St.

Paul University Philippines

Tuguegarao City, Cagayan 3500

Factors Affecting Resilience and Quality of Life of Patients with Colorectal Cancer Undergoing
Chemotherapy in Ulin Hospital Banjarmasin, Indonesia

Presented to:
Faculty of the Graduate School
St. Paul University Philippines

________________________

In Partial Fulfilment
Of Thesis

_________________________

Presented By:
CHUMAIRA ANINDAYUDINA
Master of Science in Nursing
Major in Adult Health
2022
 Chapter 1

THE PROBLEM AND REVIEW OF RELATED LITERATURE

Introduction

Colorectal cancer is currently the second leading cause of cancer death and the

third most frequently diagnosed cancer, with half of all new cases occurring in people 66

years of age and under; it is estimated that there will be more than 160,000 new cases of

colon and rectal cancer in the US alone (WHO, 2022). Although most colorectal cancers

are in adults aged 50 and older, the second most common cause of cancer death is when

the figures for men and women are combined. It is estimated to cause around 52,580

deaths (American Cancer Society, 2022).

Colorectal cancer is one of the most common cancers in Indonesia, and its

incidence is slowly increasing (A.B. Dharmaji et al., 2021). According to the

GLOBOCAN 2018 database belonging to the International Agency for Research on

Cancer (IARC) Global Cancer Observatory, the incidence of CRC in Indonesia is 30,017

out of 348,809 cancer cases and has the fifth highest mortality rate (7.7%) among all

cancers (F. Bray et al., 2018). Differences in survival rates observed in clinical trials may

be due to variations in patient characteristics and prognostic factors. The prevalence rate

of colorectal cancer in Banjarmasin is 2.22% (RISKESDAS, 2019).

The incidence of colorectal cancer is increasing along with the increase in

population and aging. The response rate to colorectal cancer treatment has grown with the

development of new anticancer drugs. Colorectal cancer is curable by tumor resection

and adjuvant chemotherapy, increasing the five-year survival rate (Allemani C et al.,

2018). Even if the patient's condition worsens and they have recurrent unresectable
colorectal cancer, chemotherapy has prolonged survival. This condition causes an

increase in the length of the treatment period and the number of colorectal cancer patients

undergoing chemotherapy.

It has been reported that colorectal cancer patients undergoing chemotherapy

develop peripheral neuropathy, side effects that are known to be challenging to control,

and face difficulties adjusting their lifestyle to prevent worsening symptoms due to side

effects. Previous research has found that colorectal cancer patients who are undergoing

chemotherapy experience more resilience than those who were not undergoing

chemotherapy; despite their illness, some colorectal cancer patients show resilience (Üzar-

Ozҫ;etin et al., 2019), which is defined as the ability to overcome adversities with confidence in

the future and themselves (Connor and Davidson, 2003; Sisto et al., 2019).

Resilience is often described as an outcome, precisely, an individual response to a

difficult life situation (Deshields et al., 2016) and a psychosocial result of growth (Molina

et al., 2014). The previous research also found that common mental health disorders are

low in cancer patients with high resilience, and mental health is related to resilience

(Walker ER et al., 2015). Psychological resilience represents an ability of a person to

protect their mental health when faced with adversity such as a cancer diagnosis.

Adversity, through resilience mechanisms, can be reframed and become a possibility that

one can learn and even benefit from psychiatry, as well as psychology, which has

repeatedly addressed the negative outcomes derived from cancer experience, such as

depression, post-traumatic stress symptoms, and anxiety (Carlson LE et al., 2015). But,

very little is known about what drives people to fight, survive and grow when faced with

cancer. When describing the cancer experience, one can approach resilience from several

aspects (Molina Y et al, 2015). Cancer medicine, especially chemotherapy, has become
increasingly effective, so the attention has shifted to cancer survivorship issues. The

central challenge of cancer is still focused on being cancer free, but it is increasingly vital

to maintain and improve the patient's quality of life (Nida et al., 2019). The psychological

distress following cancer diagnosis and treatment negatively affects the psychological

components of QoL at the beginning of the cancer experience. What is not sufficiently

explored is how much the initial psychological distress influences the QoL of patients

who are cancer survivors. Also, the long-term side effects of breast cancer treatments on

QoL are not conclusively confirmed nor dismissed ( ). Resilience has an essential impact

on the QoL of a cancer patient. Hence, over the last few years, QoL has become a crucial health-

related outcome measure in communities and healthcare systems (Nida et al., 2019). It shows

that resilience is vital to maintaining cancer patients' quality of life and mental health.

Resilience is the mental strength to return to its original state and is a factor when facing

challenging life situations. Resilience is considered to be acquired throughout life,

suggesting that resilience may be a key element in maintaining the quality of life in

patients with colorectal cancer undergoing chemotherapy.

Previous studies have shown associations between resilience and psychological

distress, resilience and quality of life, and resilience and social support in cancer patients

(Harms CA et al., 2019). However, no specific studies have been found to clarify the

factors affecting resilience and quality of life. There are also no studies on colorectal

cancer, except those involving patients with a terminal disease or permanent stoma (Dong

X et al., 2017). It can be assumed that the number of colorectal cancer patients

undergoing chemotherapy will increase. Thus, it is vital to look for support to maintain

their resilience and quality of life. Hence, this study aimed to determine factors affecting
the resilience and quality of life of patients with colorectal cancer undergoing

chemotherapy.

Review of Related Literature and Studies

Resilience. Resilience is the process of successfully adapting to complex or

challenging life experiences, primarily through mental, emotional, and behavioral

flexibility and adjustment to external and internal demands (American Psychological

Association, 2020). In defining resilience, it is essential to determine whether resilience is

viewed as a trait, process, or outcome. It is often tempting to take a binary approach to

consider whether resilience exists.

However, resilience is more likely to exist on a continuum that may be present at

different levels in different life domains (Pietrzak & Southwick, 2011). Resilience can

change over time as a function of a person's development and interaction with the

environment (Kim-Cohen & Turkewitz, 2012). For example, high maternal care and

protection levels may increase resilience during infancy but impair individuation during

adolescence or young adulthood. In addition, our responses to stress and trauma occur in

interactions with other humans, available resources, particular cultures and religions,

organizations, communities, and societies. Each of these contexts may be more or less

resilient in its own right and, therefore, more or less able to support the individual. The

more we learn about resilience, the greater the potential to integrate significant resilience

concepts into relevant fields of medicine, mental health in palliative care, and science.

Resilience is defined to be related to the quality of life. Further, it has been

reported that the quality of life of patients with colorectal cancer is associated with
psychological problems, age, and fatigue. Resilience is an important trait that contributes

to a person's mental and physical well-being. Evidence suggests that resilience is related

to motivation. This motivation to recover from physical or psychological traumatic events

minimizes the impact of risk factors, thus increasing a person's ability to deal with the

challenges of life. Resilience thus protects against psychosocial health-related issues,

such as depression, anxiety, fear, and helplessness, and helps to reduce their associated

negative effects. Therefore, the present study considers that personal and disease-related

factors are also related to the quality of life (American Psychological Association, 2020).

This integration is starting to drive an essential and much-needed paradigm shift.

Rather than spending most of their time and energy examining the negative consequences

of trauma, clinicians and researchers can learn to evaluate and teach methods to increase

resilience simultaneously. Such an approach shifts the field away from a purely deficit-

based mental health model towards including a strengths and competency-based model

that focuses on prevention and building strengths in addition to addressing

psychopathology. Cancer patients suffer clinically significant symptoms of emotional

distress, such as depression and anxiety, that reduce their quality of life (QoL) and

resilience and interfere with their treatment compliance (Nida Zahid et al., 2019).

Resilience can change and modify over time and is affected by many different situations

and adversities a person overcomes in a lifetime. Resilience represents a newer concept

that deserves to be targeted from the beginning of life with cancer. Clinicians should

spend more time and effort creating interventions that foster patients' resilience

(Ristevska-Dimitrоvska, 2015).
 Quality of Life. Definitions of quality of life range from those that emphasize

social, emotional, and physical well-being to those that describe the impact of a person's

health on daily life. In the past, researchers used only one dimension of quality of life,

such as physical functioning, economic attention, or sexual function. The researchers then

used a broader definition of quality of life. These are various definitions, but no general

acceptance of their use exists. World Health Organization defines quality of life as

individuals' perceptions of their position in life in the context of the culture and value

systems in which they live and concerning standards of expectations and concerns of

their goals (WHO, 2017). This broad definition includes domains such as physical health,

psychological state, level of independence, social relationships, and personal beliefs.

Other existing purposes include quality of life in cancer safe. They explain the domain of

cancer safe with four parameters (Maria Lavdaniti and Nikolaos Tsitsis, 2015):

1. Physical well-being is the control or reduction of symptoms and the ability to have

physical independence and able to perform all the basic functions.

2. Psychological well-being is maintaining a sense of control in facing life against

disease marked by life changes, priorities, emotional stress, fear of the unknown, and

positive life changes.

3. Social welfare adjusted for the impact of cancer on individuals, their roles and

relationships, and how well they can overcome these factors.

4. Spiritual well-being depends on how well the individual can control the uncertainty

created by expectations and comes from cancer experience

Quality of life significantly affects managing cancer patients, especially colorectal

cancer. Every therapeutic approach should be considered in this new and expanded
definition. In this sense, the goal of treatment is not only to promote the absence of

disease or relieve symptoms but to improve the patient's quality of life at home and

abroad in terms of their internal status and relationships with others. Quality of life then

becomes a two-dimensional entity: an inner dimension (patient feels good about himself)

and an external dimension (patient feels good about others).

On the other hand, here are four broad health dimensions described that will summarize

specific components of quality of life:

1. Physical health (somatic sensations, disease symptoms)

2. Mental health (positive feelings of well-being, non-pathological forms of

psychological distress, or diagnosis with mental disorders)

3. Social health (aspects of social contact and interaction)

4. Functional health (self-care, mobility, level of physical activity, and functioning of

social roles in relationships of family and work)

Quality of Life an Important Indicator of Health

In the health sciences, the concept of quality of life is used in the context of

research on health and the consequences of non-health related diseases and also for

assessing medical and extra medical outcomes of health care and medical interventions. It

is part of a broader concept of responsible medical care in prolonging life and making

therapeutic efforts to ensure optimal vital activity. It is important because health is more

than the absence of disease or disability, but also good physical, psychological, and social

well-being, the capacity to perform social roles, and the ability to adapt to a changing

environment and cope with change. Quality of life is a function of the difference between

the desired and actual situations. It is a subjective satisfaction that a person experiences
and that person projects onto all aspects of their life (physical, psychological, social and

spiritual).

The irreversible deterioration of health and limited mobility leads to disability in

activities of daily living and a poorer quality of life. The difference between the desired

and actual situation is increasing and getting bigger the worse the patient's assessment of

his quality of life is. It is because all activities that determine the range of independence

have direct and indirect effects on the extent to which the patient needs the help of others

and the health care system. One of the reasons why we assess health-related quality of

life is that we also want to gain an in-depth understanding of the well-being of an

individual patient or a particular group of patients and to evaluate the advantages or

disadvantages of specific medical treatments and procedures by assessing the quality of

life, we obtain valuable information about the patient's health status, including its

psychosocial aspects, and the effectiveness of our therapeutic interventions.

Quality of life assessment also allows us to determine the clinical and economic

effectiveness of treatment, medical interventions, and their impact on patients' lives and

to evaluate the legitimacy of expensive medical procedures and the cost-effectiveness of

the health care system. Quality of life assessments can produce fascinating and valuable

results in the context of improving the economic effects and functioning of health

systems. This system results in huge costs. There is no limit to the amount of money the

system can absorb, digest, and throw away. Hence the socially justified need to increase

the economic legitimacy of the functioning of such a system.

From this point of view, it would be interesting and valuable to take a closer look

at the relationship between patient quality of life and healthcare budgets. By analyzing
the regression curves for these two variables, we can make accurate predictions about the

extent to which pumping more money into the system is still rational and economical.

Beyond that, more money will not mean an overall improvement in patient quality. Life.

is comparable. Self-assessments of patients' quality of life are reliable data for insurance

companies, which use this data to estimate the effect of chronic disease on treatment

costs. It is a legitimate quality of life assessment application, rationalizing the health

system's management (Tommaso Cai et al., 2021).

Several positive and negative factors can influence a cancer patient's resilience

and QoL. These are illness-related risks, which include perceived illness, ambiguity and

complexity, the stress of symptoms, and severity of illness; family protective factors,

which include perceived social support from family and socioeconomic variables; social

protective factors, which include perceived social support from friends, the influence of

others with similar conditions and perceived support from providers; individual risk

factors including evasive, emotive and fatalistic coping measures/strategies; individual

protective factors, which include confronting, optimistic and support, coping, along with

hope and spiritual factors (Nida Zahid et al., 2019).

Conceptual/Theoretical Framework

The objective of this study is to know the Factors Affecting Resilience and Quality of

Life of Patients with Colorectal Cancer Undergoing Chemotherapy in Ulin Hospital

Banjarmasin, Indonesia

Factors affecting

Personal Factors Disease Related Factors

Age, gender, family, Symptoms, severity, stage,
employment status, household times after diagnosis, treatment
income, education level, stage, number of treatments,
religion, social support treatment changes
 Resilience

Quality of Life
### I think it is better to use the IPO method

Personal Factors
Age, gender, family, employment status, Data gathering procedure on resilience of
household income, education level, religion, patients with colorectal cancer
social support

Disease Related Factors Quality of Life

Symptoms, severity, stage, times
after diagnosis, treatment stage,
number of treatments, treatment
changes

Figure 1. Conceptual framework of Factors Affecting Resilience and Quality of Life of

Patients with Colorectal Cancer Undergoing Chemotherapy with IPO method

Disease-related factors are related to resilience, and resilience is also related to

mental, emotional, and behavioral flexibility and adjustment to external and internal

demands in patients with colorectal cancer, resilience is also regarded to be related to

mental problems. Further, it has been reported that the QOL of patients with colorectal

cancer is related to mental issues, emotions, age, and fatigue. Factors identified in the

literature related to resilience were classified into personal and disease-related factors.

While the former includes age, living with family, with a partner, with children, financial
difficulties, educational background, and self-disclosure of cancer, the latter includes

cancer stage, metastases, length of time after the cancer diagnosis, physical symptoms,

details of physical symptoms, comorbidities, and surgical treatment.

Statement of the Problem

Generally, the formulation of the problem in this study is whether factors affect the

resilience and quality of life of patients with colorectal cancer undergoing chemotherapy.

Precisely, the study ought to answer the following questions:

1. Will the effect of chemotherapy can affect resilience and quality of life?

2. How do resilience and quality of life affect colorectal cancer patients undergoing

chemotherapy?

3. What factors affect resilience and quality of life in patients with colorectal cancer

undergoing chemotherapy?

4. How does resilience affect the quality of life in patients with colorectal cancer

undergoing chemotherapy?

5. Will resilience in colorectal cancer patients undergoing chemotherapy lead to a better

quality of life?

Hypotheses

The hypothesis of this study there are:

1. Factors affecting resilience in colorectal cancer patients undergoing chemotherapy

will cause good mental, emotional, and behavioral flexibility and adjustment to

external and internal demands and a better quality of life

2. Factors affecting the quality of life in colorectal cancer patients undergoing

chemotherapy will cause emphasis on social, emotional, and physical well-being and

a better resilience

3. Individual and disease-related factors affect patients' resilience and quality of life

Significance of the Study

The results of this study are expected to be able to add information to the following:

1. Staff Nurses /Oncology Nurses

Knowing about factors affecting the resilience and quality of life of patients with

colorectal cancer undergoing chemotherapy to prevent or reduce and maintain quality

of life in colorectal cancer patients undergoing chemotherapy is vital to provide

support to improve resilience.

2. Participants

Knowing about factors affecting the resilience and quality of life of patients with

colorectal cancer undergoing chemotherapy to prevent or reduce and maintain

resilience and quality of life and apply that knowledge in real life.

3. Hospital Administration

4. Future Researches

The results of this study can be used as reference material for further research

candidates, especially in Indonesia.

Scope and Limitation

This study focuses only on colorectal cancer patients undergoing chemotherapy from

2019-2023 at Ulin Hospital Banjarmasin. Since there are few patients who suffered from

colorectal cancer this year, I included in my study the patients from the past four years

provided they are still living.

Definition of Terms

Chapter 2

METHODOLOGY
 This chapter outlines that methods were used in undertaking this research. It

discusses the recruitment of participants as well as the rationale for selection. Chapter 2

addresses how the data were collected and analyze incorporating ethical considerations.

Research Design

This research uses a qualitative approach with a Grounded theory method.

Qualitative research methods are research methods used in natural object conditions

where the researcher is a key instrument and research results emphasize meaning rather

than generalization. Data obtained through in-depth interviews with a semistructured

interview guide.

Participants of the Study

The participants in this study were colorectal cancer patients undergoing chemotherapy in

Edelweiss Room Ulin Hospital Banjarmasin, Indonesia, above 40 years old. Samples are

3 colorectar cancer patients undergoing chemotherapy in Edelweiss room Ulin Hospital

Banjarmasin, Indonesia met the inclusion and exclusiom criteria as follows:

Inclusion Criteria:

1) Willing to be a respondent

2) Colorectal cancer patients undergoing chemotherapy

3) Above 40 years old

4) A patient who can communicate

Exclusion Criteria

1) Not willing to be a respondent

2) Patients under 40 years old

3) Unconscious patients

Instrumentation

We performed in-depth interviews lasting from 30 to 60 minutes using a semistructured

interview guide to ensure we included the issues under study.32 We asked the patients

questions such as

"How do you experience your life after you became ill?"

"What is important for you?"

"How is your relationship with your nearest family and friends?" and thoughts about God

or greater power. After the 11th interview, we did some preliminary analyses and made

minor changes to the interview guide. We approached patients based on their availability

to achieve sample variation, data saturation, and Polit's36 recommendation of sample size

in qualitative studies. Nineteen interviews occurred in the hospital and one in the patient's

home. All interviews were recorded and transcribed verbatim by G.R., a researcher who

has previously worked in a surgical department with colorectal cancer patients. The

interview can doing face to face, call and video call.

Ethical Consideration (Human Participants Protection)

Permission for data collection at the previously mentioned study settings was obtained

from hospital administrative personnel through submission of a formal letter from the

dean of the Faculty of Nursing, St. Paul University. Meeting and discussions were held

between the researchers and nursing administrative personnel to make them aware about

the aims, objectives and expected outcomes, as well as to get better cooperation during
the implementation phase. A clear and simple clarification was given to each study

subjects. They were secured that all the gathered information will be confidential and

used for research purpose only. They were allowed to withdraw from the study at any

phase and an informed consent was obtained prior to their inclusion in the study.

Data Collection Procedures

Research conducted at Edelweis Room Ulin Hospital Banjarmasin, Indonesia with the

following procedures:

1. Permit research submitted to the Head of Research Department of Ulin Hospital

Banjarmasin, Indonesia and Head of Edelweiss Room Banjarmasin, Indonesia.

2. The initial visit to a research done by bringing research license to report the research

plan and explain the objectives and technical implementation.

3. The research instruments to be used in the study was prepared.

4. Samples were selected according to predetermined criteria. Data collected by

requesting data from the edelweis room/chemotherapy room.

5. To patients explained about the research samples and research procedures given

informed consent sheet.

6. The research will filling form while observation on chemotherapy patients until the

end of the chemotherapy.

7. The researcher will be interviewing and observations the samples

8. The results documented research data.

Three people were recruited for this study. Individual interview happens in a hospital
setting. Guided interviews, semistructured interview guides developed by
researchers. The broad focus of the interviews included: (1) participants' experience
 of colorectal cancer diagnosis, treatment and subsequent recovery; (2) challenges
and strategies participants used during the colorectal cancer experience; (3)
participants' perspectives on the concepts of resilience and quality of life in the
context of their disease; (4) participant's reflection on their illness experience. All in-
depth interviews were conducted face to face, one on one and semi structured with a
focus on developing a conversational approach. With the participants' consent, the
interviews were audio-recorded to allow the researcher to focus on the participants,
their feelings and their responses. Prior to the interview, the research objectives were
explained to the participants. The interview participants sat facing the researcher. At
the interview, brief patient demographic information was also captured. After the
interview, field notes were taken to support interview memory and reflection. The
duration of the interview lasted between 30 to 60 minutes. Data analysis was carried
out simultaneously with data collection. When no new information was identified
after analysis of 3 interviews. One repeat interview was conducted with the
participant offering to add more information to the first round of interviews.
Data Analysis

The data collection is done in chemotherapy patients Banjarmasin, Indonesia who met the

inclusion criteria. The research data obtained through interviews and completed with

observations will then be analyzed narrative analysis

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 Barriers and Facilitators of Your study

This research needs materials like observation sheet and inform consent sheets,

for me the barriers of this research that I plan it is hard to find the specific references like

benefits of 0.9% NaCl compress for chemotherapy patients and looking for the other

facilitators like observation sheet to support my research.

Appendices 1. Inform consent sheets for participant

I who undersigned below:

Name :
…………………………………………………………………………………………
Address :
…………………………………………………………………………………………
With this willing to be participant of a study entitled " The Effect of 0.9% NaCl
Compress to Extravasation Prevention On Chemotherapy Patients In Ulin Hospital
Banjarmasin, Indonesia A Study Towards by the Capability in Addition Mathematics". I
have been getting information carefully about the procedures for implementing the
research and benefits of the research, and I do not claim damages for anything that
happens during the study run by the existing procedural because I am fully aware of the
benefits of this research to science.
This statement I made in a conscious state without any coercion from any
person.

Banjarmasin,
…………………………………
Witness, Participant,
 (........................ ) (......................... )

Researcher,

(Chumaira Anindayudina)

Appendices 2. Observations sheets

OBSERVATION SHEETS
THE EFFECT OF 0.9% NaCl TO EXTRAVASATION PREVENTION ON
CHEMOTHERAPY PATIENTS IN ULIN HOSPITAL BANJARMASIN, INDONESIA

Instructions:
I pleased to Mr. / Mrs. / Ms. to give the researcher time to observe the effect of NaCl compress
on the signs and symptoms of extravasation. The researcher will filling the observation form
properly:
Thank you for the willingness and cooperation that Mr / Mrs / Brother (i) have given.

I. RESPONDENT PERSONAL DATA

A number of Participant

II. EXTRAVATION SIGNS AND SYMPTOMS

Instructions:
- Observation at the immediate stage <24 hours
- Observation at the late stage >24 hours
- Fill in the available answer options column.
There are 5 signs and symptoms of extravasation:
 1. Pain
2. Redness
3. Swollen
4. Erythema
5. Induration
- Extravasation events occur due to leakage of chemotherapy drugs
 EXTRAVASATI PRE-TEST POST-TEST
N
ON (<24 HOURS) (>24 HOURS)
O
SIGNS AND
SYMPTOMS

1 Pain

2 Redness

3 Swollen

4 Erythema

5 Induration
EXTRAVATION EVENTS

DRUG LEAKAGE OCCURRED YES NO <24 hours

YES NO >24 hours

CONCLUSION:

Extravasation occurs (can trigger extravasation)

No extravasation occurs (can't trigger extravasation)