W O M EN A N D C H I L D R E N

Breast cancer: evaluation of the Common Journey Breast Cancer

Support Group
Linda Zeigler BA, ASc, RN
Education Department, Penobscot Bay Medical Center, Rockport, ME, USA

Patricia A Smith BA, RN

Center for Health and Healing, Rockland, ME, USA

Jacqueline Fawcett PhD, RN, FAAN

Department of Nursing, College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA

Submitted for publication: 11 February 2003

Accepted for publication: 9 October 2003

Correspondence: Z E I G L E R Z , S M I T H P A & F A W C E T T J ( 2 0 0 4 ) Journal of Clinical Nursing 13,

Dr Jacqueline Fawcett 467–478
3506 Atlantic Highway Breast cancer: evaluation of the Common Journey Breast Cancer Support Group
PO Box 1156
Background. Most studies of cancer support groups have focused on the effects of
Waldoboro
groups established for research purposes, from the exclusive perspective of the group
ME 04572
USA participants.
Telephone: (207) 832-7398 Aim. This Roy Adaptation Model-based programme evaluation project focused on
E-mail: jacqueline.fawcett@umb.edu identifying the experiences of both participants in and facilitators of a community
hospital-sponsored breast cancer support group.
Design. Repeated measures survey methodology.
Methods. Ten women with breast cancer and two Registered Nurse group facili-
tators participated in the programme evaluation project. Qualitative data were
analysed using content analysis. Themes extracted from the data were categorized
according to the Roy Adaptation Model modes of adaptation. The group partici-
pants completed Initial and End of Year Interview Guides and Group Voices Forms;
the group facilitators completed the Facilitators’ Voices Form. The Institutional
Review Committee of a community hospital approved the programme evaluation
project.
Results. The Common Journey Breast Cancer Support Group is a community
hospital-sponsored cancer support group established to meet the informational,
emotional support, and social support needs of women with breast cancer who
reside in a rural state in the New England region of the USA. Responses of par-
ticipants and facilitators, which reflected all four of the Roy model modes of
adaptation, indicated that the combination of information and emotional and social
support was effective.
Conclusions. Nurses and other health professionals who establish community-
based cancer support groups should consider formal evaluation of the outcomes,
from the perspectives of both participants and facilitators, and should publish the
results. The results of this programme evaluation project are limited to one breast
cancer support group with a small number of female participants and two facili-
tators. Results cannot be generalized to support groups for other types of cancer or
to cancer support groups for men.

2004 Blackwell Publishing Ltd 467

L Zeigler et al.

Relevance to clinical practice. Nurses and other health professionals should con-
sider establishing and facilitating community hospital-sponsored support groups for
women with breast cancer, which have the potential to meet the women’s infor-
mational, emotional support, and social support needs.

Key words: breast cancer, evaluation research, Roy Adaptation Model, support
group

project that was designed to identify the experiences of both

Introduction
Psychosocial support, including provision of information, is
regarded as an important component of cancer treatment.
Indeed, ‘It is now widely accepted that patients benefit from
being well informed [and supported] throughout the cancer
journey’ (Fogg, 2000, p. 136). Information, emotional
support and social support from peers and health profession-
als are the major components of cancer support groups
(Samarel et al., 1997, 2002; Geiger et al., 2000). Some groups
also include an expressive therapy component (Goodwin
et al., 2001; Spiegel & Cordova, 2001).
The informational and support components of cancer
support groups typically are delivered via in-person meetings
(Spiegel et al., 1989; Samarel et al., 1997, 2002; Goodwin
et al., 2001) or internet discussion boards (Weinberg et al.,
1996; Shaw et al., 2000; Fogel et al., 2002). Information is
also delivered via printed materials, videotapes and telephone
calls, which may augment or replace group support (Samarel
et al., 1999, 2002; Hoskins et al., 2001). The documented
beneficial outcomes of cancer support group participation
range from simply feeling better through enhanced quality of
life to prolonged survival (Spiegel et al., 1989; Samarel et al.,
1997, 2002; Goodwin et al., 2001; Bui et al., 2002). No
adverse outcomes have been reported, although hypotheses of
the superiority of group support over such control treatments
as individualized telephone support have not always been
upheld (Samarel et al., 2002). Moreover, recent findings
(Goodwin et al., 2001) have called into question earlier
findings (Spiegel et al., 1989) of prolonged survival associated
with participation in supportive–expressive therapy groups.
To date, most reports of the components and outcomes of
cancer support groups have focused on groups that were
established for the purposes of research, conducted primarily
by nurses and other health care professionals affiliated with
academic institutions. Although anecdotal reports indicate
that many community agencies, including hospitals and
wellness centers, sponsor cancer support groups, little is
known about the experiences of individuals who participate
in those groups. Furthermore, no studies of support group
facilitators’ experiences were located. The purpose of this
article is to report the findings of a programme evaluation
the participants in and facilitators of a community hospital-
sponsored breast cancer support group. The evaluation
project encompassed two parts: part one focused on the
participants’ experiences, and part two focused on the
facilitators’ experiences.
Background
The Common Journey Breast Cancer Support Group (the
Group), which was established in 1999, was initially funded
by an award from the state affiliate of the Susan G. Komen
Breast Cancer Foundation. Conducted by two registered
nurses in collaboration with a community hospital in a rural
New England region of the USA, it is the first facilitated
breast cancer support group in the counties served by the
hospital. The Group has met a need, expressed by many
participants, for a place to listen, learn and share with others
in a supportive setting (Samarel et al., 1998; Rees & Bath,
2000; Lindrop & Cannon, 2001).
The Group, which meets on the first and third Mondays of
each month, from 6 to 8 p.m., offers a safe place for the
women to talk about anything they are experiencing or
feeling. Approximately 80% of group time is devoted to
emotional and social support and free discussion, and 20% of
the time is used for sharing information and providing
education. An important part of the Group’s process is the
healing, peaceful and comfortable environment offered by an
attractive, non-clinical setting. Each meeting begins with a
nourishing vegetarian meal prepared by the facilitators. The
meal offers time for easy conversation, which continues and
deepens as the Group moves into a more formal process circle,
where the participants talk about their concerns and feelings.
The nurses who lead the Group, work within the context of
a leadership practice model that reflects a feminist perspec-
tive. The leadership practice model, which is based on work
by Young-Eisendrath & Wiedemann (1987) and Price
(1998), was developed by those nurses in collaboration with
an organizational development consultant. Following each
Group meeting, the nurses confer to identify areas of concern
that arise during the meeting and to evaluate group dynamics.
They also meet regularly with the organizational develop-

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2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 467–478
Women and children
ment consultant, who supervises their work with respect to a
Feminist Collaborative Model of Professional Supervision
(Young-Eisendrath & Wiedemann, 1987; Price, 1998). This
guidance monitors the effectiveness of their leadership and of
the work done within the Group; it also acknowledges the
Group’s process.
The development of an ethic of care, which is based on
Gilligan’s (1982) work, extends both to the Group members
and to the leadership team. The ethic of care, as operationalized
in the Group, evolves from the central insight that the women
who participate in the Group and the nurse facilitators who
lead it are interdependent, and that the nurse facilitators in
their professional collaboration with the organizational devel-
opment consultant also are interdependent. This recognition of
relationship manifests as equal attention to and caring about
the evolving Group process, as well as its leadership. The
interpretation of the leadership experience and the Group
experience as the ethic of care creates a vision of fairness: that
everyone will be responded to and included. The agency of
authority is equal within the professional collaboration. This
format creates a relational model that is based on the inclusion
of equals. It provides a non-hierarchical vision of human
connection as opposed to a construction of supervision that is
based on oversight, judgement, and authority.
Part one
Methods
Design and sample
A survey design was used to evaluate the Group participants’
experiences. The sample consisted of the 10 women who
participated in the Group during 2001. The programme
evaluation project encompasses 23 meetings of the Group.
Five of the 10 women were continuing members of the
Group, having participated since 2000. The only criterion for
Group participation was a history of breast cancer. Group
participants were recruited via newspaper announcements
and referrals from physicians.
Instruments
The Common Journey Initial Interview Form, which was
developed by the two nurses who facilitated the Group and
the evaluation project consultant, consists of several semi-
structured demographic and cancer-related questions and 13
open-ended questions. The open-ended questions were writ-
ten to reflect the four adaptive modes of the Roy Adaptation
Model of Nursing (Roy & Andrews, 1999): the physiological
mode, self-concept mode, role function mode, and inter-
dependence mode. The physiological mode emphasizes

2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 467–478
Common Journey Breast Cancer Support Group evaluation
maintenance of the physiological integrity of the human
adaptive system and encompasses oxygenation, nutrition,
elimination, activity and rest, immune processes and the in-
tegument, the senses, fluids and electrolytes, neurological
function and endocrine function. The questions reflecting this
mode asked the woman how she was feeling physically and
what (if any) was her most distressing physical problem. The
self-concept mode focuses on psychic integrity and deals with
perception of the physical self in terms of body image and
body sensation, as well as perception of the personal self,
including self-consistency, self-ideal and the moral–ethical–
spiritual self. The questions reflecting this mode asked the
woman how she was feeling about her body and herself. The
role function mode deals with social integrity by focusing on
performance of activities associated with the various roles
one enacts throughout life. The questions reflecting this mode
asked the woman what activities she had been doing recently
and how satisfied she was about those activities. The inter-
dependence mode also deals with social integrity and
emphasizes behaviours underlying the development and
maintenance of satisfying affectional relationships with sig-
nificant others, as well as the provision and receipt of social
support. The questions reflecting this mode asked the woman
who the members of her support system were, how much
support she got from and was able to give to her support
system members, what resources were helpful, what she
wanted to get from the Group, what she needed and what she
would like to know more about.
The Common Journey End of Year Interview Form, also
developed by the two nurses who facilitated the Group and
the evaluation project consultant, consists of the same 13
open-ended questions that are part of the Common Journey
Initial Interview Form.
The Common Journey Group Voices Form asked each
woman to write a short narrative about her personal
experience with breast cancer and how the Group has helped
to meet some of her needs. The two nurses who facilitated the
Group developed this form.
Procedure
The evaluation project was approved by a hospital Institu-
tional Review Committee. Each woman signed a written
consent form and indicated whether she agreed to have her
responses to the instruments used for the evaluation project.
All Group participants were told that willingness to partici-
pate or not participate in the evaluation project would not
affect their nursing or medical care or their participation in
the Group.
The Common Journey Initial Interview Form was distri-
buted by the facilitators at the first meeting of the Group in
469
L Zeigler et al.
2001. The End of Year Interview Form was distributed by the
facilitators at the last meeting of the Group in 2001. The
Common Journey Group Voices Form was distributed by the
facilitators after 6 and 12 months of Group participation.
The women completed all forms in the privacy of their homes
and returned the forms to the facilitators in person or via
mail.
Data analysis
All data were analysed by the evaluation project consultant.
The facilitators did not participate in any aspect of the data
analysis. The evaluation project consultant did not attend any
of the meetings of the Group and had no other contact with
the women who participated in the Group. Furthermore, she
had no access to any specific identifying information about
the women.
The demographic and cancer-related questions that are
part of the Common Journey Initial Interview Form were
analysed using a simple tally of responses to each question.
Content analysis (Weber, 1990) was used to identify the
women’s responses to the open-ended questions on the
Common Journey Initial Interview Form and the Common
Journey End of Year Interview Form. The unit of analysis
was the word, phrase or sentence that expressed a
response. In keeping with the Roy Adaptation Model, the
responses to the open-ended questions were categorized as
adaptive or ineffective. Responses were judged as adaptive
when the woman’s goals related to participation in the
Group were achieved. Responses were considered ineffec-
tive when the woman’s goals were not achieved. Ineffective
responses do not, however, reflect inappropriate goals
or behaviours. Rather, those responses usually are appro-
priate for the situation but signal a need for nursing
intervention.
Content analysis (Weber, 1990) also was used to identify
themes in the women’s responses to the Common Journey
Group Voices Form. The unit of analysis was the word,
phrase or sentence that expressed a response. The themes
were examined to determine whether they reflected any of the
Roy Adaptation Model modes of adaptation (physiological,
self-concept, role function, interdependence).
Results
All 10 women agreed to use of their responses for the
evaluation project. All 10 women completed the Common
Journey Initial Interview Form. Two of the women did not,
however, provide responses to the open-ended questions. All
10 women also completed the Common Journey End of Year
Interview Form.
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2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 467–478
The women ranged from 42 to 76 years of age. Nine
(90%) women were White, non-Hispanic; the other woman
indicated that she was both White, non-Hispanic and
American Indian. One-half of the women were married and
one woman had a domestic partner. One woman was single,
one was widowed and two were divorced. Two women did
not have children; the remaining women’s children ranged
from school age to adult. The women’s education ranged
from 12 years (high school) to 20 years (graduate school).
One woman indicated that she was a homemaker, three were
employed full-time, two were employed part-time, two were
unemployed due to their illness and two were retired. Eight
women provided data about occupation; seven of those
women had professional occupations and one had a sales/
clerical occupation. Seven women provided data about
religion. Two women were Catholic and two were Protestant.
One woman listed her religion as ‘my own brand of Jewish’;
another, as ‘ecumenical’; and still another, as ‘spiritual
connection, no organized religion’.
Three-fifths (60%, n ¼ 6) of the women had received the
diagnosis of breast cancer in 2000 or 2001. Two other women
had received the diagnosis in 1998 and one each in 1995 and
1983. All but two of the 10 women were experiencing an
initial diagnosis of breast cancer. One of those two women
was found to have metastatic disease when initially diagnosed.
The other woman had a non-metastatic recurrence of breast
cancer 5 years after the initial diagnosis. All of the women had
had surgery, ranging from lumpectomy to bilateral mastec-
tomy. Four (40%) women had received radiation therapy,
seven (70%) had received chemotherapy and seven (70%) had
received hormonal (Tamoxifen, AstraZeneca Pharmaceuticals
LP, Wilmington, DE, USA) therapy. Five women indicated
that they used complementary or alternative therapies; three
used various nutritional supplements, including antioxidants
and herb teas and two used a combination of such therapies as
acupuncture, massage, Reiki, homeopathy, osteopathy, and
meditation. None of the women had menstrual periods at the
time of their participation in the Group.
The percentages of responses to several of the open-ended
questions on the Common Journey Initial Interview Form
and the Common Journey End of Year Interview Form are
given in Table 1. As can be seen in Table 1, the larger
percentage of responses to all but one question was classified
as adaptive. The one exception, which might be expected,
was the larger percentage of responses classified as ineffective
for the question about each woman’s most distressing
physical problem. Moreover, with the exception of the role
function and interdependence modes of adaptation, responses
to both the Initial Interview Form and the End of Year
Interview Form were classified as adaptive or ineffective. No
Women and children Common Journey Breast Cancer Support Group evaluation

Table 1 Responses to the Common Journey Initial Interview Form and the Common Journey End of Year Interview Form, in percentages

Initial interview End of Year Interview

Adaptive Ineffective Adaptive Ineffective

Roy Adaptation Model mode of adaptation and question responses (%) responses (%) responses (%) responses (%)

Physiological mode
How are you feeling physically? 50 50 60 40
What is your most distressing physical problem, if any? 12.5 87.5 10 90
Self-concept mode
How do you feel about your body? 62.5 37.5 60 40
How do you feel about yourself? 87.5 12.5 60 40
Role function mode
What activities have you been doing recently? 100 0 100 0
How satisfied are you about the activities you have been doing? 87.5 12.5 55.6 44.4
Interdependence mode
Who are the members of your support system? 100 0 100 0
How much support do you get from your support system? 100 0 100 0
How much support do you give to the members of your 100 0 100 0
support system?

responses that would have been classified as ineffective were
given to one of the role function mode questions and all three
interdependence mode questions.
Two questions addressed the physiological mode of adap-
tation. Analysis of responses to the Initial Interview Form
revealed that one-half of the responses to the first question,
‘How are you feeling physically?’, were classified as adaptive;
examples include ‘excellent’, ‘very good’, and ‘very well’. The
other one-half of the initial interview responses to that
question that were classified as ineffective; examples are ‘not
much energy’, ‘tired a lot’ and ‘depressed’. Analysis of the
End of Year Interview Form revealed that three-fifths of the
responses to the first question were adaptive; examples are
‘really well’, ‘very good’ and ‘good’. The remaining two-fifths
of the responses were classified as ineffective; examples
include ‘not very well’ and ‘poorly’.
In contrast, the vast majority (87.5%) of the initial
interview responses to the second physiological mode ques-
tion, ‘What is your most distressing physical problem, if
any?’, were classified as ineffective; examples are ‘sleep
poorly’, ‘tired much of the time’, ‘arthritis’, ‘infection’ and
‘weight gain’. Just one-eighth of the responses to that question
were classified as adaptive; an example is ‘none’. Similarly,
the vast majority (90%) of the end of year interview responses
to that question were classified as ineffective; examples
include ‘pain’, ‘tired a lot’, ‘short of breath’ and ‘abnormal
bleeding’. Only one-tenth of the responses were classified as
adaptive; once again, an example is ‘none’.
Another two questions addressed the self-concept mode of
adaptation. Almost two-thirds (62.5%) of the initial inter-
view responses to the first question, ‘How do you feel about
your body?’, were classified as adaptive; examples are ‘like
my body’, ‘fine’ and ‘good’. Slightly more than one-third
(37.5%) of the initial interview responses to that question
were classified as ineffective; examples include ‘embarrassed’
and ‘dissatisfied’. Three-fifths of the end of year interview
responses to the first self-concept mode question were
classified as adaptive; examples include ‘happy’, ‘comfort-
able’ and ‘good’. The other two-fifths of the responses were
classified as ineffective; an example is ‘not what I would like
it to be’.
Many (87.5%) of the initial interview responses to the
second self-concept mode question, ‘How do you feel about
yourself?’, were classified as adaptive; examples are ‘great’
and ‘very good’. A few (12.5%) responses were classified as
ineffective; an example is ‘dissatisfied’. At the end of the year,
the pattern of more adaptive than ineffective responses
continued, although the difference was not as great. Three-
fifths of the responses were adaptive, including ‘fine’, ‘pretty
good’ and ‘like myself’. Two-fifths of the responses were
ineffective, such as ‘low esteem due to finances’, ‘discouraged’
and ‘useless’.
Still another two questions addressed the role function
mode of adaptation. All of the initial and end of year
interview responses to the first question, ‘What activities have
you been doing recently?’ were classified as adaptive;
examples are ‘walking’, ‘cooking’, ‘reading’, ‘writing’, ‘gar-
dening’ and ‘working’. The vast majority (87.5%) of the
initial interview responses to the second question, ‘How
satisfied are you about the activities you have been doing?’,
were classified as adaptive; examples are: ‘very satisfied’ and
‘I like my life’. Just one-eighth of the responses were

2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 467–478 471
L Zeigler et al.
ineffective; an example is ‘wish I could do more’. The end of
the year interview responses to that question were more
evenly distributed. Slightly more than one-half (55.6%) of the
responses were adaptive, such as ‘just great’, ‘content’ and
‘OK’. Slightly less than one-half (44.4%) of the responses
were ineffective, including ‘very unsatisfied’ and ‘want more
physical activity’.
Three questions addressed the interdependence mode of
adaptation. All initial and end of year interview responses to
all three questions were classified as adaptive. Examples of
responses to the first question, ‘Who are the members of your
support system?’, are ‘family members’, ‘friends’, ‘co-work-
ers’, ‘church’, ‘support group’ and ‘pet’. Examples of
responses to the second question, ‘How much support do
you get from your support system?’, include ‘a lot’, ‘all I need’
and ‘always there for me’. Examples of responses to the third
question, ‘How much support do you give to members of
your support system?’, are ‘I try to help them all’, ‘I give back
to others’ and ‘I give as much as I get’.
Comparison of the women’s responses to selected ques-
tions from the initial and end of year interview forms revealed
considerable consistency in classification of responses, espe-
cially the responses to self-concept, role function, and
interdependence mode questions (Table 2). The classification
of some women’s responses did, however, change from
ineffective to adaptive, and the classification of still other
women’s responses changed from adaptive to ineffective.
Within the physiological mode, an example of a change in
response to the question, ‘How are you feeling physically?’,
from ineffective to adaptive is from ‘perhaps not quite as
energetic as normal’ to ‘good’. Within the self-concept mode,
an example of a change in response to the question, ‘How do
you feel about your body?’, from ineffective to adaptive is
from ‘I’m embarrassed’ to ‘I feel self-conscious but at my age,
it’s not a problem’. Within the role function mode, an
Table 2 Changes in responses to selected Common Journey Initial Interview Form and the Common Journey End of Year Interview Form
Questions
Roy Adaptation Model mode of adaptation and question
Physiological mode
How are you feeling physically? (n ¼ 8)
Self-concept mode
How do you feel about your body? (n ¼ 8)
How do you feel about yourself? (n ¼ 8)
Role function mode
How satisfied are you about the activities you have been doing? (n ¼ 7)
Interdependence mode
How much support do you get from your support system? (n ¼ 7)
How much support do you give to the members of your support system? (n ¼ 7)
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2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 467–478
example of a change in response to the question, ‘How
satisfied are you about the activities you have been doing?’,
from ineffective to adaptive is from ‘I wish I could do more
decorating’ to ‘Sometimes it’s pretty routine’. No changes
were found in the women’s responses to interdependence
mode questions.
Four (40%) of the 10 women’s responses to questions
reflected changes from adaptive to ineffective responses.
Those changes were noted in responses to physiological, self-
concept and role function mode questions; no changes were
found in the women’s responses to interdependence mode
questions. The responses from one of those women reflected
changes in both the physiological and self-concept modes.
That woman’s response to the physiological mode question
changed from ‘pretty good’ to ‘I am very tired very often’.
Within the self-concept mode, the change in the woman’s
response indicated that she felt that she had aged during the
year. That woman received neither radiation therapy nor
chemotherapy but was taking Tamoxifen.
Responses from another women that changed from adap-
tive to ineffective were in both the role function and self-
concept modes. She reported that over the year she was not
able to work, which began to have a negative impact on her
financial situation and her feelings about herself. Her
response to the role function mode question changed from
‘I’m liking the strength training’ to ‘I have been frustrated and
anxious about paying work’. Her response to the self-concept
mode question regarding feelings about self changed from ‘I
feel good about how I’ve dealt with the cancer and about
what I’ve learned from it’ to ‘I have been feeling low esteem
as my financial situation has worsened’. The woman did not
give a reason why she was unable to work. She received
radiation therapy and was taking Tamoxifen.
Still another woman provided responses that reflected
changes in both the physiological and role function modes.
No change Change to adaptive Change to ineffective
(%) response (%) response (%)
37.5 25 37.5
87.5 12.5 0
75 0 25
42.8 28.6 28.6
100 0 0
100 0 0
Women and children
She reported feeling increasingly tired and depressed, with a
lower level of energy as time when on. That woman had
received radiation therapy and chemotherapy approximately
4 years prior to her participation in the Group, and had been
taking Tamoxifen for approximately 1 year.
The fourth woman gave responses that reflected changes in
just the physiological mode. She reported a decrease in
physical health during the year, due primarily to an infection
that continued despite treatment. She was treated with both
radiation therapy and chemotherapy.
Results of the analysis of the other open-ended questions
on the Common Journey Initial Interview Form and the
Common Journey End of Year Interview Form, all of which
reflect the Roy Adaptation Model interdependence mode, are
summarized in Table 3. Initially, the women reported that a
wide array of resources was helpful. By the end of the year,
fewer resources were reported as helpful. Comparison of the
initial and end of year interview responses regarding what the
women wanted to get out of the Group and what they did gain
from their participation indicated that the women’s expecta-
tions for information and support had been met. Comparison
of what the women stated they needed initially and at the end
of the year revealed some consistency in somewhat existential
responses, such as needs for support and encouragement to
carry on, along with a tendency toward more specific needs at
the end of the year, such as help with medical bills.
Comparison of what the women would like to know more
about initially and at the end of the year revealed a longer and
more specific list at the end of the year.
The Common Journey Group Voices Form was completed
by eight of the 10 women 6 months after the Group began
and by all 10 women at the end of the year. The results of the
content analysis of the women’s responses, with examples,
are summarized in Table 4. The themes clearly reflected the
four Roy Adaptation Model modes of adaptation. The
themes, food and physical feelings, reflect the physiological
mode. The theme, emotional feelings, reflects the self-concept
mode. The role function mode is reflected in three themes –
competence, self-advocacy, and health-related activities.
Three other themes – information, support, and sharing –
reflect the interdependence mode.
Part two
Methods
Design and sample
A survey design was used to evaluate the Group facilitators’
experiences. The sample consisted of the two registered
nurses who facilitate the Group.

2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 467–478
Common Journey Breast Cancer Support Group evaluation
Instrument
The Common Journey Facilitators’ Voices Form asked each
facilitator to write a short narrative about her personal
experience as a facilitator of the Group, including her experi-
ences using the Feminist Collaborative Model of Professional
Supervision. The two nurses who facilitated the Group devel-
oped this form. This instrument development strategy allowed
the facilitators to identify what they thought was important.
Procedure
The Common Journey Facilitators’ Voices Form was to have
been completed by the two registered nurses who facilitate
the Group 6 months after the first meeting of the Group in
2001 and again after 12 months of Group meetings that year.
Informed consent was implied by the completion of the
Common Journey Facilitators’ Voices Form.
Data analysis
All data analysis was done by the evaluation project con-
sultant. The facilitators did not participate in the analysis of
the data they provided. Content analysis (Weber, 1990) was
used to identify themes in the Group facilitators’ responses to
the Common Journey Facilitators’ Voices Form. The unit of
analysis was the word, phrase or sentence that expressed a
response. The themes were examined to determine whether
they reflected any of the Roy Adaptation Model modes of
adaptation (physiological, self-concept, role function, inter-
dependence). The interpretation of the facilitators’ data was
aided by review of the notes the evaluation project consultant
took as she discussed the Group process with the facilitators.
Results
One of the two Group facilitators completed the Common
Journey Facilitators’ Voices Form 6 months after the first
Group meeting in 2001; both facilitators completed the form
12 months after the first Group meeting in 2001. The results
are summarized and examples are given for each theme in
Table 5. The themes reflected all four of the Roy Adaptation
Model modes of adaptation. The physiological mode is
reflected in the theme, food. The theme, emotional feelings,
reflects the self-concept mode. Two themes, group facilitation
skills and role model, reflect the role function mode. The
interdependence mode is reflected in the theme, group
effectiveness.
Discussion
The results of this evaluation project highlight the beneficial
effects of the Group for both the women who participated in
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L Zeigler et al.

Table 3 Results of Analysis of Common Journey Initial Interview Form and the Common Journey End of Year Interview Form questions about
resources, expectations, and needs

Initial Interview Form questions and examples of responses (N ¼ 8)

What resources are helpful to you?
Friends
Support system
Cancer support group
Doctor’s office
Reiki
Acupuncture
Yoga
MAMM magazine
Books
Media
Computer
Sailing trip
What do you want to get out of the Group?
‘More understanding about physical and emotional effects of cancer treatment and repercussions of dealing with this disease.’
‘Sharing of information, support–give and receive.’
‘Insight into other women and how they deal with their lives…[to] use in my own life.’
What do you need?
‘A place to check in with other people who understand just what it’s like, and who can share with me their feelings and what they are learning.’
‘To live each day to the fullest.’
‘Someone to take care of me, because self-care takes all my energy–none left for life. [If] I do life, my self-care suffers.’
‘Support, connections with people I care about, exchange of ideas, thoughts.’
‘More fun in my life.’
What would you like to know more about?
‘Where I go from here.’
The Canadian drug programme
New treatments
End of Year Interview Form Questions and Examples of Responses (N ¼ 10)
What resources have been helpful to you?
Common Journey Breast Cancer Support Group
Internet
Networking
Church
Did you get what you wanted from participation in the Group?
‘Yes, the Group is wonderful therapy…I’ve learned a lot and have been helped by it.’
‘Yes, information and friendship; we have a special bond.’
‘Yes, it makes me feel uplifted and more ‘normal’.
‘Yes, I needed support early on, and it was there.’
‘Yes, support, connection, information, and healing energy.’
‘Yes, I am supported in expressing my feelings, and educational questions are answered.’
What do you need now?
‘Just more of the same…Each meeting I feel I’ve gained some insight on my problems and also on others in the Group.’
‘Some help if possible with my medical bills.’
‘Continued support in my search to deal with my body’s reaction to Tamoxifen.’
‘To be able to continue seeing my Group friends.’
‘To get well.’
‘Encouragement to carry on.’
What would you like to know more about now?
New drug for hormonal treatment
Long-term effects of Tamoxifen
New facts
Tumor marker blood tests
Financial resources
Use of herbs in breast cancer

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2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 467–478
Women and children Common Journey Breast Cancer Support Group evaluation

Table 4 Results of analysis of the Common

Roy Adaptation Model mode Examples: Sixth month Examples: End of year
Journey Group Voices Form
of adaptation Theme responses responses

Physiological mode
Food
Physical feelings
Self-concept mode
Emotional feelings
Role function mode
Competence
Self-advocacy
Health-related activities
Interdependence mode
Information
Support
Sharing
Nurturing meals Meals
Dietary advice
Healthy, delicious meals
Physical comfort
Feel really good Feel lucky
Feel happy to be alive Feel happy
Feel fine about my body
Feel uplifted
Feel strong and healthy Can handle what happens
Can advocate for myself within Can advocate for self
the medical system
Eat better Do activities to help myself
feel healthier
Important information Helpful information
Concrete information
Referrals
Practical suggestions
Emotional support Caring, competent leaders
Social support Not alone
Sense of community Special bond
Listen to each other Unconditional love
Give and receive support
Share experiences, concerns, fears Mutual sharing
Group voices heard
Talk frankly

and the nurses who facilitated the Group. A special feature of
this evaluation project was the inclusion of the facilitators’
experiences. The results revealed that the nourishing meal,
concrete information, emotional and social support, and a
place to share experiences, concerns and fears were the most
outstanding features of the Group. Beginning each Group
meeting with a healthy, delicious meal prepared by the
facilitators was an effective and nurturing strategy that
fostered feelings of comfort and relaxation that, in turn,
eased movement of the Group participants to the more
formal support and educational aspects of the meeting. The
preparation and serving of the meals by the facilitators may
symbolize a nurturing and caring concern that might not have
been evident if the meals had been catered or if each woman
had contributed to ‘pot luck’ suppers.
The women’s responses indicated that the planned combi-
nation of information and support was an effective way to
meet their cognitive and affective needs. The women valued
the accurate information they received from the Group
facilitators. They also valued the support they received from
the facilitators and other Group participants, as well as being
able to give support to their fellow participants. The
facilitators’ specific needs were met through their dialogue
with each other following each Group meeting, and the
supervision provided by the organizational development
consultant.
The feminist perspective undergirding the leadership prac-
tice model used by the facilitators fostered an egalitarian,
non-hierarchical Group environment. Each person who
participated in the Group was equal. The facilitators, as well
as any women who were symptom-free or women who had
endured prolonged treatment, were not regarded as ‘better’
than the other women in the Group. Moreover, no blame or
praise was accorded to anyone for attending or not attending
every meeting of the Group, nor was there any expectation of
certain behaviours by Group participants. In other words,
there were no ‘rules’ of membership. All participants were
engaged in a ‘common journey’ of careful listening to each
other and sharing knowledge and experiences.
A review of the literature revealed that the leadership
practice model used by the facilitators of the Group includes
elements that are similar to the self-transcendence breast

2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 467–478 475
L Zeigler et al.

Table 5 Results of analysis of the Common

Roy Adaptation Model Examples: Sixth Examples: End of year
Journey Facilitators’ Voices Form
mode of adaptation Theme month responses responses

Physiological mode
Food Fine meals Food
Self-concept mode
Emotional feelings Grateful Grateful
Humble Honored
Feel good
Pride
Delight
Role function mode
Group facilitation skills Communication skills Reflection
Listening skills Personal and professional
Observation skills growth and development
Nursing experience
Personal experience
Role model Trust
Advocacy
Leadership
Interdependence mode
Group effectiveness Mutual support Sensitivity to each other
Sharing Nurturing
Listening Kindness
Mutual respect Unconditional acceptance
Sensitivity to the individual Friendship
Information Information
Facilitator team Facilitator team personal styles
Professional supervision Professional supervision

cancer support group model described by Coward (1998) and
the nurse coaching model for women with breast cancer
described by Lewis & Zahlis (1997). Yet neither of those
models addresses power relationships between nurses or
other health care professionals and women with breast
cancer. The inclusion of the feminist perspective in the
leadership practice model directly addresses the issue of
power by promulgating an egalitarian environment for the
Group. More specifically, the other models emphasize the
expertise of the nurse as group leader or coach, whereas the
leadership practice model emphasizes the ‘common journey’
experienced by the women and the facilitators.
The Group embraced women with breast cancer, regard-
less of stage of disease. Although conventional wisdom might
guide a separation of women with early stage disease from
those with metastatic disease or those with a recurrence of
breast cancer, Group membership was based on the premise
that cancer is a chronic disease, and that any woman with
metastatic or recurrent cancer can serve as a role model for
other women. The one woman with metastatic cancer and the
woman who had a non-metastatic recurrence of breast cancer
shared their experiences with the other women, who in turn
shared their own experiences. The facilitators observed no
evidence of distress in response to the experiences shared by
the women with metastatic or recurrent cancer. Rather, the
notion of a ‘common journey’ pervaded the Group meetings,
with an emphasis on sharing experiences rather than trying to
‘fix’ situations.
The finding that some women experienced changes from
adaptive to ineffective responses over the course of a year
(Table 2) may reflect the trajectory of the chronic nature of
cancer and of cancer treatment. There was, however, no
obvious direct link between specific cancer treatment and the
changes in those women’s responses. Cancer support groups
cannot cure cancer or prevent the side effects of treatment.
That those women still found the Group beneficial most
likely reflects their understanding of the waxing and waning
of symptoms during cancer treatment and the value they
placed on the nurturing and support they received, as well as
the support they were able to give to others despite the
presence of sometimes distressing symptoms. The Group,
then, provided support and coping mechanisms that the
women could use as they dealt with the trajectory of the
disease and treatment.

476
2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 467–478
Women and children
Limitations
The possibility of socially desirable responses from the
women cannot be dismissed. That the study design called
for distribution and collection of the women’s forms by the
facilitators may have led some women to provide responses
that they thought the facilitators would prefer. The finding of
some changes from adaptive to ineffective responses over the
year of data collection, however, provides some evidence that
the women were willing to provide accurate reports of their
experiences. Inasmuch as one goal of the evaluation project
was to situate evaluation within a community hospital-
sponsored cancer support group, rather than conduct a
formal experimental research project, distribution and col-
lection of forms by the evaluation project consultant prob-
ably would not have been appropriate.
The evaluation project consultant did, in contrast, collect
the forms directly from the facilitators. The possibility of
socially desirable responses from those nurses also cannot be
eliminated. Certainly they were invested in the Group and its
success. They were also, however, committed to an evalua-
tion of the experiences of participation in and facilitation of
the Group, which suggests that they also provided accurate
reports of their experiences.
The data collection points in this evaluation project
provide a snapshot of each woman’s experiences at particular
times. Although collecting data at the beginning of a project,
such as this Group, and after 6 and 12 months was intuitively
appropriate, there was no way to know whether the women’s
experiences differed during the intervening months, or what
happened after the evaluation project was completed. Future
evaluation projects might benefit from a design that includes
more frequent and extended collection of data.
The Group was targeted to women who were dealing with
one type of cancer. Whether the results would be as positive if
participants had various types of cancer and if both women
and men participated in the Group cannot, of course, be
determined from the results of this evaluation project.
Anecdotal comments from women who have participated in
cancer support groups that included people with various
types of cancer, however, indicate that single type and single
gender groups may be more effective than mixed groups
(B. Lowery, pers. comm., 4 April 1990).
Conclusion
The findings of this programme evaluation project extend
knowledge of the outcomes of participation in a breast cancer
support group and make explicit heretofore-implicit
knowledge of the experiences of members of community

2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 467–478
Common Journey Breast Cancer Support Group evaluation
hospital-sponsored cancer support groups. The findings also
add to the literature about the value of nurses as facilitators
of cancer support groups (Zabalegui Yarnoz et al., 2002).
Nurses and other health professionals are encouraged to
establish cancer support groups in their communities, to
formally evaluate the outcomes of group participation, and to
report the results in the literature.
Acknowledgements
The Group was established through an award from the Susan
G. Komen Breast Cancer Foundation-Maine Affiliate.
Contributions
Study design: LZ, PAS, JF; data analysis: JF; manuscript
preparation and literature review: LZ, PAS, JF.
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