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CNRXXX10.1177/1054773817714562Clinical Nursing ResearchPan et al.

Article
Clinical Nursing Research
2019, Vol. 28(1) 107­–124
Resilience and Coping © The Author(s) 2017
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DOI: 10.1177/1054773817714562
https://doi.org/10.1177/1054773817714562
Quality of Life in Patients journals.sagepub.com/home/cnr

With Brain Tumor

Chiu-Ju Pan, BSN, RN1, Hui-Chun Liu, MSN, RN2,

Shu-Yuan Liang, PhD, RN3, Chieh-Yu Liu, PhD3,
Wei-Wen Wu, PhD, RN4,
and Su-Fen Cheng, PhD, RN3

Abstract
The study purpose was to evaluate how much of the variance in quality of
life (QOL) among Taiwanese patients with brain tumor could be accounted
for by resilience and coping strategy. This cross-sectional study included 95
patients who had undergone a treatment of operations or chemotherapy or
radiotherapy relevant to brain tumor after at least 1 month and completed
the European Organization for Research and Treatment of Cancer QOL
Questionnaire–Brain Cancer Module (EORTC QLQ-BN20), Resilience
Scale (RS), and Ways of Coping Checklist–Revised (WCC-R). There was
a significant negative correlation between resilience and future uncertainty
QOL and motor dysfunction QOL. In addition, there was a significant positive
correlation between the emotion-focused coping and future uncertainty
QOL, as well as a significant negative correlation between problem-focused
coping and motor dysfunction QOL. Resilience accounted for 4.8% and the
emotion-focused coping accounted for 10.20% of the variance in separately

1Cardinal Tien Hospital, New Taipei City, Taiwan

2TaipeiVeterans General Hospital, Taipei, Taiwan
3National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
4National Taiwan University, Taipei, Taiwan

Corresponding Author:
Shu-Yuan Liang, Professor, College of Nursing, National Taipei University of Nursing and
Health Sciences, 365 Ming Te Road, Peitou, Taipei 112, Taiwan.
Email: shuyuan@ntunhs.edu.tw
108 Clinical Nursing Research 28(1)

predicting the future uncertainty QOL. This study highlights the potential
importance of resilience and coping strategies in patients’ QOL, which is
relevant to brain tumor treatment.

Keywords
resilience, coping, quality of life

Introduction
The prevalence of brain tumors has been increasing in Taiwan (Health
Promotion Administration, Ministry of Health and Welfare, Taiwan, 2016).
Patients with brain tumors suffer from compression of brain tissue, resulting
in impairments such as motor deficiencies, personality changes, cognitive
deficits, aphasia, or visual field defects (Mukand, Blackinton, Crincoli, Lee, &
Santos, 2001; Ullrich, Scott, & Pomeroy, 2005). Such occurrences affect
patients’ social and behavioral functions. Furthermore, patients face side
effects relating to cancer treatment (Molassiotis et al., 2014; Shahid, 2016) as
well as fears of recurrence of brain tumors (Baker, Denniston, Smith, & West,
2005; Faithfull, 1991). All of these episodes can contribute to physical and
mental distress, overwhelming the overall dimensions of patients’ quality of
life (QOL; Janda et al., 2007). QOL is defined as a multidimensional concept
including disease and treatment-related symptoms, physical, psychological,
and social functioning (Velikova et al., 2012). For example, the physical
domains like motor dysfunction QOL in patients with brain tumor indicate the
weakness of body, unsteadiness on feet, and trouble with coordination.
Consequently, understanding the QOL of patients with brain tumors and how
such patients may adjust to their QOL is an important issue for health profes-
sionals. Not only is the understanding of such concerns a crucial indicator for
cancer treatment outcomes (Buchanan, O’Mara, Kelaghan, & Minasian, 2005;
Sharma, Walker, & Monson, 2013), but also studies have reported QOL as an
independent predictor of survival from brain tumors (Sehlen et al., 2003).
Resilience is defined as the resistance, recovery, or rebounding of psycho-
logical and physical health after a challenging life event (Szanton & Gill,
2010). It is considered an important trait or ability of individuals that sustains
well-being in the face of the many stresses that individuals encounter in their
lives (Luthar, Cicchetti, & Becker, 2007; Masten, 2001, 2014). Optimistic
individuals with resilience may be more positive in adjusting to mental dis-
tress derived from their cancer diagnosis and relevant treatment (Mancini &
Bonanno, 2009; Molina et al., 2014; Rosenberg et al., 2015) therefore improv-
ing their overall QOL (Manne et al., 2015; Wu et al., 2015).
Pan et al. 109

Coping is the key mechanism toward adjusting to stressful events, such as

mental distress and physical symptoms (Lazarus, 1993). Coping has two
major types: one for managing the root cause of the distress and another for
regulating emotional distress (Folkman, Lazarus, Dunkel-Shetter, Delongis,
& Gruen, 1986; Folkman, Lazarus, Gruen, & Delongis, 1986). Individuals
who adopt appropriate coping strategies perhaps may effectively decrease the
impact of cancer on their psychosocial and physical distress (Elsheshtawy,
Abo-Elez, Ashour, Farouk, & El Zaafarany, 2014) thereby increasing their
QOL (Lafaye et al., 2014; Lim, 2014). Examples of such strategies include
the active seeking of resources to face the challenges resulting from their
cancer treatment (Lafaye et al., 2014).
Resilience has been related to psychological adaptation to many life-
threatening events and has become a major focus of research and clinical
intervention (Fredrickson, 2001; Loprinzi, Prasad, Schroeder, & Sood, 2011;
Manne et al., 2015). Limited research has focused on the association between
resilience, coping strategy, and QOL in patients with brain cancer (Jalali &
Dutta, 2012; Janda et al., 2007). This study’s primary purpose is to explore
the relationship between resilience, coping strategy, and patients’ QOL. Its
second purpose is to evaluate how much of the variance in QOL among
Taiwanese patients with brain tumors could be accounted for by resilience
and coping strategies.

Method
Sample and Procedures
This is a cross-sectional and correlational study involving a convenience
sample of 95 subjects. The benign brain tumor is often recurrent and com-
bines the treatment of operation and radiotherapy (Akeyson & McCutcheon,
1996; Wen, Quant, Drappatz, Beroukhim, & Norden, 2010). The impact of
benign brain tumor to the patients therefore may be not less than those of
malignance (al-Mefty, Kersh, Routh, & Smith, 1990). The sampling frame
comprised all patients with primary brain tumors who were admitted to the
outpatient division of a neurosurgery unit of the one teaching hospital in the
Taipei area of Taiwan. Patients were eligible for study enrollment if they met
the following inclusion criteria: (a) had a benign or malignant primary brain
tumor diagnosis and had undergone a treatment including an operation or
chemotherapy or radiotherapy relevant to brain tumor treatment, (b) at least
1 month had elapsed posttreatment, (c) were older than 20 years, and (d) were
conscious and able to sign a consent agreement. The informed consent forms
were signed earlier to include the research participants. The study obtained
ethics committee approval from the hospital.
110 Clinical Nursing Research 28(1)

Measures
Sociodemographic variables.  Sociodemographic variables—including age, gen-
der, education, marital status, employment status, and household income—
were measured. Medical variables consisted of the type of brain tumor, tumor
treatment, and recurrent status. Moreover, to assess participants’ physical
function, the Karnofsky Performance Status scale (KPS) was utilized from 0
(death) to 100 (normal condition; Karnofsky, Abelmann, & Craver, 1978).

European Organization for Research and Treatment of Cancer

QOL Questionnaire–Brain Cancer Module (EORTC QLQ-BN20)
EORTC QLQ-BN20 is a specific QOL questionnaire designed for brain can-
cer patients (Taphoorn et al., 2010). Items were rated according to a scale
ranging from 1 to 4, with 1 = not at all, 2 = a little, 3 = quite a bit, and 4 =
very much. The QLQ-BN20 consists of four domains scales, including future
uncertainty (four items), visual disorder (three items), motor dysfunction
(three items), and communication deficit (three items). In addition, seven
single items assess headaches, seizures, drowsiness, hair loss, itchy skin,
weakness of legs, and bladder control. All items and scale scores are con-
verted into a 0 to 100 scale, with higher scores representing a worse QOL.
Details of the development and initial testing of the QLQ-BN20 in a mul-
tinational and multilingual population have been previously published (Osoba
et al., 1996; Shin & Kim, 2013; Taphoorn et al., 2010). The results commonly
support the validity and reliability of the EORTC QLQ-BN20. The internal
consistency reliability coefficient from the current study ranged from .80 to
.89 for total scale and subscales.

Resilience Scale (RS)

Resilience was measured with the 25-item RS developed by Wagnild and
Young (1993). The RS consists of two domain scales including personal
competence and acceptance of self and life. Items were rated using a scale
ranging from 1 to 7, with total scores ranged from 25 to 175, and higher
scores signifying higher resilience. Scores at or exceeding147 indicate high
resilience, scores ranging from 121 to 146 indicate midrange resilience, and
scores below 121 are considered weak resilience. In the study by Wu et al.,
Cronbach’s alpha coefficient was .95 (Wu et al., 2015). The concurrent valid-
ity was significantly and positively correlated with life satisfaction (r = .30;
Yang, 2009). The internal consistency reliability coefficient from the current
study ranged from .92 to .96 for total scale and subscales. Three examples of
Pan et al. 111

items in the RS were listed to aid understanding; for instance, “keeping inter-
ested in things is important to me,” “I feel proud that I have accomplished
things in life,” and “I feel that I can handle many things at a time.”

Coping scale (Ways of Coping Checklist–Revised [WCC-R])

The Chinese version (Sheu, 2001) of the coping scale comprises 42 items and
assesses two coping strategies: problem-focused coping and emotion-focused
coping. This scale was derived from Lazarus and Folkman’s WCC (Lazarus
& Folkman, 1984) and was validated by Vitaliano, Russo, Carr, Maiuro, and
Becker (1985). Vitaliano et al.’s study supported evidence for the construct
and concurrent validity of the WCC-R. The Cronbach’s alpha coefficient
from Vitaliano et al.’s study ranged from .74 to .88. In Sheu’s study for the
Chinese version of the WCC-R, Cronbach’s alpha coefficient was .80 (Sheu,
2001). The internal consistency reliability coefficient from the current study
ranged from .84 to .89 for total scale and subscales. Respondents use a 4-point
Likert-type summative scale, with 0 = does not apply and or not used, 1 =
used somewhat, 2 = used quite a bit, and 3 = used a great deal, with higher
scores representing the coping strategy often adopted.

Statistics
Data were analyzed using the SPSS for Windows Version 18.0 (Chicago, IL,
USA). Descriptive statistics (mean, SD, frequency, and percentage) were
used to summarize the sociodemographic variables and medical characteris-
tics of the sample. ANOVA and t test were used to examine the relationships
between sociodemographic variables, medical characteristics, and QOL. As
well, Pearson product–moment correlation was used to examine the relation-
ships between resilience, coping strategies, and QOL. Hierarchical multiple
regressions were used to explore how much variance in QOL could be
accounted for by resilience and coping strategies.

Results
Demographics, Medical Characteristics, KPS, Resilience, Coping
Strategy, and QOL of the study participants
The sample had a mean age of 47.7 years (SD = 12.15, range = 21-68 years).
The majority of participants were female (61.1%), married (57.9%), not work-
ing (56.8%; see Table 1), and 51.6% had a benign brain tumor diagnosis (see
Table 2). The patients had a mean KPS of 90.32 (SD = 11.71, range = 60-100),
112 Clinical Nursing Research 28(1)

Table 1.  Demographic Data of the Sample (N = 95).

Variable Frequency %
Gender
 Female 58 61.1
 Male 37 38.9
Age (years)
 <40 31 32.6
 40-49 30 31.6
 50-59 20 21.1
 >60 14 14.7
Educational level
  Senior high school or below 36 37.9
  Diploma/bachelor’s or above 59 62.1
Married
 Yes 55 57.9
 No 28 29.5
 Other 12 12.6
Employment status
 Employed 41 43.2
 Unemployed 54 56.8
Financial means
  By self 39 41.1
  By others 56 58.9
Household income/month (NT$)
 <40,000 26 27.4
 40,000-80,000 40 42.1
 >80,000 29 30.5

Note. NT$ = New Taiwan dollar.

problem-focused coping of 2.79 (SD = 0.52, range = 1.14-3.95), and emotion-

focused coping of 2.07 (SD = 0.58, range = 0.62-3.57). Average levels of resil-
ience indicated midrange scores (M = 125.48, SD = 28.53, range = 31-175).
Moreover, the participants had a mean future uncertainty QOL of 30.09 (SD =
20.96), visual disorder QOL of 20.00 (SD = 27.10), motor dysfunction QOL
of 16.73 (SD = 23.76), and communication deficit QOL of 7.95 (SD = 17.05).

Relationship Between Demographic/Medical Characteristics,

KPS, Resilience, Coping Strategy, and QOL
Independent-sample t tests or ANOVAs were conducted to test differences
in QOL among selected demographic and medical groups. These results
Pan et al. 113

Table 2.  Medical Characteristics of the Sample (N = 95).

Variables/groups Frequency %
Tumor type
 Benign 49 51.6
 Malignant 46 48.4
Tumor recurrent
 Yes 34 35.8
 No 61 64.2
Tumor treatment
  Surgery only 53 55.8
  Surgery plus CTx or RTx or both 42 44.2

Note. CTx = chemoradiotherapy; RTx = radiation therapy.

indicate significant differences in the future uncertainty QOL for partici-

pants’ household incomes (F = 4.13, p < .05) and tumor recurrence (t =
2.28, p < .05). Participants with low household incomes and tumor recur-
rent status displayed a significantly higher score in future uncertainty QOL
than did patients with a contrary situation. In addition, there were signifi-
cant differences in the visual disorder QOL for participants’ tumor recur-
rence (t = 2.65, p < .05). Patients with a tumor recurrent status showed a
significantly larger deterioration in visual disorder QOL. Moreover, there
were significant differences in the motor dysfunction QOL of persons of
different household incomes (F = 3.52, p < .05), employment status (t =
−2.05, p < .05), financial means (t = −2.31, p < .05), and tumor type (t =
−2.42, p < .05). These results indicate that participants with malignant
tumors and household income of below NT$40,000 and who were unem-
ployed and depended on a financial means by others experienced a signifi-
cantly higher motor dysfunction QOL than did patients of a contrary
situation. Furthermore, there were significant differences in communica-
tion deficit QOL for persons of different educational levels (t = −2.66, p <
.01) and tumor types (t = −2.16, p < .05). Participants with educational
levels of diploma or above and with a malignant tumor displayed signifi-
cantly higher scores in terms of communication deficit QOL than did
patients of a contrary situation (see Table 3).
Pearson’s correlations were conducted to assess the relationships between
the patients’ KPS, resilience, coping strategy, and QOL. The results indicated
that KPS was significantly and negatively correlated with future uncertainty
QOL (r = −.38, p < .001), visual disorder (r = −.31, p < .01), and motor dys-
function QOL (r = −.69, p < .001). In addition, the results indicate that resil-
ience was significantly and negatively correlated with future uncertainty
114 Clinical Nursing Research 28(1)

QOL (r = −.40, p < .001) and motor dysfunction QOL (r = −.43, p < .001).
Moreover, there was a significant and positive correlation between emotion-
focused coping and future uncertainty QOL of patients (r = .24, p < .05).
However, there was a significant and negative correlation between problem-
focused coping and motor dysfunction QOL of patients (r = −.27, p < .05).
The results suggest that higher perceived resilience was related to greater
QOL. Furthermore, the results suggest that emotion-focused coping was
associated with poorer QOL (related to future uncertainty); conversely, prob-
lem-focused coping was associated with higher QOL (related to motor dys-
function; see Table 4).

Demographic/Medical Characteristics, KPS, Resilience, and

Coping Strategy Predicting QOL
Four separate hierarchical multiple regression analyses were performed to
ascertain how much variance among the four indicators of QOL (future
uncertainty, visual disorder, motor dysfunction, and communication defi-
cit) could be accounted for by influencing variables (demographic and
medical, KPS, resilience, and coping strategy). Regarding the hierarchical
multiple regression analysis, the demographic and medical variables—
which were initially discrete or nominal—underwent a process of dummy
coding. The demographic and medical variables, KPS, resilience, and cop-
ing strategy were entered into the hierarchical multiple regression analysis
to predict the patients’ various subscales of QOL; these variables were
selected based on the results of a previous analysis, which revealed a sig-
nificant association with the patients’ QOL. During the first step, we entered
the demographic and medical variables and KPS as predictors. In Step 2,
we entered the resilience as the predictor. Finally, in Step 3, we entered the
coping strategy as the predictor. For future uncertainty QOL, our results
indicate that the model was significant (F = 7.757, p < .001), and that resil-
2 2
ience ( Rinc = .048, p < .05) and emotion-focused coping ( Rinc = .102, p <
.001) could predict patients’ future uncertainty QOL. For motor dysfunc-
tion QOL, the results indicate that the model was significant (F = 11.464, p
2 = .013, p > .05) and problem-focused cop-
< .001), but that resilience ( Rinc
2
ing ( Rinc = .003, p > .05) could not predict patients’ motor dysfunction
QOL. The current study did not enter resilience and coping strategies to
predict the visual disorder and communication deficits. The results of a
previous analysis revealed no significant relationships between resilience
and coping strategy and the patients’ visual disorder QOL and communica-
tion deficit QOL (see Table 5).
 Table 3.  Demographic Characteristics by Quality of Life Subscales (N = 95).
Future uncertainty Visual disorder Motor dysfunction Communication deficit

Variables Groups M SD t/F M SD t/F M SD t/F M SD t/F

Gender Male 30.86 21.59 t = 0.28 16.52 21.69 t = −1.07 19.52 24.32 t = 0.92 8.11 14.73 t = 0.07
Female 29.60 20.72 22.22 30.02 14.94 23.41 7.85 18.50  
Age (years) <40 30.38 18.70 F = 0.26 12.54 21.42 F = 1.72 9.32 13.49 F = 2.05 10.03 16.82 F = 1.01
40-49 31.39 23.54 24.81 29.71 17.78 24.17 10.37 22.40  
50-59 30.83 22.96 27.22 32.14 19.44 26.21 3.33 10.26  
>60 25.60 18.33 15.87 22.10 26.98 33.11 4.76 10.42  
Married No 36.31 22.93 t = 1.84 25.00 30.18 t = 1.43 18.25 22.47 t = 0.14 10.71 16.97 t = 0.93
Yes 27.88 19.98 19.80 27.27 16.57 25.74 7.68 18.50  
Other 25.69 18.96 9.26 14.08 13.89 17.81 2.78 6.91  
Educational level Senior high school or 29.40 19.87 t = −0.25 16.67 22.77 t = −0.94 20.06 27.58 t = 1.00 3.09 7.79 t = −2.66**
below
Diploma/bachelor’s or 30.51 21.75 22.03 29.43 14.69 21.09 10.92 20.27  
above
Employment Employed 29.27 18.55 t = −0.33 17.89 23.29 t = −0.66 10.30 16.92 t = −2.50* 10.30 21.57 t = 1.09
status Unemployed 30.71 22.77 21.60 29.78 21.60 26.99 6.17 12.52  
Household income <40,000 38.14 28.01 F = 4.13* 27.78 33.59 F = 1.71 24.36 29.32 F = 3.52* 7.69 13.25 F = 0.62
(NT$) > >
40,000-80,000 30.42 17.76 18.89 27.24 18.06 23.29 10.00 17.76  
>80,000 22.41 14.62 14.56 18.33 8.05 15.40 5.36 19.16  
Financial means By self 25.64 20.18 t = −1.74 17.09 24.30 t = −0.87 10.54 17.65 t = −2.31* 6.55 18.51 t = −0.67
By others 33.18 21.11 22.02 28.93 21.03 26.52 8.93 16.06  
Tumor type Benign 29.76 24.06 t = −0.16 21.32 27.58 t = 0.49 11.11 19.51 t = −2.42* 4.31 11.96 t = −2.16*
Malignant 30.43 17.32 18.60 26.82 22.71 26.50 11.84 20.61  
Tumor treatment Surgery only 26.10 17.91 t = −2.06 15.93 25.27 t = −1.66 10.06 16.49 t = −3.04 7.76 15.34 t = 3.70
Surgery plus CTx or RTx 35.12 23.54 25.13 28.73 25.13 28.62 8.20 19.18  
or both
Tumor recurrent Yes 36.52 22.94 t = 2.28* 30.39 31.34 t = 2.65* 23.53 28.53 t = 1.92 9.48 21.91 t = 0.65
No 26.50 19.03 14.21 22.69 12.93 19.89 7.10 13.76  

115
Note. CTx = chemoradiotherapy; RTx = radiation therapy.
*p < .05. **p < .01.
116 Clinical Nursing Research 28(1)

Table 4.  Correlations Between the Participants’ KPS, Resilience, Coping Strategy,
and QOL (Pearson’s r; N = 95).

Future Visual Motor Communication

Variable uncertainty disorder dysfunction deficit
KPS −.38*** −.31** −.69*** −.06
Resilience −.40*** −.17 −.43*** −.02
Coping strategy
 Problem-focused −.20 −.01 −.27* −.003
 Emotion-focused .24* .03 .10 .04

Note. KPS = Karnofsky Performance Status; QOL = quality of life.

*p < .05. **p < .01. ***p < .001.

Discussion
The study purpose was to explore the association between resilience, coping
strategy, and patients’ QOL and to evaluate how much of the variance in QOL
among Taiwanese patients with brain tumors could be accounted for by resil-
ience and coping strategies. The results suggest a significant relationship
between resilience, coping strategies, and the participants’ future uncertainty
QOL and motor dysfunction QOL. In particular, this study shows that resil-
ience and emotion-focused coping significantly predicted the patients’ future
uncertainty QOL. This research enriches literature on resilience and coping
by identifying possible strategies that patients diagnosed with brain tumors
may use to maintain their QOL during the cancer experience.
The study findings revealed items relating to future uncertainty QOL had
the highest mean scores. However, this distribution of QLQ-BN20 scale
scores was skewed, with scores mainly on the lower end of scale (indicating
few functional problems)—an outcome that is related to the inclusion in both
trials of patients with a relatively good performance status. These results are
consistent with those of previous studies (Shin & Kim, 2013; Taphoorn et al.,
2010). Indeed, participants in this study had a high KPS score with normal
activity or minor health complaints.
Despite having good functional abilities, participants in the current study
reported midrange resilience compared with those participants of an early
study of newly diagnosed gynecological cancer, the results of which indi-
cated relatively high average levels of resilience (Manne et al., 2015). In
addition, findings of Dubey et al. study reveal patients with gastrointestinal,
head and neck, and lung cancer exhibited the lowest resilience scores (Dubey,
De Maria, Hoeppli, Betticher, & Eicher, 2015). Resilience may not only man-
ifest an individual trait, but also may vary according to different cancer
 Table 5.  Hierarchical Multiple Regression Analysis for Variables Predicting QOL (N = 95).

Variable B SE B β R2 R2 increment F increment

Criterion: Future uncertainty
  Step 1: Demographic characteristics .196 .196 5.485***
   Household income/month (NT$)  
   >80,000 vs. <40,000 −10.272 5.010 −.225*  
   40,000-80,000 vs. <40,000 −3.582 4.491 −.085  
   Tumor recurrent (no vs. yes) −4.004 3.977 −.092  
  KPS −0.335 0.183 −.187  
  Step 2: Resilience −0.224 0.074 −.305** .244 .048 5.604*
  Step 3: Emotion-focused coping 0.567 0.153 .326*** .346 .102 13.766***
  Overall model R2 = .346, F(6, 88) = 7.757, p < .001
Criterion: Visual disorder
  Step 1: Demographic characteristics .140 .140 7.476***
   Tumor recurrent (no vs. yes) −12.207 5.671 −.217*  
  KPS −0.576 0.233 −.249*  
  Overall model R2 = .140, F(2, 92) = 7.476, p < .01
Criterion: Motor dysfunction
  Step 1: Demographic characteristics .500 .500 14.660***
  Employment status 5.112 4.448 .107  
   Household income/month (NT$)  
   >80,001 vs. <40,000 −1.189 4.981 −.023  
(continued)

117
118
Table 5. (continued)
Variable B SE B β R2 R2 increment F increment
   40,001-80,000 vs. <40,000 4.246 4.462 .089  
   Financial means (others vs. self) −5.101 4.797 −.106  
   Tumor type (malignant vs. benign) 5.432 3.708 .115  
  KPS −1.221 0.186 −.602***  
  Step 2: Resilience −0.159 0.096 −.191 .513 .013 2.308
  Step 3: Problem-focused coping 0.173 0.228 .081 .516 .003 0.577
  Overall model R2 = .516, F(8, 86) = 11.464, p < .001
Criterion: Communication deficit
Step 1: Demographic characteristics .098 .098 4.976**
   Educational level (above vs. below) 7.694 3.463 .220*  
   Tumor type (malignant vs. benign) 7.387 3.362 .218*  
  Overall model R2 = .098, F(2, 92) = 4.976, p < .01

Note. QOL = quality of life; KPS = Karnofsky Performance Status.

*p < .05. **p < .01. ***p < .001.
Pan et al. 119

diagnoses, presenting diverse effects on participants’ coping strategies of the

cancer experience (Mancini & Bonanno, 2009).
This study analyzed the coping strategies used by a group of patients with
brain tumors. Most of its patients tended to use both types of coping strate-
gies: problem-focused coping and emotion-focused coping strategies. The
results indicated that problem-focused coping was more frequently used than
emotion-focused coping, a result consistent with the outcome of previous
researches (Butow et al., 2013; Tuncay, 2014; Yahaya, Subramanian, Bustam,
& Taib, 2015). Lazarus (1993) concluded that subjects used problem-focused
coping more when individuals perceive they can change the adverse situa-
tion, and used emotion-focused coping when there are few changeable per-
sonal factors to alter the situation.
With respect to the relationship between coping strategy, resilience, and
patients’ QOL, the results indicate that participants with higher problem-
focused coping were significantly associated with higher QOL (related to
motor dysfunction). In addition, participants with higher emotion-focused
coping mechanisms were significantly associated with poorer QOL (related
to future uncertainty). Moreover, participants with higher resilience were sig-
nificantly associated with both lower future uncertainty QOL score (higher
QOL) and motor dysfunction QOL score (higher QOL). Furthermore, all
variables found to have significant bivariate relationships with QOL were
included in the hierarchical multiple regression models to determine whether
they were QOL predictors. The results of this study suggest that higher emo-
tion-focused coping contributes to the prediction of the participants’ poorer
QOL (related to future uncertainty). This indicates that patients experienced
an increase in uncertainty when they choose emotion-focused coping. Yahaya
et al. (2015) and Tuncay (2014) reported similar findings. They found that
emotion-focused coping was associated with poorer psychological QOL.
Lazarus and Folkman (1984) asserted that the frequency of use of the differ-
ent coping strategies is not necessarily related to their efficacy. However,
patients choose emotion-focused coping when psychological distress has
increased. This fact is consistent with the theory that emotion-focused coping
is more useful than problem-focused coping when little can be done about the
uncontrollable situation (Lazarus & Folkman, 1984). Living as a brain tumor
survivor under a situation of uncertainty, a patient may select the emotion-
focused coping that finally decreased his or her QOL. The patients’ future
uncertainty QOL and emotion-focused coping strategy, however, may worsen
each other. The current results warn the inefficiency of use of the emotion-
focused coping strategies particularly by patients in an uncertainty situation.
In contrast, higher resilience makes a unique contribution to predicting
participants’ lower uncertainty QOL score (higher QOL). Rosenberg et al.
120 Clinical Nursing Research 28(1)

(2015) and Tian and Hong (2014) reported similar findings, finding that resil-
ience is a main factor influencing psychological outcomes and patients’ QOL.
Resilience may play a crucial role in buffering the impact of cancer on
patients’ psychological perception of QOL. In a study of the QOL of patients
with brain tumors, researchers should focus on strategies that improve
patients’ resilience.
This study has numerous implications toward clinical practice. The asser-
tion of the predictor of resilience on the participants’ QOL recommends that
the assessment of the participant’s resilience in practice may aid in identify-
ing patients who are susceptible to poor QOL of future uncertainty. In addi-
tion, resilience is a regulating variable and by itself can offer a basis for
potentially useful intervention to increase QOL (Loprinzi et al., 2011; Wu
et al., 2015), such as a resilience-based intervention on psychosocial well-
being and QOL improvement (Loprinzi et al., 2011). Loprinzi et al. (2011)
used a stress management and resiliency training program focused on atten-
tion and interpretation of patients’ stressful experience. In term to guide
patients’ interpretations away from flat prejudgments and concerning on
more flexible viewpoints through developing skills, for example, gratitude,
compassion, acceptance, forgiveness, and higher meaning and purpose.
However, the study results reflect the importance of taking individual coping
strategies into consideration when assessing the impact of brain tumors on
QOL. An evaluation of coping strategies might be helpful toward recognizing
subjects in need of certain counseling and support.
There are some limitations in this study, which is limited by its cross-
sectional nature. As such, more research adopting a prospective approach is
expected to further explore the potential role of coping strategies and resil-
ience in patients’ QOL. Moreover, this study employed patients from one
teaching hospital in an urban setting, which consisted of a convenience sam-
ple of patients with brain tumors. It is likely that participants who agreed to
participate are more likely to be coping well, and we may not have obtained
some patients who are mostly susceptible to distress. This may limit the gen-
eralizability of the current findings.

Conclusion
This study reveals that resilience and coping strategy significantly affected
participants’ future uncertainty QOL and motor dysfunction QOL. A strength-
ening in the level of resilience can negatively affect future uncertainty QOL
of patients with brain tumors. In addition, a rising level of emotion-focused
coping positively affects participants’ future uncertainty QOL. In caring for
patients with brain tumors, health professionals should focus on strategies
that strengthen patients’ resilience to improve their QOL. In addition, health
Pan et al. 121

professionals can benefit patients with brain tumors via the employment of
problem-focused coping strategies and the reduction of emotion-focused
coping strategies.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the
research, authorship, and/or publication of this article: The authors have full control
of all primary data and we agree to allow the journal to review our data if required.

Funding
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: This study was partially supported by the
Cardinal Tien Hospital (CTH105A-2N02) in Taiwan.

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Author Biographies
Chiu-Ju Pan, BSN, RN, is a head nurse in the Department of Nursing at Cardinal
Tien Hospital.
Hui-Chun Liu, MSN, RN, is a nurse in the Department of Nursing at Taipei Veterans
General Hospital.
Shu-Yuan Liang, PhD, RN, is a professor in the College of Nursing at National
Taipei University of Nursing and Health Sciences.
Chieh-Yu Liu, PhD, is an associate professor in the Department of Speech Language
Pathology and Audiology at National Taipei University of Nursing and Health
Sciences.
Wei-Wen Wu, PhD, RN, is an assistant professor in the School of Nursing at National
Taiwan University.
Su-Fen Cheng, PhD, RN, is a professor in the College of Nursing at National Taipei
University of Nursing and Health Sciences.