants

Age category (number of participants)	Patients: 20–29 (4), 30–39 (6), 40–49 (6), 50–59 (7), 60–69 (6), 70–79 (5)Nurse: 34–42 (3), oncologist (1): 48, psychologist (1): 38, family members (4): 20–50
Gender	Male (17), Female (26)
Type of cancer	Prostate cancer (1), bladder cancer (1), gastrointestinal (GI) cancer (10), breast (7), lung (2), bone (2) lymphoma (3), tongue (1), brain (1), ovarian (1),uterus (2), acute lymphoblastic leukemia (1), chronic lymphocytic leukemia (1), acute myeloid leukemia (1)
Marital status	Married (35), Divorced (2), Single (6)
Educational status	Pre-diploma (9), Diploma (12), BSc/BA (13), MSc/MA (4) Ph.D. (4), Higher than PhD (1)
Adjuvant therapy	Chemotherapy (18), Radiotherapy (10), Others (6)
Occupational status	Retired (7), Employee (15), Housewife (6), Unemployed (6) Other (9)
Surgery	30 cases
Time passed since cancer diagnosis	Less than 1 year (13), between 1 and 2 years (7), between 2 and 5 years (3), 5 to 10 years (11)

In-depth, semi-structured interviews were carried out and were started with a general question related to the research objective: “Please share with us how you made the decision to be treated after your illness was diagnosed? Please explain.” Then, more specific questions based on the patients' responses were asked to clarify ambiguities and to deepen the interviews. Some examples are “Did you change your mind regarding the treatment? Please give an example in this regard.” “Would you like to explain more?” “What do you mean by this?” The family members and treatment team were interviewed about the patients' motivation for healing and they were asked more questions based on their responses to clarify ambiguities and to deepen the interviews.

Data were analyzed using the inductive content analysis method of Elo and Kyngas. The organization phase involves the development of the categorization matrix, whereby all the data were reviewed for content and coded for correspondence to or exemplification of the identified categories. Then, the data were broken down into semantic units in the form of sentences and paragraphs related to the original meaning. Semantic units were also reviewed several times, and then, each semantic unit was given an appropriate code. The codes were classified according to the semantic and conceptual similarity, and the same meanings were categorized together, which formed subcategories. The subcategories were combined to create categories. Each category was named using content-characteristic words. In the reporting phase, the results were described.[10]

Data analysis was carried out using the MAXQDA software (version 10; VERBI Software GmbH, Berlin, Germany). To establish rigor, the following steps were taken to improve the credibility of the study. In the first step, the researchers maintained prolonged engagement with the study participants, which means that the researchers spent 7 months in the cancer clinic and chemotherapy ward. The second step was the use of data triangulation. Data were collected from various hospitals. The third was peer debriefing; two experienced experts in qualitative research confirmed the accuracy of the analysis. Finally, after data coding by the researchers, member checking was performed, meaning that some patients compared the findings with their experiences. They confirmed the codes and categories. To enhance dependability and conformability, the participants were selected from various genders and diverse socioeconomic classes. Moreover, for enhancing transferability, a sufficient and thick description of the data and methodology were provided.

Ethical considerations

This study was approved by the Ethics Committee of Kashan University of Medical Sciences (KAUMS.NUHEPM.REC.1398.053). All the participants had the right to voluntarily participate or withdraw from the study, and verbal and written informed consents were obtained from all the participants before the interviews were started and recorded.

Results

Results of the data analysis from the 43 conducted interviews included 1,480 Primary Codes [Table 2]. Following data collection and analysis, three main themes and seven categories were determined, which are explained in the following segments.

Table 2

Themes, categories, and subcategories based on the content analysis method of Elo and Kyngäs

Subcategories	Categories	Themes
Fear of adverse outcomes	Alertness and trying to preserve life	Desire to survive
Trying to adapt to and accept the illness
Fear of losing independence
Willingness to fight the disease
Understanding the value of life	Willingness to live
The desire for returning to one’s previous health status
The desire for returning to one’s previous normal life
The desire to achieve goals and wishes
The desire to use the personal fruitage during the life
Believing in a miracle	Trust in superior divine powers	Spirit of optimism
Considering the disease as a divine test
Hope for divine help
Inspiration from healing experiences	Positive thinking ability
Believing the treatment is temporal
Feeling lucky despite the illness
Positive self-talk and avoidance of negative thinking
Attention to the advancement of science	Trust in the treatment
A good prognosis of the disease
Trust in physicians and the treatment
Perceived family and friends’ kindness	Sense of belongingness	Belongingness and responsibility
Love for the family and friends
Support from family and friends
Feeling responsible for the damage to the family caused by the illness	Sense of responsibility
Feeling responsible for the future of the family

Desire to survive

One theme that emerged in this study was the desire to survive, which is a behavior that ensures the survival of an organism. Fear motivates the individual to withdraw from damaging situations and to protect a damaged body part while it heals. When one feels that his/her life is in danger, life becomes more valuable, and he/she strives to survive and starts to wonder about the things that should be done if the condition is relieved and he/she returns to a healthy life.

Alertness and trying to preserve life

One of the hallmarks of this concept is fear of adverse outcomes. Patients feel that they are at risk of a life-threatening condition, and they need to do something to relieve these dangerous health conditions; they sense alertness to preserve their lives. In the present research, fear led to the search for treatment; therefore, patients whose physician did not give them enough warning did not follow-up on their situation and might experience disease recurrence. The daughter of a patient said: “The doctor told her that if she refuses the treatment, she'll die in 6 months, and that she has to do this if she wants to live.” (Participant 35).

Many research participants noted that illness acceptance and coping could motivate them to preserve their lives. Moreover, patients seek healing to avoid pain, complications, other organ involvement, and loss of independence. In other words, patients tend to choose the difficult option in order to avoid more pain and death. The husband of a patient stated: “It is hard to hear her say: 'I won't die… I want to get well.' I hope she can make it.” (Participant 36).

An oncology nurse said: “. If the patient accepts his/her condition, he/she can easily tolerate the side effects of chemotherapy.” (Participant 37).

The patients tried to cope with the conditions of their illness and adjust to their lifestyles. They wanted to fight the disease. A patient said: “I want to fight the disease and not to give up trying.” (Participant 18).

Willingness to live

Willingness to live is defined as when a cancer patient suffering from the effects of the disease is afraid of losing his/her health and wants to become healthy again. Patients who are satisfied with their past life strive to live as they did in the past. In this regard, a patient said: “Since I got sick, my life and work have been messed up. I want to go back to my life, as soon as possible.” (Participant 16).

They wanted to achieve their unfulfilled dreams and enjoy their lives. They dreamed of achieving healing. A daughter of a patient said: “She hopes for the future, to get well and live” (Participant 4).

Regaining health becomes a goal for a patient who understands the value of life. They grasp every opportunity for treatment. The son of a patient said: “Ever since my father became sick, he has been telling me that I should take care of my health. Now, I understand the value of health, and that it is more important than anything else.” (Participant 40).

Spirit of optimism

The spirit of optimism was mentioned by the participants even in the most deplorable conditions of the disease. This theme includes

Trust in the superior divine powers

Most patients pay attention to the divine power as most of them believe that God will help them in times of suffering and grief. Patients who were medically unable to heal believed that only miracles from God may save them. These patients expressed that they would be healed with “God's will.” A patient stated: “I thought, maybe, it was a divine test. God wants to test me by making me ill.” (Participant 2).

Positive thinking ability

Positive thinking ability is an aspect of the “spirit of optimism” theme in the patients. Patients said that they were continually encouraging and telling themselves that they had to put aside” negative thoughts so they could seize the opportunity to improve. The oncologist said: “We have to make it seem like a simple disease to the patients, so that the patients can live with it, continue the treatments, maintain high morale, and do not let themselves go.” (Participant 38).

Some patients mentioned that they always tell themselves that the side effects of chemotherapy such as hair loss are not permanent. Social comparison was also a source of motivation that was mentioned repeatedly. A patient said: “Thank God I am better than most of the patients that are coming here.” (Participant 13).

Most patients said they would like to meet those who had the same condition and had been healed so that they can have a positive feeling about their condition. A psychologist said: “We provide group therapy for patients, and we invite individuals who have been successfully cured from cancer to talk to the patients. It is proof for them that this disease is curable, and if somebody has been cured, I also have a chance. This gives them motivation and courage to continue the treatments.” (Participant 39).

Trust in the treatment

Trust in the treatment is another aspect of the “spirit of optimism” theme, which is observed in those patients who have had a good relationship with their physician, and the treatment team has been successful in gaining their trust. Most patients who were told that their prognosis is good had positive expectations from the treatments that could lead to acceptable healing. Such information often strengthens the spirit of optimism. The oncologist said: “Some patients ask if they have a chance to survive. Then, they say that if they do not have chance, they prefer to do nothing.” (Participant 38).

Another aspect of this category was the patients' attention to the advancement of science. If a new effective medicine comes in the market, they will have a greater chance to survive. For example, a patient's daughter said: “It was hard to cure (cancer) in the past, but now a new medicine has been discovered and many cancer patients can be treated successfully.” (Participant 35).

Belongingness and responsibility

In this theme, the patients think beyond themselves and their illness and pay attention to others. It includes the two categories of sense of belongingness and sense of responsibility.

Sense of belongingness

Patients who had a good emotional connection with their family, felt the compassion of their family and friends and regarded death as a separation from them, strove to stay with them. Perceived family and friend support was another aspect of the subject, indicating that the patient's family played an essential role in their willingness to heal. In this regard, a nurse with 5 years of work experience stated: “There was a young woman who was suffering from uterine cancer. Her husband left her and she said: 'What is the use of my treatment?' And finally, she stopped coming to the treatment sessions.” (Participant 42).

Sense of responsibility

When patients realized how their family suffered and witnessed their struggles, to prevent them from suffering further, they complied with treatments. Patients were also worried about the way their relatives would live after their death, especially if there was a dependent person in the family who needed their support. “I told myself I have to stick to the treatment,” said a 40-year-old patient “My children depend on me. They have no one to take care of them.” (Participant 5).

Patients' focused less on themselves and more on other people's future. The nurse, who had 5 years of experience in the field of cancer, said: “We have a man who is 48 years old. He has been undergoing chemotherapy for 2 years. He is single and has to take care of his old father, he says that he must be cured and get back on his feet so that he can take care of his father.” (Participant 41).

Discussion

According to this study, the meaning of motivation for healing in cancer patients is a natural desire to survive, and the spirit of optimism, belongingness, and responsibilities that individuals acquire throughout their life strengthen this motivation. The use of theoretical frameworks can provide a definition of this construct.[1] Theories in the field of health promotion and healthcare define motivation as a choice to grow, evolve individually and socially, and have optimal performance.[2] The most prominent theory raised with regard to motivation is the self-determination theory. In this theory, the patient must feel competent and autonomous in executing tasks. Cancer is a potentially life-threatening condition, so the motivation for healing is influenced by various factors such as the prognosis and the lack of sufficient time for behavioral changes. These specific conditions limit the application of existing theoretical frameworks for motivation that see this concept as a general state. According to the present study results, the patients who struggle with cancer and its treatments try to survive and preserve their life. Growing and evolvement might not be the priority of these patients.[12]

The participants in this study experienced a desire to survive. Chao et al.[12] also reported the desire to survive as their core category. This is a strong and natural instinct that exists in all creatures. Cancer patients do everything in their power to increase their chance of survival. We found that, when confronted with this serious disease, the cancer patients become alert to the importance of their health and try to preserve their life. This alertness might not be prominent when the individuals feel well. According to the other studies, when the patients are faced with life-threatening conditions, they directly or indirectly try to survive.[413] Relatedly, a central component of protection motivation theory is that people must perceive the risks before they undertake positive health behaviors.[14] On the contrary, Rastad et al.[7] found that patients postponed their medical consultation because of the fear of being diagnosed with cancer. These are the normal biological reactions of fight or flight in facing a serious situation. These different reactions that seem ambiguous show the complexity of internal motivations and the confusion that patients experience when diagnosed with cancer. These contradictory feelings and conflicts must be considered when investigating internal motivations and adaptation reactions in persons that have experienced a cancer diagnosis.[15] In our study, pain and fear motivated the individuals to avoid damaging situations, and to seek healing. The motivated patients tried to fight the disease and tried to adapt to the illness and the treatments. This active sense of motivation helps them to feel secure and keeps the thoughts of death at a safe distance.[1315]

We found that the motivated patients were willing to live. A literature review showed that life goals improve cancer patients' psychological outcomes.[16] Taleghani et al.[17] found that the hope to live and return to normal life was the main motivation for the recovery. Abotalebidariasari et al.[4] reported that the participants' motivations were the love of life and returning to their previous physical health status. Relatedly, Shrira et al.[18] showed that many cancer patients maintained a high willingness to live to the end of their lives. This is the psychological expression of one's desire to continue living and encompasses instinctual and cognitive levels.[19]

The spirit of optimism is a concept of the motivation for healing that emerges from internal perceptions and views. In this state, trust in the superior divine powers and reliance on god stimulate optimism in cancer patients. This finding was similar to that of Taleghani et al.[17] who found that relying on god played an important role in the healing of patients with cancer. Relying on god motivated patients' engagement in self-care activities.[4] In our study, the patient's efforts to avoid negative thoughts about the disease, and meeting persons who have healed successfully gave them a positive mindset toward their abilities and empowered them; this was in line with the results of the study by Taleghani et al.[17] Trust in superior divine power and positive thinking have been categorized as hope in some studies,[182021] but in our study, they represented a sense of optimism. Optimism may be more suitable for expectancies about the future that might not be within one's control.[4] The present study showed that trust in the treatment could promote optimism in cancer patients. In the study by Grunfeld et al.,[22] the key motivation for accepting to undergo chemotherapy was the belief that this therapy is effective and its benefits are more than its complications. The patients in our study wanted information, especially about the effects of cancer treatments and their prognosis, and thought of their physician and the health system as reliable sources. The results of the review study by Hillen et al.[20] supported this finding. Another study found that patients who trusted their physicians were more likely to follow their advice and trust in the physician has been identified as a key factor in cancer care.[23] Some patients had unrealistic optimism caused and created by their relatives, and even the treatment staff. Unrealistic optimism is created when an individual underestimates the risk or the seriousness of a situation for himself or overestimates it for others. It can have important, and sometimes harmful, consequences for patients and decrease their compliance.[14] It seems that realistic optimism plays a great role in the patients' motivation for healing.

The patients who participated in this study stated that a sense of belonging and responsibility toward others motivate them for healing. They wanted to support their family members, and prevent them from feeling lachrymose. Consequently, they did their best to prevent the family members from experiencing distress. Henderson et al.[21] found that belongingness to the family members was a motivation to conquer the disease and struggle to recover as soon as possible. A sense of belonging is facilitated by the conveyance of respect and thoughtfulness. On the contrary, individuals without a feeling of belongingness have less motivation for healing.[14] The present study results also confirmed that belongingness and responsibility influence the patients' treatment decisions, as previously reported by Hillen et al.[20] Patients with cancer tolerated the difficulties because they wanted to protect their families.[12] Bergqvist and Strang also found that external factors such as wishes related to family members and friends can act as motivation for the patients.[13] Furthermore, a study showed that the feeling of being a burden to the family members can cause patients to wish to die sooner to prevent the suffering of others and even the treatment expenses. The feelings of being a burden to others are a moral challenge to the patients and their families and threaten their dignity, and patients may decide to hasten their death to stop being a burden to others.[24] Patients should be educated by nurses that feeling like a burden is not abnormal and, above all, it is not morally wrong. We should find ways to reduce the burden of cancer on family members by delivering cancer care in the social system. The results of this research, as is true of any qualitative study, cannot be generalized to the whole population of cancer patients. Therefore, more qualitative and quantitative studies should be designed to examine motivation in the cancer patients from different socioeconomic backgrounds.

Conclusion

The meaning of motivation for healing in cancer patients was a natural desire to survive. The patient is more alert to preserve his/her life and shows a willingness to live. Belongingness and responsibility toward others that are formed during an individual's life span cause the patients to go beyond self-interest and reinforce their external motives. Optimism about the future of treatments, thinking positively, confidence in treatments, and relying on a divine power create and strengthen healing motivations in cancer patients. This study provides a better understanding of the experiences of the cancer patients and can be helpful for the researchers who are interested in designing a tool for the measurement of motivation for healing in cancer patients and nurses who want to implement interventions to enhance the patients' motivation in cancer care. Understanding the concept of motivation for healing in cancer patients can help the nurses in providing psychosocial support to the patients and their families.

Financial support and sponsorship

Kashan University of Medical Sciences

Conflicts of interest

Nothing to declare.