Psychological Impact of Newly Diagnosed Lung Cancer

amiable Impact of impertinently Diagnosed Lung CancerCHAPTER ONEIntroductionThe c formerlyrn addressed in this oration is to look the mental feign on a fresh diagnosed lung crabby person patient. Patients with lung crabmeat norm aloney nonplus variety of melancholy symptoms, galore(postnominal) of which sustain prior to diagnosis and pass on finishedout the words of the disease and the sermon, which adversely tinges the functional status and quality of life story (Julkunen et al, 2009). The experience of lung crabmeat is non limited to only the victims save whitethorn equ on the wholey devour wide-range impact on families somatogenic and unrestrained well-being. indeed it is essential to critic tout ensembley appreciate the extent of this mental impact of lung malignant neoplastic disease on the patient.This topic is mighty examined in con schoolbook of a critical lit polish come up. The onslaught has adopted the traditional manner which is con stead red appropriate for the purpose of this piece of work. This manner involves a critique, summary and synthesis of a system of writings later on which a conclusions is drawn, (Coughlan,et al. 2008). According to Crombie (1996), the purpose of writing a literary productions polish is to convey to readers the knowledge and ideas which hurl been established on the chosen topic, and look for the strength and weaknesses. This helps to find out gaps and inconsistencies in the literature. Gomm et al, (2000) stated that the purpose of a freshen is to analyse critic aloney a create physical structure of knowledge done summary, classification, and likeness of prior explore stu belongs, reviews of literature, and theoretical articles. A further status for the literature review testament non merely be a descriptive list of materiamyotrophic lateral sclerosis obtained, or a summary of relevant resources, but rather to provide the framework of the look to investigation and summ arise the literature studied in order to develop the re look for plain (Brink and Wood, 2001).A brief description of the anatomy and physiology of the lungs go forth be dealed to enhance decent construeing of the topic. Pathophysiology, aetiology and epidemiology of lung malignant neoplastic disease ordain be adumbrate. The methodology go out be described including a brief description of the models and strategies adopted in conducting the review. The review of 10 peer review typographys ar presented in chapters apply critical appraisal tools to evaluate the strengths and limitations of the re face papers. Both soft and quantitative autochthonic look papers ordain alike be utilise. Limitations of the literature and the process of the review will be determine.The dissertation will be structure in the following modality Chapter 2 will explore the background selective schooling closely lung genus Cancer by examining the pathophysiology, aetiology, and epidemiolog y, pathogenesis, intercession and evaluation of the disease. It also considers the rationale behind the chosen topic. Chapter 3, Research modeology, outlining the mingled strategies employed to gather and analyse the sources of information. Chapter 4, psychological distraint perplexity, low gear, thirst for hastened remainder, none of guilt and hopelessness. Chapter 5, Discusses the impact psychological tribulation has on quality of life of impudently diagnosed lung crabmeat patients. Chapter 6, Summary of findings of the literature reviewed. Chapter 7, Limitations of the literature reviewed. Chapter 8, Limitations of the whole literature reviewing process. Chapter 9, Conclusion and Recommendations, distils the key points and relates them to proper management of lung crabby person. It also proposes a anatomy of recommendations to tackle the problems identified above.CHPTER 2Lung malignant neoplastic disease2.1 IntroductionThe take away is to refer the psychologica l impact of impudently diagnosed lung crabby person on the patient. Lung Cancer is a disease that begins in the tissue of the lungs. To better understand lung pubic louse, it is vital to understand the anatomy and physiology of the lungs.2.2 Anatomy and physiology of the lungsThe lungs argon dickens cone-shaped structures positioned on all side of the heart. In the mediastinum. They are sponge-like organs that are snap off of the respiratory system. During breathing, air enters the mouth or nasal cavity and travels down the trachea. The trachea, divides into ii smaller tubes the near bronchus and the left bronchus. The right bronchus enters the right lung and the left bronchus enters the left lung. The right and left bronchus fall apart into bronchioles. These bronchioles end in tiny balloon-like air sacs called alveoli. The alveoli are where oxygen, carbon dioxide, and opposite substances are exchanged mingled with the lungs and the line of descent stream. (Gould, 2006 ).Pathophysiology, aetiology and epidemiology of lung crab louseLung cancer is a term, which covers a collection of some(prenominal) different forms of malignant neoplasm arising in the lungs and in the major airways (The Royal College of Physicians, 2005). There are ii major types of lung cancer, non-small cell and small cell. Non-small cell lung cancer (NSCLC) arises from epithelial cells which is the some common type of lung cancer. Small cell lung cancer begins in the governance cells or hormone-producing cells of the lung. The term small cell refers to the surface of it and shape of the cancer cells when seen under a microscope. According to (McCance and Heuther 2005) the non-small cell lung cancer (NSCLC) accounts for about 80% of all lung cancers. There are different types of NSCLC, these areSquamous cell carcinoma (also called epidermoid carcinoma). This is the close common type of NSCLC. It forms in the lining of the bronchial tubes and is the near common type o f lung cancer in men.Adenocarcinoma. This is found in the glands of the lungs that cause mucus. This is the nigh common type of lung cancer in women and also among people who hand over not smoked.Bronchioalveolar carcinoma. This is a rare subset of adenocarcinoma. It forms near the lungs air sacs. Recent clinical enquiry by Scullion and Henry (1998) has shown that this type of cancer responds much efficaciously to the newer targeted therapiesLarge-cell undifferentiated carcinoma. This cancer forms near the surface, or outer edges, of the lungs. It can uprise rapidly.The small cell lung cancer (SCLC) as (MacCance and Huether, 2005) puts it, accounts for about 20% of all lung cancers. Although the cells are small, they multiply quickly and form large tumours that can scatter throughout the body. Smoking is almost always the sheath of SCLC.Lung cancer begins when cells in the lungs grow out of control and form a neoplasm. A tumor can be benign (non malignant) or malignant (can cerous). A cancerous tumor is a collection of a large number of cancer cells that have the ability to spread to some new(prenominal) parts of the body. A lung tumor can begin anywhere in the lungs (Muers et al, 2001).According to Hughes and Pride (1999), once a cancerous lung tumor begins to grow, it whitethorn or may not shed cancer cells. These cells can be carried away in blood or float away in the natural fluid called lymph, which surrounds lung tissue. Lymph flows through the lymphatic vessels that drain into lymph nodes. Cancer cells metastasise when it leaves its site of origin and moves into a lymph node or to a far away part of the body through the bloodstream.The reparation and size of the initial lung tumor, and whether it has spread to lymph nodes or more than distant sites, adjusts the stage of lung cancer. The type of lung cancer and stage of the disease determine what type of interposition is needed. The staging system describes the extent of the disease at the time and accordingly provides a basis for discussion and panorama. The staging systems as described by McCances and Huether, (2006) are ground on the followingThe size of the primary tumour (T)The extent of regional lymph nodes (N) andThe spread of the tumor (M).Lung cancer is the most common form of cancer in the UK, sequeling in 36,000 deaths from each one year (DOH, 2007). Lung cancer is the leading cause of cancer motality in the UK In e real(prenominal) 15 minutes, a new diagnosis is made with near 40,000 fresh cases every year (NICE, 2009). It re chief(prenominal)s the most frequent of all malignant diseases and the one with the poorest prognosis. 80 percent of effected people die within a year (DOH, 2007). Lung cancer continues to rise and is now very high in women as well as men (Hamer et al, 2008). many epidemiological studies have assessed the extent and nature of problem in the UK, (Blackler et al, 2007) overlay that lung cancer occurs in people who smoke. This i s supported by further research from the United States of America, including other comprehensive workplace conducted by Scullion and Henry (1998) that the put on the line of lung cancer is higher in persons who begin smoking early, continue for many years, and are considered heavy smokers.However (Gould, 2006) posited that people who dont smoke can also develop lung cancer, although this is much rarer. This confirms (McCance and Huethers, 2005) statement that people who have been in protract or close contact with asbestos have a higher gamble of lung cancer, especially if they smoke. Lung cancer is rarely diagnosed in people junior than 40 most cases occur in people over the age of 60.2.3 Pathogenesis, discussion and EvaluationThe treatment of lung cancer is based on the size and location of the tumor, whether the cancer has spread, and also the persons overall health. There are four canonic ways to treat lung cancer surgery, radiation therapy, chemotherapy, and targeted ther apy (NICE, 2005). Treatment options differ for each individual and may depend on other factors such as age, somatogenetic condition, and other medical problems. The goal of Surgery is to remove the part of the lung where the tumor is isolated. Chemotherapy is to kill rapidly dividing cells in the body, including cancer cells development drugs. It is the main treatment for people with small cell lung cancer. In many people, chemotherapy will en equal to(p) them to live for longer, with better control of symptoms. (NICE 2009) Chemotherapy may be abandoned on its own, or onwards light beam. Sometimes chemotherapy and radiation therapy are given at the same time this is known as chemoradiation. Targeted therapy is a treatments intentional to target cancer cells in more specific ways, usually involving the mechanisms that cause cancer cells to grow or divide (DOH, 2007). The diagnosis of lung cancer becomes a crisis in victims life when experienced, confronting them with changes in identity, role, and social interactions and presenting them with an uncertain emerging (Waller and caroline, 1996).Kemp (1999) posited, the psychosocial distress can interfere with the patients health misgiving and diminish his or her health and functioning. more patients who face cancer diagnosis that require physical effects of treatment appear to experience emotional difficulties, including care and depression. Equally, patients with untreated depression or anxiety may be less likely to take their cancer medication and maintain their health. Moreover they may withdraw from family or other social support services which may affect the treatment outcome.2.4 preceptThe rationale for the choice of topic was based on a desire to understand the psychological impact of lung cancer on the patient. Often the physical effects of the cancer disease and treatment are foc employ more on the curative effort. Therefore, it is important for the health-care team to address psychological e ffects, that cancer patients normally encounter that can greatly affect their sense of well-being. treat is expected to deliver high quality care that is effective in promoting health and well being (LoBiondo-Wood and Haber, 2006). Evidence-based practice is a key system in the use of modern health services and crucial to the development of nursing practice (Parahoo, 1997). Evidence-based care as Brink and Wood (2001) purport and supported by (Carnwell 1997), is the conscientious use of current best depict in making decisions about the care of individual patients or the rake of health services. The successful completion of the review will investigate primary research. In doing so this may act as an additional information source for healthcare professionals and as a basis for further enquiry.Chapter 3METHODOLOGY3.1 Aims and research questionsAgainst the background of the fore issue explanation, it is desirable to identify the psychological distress associated with lung cancer and how it affects the patient.The questions the review seeks to address/answer are1. What are the psychological reactions of newly diagnosed lung cancer patients?2. How do these psychological reactions affect physical and psychological wellbeing of theses patients?3. What interventions can be used to address these psychological reactions of newly diagnosed lung cancer and manage them effectively?3.2 Parameters for the literature searchThe chosen method is a systematic literature review of twain qualitative and quantitative research in the mull area. A systematic literature review as defined by (Parahoo, 1997) is a summary of research that uses explicit approach to perform a thorough literature search and critical appraisal of existing body of published knowledge to identify the valid and applicable evidence. It is a means of managing very large volumes of information to identify evidence on which recommendations can be made (Holloway and Wheeler, 2002). Studies were used if they include adults (age 45 +) who have been newly diagnosed of lung cancer.3.3 Inclusion CriteriaThis review include literature published from the year 1999 onwardsAll papers published in English Language only.Primary research directly associate to the topic andPublished research articles only.3.4 Exclusion criteriaPrimary research not directly related to the topicUnpublished research articlesArticles published before the year 1999Other people were involved also, people from the specialist cancer services and the librarians whose help was invaluable in developing a search strategy and in sourcing and retrieving papers.3.5 Literature searching strategiesThe search was completed utilize electronic infobases. These were the Cochrane Library, CINAHL, British Nursing Index, Northampton Full Text emailprotected, Proquest, Medline, and PsycInfo. The Cochrane Library was searched ab initio to see if a similar study had been done. The other info based were then searched from 1999-2009. Medl ine is a nursing and medical database. It is known to be uncomplete (Markinson, 2002) however (Tagney and Haines, 2009) demonstrated that a search on MEDLINE is likely to produce most of the appropriate papers because it publishes articles from a worldwide source. The hospital subroutine library service was used to find studies which were not lendable in bounteous text form on the internet or locally held journals. not all could be located however this potentially could be a source of bias. In discussing the problems and importance of incomplete retrieval of papers, (Chalmers and Altman, 1995) argue that trials that are difficult to locate tend to be smaller and lower methodological quality than trials that are easily accessible.The key words used to search the database were LUNG CANCER, DIAGNOSIS, DEPRESSION, CANCERS, PSYCHOLOGY, PSYCHOLOGICAL INTERVENTION, MEN, ANXIETY, ANGER, SADNESS, FEELING OF GUILT OR REGRET and PATIENTS FEELINGS. The nature of the study necessitated the u se of very general terms such as lung cancer, and psychology. sensitivity was chosen rather than specificity in the selection process and this meant that the search ab initio uncovered a large number of papers unrelated to the study. The result of the search was initially screened by reading the abstract online and retrieving the relevant ones using the inclusion and exclusion criteria. The studies which were retrieved were screened again to make sure they fulfil all the criteria required to be used for the review. To avoid bias, this study used methods outlined by Aveyard (2008). The methods were simplified for people who are new to or have little experience in doing a literature review. As suggested by (Cutcliffe and Ward, 2003) methods used in systematic reviews reduce the potential bias of the review.3.6 Method of EvaluationThe literature is evaluated using Greenhalg T (1997) structure for evaluating qualitative research. (See appurtenance 2) This model was selected because mo st of the research was qualitative due to the nature of the selected topic. fretting and depression are difficult to measure because its an emotional repartee and therefore immeasurable.3,7 Method of AnalysisThe research is analysed using a summing up approach as described by (Aveyard, 2008) which is adopted from the approaches given by Paterson et al (2001). This model was chosen because it facilitates the extraction of themes from research literature of a versatile nature. Again is suitable for people who are new to the literature review process. The themes generated arePsychological distress perplexity, depression, feeling of hopelessness and the desire for hastened death. put of psychological distress on quality of life of people with newly diagnosed lung cancer.3.8 entropy handling methodThe data was retentiond and concomitantly analysed using data shop system described by (Cormack, 2000) this system has two unremarkably methods of storing data storage in original form , and storage using computer. The printed research papers were stored in a ring binder file and a memory stick was used to store computerised data. The purpose of data storage as LoBiondo-Wood and Haber (2006) puts it has three basic related purposes to make sure that no data are lost to ensure that information are obtained in a way which makes it reasonably accessible and to ensure that the researcher is able to analyse the data. A separate note book was used to store references.3.9 Resources required and sources identifiedResources required are computers, various libraries, search engines, text books, stationary, supervisor, and librarian. Sources identified are internet and printed journals.CHAPTER FOURTHEME 1Psychological distress disquiet, depression, desire for hastened death, feeling of guilt and hopelessness.Following exploration of the available and chosen research for this literature review, various themes have been identified. This chapter depends to discuss and explore the reviewed literature regarding the psychological distress of newly diagnosed lung cancer patients. It will discuss anxiety, depression, feeling of guilt and hopelessness which influence the disease-related factors on the desire for hastened death which have emerged from the data. Five studies (Akechi et al (2006), food turner et al, (2006), Wilson et al, (2007), (Rodin, et al 2009) and Mystakidou et al, (2008) will be examined using the methodology, discussions and analysis of the research to evaluate their findings. (See appendix 3 for research articles) In order for this to be achieved, the chapter has been divided into three sub-themes these arePsychological distress.Anxiety and depression.Feeling of guilt/hopelessness and the desire for hastened death.There will be a small summary to conclude the chapter.4.1 Psychological distressA cancer diagnosis can be viewed as a very stressful event for patients as they must adapt to the cut and uncertainty that such a diagnosis presen ts Fox et al (2006). As a result of life-threatening nature of cancer, psychological distress in cancer patients has been widely studied. Previous studies have indicated that 10-40% of cancer patients suffer from psychological distress (Skarstein, 1999). Vos et al, (2008) reported that 19% of lung cancer patients experienced depression in the midst of the time of diagnosis and initial treatment and 35% of them continued to experience the same disorder 6 months later on. It is therefore vital to investigate the hold predictive factors of the psychological factors experienced by newly diagnosed lung cancer patients.The start research paper identified was conducted by Akechi et al (2006). The purpose of the study was to investigate longitudinal changes and predictive factors for psychological distress among newly diagnosed lung cancer patients. The study was conducted among 85 newly diagnosed advanced non-small cell lung cancer patients. Data were obtained in structured call into question and validated self-report questionnaires. Psychological distress was evaluated using the Profile of Mood State (POMS) exceed. This scale was developed by McNair et al., 1977. The POMS scale according to Akechi et al (2006) is a self-rating scale measuring six emotional sates (tension-anxiety, depression-dejection, anger-hostility, vigor, fatigue, and confusion) and total musical mode disturbance. It was hypothesized that a lower fighting spirit and a higher helplessness/hopelessness were square predictors of total mood disturbances. Therefore initial psychological response after lung cancer diagnosis was the most relevant predictor of subsequent psychological distress.Their findings indicate that initial mood disturbance after the disclosure of a diagnosis of cancer (shock and uncertainty) is the most relevant predictor for subsequent psychological distress and that early intervention beginning immediately after a diagnosis is one way of preventing and/or reducing subseq uent psychological distress in lung cancer patients. Initial psychological response after cancer diagnosis seems to continue the subsequent indisposition flight of steps for at least several(prenominal) months, although several dimensions of psychological response, including anxiety and depression, may decrease. In their words, the overall psychological distress does not decrease naturally in the usual clinical care setting.Their study has several methodological advantages as compared with other studies because the method used for collection and analysis of the data were clearly described in the study which confirms that the qualitative method used was appropriate for the study (Greenhalg, 2001). However it has several limitations and fears must be used when interpreting its findings. First, it was stated in the methodology that the researchers were not able to obtain longitudinal data on most 40% of the potentially eligible subject at the time of the investigation (Akechi et al, 2006). This introduces the possibility of a selection bias (Crombie 1996). The absence of this longitudinal data mentioned demonstrate that individual level change over time could not be studied on 40% of the sample therefore the researchers could not obtain the longitudinal course of psychological distress of those people(Akechi et al, 2006). This indicate that the findings may be distorted by the bias, even though it seems to be very common and one of the most difficult issues that cannot be completely overhaul in the studies focusing on advanced cancer patients. Secondly, of all, this study included up to 6 months follow-up after cancer diagnosis, the longitudinal course of patients psychological status thereafter is unclear. Six months after diagnosis may not be enough long time to evaluate the longitudinal course of distress experienced by advanced lung cancer patients. For example, a recent study, examining the course of psychological distress in metastatic dope cancer pati ents demonstrated that distress remained constant or declined during the illness trajectory however distress significantly increased proximal to death (Hill et al, 2002). Considering the prognosis of advanced non-small cell lung cancer patients, it seems plausible that many dimensions of psychological distress, including anxiety and depression, may increase as death approaches.The convenience take method used also poses threat to the generalisation of the findings, because the study subjects consisted entirely of newly diagnosed advanced non-small cell lung cancer (NSCL) patients who go steadyed one Thoracic Oncology Division in Japan. Since patients with other lung cancer types at other sites were not examined in the study, it corpse unclear whether the results can be extrapolated to patients with other lung cancer types at other sites.Lastly, psychological distress after cancer diagnosis was the only significant predictive factor of subsequent psychological distress after cancer diagnosis. To the best of our knowledge, very few studies have addressed the predictive factors for psychological distress in lung cancer patients while several studies have investigated predictors for subsequent psychological distress in other types of cancers (REF). Edward and Clarke (2004) demonstrated that family functioning and patients illness characteristics were associated with anxiety and depression in newly diagnosed lung cancer patients. Consequently, because the follow-up stay in this study was short and the sampling method used caution must be taken when interpreting the findings.4.2 Anxiety and first geardepressive disorder refers to an emotional disturbance marked by the cardinal symptoms of persistent and permeant low mood and the loss of interest or pleasure in normal activities (Skarstein et al, 2000). McPherson (2004) defined anxiety as a feeling of snap and fear characterized by physical symptoms such as palpitations sweating, and feelings of stress. Depress ion and anxiety disorders are thought to be common in palliative cancer care ( Strutkowski et al, 2008).The first study identified was conducted by Turner et al, (2006). It was a prospective observational cohort study of patients undergoing palliative radiotherapy for lung cancer. The aim was to measure psychological distress and concerns before and after treatment using the Hospital Anxiety and Depression (HADS) and a concern checklist. Participants were selected randomly from radiotherapy clinics in various hospitals. Data were obtained from a convention of 83 immemorial patients (aged 75 and above) being treated with palliative radiotherapy for lung cancer, with a comparison congregation of 49 younger patients (aged 65 and under).They completed the HADS (Hospital Anxiety and Depression Scale) and a concerns checklist before and after treatment. The HADS according to Skarstein, (1999) is an instrument which rates anxiety and depression in patients with physical illness. It has two sub-scales, one assessing anxiety, and another evaluating depression. Anxiety and depression subscales of the HADS were scored using a score of 0-7 = normal, 8-10 = borderline, and 11-21 = probable case (i.e. likely to have the diagnosis of anxiety or depression confirmed after formal psychiatric assessment). The concerns checklist data were examined to provide median numbers of concerns identified by each patient conclave before and after treatment and, the changes over time were compared statistically.They hypothesized that majority of newly diagnosed lung cancer patients experience knockout level of depression and anxiety. The result of the study shows that the 60% of young group and 40% of elderly group had anxiety. And 30% of young group and 60% of the elderly group had depression. The young group consistently ranked the illness, the future relating to the illness, family and their energy level as their major concern and the elderly group also ranked family and breathless ness as their major concern. This findings suggested that people of all ages have similar concerns and level of anxiety and depression whiles receiving palliative radiotherapy for lung cancer.A year after a similar study was conducted by Wilson et al, (2007). It examined depression and anxiety disorders in 381 patients who were receiving palliative cancer care. The study group consisted of 212 women and 169 men (age 26-93). Data was obtained through the development of a structured interview of symptoms and concerns. Depression and anxiety disorders were assessed with a modified version of the Primary charge Evaluation of Mental Disorders (PRIME-MD) clinician evaluation guide. The PRIME-ED according to Fox, (2006) provides a quick coating method for a wide range of mental health disorders. The findings of the study suggested that physical symptoms (such as pain and breathlessness) as well as issues about the illness itself and its treatment were more likely to have been addressed. Anxiety and depression were the frequent individual diagnosis. But there was no association between these disorders and the time to death. However it makes it more difficult to treat their physical symptoms.The findings from these two studies suggest that depression and anxiety disorders are common in newly diagnosed lung cancer patients. However Turner et al (2006) suggested that people of all ages have similar concerns and levels of anxiety and depression while receiving palliative radiotherapy for lung cancer. Turner et als (2006) findings supported Wilson et al, (2007) because it also established that issues about the illness itself and its treatment outcome were the major concerns of the participants which influence anxiety and depression.However the two studies are limited to the method used. Turner et al (2006) clearly identified the data collection method used in the methodology. Patients completed the Hospital Anxiety and Depression Scale and the Concerns Check List. The qu estionnaire was completed by patients during their first visit for radiotherapy using touch-screen technology to record their responses. This method has been validated against paper questionnaire (Holloway and Wheeler, 2002). Some patients also used the paper version of the questionnaire. Data obtained from these two methods were compared in the analysis. Follow up was made during the next visit of patients to their outpatient appointment. Lung cancer specialist nurses were used for the collection of follow-up data. Where this was not possible, questionnaire, along side paid envelopes were sent directly to the participants. Those who returned completed questionnaires were sent a earn of thanks. On the other hand, Wilson et al, (2007) used a diagnostic interview which was a modification of a protocol that has been developed for the rapid screening of mental disorders in primary rather than palliative care. Although it has been used in old studies in oncology settings, admittedly th ere is not enough strong body of validating research to support it use (Skarskein, 2000).Moreover Turner et als (2006) study was conducted in the United Kingdom while Wilson et al, (2007) was conducted in Canada. This could affect the interpretation of the findings because of the existing cultural differences and healthcare systems among these two countries.Conversely, in both(prenominal) papers the researchers achieved excellent sample sizes and responses (LoBiondo-Wood, 2006). Greenhalg (2001) stated that when examining studies it is important to distinguish whether the sampling strategy is appropriate for the design of the study and level of evidence provided by the design.Turner et al, (2006) selected a sample size of 191 patients undergoing palliative radiotherapy in radiotherapy centres in various hospitals. From this, 132 were recruited into the study, 83 elderly and 49 younger patients. Wilson et al, (2007) selected an eligible sample of 381 lung cancer patients receiving p alliative care in octet sites across Canada. In both studies the researchers achieved excellent sample size and response rate. The sample sizes were large enough to give an accurate picture of what is going on (Greenhalg, 2001). Crombie (2008) stated that studies which use too small sample size often fail to detect clinically important effects. Moreover both studies used random sampling to recruit participants for the studie