563758

research-article2015

JPOXXX10.1177/1043454214563758Journal of Pediatric Oncology NursingWu et al.

Article

The Mediating Role of Resilience on

Quality of Life and Cancer Symptom
Distress in Adolescent Patients With
Cancer

Journal of Pediatric Oncology Nursing

110
2015 by Association of Pediatric
Hematology/Oncology Nurses
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DOI: 10.1177/1043454214563758
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Wei-Wen Wu, PhD, RN1, Shao-Yu Tsai, PhD, RN2, Shu-Yuan Liang, PhD, RN1,
Chieh-Yu Liu, PhD1, Shiann-Tarng Jou, MD2,
and Donna L. Berry, PhD, RN, AOCN, FAAN3

Abstract
Understanding how cancer symptom distress and resilience contribute to quality of life (QoL) in adolescent cancer
and may potentially help these patients achieve better health-related outcomes. The objective of this study was to
describe cancer symptom distress, QoL, and resilience in adolescents with cancer and to determine whether resilience
is a mediating variable. Forty adolescent cancer patients were recruited, and data were collected via a demographic
questionnaire, the Cancer Symptom Distress Scale, the Resilience Scale, and the Minneapolis-Manchester Quality
of Life Scale. Pearsons correlation, multiple regressions, and the Sobel test were conducted. Both resilience and
cancer symptom distress were regressed against QoL, accounting for 62.1% of observed variation in QoL scores.
The bootstrap result estimated the true indirect effect between .0189 and .0024, with a 95% confidence interval.
Resilience mediates the relationship between cancer symptom distress and QoL. Clinical use of a resilience measure,
for example to use in developing and evaluating interventions focused on enhancing resilience, may be practical for
nurses.
Keywords
resilience, cancer symptom, quality of life, adolescent, mediating effect

Background

Literature Review

Adolescent cancer patients have lower survival rates and

poorer health outcomes compared to child or adult cancer
patients (Desandes, 2007; Smith, Bellizzi, et al., 2013; Toft
et al., 2013). These outcomes are related to several factors,
including lower enrollment in appropriate clinical trials,
lack of adequate psychosocial services, and little theoretical-based research (Haase, Kintner, Monahan, & Robb,
2013). Consequently, insight into adolescents health concerns has been suboptimal. Quality of life (QoL) is an
important indicator in determining whether cancer patients
have received appropriate care (Johnson & Temple, 1985).
Determining the mediator of QoL is important for improving QoL. The mediator represents an intervening variable
through which an independent variable may influence the
dependent one (Baron & Kenny, 1986). However, to the
best of our knowledge, little research has examined the
mediating relationship of QoL against other health-related
variables. There is thus a compelling need to examine the
mediator of QoL in order to develop interventions relevant
to adolescent cancer patients.

Theoretical Framework: The Resilience in

Illness Model
In 2001, the Committee on Future Directions for
Behavioral Health and Social Science Research at the
National Institutes of Health recommended additional
research into resilience (Singer & Ryff, 2001). Resilience
is defined as the process of identifying or developing
resources and strengths to flexibly manage stressors to
gain a positive outcome, a sense of confidence, mastery,
and self-esteem (Haase, Heiney, Ruccione, & Stutzer,
1

National Taipei University of Nursing and Health Sciences, Taipei,

Taiwan
2
National Taiwan University, Taipei, Taiwan
3
Harvard Medical School, Boston, MA, USA
Corresponding Author:
Wei-Wen Wu, Department of Nursing, National Taipei University of
Nursing and Health Sciences, No. 365, Ming-Te Road, Taipei 11219,
Taiwan.
Email: weiwen@ntunhs.edu.tw

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Journal of Pediatric Oncology Nursing

1999, p. 125). It is an essential concept for the positive

psychosocial adjustment of adolescent cancer patients
(Molina et al., 2014). Haase et al. (2013) further explains
that resilience plays a positive role as a protective factor
that can buffer cancer-related adverse effects. Moreover,
it is amenable to intervention in which it allows adolescents to recover from stress caused by cancer (Haase et
al., 2013). Enhancing resilience is one potential way of
improving QoL in adolescent and young adult cancer
patients (Nelson, Haase, Kupst, Clarke-Steffen, & BraceONeill, 2004). Based on the above reasons, our current
study used Haase et al.s adolescent resilience model as
its theoretical framework.
This model contains health-protective factors (eg,
social integration, family environment, courageous coping, derived meaning), risk factors (eg, illness-related
distress, defensive coping), and outcome (eg, QoL;
Haase, 2004). The model may interpret the relationship
of cancer symptom distress, resilience, and QoL among
adolescent cancer patients, indicating that cancer symptom distress negatively affects QoL and that resilience
can mediates this adverse effect. Therefore, when psychosocial services are provided to adolescent cancer
patients, QoL can be improved (Smith, Parsons, et al.,
2013; Zebrack et al., 2013).
The ways in which health care providers enhance
resilience for adolescents with cancer include understanding of individual patients needs, psychological
counseling, interdisciplinary school-based interventions,
and offering culturally appropriate care to reduce adverse
effects of cancer on resilience (Chen, Chen, & Wong,
2013; Ishibashi et al., 2010). For instance, a randomized
clinical trial of a therapeutic music video intervention in
adolescents undergoing hematopoietic stem cell transplantation successfully enhanced resilience through
increasing protective factors and decreasing risk factors
of illness-related distress (Robb et al., 2014). Despite its
importance, resilience in adolescents with cancer has not
been well studied, and no study has examined the mediating effect of resilience on the relationship between cancer
symptom distress and QoL.

Cancer Symptom Distress

The entire course of cancer treatment ranges from a few
months to several years. Repeated admissions are necessary for receiving cancer treatment and treating complications/late effects, resulting in physical and psychological
damage. For adolescent patients, lengthy cancer treatments of chemotherapy, radiotherapy, surgery, and/or
bone marrow transplantation continue to be stressful
experiences. The most reported cancer symptoms are
pain and fatigue (Kestler & LoBiondo-Wood, 2012;
Smith, Bellizzi, et al., 2013). Appropriate measurement

of cancer symptom distress can assist health care providers with designing proper treatment plan, facilitating
patientphysician communication, improving patient satisfaction, and identifying hidden morbidities (Varni,
Burwinkle, & Lane, 2005). Nevertheless, Ericksons
(2013) review indicates a lack of measurements related to
symptom distress in adolescents with cancer. To assist
adolescent management of cancer symptoms, regular
symptom measurement during cancer treatment is needed
(Erickson et al., 2013).

QoL and Psychosocial Well-Being

Cancer symptom distress is not only negatively correlated with QoL but also affects adolescents psychosocial
well-being (Li, Williams, Lopez, Chung, & Chiu, 2013).
Adolescent cancer survivors report a worse QoL than
child cancer survivors (Kazak et al., 2010). Results from
Smiths research suggest that adolescent cancer patients
display a major decrease in physical and mental health
related QoL domains (Smith, Bellizzi, et al., 2013). These
psychological and QoL-related issues may present a significant threat to the psychological adjustment of adolescent cancer patients. As Alriksson-Schmidt, Wallander, &
Biasini (2007) have stated, A high level of personal and
social resources, from among social competence, family
functioning, and peer social engagement, was generally
associated with better QoL (p. 377).
For adolescent cancer patients, psychosocial wellbeing is an important issue, but it is relatively overlooked.
Adolescent patients encounter the dual crisis of normative developmental tasks combined with traumatic experiences related to cancer and cancer treatment (Wicks &
Mitchell, 2010). According to Eriksons (1968) psychosocial theory, adolescents are at a stage of developing
identity versus role confusion. The psychological impact
of cancer, a major health disruption, may lead to a failure
in developmental tasks and role confusion. Additionally,
adolescents lack sufficient life experience, tolerance for
frustration, and careful judgment about responding positively to life events, which may put them further at risk
(Ahern, Kiehl, Sole, & Byers, 2006). The research indicates that adolescent cancer patients experience uncertainty, altered self-image, identity issues, increased
dependency, and decreased cognitive and academic performance (Haase et al., 2013). For instance, it has been
established that adolescents with primary malignant bone
tumors are at risk for psychosocial maladjustment
(Paredes, Canavarro, & Simes, 2012). Ensuring healthy
psychosocial well-being and enhancing QoL should be a
prime concern for nurses (Li, Chung, Ho, Chiu, & Lopez,
2012). It is important to develop appropriate interventions that promote psychosocial well-beings and QoL
among this understudied group.

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Wu et al.

Study Objectives
The study objectives were (a) to describe cancer symptom distress, QoL, and resilience and (b) to determine
whether resilience was a mediating variable between cancer symptom distress and QoL for adolescent patients
currently receiving treatment for cancer in ambulatory
settings.

Method
Design, Setting, and Sample
This cross-sectional, descriptive study was conducted at a
childrens hospital in Washington State from November
2008 to January 2009. Approval to conduct this research
was obtained from the institutional review board.
The findings reported are an analysis of the secondary
objective of the original study (Wu, Johnson, Schepp, &
Berry, 2011). A convenience sample of 40 consecutive
adolescents was recruited. To qualify for the study,
patients had to meet the following inclusion criteria: (a)
be between 13 and 20 years old, (b) be currently undergoing cancer treatment, (c) be able to speak and read
English, (d) understand the study information, and (e)
give informed consent (ages 18-20 years) and assent
(ages 13-17 years). Participants younger than 17 years
were accompanied by their parents while they answered
the computerized questionnaires.
Assenting and consenting participants were asked to
complete questionnaires in the Electronic Self Report
AssessmentCancer Adolescent Form (ESRA-C AF)
electronic survey system on a touch screen computer in a
separate, private room. Parents were present, but participants were encouraged to answer questions independently. The ESRA-C AF was completed once by each
study participant (Wu et al., 2011).

Instruments
The instruments in the ESRA-C AF included a selfreported demographic questionnaire designed by the
authors as well as 3 standardized questionnaires: the
Minneapolis-Manchester Quality of Life Instrument
Adolescent Form (MMQL-AF; Bhatia et al., 2002), the
Symptom Distress Scale (SDS; McCorkle, Cooley, &
Shea, 2000), and the Resilience Scale (RS; Wagnild &
Young, 1993). The software infrastructure and user interface have been described elsewhere (Berry et al., 2011).
The MMQL-AF, designed specifically for adolescent
cancer patients aged 13 to 20 years old, was published in
2002 (Bhatia et al., 2002). The MMQL-AF is a validated,
multidimensional self-report instrument for adolescents
with cancer. The 46 items are reported as acceptable for
adolescents, and the wording is considered appropriate

for a sixth-grade reading level. There are 7 subscales in

the MMQL-AF, including (1) physical functioning (eg, I
have a lot of energy for running or sporting activities), (2)
cognitive functioning (eg, Do you have difficulty concentrating at school?), (3) psychological functioning (eg,
Report the level of Sadthe statement that people have
used to describe you), (4) body image (eg, How satisfied
are you with your weight?), (5) social functioning (eg,
People like to be with me), (6) outlook on life (eg, I am
happy with life in general), and (7) intimate social relations (eg, I find it easy to have an intimate relationship).
Item responses are on a 5-point Likert-type scale ranging
from 1 (worse) to 5 (better). The item scores are summed,
and the mean is calculated for each of the 7 subscales
with higher scores indicating maximal health-related
quality of life (HRQoL). Cronbachs was .91 in the current study (Table 1). Construct validity is conducted by
comparing similar constructs in MMQL-AF and the
Child Health Questionnaire (CHQ). There are high correlations between MMQL-AF scales and similar CHQ
domains (Bhatia et al., 2002).
The SDS is a cancer symptom scale consisting of
5-point, mixed-response dimensions of distress and frequency for each of 13 items (McCorkle et al., 1998). The
scale is applicable to (Linder, 2005), and reliable for, and
valid in (Hinds, 1990) adolescent cancer patients. The
SDS total summed scores range from 13 to 65; higher
scores indicate more severe symptom distress. For our
study, the Cronbachs was .84 (Table 1). Construct
validity was appropriate (McCorkle, Cooley, & Shea,
2000).
Developed by Wagnild and Young (1993) for use with
measuring adolescents resilience, RS is regarded as the
best instrument to survey adolescents resilience (Ahern
et al., 2006). It uses 7-point Likert-type scale responses
on 25 items, with total scores ranging from 25 to 175;
higher scores reflect higher resilience. Scores equal to or
greater than 147 indicate high resilience, scores ranging
from 121 to 146 are in the mid-range, and scores below
121 indicate weak resilience. For our study, Cronbachs
was .93 (Table 1). Construct validity was appropriate
through factor analysis (Wagnild & Young, 1993). Three
examples of questions in the RS were listed for readers
improved understanding, for example, Keeping interested in things is important to me; I feel proud that I
have accomplished things in life; I feel that I can handle many things at a time.

Data Analysis and Interpretation

All numerical data were imported to SPSS 18.0 for analysis. Descriptive frequencies and measures of central tendency were used to describe sample characteristics.
Hinds, Schum, and Srivastava (2002) have argued that

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Journal of Pediatric Oncology Nursing

Table 1. Summary of Participants Questionnaire Outcomes.

MMQL-AF
Physical functioning
Cognitive functioning
Psychological functioning
Body image
Social functioning
Outlook on life
Intimate social relations
SDS
Nausea frequency
Nausea severity
Appetite
Insomnia
Pain frequency
Pain severity
Fatigue
Bowel pattern
Concentration
Appearance
Breathing
Outlook
Cough
RS

Possible range

Actual range

SD

No. of items

40
40
40
40
40
40
40
40
40
40
40
40
40
40
40
40
39
40
40
39
39
39
39

1.00-5.00
1.00-5.00
1.00-5.00
1.00-5.00
1.00-5.00
1.00-5.00
1.00-5.00
1.00-5.00
13.00-65.00
1-5
1-5
1-5
1-5
1-5
1-5
1-5
1-5
1-5
1-5
1-5
1-5
1-5
25.00-175.00

2.14-4.93
1.67-4.89
2.00-4.89
1.88-5.00
1.67-5.00
3.17-5.00
1.33-5.00
1.50-5.00
13.00-42.00
1-5
1-3
1-4
1-4
1-5
1-4
1-5
1-5
1-5
1-5
1-2
1-5
1-3
54.00-174.00

3.92
3.43
3.67
3.93
3.96
4.41
3.94
4.11
22.03
1.68
1.73
1.35
1.85
2.18
1.88
2.4
1.64
1.90
1.48
1.15
1.77
1.18
134.62

0.56
0.89
0.74
0.67
0.70
0.45
0.99
0.74
7.10
0.944
0.751
0.662
1.027
1.412
1.067
1.057
0.959
0.928
0.847
0.366
1.012
0.451
25.43

46
9
9
8
6
8
3
4
13
1
1
1
1
1
1
1
1
1
1
1
1
1
25

.91
.84
.86
.84
.77
.78
.83
.70
.84

.93

Abbreviations: MMQL-AF, Minneapolis-Manchester Quality of Life InstrumentAdolescent Form; SDS, Symptom Distress Scale; RS, Resilience
Scale.

mean scores may cause health professionals to misunderstand patients cancer symptom distress level. Individual
scores can serve as the prompt for a subsequent, more
detailed, symptom-specific assessment (p. 352) (Hinds
et al., 2002). They have been applied to research and
found to be a feasible way of addressing cancer symptom
distress and QoL in adults (Berry et al., 2011). Researchers
have decided to describe the most reported symptoms and
dysfunctional QoL categories by the beyond midpoint
ranking rather than via calculation of the sum or mean
score of each scale. A midpoint score was defined as the
score of the third response on the 5-point SDS for each
item and the 5-point MMQL-AF for each category.
Individual SDS items would be counted as beyond midpoint if scores were at or above the midpoint (3 points),
indicating that the counted items would be recognized as
distressed. Individual MMQL-AF categories would be
counted as beyond midpoint if scores were at or less than
the midpoint (3 points), indicating that those counted categories would be recognized as dysfunctional.
Pearsons correlation, multiple regressions, and the
Sobel test determined the relationship among cancer
symptom distress, resilience, and QoL. The researchers
hypothesized that QoL was the dependent variable, cancer symptom distress was the independent variable, and

resilience was the mediating variable (Baron & Kenny,

1986). The proposed model in this study (the adolescent
resilience model) included an antecedent variable (cancer
symptom distress), a mediator (resilience), and an outcome (QoL). The mediator was assumed to be a protective variable.

Results
Sample Characteristics
From December 2008 through February 2009, data were
collected at a hematology/oncology setting and an orthooncology ambulatory setting of a childrens hospital.
Fifty-four eligible patients were approached, with 40
agreeing to participate in the study. Fourteen adolescents
declined participation due to reasons of physical distress
(n = 4), emotional distress (n = 2), not wanting to delay
appointments (n = 3), language barriers (n = 2), concern
about personal privacy (n = 1), no reason given (n = 1),
and parents rejecting for hiding the truth of getting cancer (n = 1). Almost half (6 out of 14) the participants who
had declined participation chose to do so out of physical
or psychological distress. All participants were in cancer
treatment, regardless of cancer stage. The sample included

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Wu et al.
Table 2. Beyond Midpoint Ranking of Cancer Symptom
Distress and Quality of Life.

Item

No.
responding

Quality of life (MMQL-AF categories)

Physical functioning
40
Cognitive functioning
40
Outlook on life
40
Psychological functioning
40
Intimate social relations
40
Body image
40
Social functioning
40
Cancer symptom distress (SDS items)
Fatigue
40
Pain frequency
40
Pain severity
40
Insomnia
40
Nausea severity
40
Nausea frequency
40
Bowel pattern
39
Concentration
40
Outlook
39
Appearance
40
Appetite
40
Cough
39
Breathing
39

% ranked at
or beyond
midpoint

Beyond
midpoint
rankinga

40.0
20.0
20.0
15.0
10.0
7.5
2.5

1
2, 3b
2, 3b
4
5
6
7

35.0
32.5
25.0
20.0
17.5
15.0
15.0
15.0
10.3
10.0
5.0
2.6
0

1
2
3
4
5
6, 7, 8b
6, 7, 8b
6, 7, 8b
9
10
11
12
13

Abbreviations: MMQL-AF, Minneapolis-Manchester Quality of Life Instrument

Adolescent Form; SDS, Symptom Distress Scale.
a
The beyond midpoint ranking counts the frequency of the most reported
distress symptoms and dysfunctional quality of life categories. bItems rank is a
tie.

25 males and a median age of 16.4 (range 13-20). Ten

(25%) participants were of minority background. Twentyfour (60%) participants had been treated for leukemia
(n = 13, 32.5%)/lymphoma (n = 11, 27.5%) and 10 participants had been treated (25%) for osteosarcoma. All
the participants were students and currently living with
their parents.

Descriptive Statistics for the MMQL-AF, SDS,

and RS
A summary of results for participants MMQL-AF, SDS,
and RS scores is presented in Table 1. According to
MMQL-AF scores, the physical functioning scale was
lowest (3.43 .89) and social functioning was highest
(4.41 .45). The SDS single items indicated fatigue was
most distressful (2.4 1.057) and breathing was the least
(1.15 .366). Mean total scores (standard deviations) of
the MMQL-AF, SDS, and RS were 3.92 (0.56), 22.03
(7.10), and 134.62 (25.43), respectively. To identify the
most frequently reported symptoms and the most dysfunctional QoL scales, a midpoint ranking of SDS and
MMQL-AF has been depicted in Table 2.

Table 3. Pearsons Correlation Among Cancer Symptom

Distress, Quality of Life, and Resilience Scores.
Variables
MMQL-AF
SDS
RS

MMQL-AF

SDS

RS

1.00
.761a (P = .000)
.558a (P = .000)

1.00
.440a (P = .000)

1.00

Abbreviations: MMQL-AF, Minneapolis-Manchester Quality of Life

InstrumentAdolescent Form; SDS, Symptom Distress Scale; RS,
Resilience Scale.
a
Correlation is significant at the .01 level (two-tailed).

Relationships Between Cancer Symptom

Distress, Resilience, and QoL
There was a significant negative correlation (r = .761)
between cancer symptom distress and QoL (P = .000), a
significant positive correlation (r = .558) between QoL
and resilience (P = .000), and a significant negative correlation (r = .440) between cancer symptom distress and
resilience (P = .000). The correlations are presented in
Table 3.

The Mediating Effect of Resilience on the

Relationship Between Cancer Symptom
Distress and QoL
A series of regression equations examined whether resilience was a mediator on the relationship between cancer
symptom distress and QoL. As depicted in Table 4, the
result of Equation showed that the independent variable
(cancer symptom distress) was a significant predictor of
the mediator (resilience) with = .440, P = .005,
accounting for 17.2% of the observed variation in resilience scores. The result of the second equation (Equation
2) demonstrated that the independent variable (cancer
symptom distress) was a significant predictor of the outcome variable (QoL) with = .761, P = .000, accounting for 56.7% of the observed variation in QoL scores.
The third equation (Equation 3) contained both the independent variable (cancer symptom distress) and the mediator (resilience) entered simultaneously with the outcome
variable (QoL). The result indicated that both resilience
and cancer symptom distress predicted QoL ( = .277, P =
.018; = .639, P = .000, respectively) and accounted for
62.1% of observed variation in QoL scores. In other
words, the observed variation increased from 56.7% to
62.1% when resilience was included in the equation. To
determine whether this increase was significant or not, a
bootstrapping approach (the Sobel test for small samples)
was used (Preacher & Hayes, 2004). The result revealed
that the true indirect effect was estimated to fall between
.0189 and .0024, with a 95% confidence interval (CI).

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Journal of Pediatric Oncology Nursing

Table 4. Mediating Effect of Resilience on the Relationship Between Cancer Symptom Distress and Quality of Life.
Sequence

Dependent
variable

Independent
variable

Equation 1
Equation 2
Equation 3

Resilience
Quality of life
Quality of life

Cancer symptom
Cancer symptom
Cancer symptom
Resilience

R2

.172
.567
.621

.440a
.761b
.639b
.277c

.005
.000
.000
.018

Sobel Test, 95%

confidence interval
[.0189, .0024]

P < .01. bP < .001. cP < .05.

Figure 1. The relationship among cancer symptom distress,

quality of life, and resilience.
Abbreviations: MMQL, Minneapolis-Manchester Quality of Life
Instrument: Qol scores; SDS, Symptom Distress Scale: cancer
symptom distress scores.

Because zero was not in the 95% CI, the null hypothesis
was rejected, and it was concluded that the indirect effect
was indeed significantly different when resilience was
included. Thus, resilience could be confirmed as a mediator. The relationships among cancer symptom distress,
QoL, and resilience is shown in Figure 1.

Discussion
Cancer Symptom Distress
Our findings suggest the commonality of fatigue, pain,
and insomnia in adolescent cancer patients. Of these,
fatigue was the most reported symptom, which is consistent with previous studies on adolescents and young
adults with cancer (Daniel, Brumley, & Schwartz, 2013;
Kanellopoulos, Hamre, Dahl, Fossa, & Ruud, 2013;
Strauss et al., 2007). Fatigue often has no overt signs
(Wesley, Zelikovsky, & Schwartz, 2013) and may be easily overlooked by medical staff (Erickson et al., 2013;
Gordijn et al., 2013; Kanellopoulos et al., 2013; Mort,
Lahteenmaki, Matomaki, Salmi, & Salantera, 2011;
Orsey, Wakefield, & Cloutier, 2013; Verberne, MauriceStam, Grootenhuis, Van Santen, & Schouten-Van
Meeteren, 2012).

The relationship between fatigue and impaired sleep

has been previously reported in Verberne et al.s (2012)
study. Verberne indicated that adolescents who are treated
for CNS (central nervous system) tumors report more
issues with initiating and maintaining sleep during the
night compared with the norm; the excessive somnolence
during the daytime is correlated with fatigue-related QoL
and worse psychosocial functioning. In fact, sleep impairment during the night is not the only cause of daytime
sleepiness. Delayed sleep phase disordera circadian
rhythm sleep disorderis most commonly observed in
healthy adolescents (Bartlett, Biggs, & Armstrong, 2013).
To the best of our knowledge, research conducted to measure sleep quality for adolescent cancer patients is insufficient. More studies are needed regarding the evaluation
of sleep habits and the impact of this unique sleep impairment instance on adolescents with cancer either in treatment or off treatment to provide appropriate suggestions
to enhance sleep quality.

Quality of Life
Among all QoL categories of the MMQL-AF, physical
functioning was the most reported dysfunctional dimension. Park et al. (2013) conducted a descriptive study in
Korea with a translated MMQL-AF instrument and
reported similar findings: Adolescent cancer patients
reported the highest dysfunction in physical functioning
while cognitive functioning was ranked as the secondreported dysfunctional category. Adverse cognitive outcomes have been documented by other studies (Haddy,
Mosher, & Reaman, 2009; Kahalley et al., 2013; Persoon
et al., 2013; Sung et al., 2012). A decline in cognitive
functioning may cause poor academic performance,
resulting in poor adaptation to returning to school life
(Gurney et al., 2007). School-based interventions may be
required.
A few of our participants reported body image issues.
Meanwhile, the majority were not concerned about
changes to their physical appearance, perhaps realizing
that appearance is not as important as health. This finding
is consistent with qualitative research conducted by
Wallace, Harcourt, Rumsey, and Foot (2007) involving

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Wu et al.
interviews with 6 female adolescent cancer survivors
aged 14 and 19 years who expressed an apparent shift in
perspective and expectation for their appearances. They
report increased appreciation for regaining their health
and had a more positive life outlook. However, other
studies demonstrated the opposite finding: Adolescents
have a negative view of their physical appearance due to
changes resulting from cancer treatment (Huang, Xia,
Sun, Zhang, & Wu, 2009). The mixed findings may be
explained by researchers tendency to focus on signs of
maladjustment (Wallace et al., 2007).

Resilience
In this study, the majority of participants reported moderate to high resilience, which may be explained by a previous study discovering that adolescents with cancer who are
resilient may receive a higher level of social support (Park
et al., 2013; Wesley et al., 2013). Receipt of support has
been associated with social functioning (Smith, Parsons, et
al., 2013). Indeed, participants in our study rated social
functioning as the highest among the 7 MMQL-AF categories. In comparison, less social support was associated with
lower levels of resilience, and outcome consistent with the
study conducted by Rew that uses the same RS as in our
study (Rew, Taylor-Seehafer, Thomas, & Yockey, 2001).
Fifty-nine homeless youth were recruited and reported low
levels of resilience (M = 112, SD = 18), which may be
related to insufficient social supports from family members and school authorities (Rew et al., 2001).

Resilience as Mediator Between Cancer

Symptom Distress and QoL
The second objective of this analysis was to determine
whether resilience was a mediating variable between cancer symptom distress and QoL. Cancer symptom distress
has had an inevitably negative effect on adolescent patients
QoL (Li et al., 2013). Our finding indicated that resilience
was likely to mediate the adverse relationship between
cancer symptom distress and QoL for adolescent cancer
patients, demonstrating that resilience might play a role in
buffering the adverse effects of cancer symptoms on QoL.
This is consistent with the finding that examined relationships among physical symptoms, perceived social support
(a resilience characteristics), and life impact among 102
adolescents aged 13 to 19 with cancer. This study reported
that those with greater physical symptoms were more vulnerable to poor adjustment, whereas higher perceived
social support was related to higher positive outcomes
(Wesley et al., 2013). A similar result has been described in
adult women with breast cancer, enhancing resilience (eg,
social support, cognitive strategies, accepting life circumstance, and attempting to recover) and resulting in better

QoL and lower psychological symptom distress (Silva,

Crespo, & Canavarro, 2012). There have been similar findings among adults with cancer (Lam et al., 2010; Molina
et al., 2014; Strauss et al., 2007).

Limitations
First, our study was conducted at a single, U.S.-based
institution dedicated to pediatric care, precluding generalization beyond such a setting. Although information
about the treatment stage was not collected, all participants were outpatients who were receiving cancer treatment in hematology/oncology and orthopedics
ambulatory settings. It is assumed that participants cancer symptom distress and QoL will not vary significantly
with similar treatment stages and treatment protocols.
Second, almost half (6 out of 14) of participants who had
declined participation chose to do so out of physical or
psychological distress. Our sample may be biased toward
less distressed patients. Last, a Pearson correlation determination was required to analyzing the mediating effect.
The strong correlation between QoL and cancer symptom
distress was found, which might be related to similar
instrument constructs between SDS and MMQL-AF.
Future QoL studies performing correlation analysis may
pay attention to this confounding issue common in QoL
research.

Clinical and Research Implications

Pediatric oncology nurses must be trained to recognize
factors of resilience and develop interventions for promoting patients QoL. Monitoring sleep quality with
physiological measurement tools may help practitioners
to recognize sleep disorders.

Conclusion
Our findings confirm the mediating role of resilience in
the relationship between cancer symptom distress and
QoL. The results serve to increase clinicians awareness
of the importance of assessing and improving patients
resilience.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.

Funding
The authors disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
MaLaw scholarship of University of Washington, School of
Nursing; Scholarship of Sigma Theta Tau.

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Journal of Pediatric Oncology Nursing

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Author Biographies
Wei-Wen Wu, PhD, RN, is an assistant professor for
Department of Nursing (National Taipei University of Nursing

and Health Sciences) with a special interest in pediatric oncology nursing.

Shao-Yu Tsai, PhD, RN, is an associate professor for
Department of Nursing (National Taiwan University) with a
special interest in behavioral sleep medicine.
Shu-Yuan Liang, PhD, RN, is an associate professor for
Department of Nursing (National Taipei University of Nursing
and Health Sciences) with a special interest in oncology
nursing.
Chieh-Yu Liu, PhD, is an associate professor for Department
of Nursing (National Taipei University of Nursing and Health
Sciences) with a special interest in Biostatistics.
Shiann-Tarng Jou, MD, is a clinical assistant professor for
College of Medicine (National Taiwan University) with a special interest in pediatric hematology/oncology.
Donna L. Berry, PhD, RN, AOCN, FAAN, is an associate professor for Harvard Medical School, and the Director of the
Phyllis F. Cantor Center, Dana-Farber Cancer Institute.

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