AIMS The aims of this thesis are to provide understanding of the psychosocial impact of
recurrent cancer on patients and family members and to develop a substantive theory that
explains the phenomenon of recurrence from a psychosocial perspective.
BACKGROUND Cancer survival is increasing, and as people live longer, cancer recurrence
is a real possibility. Recurrence has been described as one of the most stressful phases of
cancer. Despite this reality, recurrence is poorly understood from a psychosocial perspective.
Nurses, caring for patients and family members through their cancer trajectory, need to
develop new understanding of how families experience recurrence in order to help them
adapt to this phase of cancer.
METHODS This grounded theory study was conducted in four cancer units of two hospitals
in North of Spain. The sample consisted of 15 patients, 13 relatives, and 14 nurses.
Triangulation of sources of data including family interviews, individual interviews, memos,
and literature was used to provide a different but complementary view of the impact of
cancer recurrence. Data collection and analysis were based on the constant comparative
method of grounded theory.
RESULTS A core category and three main categories have emerged from the data. The first
main category, “again”- when fear of recurrence becomes reality, shows the suffering of
cancer survivors and their family members after a diagnosis of recurrent cancer. The term
“again” symbolises past suffering due to the fear of recurrence and new sufferings as a result
of the diagnosis of recurrent cancer; it also implies a re-encounter with health services and
nurses. Suffering has been found to take on a social dimension in that recurrence was not an
individual experience, but also a family experience. In addition, the social construction of
suffering impacted on the nurses caring for the patients and families. The second main
category, identified as demoralisation as a response to the suffering of recurrence, refers to
the nature of suffering after the families knew that cancer had come back. Demoralisation
has been found to be an emotional reaction characterised by feelings of exhaustion,
uncertainty, and a resurgence of the fear of death. Such a condition posed great challenges to
the nurses who described caring for these patients as harder than caring for newly diagnosed
cancer patients. The third main category, identified as rebuilding morale in the experience of
recurrence, highlights families’ search for meaning in their experience of recurrence and
how nurses shifted the focus of care when caring for patients with recurrent cancer. The core
category of this study is demoralisation in cancer recurrence. It is the foundation of a
proposed theory for family nursing which explains what the experience of cancer recurrence
involves for patients and families, and proposes a psychosocial framework for the
management of demoralisation in families facing recurrent cancer.
CONCLUSIONS This thesis contributes to new understanding of the psychosocial impact
of cancer recurrence on families and the nurses’ experiences of caring during the recurrent
phase of cancer. The re-conceptualisation of demoralisation brings an original understanding
of the concept, which has been unpublished and unexplored in cancer nursing so far
