This study used a two-group, pretest post test, quasi experimental
design to examine the effectiveness of relaxation
with guided imagery. The study period was from
2011 to 2012. Patients were randomly assigned to the experimental
or the control group. Both groups received
chemotherapy self-care education, but the experimental
group also received training in relaxation with guided
imagery. Each patient in the experimental group received
1 h of relaxation with guided imagery training before
chemotherapy and a compact disc (CD) for performing
relaxation with guided imagery 20 minutes daily at
home for 7 days after chemotherapy. The patients in the
control group did not receive guided imagery. The hospital
anxiety and depression scale (HADS) and the symptom
distress scale (SDS) were administered to the patients in
both groups to collect data on symptoms of distress, depression,
and anxiety. We completed two questionnaires
by conducting face-to-face interviews with patients before
chemotherapy and within 10 days after chemotherapy.
Each questionnaire was completed in approximately
15 minutes.
MacKay Memorial Hospital Tamshui branch is a private
hospital that has 1549 beds. A total of 129 patients were
eligible among the 655 identified to have been treated in
the period of 2011 to 2012. Among the eligible patients, 28
deaths were recognized and 35 were inaccessible. Accordingly,
the population available for research was 66 women.
A convenience sample random sampling approach
was used to recruit participants from one medical center
(MacKay Memorial Hospital Tamshui Branch) in Taiwan.
All participants were breast cancer patients.
Patients who (a) were older than 20 years, (b) had the
ability to communicate in Chinese, (c) and received cyclophosphamide,
epirubcin, and 5-FU (CEF) chemotherapy
for the first time were eligible for inclusion. Power
analysis was used to detect the significant difference
in the anxiety scores (power at 0.80; alpha at 0.05) of
patients. In the study, the sample size was estimated by
a pilot study on 20 participants to test the mean and
standard deviation (SD) of the anxiety scores. In the
experimental and control groups, these anxiety scores
were 5.24 (± 2.10) and 4.89 (± 1.91), respectively. We calculated
that each group required 30 participants. We
randomly assigned 66 subjects to the experimental
group (n = 33) and the control group (n = 33). One of
the experimental participants who had not been discharged
was excluded.
Before the study was initiated, approval was obtained
from the ethics committee of MacKay memorial hospital
(ID 12MMHIS062), where the study was conducted. All
participants were informed about the aims of the study,
and they provided their informed consent. The participants
were informed that they could withdraw from the
study at any time and that all information that they provided
would be kept confidential.
Data were collected using the Chinese versions of the
HADS and SDS, which were modified from similar research
surveys (15-18). Demographic (e.g., age, education,
marital status, religion, and employment status) and
clinical information (e.g., operation, cancer stage, and
previous chemotherapy) were also collected. The HADS,
which was developed by Zigmond and Snaith, is used to
screen for depression and anxiety in cancer patients (19).
The English version of the HADS was translated to Chinese
by Leung and was used in the present study; its norm and
validation had been previously testified (20). This version
consists of seven anxiety items and seven depression
items that are rated using four grades: no problem to
very serious (0 - 3). The scale was adapted to each patient’s
narrative experience, and a higher score indicates higher
levels of anxiety and depression (21). Bjelland et al. (2002)
conducted a systematic review of many studies and identified
a cutoff point of 8/21 for anxiety or depression. The
Cronbach’s alpha of the HADS was 0.81 (21).
The SDS, which was developed by Lai et al. (22), is used
to measure the degree of patient discomfort during chemotherapy.
This scale comprises 23 items that are rated
using five grades: no problem to very serious (0 - 4). A
higher score indicates a higher number of distress symptoms.
The Cronbach’s alpha of the SDS (Chinese version)
was 0.89 - 0.91 (22). The Cronbach’s alpha of the SDS (the
study) was 0.82.