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 European Journal of Oncology Nursing 14 (2010) 283e290

Contents lists available at ScienceDirect

European Journal of Oncology Nursing

journal homepage: www.elsevier.com/locate/ejon

Ensnared by positivity: A constructivist perspective on ‘being positive’

in cancer care
May McCreaddie*, Sheila Payne, Katherine Froggatt
Nursing and Midwifery, University of Stirling, Stirling, Scotland, FK9 4LA

a b s t r a c t
Keywords: Background: The concept of ‘positive thinking’ emerged in cancer care in the 1990s. The usefulness of this
Positive thinking approach in cancer care is under increasing scrutiny with existing research, definitions and approaches
Being positive
debated. Nurses may wish to judiciously examine the debate in context and consider its relevance in
Positivity
Constructivist
relation to their experience and clinical practice.
Grounded theory Purpose: To offer a constructivist perspective on ‘being positive’ we extract data from a constructivist
Interactions grounded theory study on humour in healthcare interactions in order to identify implications for practice
Humour and future research.
Methods: We offer three areas for consideration. First, we briefly review the emergence of ‘positive
thinking’ within cancer care. Second, we present data from a grounded theory study on humour in
healthcare interactions to highlight the prevalence of this discourse in cancer care and its contested
domains. We conclude with implications for practice and future research.
Findings: Patients actively seek meaningful and therapeutic interactions with healthcare staff and ‘being
positive’ may be part of that process. Being positive has multiple meanings at different time-points for
different people at different stages of their cancer journey. Patients may become ensnared by positivity
through its uncritical acceptance and enactment.
Conclusion: Positive thinking does not exist in isolation but as part of a complex, dynamic, multi-faceted
patient persona enacted to varying degrees in situated healthcare interactions. Nurses need to be aware
of the potential multiplicity of meanings in interactions and be able (and willing) to respond
appropriately.
Ó 2010 Elsevier Ltd. All rights reserved.

Introduction Wilkinson and Kitzinger (2000) claim there is an inappropriate

Positive psychology e a response to psychology’s previous
emphasis on the abnormal e emerged to much acclaim at the turn of
the century (Seligman and Csikszentmihalyi, 2000). Notably, this
turn to ‘flexible optimism’ took place against the backdrop of the
discussion on ‘positive thinking’ in cancer care in the 1990s (Gray
and Doan, 1990; Rittenberg, 1995; de Raeve, 1997). ‘Positive
thinking’, ‘being positive’ or any combination of a ‘positive’ attitude,
thought/belief or behaviour, including psychological constructs
such as optimism and hope, arguably emerged by stealth via a
plethora of quantitative, cognitive scale-based studies (e.g. Folkman,
1997; Taylor and Armor, 1996; Greer and Watson, 1987; Taylor, 1983;
Greer et al., 1979). The usefulness of much of the research carried
out in this area is debatable. Consequently, Wilkinson and Kitzinger
(2000) offer a different analysis of ‘positive thinking’.
* Corresponding author. Tel.: þ44 (0) 01786 466349.
E-mail addresses: may.mccreaddie@stir.ac.uk (M. McCreaddie), s.a.payne@
lancaster.ac.uk (S. Payne), k.froggatt@lancaster.ac.uk (K. Froggatt).
over-reliance on self-report data (e.g. interviews or questionnaires)
in previous literature and offer their data of unstructured focus
groups and interviews analysing spontaneous utterances of ‘posi-
tive thinking’. Their discursive approach views talk as action with
meaning constructed for its local interactional context. Talk is
therefore, not necessarily accepted as an accurate depiction of the
speakers’ cognitive processes (i.e, what they say is not necessarily
what they mean). Accordingly, Wilkinson and Kitzinger’s (2000)
analysis suggests that ‘positive thinking’ may operate, in part, as
a conversational idiom or, as a normative way of talking about
cancer.
The value of ‘positive thinking’ in cancer care is therefore, under
increasing scrutiny irrespective of the relevance of the research
approach adopted and its subsequent interpretation (Ehrenreich,
2009; Pistrang and Barker, 1998; McGrath et al., 2006a). Never-
theless, the prevailing view suggests that ‘positive thinking’ may be
at least an ‘artificial pressure’ (McGrath, 2004:5) if not, oppressive
(de Raeve, 1997). We contend that nurses should judiciously
examine the debate in context and consider its relevance in relation

1462-3889/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ejon.2010.03.002
284 M. McCreaddie et al. / European Journal of Oncology Nursing 14 (2010) 283e290
to their experience and clinical practice. Thus, we consider it
appropriate and timely to offer a constructivist perspective on
‘positive thinking.’
A constructivist perspective
Constructivism is based upon a philosophy of learning and the
premise that, by reflecting on our experiences, we construct our
own understanding of the world we live in (Vygotsky, 1978). Indi-
viduals actively generate their own understanding and ‘rules’ are
then used to make sense of their experiences. Social constructivists
therefore, explore how individuals make meaning within a social
context while social constructionists (e.g. Wilkinson and Kitzinger,
2000; Edwards and Potter, 1992; Gilbert and Mulkay, 1984) review
phenomena (like ‘positive thinking’) relative to context.
The constructivist paradigm draws upon the sociological
perspective of symbolic interactionism (SI) (Blumer, 1969) and SI is
based upon the triumvirate of meaning, thought and language. A
constructivist perspective based upon SI focuses on meaning
making within a social context and the multiple realities of the
participants. Those multiple realities are individual interpretations
(not shared realities) that arise out of interaction and introspection.
The constructivist perspective also recognizes the proactive and
a priori role of individual agency: the capacity to make choices and
act upon them. Thus, participants actively engage in constructing,
adapting and making sense of their interactions and draw upon
a host of experiences in order to do so.
We offer three areas for consideration. First, we briefly review
the emergence of ‘positive thinking’ within cancer care. Second, we
present data from a grounded theory study on humour in health-
care interactions to highlight the prevalence of this discourse in
cancer care and its contested domains. We conclude with impli-
cations for practice and future research.
‘Positive thinking’ e what is it?
One of the difficulties in reviewing existing research on ‘positive
thinking’ is the diverse definitions and interpretations of its
constitution and meaning(s). Generally, positive thinking is taken
to indicate a particular attitude, belief, mental state or behaviour
(e.g. articulating positive thinking). However, with regards to the
latter, we agree with Wilkinson and Kitzinger (2000) that when
someone says ‘I am being positive’ e what they say is not neces-
sarily what they ‘think’. Moreover, we concur with Wilkinson and
Kitzinger (2000) that ‘positive thinking’ is a relatively ambiguous
concept. It follows therefore, that ‘positive thinking’ may hold
multiple meanings depending upon the participants, (individual)
experiences and context.
A further difficulty emerges when positive thinking diffuses into
the considerable research on related issues such as hope (Herth,
1990, 1992), optimism (Scheier and Carver, 1992) and spirituality
(Larimore et al., 2002). Inevitably, these issues have their own
semantic tensions to resolve and, correspondingly, their preferred
research approaches (see Eliot and Olver, 2002). For example, much
of the research quoted does not specifically address the topic of
positive thinking but, rather includes it, or some aspect thereof, on
a trait measurement scale, e.g. optimism. Accordingly, while
psychological constructs such as optimism, positive mental attitude
or hope are distinguishable from each other, they are often attrib-
uted to, or cited as, part of an amorphous tranche of literature on
‘positive thinking’ depending upon the perspective being
presented.
From our constructivist perspective, what is relevant is not our
interpretation (or a particular definition), but the co-construction
of ‘positive thinking’ by researchers and participants from data.
However, for the purposes of this paper, we believe it is necessary at
this juncture to offer a broad a priori interpretation of ‘positive
thinking’. Thus, ‘positive thinking’ is a generic phrase used to
describe any derivative encompassing hope, optimism, positive
mental attitude, including ‘being positive’ It is taken to mean
a particular attitude, belief, feeling or behaviour that may infer
optimism but may not represent the ‘realities’ of the individual or of
their situated context.
Positive thinking e a contested domain
It appears to be broadly accepted that positive thinking is better
than negative thinking (Moberly and Watkins, 2008). However,
fairly early in the debate, the idea that positive thinking had a direct
causal link with well-being (or illness) was refuted (Cassileth and
Stimnett, 1982) although this is contested (Siegel, 1986). Conse-
quently, there has been a focus on positive thinking as an indirect or
mediating influence. Notwithstanding, the theoretical, methodo-
logical and definitional tensions, the broad body of work in this area
reviews positive thinking in terms of coping per se (mental
adjustment, reframing) and postulates the potential for this to
(indirectly) impact upon the progression or otherwise of the disease
(e.g. Yu et al., 2003). Thus, Shou et al. (2005) suggest that positive
thinking is more likely to create a perception of a better quality of
life rather than a better quality of life per se.
However, while positive thinking may be useful it may also
impede important conversations at the end of life in an attempt
to protect loved ones (McGrath et al., 2006b). Moreover, it exists
as a contested domain among patients, particularly the notion
that positive thinking is a social norm or moral obligation (Coreil
et al., 2004; Holland and Lewis, 2000). Although patients are a
valuable and arguably under-used resource in healthcare as a
means of peer support (Isaksen and Gjengedal, 2000) they can
also project ‘unwanted pressure’ onto their peers via inappro-
priate ‘cheerleading’ or as McGrath (2004) terms it e the ‘ra ra
positives’. Interestingly, nurses and patients have different
understandings of positive thinking: nurses view it as an attribute
(e.g. courage) while patients reportedly perceive it as a way to
attain normality (O’Baugh et al., 2003).
Finally, several authors raise the issue of the potential for ‘blame’
or the marginalization of individuals for their ‘failure’ to think
positively and perhaps even for the resultant worsening of disease
(de Raeve, 1997; Rittenberg, 1995 Coreil et al., 2004). However,
there is no evidence whatsoever to support the notion that
psychological coping styles impact upon disease progression
(Petticrew et al., 2002).
We now present data from a constructivist grounded theory
study which explored spontaneous humour in Clinical Nurse
Specialist-patient interactions (McCreaddie, 2008).
Method
The data upon which this paper is based was drawn from the
main study which took place over an 18-month period
(McCreaddie, 2008). The theory (McCreaddie and Wiggins, 2009)
and the methodology (McCreaddie and Payne, in press) are pre-
sented in full elsewhere. We will first, briefly outline the main study
to provide the reader with appropriate background and context.
The main study (methods)
The main study reviewed the phenomenon of spontaneous
humour in Clinical Nurse Specialist e patient interactions and their
respective peer groups using a constructivist grounded theory
approach (Charmaz, 2006). Grounded theory is particularly useful
 M. McCreaddie et al. / European Journal of Oncology Nursing 14 (2010) 283e290
for exploring phenomena about which little is known (Morse,
2001). Moreover, a constructivist GT approach aims to develop an
interpretive theory that ‘assumes emergent, multiple realities; inde-
terminancy; facts and values as inextricably linked, trust as provisional
and social life as processural’ (Charmaz, 2006: 126).
Twenty CNS-patient interactions e naturally occurring interac-
tions audio-recorded independently of the researcher (Silverman,
2007) e formed the baseline data corpus in the main study.
Other data collection methods such as interviews and/or focus
groups offer a second-hand account and presume that participants
‘know’ the phenomenon under study, e.g. humour. To further
facilitate the natural, spontaneous emergence of humour, partici-
pants; CNSs and patients e were informed that the study was
broadly about communication. Ethical review agreed that being
explicit about the aim of study may compromise findings with the
proviso that participants must not be harmed by the process
(Chantler and Chantler, 1998). The CNSs also recorded pre- and
post-interaction audio-diaries responding to questions provided in
a sealed envelope on general pre-interaction information (envi-
ronment, length of relationship) and post-interaction humour-
specific information (smiling, humour awareness).
Written consent was only obtained for audio-recording with
verbal consent for observation (e.g. negative case) following the
provision of information sheets or A4 posters highlighting an opt-
out provision (05/SO709/6, 06/S0709/7).
Interviews, field notes, observations and focus groups were
added to the baseline data corpus to provide introspective data and
different perspectives. Consequently, a second ethics submission
was necessary to extend the data collection timeframe and allow
follow-up data and different data to be added (see Fig. 1). Theo-
retical sufficiency (Dey, 1999) was declared on the basis of
decreasing interrogation, increasing abstraction, time in the field
Fig. 1. Data collection (whole study).
285
and the pursuit of a negative case. Data comprised a total of 88
participants involving 51 patients, 17 next of kin/volunteers, 14
CNSs and 5 other staff.
The constant comparison method of data collection and analysis
was applied. Open, axial and selective coding (Strauss and Corbin,
1998) were undertaken on all data. Specially devised interpreta-
tive and illustrative frameworks comprising the three main
(motivational) humour theories: superiority, incongruity and
release and Hay’s (2001) humour support implicatures: a non-
laughter based interpretation of humour support based upon
a Conversation Analytic study, were applied to data. Aspects of
Discursive Psychology (Edwards and Potter 1992) were applied
where appropriate e specifically the baseline data corpus e and an
amended form of the Jefferson system (Sacks et al., 1974) which
highlights the prosodical features of speech (intonation, breath
sounds, laughter particles) was used to illustrate, rather than
interpret data. Martin’s (2001) psychological overview of humour
highlighted contextual aspects at the level of axial coding. There-
fore, open, axial and selective coding was applied to all data in
conjunction with the interpretive and illustrative frameworks
and a discursive grounded theory methodology (DGTM) evolved
(McCreaddie and Payne, in press).
The main study (theory)
The main study presented a substantive grounded theory:
reconciling the good patient persona with problematic and non-
problematic humour (McCreaddie and Wiggins, 2009). The theory
differentiates potentially problematic humour from non-problem-
atic humour and notes that how humour is identified and
addressed is central to whether patients concerns are resolved or
not.
286 M. McCreaddie et al. / European Journal of Oncology Nursing 14 (2010) 283e290

The theory and data extraction rationale Table 1

First dataset e Janet’s case study data.

A case study; Janet e and data from a breast cancer focus group Data and date Participants Format
are presented. Both datasets comprise female participants only. It CNS-patient interaction CNS and patient, ‘normal’ clinical
should be noted that we have not purposefully chosen to focus on (researcher not present) with one trainee consultation lasting
gender-specific data. Rather, we have extracted this data for the August 2005 radiographer 22 min in clinic
observing
reasons outlined below.
CNS pre- and post- CNS only 6 Semi-structured
We have extracted and presented this data separately for two interaction audio questions contained in
reasons. First, this data was noted to be particularly rich in certain diary August 2005 sealed envelopes
dimensions of the good patient persona: positive coping and dis- CNS Follow-up CNS and Researcher Field note follow-up
placed concern. Second, this data also offers a unique perspective as September 2005 lasting 70 min in clinic
Janet e patient Janet and researcher Audio-recorded, 90 min.
it represents (a) different time-points in the study and in the follow-up In cancer support centre.
participants’ treatment as well as (b) different data sources (CNS- March 2006
patient interaction, interview and focus group). Therefore, we
believe our data is most suited to offering a constructivist
perspective on ‘positive thinking’.
offers her perception of her presentation at the initial CNS-patient
The data interaction.
Pseudonyms are used in the reporting of the following to Extract 1
preserve anonymity. The first dataset is the case study of Janet: Janet follow-up interview 7 months after the initial CNS-patient
a 66-year old lady with low posterior rectal carcinoma treated with interaction:
radiotherapy prior to surgery for stoma formation. Janet had 1 Janet I wasn’t a person that moaned or groaned. I was a good
particular past experiences a propos cancer and these are high- 2 patient. I was a quick healer which helped.
lighted in Fig. 2. [slightly later]
Janet took part in CNS-patient interaction six e a radiotherapy 3 int You said there that you were a good patient,
review e and a follow-up interview seven months post-interaction 4 what do you think a good patient is?
and surgery for stoma formation. Janet’s case study data comprises 5 Janet Well I think a good patient is if you don’t moan, what’s the
(a) the initial CNS-patient interaction, (b) the CNS pre- and post- 6 sense in moaning, trying to get better, try and help
interaction audio diary and (c) Janet’s follow-up interview and (d) yourself.
a follow-up field note of the CNS (see Table 1). A second dataset e First, Janet self identifies as a good patient. Further, Janet
a focus group of three female breast cancer patients undertaken at describes a good patient as someone who is overtly uncomplaining
the end of the study timeframe (17 months) e is also presented (line 1) and independent (line 6) while there may be an element of
(see Table 2). expectation or moral obligation of self-help in the phrase: ‘trying to
get better’. The notion of Janet being ‘a quick healer’ is intriguing.
Does Janet’s quintessential good patient persona; uncomplaining,
Findings independent and positive, assume somatic form? Notably, Janet
repeats this colloquial metaphor several times during the course of
Being positive and being a good patient the follow-up interview. However, there is no causal association
between positive thinking and morbidity. Does Janet ‘believe’ that
We propose that positive thinking, being positive or positive being a good patient or being positive in some way helps her
coping is but one dimension of a good patient persona which physically and/or emotionally or is it something expected of people
patients may present as a means of engaging the CNS in a mean- with cancer e to ‘fight’ their disease.
ingful and therapeutic interaction. For example, in the initial CNS- Interestingly, Temoshok (1983, 1987) posits a Type C coping
patient interaction Janet was perceived (by the researcher) to be style or response where there is a discrepancy between the
very sycophantic and (by the CNS) to be ‘very positive’. The CNS conscious experience and the self-report of emotion. Thus, what
perceived her to have a ‘bubbly personality’ (post-interaction audio an individual thinks or more importantly feels is not necessarily
diary) with a good social network. These perceptions contrasted what they report, e.g. the suppression of anger following
with Janet’s lone attendance at clinic, limited use of humour and a diagnosis.
specifically her (over) use of self-disparaging humour (SDH) as, In the following extract, Janet has been recounting her family
according to scale-based studies, SDH correlates with poor social history of cancer to the CNS: her breast cancer, her sister’s death
networks and loneliness (Hampes, 2005). In this first extract Janet from cancer and her daughter’s breast cancer.

Fig. 2. Case study Janet.

 M. McCreaddie et al. / European Journal of Oncology Nursing 14 (2010) 283e290
Table 2
Second dataset e Breast Cancer Focus group.
Condition Breast cancer
Number n ¼ 3, Breast cancer treated with radiotherapy, chemotherapy
and surgery. All recently completed treatments. Age range from
late 40s e late 50s in professional occupations.
Participants Patients only, group meets weekly
Venue Cancer support centre
Format Audio-recorded for 75 min, Open discussion of communication
and then humour
Date September 2006
Extract 2
CNS-patient interaction (Janet) seven months previously:
1 CNS But having all that in your family and yourself
2 Janet Well my daughter had it when she was 40
3 CNS And you coming through it again. It is quite amazing
4 that you have kept quite so positive.
5 Janet Well I think it does help, that’s what I tell everybody.
There are two points of note in this extract. First, is the CNSs’
‘naming’ of Janet’s presentation as positive. The CNS described
Janet in her post-interaction audio diary as ‘very positive’ and
confirmed this perception at a field note follow-up interview
undertaken one month post CNS-patient interaction:
Extract 3
CNS follow-up from interaction 6, one month post-interaction:
“Perhaps that’s more of a reflection about me e positive coping.
I think that’s how I would respond.”
The CNS further elaborates that she would ‘need’ to be positive
were she in Janet’s position, using it as a stress moderator to cope
and keep the dark side in abeyance (McGrath et al., 2006a). Notably,
the CNS stated that she preferred working with older patients as
they were ‘easier to jolly along’. The CNS therefore, arguably
distances herself from the tragedy (of cancer) rather than engaging
with it (Bolton, 2001).
The second point of note is Janet’s utterance that she thinks
being positive is helpful which she articulates to ‘everybody’.
However, if being positive is helpful is it necessary to articulate this
to others?
Being positive: articulating positivity
The following extract from the breast cancer focus group may
give some insight into the relevance of articulating positivity:
Extract 4
Breast cancer group 17 months into field work:
1 Irene: People keep saying to me, you’re a strong person.
I don’t see
2 myself as a strong person but people keep saying
that to me and
3 it’s, well it’s like yesterday, I had a long conversation
with
4 somebody, and she said, you’ve got a positive
attitude.
5 (Lara) It’s other people’s perception
6 Irene Yes.
7 int You are saying you are positive? (to Irene)
8 Irene I am really positive about it most of the time but I
don’t think
9 anybody is positive all the time and you have to give
yourself that
10 time to have your little cry or be angry or be upset.
And I don’t like
11 to be pressurised and the very few times when I
don’t feel
287
12 positive, I do want to have a wee cry. I want to have a cuddle.
Strength and positivity are not necessarily one and the same
attribute whether ‘real’ or enacted. ‘Other people’s perceptions’
equating strength with positivity although possibly well-meaning
may be complicit in leading Irene to feel that she has to ‘be’
positive e or, at least articulate it. Her use of the term ‘pressurised’
is interesting and resonates with other studies which suggest that
some patients object to inappropriate ‘cheerleading’ (McGrath,
2004; Coreil et al., 2004). Nonetheless, Irene appears to be reti-
cent in articulating ‘the very few times’ she lacks positivity. Surely
an individual who has been diagnosed with a life-threatening
illness facing lengthy therapy, that may not necessarily be cura-
tive, be expected to be less than positive, some, if not all of the
time?
Both Janet and Irene attest to ‘being’ positive and articulating
positivity e the latter to greater or lesser degrees. Whether Janet
or Irene ‘believe’ being positive is useful and/or expected is not
clear. Who comprises the ‘cheerleaders’ that may make Irene feel
‘pressurized’ into articulating positivity? Is it her fellow patients
or non-cancer patients e well-meaning friends e who like the
CNS in extract two, affirm positivity. If positivity is not already an
expectation initially, then it may become so via others articu-
lating it. By naming it and making it explicit it may become a fait
accompli. A patient may have articulated positivity at some
point and by doing so effectively give others permission to do
likewise. However, the expression may become fossilized, like
Wilkinson and Kitzinger’s (2000) notion of positive thinking as
conversational idiom e emerging at times when the patient is
not feeling positive. Consequently, the patient becomes ensnared
by positivity e a situation that may, or may not, be of their own
making.
Being positive and displaced concern
This data strongly suggests that patients have an acute aware-
ness of how others may be affected by a cancer diagnosis e
especially so with regard to close family members and partners.
Extract 5
Breast cancer group: 17 months into field work:
1 Lara The tears were simmering but I just could not (), and
2 watching your husband and daughter at the same
time. I
3 think about them more than I think about myself.
Lara articulates displaced concern: concern for others rather
than herself e how she felt like crying at one point but tried to
remain composed so not to distress her husband and daughter,
which would, in turn, add to Lara’s distress. Notably, Janet also
expressed displaced concern for others; patients and staff e several
times during the initial CNS-patient interaction. However, it was
only in the follow-up interview she expressed displaced concern
for her husband and daughter within the context of being positive:
Extract 6
Janet follow-up interview 7 months after the initial CNS-patient
interaction:
1 I didn’t want them to be ill or anything. I think if you are
showing that
2 you are trying to get better and you are going to get better, it
makes them
3 feel better.
Thus, Janet clearly states that being positive can have a somatic
effect e not necessarily for her e but for her husband and daughter.
Somewhat ironically, Janet also stated that ‘she had to think of him
(her husband) e because he doesn’t show his feelings’ so Janet did not
‘show’ her feelings. Consequently, Janet like Irene in extract four
may become trapped inexorably into articulating positivity to
protect others e particularly those closest to her e from her own
distress.
288 M. McCreaddie et al. / European Journal of Oncology Nursing 14 (2010) 283e290
However much as patients wish to protect their loved ones from
their own plight there was also a sense that being positive could
potentially became a somewhat muddled entity for the individual
concerned.
Extract 7
Breast cancer group: 17 months into field work:
1 Sarah I think you are conscious because the people close to
you, they
2 feel it, but they feel helpless because there is nothing
they can do.
3 So you are aware of that. So you have to try and be
positive and
4 show a bright side and it’s all going to be alright.
5 int So how do you do that?
6 Sarah Just by saying those words. That’s the kind of person
that I am e
7 I’ve been saying that to my husband all along, it will
be alright.
8 Because I believe it. It suits me to believe that it’s true
for myself.
In the above extract Sarah attests to an awareness of the
powerlessness of loved ones, of their concern and concomitant
positivity with a view to possible cure (line four). Of note is her use
of a deontic modality in line 3: ‘you have to try and be positive’ e as if
there is no other option but an obligation to be positive. Her
interpretation is that positivity is required and she articulates this
along with the notion that cure is therefore, a tangible endpoint.
Note how Sarah uses the future progressive tense in line four in
reference to herself (going to be alright), but the simple future tense
of the verb when articulating this to her husband in line seven (will
be alright): the latter verb tense being more definitive than the
former. Similarly, Irene softens the epistemic modality ‘I believe it’
to ‘it suits me to believe’ (line eight). Sarah may therefore, be
expressing a view that positive thinking may lead to cure
(Wilkinson and Kitzinger, 1993). Moreover, it arguably constructs
belief as if it is a matter of choice. Clearly it is not, more so in this
instance, where a variety of variables (e.g. stage of cancer) are more
likely to determine outcome.
There is patently a difference between an individual’s ‘need’ for
positivity and others ‘expectation’ of positivity. Sarah arguably
demonstrates need and expectation colliding and being obfuscated
by the emotions, uncertainty and multiple meanings for her and
her husband.
Many healthcare consultations involve partners or others, e.g.
seven out of the twenty CNS-patient interaction involved at least
one other party. Given patients’ apparent difficulty in expressing
emotions in the presence of loved ones, the interviewer was moved
to ask the women in the breast cancer group whether they felt that,
sometimes, the involvement of others in those circumstances may
be unhelpful. This provoked a strident retort:
Extract 8
Breast cancer group: 17 months into field work:
Lara They should be involved e it’s like labour! (laughter)
Lara humorously invokes the analogy of labour to justify partner
involvement, simultaneously dismissing the researcher’s sugges-
tion. Lara’s use of labour as a simile is however, somewhat incon-
gruous. First, the act of labour, or rather conception, is a joint
undertaking whereas cancer is not, although arguably the support
expected from a partner is similar, which is presumably what Lara is
referring to. Second, labour usually involves a positive, even joyous
outcome, whereas cancer treatment brings relief at best. Labour/
pregnancy and cancer treatment however, are generally unfamiliar,
uncertain, protracted and medicalised events and consequently
they may therefore, remain enduring experiences. As such, it may be
reasonable to expect partners to be part of the process.
Lara, Irene and Sarah were adamant despite their displaced
concern and possible feelings of being pressurised, that partners
should be part of the process e unlike Janet. Janet attended clinic on
her own. In contrast, Lara described how her partner had been
involved in her chemotherapy and did, according to her, provide
‘support’. Nonetheless Lara noted e like Janet in extract six e that
there were times when those closest to the patient, in this instance
her partner and daughter, were the very same people of whom she
was protective of for fear of causing distress (extract five). They
were therefore, the individuals she was least likely to burden with
her concerns.
And finally, being positive and healthcare workers
Patients may not burden nearest and dearest with their
concerns and emotions. Can patients therefore, discuss their
concerns with nurses or, like Janet’s CNS, do patients perceive that
healthcare workers also prefer them to display positivity?
Extract 8:
Breast cancer group: 17 months into field work:
1 Sarah I think medical people like you to be positive because
it makes
2 their job easier doesn’t it?
3 Irene well less consulting time .hha
Irene cites the pervasive element of time-workload pressures
and does so with superiority humour and post-construction stance
laughter (Haakana, 2002). Sarah’s view appears to resonate with
Janet’s CNS who liked older patients who were ‘easier’ to ‘jolly
along.’ Both, arguably, suggest an awareness of ‘medical peoples’
predicament: busy clinics filled with people with cancer all with
varying degrees of fears and anxieties. Patients are therefore
attendant to the idea that as much as their cancer is, for them,
hugely significant, e for healthcare staff working in that area, it is
simply an everyday occurrence.
Discussion
The data presented here corroborates much of the literature
about positive thinking e it exists as a front to protect loved ones
(McGrath et al., 2006a: Janet, Sarah, Lara), may be unwelcome/
oppressive (McGrath et al., 2006b; McGrath, 2004; de Raeve, 1997;
Lara), a normative way of talking about cancer (Wilkinson and
Kitzinger, 2000; Janet) and/or an attribute that is positively
appraised by nurses (O’Baugh et al., 2003, CNS).
There is a large body of literature on positive experiences
following cancer care (e.g. post-traumatic growth, Foley et al.,
2006; Steel et al., 2008; Hefferon et al., 2009) and some may
argue that this contradicts our ‘negative’ perspective on ‘positive
thinking’. We do not dispute the potential for a diagnosis of cancer
to engender positive experiences. However, ‘positive experiences’
per se are arguably very different from our examination of ‘positive
thinking’ within the context of dynamic, situated healthcare
interactions. What this paper does is demonstrate multiple mean-
ings at different time-points for different people at different stages
of their cancer journey. It draws upon several timeframes, data
sources, perspectives and a robust analysis demonstrating how
patients reflect upon their experiences (Janet’s family cancer
history), interpret meaning making (Sarah and Irene, extract 8), and
create ‘rules’ such as articulating positive thinking (Sara, extract 7).
Patients are cognizant of the difficulties healthcare staff working in
this area face and thus, what they say is not necessarily what they
mean. In taking a constructivist approach this paper demonstrates
that patients actively engage with healthcare staff to effect a more
therapeutic interaction and being positive may be (a negative) part
of that process.
The inscrutable concept of mind-body dualism and positive
thinking is also highlighted here. Healthcare staff, partners,
 M. McCreaddie et al. / European Journal of Oncology Nursing 14 (2010) 283e290
relatives and society have expectations of people with cancer and
these may sublimate the feelings of the individual. Sontag (1991)
properly suggested that disease is a physiological entity that is
not engendered, or affected by, psychological factors. Consequently
it is improper (whether intentional or not) to propagate a fallacy
that may make a difficult situation worse. Patients may well initiate
positivity but they can eventually become ensnared by it. In turn,
nurses may recognize the emotional impact of cancer, but under-
state it (Kendall, 2007). Thus, while patients are unwilling to
burden their nearest and dearest with their concerns, they are also
uncertain or dissuaded from doing so with (or by) healthcare
workers.
Finally, ‘positive thinking’ in conjunction with displaced
concern, similar to Wilkinson and Kitzinger’s (2000) data, is pre-
sented within an all-female dataset. Women are positioned as
a competent nurturer of others (O’Grady, 2005). Women may also
face greater expectation to cope leading to reduced emotional
expression and ‘self-silencing’ (Ussher and Sandoval, 2008) and less
‘self-silencing’ evidently leads to better coping (Kayser et al., 1999).
However, Emslie et al (2009) suggests that both men and women
control emotion and there are, as Moynihan (2002) notes meth-
odological challenges in studying gender and cancer. ‘Positive
thinking’ may well be a gendered concept. Nevertheless, it is
a concept that needs further exploration.
Limitations
There are two particular limitations with this study as a conse-
quence of the data extraction rationale and the constructivist
approach adopted. First, this study extracted data from the main
study to review a particular aspect that emerged. While positive
thinking cannot be viewed in isolation it is possible that being
selective about the data discussed gives a de-contextualised view of
the issue. Second, all the participants are female and this gender
imbalance may be significant.
Implications for research and practice
Nurses should be aware of the potential multiplicity of mean-
ings in interactions and be able (and willing) to respond appro-
priately. In our view current oncology communication skills
training in the UK (ConnectedÓ) may benefit from adopting a more
constructivist-orientated approach.
Longitudinal studies on positive thinking that follow patients
through their experiences of cancer and its treatment journey
would make a constructive contribution to the existing evidence
base. It would also be useful to investigate how positive thinking
operates across genders for e staff, patients, relatives, individually
and collectively in support groups.
Conclusion
Positive thinking or being positive does not exist in isolation but
as part of a complex, dynamic, multi-faceted patient persona
enacted to varying degrees in situated healthcare interactions.
Nurses need to be aware of the potential multiplicity of meanings in
interactions and be able (and willing) to respond appropriately.
When patients actually say what they mean rather than what they
think ‘we’ want to hear we will have truly made progress. In short,
it is not for patients to make our job ‘easier’ but for us to make their
cancer journey, an understanding, supportive and therapeutic
experience.
289
Conflict of interest statement
None of the authors have any conflict of interests relating to the
development and submission of this paper.
Acknowledgements
The patients and staff who took part in the research. The reviewers
for their constructive comments. This paper was developed and
prepared as part of a scholarship funded by the Cancer Experiences
Collaborative (CECo) at the International Observatory on End of Life
Studies, Lancaster University.
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